The meaning of postpartum sexual health for women living in Spain: a phenomenological inquiry

There is 'no cure for caregiving': the experience of women caring for husbands living with Parkinson's disease

BACKGROUND

Parkinson's disease is a progressive neurodegenerative disorder. The majority of the nearly 9 million people living with Parkinson's disease are men. As such, caregiving is often assumed by wives as the disease progresses. However, there is little research about the lived experience of wives as they transition to caregivers.

OBJECTIVE

To describe the lived experience of wife caregivers of male spouses living at home with Parkinson's disease.

METHODS

A descriptive phenomenological study. Semi-structured interviews were recorded and transcribed for analysis in Atlas.ti using Colaizzi's method.

RESULTS

Thirteen women, aged 50 to 83 years, were interviewed. Five themes emerged from the analysis, (1) caregiver who? (2) taking it day by day, (3) not sure what to do next, (4) just too much, and (5) caring is your soul's growth, to support the central theme "there is no cure for caregiving."

CONCLUSION

Transitioning from wife to caregiver was a gradual but difficult process. Although the wife caregivers wanted to be part of the health care team, they remained outsiders. Clinicians need to recognize the wives as care coordinators linking medical management with home care. Policy makers need to develop reimbursement models that provide wife caregivers with support groups, education programs, and telemental health services.

Impact of a keto diet on symptoms of Parkinson's disease, biomarkers, depression, anxiety and quality of life: a longitudinal study

Aim: Evidence suggests low-carbohydrate diets (LCHF) may assist in treating neurodegenerative diseases such as Parkinson's disease (PD); however, gaps exist in the literature. Patients & methods: We conducted a small 24-week pilot study to investigate the effects of an LCHF diet on motor and nonmotor symptoms, health biomarkers, anxiety, and depression in seven people with PD. We also captured patient experiences during the process (quality of life [QoL]). Results: Participants reported improved biomarkers, enhanced cognition, mood, motor and nonmotor symptoms, and reduced pain and anxiety. Participants felt improvements enhanced their QoL. Conclusion: We conclude that an LCHF intervention is safe, feasible, and potentially effective in mitigating the symptoms of this disorder. However, more extensive randomized controlled studies are needed to create generalizable recommendations.

Puerperal women's social interactions related to their sexual health after childbirth

OBJECTIVE

To analyze puerperal women's experiences of sexual health after childbirth from the perspective of symbolic interactionism.

METHOD

Descriptive, qualitative study. Twenty semi-structured interviews were conducted by videoconference with women in the remote puerperium, captured by snowball technique and searched for "seeds" on Instagram®. Bardin's content analysis and Symbolic Interactionism were used as references.

RESULTS

The puerperal women signify sexual health from a perspective of comprehensive healthcare. However, due to the duality between "being a woman" and "being a mother", they recognize fear, bodily transformations and changes in focus from the love relationship to caring for the baby as factors that interfere with sexual health. And they choose to put themselves aside, prioritizing caring for others. They re-signify sexual health by recognizing the importance of taking care of themselves in biopsychosocial aspects and try to recover self-care for a healthy sexual experience.

CONCLUSION

Despite the meanings attributed, women's social interactions with the puerperium interfere negatively with sexual health. Professionals should be sensitized to the inclusion of actions that promote changes in the social action of these women towards self-care.

'Feeling Ready': A Feminist Poststructural Analysis of Postpartum Sexual Health

There exists a lack of literature surrounding how postpartum individuals define feeling 'ready' to resume sexual activities after childbirth. Many factors may influence feelings of desire or readiness for sexual activities, such as breastfeeding. Therefore, it is important to understand why and how postpartum individuals understand and make meaning of their experiences surrounding postpartum sexual activities, as well as how those experiences are influenced or negotiated through relations of power. This study was guided by feminist poststructuralism and discourse analysis. Eleven participants who were between 1 and 6 months postpartum and living in Nova Scotia, Canada, were interviewed using semi-structured interviews. Participants challenged certain discourses surrounding sexual activities postpartum, including the social discourse that positions sexual activities as a requirement within romantic relationships and the discourse that positions health care providers as the authority on postpartum sexual health. 'Feeling ready' centered on four main issues: (1) navigating physical recovery; (2) personal knowing and emotional readiness; (3) the 6-week check; and (4) redefining intimacy. This article describes one branch of the findings within the overall study. Choosing to resume sexual activities postpartum, or feeling ready to do so, is individual, fluid, and complex. This research has important implications for practice and policy, specifically as it pertains to postpartum care.

