Community and healthcare provider perspectives on HIV- and COVID-19–related stigma, fear and health-seeking barriers among pregnant and breastfeeding women in Uganda

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These intersecting social processes may undermine health-seeking behavior, treatment adherence, and maternal health outcomes. The study explored experiences of HIV stigma, COVID-19–related fear, and health-seeking barriers among pregnant and breastfeeding women, healthcare workers, and community stakeholders in Uganda. Methods A qualitative study was conducted in selected districts in Uganda in March-July 2025. Data were collected using 12 focus group discussions (FGDs), 24 in-depth interviews (IDIs), and 21 key informant interviews (KIIs). Participants included pregnant and breastfeeding women, healthcare workers, and community stakeholders, selected purposively. Interviews were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis using Nvivo version 12 software guided by the Social Ecological Model. Results HIV stigma was pervasive, expressed through gossip, discrimination, secrecy, and moral judgment, shaping disclosure and access to care. COVID-19–related fear intensified social isolation, movement restrictions, and unintended disclosure of HIV status. The coexistence of both conditions created layered stigma that disrupted antenatal attendance, ART adherence, and household relationships. Despite these barriers, participants demonstrated resilience driven by child protection and survival. Coping strategies included discreet ART delivery, peer support, telehealth communication, and community sensitization. Trust in healthcare workers and confidentiality were central to service utilization. Conclusions Intersecting HIV and COVID-19 stigma and fear appeared to contribute to barriers in maternal health-seeking among women in Uganda. These influences may be reduced through targeted approaches such as confidential service delivery, peer-led support, and community education. Integrating stigma-sensitive practices into maternal and HIV care services could help strengthen trust, support service use, and improve maternal health outcomes during concurrent public health challenges. HIV COVID-19 stigma breast feeding pregnant women Uganda qualitative study Introduction HIV-related stigma remains a persistent global public health challenge, undermining efforts to achieve optimal treatment outcomes and quality of life for people living with HIV( 1 ). Defined as negative attitudes, prejudice, and discriminatory practices directed toward individuals living with HIV, stigma affects disclosure, social relationships, and access to health services across diverse contexts. Uganda has made substantial progress in the HIV response, aligning with UNAIDS’ “95 95 95” targets ( 2 ) as part of its national strategy to end the AIDS epidemic by 2030. This framework aims for 95% of people living with HIV to be aware of their status, 95% of those diagnosed to receive sustained antiretroviral therapy (ART), and 95% of individuals on ART to achieve viral suppression. While Uganda successfully reached the second target ahead of schedule, the emergence of COVID 19 in March 2020, accompanied by stringent lock-downs, curfews, transport bans, and closure of non-essential services, posed serious disruptions to HIV service delivery ( 2 ). In Uganda, HIV stigma continues to shape the lived experiences of women, including pregnant and breastfeeding populations, by reinforcing secrecy, internalised shame, and social exclusion despite advances in antiretroviral therapy (ART) and prevention of mother-to-child transmission programs. Moralized narratives reinforced stigma, particularly toward pregnant, breastfeeding, and HIV-positive women, shaping behaviours such as social distancing, secrecy, and avoidance of health services. By combining reliable messaging with digital access, women can engage safely with maternal and HIV care despite persistent moralized narratives. Qualitative evidence from rural Uganda highlights that social rejection and public ridicule remain dominant stigma experiences among pregnant women living with HIV, limiting care engagement and psychosocial well-being( 3 ). All women diagnosed with HIV during pregnancy or breastfeeding require ART for life ( 4 ). They may face several challenges that hinder their ability to adhere to medication and maintain regular appointments for routine care. Factors such as stigma, access to health care play a significant role. By identifying these factors, we can tailor interventions to meet women’s unique needs. Stigma associated with HIV can lead to fear of disclosure and discrimination: Some women may turn to alternative or traditional healing methods, which could impact their adherence to prescribed medications: Lack of consistent follow-up by healthcare providers can result in missed appointments and poor treatment adherence. Insufficient counselling, fear of disclosing HIV status, stigma, and discrimination have been identified