Identity management in the face of HIV and intersecting stigmas: A metasynthesis of qualitative reports from sub-Saharan Africa

Abstract

While stigma experienced by people living with HIV (PLWH) is well documented, intersectional stigma and additional stigmatized identities have not received similar attention. The purpose of this metasynthesis is to identify salient stigmatized intersections and their impact on health outcomes in PLWH in sub-Saharan Africa. Using Sandelowski and Barroso’s metasynthesis method, we searched four databases for peer-reviewed qualitative literature. Included studies (1) explored personal experiences with intersecting stigmas, (2) included ≥1 element of infectious disease stigma, and (3) were conducted in sub-Saharan Africa. Our multinational team extracted, aggregated, interpreted, and synthesized the findings. From 454 screened abstracts, the 34 studies included in this metasynthesis reported perspectives of at least 1258 participants (282 men, 557 women, and 109 unspecified gender) and key informants. From these studies, gender and HIV was the most salient stigmatized intersection, with HIV testing avoidance and HIV-status denial seemingly more common among men to preserve traditional masculine identity. HIV did not threaten female identity in the same way with women more willing to test for HIV, but at the risk of abandonment and withdrawal of financial support. To guard against status loss, men and women used performative behaviors to highlight positive qualities or minimize perceived negative attributes. These identity management practices ultimately shaped health behaviors and outcomes. From this metasynthesis, the Stigma Identity Framework was devised for framing identity and stigma management, focusing on role expectation and fulfillment. This framework illustrates how PLWH create, minimize, or emphasize other identity traits to safeguard against status loss and discrimination. Providers must acknowledge how stigmatization disrupts PLWH’s ability to fit into social schemas and tailor care to individuals’ unique intersecting identities. Economic security and safety should be considered in women’s HIV care, while highlighting antiretrovirals’ role in preserving strength and virility may improve care engagement among men.

Studying the Literary Features of the “Arctic Robinsonade” Plot in the Artistic Discourse of the 21st Century

“…The publications of scholars from various subject areas, including advocacy (Willgens et al, 2016), education (Deggs & Hernandez, 2018;Morgan, 2022), medicine (Bergman et al, 2023), and sociology (Khoa et al, 2023), were devoted to qualitative research methodology. Philology is not found in these studies.…”

Experiences of gender-based stigma and health care-related outcomes in the African region: A scoping review.

“…A literature review of people living with HIV in Africa noted less tolerance of, and more blame toward, women compared to men living with HIV (Mbonu et al, 2009), and a multicountry study in Uganda and Kenya more than a decade later reported that HIV-related stigma remains gendered and higher among women versus men (Akatukwasa et al, 2021). A metasynthesis of qualitative studies with people living with HIV in sub-Saharan Africa explored experiences of intersecting stigma in the context of infectious disease stigma (Bergman et al, 2023). This review found that people living with HIV managed intersecting social identities through disclosure processes, whereby identity management included focusing on other expected social roles (e.g., roles as parents, adults, gender roles) to avoid discrimination and losing status (Bergman et al, 2023).…”

“…A metasynthesis of qualitative studies with people living with HIV in sub-Saharan Africa explored experiences of intersecting stigma in the context of infectious disease stigma (Bergman et al, 2023). This review found that people living with HIV managed intersecting social identities through disclosure processes, whereby identity management included focusing on other expected social roles (e.g., roles as parents, adults, gender roles) to avoid discrimination and losing status (Bergman et al, 2023). Specific to gender considerations for women, this study found that women were perceived as physically subordinate to men, femininity and womanhood were linked with maintaining households and raising children, and as a result of these social roles, women often financially depended on male partners which elevated their precarious economic position (Bergman et al, 2023).…”

“…This review found that people living with HIV managed intersecting social identities through disclosure processes, whereby identity management included focusing on other expected social roles (e.g., roles as parents, adults, gender roles) to avoid discrimination and losing status (Bergman et al, 2023). Specific to gender considerations for women, this study found that women were perceived as physically subordinate to men, femininity and womanhood were linked with maintaining households and raising children, and as a result of these social roles, women often financially depended on male partners which elevated their precarious economic position (Bergman et al, 2023). Women, in particular, reported fearing HIV testing due to concerns regarding being subjected to violence and abandonment (Bergman et al, 2023).…”

“…Specific to gender considerations for women, this study found that women were perceived as physically subordinate to men, femininity and womanhood were linked with maintaining households and raising children, and as a result of these social roles, women often financially depended on male partners which elevated their precarious economic position (Bergman et al, 2023). Women, in particular, reported fearing HIV testing due to concerns regarding being subjected to violence and abandonment (Bergman et al, 2023). Another study of intersecting stigma conducted in Uganda found that the nexus of multiple dimensions of marginalization (for instance, devaluation of refugees, girls and women, adolescents, sex workers, sexually diverse persons, and people with HIV) produced intersectional stigma that was a barrier to HIV testing with urban refugee youth in Kampala (Logie et al, 2021).…”