Motherhood in the context of maternal HIV infection

Unplanned pregnancies and social and partner support during pregnancy in Spanish women living with HIV

OBJECTIVES

To describe prevalence and factors associated with unplanned pregnancies, and social and partner support during pregnancy among women from the Cohort of the Spanish HIV/AIDS Research Network (CoRIS).

METHODS

We included all women recruited in CoRIS from 2004 to 2019, aged 18-50 years at recruitment who were pregnant during 2020. We designed a questionnaire, organized into the following domains: sociodemographic characteristics, tobacco and alcohol consumption, pregnancy and reproductive health, and social and partner support. The information was gathered via telephone interviews conducted from June to December 2021. We calculated prevalence of unplanned pregnancies as well as odds ratios (ORs) of association and 95% confidence intervals (CIs) according to sociodemographic, clinical and reproductive characteristics.

RESULTS

Among 53 women who were pregnant during 2020, 38 (71.7%) answered the questionnaire. Median age at pregnancy was 36 years [interquartile range (IQR) 31-39], 27 (71.1%) women were born outside of Spain, mainly in sub-Saharan Africa (39.5%) and 17 (44.7%) were employed. Thirty-four (89.5%) women had been through previous pregnancies and 32 (84.2%) had experienced previous abortions/miscarriages. Seventeen (44.7%) women had shared with their clinician their desire to get pregnant. Thirty-four (89.5%) pregnancies were natural and four used assisted reproductive techniques (in vitro fertilizations; one additionally used oocyte donation). Of 34 women with natural pregnancies, pregnancy was unplanned in 21 (61.8%) and 25 (73.5%) had information on how to become pregnant avoiding HIV transmission to the baby and partner. Women who did not seek advice from their physician about becoming pregnant had a significantly increased risk of unplanned pregnancy (OR = 71.25, 95% CI: 8.96-566.67). Overall, 14 (36.8%) women reported having low social support during pregnancy and 27 (71.0%) had good/very good support by their partner.

CONCLUSIONS

Most pregnancies were natural and unplanned and very few women had talked with their clinician about their desire to become pregnant. A high proportion of women reported low social support during pregnancy.

Psychosocial health in pregnancy and postpartum among women living with - and without HIV and non-pregnant women living with HIV living in the Nordic countries - Results from a longitudinal survey study

BACKGROUND

The success of antiretroviral therapy has normalized pregnancy among women living with HIV (WWH) with a very low risk of perinatal transmission of HIV. Despite these advances, WWH still face complex medical and psychosocial issues during pregnancy and postpartum. The aim of this study was to assess differences in psychosocial health outcomes between pregnant WWH, non-pregnant WWH, and pregnant women without HIV, and further identify factors associated with probable depression in the third trimester and postpartum.

METHODS

In a longitudinal survey study, participants were included from sites in Denmark, Finland, and Sweden during 2019-2020. Data was collected in the 3rd trimester, 3 and 6 months postpartum using standardized questionnaires assessing depression, perceived stress, loneliness, and social support. Mixed regression models were used to assess changes over time within and between groups. Logistic regression models were used to identify factors associated with depression in pregnancy and postpartum.

RESULTS

A total of 47 pregnant WWH, 75 non-pregnant WWH, and 147 pregnant women without HIV were included. The prevalence of depression was high among both pregnant and non-pregnant WWH. There was no significant difference between pregnant and non-pregnant WWH in depression scores, perceived stress scores, or social support scores at any time point. Compared to pregnant women without HIV, pregnant WWH reported worse outcomes on all psychosocial scales. Social support and loneliness were associated with an increased odds of depressive symptoms in the adjusted analysis.

CONCLUSIONS

A high burden of adverse psychosocial outcomes was observed in both pregnant and non-pregnant women living with HIV compared to pregnant women without HIV. Loneliness and inadequate social support were associated with increased odds of depression in pregnancy and should be a focus in future support interventions.

The experience of pregnancy among women living with HIV in Nordic countries: A qualitative narrative enquiry

Objective:

The success of antiretroviral therapy has resulted in the normalization of pregnancy among women living with HIV and a very low risk of perinatal transmission of HIV. Despite these advances, women living with HIV still face complex medical and psychosocial issues during pregnancy. The purpose of this study is to describe experiences of pregnancy and the relevance of social support among women living with HIV in Nordic countries.

Methods:

This qualitative study examined data from pregnant women living with HIV from sites in Denmark, Sweden and Finland from 2019 to 2020. Data were collected in the third trimester via individual interviews using a hybrid, narrative/semistructured format. The transcribed interviews were analyzed using narrative thematic analysis.

Results:

In total, 31 women living with HIV were enrolled, of whom 61% originated from an African country and 29% from a Nordic country. The analysis generated four primary narrative themes: just a normal pregnancy, unique considerations and concerns, interactions with healthcare, and social support. Women living with HIV have a strong desire to have normal pregnancies and to be treated like any other pregnant woman. However, this normality is fragile, and being pregnant and living with HIV does come with unique considerations and concerns, such as fear of transmission, antiretroviral therapy, and the need for specialized care, which are fundamental to the women’s experiences. Interactions with healthcare providers and social support influence their experiences in both positive and negative ways.

Conclusion:

The findings emphasize a sense of normality in pregnancy among women living with HIV. However, pregnancy does come with unique considerations and concerns, which highly influence the women’s experience of pregnancy. Healthcare providers should focus on person-centered care, ensuring continuity and that women living with HIV do not feel discriminated against throughout their pregnancy.

Enduring stigma and precarity: A review of qualitative research examining the experiences of women living with HIV in high income countries over two decades

The lived experience of HIV for women remains poorly understood. In particular, there has been little attention to the consequences for women living with HIV (WLHIV) of changing social, epidemiological, biomedical and policy contexts, or to the implications of long-term treatment and aging for the current generation of HIV-positive women. We reviewed qualitative research with WLHIV in selected high-income countries (Australia, Canada, New Zealand, the UK and the USA) to identify the most prevalent experiences of HIV for women and trends over time. Our synthesis highlights the relative consistency of experiences of a diverse sample of WLHIV, particularly the enduring prevalence of gendered HIV-related stigma, sociostructural barriers to healthcare and support, and negative encounters with health professionals. We also identified gaps in knowledge. Understanding women's experiences, particularly their changing needs and strategies for coping as they live long-term with HIV, is key to effective support and services for WLHIV.

