1.1 Background of the study  

The fact that formula feeding can be difficult to achieve in resource poor settings, coupled with breastfeeding’s recorded benefits for preventing malnutrition and serious infectious diseases, has resulted in exclusive breastfeeding being recommended by WHO for women living with HIV in resource poor settings provided they have access to ART. Formula feeding is recommended for women living with HIV in countries in high resource settings (Ngoma-Hazemba and Ncama, 2016; WHO, 2016). The fact that advice for women is different in low and high resource settings has led to a certain amount of confusion about the best approach to breastfeeding for women living with HIV(Ngoma-Hazemba and Ncama, 2016)One study from Malawi reported that while the majority of mothers chose to exclusively breastfeed because “that’s the advice they give to HIV-positive women”, most mothers reported mixed feeding in the first six months. A number of reasons were given for this including traditional feeding practices, a poor understanding of what exclusive breastfeeding involves, as well as poor communication about why women should exclusively breastfeed (Levy, 2010).Research from Tanzania compared two hospitals that offered different infant feeding options. Hospital A promoted exclusive breastfeeding as the only infant feeding option, while hospital B followed Tanzanian PMTCT infant feeding guidelines which promote patient choice. Women in hospital A trusted the advice given and were confident in their ability to exclusively breastfeed, whereas women in hospital B expressed confusion and uncertainty about how to best feed their infants (Vaga, 2014).In a study carried out in Jos, Nigeria, it was revealed that women who primarily gave formula milk complained of family pressure as their reason for breastfeeding (Sheela, Pam, Dilhatu, Edwina, Buki and Anuri, 2015). In Zaria, mothers that practiced formula feeding complained of feelings of anger and guilt as well as inadequacy for not being able to play their motherly role of breast-feeding their babies. They also complained of high cost of formula, the fear of stigmatization and social discrimination. These often force them to breast-feed (Musa, Muktar and Adulkadir, 2016). Factors that supported formula feeding include active coping ability, disclosure of status to spouse or important family members, household income, educational status of mother, occupation of mother and mode of delivery especially by caesarian section (Yetayesh and Jemal, 2014).

1.2 Statement of the Problem

The effectiveness of exclusive breastfeeding among HIV exposed infants is still unclear. There are numerous controversial and ethical issues surrounding this intervention. Through postnatal experience, some health care professionals do not approve of exclusive breastfeeding in HIV cases due to reported high transmission rates; as a result they fail to reinforce exclusive breastfeeding when it is applicable. Mothers are exposed to the HIV stigma if they do not breastfeed, as there is an assumption that the mother is HIV positive, while in other cases women suffer the abuse of family members, especially from male family members. Most women lack information on the effectiveness of exclusive breastfeeding in HIV exposed infants. Exclusive breastfeeding is considered the best feeding option in poorly resourced communities where formula feeding is not feasible, unacceptable, unsafe, not sustainable and unaffordable. An extensive literature search has shown that exclusive breastfeeding reduces other significant risks, such as increased diarrhoea and pneumonia morbidity and mortality (Thior et al., 2006:1-13: Newell 2004:5). Exclusive breastfeeding with antiretroviral prophylaxis is associated with less than 5% HIV transmission. In the MITRA Plus trial from Tanzania, ART and breastfeeding was associated with a cumulative transmission at six months of only 5.0% (less than 1% had been infected during the period of breastfeeding) (Kilewo, Karlsson, Ngarina, Massawe, Lyamuya et al., 2008:1). The AMATA study in Rwanda, found that only one out of 174 (0.6%) breastfeeding women on maternal Highly Active Antiretroviral Therapy transmitted HIV to her infant (Peltier, Ndayisaba, Lepage, Griensven, Leroy et al., 2009:2415). Coovadia et al., (2007:1107) conducted a study in Durban, South Africa and found that mixed feeding was associated with an increased HIV transmission rate, while exclusive breastfeeding had a lower transmission rate. This influenced the revision of the present UNICEF, WHO and UNAIDS infant feeding guidelines. Exclusive formula feeding has a 0% HIV transmission rate but the rate of mortality from causes other than HIV is higher (Peltier et al., 2009:2415). Despite HIV infection via breastfeeding in HIV exposed infants, breastmilk has been proved to be a cost effective intervention and is associated with good maternal and child health.