From 'half-dead' to being 'free': resistance to HIV stigma, self-disclosure and support for PMTCT/HIV care among couples living with HIV in Kenya

Navigating cultural and gender aspects of stigma among women living with HIV in Vietnam

Women living with HIV often face intersecting challenges of stigma and gender inequality. In Vietnam, this issue is potentially exacerbated by the patriarchal culture. From December 2021 to March 2022, we conducted in-depth interviews with 30 women living with HIV in Hanoi to better understand their experiences and the coping mechanisms to navigate HIV stigma, cultural beliefs and gender norms. The interviews explored various topics including women's social and family roles in Vietnam, HIV-related beliefs, stigma and its impact on one's health and coping strategies. Participants reported stereotypes that assumed that women living with HIV had either engaged in sex work or behaved promiscuously. These stereotypes render them vulnerable to judgement and discrimination owing to widespread expectations of female virtue. As a result, women living with HIV often enacted non-disclosure and self-isolation to avoid stigma. This self-stigmatisation negatively impacted their healthcare-seeking, employment opportunities and ability to fulfil traditional family-caring roles. Conversely, many participants exhibited resilience with the support of family and peers. Overall, the complex interplay between gender, culture and HIV stigma underscores the importance of developing culturally appropriate, multifaceted approaches to engaging family and peers, modifying gender-based discriminatory social practices and enhancing women's self-efficacy and empowerment in Vietnam.

Experiences of, and motivations for, disclosing HIV to social and familial networks: considering the social and relational domains of HIV disclosure

For people living with HIV, decisions about when, how and who to tell about their HIV status can involve navigating complex social, legal and health domains. With a focus on disclosure to broader social and familial networks, we explored the experiences of, and motivations for, HIV (non-)disclosure among recently diagnosed people living with HIV in Australia. Semi-structured interviews were conducted with 35 people diagnosed with HIV from 2016 onwards, of whom 25 completed follow-up interviews. Participants commonly reported anticipating negative responses and rejection from others when considering whether to disclose their HIV status. Some participants also took on the role of ensuring others' wellbeing when disclosing (or not), even as they themselves needed emotional support. Finally, some participants felt it important to be open about their HIV status to raise awareness of HIV and challenge HIV-related stigma. Our findings highlight the complex relational and social contexts that shape HIV disclosure. In addition to supporting individual people living with HIV when disclosing, we argue that educational programmes that target the broader, HIV-negative population are needed to shift the social landscape in which people living with HIV disclose.

Supportive couple relationships buffer against the harms of HIV stigma on HIV treatment adherence

INTRODUCTION

HIV stigma can impact couple relationships through stress or bring partners closer through shared experiences. Conversely, couple relationships may protect against the harms of stigma, including anticipated stigma on negative health outcomes. Yet few studies have assessed the potential link between HIV stigma, relationship dynamics, and antiretroviral therapy (ART) adherence. Using dyadic data from a cross-sectional study of Malawian couples living with HIV, we tested associations between anticipated stigma and: 1) relationship dynamics (e.g., trust, sexual satisfaction, communication) and partner support; and 2) self-reported ART adherence.

METHODS

Heterosexual couples (211 couples, 422 individuals) with at least one partner on ART were recruited from clinics in Zomba, Malawi. Partners completed separate surveys on anticipated stigma, relationship dynamics, and ART adherence. Linear mixed models evaluated associations between anticipated stigma and relationship dynamics, and whether associations varied by gender. Generalized estimating equation models tested for associations between anticipated stigma and high ART adherence (90-100% vs. < 90%) at the individual level, and whether they were moderated by relationship dynamics at the couple level.