Understanding the Importance of Fatherhood among Men Living with HIV in Ontario

While pregnancy and motherhood have become paramount clinical issues for women living with HIV, parenting has received less attention among men living with HIV (MLWH). We conducted a secondary analysis of a cross-sectional study assessing fertility desires and intentions of MLWH using a 5-point Likert scale based on the question: "Being a father is important to me". Logistic regression models were fit to calculate unadjusted and adjusted odds ratios (ORs) and confidence intervals (CIs) for significant correlates. Of the 276 respondents, 118 were heterosexual, 158 were gay, bisexual, 2-spirit, or queer (GBTQ), 55% had never parented before, and 65% wanted to parent. 191 (69%) respondents agreed that fatherhood was important to them. In unadjusted analyses, heterosexuality (OR 1.52; 95% CI 1.15 to 2.03), African/Caribbean/Black ethnicity (OR 1.57; 95% CI 1.12 to 2.19), African/Caribbean birthplace (OR 1.48; 95% CI 1.06 to 2.05), and history of parenting (OR 1.60; 95% CI 1.10 to 2.39) were significantly (p < 0.05) associated with importance of fatherhood. However, none of these variables were significant in adjusted analyses. From the unadjusted model, factors such as sexual orientation, ethnicity, and current parenthood may influence how MLWH value fatherhood, suggesting HIV and fatherhood is complex and must be explored further.

High Rates of Biomarker-Confirmed Alcohol Use Among Pregnant Women Living With HIV in South Africa and Uganda

BACKGROUND

Alcohol use is common among people living with HIV and particularly harmful during pregnancy. However, objective data on alcohol use in pregnant women living with HIV (WLWH) are lacking. In areas with high levels of alcohol use generally, such as South Africa and Uganda, these data are needed to inform interventions.

METHODS

Pregnant and nonpregnant, antiretroviral therapy-naive WLWH were recruited from outpatient clinics in South Africa and Uganda. Women provided self-report data on previous three-month alcohol use and potential mental health correlates of alcohol use (depression and stigma). Blood samples were used to measure phosphatidylethanol (PEth), an objective biomarker of recent alcohol intake. We analyzed any alcohol use (ie, any self-reported use or PEth-positive [≥8 ng/mL]) and under-reporting of alcohol use (ie, no self-reported use with concurrent PEth-positive).

RESULTS

Among pregnant WLWH (n = 163, median age was 26 [interquartile range: 23-29], median gestational age was 20 weeks [interquartile range: 16-26]), 40% were using alcohol and 16% under-reported alcohol use. Neither any alcohol use nor under-reporting of alcohol use differed significantly between pregnant and nonpregnant women or by country (P > 0.05). Greater depression (but not greater stigma) was significantly associated with any alcohol use (adjusted odds ratio = 1.41, 95% confidence interval: [1.01 to 1.99]; P = 0.045).

CONCLUSIONS

Alcohol use was prevalent and under-reported among pregnant WLWH in South Africa and Uganda, similar to nonpregnant participants, and associated with depression. General health care and antenatal clinic settings present opportunities to provide integrated alcohol-based counseling and depression treatment.

Childbearing through the Lens of Women with Minor Thalassemia: A Qualitative Study

Background:

It is essential to provide key information and support to every woman regarding pregnancy and childbirth to enable all women to make a fully informed decision regarding their choice to reproduce. Of particular importance; however, is that women who suffer from a specific condition that increases risks associated with reproduction, to receive specific information regarding such risks and health complications regarding pregnancy and childbirth. This study aims to explore the feelings, experiences, and needs of women with minor thalassemia in relation to childbearing.

Materials and Methods:

This sample comprised of 12 Iranian women with minor thalassemia who attended to local health centers in Minudasht, Golestan province, from October 2017 to January 2018. The purposeful sampling technique was employed. The data were collected through deep semi-structured interviews, analyzed using conventional content analysis and processed by using the Graneheim and Lundman method.

Results:

The findings were based on the participants’ experiences of pregnancy and fertility. Three major themes emerged; ‘Emotional and Physical Experience,’ ‘Satisfaction’ and ‘Social and Cultural Issues.’ The most common problem identified was the impact of emotional problems and difficulties regarding the negative implications of thalassemia on reproduction as well as the views and perceptions of family members and those within the community.

Conclusion:

From the findings, it is evident that thalassemia imposes a heavy psychosocial burden on those women who suffer from the condition. Local health centers in areas most affected by thalassemia would be considered the most suitable venues to introduce key health educational interventions.

Contours of Positive Mental Health: An Exploratory Delphi Study from India

The need to broaden attention from a narrow focus on mental illness and pathology to investing in understanding and enhancing positive mental health is well recognized. The bulk of research on positive mental health tends to be largely based onwestern developed nationconceptualizations. This highlights the need to examine the construct of positive mental health in diverse socio-cultural contexts. Present study aimed at exploring indicators and dimensions of positive mental health in Indian adults. A two-step Delphi technique, involving a vignette-based tool was used for facilitating a contextualised understanding of indicators of positive mental health. The sample consisted of a panel of 35 experts from different regions of India, majority of whom had >10 years of professional experience. Using a bottom-up approach, content analysis of the emergent data in terms of responses of experts to 10 vignettes resulted in identification and operationalisation of 33 indicators which could be grouped under 13 dimensions. Comparisons with popular well-being frameworks indicated that eight of these could be considered newer dimensions. Though the remaining dimensions significantly overlapped with existing dimensions of well-being in the western literature; finer differences in their meanings and constituents were observed. Finding have implications for further research.