Development of an educational guide for postpartum sexual health promotion: The Delphi method

BACKGROUND

The Promotion of sexual health has been emphasized in Sustainable Development Goals (SDGs). As a primary prevention strategy, the promotion of sexual knowledge can reduce the incidence of postnatal sexual disorders. This study aimed to develop an educational guide for postpartum sexual health promotion.

MATERIALS AND METHODS

This qualitative study was conducted in 2021 in Tehran. The steps of developing the educational guide were based on the model of the National Institute for Health and Clinical Excellence (NICE). First, the related guidelines, books, booklets, and original articles were comprehensively reviewed. Based on the scientific evidence, the educational content was compiled. Then, the quality of this content was evaluated using the Delphi method; It was performed using expert opinions with the Appraisal of Guidelines for Research and Evaluation (AGREE) tool.

RESULTS

The educational content was developed in three chapters as follows: basic sexual education, postpartum changes and prevalent sexual problems of this period, and strategies for solving or adapting to postpartum sexual problems. This guide was developed in two separate sections for healthcare providers and mothers. The content was of excellent quality in all 6 domains of the AGREE tool (>90%); and evaluated to be optimal in terms of scientificity, significance, and feasibility with the consensus of experts (>95%).

CONCLUSIONS

In this research, the steps of developing a comprehensive evidence-based educational guide for sexual health services in postpartum care were described, and its content was presented. The validity of the compiled content was also confirmed.

Prevalence and factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysis

INTRODUCTION

Postpartum sexual health is indicated by a resumption of sexual activity as well as arousal, desire, orgasm, and sexual satisfaction. The issue of resuming sexual intercourse after childbirth has received limited attention because healthcare professionals rarely provide adequate care to postnatal women. The present study aimed to ascertain the overall prevalence of early resumption of sexual intercourse among most women.

METHODS

Searches were conducted in PubMed, Web of Science, Science Direct, Google Scholar, African Journals Online, and the Cochrane Library. Data were extracted using Microsoft Excel, and STATA version 14 was used for analysis. Publication bias was checked by funnel plot, Egger, and Begg regression tests. A p-value of 0.05 was regarded to indicate potential publication bias. Using I2 statistics, the heterogeneity of the studies was evaluated. By country, a subgroup analysis was conducted. A sensitivity analysis was carried out to determine the effect of each study's findings on the overall estimate. The random effects model was used to assess the overall effect of the study and then measured using prevalence rates and odds ratio with 95% CI.

RESULTS

Twenty-one studies with 4,482 postpartum women participants were included in the study. The pooled prevalence of early resumption sexual intercourse among post-partum women was 57.26% (95% CI 50.14, 64.39) with significant heterogeneity between studies (I2  =  99.2%; P-value ≤ 0.000) observed. Current contraceptive use (AOR = 1.48, 95%CI = 1.03, 6.21), primipara (AOR = 2.88, 95%CI = 1.41, 5.89), and no history of severe genital injury on the last delivery (AOR = 2.27, 95%CI = 1.05, 4.93) were significantly associated with early resumption of sexual intercourse.

CONCLUSION

This study found that more than half of women resumed sexual intercourse early after giving birth. This suggests that a significant number of women may be at higher risk of unwanted pregnancies, short birth intervals, and postpartum sepsis. Thus, stakeholders should improve the integration of postpartum sexual education with maternal health services to reduce the resumption of postpartum sexual intercourse.

