Background
Exclusive breastfeeding has the potential to reduce infant and under-five mortality, but research shows the practice is not widespread in resource-poor settings of sub-Saharan Africa. We explored factors influencing the decision to exclusively breastfeed among HIV-positive mothers accessing interventions for prevention of mother-to-child transmission of HIV in selected sites of Zambia.

Methods
This exploratory qualitative study was embedded in research conducted on: HIV and infant feeding; choices and decision-outcomes in the context of prevention of mother-to-child transmission among HIV-positive mothers in Zambia. Thirty HIV-positive mothers and six key informants were recruited from two health facilities providing mother-to-child HIV transmission prevention services. A semi-structured guide was used to conduct interviews, which were digitally recorded and simultaneously transcribed. Data coding and analysis was done with the support of QRS Nvivo 10 version software.

Results
Despite the known benefits of exclusive breastfeeding, gaps in understanding and potential for behaviour change remained. We found that information promoting exclusive breastfeeding may have been understood by mothers as instructions from the health care workers indicating how to feed their HIV-exposed babies rather than as an option for the mothers’ own informed-decision. This understanding influenced a mother’s perceptions of breast milk safety while on antiretroviral medicine, of the formula feeding option, and of the baby crying after breastfeeding. The meanings mothers attached to exclusive breastfeeding thus influenced their understanding of breast milk insufficiency, abrupt weaning and mixed feeding in the context of preventing mother-to-child transmission of HIV.

Conclusion
In order to enhance feeding practices for HIV-exposed infants, our study suggests a broader health campaign supporting all mothers to exclusively breastfeed.