In this section, the participants’ sociodemographic information and themes are presented. The identified themes are organized into six distinct categories exploring HIV-positive mothers’ infant feeding practices and what influenced their decisions.

Sociodemographic information

Table 1 shows the sociodemographic characteristics of the 27 HIV-positive breastfeeding mothers who were interviewed. The mothers were between the ages of 20 and 57 years old, with the majority being between 30 and 39 years (52%). Most of the mothers completed secondary or high school level (44%), with a few having attended a college or university (22%). The majority of mothers were unemployed and full-time housewives (70%) while a quarter reported that they were informally employed (i.e., self-employed, or casual labourers) (26%). Only one gave birth at home (4%), with the remaining 96% of mothers giving birth at the hospital. Two-thirds (67%) reported EBF at the time of the interview, with the remainder practicing mixed feeding.

Table 1 Socio-demographic characteristics of the study participantsKey themes and sub-themesNormative feeding practices

As can be seen in Table 1, mothers described variations in how they fed their infants, from EBF to mixed feeding. Regardless of actual practices, there was a common sentiment expressed by the mothers that EBF is difficult. There were three critical aspects of feeding that mothers talked about in interviews about their infant feeding practices—initiation, duration of breastfeeding, and exclusive feeding, which are how these results are shared in the following sections.

Initiation of breastfeeding

The initiation of breastfeeding among the participating mothers showcased a dynamic interaction of factors, including their HIV status (all positive) and delivery context (place and mode of delivery), which resulted in varied practices. They described the immediate integration of medication alongside breastfeeding practices tailored to each mother’s unique situation. One mother narrated, “Immediately after delivery, my baby was given his medication and then I breastfed him.” (38, married, six children, infant age 3 months).

Another explained,

I knew my HIV status, but I did not know what would happen to my baby because I delivered at home…when I delivered, I gave my baby that medication [Zidovudine syrup] before we went to the hospital. (46, single, five children, infant age 5 months)

For mothers who underwent caesarean section (CS) deliveries, their initiation of breastfeeding often faced delays compared to those who delivered normally. This was due to the recovery period. A mother shared,

It took me almost three hours to breastfeed her. This is because, after my CS, I was left to recover completely from the anaesthesia I had been injected while being operated. (39, married, two children, infant age 4 months)

Reported insufficient breastmilk at birth emerged as a critical factor that led some mothers to delay initiating breastfeeding until they felt they had enough milk. Additionally, mothers perceived the insufficient amount of their breastmilk as a significant trigger to introduce alternative feeds, including formula milk. “Because I did not have any breastmilk, my baby was given NAN [infant formula] for almost three days.” (34, single, two children, infant age 5 months).

First-time mothers’ anxiety and frustration while initiating breastfeeding were commonly reported, with a recurring challenge being the self-reported insufficient breastmilk supply. “I didn’t have any breastmilk production, and to make it worse, this is my first child. So, it gave me a challenge.” (26, single, one child, infant age 2 months).

This highlights how structural and personal factors such as delivery mode, maternal experience, and perceived milk insufficiency shaped the timing of breastfeeding initiation, often influencing how mothers approached subsequent feeding practices.

Duration of breastfeeding

The participants also provided insight into the duration of breastfeeding. Mothers reported variations in their breastfeeding duration, with some influenced by personal preferences and others influenced by the baby’s needs and the associated benefits of prolonged breastfeeding.

I will breastfeed her exclusively for six months… Breastmilk helps to protect a baby against infections and diseases. Also, breastmilk has all the nutrients a baby wants; water and vitamins. (33, married, three children, infant age 4 months)

Despite early initiation of breastfeeding and establishment of breastmilk supply by mothers in this study, they cited that their intentions and likelihood to sustain EBF for the recommended duration were challenged by the baby’s excessive crying and low weight gain. One mother said,

I just didn’t like the way she cried a lot, which made her not add weight altogether. I felt like my baby was not breastfeeding enough to be full, and so I decided to supplement her against the doctor’s advice. (36, married, three children, infant age 5 months)

Another mother narrated how meeting her baby’s persistent desire for breastfeeding was affecting her confidence to prolong practising EBF. “Even with this current baby, sometimes he is not satisfied with my breastmilk. He wants to suckle all the time.” (26, married, three children, infant age 2 months). Despite her concerns about breastmilk production, her baby’s eagerness to keep breastfeeding suggested a need for both nourishment and comfort, reinforcing her commitment to exclusive breastfeeding.