as factors that impact adherence to Antiretroviral Therapy (ART) ( 5 , 6 ). Addressing stigmas through education, and culturally sensitive interventions is essential to promote positive attitudes towards breastfeeding and support optimal infant feeding practices and good child care ( 7 ). Pregnant and breastfeeding women represent a particularly vulnerable group within the HIV epidemic due to biological, social, and structural factors that intersect to affect maternal and infant health outcomes. Stigma not only threatens personal well-being but also contributes to delayed initiation of care, suboptimal ART adherence, and increased risk of vertical transmission. In addition, studies in sub-Saharan Africa report HIV stigma’s negative effects on mental health, social support, and maternal health-seeking behaviours, underscoring the urgency of addressing stigma within maternal care services ( 8 ). The emergence of the COVID-19 pandemic introduced additional psychosocial stressors and structural barriers that have reshaped health systems and care engagement worldwide ( 9 ). COVID-19-related stigma where individuals diagnosed or suspected of having the disease experience fear, avoidance, and discriminatory behaviors has been documented during the pandemic and linked to reduced utilisation of essential health services, including maternal care. Mitigation measures such as movement restrictions and fear of infection have further altered health-seeking patterns among pregnant women and mothers, contributing to anxiety, reduced facility attendance, and disruptions in continuity of care ( 10 ). Despite growing evidence on HIV stigma and separately on COVID-19 impacts, research on how intersecting stigmas specifically HIV stigma and COVID-19-related fear simultaneously shape the lived experiences of pregnant and breastfeeding women is limited. Understanding this intersection is essential because dual stigma may exert compounded effects on disclosure, caregiving decisions, and utilisation of HIV and maternal health services. The socioecological model ( 11 ) explains how individual beliefs, relationships, community norms, and structural systems interact to shape human behavior and health outcomes across personal, social, cultural, and institutional levels, contexts worldwide. The social ecological model (SEM) provides a comprehensive framework for understanding how various contextual layers shape COVID-19 and HIV related stigma. By applying the SEM, this study aims to mapped out the multilevel factors influencing the individual experiences (e.g., fear of infection) interact with community norms (e.g., stigma around COVID-19). Healthcare policies (e.g., telehealth options) intersect with network support (e.g., family encouragement). Understanding these interactions is vital for designing effective interventions that support pregnant and breastfeeding women living with HIV to overcome stigma during this challenging time ( 12 ). In Uganda, where HIV prevalence remains high among women of reproductive age and maternal mortality indicators continue to challenge health systems, the combined burden of HIV and COVID-19 stigma may undermine progress toward effective maternal HIV care. However, there is a paucity of empirical evidence exploring how these intersecting stigmas influence health-seeking behaviour, treatment adherence, and social dynamics among pregnant and breastfeeding women living with HIV. This study seeks to fill that gap by examining the nature and consequences of intersecting HIV and COVID-19 stigma in Uganda’s maternal health context. Setting and method We adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure transparent reporting of this qualitative study (13). A qualitative cross-sectional design was used, conducted in March to July 2025 in selected high-volume public and private-not-for-profit HIV care facilities in central Kampala and Wakiso districts, Uganda. Seven strategically selected sites, including the Infectious Diseases Institute Clinic Mulago, Komamboga, and Kasangati HCIV, were included. These facilities provide comprehensive HIV, maternal, and reproductive health services and also served as COVID-19 vaccination sites during the pandemic. Study population A qualitative study was conducted in selected districts in Uganda. Data were collected using 12 focus group discussions (FGDs), 21 in-depth interviews (IDIs) among breast feeding and pregnant women living with HIV. 24 key informant interviews (KIIs) included: ART case managers (clinical officers, health managers, midwives, counsellors, social workers, peer mothers, and sociologists), HIV activists, community advisory board members, and policymakers involved in HIV care and pandemic response in Kampala and Wakiso, Uganda. Maximum variation sampling (14) was used to ensure diversity in role, facility type, and geographic location. Data collection All interviews were conducted using an interview guides developed based on the socio-ecological model. The topic guides (Supplementary 1,2, &3) explored