Quality of Life and Sexual Satisfaction in the Early Period of Motherhood-A Cross-Sectional Preliminary Study

The aim of the study was to assess the impact of breastfeeding-related fatigue and family support on the sexuality and quality of life of mothers during early motherhood. A cross-sectional preliminary study was conducted between 1 October 2021 and 15 May 2022 in 65 women being in early postpartum period. We used the authors' questionnaire developed for the purposes of the study; the Sexual Satisfaction Scale for Women-SSS-W; the Mell-Krat scale for women; and the General Health Questionnaire-GHQ28. A significant negative correlation was found between the age of the patients and the reduction in somatic symptoms (GHQ28 questionnaire) (r = -0.315, p = 0.011). Women working professionally achieved significantly higher results in the SSS-W contentment category (r = 0.313, p = 0.014). Frequent sexual activity reduced disorders in social functioning (the GHQ28 questionnaire) (r = -0.107, p = 0.283). Women who breastfed up to 5 times a day (p = 0.033) reached significantly higher SSS-W scores in terms of communication. The partner's help significantly contributed to higher sexual satisfaction in the aspect of compatibility (p = 0.004) and the overall level of satisfaction determined with the SSS-W questionnaire (p = 0.016). The presented study suggests that older mothers who are employed and supported by a partner have a higher level of contentment, sexual satisfaction and quality of life.

How do new mothers describe their postpartum sexual quality of life? a qualitative study

BACKGROUND

Sexuality plays a critical role in a woman's postpartum quality of life and also has a strong impact on the quality of her relationship. Given the sparse body of published literature on the subject, we aimed to explore how new mothers explain their postpartum sexual quality of life.

METHOD

A qualitative study was carried out in Iran and Switzerland from December 2018 to March 2019. Focus groups and semi-structured in-depth interviews (IDIs) were conducted with mothers in the first four months after parturition. Mothers who were older than 18 years, were married or in a stable relationship, and experienced a low-risk vaginal birth or cesarean section participated in the study. We used Graneheim and Lundman's approach for analyzing the data. Multiple data collection methods, maximum variation sampling, and peer checks were applied to enhance the rigor of the data.

RESULTS

We achieved data saturation after two focus group discussions (FGDs), 15 IDIs in Iran, and 13 IDIs in Switzerland. We extracted three themes for postpartum sexual quality of life: (a) sexual worldview, (b) interpersonal relationship, and (c) postpartum sex storm. The participants described sexual worldview as "sexual beliefs", "sexual perceptions", and "sexual behaviors". The interpersonal relationship consists of "changes in postpartum interpersonal relationships" and "supportive role of the husbands/partners". The last one, postpartum sex storm, has three categories including "direct changes in sexual life", "indirect changes in sexual life", and "resumption of sexual intercourse". Differences between the two cultures were identified in some subcategories such as "sexual interests", "comparable to the first intercourse in life", "negative sexual behaviors of husbands/partners", "positive sexual behavior of mothers", "helping with child care and housework", and "emotional support".

CONCLUSION

New mothers explained postpartum sexual quality of life as a three-theme phenomenon. Although most results were similar in both cultures, there were some differences. Our study's results suggest that sexual quality of life is a topic that encompasses international as well as cultural aspects.

Pregorexia: a systematic review and meta-analysis on the constructs of body image dissatisfaction and eating disturbances by gestational age in the peripartum

PURPOSE

Pregorexia is a phenomenon posited to occur in the peripartum, characterized by an attempt to counter pregnancy's physiological changes in body shape through reduced calorie intake or increased physical activity.

METHODS

In this pre-registered systematic review and meta-analysis, body image dissatisfaction and eating psychopathology in the peripartum according to gestational age were formally assessed. PubMed was searched up to May 2023. Selection criteria were represented by studies on body image concerns or eating psychopathology in the peripartum (up to 1 year after delivery). The population needed to include women from the general population or among patients with a history of (or current) eating disorder. For the meta-analysis, 17 studies were included: 10 for body image dissatisfaction (2625 individuals overall), 7 for eating behaviors (2551 individuals overall). The interplay between body image and the following themes was examined in depth: the adoption of breastfeeding, peripartum depression, sociocultural influences on body image, sexual disturbances, experiencing or reporting an altered food intake.

RESULTS

Progressive dissatisfaction with body image during pregnancy by gestational age was observed, stably elevated for at least 12 months postpartum. Eating psychopathology was observed as elevated only at 12 months in the postpartum, but not during pregnancy.

DISCUSSION

The current work offers normative values of body image satisfaction and eating psychopathology in the peripartum by gestational age. The relevance of current results was discussed, in order to inform both current clinical practice and future public policies.

LEVEL OF EVIDENCE

Level I-Evidence obtained from: systematic reviews and meta-analyses.