Sexuality and childbearing as it is experienced by women living with HIV in Sweden: a lifeworld phenomenological study

The effectiveness of antiretroviral treatment has reduced sexual HIV transmission and mother-to-child-transmission. To optimally support women living with HIV, health care providers need deepened knowledge about HIV, sexuality and childbearing. The aim of this study was to describe the phenomenon sexuality and childbearing as experienced by women living with HIV in Sweden. Data were collected by phenomenon-oriented interviews with 18 HIV-positive women. A reflective lifeworld analysis based on phenomenological philosophy was conducted, describing the meaning structure of the phenomenon. The essence of the phenomenon is that perceptions about HIV and its contagiousness profoundly influence sexual habits and considerations in relation to pregnancy and childbearing. These perceptions are formed in combination with knowledge and interpretations about HIV by the women themselves and by their environments. The essence is further described by its constituents: Risk of transmission imposes demands on responsibility; The contagiousness of HIV limits sexuality and childbearing; Knowledge about HIV transmission provides confident choices and decisions; and To re-create sexuality and childbearing. Although HIV has a low risk of transmission if being well treated, our study shows that HIV-positive women feel more or less contagious, which influences sexuality and decision-making in relation to become pregnant and give birth.

Analysing the experience of motherhood among adolescents living with HIV

Aim

Adolescent motherhood is considered a condition of vulnerability that can be further complicated by the presence of HIV infection, but little is known about how adolescent mothers experience this process. The aim of this study was to analyse the experience of motherhood among adolescents living with HIV.

Method

Seven mothers (15-21 years) recruited in specialized services in Porto Alegre/Brazil, whose babies’ ages ranged from four to six months, were interviewed. Interviews were tape-recorded and transcribed verbatim.

Results

The qualitative content analysis of the interviews revealed a positive vision of motherhood, related to satisfaction with the maternal role and personal fulfilment. Pregnancy and motherhood served to these adolescents as an encouragement for self-care. The mothers’ difficulties were related to HIV and to the repercussions of this clinical condition, especially feelings of frustration and incompleteness of motherhood on the impossibility of breastfeeding, as well as fear facing the risk of MTCT.

Conclusion

Future research of longitudinal design and with larger samples will be important to extend the knowledge of the specificities of this experience over time for young people of different ages and social backgrounds.

Capturing the Social Location of African American Mothers Living With HIV: An Inquiry Into How Social Determinants of Health Are Framed

BACKGROUND

The disparate health outcomes of African American mothers living with HIV are considerable. Multidimensional approaches are needed to address the complex social and economic conditions of their lives, collectively known as the social determinants of health.

OBJECTIVES

The purpose of this study was to explore the social determinants of health for African American mothers living with HIV by examining how mothers describe their social location at the intersection of gender, race, and class inequality; HIV-related stigma; and motherhood. How they frame the impact of their social location on their health experiences is explored.

METHODS

This exploratory study included in-depth, semistructured interviews with 18 African American mothers living with HIV at three time points. We used an intersectional framework and frame analysis to explore the meaning of these constructs for participants.

RESULTS

Findings from 48 interviews include a description of the intersecting social determinants functioning as systems of inequality and the heterogeneous social locations. Three frames of social location were used to organize and explain how African American mothers living with HIV may understand their social determinants of health: (a) an emancipatory frame, marked by attempts to transcend the negative social connotations associated with HIV and socially constructed identities of race, gender, and class; (b) a maternal frame, marked by a desire to maintain a positive maternal identity and maternal-child relations; and (c) an internalized frame, marked by an emphasis on the deleterious and stigmatizing effects of HIV, racial, gender, and class inequality.

DISCUSSION

The findings offer knowledge about the heterogeneity in how demographically similar individuals frame their social location as well as how the intersections of social determinants influence participant's health experiences. Potential health implications and interventions are suggested for the three frames of social location used to describe intersecting social determinants of health. The study offers an analytic approach for capturing the complexity inherent in intersectional methodologies examining the role of social determinants in producing health inequities.

The Experience of Pregnancy in Women Living With HIV: A Meta-Synthesis of Qualitative Evidence

The lived experience of pregnancy from the perspectives of women living with HIV (WLWH) is not well understood. We aimed to understand the meaning of pregnancy for WLWH. A meta-synthesis was conducted to review and integrate qualitative studies about the phenomena; 12 databases were used to perform the search in English, Spanish, and Portuguese. Articles using qualitative methods published in peer-reviewed journals were included. Data were analyzed using the meta-synthesis method. We found that, for pregnant WLWH, pregnancy evolved as a mediated experience of commitment and dedication. The vital life experience of pregnancy was defined as an interplay of emotions, coping strategies, and feelings of satisfaction. Pregnancy in WLWH was experienced and impacted by societal beliefs, as the women focused all their efforts to take care of themselves and their babies.

Exploring the Factors Considered by People Living with HIV and Their Partners during Preconception

Data are lacking on factors that may impact conception-related decision-making among individuals living with HIV. This study's aim was to shed light on these considerations. Participants were invited to complete a survey on preconception considerations. A rank-ordered logit model was fit to estimate the relative importance of listed consideration factors; the interaction of HIV status and the factors was assessed. Fifty-nine participants living with HIV and 18 partners (11 HIV-negative participants and 7 living with HIV) were included. Risk of vertical and horizontal HIV transmission and the effect of antiretroviral therapy on the fetus were the top considerations. However, individuals living with HIV prioritized vertical transmission, whereas HIV-negative participants prioritized horizontal transmission. Other factors of importance were probability of conception, stress of trying to conceive, cost associated with fertility clinics, and stigma associated with certain conception methods. This study builds our understanding of the preconception considerations for people living with HIV.

HIV-related stigma in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada

HIV-related stigma is associated with many psychological challenges; however, minimal research has explored how perceived HIV-related stigma intersects with psychosocial issues that mothers living with HIV may experience including depression, perceived stress and social isolation. The present study aims to describe the correlates and predictors of HIV-related stigma in a cohort of women living with HIV (WLWH) from across Ontario, Canada during pregnancy and early postpartum. From March 2011 to December 2012, WLWH ≥ 18 years (n = 77) completed a study instrument measuring independent variables including sociodemographic characteristics, perceived stress, depression symptoms, social isolation, social support and perceived racism in the third trimester and 3, 6 and 12 months postpartum. Multivariable linear regression was employed to explore the relationship between HIV-related stigma and multiple independent variables. HIV-related stigma generally increased from pregnancy to postpartum; however, there were no significant differences in HIV-related stigma across all study time points. In multivariable regression, depression symptoms and perceived racism were significant predictors of overall HIV-related stigma from pregnancy to postpartum. The present analysis contributes to our understanding of HIV-related stigma throughout the pregnancy-motherhood trajectory for WLWH including the interactional relationship between HIV-related stigma and other psychosocial variables, most notably, depression and racism.

