Background: The question of when and how to best wean infants born to mothers with HIV requires complex
answers. There are clinical guidelines on best approaches but limitations persist when applying them in diverse
low-income settings. In such settings, infant-feeding practices are not only dependent on individual women’s
choices but are also subject to social and cultural pressures. However, when developing infant-feeding policies little
attention has been paid to these pressures, even though they may yield useful empirical knowledge on the various
forces that shape the infant-feeding dilemmas confronting women with HIV. This study aimed to a) identify the
infant-feeding challenges that women with HIV faced when they were advised to wean their children at an early
age of six months and b) explore how the women adhered to their infant-feeding options while facing and
managing these challenges.
Methods: This study was conducted between February 2008 and April 2009 at two public health facilities where
services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were
conducted with 20 HIV-positive women. Two of the 20 women were also chosen for case studies which included
home visits.
Results: Several interdependent factors including the conflicting pressures of sexual morality and the demands
of nurturing and motherhood, in conditions of abject poverty, impeded the participating women from following
medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty
maintaining their ascribed roles as respected wives, mothers and members of the society at large. The necessity of
upholding their moral standing through continued breastfeeding, which signified HIV-negative status, put pressure
on them to ignore the medical advice.
Conclusions: The infant-feeding dilemmas for women with HIV are complex. The integration of public health
efforts with context-specific socio-cultural understanding is essential. The recent 2010 WHO guidelines offer a
possible way of resolving these challenges. They recommend breastfeeding for one year with an adaptation to
two years for Malawi. Efforts in the PMTCT programmes to supplement existing support systems, e.g. through the
mothers-to-mothers (M2M) programme or consultation with expert mothers may also help women overcome
these challenges.