RESULTS

Couples' relationship length averaged 12.5 years, 66.8% were HIV sero-concordant, and 95.6% reported high ART adherence. In multivariable models, sexual satisfaction (β = -0.22, 95%CI = -0.41;-0.03, p = 0.020) and partner social support (β = -0.02, 95%CI = -0.04;-0.01, p < 0.01) were negatively associated with anticipated stigma. Significant interaction effects showed that adherence is moderated in couples with higher partner support and sexual satisfaction such that adherence is lowest when anticipated stigma is high and social support is low, and that adherence is lowest when anticipated stigma is high and sexual satisfaction is low.

CONCLUSIONS

Increased anticipated stigma is most associated with lower ART non-adherence at lower levels of social support and sexual satisfaction. Conversely, supportive and fulfilling relationships may buffer the negative association between stigma and ART adherence. Couples' interventions that focus on improving communication and support systems within couples could reduce the negative impacts of anticipated stigma on couples living with HIV.

Intersectional Stigma and Implementation of HIV Prevention and Treatment Services for Adolescents Living with and at Risk for HIV: Opportunities for Improvement in the HIV Continuum in Sub-Saharan Africa

Adolescents in sub-Saharan Africa, specifically adolescent girls and young women, young men who have sex with men, transgender persons, persons who use substances, and adolescents experiencing homelessness experience intersectional stigma, have a high incidence of HIV and are less likely to be engaged in HIV prevention and care. We conducted a thematic analysis informed by the Health and Discrimination Framework using a multiple case study design with five case studies in 3 sub-Saharan African countries. Our analysis found commonalities in adolescents' intersectional stigma experiences across cases, despite different contexts. We characterize how intersectional stigma impacts the uptake and implementation of HIV prevention and treatment services along the continuum for adolescents. Findings reveal how intersectional stigma operates across social-ecological levels and worsens HIV-related outcomes for adolescents. We identify opportunities for implementation science research to address stigma-related barriers to the uptake and delivery of HIV services for adolescents in sub-Saharan Africa.

Antiretroviral therapy and aging as resources for managing and resisting HIV-related stigma in rural South Africa

The widespread roll-out of antiretroviral therapy (ART) in Africa has contributed to a large population of adults aging with HIV. However, little is known about how HIV-related stigma interacts with aging in the ART era. This study uses in-depth interviews with middle-aged and older South Africans living with HIV to explore stigma-related experiences and response strategies. Participants describe a persistence of stigma which requires the deployment of a range of common and age-based stigma management and resistance strategies. We find that participants minimize their exposure to stigma through selective disclosure of their HIV status; neutralize HIV-related stigma through comparisons to chronic illnesses common among older adults, and deflect stigma through asserting an ART-adherent identity and othering younger non-adherent adults. Overall, our study highlights the roles of ART and aging as resources for managing and resisting HIV-related stigma.

The effect of weekly interactive text-messaging on early infant HIV testing in Kenya: a randomised controlled trial (WelTel PMTCT)

Mother-to-child transmission of HIV remains a significant concern in Africa despite earlier progress. Early infant diagnosis (EID) of HIV is crucial to reduce mortality among infected infants through early treatment initiation. However, a large proportion of HIV-exposed infants are still not tested in Kenya. Our objective was to investigate whether weekly interactive text-messages improved prevention of mother-to-child transmission (PMTCT) of HIV care outcomes including EID HIV testing. This multicentre, parallel-group, randomised, open-label trial included six antenatal care clinics across western Kenya. Pregnant women living with HIV, aged 18 years or older, with mobile phone access, were randomised in a 1:1 ratio to weekly text messages that continued until 24 months postpartum, asking “How are you?” (“Mambo?”) to which they were asked to respond within 48 h, or a control group. Healthcare workers contacted participants reporting problems and non-responders by phone. Participants in both groups received routine PMTCT care. The prespecified secondary outcome reported in this paper is EID HIV testing by eight weeks of age (blinded outcome assessment). Final 24-months trial results will be published separately. We estimated risk ratios using Poisson regression with robust standard errors. Between June 2015–July 2016, we screened 735 pregnant women, of whom 600 were enrolled: 299 were allocated to the intervention and 301 to the control group. By eight weeks of age, the uptake of EID HIV testing out of recorded live births was 85.5% in the intervention and 84.7% in the control group (71.2% vs. 71.8% of participants randomised, including miscarriages, stillbirths, etc.). The intention-to-treat risk ratio was 0.99; 95% CI: 0.90–1.10; p = 0.89. The proportion of infants diagnosed with HIV was 0.8% in the intervention and 1.2% in the control group. No adverse events were reported. We found no evidence to support that the WelTel intervention improved EID HIV testing. A higher uptake of EID testing than expected in both groups may be a result of lower barriers to EID testing and improved PMTCT care in western Kenya, including the broader standard use of mobile phone communication between healthcare workers and patients. (ISRCTN No. 98818734. Funded by the European-Developing Countries Clinical Trial Partnership and others).