'We have beaten HIV a bit': a qualitative study of experiences of peer support during pregnancy with an HIV Mentor Mother project in England

OBJECTIVES

To explore the experiences of women living with HIV in England who received or gave Mentor Mother (trained mother-to-mother) volunteer peer support during pregnancy and early motherhood.

DESIGN

Qualitative descriptive study, using semistructured, in-depth interviews and inductive thematic analysis, theoretically informed by phenomenological social psychology.

SETTING

A London-based third sector peer support organisation for people living with HIV.

PARTICIPANTS

12 women living with HIV who had given or received Mentor Mother volunteer peer support (6 had given support and 6 had received support). 11 were black African.

RESULTS

The key themes in participants' descriptions of their lives as pregnant women and mothers living with HIV were 'fear and distress', 'stigma and isolation' and 'the gap in maternity care'. The key themes related to Mentor Mother peer support during and after pregnancy were 'support to avoid mother-to-child transmission' (with subthemes 'reinforcing medical advice', 'reframing faith issues', 'prioritisation and problem-solving' and 'practical strategies for managing HIV and motherhood'), and 'emotional support' (with subthemes 'role modelling and inspiring hope', 'openness and non-judgemental acceptance', 'a caring relationship', 'recreating the lost family network', 'being understood from the inside' and 'self-confidence'). The Mentor Mothers' support appeared to be a successful hybrid between the peer education Mentor Mothers programmes in southern Africa and the more general pregnancy volunteer peer support models operating in England.

CONCLUSIONS

A Mentor Mother peer support programme is acceptable to, and valued by, black African mothers with HIV in England. Peer support from trained volunteers during and after pregnancy can complement and reinforce medical advice on avoiding mother-to-child transmission of HIV, and can have a multidimensional positive impact on vulnerable mothers' emotional well-being. Mentor Mother peer support should be considered by those designing programmes for the support of pregnant women with HIV and the prevention of mother-to-child transmission of HIV.

“Trust Me, It’s Different”: Experiences of Peer Case Management of Women Living with HIV in Ontario, Canada

In response to the dearth of research for delivering women-centred support to women living with HIV, the Women’s HIV Empowerment Through Life Tools for Health (wHEALTH) intervention was developed. This project was grounded in a community-based research framework and aimed to respond to barriers of women living with HIV in accessing appropriate and meaningful social supports. Participants described the benefits of the peer case management intervention including support, mentorship, flexibility in which the intervention was delivered, and the notion of “moving forward” in one’s journey with HIV. Through education, awareness, and advocacy, peer case managers are important partners in addressing HIV-related stigma, and ensuring a multi-level approach to providing care and support to women living with HIV.

The stigma of mental illness in Arab families: a concept analysis

ACCESSIBLE SUMMARY

The stigma of mental illness varies significantly from culture to culture and from person to person. To date, little is known about how mental illness stigma manifests within the Arab community. This study aimed at bringing clarity to the concept of 'mental illness stigma' as it applies to Arab families. Nursing's holistic and patient-centered approach is integral to helping Arab patients and their families appropriately incorporate individual values, beliefs, and cultural perspectives into treatment plans. This study establishes a scientific alert for professionals at all levels to avoid making false generalizations about a specific culture that are not based on specific research findings from that culture.

ABSTRACT

Accessing mental health services is a critical step towards reducing the burden of mental illness. The stigma of mental illness is one of the most common reasons for not seeking mental health care leading to negative health consequences and undue suffering for many individuals and their families. Stigma is embedded in its social context. What may be considered acceptable in one society may be considered unacceptable and open to stigmatization in other societies. Arabs have a shared set of values, beliefs, and traditions that are substantially different from those of Westerners. Further, in most Arab countries, formal mental health resources are scarce and people with mental illness experience the compounded disadvantages of poverty and illness stigma. To date, little is known about how mental illness stigma manifests within the Arab community making it difficult to design and test interventions that support Arab individuals with mental illness and their families in treatment seeking and adherence. Using Rodger's concept analysis method, we examined how 'mental illness stigma' operates within an Arab context as a first step towards elucidating culturally competent approaches to treatment. This analysis provides a foundation for future work in the areas of mental illness diagnosis, education, and treatment that reflect the unique characteristics of Arab culture.

Pregnancy through the Lens of Iranian Women with HIV: A Qualitative Study

To explore the experience of pregnancy among Iranian women with HIV, 12 HIV-infected pregnant women who referred to counseling center for behavioral diseases in Imam Khomeini Hospital were recruited through purposive sampling. Data were collected by face-to-face, semi-structured interview and were analyzed using conventional content analysis method. Four main themes emerged from the data: fear and hope, stigma and discrimination, marital life stability, and trust in God. Despite concerns about mother-to-child transmission of HIV, and uncertain life span, HIV-infected women tended to continue their pregnancy, and having children was viewed as a window of hope for them.

Trajectories of Childbearing among HIV Infected Indian Women: A Sequence Analysis Approach

BACKGROUND

HIV infection closely relates to and deeply affects the reproductive career of those infected. However, little is known about the reproductive career trajectories, specifically the interaction of the timing of HIV diagnosis with the timing and sequencing of reproductive events among HIV infected women. This is the first study to describe and typify this interaction.

METHODS

Retrospective calendar data of ever married HIV infected women aged 15-45 attending a HIV clinic in Pune, Maharashtra, Western India (N=622) on reproductive events such as marriage, cohabitation with the partner, use of contraception, pregnancy, childbirth and HIV diagnosis were analyzed using sequence analysis and multinomial logistic regression.

RESULTS

Optimal matching revealed three distinct trajectories: 1) HIV diagnosis concurrent with childbearing (40.7%), 2) HIV diagnosis after childbearing (32.1%), and 3) HIV diagnosis after husband's death (27.2%). Multinomial logistic regression (trajectory 1 = baseline) showed that women who got married before the age of 21 years and who had no or primary level education had a significantly higher risk of knowing their HIV status either after childbearing or close to their husband's death. The risk of HIV diagnosis after husband's death was also higher among rural women and those who were diagnosed before 2005.

