Stigma and lack of disclosure as barriers to use of maternity and HIV services by HIV-positive pregnant women in rural Kenya

Background: In the MAMAS Study, we examined the role of HIV-related stigma in use of health services by HIV-positive pregnant women in rural Nyanza Kenya—a setting where one in every five pregnant women is HIV-infected. Methods: Of 239 HIV-positive women in the MAMAS cohort, 165 (70%) could be located and participated in structured interviews 4-8 weeks postnatally. Data on service utilization were also obtained from medical records. We examined associations of multi-item measures of HIV-related stigma with disclosure and HIV-infected women's utilization of prevention of mother-to-child transmission (PMTCT), facility-based childbirth, and HIV care services using logistic regression methods. Results: Of postpartum HIV-infected women, only 59% had disclosed their HIV status to anyone and only 31% had disclosed to their male partner. Around one-third had used facility-based childbirth services, 72% reported taking drugs for PMTCT, and 54% had enrolled in HIV care. Women who had disclosed their HIV-positive status to others were 3.5 times more likely to have taken drugs for PMTCT (95% CI: 1.68-7.36) and 5.1 times more likely to give birth in a health facility (95% CI: 2.21-11.56) than those who had not disclosed. Women with high levels of internalized HIV stigma were less likely to have enrolled in HIV care than those with low levels of internalized HIV stigma (OR=0.56, 95% CI: 0.36-0.87). Conclusions: Even in a setting where HIV infection is common among pregnant women, HIV-related stigma and the associated lack of disclosure are important barriers to HIV-infected women's use of life-saving maternity and HIV services.