Testing for saturation in qualitative evidence syntheses: An update of HIV adherence in Africa

Background

A systematic review of randomised trials may be conclusive signalling no further research is needed; or identify gaps requiring further research that may then be included in review updates. In qualitative evidence synthesis (QES), the rationale, triggers, and methods for updating are less clear cut. We updated a QES on adherence to anti-retroviral treatment to examine if thematic saturation renders additional research redundant.

Methods

We adopted the original review search strategy and eligibility criteria to identify studies in the subsequent three years. We assessed studies for conceptual detail, categorised as ‘rich’ or ‘sparse’, coding the rich studies. We sought new codes, and appraised whether findings confirmed, extended, enriched, or refuted existing themes. Finally, we examined if the analysis impacted on the original conceptual model.

Results

After screening 3895 articles, 301 studies met the inclusion criteria. Rich findings from Africa were available in 82 studies; 146 studies were sparse, contained no additional information on specific populations, and did not contribute to the analysis. New studies enriched our understanding on the relationship between external and internal factors influencing adherence, confirming, extending and enriching the existing themes. Despite careful evaluation of the new literature, we did not identify any new themes, and found no studies that refuted our theory.

Conclusions

Updating an existing QES using the original question confirmed and sometimes enriched evidence within themes but made little or no substantive difference to the theory and overall findings of the original review. We propose this illustrates thematic saturation. We propose a thoughtful approach before embarking on a QES update, and our work underlines the importance of QES priority areas where further primary research may help, and areas where further studies may be redundant.

Undisclosed HIV Status to Sex Partners and Its Unintended Consequences in the Era of Undetectable = Untransmittable

BACKGROUND

Adherence to antiretroviral therapy (ART) and sustained HIV suppression virtually eliminate HIV transmission, eg, having an undetectable viral load renders HIV untransmittable (U=U). Owing to the greatly reduced likelihood of HIV transmission when viral load is undetectable, we studied one behavioral ramification of adopting a U=U prevention strategy-not disclosing HIV status to sex partners.

SETTING

Cisgender men recruited through community outreach in the state of Georgia, USA.

METHODS

We examined HIV status disclosure to sex partners among 345 young (median age = 29 years) men receiving ART. Data were collected using computerized interviews, daily sexual behavior surveys over 28 days, unannounced pill counts for ART adherence, urine tests for drug use and urogenital health, and blood samples for HIV viral load.

RESULTS

One in 3 participants (34%) engaged in condomless anal/vaginal intercourse with an HIV-negative/unknown HIV status partner over 28 days. Average ART adherence was 76%, and one in 5 men had detectable HIV viral loads. Men who engaged in condomless sex with undisclosed partners demonstrated significantly less HIV disclosure to family and friends and had fewer enacted stigma experiences. Hierarchical regression models showed that endorsing U=U as a personal HIV prevention strategy predicted undisclosed condomless sex over and above substance use, HIV stigma experiences, disclosure to family and friends, ART adherence, and HIV viral load.

CONCLUSIONS

Interventions are needed to improve ART adherence and assist men living with HIV in their decisions to disclose HIV status to sex partners.