The impact of stress was evident among mothers in this study, who revealed the interconnection between maternal mental well-being and breastfeeding duration. The stories of the mothers brought to light the frequently difficult choices they had to make, balancing external stresses with their commitment to the recommended duration of EBF. One mother disclosed, “I went through a lot of stress, which made my breastmilk disappear completely.” (24, married, two children, infant age 3 months).

Another mother expressed her intention to shorten her breastfeeding period due to the current stress she was going through, looking for a casual job to support her family. “Anytime from now. I was just waiting for him to finish two months, then I start introducing different foods to him.” (32, married, three children, infant age 3 months). Her narration reflects the complicated nature of decision-making, where maternal well-being, influenced by various stressors, becomes a critical factor in determining the duration of practising EBF.

Exclusivity versus mixed feeding

The study uncovered a diverse range of perspectives on exclusivity versus mixed feeding, shedding light on the complex interplay of cultural influences, knowledge gaps regarding HIV and breastfeeding, and individual experiences shaping maternal decisions in infant feeding practices. Some adhered to EBF, based on knowledge and experience, evident in the following quote.

I breastfeed exclusively because of my HIV status, and that is the only method we are taught to practice. So, I have practiced exclusive breastfeeding before, and both my children tested negative. (33, married, three children, infant age 5 months)

However, a common opinion among the mothers was that navigating these decisions involved difficult considerations beyond the challenging nature of EBF, encompassing historical beliefs, socio-economic conditions, and varied cultural norms that collectively influenced their approaches to infant nutrition.

According to our African traditions, I know some people feed their babies with porridge and cow’s milk when they are still young. (24, married, two children, infant age 3 months)

As shown in Table 1, mixed feeding practices were common. As will be expanded upon in other themes, this was influenced by factors such as traditional norms and practices, and perceptions of the baby’s nutritional needs. One mother acknowledged practicing mixed feeding due to cultural norms, before she knew her HIV status:

To be honest, I mixed feeds. It was not my wish at all. At that time, I had not been tested for my HIV status. So, I fed her the normal way we feed children according to our culture. I gave her water, milk, porridge, and other light foods, and breastfeeding at the same time. (33, married, two children, infant age 4 months)

One older mother shared a unique experience, recounting a period when HIV-positive breastfeeding mothers were advised against breastfeeding due to the risk of HIV transmission to the child. Her narration reflected evolving medical guidance and highlights the historical context of infant feeding practices in the face of HIV.

I have only breastfed this one. I fed formula milk to my previous children because by that time, we were not allowed to breastfeed. Those children who were breastfed were being infected with the virus. So, at AMPATH, they used to issue formula milk to all breastfeeding mothers who were HIV-positive for six months. That was our exclusive formula feeding for the first six months, and then we were allowed to start weaning at the seventh month. So, this is my first child I am breastfeeding. (42, widowed, three children, infant age 6 months)

Another mother of the same age strongly stated concerns about the practice of mixed feeding, emphasizing its potential negative impact on a baby’s health. The mother portrayed her experience of raising her five out of eight children, being HIV-exposed, and described that mixing different types of feeds before the recommended age introduced complications.

It is not good to mix feeds for babies under the age of six months. If you mix feeds for your baby, the health of that baby will not be good. That baby will always be sick because of that. (42, widowed, eight children, infant age 4 months)

Collectively, these narratives show the tension between medical advice, cultural traditions, and real-life experiences. They also show how women dealt with different kinds of pressure when they had to choose whether to breastfeed their babies all the time or introduce other types of feeds.

Competing knowledge(s)

Competing knowledge(s) regarding HIV-exposed infant feeding were a significant theme in this study. The mothers exhibited a solid grasp of EBF guidelines, emphasizing the importance of giving newborns breast milk exclusively for their first six months. However, mothers disclosed that they were navigating conflicting types of information about infant feeding, including biomedical, social, and their own experiences, as illustrated in Fig. 1. The mothers emphasized how this competing knowledge(s) shaped their decisions concerning their actual infant feeding practices.

