Stigma, Structural Vulnerability, and “What Matters Most” Among Women Living With HIV in Botswana, 2017

Abstract

Objectives. To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from “what matters most” in local culture. Methods. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Results. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners’. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner’s status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as “promiscuous” and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Conclusions. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies. (Am J Public Health. Published online ahead of print June 10, 2021: e1–e9. https://doi.org/10.2105/AJPH.2021.306274 )

A pilot pragmatic trial of a “what matters most”-based intervention targeting intersectional stigma related to being pregnant and living with HIV in Botswana

“…Our study has several limitations. First, whereas societal change is needed to gradually decrease harmful rigidity in gender roles and reduce inequitable power dynamics, we believe that achieving capabilities that “matter most” is particularly valuable when these are participant-identified [ 4 ]. Of note, the intervention assists participants in making use of these core values when beneficial and when they are often experienced as paramount (i.e., during pregnancy).…”

“…Third, the MME intervention is well-suited for embedding within routine ANC, which is free in Botswana. Finally, given prior findings that stigma manifests in ANC clinic-level practices among pregnant women with HIV in Botswana [ 4 ] and the desirability of intervening at the structural level to address intersectional stigma, targeting stigma at the healthcare facility level could augment effects via a multi-level intervention [ 7 , 24 , 25 ]. In closing, we found that identifying and targeting intersectional stigma via the WMM framework and promoting capabilities that ‘matter most’ for achieving ‘personhood’ facilitated a targeted HIV stigma intervention to show initial reductions in stigma and depression among WLHIV.…”

“…Gendered conceptions for women link HIV with promiscuity and immorality, and can lead to being blamed for contracting HIV and spreading it to partners, feared and actual abandonment by partners, and community rejection [ 3 ]. These gendered manifestations of HIV-related stigma can further intersect with pregnancy, as HIV-related stigma is often elicited during routine antenatal care (e.g., pregnant WLHIV being identified first through routine testing for prevention of mother to child transmission [PMTCT] [ 4 ]); further, in addition to rejection by partners and the community, women may experience rejection from clinic staff who may hold beliefs that women with HIV should not become pregnant or become mothers [ 4 ].…”

“…In Botswana, we found achieving full ‘womanhood’ is primarily expressed by being a ‘respected mother.’ Correspondingly, our two-step directed content analysis of 5 focus group discussions and 46 in-depth semi-structured interviews of people with known and unknown HIV status in Botswana using the WMM framework found HIV-related stigma threatens ‘womanhood’ because having HIV elicits perceptions of promiscuity and risks abandonment by partners, thus threatening achievement of ‘womanhood’ that accompanies giving birth. Then, during pregnancy, this stigma further threatens ‘respected motherhood’ by eliciting perceptions of irresponsibility by potentially endangering the baby (i.e., by exposing the baby to HIV) [ 4 ].…”

Theory-Driven, Multi-Stage Process to Develop a Culturally-Informed Anti-Stigma Intervention for Pregnant Women Living with HIV in Botswana

“…1) Qualitative Study: identifying WMM for men and women in Botswana and examining how the fulfillment of these goals is shaped by HIV and structural vulnerability in Botswana 15 , 16 …”