Designing a couple-based relationship strengthening and health enhancing intervention for pregnant women living with HIV and their male partners in Zambia: Interview findings from the target community

INTRODUCTION

Interpersonal support can promote positive outcomes among people living with HIV. In order to develop an acceptable psychoeducational couples-based intervention aimed at strengthening the relationship context and improving HIV outcomes before and after pregnancy, we conducted qualitative interviews with pregnant women living with HIV and their male partners.

METHODS

We interviewed a convenience clinic-based sample of pregnant women living with HIV (n = 30) and male partners (n = 18) in Lusaka, Zambia. Interviews included pile sorting relationship topics in order of perceived priority. Interviews also focused on family health concerns. Interviews were audio-recorded, translated, transcribed, and thematically analyzed. Pile sorting data was analyzed using descriptive statistics.

RESULTS

All female participants were living with HIV; 61% of the male partners interviewed were additionally living with HIV. The most prioritized relationship topic among both genders was communication between couples. Honesty and respect were important relationship topics but prioritized differently based on gender. Female participants considered emotional and instrumental support from male partners critical for their physical and mental health; men did not prioritize support. Intimate partner violence was discussed often by both genders. Family health priorities included good nutrition during pregnancy, preventing infant HIV infection, safe infant feeding, sexual health, and men's alcohol use.

CONCLUSIONS

A major contribution of this study is a better understanding of the dyad-level factors pregnant women living with HIV and their male partners perceive to be the most important for a healthy, well-functioning relationship. This study additionally identified gaps in antenatal health education and the specific family health issues most prioritized by pregnant women living with HIV and their male partners. The findings of this study will inform the development of an acceptable couples-based intervention with greater likelihood of efficacy in strengthening the relationship context and promoting family health during and after pregnancies that are affected by HIV.

Perceived Stigma as a Contextual Barrier to Early Uptake of HIV Testing, Treatment Initiation, and Disclosure; the Case of Patients Admitted with AIDS-Related Illness in a Rural Hospital in South Africa

We explored the extent to which perceived HIV-related stigma influences the disclosure and concealment of HIV status to family among adult patients hospitalised for AIDS-related illness, and described reports of negative responses and enacted stigma following disclosure. We conducted interviews with a purposeful sample of 28 adult patients in a rural South African hospital. Data analysis was deductive and inductive and followed the thematic approach. We found evidence of delayed HIV diagnosis and initiation of treatment. There was delayed and selective disclosure as well as concealment of the HIV-positive status. The disclosure was delayed for months or even years. During that time, there was active concealment of the HIV status to avoid stigma from family, friends, and community. When disclosure occurred, there was selective disclosure to close family members who would keep the secret and respond favorably. Although the participants disclosed mostly to close family, some of their post-disclosure experiences included incidents of enacted stigma and discrimination. The fear of perceived stigma and self-stigma influenced the active concealment of their HIV status from others. Continuous concealment of one's HIV status and delayed disclosure limit the opportunities for support and care. There is a need to take into consideration the interaction between HIV-related stigma and disclosure to develop disclosure-counselling strategies in primary health care settings.

Understanding the determinants and consequences of HIV status disclosure in Manicaland, Zimbabwe: cross-sectional and prospective analyses