Comparison Between the Effect of the Information-Motivation-Behavioral (IMB) Model and Psychoeducational Counseling on Sexual Satisfaction and Contraception Method Used Under the Coercion of the Spouse in Iranian Women: A Randomized, Clinical Trial

OBJECTIVE

 Women play an essential role in maintaining the family's health, and family planning is part of women's and families' health. The couple's mutual understanding of family planning methods is essential in selecting contraception. Acceptance of and satisfaction with different contraception methods can impact sexual satisfaction. The present study aimed to compare the effect of the information-motivation-behavioral (IMB) model and psychoeducational counseling on sexual satisfaction and contraception methods of women referring to health centers in Kerman.

METHODS

 This trial was conducted on 81 women aged 18 to 45, in Kerman health centers, from 2021 to 2022. Participants were randomly divided into 3 groups of 27 people (control, psychoeducational counseling, and IMB method). Three online counseling sessions were held for the psychoeducational group, and four were held for the IMB group. The control group received routine care. The IBM SPSS Statistics for Windows, version 22 (IBM Corp. Armonk, NY, USA) was used for data analysis using nonparametric Friedman and Kruskal-Wallis tests.

RESULTS

 The mean age of participants was 32.59 ± 7.04, and the majority of them had university degrees and were homemakers. The mean sexual satisfaction score significantly increased immediately after the intervention and 1 month later in the 2 interventional groups (p < 0.0). Changes in contraception methods after intervention were significant in the psychoeducational group (p = 0.0) CONCLUSION:  The results indicate the positive impact of psychological counseling on women's sexual satisfaction and contraception method. The IMB method also impacted men's sexual satisfaction but did not lead to any changes in the contraceptive method.

Does the postpartum body image of primiparous women giving vaginal delivery affect their sexual functions and depression and fatigue levels?

The body image-related problems can negatively affect women's lives in many ways. The study was aimed at investigating the effects of postpartum body image on sexual functions, and fatigue and depression levels of primiparous women who gave birth vaginally. This cross-sectional study was conducted with 133 women who presented to the obstetrics and gynecology clinics of a state hospital in Turkey between June 2021 and December 2021. At the end of the study, a moderate relationship was determined between the women's body image and their depression (r = 0.500; p < 0.001) and fatigue (r = 0.666; p < 0.001) levels, and a weak relationship between their body image and sexual functions (r = -0.372; p < 0.001). According to the backward regression model used in the study, the women's fatigue and education levels accounted for their body image by 45.7%.

Percepções e vivências de mulheres acerca da sexualidade durante o período de amamentação

Objetivo: apreender como as mulheres percebem e vivenciam a sexualidade durante o período da amamentação. Método: estudo descritivo de abordagem qualitativa, realizado com mulheres lactantes ou que já haviam amamentado, em seis Unidades Básicas de Saúde de município da região Sul do Brasil. Os dados foram coletados no período de maio a agosto de 2018, mediante entrevistas semiestruturadas, áudio-gravadas, realizadas em local reservado nas unidades de saúde. As informantes foram 18 mulheres com filhos de até 12 meses de vida, que estava sendo ou tivesse sido amamentado ao seio por algum tempo, e que compareceram à Unidade de Saúde para puericultura ou consulta com pediatra durante o período da coleta de dados. Foram excluídas as mulheres que referiram não ter iniciado a prática sexual no período de amamentação. Os dados produzidos foram submetidos à análise de conteúdo modalidade temática. Resultados: as mulheres percebem e vivenciam a sexualidade durante a amamentação por meio de mudanças na autoimagem, na autoestima e no relacionamento com o parceiro. As modificações mamárias foram bem percebidas no período gestacional e no início da amamentação, porém, com o decorrer do tempo, algumas mulheres as perceberam de forma negativa, sobretudo aquelas que tiveram mais dificuldade na retomada do peso pré-gravídico. Os resultados mostraram também que as mulheres passaram por um período de incertezas e inseguranças em relação a sexualidade e que mudanças da dinâmica conjugal foram necessárias neste período de transição para o exercício da sexualidade, considerando necessidades do suporte nutricional e afetivo do bebê. Conclusão: as mulheres percebem e vivenciam dificuldades em conciliar a sexualidade com a amamentação, visto que a nova dinâmica familiar decorrente do nascimento de um filho, associada as alterações na estética corporal, podem repercutir de forma negativa na sexualidade.

