Breastfeeding and HIV: experiences from a decade of prevention of postnatal HIV transmission in sub-Saharan Africa.

Infant feeding by HIV-infected mothers has been a major global public health dilemma and a highly controversial matter. The controversy is reflected in the different sets of WHO infant feeding guidelines that have been issued over the last two decades. This thematic series, 'Infant feeding and HIV: lessons learnt and ways ahead' highlights the multiple challenges that HIV-infected women, infant feeding counsellors and health systems have encountered trying to translate and implement the shifting infant feeding recommendations in different local contexts in sub-Saharan Africa. As a background for the papers making up the series, this editorial reviews the changes in the guidelines in view of the roll out of prevention of mother to child transmission (PMTCT) programmes in sub-Saharan Africa between 2001 and 2010.

Reflections on global policy documents and the WHO's infant feeding guidelines: lessons learnt.

As the papers in this thematic series have illustrated, the postnatal prevention of mother to child transmission of HIV (PMTCT) strategy has struggled with lack of local relevance. In an attempt to increase our understanding of the great dissonance between the policy intention and the experiences of the participants in concrete PMTCT programmes, we will in these concluding remarks draw upon writings in institutional ethnography. Through the concept of 'global texts' we reflect upon the scientific and ideological underpinnings of the WHO policy guidelines on HIV and infant feeding, and the influence that this policy has had across multiple local settings. The particular impact of the global postnatal PMTCT policy guidelines on the position of breastfeeding lies at the core of the discussion.

Ways ahead: protecting, promoting and supporting breastfeeding in the context of HIV.

The HIV epidemic coupled with the assumed benefits of infant formula for the children of all HIV-infected mothers have in complex ways changed public ideas about infant feeding and represents a threat to well established breastfeeding practices. In the wake of the confusion that postnatal prevention of mother to child transmission of HIV (PMTCT) interventions have created among HIV-infected mothers, infant feeding counsellors and the public at large, it is time to reinstate the principles of the Innocenti Declaration to protect, promote and support breastfeeding in the context of HIV. The challenge that lies ahead is a search for ways to restore the trust in breastfeeding as the normal and safest way to feed an infant. This requires continued research as well as concerted advocacy and action.