HIV Stigma in Lilongwe, Malawi: Influence of Gender Roles and Impact on Adherence in Women Accessing HIV Treatment Through Option B+

Abstract

We conducted a mixed-methods study on HIV stigma, comparing two groups of women receiving care through Malawi’s Option B+ program, which since 2011 has provided lifelong treatment to pregnant and breastfeeding women testing positive for HIV. We performed a comparison of characteristics at antenatal recruitment of newly diagnosed women versus those who had previously been diagnosed but had stopped treatment, followed by a qualitative assessment of the experiences of gender roles and community, enacted, anticipated, and internalized stigma in 55 women recruited from the larger cohort for either adherence or non-adherence. We found that the non-adherent cohort had a greater likelihood of knowing their partner’s status but a lower likelihood to intend to disclose to him, lower rates of desire for their current pregnancy, and lower education than a group of newly diagnosed women. In interviews and focus groups, most women described a changing face of community stigma with perceptions of a decrease in overt acts of enacted discrimination, but continued negative discussion and labeling. There was a high prevalence of anticipated and internalized stigma across all women. Higher levels of partner involvement were noted in the adherent group. Internalized stigma in the form of denial was frequently reported as a source of non-adherence. Avenues for addressing stigma include increased male partner involvement, peer support programs, and efforts to increase privacy at medication collection clinics.