| Description |
Background Women living with HIV (WLHIV) commonly experience internalized HIV stigma, which refers to how they feel about themselves as a person living with HIV. Internalized stigma interferes with HIV care seeking behavior and may be particularly heightened during the pregnancy and postpartum periods. This thesis aimed to describe internalized HIV stigma among WLHIV giving birth, identify factors associated with internalized HIV stigma, and examine qualitatively the impacts of internalized HIV stigma on the childbirth experience. Methods Postpartum WLHIV (n=103) were enrolled in the study between March and July 2022 at six clinics in the Kilimanjaro Region, Tanzania. Participants completed a survey within 48 hours after birth, prior to being discharged. The survey included a 13-item measure of HIV-related shame, which assessed levels of internalized HIV stigma (Range: 0-52). Univariable and multivariable regression models examined factors associated with internalized HIV stigma. Qualitative in-depth interviews were conducted with pregnant WLHIV (n=12) and postpartum WLHIV (n=12). Thematic analysis, including memo writing, coding, and synthesis, was employed to analyze the qualitative data. Results The survey sample had a mean age of 29.1 (SD = 5.7), and 52% were diagnosed with HIV during the current pregnancy. Nearly all participants (98%) endorsed at least one item reflecting internalized HIV stigma, with an average endorsement of 9 items (IQR = 6). The most commonly endorsed items were: "I hide my HIV status from others" (87%), "When others find out I have HIV, I expect them to reject me" (78%), and "When I tell others I have HIV, I expect them to think less of me" (75%). In the univariable model, internalized stigma was associated with two demographic characteristics: being Muslim vs. Christian (ß = 7.123; 95%CI: 1.435, 12.811), and being in the poorest/middle national wealth quintiles (ß = 5.266; 95%CI: -0.437, 10.969). Internalized stigma was associated with two birth characteristics: having first birth vs. having had previous births (ß = 4.742; 95%CI: -0.609, 10.093), and attending less than four antenatal care appointments (ß = 5.113; 95%CI: -0.573, 10.798). Internalized stigma was associated with two HIV experiences: being diagnosed with HIV during the current pregnancy vs. diagnosis in a prior pregnancy (ß = 5.969; 95%CI: -1.196, 10.742), and reporting experiences of HIV stigma in the health system (ß = 0.582; 95%CI: 0.134, 1.030). In the final multivariable model, internalized stigma was significantly associated with being Muslim vs. Christian (ß = 6.80; 95%CI: 1.51, 12.09), attending less than four antenatal care appointments (ß = 5.30; 95%CI: 0.04, 10.55), and reporting experiences of HIV stigma in the health system (ß = 0.69; 95%CI: 0.27, 1.12). Qualitative discussions revealed three key themes regarding the impact of internalized HIV stigma on the childbirth experience: reluctance to disclose HIV status, suboptimal adherence to care, and the influence on social support networks. Conclusions WLHIV giving birth in this sample experience high rates of internalized HIV stigma. This stigma was significantly associated with being Muslim, as opposed to being Christian, attending less than four ANC appointments, and reporting experiences of HIV stigma in the healthcare setting. Other factors that were correlated to higher levels of internalized stigma were socioeconomic status, parity, and timing of HIV diagnosis, all of which can impact access to and engagement in healthcare services during the intrapartum and postpartum periods. Internalized HIV stigma impacts the childbirth experience for WLHIV, making the labor and delivery setting an important site for intervention and support. |
