Lynae A. Darbes

Childbearing is of central importance in Eastern and Southern Africa and is deeply intertwined with social, cultural, and economic factors (Abdi et al. 2020; Barbi et al. 2021; Ngotie, Kaura, and M...

Data from East and Southern Africa shows that the desire for children is strong (between 35–80%) among people living with HIV (PLHIV) and among those in sero-different relationships (where one part...

Data from eastern and southern Africa show the desire for children is strong among people living with HIV (PLHIV) and among those in sero-different relationships, with between 35 and 80% expressing...

Objective: Safer conception strategies to reduce HIV transmission to sero-different partners are underused. Studies suggest this may be due to HIV-related stigma. We conducted a qualitative study to examine how forms of HIV stigma may impact reproductive decisions and seeking safer conception services.Methods: In-depth interviews (IDIs) with 16 sero-different couples residing in Kisumu County, Kenya, explored HIV-related stigma surrounding pregnancy, where stigma comes from, and if stigma might impact couples seeking safer conception services. Deductive and inductive approaches and framework analysis were used to analyze data at individual and dyadic levels.Results: Couples reported anticipated and enacted HIV stigma from the community. Among couples, there was little evidence of internalized stigma, and most participants described partner support and acceptance. Enacted stigma from healthcare workers was also rare. Although not described as internalized stigma, most participants expressed fear of HIV transmission to children and partners.Conclusion: These findings provide insight into sources and types of stigma that sero-different couples experience while navigating reproduction and its effect on seeking safer conception services. Interventions that address stigma from the community may help couples overcome stigma experienced at that level.

Introduction While improvements have been made across the HIV care continuum in South Africa, gaps remain. Relationship-focused couples-based approaches may be one avenue to improve HIV-related outcomes for men and women. Prior couples-based studies have been found to improve several HIV care and treatment outcomes in this context, but few have considered viral suppression as the primary outcome. We aimed to compare a couples-based motivational-interviewing intervention delivered to couples to similar content delivered to men and women in couples separately. We will test the efficacy of this approach in a randomised controlled trial. Methods and analysis Our goal is to enrol 270 heterosexual couples for this trial, with at least one partner living with HIV. Couples will be randomised into one of two arms, stratified by couples’ HIV status. The intervention arm, Simunye (‘We are one’ in isiZulu), will provide two sessions of motivational information and skills regarding HIV-related behaviours to couples together, along with relationship-focused content and skills. The content is based on Partner Steps (P-steps), a couples-focused adaptation of Life Steps, an evidence-based programme shown to improve adherence and viral suppression. The control group will receive two sessions as individuals, with similar HIV-related information but without relationship-focused content. Participants will be followed up at 6, 12 and 18 months postrandomisation. The baseline questionnaire will include measures of relationship domains such as satisfaction and communication, and measures pertaining to HIV and reproductive health (eg, fertility intentions, HIV knowledge and risk perception, and sexual behaviour), and mental health (eg, depression symptoms). The primary outcome is viral suppression, based on dried blood spots. Secondary outcomes will include other aspects of treatment engagement. We will also examine hypothesised mediators of intervention participation, for example, relationship dynamics. Primary analyses will use a multilevel modelling approach, which will feature planned time-averaged comparisons of postbaseline measurements across the intervention and control groups to test the primary hypothesis. The analysis will account for the dyadic nature of the data, for example, participants nested within couples. Ethics and dissemination This trial was approved by the Institutional Review Board (IRB) at the Human Sciences Research Council in South Africa, protocol number 2/27/01/21, and the IRB at the University of Michigan (HUM 00203672). Human subjects’ concerns or adverse events will be reported to both IRBs and the Data Safety and Monitoring Board. We will disseminate findings to community members and stakeholders via community meetings, as well as by conference presentations and publications in peer-reviewed journals. Trial registration number Clinicaltrials.gov Protocol Registration NCT05231707 registered on 8 February 2022. Protocol version 2.0, 31 October 2025.

