Public Health Nutrition: 12(11), 1983–1990 doi:10.1017/S1368980009005199 Mothers’ infant feeding experiences: constraints and supports for optimal feeding in an HIV-impacted urban community in South Africa Lindiwe Sibeko 1 , Anna Coutsoudis 2 , S’phindile Nzuza 2 and Katherine Gray-Donald 1, * 1 School of Dietetics and Human Nutrition, McGill University, 21,111 Lakeshore Road, Ste. Anne de Bellevue, Quebec, Canada, H9X 3V9: 2 University of KwaZulu-Natal, Department of Paediatrics & Child Health, Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, 710 Umbilo Road, Durban 4001, South Africa Submitted 14 November 2007: Accepted 7 January 2009: First published online 27 March 2009 Abstract Objective: To better understand the enabling and challenging factors impacting on infant feeding practices in communities with a high HIV prevalence. Design: Qualitative study, with data collected through in-depth interviews and observations of mothers, in addition to discussions with health-service providers. Setting: Urban settlement in the province of KwaZulu-Natal, South Africa. Subjects: Mothers recruited from an HIV clinic and from within the community. Results: Emerging from discussions with mothers on the acceptability of alter- native feeding methods were the challenges they encountered in feeding their infants. Mothers readily identified feeding in the context of HIV infection as an issue of great concern, encompassing three central themes: (i) stigma and dis- closure of HIV; (ii) confusion and coercion; and (iii) diarrhoea, sickness and free formula. It became evident that mothers rarely received quality infant feeding counselling and consequently mixed feeding, a widespread practice but one that is highly risky for HIV transmission, remained a common feeding practice. Exclusive breast-feeding (EBF) was best practised with support, following dis- closure of HIV status. Availability of free formula did not guarantee exclusive formula feeding but instead led to inappropriate feeding practices. Conclusions: In addition to providing accurate information, health-care workers must be empowered to counsel mothers effectively, addressing issues of dis- closure and thereby facilitating mobilization of maternal support networks. These findings illustrate the challenges that exist in policy translation within the context of quality of training for health-care workers on optimizing maternal infant feeding practices, particularly in HIV-prevalent, resource-poor settings. Keywords HIV Infant feeding practices Exclusive breast-feeding Stigma and disclosure Qualitative data South Africa The African continent is home to approximately 22 mil- lion adults and children living with HIV/AIDS (1) , sub- stantially burdening an already marginalized region of the world to bear the brunt of the global HIV epidemic. Furthermore, by the end of 2006, paediatric infections accounted for an estimated 2?3 million of the world’s children living with HIV, 90 % of whom are infected through vertical transmission of the virus (2) . An estimated 280 000 South African children under 15 years of age live with HIV (1) , the majority infected through mother-to-child transmission (MTCT). Hence, on a national level, pre- vention of MTCT (PMTCT) is considered a public health concern of high priority. Non-exclusive breast-feeding is associated with the infection of about 300 000 children annually (3) ; however, breast-feeding in resource-poor countries is a powerful child survival tool with the potential of preventing an esti- mated 13 % of child deaths from malnutrition and non-HIV common childhood infections (4) . Substantial evidence now exists illustrating the role of exclusive breast-feeding (EBF) in minimizing transmission risk of HIV while promoting child health, resulting in greater HIV-free child survival (5–7) . Recently, an African-based prospective study with feeding data on 1276 infants found a low transmission risk (4 %) following 6 months of EBF, with mortality at 3 months more than double in formula-fed babies compared with EBF infants (8) . Although infant formula is the recommended feeding option for HIV-positive mothers in developed countries (9) , this is rarely feasible or a preferred choice for women living in resource-poor communities due to the prohibitive cost of formula, lack of safe water, lack of infrastructure to ensure *Corresponding author: Email katherine.gray-donald@mcgill.ca r The Authors 2009