CONCLUSIONS

Three distinct patterns of interaction of timing of HIV diagnosis with timing and sequencing of events in the reproductive career were observed that have clear implications for (i) understanding of the individual life planning process in the context of HIV, (ii) formulation of assumptions for estimating HIV infected women in need of PMTCT services, and (iii) provision of care services.

Using an intersectional approach to study the impact of social determinants of health for African American mothers living with HIV

Heightened awareness of the social determinants of health by health scientists and clinicians has failed to translate into significant progress in the amelioration of those social determinants contributing to health inequities. The purpose of this article is to broaden the discussion about conceptual approaches nurse scientists can use to address health and health inequities. We will apply an intersectional approach to the study of the social determinants of health for African American mothers living with human immunodeficiency virus and through this explore the utility of an intersectional approach to generate knowledge in nursing.

To tell or not to tell: disclosure to children and family amongst Thai women living with HIV/AIDS

HIV disclosure is a complex phenomenon. The choice of disclosure or non-disclosure is a reflection of how each HIV-positive person experiences and deals with HIV/AIDS in their everyday life. In this study, we qualitatively explore the experiences of disclosing HIV status to family members and children among HIV-positive women living in Thailand. Due to fear of stigma and discrimination, the women decided to tell only a few people, usually their significant others including parents and children. Although most women received good support from their family members, some were rejected and discriminated against by their family members. This stems from lack of knowledge about HIV/AIDS among family members. Women found disclosure to their children a difficult decision to make. Only some women told their children about their HIV status. They wished to protect their children from emotional burden. This protection also appeared in their attempts to prepare their children for dealing with HIV/AIDS. Support from family members played a major role in the lives of HIV-positive women. Although disclosure has been promoted as a means of ending stigma and discrimination, our data suggested that disclosure may not be positive for some women. This has implications for health promotion in HIV health care. Healthcare providers need to appreciate the ramifications of promoting disclosure to HIV-positive women who are mothers.

Gestação e HIV: Preditores da Adesão ao Tratamento no Contexto do Pré-natal

Este estudo avaliou adesão ao tratamento em gestantes vivendo com HIV. Foram entrevistadas 89 gestantes com HIV, no último trimestre gestacional, que forneceram informações sobre dados sociodemográficos, apoio social, pré-natal e tratamento, além de exames laboratoriais. Constatou-se que 51,7% das gestantes aderiam à medicação. Essas gestantes eram mais escolarizadas, começaram o pré-natal antes, realizaram mais consultas e referiram maior apoio emocional. No modelo de regressão logística, o número de consultas realizadas e a presença de maior apoio emocional foram preditores da adesão. Adesão em gestantes vivendo com HIV ainda é um desafio, mesmo quando há acesso e disponibilidade de tratamento. Início precoce do pré-natal e fortalecimento da rede de apoio social são cruciais para a promoção da adesão em gestantes.

"Why Aren't You Breastfeeding?": How Mothers Living With HIV Talk About Infant Feeding in a "Breast Is Best" World

Infant feeding raises unique concerns for mothers living with HIV in Canada, where they are recommended to avoid breastfeeding yet live in a social context of "breast is best." In narrative interviews with HIV-positive mothers from Ontario, Canada, a range of feelings regarding not breastfeeding was expressed, balancing feelings of loss and self-blame with the view of responsibility and "good mothering" under the current Canadian guidelines. Acknowledging responsibility to put their child's health first, participants revealed that their choices were influenced by variations in social and cultural norms, messaging, and guidelines regarding breastfeeding across geographical contexts. This qualitative study raises key questions about the impact of breastfeeding messaging and guidelines for HIV-positive women in Canada.

The relationship between social support and anxiety among caregivers of children in HIV-endemic South Africa

Caring for children can be a source of joy and fulfilment, but also a source of stress, especially for caregivers living with illness and/or coping with difficult socio-economic conditions. Risks for poor caregiver mental health are especially salient in many parts of southern Africa affected by a generalised HIV-epidemic, high rates of physical illness, difficult livelihood conditions and an increasing number of orphaned and vulnerable children in need of care. Given limited availability and low uptake of formal mental health services in South Africa, the potential protective role of informal community or "social" resources for caregiver populations requires greater attention. To our knowledge, this is the first study to quantitatively assess the relationship between social support and symptomatic anxiety among caregivers of children living in HIV-endemic southern African communities. The data are from household survey interviews with 2477 adult primary caregivers of children aged 10-17 years living in two (urban and rural) resource-deprived HIV-endemic South African communities. Hierarchical logistic regression analysis with interaction terms was conducted to assess whether HIV and other illness were significant stressors for caregiver anxiety, whether social support had main or stress-buffering protective effects on anxiety and whether gender moderated the association between social support and anxiety. Our findings showed significant main effects of social support on caregiver anxiety, but no evidence of stress-buffering effects of support or of gender moderating the support-anxiety relationship. This suggests that social support is a general mental health resource for both male and female caregivers of children in these HIV-endemic communities, regardless of whether they are facing specific stressors related to HIV or other illness. Our results highlight the importance of paying greater attention to the social environment when designing and implementing caregiver health interventions, and indicate that social support could be a valuable component of such interventions.

Quality of Life and Emotional Distress among HIV-Positive Women during Transition to Motherhood

The purpose of this preliminary study was to describe the quality of life (QOL) and emotional distress during pregnancy and early postpartum, and to examine the ability of psychopathological symptoms to predict QOL at early postpartum.Asample of 75 pregnant women (31 HIV-positive and 44 HIV-negative) was assessed during the second trimester of pregnancy and two to four days postpartum. QOL was assessed with the WHOQOL-Bref. The emotional distress was assessed with the Brief Symptom Inventory, and with the Emotional Assessment Scale. Seropositive women reported increased negative emotional reactivity and lower scores in social relationships and overall QOL during pregnancy than HIV-negative women. Both HIV-positive and HIV-negative women reported better QOL after the birth of their child, when compared with the pregnancy period. Among HIV-positive women, lower anxiety and depressive symptoms during pregnancy were, respectively, significant predictors of better psychological QOL and overall QOL at early postpartum. Less intense somatic symptoms predicted better physical QOL. Longitudinal assessment of QOL and emotional status may provide potentially useful information for tailoring psychological interventions in the maternity care of HIV-infected women, during their transition to motherhood.