perspectives about HIV and antenatal seeking behaviours during COVID-19, care provision during the pandemic, HIV and COVID-19 stigma, their effects on maternal care-seeking, disclosure, and support systems, alongside community, health system, and pandemic-related barriers, coping strategies, and potential stigma-reduction interventions. FGDs and IDIs were conducted in local language-Luganda and lasted about 90 minutes. While most Key informant interviews lasted 20–60 minutes, one key informant interview was limited to approximately 20 minutes due to the participant’s restricted availability and time constraints. All interviews were audio-recorded with consent and translated as appropriate and transcribed verbatim for analysis. Quality assurance To maintain high data quality, the study implemented rigorous control procedures throughout and after fieldwork. All the FGDS, IDIs and KIIs were audio-recorded, then transcribed by the principal investigator with two trained research assistants to ensure consistency. The research adhered to Lincoln and Guba’s (1985) trustworthiness framework covering credibility, confirmability, dependability, transferability, and authenticity (15-18). Standard operating procedures (SOPs) and pre-tested topic guides were used to guide data collection. Quality assurance was further reinforced through regular team debriefings and spot checks. Transcriptions were done verbatim, preserving both meaning and context to support accurate and reliable qualitative analysis. Data analysis For data analysis,first, the researcher familiarized herself with the data by transcribing audio recordings, reading through transcripts, and taking initial notes. Next, she coded (16-18) the data by highlighting relevant text and assigning descriptive labels. Data analysis was conducted using NVivo software (19). Two qualitative data analysts independently coded a subset of transcripts to ensure intercoder reliability. Thematic analysis (16) was conducted using both inductive and deductive approaches. A coding framework (20) was developed from initial readings of transcripts and refined iteratively and a final code book generated (supplementary 4). Emergent themes were discussed and synthesized across SEM levels: (individual, interpersonal, institutional, community, and policy) to identify patterns in HIVand COVID-19 stigma and health seeking barriers among stakeholders. Finally, the findings were presented in a written report, supported by relevant data excerpts. Ethics approval and consent to participate Ethical approval was obtained from the Makerere University School of Public Health Research and Ethics Committee (SPH-REC, Ref: SPH-2024-619) and the Uganda National Council for Science and Technology (UNCST, Ref: SS3219ES). Additional support was provided by the Institute of Anthropology, Gender and African Studies at the University of Nairobi. All participants provided written informed consent in accordance with the Declaration of Helsinki prior to participation. Anonymity and confidentiality were ensured, and participants were informed of their right to withdraw at any time. They were also compensated for their time. All data were stored securely and used solely for research purposes. Results Socio-demographic characteristics of stakeholders The study included 136 participants across focus group discussions (FGDs), in-depth interviews (IDIs), and key informant interviews (KIIs). The majority of participants were female, reflecting the maternal health focus of the study population. The mean age was 32 years among IDI participants and 27 years among FGD participants. Most FGD and IDI participants had attained secondary-level education and were either married or cohabiting. A substantial proportion of women were pregnant or breastfeeding at the time of data collection. COVID-19 vaccination coverage among participants was 66.7%. Among IDI participants living with HIV, viral suppression was high (92.9%), indicating strong treatment adherence within this subgroup Intersection of HIV- and COVID-19–related stigma and health care seeking barriers Findings are presented using the Social Ecological Model to illustrate how intersecting HIV- and COVID-19–related stigma and fear shaped maternal health-seeking behavior among pregnant and breastfeeding women in Uganda across individual, interpersonal, community, health system, and policy levels. Individual level Internalized stigma, fear, and resilience At the individual level, women described internalized HIV stigma, fear of COVID-19 infection, and anxiety about pregnancy outcomes as major drivers of secrecy, emotional distress, and delayed care-seeking. Anticipated gossip and judgment reinforced concealment of HIV status, even when symptomatic, contributing to delayed or inconsistent engagement with antenatal and ART services. However, fear also functioned as a motivator for continued care, particularly when linked to maternal and child survival, with many women demonstrating resilience grounded in motherhood