Evaluating infant feeding practice guidelines for individuals with HIV: a pilot study using qualitative findings with healthcare workers and normalization process theory
Frontiers in Reproductive Health
Authors: Julia López, Elaine Schmidt, Kneeshe Parkinson, Virginia McKay, Sydney M. Thayer & Amanda Zofkie
This study examined how healthcare workers understand and implement updated U.S. guidelines regarding breastfeeding/chestfeeding among people living with HIV. In 2023, WHO and CDC guidelines shifted from generally discouraging breastfeeding/chestfeeding to supporting shared decision-making for individuals who maintain sustained viral suppression, reflecting advances in antiretroviral therapy (ART), patient autonomy, and a growing emphasis on equitable, patient-centered HIV care. Despite this policy shift, implementation in clinical settings remains inconsistent.
The research team conducted 10 semi-structured interviews with healthcare workers in Missouri and Kansas, including OB-GYNs, pediatric and adult infectious disease providers, nurses, and disease intervention specialists. Interviews were analyzed using Normalization Process Theory (NPT), which examines how new practices become understood, accepted, integrated, and evaluated within healthcare systems.
Participants generally viewed the updated guidelines as evidence-based and supported their underlying principles. However, implementation varied across clinical roles. OB-GYN providers tended to emphasize reproductive autonomy and informed choice, while infectious disease and pediatric providers more often prioritized minimizing the risk of vertical HIV transmission. Uncertainty about viral-load thresholds and limited practical guidance also contributed to differences in clinical decision-making.
The study identified several important barriers to consistent implementation, including inconsistent provider training, fragmented communication between OB-GYN and pediatric teams, geographically separated services, and structural challenges affecting patients, such as insurance instability, transportation, childcare, and the additional monitoring associated with breastfeeding/chestfeeding while living with HIV. Institutional leadership, interdisciplinary collaboration, and clinical champions were identified as important facilitators.
The authors conclude that successfully implementing updated HIV infant-feeding guidelines requires more than disseminating recommendations. Clearer practical guidance, stronger interdisciplinary coordination, consistent provider education, and care models that address patients’ structural circumstances will be essential to ensuring that shared decision-making is implemented consistently and equitably. The study provides an important foundation for developing tools to support clinicians and patients navigating infant-feeding decisions in the context of HIV.