Making the choice: The translation of global HIV and infant feeding policy to local practice among mothers in Pune, India

In 2003, India had over 5.1 million infected individuals living with HIV/AIDS. The percentage of all HIV cases attributed to perinatal transmission has been increasing steadily from 0.33% of total cases in 1999 to 2.80% in 2004. Recent statistics indicate that over 130,000 infants have been infected through this route. Despite recent advances in reducing in utero and interpartum transmission with the use of antiretrovirals, there is a critical need to make infant feeding safer. Current UNAIDS/WHO/UNICEF recommendations stress avoidance of all breastfeeding if replacement feeding fulfills the key requirements of being affordable, feasible, acceptable, sustainable, and safe. In this paper, we examine how the UNAIDS/WHO/UNICEF recommendations have been actualized within the context of an urban government hospital in India. The documented patterns of infant feeding by HIV-positive mothers in Pune, India, from 2000 to 2004, highlight the complexities of making an informed and healthy choice under suboptimal conditions. The data indicate that interpersonal variations in the key requirements greatly influence the optimal practice to minimize mortality risks. Moreover, local information on health outcomes is crucial to tailoring policy recommendations to save lives. We propose the development of a decision-making algorithm that includes factors affecting mother-to-infant transmission, including site-specific data on health risks to the mother and the child. Such an algorithm would allow identification of the healthiest feeding choice and would minimize the pitfalls of promoting homogeneous practices lacking site-specific evidence-based evaluation.