Fig. 1

Study themes and sub-themes

Fig 1 highlights the relationship between the themes and sub-themes in this study. The arrows show how factors such as stigma, tough economic realities, social support, and competing knowledge(s) interact to shape mothers’ mixed attitudes, which in turn influence normative feeding practices. Feeding practices, in turn, contribute directly to the lived experience (knowledge) of mothers, reshaping experiences of support and their attitudes

Biomedical knowledge

Mothers reported that their decisions regarding infant feeding were significantly influenced by the biomedical advice they received at healthcare institutions. Their practices were impacted by the emphasis on EBF for the first six months, which is frequently based on biological guidelines. One mother reflected,

I know that in our HIV status, we only give breastmilk, and we are not allowed to give water or anything else. But after a child turns six months, you are allowed to give porridge and milk. (46, single, five children, infant age 6 months)

Likewise, mothers acknowledged that the healthcare professionals taught and encouraged breastfeeding practices for mothers living with HIV, echoing the biomedical knowledge they had previously acquired. The mothers reported feeling positive about the information they were given by the medical professionals, which demonstrated their confidence in the instructions, particularly those about the advantages of feeding an infant exposed to HIV.

They also educated us, freshly married young girls, that all children are breastfed, despite their parents’ HIV status. And it is an added advantage for an HIV-exposed baby to be breastfed fully because breastmilk makes them stronger. (33, married, three children, infant age 5 months)

Social knowledge

In addition to biomedical knowledge, mothers received conflicting information about feeding HIV-exposed infants from their neighbours and peers. A few women reported that their decisions were significantly influenced by suggestions that were circulated within their social groups. The information they received from their neighbours and other community members often conflicted with medical advice. One mother, for example, described how the customs and beliefs of her society around baby feeding interfered with the way she planned to feed her baby. She lamented,

I can say that with my first child, I was influenced by my neighbours and other people who said that it is not compulsory for a child to complete six months to introduce foods. They gave me a lot of pressure to give food to my child before she finished six months. (32, married, three children, infant age 2 months)

Mothers also reported that cultural traditions and beliefs promoted or modelled by peers had a big impact on their baby feeding methods. A mother who was newly diagnosed with HIV after giving birth to her second baby described how her friends encouraged her to practice mixed feeding, which was against the biomedical knowledge she had been taught.

The most common thing they say is, ‘feed that baby with porridge.’ Others will testify that, ‘I fed my baby with ugali after one month and he grew up to be a strong boy. Did he die because of food? No. So, go ahead and feed yours as well’…. (24, married, two children, infant age 3 months)

There were mothers in the study who did not perceive anything wrong with practicing mixed infant feeding. Despite the recommended guideline for EBF, mothers expressed that introducing complementary foods alongside breastfeeding was common and acceptable.

Mothers’ own experiences

As has already been alluded to, mothers stated that their present ways of breastfeeding were influenced by their previous experiences. Positive experiences of raising HIV-negative babies were shared, bolstering their confidence to adhere to HIV-exposed infant feeding guidelines. The shared narratives emphasized the positive outcomes associated with EBF, fostering a sense of assurance and motivation among these mothers to continue prioritizing breastmilk as the primary source of nutrition for their infants.

When I breastfed my first child and later, she tested HIV-negative, I believed that although I am HIV-positive, I can protect people who are dear to me, and they will not be infected. With that assurance, I breastfeed without any fear because I know my children will be HIV-negative. Also, immediately after childbirth, they are given their medication, which reduces the risk of being infected. (29, single, two children, infant age 3 months)

Past experiences could also undermine biomedical knowledge. For instance, one mother explained a positive experience of mixed feeding, saying, “To be honest, if it was not for this HIV status, I don’t see any harm in feeding my baby because I did it with the first one and she grew up well.” (34, single, two children, infant age 5 months).

These narratives highlight how mothers’ real-life experiences can either support or go against medical advice, which affects their trust and choices about breastfeeding their babies while living with HIV.

Stigma

Stigma, competing knowledge(s), and normative feeding practices were found to be deeply intertwined themes that collectively influenced mothers’ infant feeding journeys. HIV stigma in community and healthcare settings profoundly affected their breastfeeding behaviours, leading to emotional distress and challenges in adhering to recommended practices. Despite understanding the importance of breastfeeding, those who reported stigma described feeling isolated and discriminated against, hindering their ability to breastfeed effectively.

Stigma in the community

Mothers said that one of the main causes of the stigma they face in their communities is the widespread perception that breastfeeding transfers HIV to the baby. One participant expressed the general opinion stating, “…they always say it is infected with the virus and if you breastfeed your baby, she will also be infected.” (22, single, one child, infant age 4 months) Another mother shared a similar feeling, recounting, “I have even heard someone say that our breastmilk is full of the virus and if we feed our babies, we are feeding them the virus.” (42, widowed, three children, infant age 6 months).