Few longitudinal studies have measured trends and effects of disclosure over ART scale-up in general-population samples. We investigated levels, determinants and outcomes of disclosure to relatives and partners in a large general-population cohort in Zimbabwe. Trends in disclosure levels from 2003 to 2013 were analysed, and multivariable logistic regression was used to identify determinants. Longitudinal analyses were conducted testing associations between disclosure and prevention/treatment-related outcomes. Disclosure to anyone increased from 79% to 100% in men and from 63% to 98% in women from 2003 to 2008; but declined to 89% in both sexes in 2012-2013. More women than men disclosed to relatives (67.8% versus 44.4%; p < 0.001) but fewer women disclosed to partners (85.3% versus 95.0%; p < 0.001). In 2012-2013,secondary/higher education, being single, and experience of stigma were associated with disclosure to relatives in both sexes. Partner characteristics and HIV-group attendance were associated with disclosure to partners for women. Reactions to disclosure were generally supportive but less so for females than males disclosing to partners (92.0% versus 97.4%). Partner disclosure was weakly associated (p < 0.08) with having had a CD4 count or taken ART at follow-up in females. To conclude, this study shows disclosure is vital to HIV prevention and treatment, and programmes to facilitate disclosure should be re-invigorated.

Complexities of HIV Disclosure in Patients Newly Entering HIV Care: A Qualitative Analysis

The role of HIV disclosure and its influence on engagement in HIV care after initial linkage to care is not well understood. We conducted 28 in-depth interviews with patients newly entering HIV care. Gaining access to social support was a key reason that many patients disclosed their HIV status. For some, HIV disclosure improved support networks related to engagement in care at the time of care entry, in the form of appointment reminders, emotional support, and confidence to disclose more widely. However, some participants cited anticipated stigma as a barrier to disclosure, as they feared rejection or further disclosure without their permission. Early access to social support and skill building related to stigma reduction and coping can be useful resources to help patients manage HIV, as they initiate care. In addition, incorporating support for smart disclosure decisions into interventions may improve access to social support, ultimately improving engagement in care.

Support or control? Qualitative interviews with Zambian women on male partner involvement in HIV care during and after pregnancy

BACKGROUND

Efforts to promote male partner involvement in the prevention of mother-to-child transmission (PMTCT) may inadvertently exploit gender power differentials to achieve programme targets.

METHODS

We explored women's relative power and perceptions of male partner involvement through interviews with postpartum Zambian women living with HIV (n = 32) using a critical discourse analysis.

RESULTS

Women living with HIV reported far-reaching gender power imbalances, including low participation in household decision-making, economic reliance on husbands, and oppressive gendered sexual norms, which hindered their autonomy and prevented optimal mental and physical health during and after their pregnancy. When the husband was HIV-negative, sero-discordance exacerbated women's low power in these heterosexual couples. Male involvement in HIV care was both helpful and hurtful, and often walked a fine line between support for the woman and controlling behaviours over her. Inequities in the sexual divisions of power and labour and gender norms, combined with HIV stigma created challenging circumstances for women navigating the PMTCT cascade.

CONCLUSIONS

Future programmes should consider the benefits and risks of male partner involvement within specific relationships and according to women's needs, rather than advocating for universal male involvement in PMTCT. This work highlights the persistent need for gender transformative approaches alongside PMTCT efforts.

Social concerns related to HIV status disclosure and participation in the prevention of mother-to-child transmission of HIV care among pregnant women in Kenya

Background

Social concerns about unintentional HIV status disclosure and HIV-related stigma are barriers to pregnant women’s access to prevention of mother-to-child transmission of HIV (PMTCT) care. There is limited quantitative evidence of women’s social and emotional barriers to PMTCT care and HIV disclosure. We aimed to investigate how social concerns related to participation in PMTCT care are associated with HIV status disclosure to partners and relatives among pregnant women living with HIV in western Kenya.

Methods

A cross-sectional study, including 437 pregnant women living with HIV, was carried out at enrolment in a multicentre mobile phone intervention trial (WelTel PMTCT) in western Kenya. Women diagnosed with HIV on the day of enrolment were excluded. To investigate social concerns and their association with HIV disclosure we used multivariable-adjusted logistic regression, adjusted for sociodemographic and HIV-related characteristics, to estimate odds ratios (OR) and 95% confidence intervals (CI).

