Evaluating infant feeding practice guidelines for individuals with HIV: a pilot study using qualitative findings with healthcare workers and normalization process theory

Introduction: In 2023, the WHO and CDC updated HIV infant feeding guidelines, emphasizing the role of antiretroviral therapy (ART) in reducing breastfeeding/chestfeeding transmission risk among birthing people living with HIV (BPLWH). Despite this update, clinical integration remains inconsistent, shaped by provider knowledge, bias, patient engagement, and systemic barriers. Materials & methods: Between August 2025 and January 2026, we conducted 10 semi-structured, in-depth interviews with healthcare workers (HCWs) to assess their understanding of and engagement with updated HIV breastfeeding/chestfeeding guidelines. The Normalization Process Theory (NPT) informed the development of the interview guide and the thematic analysis. Transcripts were double-coded in Dedoose and thematic analysis was conducted deductively. Results: Healthcare workers generally accepted the guidelines as evidence-based, but their implementation varied across the four NPT constructs. While the guidelines were seen as logically coherent, OB-GYNs highlighted reproductive autonomy, whereas infectious disease and pediatric providers prioritized infant HIV susceptibility. Uncertainty about viral load thresholds led to variability among providers. Ethical motivation strongly supported implementation, but inconsistent training and low patient volumes reduced confidence. Institutional leaders and interdisciplinary workflows were identified as vital facilitators. Major obstacles included fragmented OB-GYN-to-pediatrics handoffs, services located in different areas, and structural patient burdens such as monitoring requirements and insurance issues, which the guidelines did not specifically address. Discussion: Systematically identifying how new breastfeeding/chestfeeding practices become embedded in healthcare among HCWs, and assessing where knowledge gaps, misunderstandings, and engagement barriers exist regarding the guidelines, will inform the development of a decision-making guide to enhance implementation of HIV breastfeeding/chestfeeding guidelines for pregnant people.