Community attitudes towards childbearing and abortion among HIV-positive women in Nigeria and Zambia

Although stigma towards HIV-positive women for both continuing and terminating a pregnancy has been documented, to date few studies have examined relative stigma towards one outcome versus the other. This study seeks to describe community attitudes towards each of two possible elective outcomes of an HIV-positive woman's pregnancy - induced abortion or birth - to determine which garners more stigma and document characteristics of community members associated with stigmatising attitudes towards each outcome. Data come from community-based interviews with reproductive-aged men and women, 2401 in Zambia and 2452 in Nigeria. Bivariate and multivariate analyses revealed that respondents from both countries overwhelmingly favoured continued childbearing for HIV-positive pregnant women, but support for induced abortion was slightly higher in scenarios in which anti-retroviral therapy (ART) was unavailable. Zambian respondents held more stigmatising attitudes towards abortion for HIV-positive women than did Nigerian respondents. Women held more stigmatising attitudes towards abortion for HIV-positive women than men, particularly in Zambia. From a sexual and reproductive health and rights perspective, efforts to assist HIV-positive women in preventing unintended pregnancy and to support them in their pregnancy decisions when they do become pregnant should be encouraged in order to combat the social stigma documented in this paper.

Proxemic communication between HIV-infected mother-child pairs

Proxemic communication (behaviours and relations of human interaction) offered by the mother in an HIV-infected mother-child pair during infancy was analysed to determine which proxemic factors promote the exchange of affection. This study, conducted in an experimental laboratory in 2007, included mother-child pairs in which the mother was HIV-positive and the children, under 6 months of age, were born exposed to the virus. Video recordings of the mother-child interaction were analysed according to proxemic factors. Of the 364 interactions recorded for analysis of proxemic communication between the mother-child pair, the most significant proxemic factors were axis, contact behavior, visual code, and tone of voice. The mothers developed communicative strategies such as closer proximity, touch, vocalisation, and smiling to promote the exchange of affection when engaging in maternal care.

Disclosure experience in a convenience sample of Quebec-born women living with HIV: a phenomenological study

BACKGROUND

In Canada, there has been a considerable increase in the number of women infected with the human immunodeficiency virus (HIV). Within a stigmatized social context, disclosure of HIV positivity is still a prevailing concern among women. Little is known about the global understanding of how French-speaking, Quebec-born women living with HIV, live their serostatus disclosure experience. The aim of this qualitative study is to describe and understand the disclosure experience of these women.

METHODS

We conducted semi-structured interviews with seven women. A convenience sample of French-speaking, Quebec-born women was chosen because they all responded to the criteria of wishing to share their disclosure experience. The mean age of the participants was 46 years old (SD±12). They lived with HIV for an average of 10 years; time since diagnosis varied from 8 months to 23 years. Two out of four mothers had given birth to HIV positive children. Data analysis proposed by van Manen was performed to discover the essential themes of the experience.

RESULTS

Seven themes were identified to understand the experience of disclosure in women: 1) Respecting for self and confidants; 2) Feeling apprehension; 3) Exercising control to ensure protection; 4) Deliberately engaging in a process of disclosure/non-disclosure; 5) Exposing oneself to stigma and social exclusion; 6) Suffering internally; and 7) Benefitting from the positive effects of one's decision. For these women, disclosing their HIV status meant: Living the ambivalence of a paradoxical process of revealing/concealing, in a state of profound suffering, exacerbated by stigma, while also being enriched by the benefits attained.

CONCLUSIONS

Understanding the experience of disclosure in WLHIV is important to guide actions in the practice to support and accompany these women in their unique reality. Health professionals have to broaden their role and work on individual, interpersonal, inter-organizational and intersectoral levels. Mobilization of actors from different sectors would facilitate the implementation of pertinent and opportune interventions.

Combining adjusted and unadjusted findings in mixed research synthesis

RATIONALE, AIMS AND OBJECTIVES

Finding ways to incorporate disparate types of evidence into research syntheses has the potential to build a better evidence base for clinical practice and policy. Yet conducting such mixed research synthesis studies is challenging. Researchers have to determine whether and how to use adjusted and unadjusted quantitative findings in combination with each other and with qualitative findings.

METHODS

Among quantitative findings, adjustment for confounding, either via study design or statistical analysis, can be a considerable source of heterogeneity. Yet there is no consensus about the best way to synthesize findings resulting from different methods for addressing confounding. When synthesizing qualitative and quantitative findings, additional considerations include determining whether findings are amenable to synthesis by aggregation or configuration, which, in turn, depends on the degree of interpretive transformation of findings.

RESULTS

Qualitative survey findings appear similar in form to unadjusted or minimally adjusted quantitative findings and, when addressing the same relationship, can be summed. More interpreted qualitative findings appear similar in form to adjusted findings found in, for example, structural equation models specifying the relationship among a host of latent variables. An option for synthesis of conceptually similar models is reciprocal translation.

CONCLUSIONS

These decisions will ultimately be judged on the meaningfulness of their results to practice or policy.

The Pregnant Women with HIV Attitude Scale: development and initial psychometric evaluation

AIM

This paper is a report of the development and initial psychometric evaluation of the Pregnant Women with HIV Attitude Scale.

BACKGROUND

Previous research has identified that attitudes toward persons with HIV/AIDS have been judgmental and could affect clinical care and outcomes. Stigma towards persons with HIV has persisted as a barrier to nursing care globally. Women are more vulnerable during pregnancy. An instrument to specifically measure obstetric care provider's attitudes toward this population is needed to target identified gaps in providing respectful care.

METHODS

Existing literature and instruments were analysed and two existing measures, the Attitudes about People with HIV Scale and the Attitudes toward Women with HIV Scale, were combined to create an initial item pool to address attitudes toward HIV-positive pregnant women. The data were collected in 2003 with obstetric nurses attending a national conference in the United States of America (N = 210). Content validity was used for item pool development and principal component analysis and analysis of variance were used to determine construct validity. Reliability was analysed using Cronbach's Alpha.