According to some mothers, stigmatization by society causes isolation because relatives and even neighbours avoid interacting with HIV-positive women and their breastfeeding infants. Some women hid their HIV status out of fear of criticism and unfavourable conversations, which prevented them from getting the support they may have otherwise received in society at large. Mothers shared instances of facing harsh treatment while breastfeeding or caring for their children due to societal stigma, which significantly influences their decisions and experiences.

I remember when I was newly diagnosed, and I was very sick; I was stigmatized by the way I was treated by my own family [sorry for that] …they didn’t even allow me to sleep in the same house with them. They took my bedding to a separate house and isolated my utensils. I was literary treated like a dog. (42, widowed, eight children, infant age 4 months)

A few mothers even resorted to mixed infant feeding to avoid judgment, believing that EBF would raise suspicions and questions about their HIV status. One mother shared,

If I breastfeed only, people will think I am hiding something. They will ask, why am I not giving porridge or water like other mothers? So, I mix feed to avoid gossip. (42, widowed, three children, infant age 6 months).

Stigma from family, community, or peers affected mothers’ emotional well-being and also directly affected how they fed their babies, sometimes leading them away from recommended EBF practices.

Stigma in a health setting

Health facilities were another key site of perceived stigmatization. Participants raised concerns about the shared space at the postnatal clinic at the hospital, where HIV-positive breastfeeding mothers are attended to. Despite the cultural norm of breastfeeding anywhere without fear or shame, due to their HIV status, these mothers expressed the need for a more confidential and private space.

I feel it is not proper to mix HIV-negative and HIV-positive breastfeeding mothers at the same clinic. I know some of the mothers already know that those who go to that private space are HIV-positive. My suggestion regarding this is that they should create this private space somewhere else. (26, married, three children, infant age 2 months)

The shared space increased the mothers’ sense of vulnerability, as they described feelings of fear, anxiety, and concern about encountering familiar people who might not be aware of their HIV status.

I know people do meet, but with this situation, it’s tough [laughing]…When I think of ever meeting with someone, I always feel so scared that I can lack the energy to even move…because if I meet with someone I know, especially in that private space, I might collapse! (33, married, three children, infant age 5 months)

As a result of the shared space at the postnatal clinic, some mothers described how a lack of privacy results in unintentional disclosure of their HIV status. The mothers further cited that the risk of unintentional disclosure could result in potential judgment from other people, especially the HIV-negative mothers present in the same venue.

We should not be mingling with HIV-negative mothers in the same space and then leaving to be attended to in this partitioned space. I think we should have our own space where we walk to directly and be attended to without worrying about who is watching which side you are heading to and coming from. (36, married, three children, infant age 3 months)

One concerning incident was shared by a mother who experienced the disclosure of her HIV status by a healthcare provider at the health facility without her consent. Despite the incident not significantly impacting her breastfeeding practices, she expressed disappointment in the unexpected breach of confidentiality by a trusted healthcare provider.

Social support

Another important theme that stood out in this study was social support. Mothers provided examples of the supportive and interconnected networks they come across in their infant feeding journey. Even though they reported breastfeeding challenges, they commonly acknowledged receiving social support from their friends and family.

Family support

Mothers overwhelmingly recognized the critical role that social support, especially from family, plays in helping them cope with the difficulties brought on by their HIV status. Spouses in particular were highlighted as key figures in providing not only emotional support but also meeting basic family needs and desires. The mothers expressed gratitude for such assistance, emphasizing the importance of a supportive marital relationship in navigating the complexities of living with HIV and breastfeeding their babies.

My husband gives me support in terms of bringing food home to feed my other children. I always feel that this is a very big support that a breastfeeding mother wants. It is not the norm for every husband to provide for his family, especially when the wife is breastfeeding. So, I appreciate his support so much. (32, married, three children, infant age 2 months)

Peer support

Mothers also talked about how crucial it is to have friends who are supportive of them when they are breastfeeding. In this instance, a mother narrated how her close friend supported her: “but there is this good friend of mine who knows my status and she always encourage me when I feel low or if I need someone to talk to, then I am open to her.” (39, married, two children, infant age 5 months). In other instances, mothers mentioned neighbours who support them while nursing their young babies. One mother explained how her neighbours demonstrated tangible support by assisting her to deliver at home. She recounted the compassion she received from her social circle, emphasizing the positive impact of a supportive community for pregnant and breastfeeding mothers.

Healthcare providers

Overall, the mothers expressed gratitude for the support they received from healthcare providers, which included encouragement, counselling, proactive follow-up for upcoming clinic appointments, and even financial support when mothers faced challenges.

