After the withdrawal of ‘informed choice’: the meanings and social effects of mothers' choice for HIV prevention in Senegal

Abstract

To prevent HIV transmission through breastfeeding, African health services in 1998 implemented the World Health Organization's approach of ‘informed choice’ when recommending infant feeding options to HIV-positive mothers. In 2010, ‘informed choice’ was withdrawn in favour of antiretroviral prophylaxis with breastfeeding. A 2010–11 ethnographic study conducted in Senegal among HIV-positive mothers revealed three broad responses to the withdrawal of choice and formula provision: ‘resistance’ from association members claiming the health system was responsible for providing formula to ensure efficient prevention; ‘compliance’ among mothers adopting ‘protected breastfeeding’ without complaints; and ‘self-reliance’ among women trying to obtain formula through other means without mentioning choice. These three responses shed light on the meanings attributed to choice and on the social impact of formula provision during the ‘informed choice era.’ The analysis shows that the top-down introduction of ‘informed choice’ as an ethical and management imperative was appropriated and re-signified locally, making space for new forms of sociality within medical and associative social spaces. These social forms could not easily be maintained after the withdrawal of formula provision; women who continue to exert choice do so silently. By focusing on the upheaval of social care arrangements after the introduction of prophylaxis by pharmaceuticals, this paper sheds light on the understudied local consequences of changes in public health policies and the social framing of ‘choice’ in low-income countries' health systems.

Keywords:

• PMTCT
• HIV
• Senegal
• informed choice
• women's strategy
• women's agency

Acknowledgements

The author thanks participants, and health care and associative teams in Centre de Recherche et de Formation (CRCF), Hôpital de Fann, in Dakar (Senegal) who helped with this research. The author would like to thank Takeo David Hymans for editorial work on a draft version of this paper. This work was supported by the Agence Nationale (France) de Recherches sur le Sida et les hépatites virales (ANRS): Grant ANRS 1215/12271. Ethical clearance was provided by the Comité National d'Ethique pour la Recherche en Santé du Sénégal. No conflict of interest.

Notes

1. The study was part of a multi-disciplinary research project on the ‘Evaluation of the bioclinical, social, individual and collective impact of antiretroviral treatment in a cohort of HIV-1 patients in Dakar, Senegal (ANRS 1215).’

2. The MTCT rate of HIV was about 5–10% under previous recommendations in Africa.

3. Oxford English Dictionaries on-line.http://oxforddictionaries.com/definition/english/choice?region=uk&q=choice

4. Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (1990) www.unicef.org/nutrition/index_24807.html

5. For a more complete description, see Desclaux (2011).

6. For fathers’ involvement in PMTCT in Senegal, see Sambou (2012).

7. 27,000 FCFA/52,000 FCFA, i.e. US$54 /US$104.