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Exclusive breastfeeding (EBF) has the potential to significantly reduce infant mortality, but is frequently not practiced in low-income settings where infants are vulnerable to malnutrition and infections including human immunodeficiency virus (HIV). This study explores mothers' experiences of infant feeding after receiving peer counselling promoting exclusive breast or formula feeding. This qualitative study was embedded in a cluster randomized peer counselling intervention trial in South Africa that aimed to evaluate the effect of peer counselling on EBF. Participants were selected from the three districts that were part of the trial reflecting different socio-economic conditions, rural–urban locations and HIV prevalence rates. Seventeen HIV-positive and -negative mothers allocated to intervention clusters were recruited. Despite perceived health and economic benefits of breastfeeding, several barriers to EBF remained, which contributed to a preference for mixed feeding. The understanding of the promotional message of ‘exclusive’ feeding was limited to ‘not mixing two milks’: breast or formula and did not address early introduction of foods and other liquids. Further, a crying infant or an infant who did not sleep at night were given as strong reasons for introducing semi-solid foods as early as 1 month. In addition, the need to adhere to the cultural practice of ‘cleansing’ and the knowledge that this practice is not compatible with EBF appeared to promote the decision to formula feed in HIV-positive mothers. Efforts to reduce barriers to EBF need to be intensified and further take into account the strong cultural beliefs that promote mixed feeding.

Background: Recent years have seen a re-emergence of community health worker (CHW) interventions, especially in relation to HIV care, and in increasing coverage of child health interventions. Such programmes can be particularly appealing in the face of human resource shortages and fragmented health systems. However, do we know enough about how these interventions function in order to support the investment? While research based on strong quantitative study designs such as randomised controlled trials increasingly document their impact, there has been less empirical analysis of the internal mechanisms through which CHW interventions succeed or fail. Qualitative process evaluations can help fill this gap. Methods: This qualitative paper reports on the experience of three CHW supervisors who were responsible for supporting infant feeding peer counsellors. The intervention took place in three diverse settings in South Africa. Each setting employed one CHW supervisor, each of whom was individually interviewed for this study. The study forms part of the process evaluation of a large-scale randomized controlled trial of infant feeding peer counselling support. Results: Our findings highlight the complexities of supervising and supporting CHWs. In order to facilitate effective infant feeding peer counselling, supervisors in this study had to move beyond mere technical management of the intervention to broader people management. While their capacity to achieve this was based on their own prior experience, it was enhanced through being supported themselves. In turn, resource limitations and concerns over safety and being in a rural setting were raised as some of the challenges to supervision. Adding to the complexity was the issue of HIV. Supervisors not only had to support CHWs in their attempts to offer peer counselling to mothers who were potentially HIV positive, but they also had to deal with supporting HIV-positive peer counsellors. Conclusions: This study highlights the need to pay attention to the experiences of supervisors so as to better understand the components of supervision in the field. Such understanding can enhance future policy making, planning and implementation of peer community health worker programmes.

Aim: We sought to study the survival of newborn children according to HIV status of the mother, that of the child and the timing of infection. Methods: This is a prospective cohort study of 883 mothers (665 HIV-positive and 218 HIV-negative) and their infants. Data were collected using semi-structured questionnaires during home visits between the antenatal period and 36 weeks post-delivery. Infant HIV status was determined at 3, 24 and 36 weeks by HIV DNA PCR. Results: The majority (81.3%) of infected infants who died were infected by 3 weeks of age. Of the HIV-exposed infants who died, 19 (28.4%) died before 6 weeks and 38 (56.7%) died by 12 weeks. The hazard ratio (HR) of mortality at 36 weeks of age in HIV-infected infants compared with exposed but negative infants was 8.9 (95% CI: 6.7-11.8). There was no significant difference in 36 week survival rates between HIV-non-exposed and HIV-exposed but negative infants (HR: 0.7; 95% CI: 0.3-1.5). The infant being HIV-positive at age 3 weeks (HR: 32 95% CI: 14.0-73.1) and rural site (HR: 4.4 95% CI: 1.2-23.4) were the two independent risk factors for infant death amongst HIV-exposed infants. Conclusion: The prognosis for infants with early HIV infection was very poor in this cohort. A greater focus on prevention of early infection, earlier screening for HIV infection and access to antiretrovirals for eligible infants is recommended.

This study examined the challenges that HIV-positive women face at different stages of early infant feeding using a longitudinal, qualitative design. The study explored factors influencing infant-feeding decision-making and behavior of HIV positive mothers and identified characteristics of women and their environments that contributed to success in maintaining exclusivity of their infant feeding practices. The study was undertaken at 3 sites in South Africa. Participants consisted of a purposive sample of 27 women who had a positive HIV test result during antenatal care and were intending to either exclusively breast-feed or exclusively formula-feed their infants. Women were interviewed once antenatally and at 1, 4, 6, and 12 wk postpartum. Just under one-half of the women who initiated breast-feeding maintained exclusivity and over two-thirds of the women who initiated formula-feeding maintained exclusivity. Key characteristics of women who achieved success in exclusivity included the ability to resist pressure from the family to introduce other fluids and to recall key messages on mother-to-child transmission risks and mixed feeding. Among women who maintained exclusive breast-feeding, a strong belief in the benefits of breast-feeding and a supportive home environment was important. For women using formula milk, having resources such as electricity, a kettle, and flask made feeding at night easier. Support for infant feeding that extends beyond the antenatal period is important to enable mothers to cope with new challenges and pressures at critical times during the early postpartum period.