Results

The majority (80%) had disclosed their HIV status to a current partner and 46% to a relative. Older women (35–44 years) had lower odds of disclosure to a partner (OR = 0.15; 95% CI: 0.05–0.44) compared to women 18–24 years. The most common social concern was involuntary HIV status disclosure (reported by 21%). Concern about isolation or lack of support from family or friends was reported by 9%, and was associated with lower odds of disclosure to partners (OR = 0.33; 95% CI: 0.12–0.85) and relatives (OR = 0.37; 95% CI: 0.16–0.85). Concern about separation (reported by 5%; OR = 0.17; 95% CI: 0.05–0.57), and concern about conflict with a partner (reported by 5%; OR = 0.18; 95% CI: 0.05–0.67), was associated with lower odds of disclosure to a partner.

Conclusions

Compared to previous reports from Kenya, our estimated disclosure rate to a partner is higher, suggesting a possible improvement over time in disclosure. Younger pregnant women appear to be more likely to disclose, suggesting a possible decreased stigma and more openness about HIV among younger couples. Healthcare providers and future interventional studies seeking to increase partner disclosure should consider supporting women regarding their concerns about isolation, lack of support, separation, and conflict with a partner. PMTCT care should be organized to ensure women’s privacy and confidentiality.

'Your husbands are bringing it to you': South African rural women and HIV in Darrell Roodt's Yesterday (2004)

The ways in which rural women living with and/or affected by HIV are portrayed in films can potentially influence how social transformation is imagined, including the extent to which the women can be involved in problem-solving processes. This is because, in addition to conceptualising the problem, such representations often place women in a certain position in relation to, or within, the problematic situation, which in turn influences how solutions are framed. This paper uses a discursive approach to explore the portrayal of South African rural women living with and/or affected by HIV in Darrell Roodt's film, Yesterday (2004), which is set in rural KwaZulu-Natal. It considers how the film deals with the tension between structural violence and rural women's agency in grappling with HIV. Structural violence has a significant impact on the experiences of rural women and, hence, their health outcomes. However, when representing rural women, too heavy an emphasis on structural violence runs the risk of portraying them as passive or helpless victims, thus severely limiting their agency.

HIV-positive Mozambican migrants in South Africa: loneliness, secrecy and disclosure

South Africa continues to bear a heavy burden of HIV and a significant proportion of the nation's population consists of immigrants from other severely afflicted African nations. Yet little is known about how migrant populations respond to HIV in shifting cultural and clinical landscapes. Analysing 21 ethnographic life history interviews, this paper explores the social complexities of living with antiretroviral therapy and disclosure of serostatus among HIV-positive Mozambican migrants in Johannesburg. It focuses on (i) conceptualising the 'biosocial ambiance of illness'; (ii) how transformations occur in perceptions of disease; and (iii) how stigma produces an ambit of loneliness and secrecy, which inflects disclosure unevenly in different life-spaces and health-worlds. The net effect of these three processes is a silence which is detrimental to the social normalisation of HIV, treatment-seeking and clinical drug adherence, which in turn may increase rates of morbidity and mortality and contribute to drug resistance.

HIV status disclosure patterns and male partner reactions among pregnant women with HIV on lifelong ART in Western Kenya