RESULTS

The new measure demonstrated high internal consistency (alpha estimates = 0.89). Principal component analysis yielded a two-component structure that accounted for 45% of the total variance: Mothering-Choice (alpha estimates = 0.89) and Sympathy-Rights (alpha estimates = 0.72).

CONCLUSION

These data provided initial evidence of the psychometric properties of the Pregnant Women with HIV Attitude Scale. Further analysis is required of the validity of the constructs of this scale and its reliability with various obstetric care providers.

Meta-analysis of qualitative studies: a tool for reviewing qualitative research findings in psychotherapy

This article focuses on the presentation of qualitative meta-analysis as a method for reviewing qualitative studies. Qualitative meta-analysis is an attempt to conduct a rigorous secondary qualitative analysis of primary qualitative findings. Its purpose*to provide a more comprehensive description of a phenomenon and an assessment of the influence of the method of investigation on findings*is discussed. The distinctive features of conducting meta-analysis approaches are presented. Several considerations important for conducting qualitative meta-analysis are also discussed. The author uses examples of the first experiences attempted with qualitative meta-analysis in the field of psychotherapy research.

The "work" of women when considering and using interventions to reduce mother-to-child transmission (MTCT) of HIV

This paper explores HIV-infected women's experiences of considering and using recommended interventions during pregnancy and postpartum to reduce mother-to-child transmission of HIV. Data were collected from 45 HIV-infected women aged 18-44 years living in Melbourne, Australia. A semi-structured interview was used to collect qualitative information on women's reproductive experience and intentions. The 15 women who had their children after their HIV diagnosis engaged in significant work including surveillance and safety work to minimise stigma and infection, information work to inform decisions and actions, accounting work to calculate risk and benefit, hope and worry work concerning a child's infection status and impact of interventions, work to redefine an acceptable maternal identity, work to prepare an alternative story to counter the disclosure effect of the intervention and emotional work to reconcile guilt when considering these interventions. This study provides a framework to help clinicians understand the real and on-going "work" that women engage in when they are considering interventions recommended by their physicians to reduce transmission of HIV. Even in circumstances where access to and acceptance of interventions are high, women continue to engage in this work even after they have a made a decision about a particular intervention.

Struggling to survive: the difficult reality of Aboriginal women living with HIV/AIDS

The increasingly high rates of mortality and morbidity among Canadian Aboriginal women who are living with HIV/ AIDS indicate that there is a need to address deficiencies in the delivery of supportive services and health care. The purpose of this qualitative study was to develop a greater understanding of the barriers, challenges, and successes experienced when accessing health and related support services from the perspective of Aboriginal women living with HIV/AIDS. The findings are organized around four themes reflected in the interview data: fear of rejection when seeking services, finding strength in adversity, struggles with symptoms, and HIV as just one of many competing problems. It is anticipated that the findings from the study will be used to inform decision making regarding the development and delivery of appropriate, responsive, and accessible policies and programs that will support Aboriginal women who are living with HIV/AIDS.

The essence of healing from sexual violence: a qualitative metasynthesis

A qualitative metasynthesis was conducted to identify the essence of healing from sexual violence, as described by adults who experienced it as children or as adults. Based on the findings of 51 reports, four domains of healing were identified: (a) managing memories, (b) relating to important others, (c) seeking safety, and (c) reevaluating self. The ways of healing within each domain reflected opposing responses. The dialectical process identified for each of the four domains include, respectively: (a) calling forth memories, (b) regulating relationships with others, (c) constructing an "as-safe-as-possible" lifeworld, and (d) restoring a sense of self. These complex processes resulted in a new reality for the participants that was based on a greater sense of agency and provided a more satisfying life course.

Vida reprodutiva de pessoas vivendo com HIV/AIDS: revisando a literatura

No contexto atual da epidemia de HIV/AIDS, temáticas como a reprodução e a transmissão materno-infantil tornaram-se frequentes e têm suscitado diversos posicionamentos por parte de pessoas portadoras e das equipes de saúde. O presente artigo teve por objetivo examinar o impacto da infecção por HIV/AIDS na vida reprodutiva de pessoas portadoras, considerando o direito à maternidade e à paternidade. Foi realizada uma revisão da literatura acerca de aspectos biológicos, psíquicos e sociais que compõem o cenário da assistência em saúde reprodutiva. Constatou-se que a prevalência da lógica biomédica e o impacto social da epidemia restringem o exercício do direito à maternidade e à paternidade dos indivíduos portadores de HIV/AIDS. Diante disso, entende se que as políticas públicas e as ações em saúde devem ser direcionadas pelo respeito ao princípio da integralidade e pelo respeito à autonomia individual, dentro de um contexto de apoio e orientação psicossocial.

Sexual behaviors and practices of women living with HIV in relation to pregnancy

It has been estimated that 80% of women infected with HIV are of childbearing age. Few data exist to describe the sexual behaviors and practices in relation to pregnancy and childbearing of women living with HIV. This study is a secondary analysis of qualitative data previously gathered to explore the lived experience of pregnancy after diagnosis with HIV. Interviews with a purposive sample of 9 mothers ages 34 to 53 who were previously diagnosed with HIV were tape recorded, transcribed, and analyzed to describe sexual behaviors and practices of women living with HIV in relation to childbearing. The data showed three themes: (a) unprotected sexual relations with the intent to become pregnant, (b) shifting responsibility for condom use as the relationship progressed, and (c) insufficient knowledge of how to reduce partner transmission risk in relation to childbearing. Participants were knowledgeable about the means to minimize transmission to the fetus. Consideration of this information may enhance the provision of health care to minimize transmission risk and encourage the development of further studies about this topic.

