Midwives recommend antenatal HIV testing in pregnancy for all women. However,limited information is available on the experience of testing HIV positive in pregnancy.This thesis explored women’s experiences of receiving a positive HIV test resultfollowing antenatal screening in United Kingdom (UK). Black Africa women have highlevels of HIV infection in the UK and notably all participants were African in origin.The theoretical basis for the study was hermeneutic phenomenology, proposed byHeidegger (1962) and further guided by van Manen (1990), exploring essence andmeaning of this lived experience. Thirteen women were recruited and participated in asemi-structured interview. Participants were recruited from two NHS sites, several HIVsupport organisations and a national advert, in order to obtain diversity of this livedexperience.The emergent phenomenon is transition and transformation of “being,” as womenintegrated HIV into their lives. As women transformed with the HIV diagnosis theybalanced major themes. The major themes consisted of shock and disbelief; anger andturmoil; loss of old self; stigma and confidentiality issues and acceptance and resilience.Primary and secondary themes included: extreme reaction on being given a diagnosiswith a cultural belief that they would die; disbelief as the result was unexpected;sadness and loss of their old self; turmoil wanting to terminate the pregnancy; isolationfrom significant others; breakdown of their relationship and considering suicide and selfharm. Most reported the pervasiveness of stigma, and how they managed both thisstigma and HIV in their lives; growing resilience was apparent with time. Copingstrategies included keeping HIV “secret” and their child or children becoming the primefocus of life, with less importance on self.This study gives midwives a unique understanding of the complexities for womentesting HIV positive and supports Bonanno (2009) and Kübler Ross’ (1969 & 2005)findings on personal loss. Additionally this study provides a unique insight into thephenomenon of transition and transformation for women who tested positive inpregnancy and explores the factors and impact of testing HIV positive. The impact of anHIV diagnosis is culturally difficult for African women and had major implications andchallenges for their future life. Midwives are crucial in supporting and improving theexperience of women when they test HIV positive.

A thesis completed by published work, Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in fulfillment of the requirements for the degree of Doctor of Philosophy Johannesburg, South Africa 24 May 2017. / Introduction: Prevention of mother-to-child transmission (PMTCT) has potential to eliminate new HIV infections among infants. Yet, in many settings in sub-Saharan Africa, women are unable to adhere to PMTCT recommendations due to social constraints. One such factor may be intimate partner violence (IPV), or any actions taken by a relationship partner that cause physical, sexual, or psychological harm. Despite theoretical and empirical rationale for understanding the links between IPV and PMTCT adherence, few studies in the extant literature have explored this association. Methods: This thesis draws upon four distinct studies that interface using an overall mixed method study design. The first study is a systematic review of the literature around women’s experience of lifetime IPV and adherence to anti-retroviral treatment (ART). The second study is formative qualitative research with pregnant women, health workers, and other local stakeholders that explores how IPV may be related to PMTCT in the urban Johannesburg setting. The third study is a deeper qualitative examination of women living with both IPV and HIV, aiming to understand the mechanisms that link partner violence to PMTCT behaviors using a social constructionist lens. The final study is a quantitative cohort study nested within a randomized control trial testing an intervention for IPV in pregnancy. Using regression techniques and structural equation modeling, I aim to determine the association between IPV and ART adherence in pregnancy and postpartum and identify pathways that mediate the relationship between partner violence and PMTCT. Results: This doctoral research contributes several new findings to the extant literature around PMTCT. I find that IPV is related to ART adherence among HIV-positive women in extant literature, with meta-analysis showing significantly worse odds of ART uptake, self-reported adherence, and viral suppression among women reporting lifetime IPV. In one of first of studies among women in sub-Saharan Africa, I learn that impact of IPV on ART adherence in pregnancy and postpartum is marked. I identify several mechanisms through which IPV influences PMTCT adherence. Mental health emerges as a robust pathway linking IPV to worse adherence in both qualitative and quantitative papers. Partner non-disclosure due to IPV can impede adherence, or women can navigate this challenge through hiding their HIV status or medication. Women experiencing IPV may attend fewer antenatal clinic visits, leading to worsened adherence. An unexpected finding was that women in our qualitative and quantitative studies were resilient and used strategies to adhere despite IPV. Motherhood seems to be a central feature of women who are resilient to the effects of IPV on adherence. Conclusion: The findings of this research have implications for research, policy, and practice. Research should incorporate social factors, such as IPV, into future studies testing PMTCT adherence interventions. Clinical practice and HIV programs should recognize that partner-level dynamics such as IPV may drive persistent gaps in PMTCT coverage. HIV policy urgently needs to incorporate ethical and safety considerations for women who experience IPV around the time of pregnancy. Women living with recent or past IPV are highly resilient and often want to protect their own health and that of their children. Only by recognizing and addressing their experience within the context of HIV care can future PMTCT programs and studies ensure maternal and infant health. / MT2017