When we come for our children’s clinic and there is a personal challenge someone is going through, like stress, the doctors are always ready and willing to counsel us, which is such a big kind of support. In addition, when a mother is challenged to attend clinics due to financial constraints, the hospital sometimes follows up and ensures they send the mother something small to facilitate her transport to the hospital. (32, married, three children, infant age 5 months)

Mothers described the comfort and confidence they felt in turning to the healthcare providers in that health facility for help when facing challenges. Their appreciation signified a strong sense of confidence and trust in the hospital’s ability to offer them assistance and care. One key area of appreciation was the role the hospital plays in making antiretroviral drugs (ARVs) easily accessible, among other services.

I can say that we are supported at the hospital by receiving our medications, we also receive guidance and counselling, and the services here are professional. (33, married, three children, infant age 5 months)

These narratives highlight how support from family, peers, and healthcare providers not only eased the challenges of breastfeeding while living with HIV but also strengthened mothers’ confidence and reinforced their trust in available health services.

Tough economic realities

Throughout interviews, mothers elaborated on how tough economic realities, including the high cost of living and food insecurity, both shaped their diets and deeply impacted their infant feeding behaviours.

High cost of living

Mothers faced financial challenges, compounded by their unemployment status, highlighted in Table 1. One mother lamented, “Life has been tough with the high cost of living, which demands a lot than I can afford.” (36, single, six children, infant age 4 months). Yet another mother expressed distress over her lack of formal employment and its impact on her ability to be with her baby, stating,

According to this tough economy we are living in, you cannot sit every day in the house without doing something to earn a living. This life will force you to seek casual jobs, and you cannot go everywhere with the baby. (26, married, three children, infant age 2 months)

The impact of economic strain on breastfeeding practices was evident in such examples.

Food insecurity

A major issue highlighted by mothers was the interconnection between food insecurity and breastmilk production. Acknowledging the role of sufficient nutrition for breastfeeding mothers, the participants outlined how challenges caused by a lack of food negatively affected their desire to breastfeed.

My breastfeeding experience has not been easy due to a lack of food. I remember visiting my neighbours during mealtime just to eat with them or drink tea at their house to help me with breastmilk. (42, widowed, eight children, infant age 4 months)

Sometimes we lack food to eat at home…this situation obviously affects my breastmilk production. If I don’t have access to enough food, then I should not expect to have enough breastmilk for my baby. (36, married, three children, infant age 3 months)

These testimonies demonstrate the direct impact that food shortages and financial difficulty have on mothers’ capacity to continue EBF, establishing a connection between family economic reality and the nutritional status of mothers and the feeding outcomes of their infants.

Mixed maternal attitudes

Analyzed together, we found that different attitudes regarding EBF in the context of HIV were influenced by the other themes of conflicting knowledge(s), socioeconomic conditions, and the mother’s personal breastfeeding experiences. Some mothers maintained a positive attitude towards practicing EBF despite their HIV status, emphasizing the importance of adhering to infant feeding guidelines.

If a breastfeeding mother adheres to the given instructions, then nothing bad will happen to their children. I have seen so many HIV-positive women raising HIV-negative children out here. (39, married, two children, infant age 5 months)

Conversely, some mothers held more ambivalent attitudes towards EBF, citing the challenges associated with the practice. Concerns about insufficient breastmilk and the difficulty of sustaining EBF for the recommended period influenced their perspectives. One mother explained,

It is difficult to breastfeed a baby for a whole six months…what if someone doesn’t have enough breastmilk? To be honest, that practice is difficult. (33, married, three children, infant age 5 months)

Such challenges, while common for many mothers, held deeper consequences in this context for women living with HIV; any difficulty maintaining EBF could heighten fears of HIV transmission and expose them to stigma or suspicion from their communities.

Other mothers’ attitudes towards EBF were more pragmatic. For instance, one mother emphasised the need for empathy and individualized support regarding the trust relationship between mothers and health workers. She noted,

Sometimes, doctors should not force breastfeeding mothers to adhere to the recommended guidelines if they are not ready. They should always have consideration by allowing a mother to decide what she wants to practice. In addition, forcing a mother to practice EBF might not be helpful because this mother will not be honest when asked what she is feeding her baby. (42, widowed, three children, infant age 6 months)

Overall, these perspectives illustrate the range of maternal attitudes toward EBF in the context of HIV, ranging from committed adherence to ambivalence or pragmatism, highlighting the need for flexible, empathetic support that respects mothers’ lived realities.