Women Caring for Husbands Living with Parkinson’s Disease: A Phenomenological Study Protocol

Parkinson’s disease (PD) is an emerging pandemic caused by aging, longevity, and industrialization. Most people diagnosed with PD initially experience mild symptoms, but over time the symptoms become debilitating. Given their intensive care requirement, most married people living with PD receive care from their spouses; most are female caregivers. Because caregiving is hard work with long hours, caregivers experience stress, fatigue, and depression, often leading to exhaustion and burnout. The purpose of this descriptive phenomenological study is to understand the lived experience of women caregivers of husbands living with PD. As part of this study protocol, women caring at home for their husbands diagnosed with PD will be purposely recruited from the Colorado Parkinson Foundation. Semi-structured interviews will be conducted by Zoom© until data saturation is achieved. Colaizzi’s seven-step process will be used to analyze the data in Atlas.ti. Strategies have been incorporated into the study protocol to maximize trustworthiness and to insure methodological rigor. The study will be reported using recommendations from the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research. Findings from this study may guide intervention development to improve the caregiving experience and to inform clinical practice guidelines for health care professionals.

Recovering Sexuality after Childbirth. What Strategies Do Women Adopt? A Qualitative Study

This study aimed to determine the strategies used by women to adapt to the changes that affect the first sexual relations after childbirth. A qualitative study with a phenomenological approach used three data collection techniques (in-depth interviews, discussion groups, and online forums). Thirty-six women in the first six months postpartum participated in the study, from physiotherapy centers with maternal child specialties in several locations in Spain. Women with different types of delivery, presence or absence of perineal trauma during delivery, previous deliveries, and different types of breastfeeding were included. Among the strategies, closeness support and understanding were the ones that women used to adjust to the new situation, in order to improve the couple's relationship, intimacy, and cope with the significant changes that appear in the first six months postpartum. Changes and adaptations in sexual practices become a tool for coping with a new sexuality, especially if it is affected by the presence of pain or discomfort associated with physical changes. Personal time facilitates emotional management and improvement of emotional changes related to the demands of motherhood. Accepting the changes that motherhood brings is critical to dealing with the new situation. Strategies used by postpartum women focus on acceptance, self-care, partner, couple time, personal time, and adapting encounters. The findings of this study are of interest to health professionals as they provide insight into how women cope with the changes that appear in the first six months postpartum. In this way, the findings will be able to transmit to couples the alternatives they can adopt before the resumption of sexual relations to improve satisfaction both as a couple and in terms of sexuality after childbirth.

Factors associated with postpartum resumption of sexual intercourse among women in China: A retrospective multicenter study

OBJECTIVE

To examine the prevalence and factors associated with early resumption of sexual intercourse among postnatal women in China.

METHOD

We conducted a retrospective multicenter study of 15 834 postpartum women from 60 hospitals in 15 different locations across China. Data were obtained from questionnaires administered to the participants. All dates were analyzed using a one-way ANOVA and two-level Cox multiple linear regression models.

RESULTS

More than half of the participating women (55.9%) resumed sexual intercourse by 3 months postpartum. The independent variables associated with the postpartum resumption of sexual intercourse included sociodemographic characteristics (age, geographic location, educational attainment) and medical histories, including the previous abortion (incorporate with spontaneous and voluntary abortion) frequency, menstrual recovery, exclusive breastfeeding, and number of living children (p < 0.05).

CONCLUSION

More than half of the women in this study resumed sexual intercourse within 3 months postpartum. Women with a lower educational attainment and from the western regions of China were more likely to resume sexual intercourse earlier. Increasing age, delayed recovery of menses, and exclusive breastfeeding were associated with a delayed resumption of sexual intercourse. Women who had greater experience with abortion or the number of living children resumed sexual intercourse earlier than their counterparts.

Sexual health issues postpartum-A mixed methods study of women's help-seeking behavior after the birth of their first baby

OBJECTIVE

To identify women's help-seeking behavior in relation to sexual health issues after the birth of their first baby.

DESIGN

A mixed methods sequential explanatory study design was utilized. Phase one of the study consisted of a prospective cohort study to identify the help-seeking behavior of women experiencing sexual health issues at 3, 6, and 12 months postpartum. Phase two consisted of a qualitative descriptive design to explore women's help-seeking behavior for sexual health issues postpartum.