Background: African refugee communities in Uganda encounter significant barriers to maternal health services, particularly regarding men’s involvement in maternal health. This study explored the perspectives of African refugees and stakeholders on men’s engagement in couple’s maternal health decisions, utilizing an interdependence‐based theoretical model as a framework. Methods: This qualitative study, conducted in Uganda’s Nakivale refugee settlement, included 14 in‐depth interviews with healthcare providers, community leaders, and religious leaders, along with eight focus group discussions ( n = 78) with refugee men and women. Participants were purposefully recruited to represent diverse experiences. Data were analyzed through deductive analysis to identify factors influencing men’s engagement and couple’s behaviors in maternal health, emphasizing predisposing factors that affect motivation and communal coping. Results: Key individual‐level factors influencing engagement included men’s financial status, mental health, and peer/community influence. At the couple level, closeness, trust, commitment, communication, and joint household decision‐making were crucial for fostering male participation. Couples with a high transformation of motivation viewed maternal health as a shared concern rather than an individual one. Those practicing effective communal coping, discussing and jointly deciding to address maternal health issues, also expressed higher engagement in health‐promoting behaviors, such as saving for birth, attending antenatal visits together, utilizing family planning, and sharing household chores. Conclusions: Maternal health should be reframed as a shared responsibility between partners, not solely women’s issue. To effectively engage African refugee couples and improve outcomes, interventions must prioritize men’s involvement alongside women‐focused efforts, eventually addressing couples together. These initiatives should enhance men’s financial literacy, mental health, knowledge, and relationship quality to foster equitable discussions, decisions, and behaviors between refugee couples.

Decision-making on childbearing and safer conception use in HIV sero-different couples involves an intricate balance of individual desires and perceived HIV acquisition risk. This paper addresses an important knowledge gap regarding HIV sero-different couples' considerations and the relationship and power dynamics involved when deciding to use a safer conception method. Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples, who exited the SAFER study - a pilot study assessing the feasibility, acceptability and cost-effectiveness of a safer conception programme for HIV sero-different couples in Zimbabwe. All couples in SAFER were provided with a choice of safer conception methods and were followed for up to 12 months of pregnancy attempts and 3 months following pregnancy. While couples generally perceived their safer conception discussions to be easy and consensus-driven, the decision-making process also involved complex gender dynamics and trade-offs in relationship power, which resulted in differing interpretations of what constituted a joint or shared couple decision. Participants regarded effective couple communication as an essential component of and precursor to good safer conception conversations and requested additional training in couple communication. Couples relied on information from healthcare providers to kickstart their safer conception discussions. Safer conception programmes should address relationship power imbalances, promote effective couple communication and offer healthcare provider support to enable HIV sero-different couples to make informed choices about conception in a manner that upholds their safety and reproductive autonomy.

Introduction: HIV stigma can impact couple relationships through stress or bring partners closer through shared experiences. Conversely, couple relationships may protect against the harms of stigma, including anticipated stigma on negative health outcomes. Yet few studies have assessed the potential link between HIV stigma, relationship dynamics, and antiretroviral therapy (ART) adherence. Using dyadic data from a cross-sectional study of Malawian couples living with HIV, we tested associations between anticipated stigma and: 1) relationship dynamics (e.g., trust, sexual satisfaction, communication) and partner support; and 2) self-reported ART adherence. Methods: Heterosexual couples (211 couples, 422 individuals) with at least one partner on ART were recruited from clinics in Zomba, Malawi. Partners completed separate surveys on anticipated stigma, relationship dynamics, and ART adherence. Linear mixed models evaluated associations between anticipated stigma and relationship dynamics, and whether associations varied by gender. Generalized estimating equation models tested for associations between anticipated stigma and high ART adherence (90–100% vs. < 90%) at the individual level, and whether they were moderated by relationship dynamics at the couple level. Results: Couples' relationship length averaged 12.5 years, 66.8% were HIV sero-concordant, and 95.6% reported high ART adherence. In multivariable models, sexual satisfaction (β = -0.22, 95%CI = -0.41;-0.03, p = 0.020) and partner social support (β = -0.02, 95%CI = -0.04;-0.01, p < 0.01) were negatively associated with anticipated stigma. Significant interaction effects showed that adherence is moderated in couples with higher partner support and sexual satisfaction such that adherence is lowest when anticipated stigma is high and social support is low, and that adherence is lowest when anticipated stigma is high and sexual satisfaction is low. Conclusions: Increased anticipated stigma is most associated with lower ART non-adherence at lower levels of social support and sexual satisfaction. Conversely, supportive and fulfilling relationships may buffer the negative association between stigma and ART adherence. Couples’ interventions that focus on improving communication and support systems within couples could reduce the negative impacts of anticipated stigma on couples living with HIV.

Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18–49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85–0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73–0.91; p < 0.01) among women. For men, depressive symptoms were positively associated with linkage to care (AOR: 1.21, 95% CI: 1.09–1.34; p < 0.01). Depression may adversely impact ART adherence for HIV-positive women and reduce the likelihood of HIV testing for women not aware of their HIV status which, in settings with high HIV prevalence, carries severe consequences. For HIV-positive men, findings suggest that depression may encourage help-seeking behavior, thereby impacting their health system interactions. These findings underscore the need for health-care settings to factor mental health, such as depression, into their programs to address health-related outcomes, particularly for women.