Experiência da maternidade no contexto do HIV/Aids aos três meses de vida do bebê

O estudo investigou a experiência da maternidade em portadoras do HIV/Aids aos três meses de vida do filho/a. Participaram seis mães (19 a 30 anos), de nível sócio-econômico baixo, três das quais já eram portadoras da doença quando engravidaram, enquanto as demais souberam no parto. As mães foram entrevistadas e suas respostas foram examinadas por meio de uma análise de conteúdo qualitativa baseada em quatro eixos teóricos: vida-crescimento, relacionar-se primário, matriz de apoio e reorganização da identidade. Os resultados mostraram que as mães tinham muitas preocupações com a possibilidade de infecção do filho/a e com a saúde do bebê, além de sentimentos de incerteza quanto ao futuro, culpa e medo do preconceito. Esses temores pareciam mais intensos para as mães que tiveram seu diagnóstico no parto. O estigma do HIV/Aids, conflitos familiares, dificuldades com o diagnóstico e o tratamento, além de restrições sócio-econômicas e em sua rede de apoio exigiam grande esforço emocional dessas mulheres, sugerindo a necessidade de intervenções psicossociais visando à adesão ao tratamento, à qualidade de vida e ao desenvolvimento do bebê.

Burden of depression among impoverished HIV-positive women in Peru

OBJECTIVES

In resource-poor settings, the mental health burden among HIV-positive women is exacerbated by poverty. We sought to describe the extent, risk factors, and experience of depression among impoverished HIV-positive women living in Lima, Peru.

METHODS

This is a case series of 78 HIV-positive women in Lima, Peru. We measured depression, stigma, and social support and performed a multivariable analysis to identify factors associated with depression.

RESULTS

Among 78 HIV-positive patients, 68% were depressed. Depression and suicidal ideation were rarely diagnosed by providers. In multivariable analysis, HIV-related stigma and food scarcity were associated with depression.

CONCLUSIONS

In our cohort of HIV-positive women in Lima, Peru, poverty and socioeconomic vulnerability contributed to depression. Findings highlight the heavy burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral component of HIV care.

Mothers' experiences of having a preterm infant in the neonatal care unit: a meta-synthesis

Neonatal nurses today are challenged not only to provide the best possible developmental care for a preterm infant but also to help the mother through an uncertain motherhood toward a feeling of being a real mother for her preterm baby. An increasing interest in mothers' experiences of having a preterm baby is seen. A meta-synthesis of 14 qualitative research studies on mothers' experiences of having a preterm baby in the neonatal intensive care unit, published from 2000 onward, was conducted. Noblit and Hare's methodological approach was used. The meta-synthesis revealed five metaphors that captured the mothers' experiences. These metaphors centered on reciprocal relationships that consisted of mother-baby relationship ("from their baby to my baby"), maternal development (a striving to be a real normal mother), the turbulent neonatal environment (from foreground to background), maternal caregiving and role reclaiming strategies (from silent vigilance to advocacy), and mother-nurse relationship (from continuously answering questions through chatting to sharing of knowledge). Implications of the meta-synthesis for neonatal nursing are addressed.

HIV-infected mothers' foci of concern during the viral testing of their infants

The objective of this study was to explore HIV-infected mothers' most worrisome concerns during their infants' HIV viral testing. A total of 20 HIV-infected women consented to one antepartum and five postpartum study visits clustered around infant HIV viral testing time points. Content analysis was used to categorize maternal responses about their concerns. The majority (80%) of mothers identified infant health as the most worrisome concern during the prenatal and early postpartum periods. This concern declined after the second infant viral test result but rebounded before obtaining the final viral test. Once the final viral test result was known, the majority (60%) of mothers identified psychosocial issues as most worrisome. Maternal health did not surpass infant health or psychosocial issues as a primary concern. The primary concern of the HIV-infected mothers in this study was infant health during the infant viral testing period. Maternal health issues remained secondary to infant health and psychosocial issues as major concerns several months after infant viral testing was completed.

HIV-related stigma among people with HIV and their families: a qualitative analysis

We examined the interconnectedness of stigma experiences in families living with HIV, from the perspective of multiple family members. Semi-structured interviews were conducted with 33 families (33 parents with HIV, 27 children under age 18, 19 adult children, and 15 caregivers). Parents were drawn from the HIV Cost and Services Utilization Study, a representative sample of people in care for HIV in US. All of the families recounted experiences with stigma, including 100% of mothers, 88% of fathers, 52% of children, 79% of adult children, and 60% of caregivers. About 97% of families described discrimination fears, 79% of families experienced actual discrimination, and 10% of uninfected family members experienced stigma from association with the parent with HIV. Interpersonal discrimination seemed to stem from fears of contagion. Findings indicate a need for interventions to reduce HIV stigma in the general public and to help families cope with stigma.

Aspectos psicológicos da gestação e da maternidade no contexto da infecção pelo HIV/Aids

A epidemia de HIV/aids tem atingido cada vez mais mulheres em idade reprodutiva, sendo que muitas já são mães ou se tornam mães quando descobrem a infecção. Os estudos revisados indicam que a infecção pelo HIV/Aids pode alterar de muitas formas a experiência da gestação e da maternidade, gerando uma sobrecarga psicológica relacionada ao estigma e ao risco de transmissão para a criança. Apesar disso, pesquisas sugerem que muitas mulheres portadoras do HIV/Aids buscam transmitir uma identidade materna positiva para os filhos e se preocupam intensamente com o futuro deles. Foram encontrados poucos estudos brasileiros sobre aspectos psicológicos da maternidade nesse contexto, em especial a respeito do impacto da profilaxia para prevenção da transmissão vertical sobre a experiência da gestação, do parto e do puerpério. As dificuldades em aderir ao tratamento e a práticas sexuais seguras denotam a falta de atenção às demandas específicas dessas mães, sendo que o foco das políticas de saúde permanece sobretudo dirigido para a criança.

Challenges in approaching metasynthesis research

The overall aim of this study was to contribute to the development of metasynthesis through an analysis of the challenges involved. The study grew out of the critique of qualitative metaresearch raised by current developers of metamethodologies. Different views on the application of methodologies have emerged in the literature, contributing to confusion and ambiguity concerning the challenging questions of what, why, how, and who in metasynthesis research, which might increase the risk of misunderstanding. The roots of metasynthesis research are seen as multifaceted and influencing the development of the methods in different directions. The primary worth of metasynthesis is theoretical and/or methodological development (synthesis) combined with the potential for reflection: going beyond and behind the studies (meta). Metasynthesis research has also the potential to raise questions of research collaboration, culture, and language.