Disclosure of HIV status to sexual partners in the context of prevention of mother-to-child transmission (PMTCT) may contribute to improved PMTCT outcomes. We administered a questionnaire to 200 women with HIV enrolled in a PMTCT study during pregnancy at 12 months after birth in Western Kenya between May-September 2017. Descriptive analysis of disclosure patterns and multivariate analysis of factors associated with male partner reactions is presented. Among 180 (90%) women who reported having a male partner, 95.5% reported disclosing their HIV status to that partner. The majority of women (82.8%) reported disclosure occurred within one year of their diagnosis, with 62.7% occurring within one week. The most common forms of disclosure were: self-disclosure (55.4%), during couple's HIV testing and counseling (CHTC) (31.5%), or at an antenatal care visit (7.7%). Most women (87.5%) reported that male partner reactions to their HIV status disclosure were positive. Those with negative reactions reported their partners were confused, annoyed, or threatened to leave, however there were no reports of intimate partner violence (IPV) or break ups. Disclosure via CHTC was associated with a positive male partner reaction compared to self-disclosure (adjusted OR (aOR) 20.2, 95% Confidence Interval (CI) 1.8-221.4). Those in concordant HIV status partnerships were more likely to have a positive reaction (aOR. 6.7, 95% CI 1.7-26.6). Women experiencing frequent verbal IPV were less likely to report a positive response (aOR 0.21, 95%CI 0.1-0.8). Most postpartum women with HIV in this cohort had disclosed to their male partners early after diagnosis and experienced a positive reaction. However, a minority had still not disclosed by 12 months after the birth and some experienced negative reactions to disclosure. The form of status disclosure and impact of intimate partner violence should be given greater attention within the context of PMTCT.

Impact of inter-partner HIV disclosure patterns in Malawi's PMTCT program: A mixed-method study

Background

Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women.

Methods

A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014–2016, all (34,637) mothers attending 54 under-5 clinics with their 4–26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were excluded. Data collected included socio-demographics, partner disclosure, maternal ART uptake, and adherence. Between 2016–2017, in-depth interviews and focus group discussions were conducted with adult mothers (n = 53) and their spouse/cohabiting partners (n = 19), adolescent mothers (n = 13), lost-to-follow up (LTFU) mothers (n = 22), community leaders (n = 23) and healthcare workers (n = 154).

Results

Of 3153 known HIV-infected mothers, 2882 (91.4%) reported having a spouse/cohabiting partner. Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART (aOR 4.7; 95%CI 2.5–8.8), suboptimal treatment adherence (aOR 1.8; 95%CI 1.1–2.8) and MTCT (aOR 2.1; 95%CI 1.1–4.1). Women’s fear of blame by partners was central to decisions not to disclose within couples and when starting new relationships. LTFU mothers struggled to accept and disclose their status, hindering treatment initiation; some were unable to hide ART and feared involuntary disclosure.

Conclusion

Partner disclosure seems to play an important role in women’s decisions regarding ART initiation and adherence. Inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence and MTCT.

A Mixed Methods Study of Anticipated and Experienced Stigma in Health Care Settings Among Women Living with HIV in the United States

Among places where people living with HIV experience and anticipate HIV-related stigma, stigma in health care settings may be particularly harmful. Utilizing an exploratory sequential mixed methods approach, we conducted interviews (n = 76) and questionnaires (N = 460) with older adult women living with HIV enrolled in the Women's Interagency HIV Study in Birmingham, AL; Jackson, MS; Atlanta, GA; and San Francisco, CA. Interviews addressed facilitators and barriers to HIV treatment adherence, including HIV-related stigma. Qualitative data were coded using thematic analysis. Questionnaires assessed self-reported antiretroviral therapy (ART) adherence and experienced and anticipated HIV-related stigma from various sources (i.e., health care personnel, family, partner, and community). Covariate-adjusted logistic regression analyses examined total and mediated effects of stigma on ART adherence. Interviewees described fears and experiences of stigma in health care settings; including privacy violations, disrespect for patient autonomy, and reproductive coercion; and how these influenced their adherence to HIV treatment recommendations. Experienced and anticipated HIV-related stigma in health care settings were associated with suboptimal (or <95%) ART adherence in separate models controlling for experienced or anticipated stigma, respectively, from other sources. When entered together, only anticipated stigma in health care settings was associated with suboptimal ART adherence, controlling for anticipated and experienced stigma from other sources. The effect of anticipated stigma in health care settings on suboptimal ART adherence may work through the pathways of lower adherence self-efficacy, higher depressive symptoms, and higher coping by substance use. These findings indicate that interventions should promote cultures of acceptance within health care settings and resilience-based strategies for women to combat stigma and promote life-sustaining behaviors.