Effect of the HIV epidemic on infant feeding in South Africa: "When they see me coming with the tins they laugh at me".

Objective: To explore how the human immunodeficiency virus (HIV) epidemic has affected the infant-feeding experiences of HIV-positive mothers in South Africa.

Methods: This was a qualitative interview study within a prospective cohort study. We purposively selected a subsample of 40 women from a larger cohort of 650 HIV-positive mothers for in-depth interviews.

Findings: The HIV epidemic has changed the context in which infant-feeding choices are made and implemented. HIV-positive mothers in this study -- who were predominantly young, single and unemployed -- were struggling to protect their decision-making autonomy. Uncertainty about the safety of breastfeeding has increased the power and influence of health workers, who now act as gatekeepers to not only this new knowledge but also to essential resources such as formula milk. Fear of disclosure of HIV status and stigma has also weakened the ability of mothers to resist entrenched family and community norms that encourage early introduction of fluids and foods and that question non-breastfeeding. Women who chose to exclusively formula feed had difficulties accessing formula milk because of inflexible policies and a lack of supplies at clinics. Limited postpartum support led to social isolation and mothers doubting their ability to care for their children.

Conclusion: The infant-feeding experiences of HIV-positive mothers have serious implications for the operational effectiveness of programmes that aim to prevent HIV transmission from mother to child. A better understanding of how HIV is changing infant-feeding practices can inform the development of interventions to improve infant-feeding counselling and postpartum support.