Unlearning prohibition: the de-implementation of HIV breastfeeding restrictions in the United States

In January 2023, U.S. perinatal HIV guidelines shifted to support shared decision-making in infant feeding, ending categorical prohibition of breastfeeding for people living with HIV (PLHIV). This change did not reflect new safety evidence, low transmission risk and near-normal life expectancy with antiretroviral therapy has been established for over a decade, but the convergence of evidence with sustained ethical critique of the harms of prohibition. Three years later, uptake remains inconsistent: clinicians report uncertainty, and patient experiences suggest limited change in counseling or practice. We argue that eliminating prohibition of breastfeeding for PLHIV is fundamentally a de-implementation challenge. It calls for deconstruction of a practice that functioned not only as clinical guidance but as moral certainty, reinforced by legal and institutional structures. Standard implementation strategies were never designed for this task. Effective change requires deliberate unlearning of outdated assumptions at the individual and institutional level, healing between clinicians and communities whose trust was broken, and active dismantling of the legal, structural, and cultural infrastructure that encoded prohibition. We outline priorities, including structured unlearning activities, institutional reform, equity-centered training, privacy-protective research infrastructure, and advocacy for repeal of HIV criminalization statutes. The goal is to replace a paternalistic, physician-centered fiction of zero-risk with an allyship model where women's and infants' interests are maximally advanced in collaboration with their physicians, systems, and communities.