SETTING & PARTICIPANTS

The setting was a large urban tertiary referral maternity unit (greater than 8000 births per year) in the Republic of Ireland. Nulliparous women aged 18 years and over were invited to participate in phase one. Phase two consisted of a subsample of women who consented to being contacted for further research on admission to the study.

FINDINGS

Few women consulted a clinician for postpartum sexual health issues at each of the study's three, six and twelve month time-points. For example, only 2.9% (n=18) of women experiencing dyspareunia, and 3.6% (n=16) of those experiencing a lack of vaginal lubrication spoke to their General Practitioner (GP) about these issues at three months postpartum. The qualitative data supported the quantitative findings and suggested that even when women proactively sought help from healthcare professionals they were met with unhelpful responses. In the absence of support from practitioners, women became active agents and sought information from other women or the internet. In an effort to improve practice women recommended a greater focus on their physical and emotional recovery from birth.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Very few women consulted with a clinician about their experience of sexual health issues after birth. Findings will contribute to and assist policy makers in planning future postnatal services for women to include extending the final postnatal assessment beyond six weeks after birth.

Exploring the Complexities of Postpartum Sexual Health

Purpose of Review

This paper explores the complexities of postpartum sexual health. It answers the question on what should be considered normal sexual health after birth and what should be considered abnormal.

Recent Findings

Many women experience physical sexual health issues in the months after birth, such as dyspareunia, lack of vaginal lubrication and a loss of sexual desire. For some women, these issues can persist 12 and 18 months after birth. Mode of birth is not associated with long-term dyspareunia 6 and 12 months after birth. There is conflict seen in the literature with regard to the association between perineal trauma and short-and long-term sexual health. Breastfeeding and the existence of pre-existing sexual health issues are strongly predictive of sexual health issues at 6 and 12 months after birth. Women have described a discordance in their sexual desire to that of their partner, for some this caused distress but for couples who communicated their feelings of sexual desire, concern over baby’s well-being and adapting to parenthood distress was not experienced. Resuming sexual intercourse after birth was not spontaneous, women considered their mode of birth, the presence of perineal trauma and their physical and emotional recovery from birth. One fifth of women had not resumed sexual intercourse 12 weeks after birth.

Summary

A discussion is presented on the challenges associated with viewing postpartum sexual health from a physical perspective only, and why prevalence studies alone do not capture the nuances of postpartum sexual health. Future research needs to take account of the psychosocial and relational dimensions of postpartum sexual health as well as physical dimensions.

'Staying alive' with antiretroviral therapy: a grounded theory study of people living with HIV in Peru

BACKGROUND

To achieve an optimal quality of life through chronic disease management, people living with HIV (PLHIV) must adhere to antiretroviral therapy (ART). ART has been available throughout Peru since 2004 without cost in all regions; yet only 60% (43 200) of PLHIV receive ART and 32% are virally suppressed. Despite the low adherence, little is known about the experience of PLHIV with ART adherence in the context of Latin America.

METHODS

A constructivist grounded theory design was used to understand the ART adherence experiences of PLHIV in Northern Peru. Unstructured interviews were conducted with 18 participants resulting in theoretical saturation. All interviews were recorded, immediately transcribed and analysed concurrently with data collection using constant comparative analysis with Atlas.ti (V.8) software. Rigour was maintained through openness, reflexivity, audit trail, memo writing, debriefings, member checks and positionality.

RESULTS

The core category 'staying alive' emerged through the interaction of four categories, including: (1) overcoming barriers; (2) working with the healthcare team; (3) tailoring self-care strategies; and (4) appreciating antiretrovirals. Adherence is not a spontaneous outcome, instead, the surprise of HIV diagnosis transitions to living with HIV as a chronic disease. The healthcare team helps PLHIV realise ART is their life source by enhancing, supporting and facilitating self-care and overcoming barriers.

CONCLUSION

Adherence emerges from experiential learning as PLHIV recognised ART as their life source in balance with their desire to continue living a normal life. Social support and healthcare team interventions help PLHIV implement tailored self-care strategies to overcome personal, social, and structural barriers to adherence. Healthcare professionals need to recognise the challenges confronted by PLHIV as they learn how to continue living while trying to stay alive.