Exploring the guidance and attitudes regarding infant feeding options provided by Healthcare workers (HCWs) to HIV positive mothers of infants 0 – 12 months of age in South Africa
South Africa’s Infant and Young Child Feeding (IYCF) policy guidelines of 2013 and its 2017 amendments recommend that mothers, including those living with HIV, exclusively breastfeed their infants until 24 months of age, followed by their gradual weaning. The 2013 changed policy guidelines occurred to align with global WHO recommendations of six-month exclusive breastfeeding for all HIV positive mothers, and consequently no longer recommended free formula feed as an option for HIV-positive mothers attending public sector services, except in limited circumstances. Despite these policy guidelines, less than a third of South African mothers exclusively breastfeed their infants. The other two thirds of mothers either formula feed or mixed feed their infants. Mixed feeding or exclusive breastfeeding by HIV positive mothers who have either not been on antiretroviral therapy (ART) long enough or are insufficiently adherent to ART to suppress their viral loads, can potentially lead to increased risk of Mother to Child Transmission (MTCT) of the Human Immunodeficiency Virus (HIV). Since healthcare workers (HCWs) play a key role in promoting the IYCF policy guidelines and encouraging its practice among HIV-positive mothers, it is crucial to determine the extent to which HCWs understand and subscribe to this important policy. Using purposeful sampling and in-depth qualitative interview techniques, this qualitative study explored the attitudes of HCWs towards different infant feeding options, especially for HIV positive mothers, against the background of their understanding of the changes in IYCF policy guidelines between 2013 and 2017. The participants in this study included ten HCWs selected from three primary health care facilities in Khayelitsha (Western Cape, South Africa), and two programme coordinators based at the Western Cape’s Department of Health Khayelitsha substructure office. By interviewing this diverse sample of HCW cadre, the study aimed to explore their perceptions related to the factors which facilitate IYCF policy implementation versus those that hinder the implementation of this policy. The findings revealed that HCWs interviewed had good overall familiarity with the IYCF policy guidelines. However, their depth of understanding and acceptability of the policy varied, especially in the context of high HIV MTCT risk. Suboptimal implementation of the policy occurred due to inadequate policy dissemination, diverse views on the limitations of the policy, such as the promotion of only exclusive breastfeeding as an option and an unclear rationale for recent policy changes. Additionally, HCWs high workload and insufficient training on the changed 2017 guidelines were identified as barriers to effectively implementing the new infant feeding policy guidelines. HCW further perceived that personal, socio-cultural and health system factors influenced new mothers’ decisions and/or ability to breastfeed. These findings highlight that improved policy dissemination strategies and training should be used to increase HCWs knowledge regarding infant feeding counselling content, including HIV MTCT risk. Western Cape Department of Health alignment and implementation of relevant National Department of Health HIV policies should occur to decrease MTCT risk while breastfeeding. Peer support groups could provide maternal support for continued postnatal ART adherence and for sustained safer feeding practices. Finally, while exclusive breastfeeding is the optimal feeding choice generally for mothers, future revision of the 2017 IYCF policy should consider allowing HCW to act more flexibly in the maternal guidance they provide on infant feeding options. This could allow greater discretion for HCW in infant feeding counselling of mothers, particularly for those women who are HIV positive. This would promote improved patient-centred counselling that takes into account both maternal socio-cultural context and the right to make individualised decisions regarding infant feeding.