A WHO review of the treatment and support needs of HIV-positive women noted constraints that impinged on coping ability and mental health. These included socio-economic deprivation, gender inequality, gender-based violence, and women’s role as primary caregivers and pregnancy. Women’s dependence on men makes it difficult for them to control their sexuality and negotiate safe sex.

Perhaps as a result of lack of resources and power, African women with HIV are more likely to be diagnosed with mental health disorders. They report higher rates of depression, attempted suicide, anxiety disorders and post-traumatic stress disorders. In addition, women’s role as primary caregivers creates additional stressors.

The finding from a qualitative study of African women entitled My Heart is loaded  found that:

• a majority of the women interviewed had already experienced at least one profoundly traumatic life event including rape, murder of partners and family members and various other forms of persecution. In addition to direct experience of HIV-related death and ill health in close relatives or friends or child from HIV.
• The lives of most African women are heavily influenced by their capacity to become pregnant and give birth. However this raises additional problems for those who are HIV-positive. Most of the women in this study stressed the importance of motherhood as a source of identity and legitimacy.
• Mothers are traditionally seen as the moral guardians of society. This meant that many of these HIV-positive women were afraid of being stigmatized for not living up to these social expectations.
• Guilt was often especially debilitating among those who were compelled to leave children behind in Africa. Changing circumstances meant that these children often had to be passed between carers and attempts to bring them to the UK were usually difficult and often unsuccessful.
• Many of the women said that the lack of a male partner was one of the most difficult things they had to face. They wanted to be in an intimate relationship but perceived the obstacles to achieving this to be very great. For many, the lack of friends and of a partner resulted in physical and emotional isolation that was very difficult to bear.

Findings from Project NASAH and the PADARE project found that access to healthcare services was poor. Very few studies have explored the needs of older women living with HIV/AIDS. The SHIBAH report glimpsed the emerging difficulties of women approaching the menopause, and recommended further research amongst this group, in particular the interactions between gender, ageing, HIV and sexual health.

Gender violence

Victimization in women who are HIV-positive or at risk for HIV has been documented. Over one-third of women with HIV in London reported a history of sexual and physical abuse. There was some evidence that among black African women in the UK those who revealed their positive status were more vulnerable to physical abuse.

Pregnancy

The majority of pregnant women with HIV in England come from overseas, mostly from sub-Saharan Africa. Concerns such as immigration and housing may be uppermost in their minds. Studies have found experiences of poverty, poor housing and racism amongst pregnant asylum seekers. The poverty experienced when living on £30 per week, in relation to HIV, places babies of HIV-positive mothers at higher risk of infection because, when the mothers cannot afford formula milk, they will occasionally resort to breastfeeding. In addition, there is evidence of particularly low uptake of voluntary confidential antenatal HIV testing among black African women in the UK. This low uptake may be related to a lack of knowledge about mother to child transmission of HIV and awareness that treatment for pregnant women was available.

A major impact of HIV for African women in London is related to their capacity to become pregnant and give birth, as motherhood is an important source of identity and legitimacy. A number of studies provide evidence that HIV status is not the major influence in reproductive decision-making for many women.

A study of 40 HIV-positive women in London showed that 18% were planning a pregnancy and 30% were still undecided. Women were found to be unsure, at times uninformed, and to desire information about interventions. Anxiety levels were high especially among black African women, regarding antiretroviral treatments and breastfeeding avoidance.