The evidence of the risk of Human Immunodeficiency Virus (HIV) transmission through breastfeeding has caused major dilemmas in public health and has created a lot of uncertainty among infant feeding counselors and HIV positive women, as well as in the population at large [1–3]. The knowledge of the fundamental significance of breastfeeding, particularly in low income contexts where mothers in most cases have no safe and affordable alternatives to breastfeeding, has been a most serious challenge in the attempts to Prevent Mother to Child Transmission (PMTCT) of HIV [2, 4].
Without intervention 30-45% of all infants born to HIV positive mothers will be infected and 10-20% will be infected through breastfeeding . However, great efforts have been put into making breastfeeding safer particularly in resource-poor settings. Research has documented that it is mixed breastfeeding - the combination of breastfeeding with other nutrients - that implies the highest risk of HIV transmission. By contrast, exclusive breastfeeding (EBF) - breastfeeding without any other nutrient fed to the infant - is almost as safe as replacement feeding in terms of HIV transmission [5–7], and safer in terms of HIV free survival. A study conducted in South Africa, showed that exclusive breastfeeding carried a transmission rate of 4% from six weeks after birth up to six months , hence approaching the transmission rate in high income contexts estimated to be 2%. A major challenge has been to ensure that breastfeeding is practiced exclusively. The same study importantly documented that the cumulative 3 month mortality rate was significantly lower in exclusively breastfed infants than in replacement fed infants (6.1% versus 15.1%) .
Infant feeding counseling in PMTCT programs in Ethiopia as elsewhere in sub-Saharan Africa has been based on the 2001 World Health Organization (WHO) infant feeding guidelines which promote replacement feeding as the best option if acceptable, feasible, affordable, sustainable and safe (AFASS) [2, 4, 8, 9]. The guideline has been criticized for its lack of local relevance and the recommended infant feeding options. Exclusive breastfeeding and exclusive replacement feeding (infant formula or animal milk) have proven to be hard to implement for women enrolled in PMTCT programs. Practical, economic, social, psychological and cultural challenges are encountered in connection with both exclusive breastfeeding and replacement feeding [4, 8, 9]. Some of the key challenges have been linked to poor counseling or poor training of counselors , to customary infant feeding practices and to social expectations to breastfeed. In sub-Saharan Africa early mixed feeding and prolonged breastfeeding, i.e. prolonged mixed feeding, is the norm [5–7] and fundamentally challenges the PMTCT concept. The social expectations to breastfeed are strong and the risk of HIV positive status disclosure if practicing replacement feeding has been experienced as critical. This has led many mothers to combine breastfeeding and replacement feeding as the situation requires [9, 10].
The increase in infant deaths linked to replacement feeding, also in cases of free distribution of infant formula , and the increasing evidence that exclusive breastfeeding can be a safe option also for HIV positive mothers have led to a shift in the guidelines of the WHO. The updated guidelines from 2007 and 2009 promote and recommend exclusive breastfeeding for six months for all HIV positive mothers if replacement feeding is not AFASS [12, 13]. Hence, replacement feeding is recommended only as the second choice and if AFASS. Although the new recommendations had not been implemented in Ethiopia at the time of the study, counselors were aware of the situation and many were concerned and uneasy about the promotion of exclusive breastfeeding as a safe infant feeding option for HIV positive mothers.
The present article explores how breastfeeding and the risk of HIV transmission through breastfeeding is interpreted by HIV positive mothers and counselors in PMTCT programs in Addis Ababa, and how this is expressed through infant feeding practices.
The study was carried out in Addis Ababa, Ethiopia, from June to August in 2007. The population of Addis Ababa city is estimated at 3,059,000 people . A single point HIV prevalence estimate in June 2007 suggested HIV prevalence in Addis Ababa of 7.5% (6% in the male and 8.9% in the female population). In 2003, the antenatal care (ANC) estimate of the HIV prevalence among pregnant women in the city was 12.4%.
The first National PMTCT guidelines were published in 2001 by the Ministry of Health, Ethiopia . Today PMTCT services are offered at health centres and hospitals in all sub-cities in Addis Ababa and are slowly expanding into the rural parts of the country .
The study settings were two governmental hospitals situated in the city of Addis Ababa. The two hospitals were among the first to offer PMTCT services in the country starting in 2003 and in 2004 respectively. The first 'infant feeding and HIV follow-up clinic' was established in one of the hospitals in 2004, and three nurses had been trained and were providing PMTCT services including infant feeding counseling at the time of the fieldwork in 2007. In the second hospital, there was no specific 'infant feeding and HIV follow-up clinic', and the PMTCT services were more fragmented. Pre-partum counseling was provided in the antenatal clinic and the post-partum follow-up was done from the pediatric Antiretroviral Treatment (ART) clinic by staff with limited training in PMTCT and infant feeding counseling.
At the time of the study, PMTCT services in the two hospitals included a standard package of pre- and post-test counseling, infant feeding counseling during pregnancy and a single dose of prophylactic antiretroviral drug (nevirapine) during labour for the mother and immediately after birth for the infant. The routine follow up at six weeks after delivery included growth monitoring, infant feeding counseling and prophylactic antibiotic (sulfamethaxazole-trimethoprim) to prevent bacterial infections in the baby. Eligible mothers were referred to adult ART clinics for treatment.