Background Breastfeeding provides optimal nutrition for infants with numerous health benefits, as recommended by the World Health Organization for the first six months exclusively and up to two years or beyond with complementary foods. Not breastfeeding results in substantial global economic losses, estimated at $341.3 billion annually (0.49% of global GDP). For mothers living with HIV in low and middle-income countries (LMICs), concerns about vertical transmission via breast milk and potential interactions with antiretroviral therapy create complex challenges that impact breastfeeding initiation and sustainment. However, concerns about HIV transmission via breast milk and negative interactions with antiretroviral therapy can impact breastfeeding initiation and sustainment in these populations.

Methods A comprehensive systematic review of nine databases was conducted in March 2024 to identify studies comparing breastfeeding versus formula feeding cost-effectiveness outcomes in LMICs. Inclusion criteria encompassed primary research with economic outcomes related to both feeding methods in HIV-affected populations. Studies lacking economic data or direct comparisons between feeding methods were excluded. The review examined both quantitative and qualitative evidence on cost-effectiveness, healthcare costs, and socioeconomic barriers to breastfeeding.

Results From 523 initially identified articles, nine studies conducted in Sub-Saharan African countries with high HIV prevalence were included in the final analysis. Two main themes emerged: 1) mothers living with HIV often engage in suboptimal breastfeeding practices due to fears of HIV transmission, economic pressures, social norms, and lack of support; and 2) breastfeeding coupled with antiretroviral treatment is a cost-effective infant feeding strategy compared to formula feeding in resource-limited settings. Breastfeeding with appropriate antiretroviral therapy was found to be cost-effective at traditional willingness-to-pay thresholds, reducing disability-adjusted life years (DALYs) and healthcare expenses related to infant morbidity and hospitalization. However, employment status, economic determinants, and workplace commitments significantly influenced feeding decisions, often resulting in lower breastfeeding rates among HIV-positive mothers compared to their HIV-negative counterparts.

Conclusion This systematic review highlights the complex interplay between socioeconomic factors and health outcomes in breastfeeding decisions among mothers living with HIV in LMICs. Breastfeeding promotion represents not only a health-beneficial intervention, but also a cost-effective and potentially cost-saving investment for resource-limited healthcare systems when HIV is comprehensively managed through antiretroviral treatment. Future policies should incorporate supportive measures such as evidence-based counseling, educational campaigns, paid maternal leave, and enhanced healthcare infrastructure to overcome the economic and structural barriers to successful breastfeeding in HIV-affected populations.