and responsibility for their unborn or breastfeeding children. “I felt so ashamed to go for medication during Covid- 19… my peers would say I was going to give birth to a child who is HIV positive because i missed drugs—I was so stressed and scared.” (IDI 7, adult, pregnant) “I had a cough but did not tell anyone because I feared gossip and judgment. In my community, people quickly assume the worst, whisper, and distance themselves. I worried they would see me as a danger to my child, so I stayed silent even when I needed support.” “ (IDI 8, adult breast feeding) “A mother’s instinct to protect life becomes stronger than shame… women continue care because their children’s survival gives them strength.” (KII 14, HIV activist) Non-disclosure and disrupted continuity of care Non-disclosure of HIV status was common and largely driven by fear of stigma and COVID-19-related labelling. Women often concealed their status even when symptomatic, which disrupted continuity of care and reduced opportunities for timely clinical support. Health workers also noted challenges in providing care to women who had not disclosed, necessitating adapted and discreet service delivery approaches. “I kept my HIV status to myself because I feared how people would label me, especially during COVID-19. If I showed any symptoms, they would quickly... I had both illnesses. Because of that fear, I chose silence, even when I was not feeling well due to pregnancy. It made it hard to for me to go for antenatal consistently...” (IDI 18, breastfeeding) “Pregnant women living with HIV who had not disclosed their status were difficult to support openly because it risked exposing them. We adapted by using motorcycles for discreet delivery and making quiet, low-profile visits. This allowed us to continue their care while protecting privacy and reducing community stigma. (KII 3, clinical officer) Interpersonal level Family control, partner influence, and peer support At the interpersonal level, partner and family dynamics significantly shaped care-seeking behavior. Some male partners restricted clinic attendance due to fear of stigma and community gossip, resulting in delayed care. In contrast, peer mothers and community health workers provided emotional support, reassurance, and shared lived experiences that strengthened adherence and reduced isolation. He[spouse] refused to let me go for testing, saying people would notice and start talking—that they would know his wife is HIV positive. In our community, gossip spreads quickly, and it brings shame not just to me but to the whole family. Because of that fear, my health had to wait, and I was left worrying in silence.” (FGD 7, Young adult). “As midwives, we noticed that peer mothers and community health workers played a very important role in reducing stigma during COVID-19. They would sit with the mothers, encourage them, and share their own experiences, which made the women feel less alone. This emotional support helped mothers stay on treatment and continue attending care, even when they were worried or afraid.” (KII 6, Midwife) Health worker level Fear of infection and enacted stigma Health workers’ fear of COVID-19 infection influenced interactions with clients, particularly in HIV care settings. Cautious behaviors such as distancing, reduced physical contact, and shortened consultations were common and, although intended for protection, were often perceived as discrimination, thereby reinforcing HIV-related stigma and weakening patient–provider trust. Health workers also experienced stigma within their households, where they were viewed as potential sources of infection. “During the COVID-19 period…health workers were also afraid of getting infected… we became more cautious in how we handled clients, especially those coming for HIV services… our fear made us keep distance or rush interactions, and patients could feel it. Some interpreted this as rejection, which affected their trust and willingness to return for care.” (KII 3, clinical officer) “At home, things changed during COVID-19. My family became afraid of me because I worked in the hospital. They would ask me to stay away from the children and even change before entering the house. It was painful because I felt like I was bringing danger instead of care, even though I was only doing my job.” (KII 11, medical officer) Community level Norms, gossip, and social surveillance Community norms strongly reinforced stigma through gossip, labeling, and social surveillance. Attendance at health facilities and ART access were highly visible and often interpreted negatively, discouraging disclosure and promoting concealment. Household stigma was also evident through segregation practices, while anticipated stigma discouraged women from seeking care. “In our community, people watch everything you do. If someone goes frequently to the clinic, others start talking and guessing. During COVID-19, this became worse because even small signs made people suspect....” (KII 15, CAB member) “They [family members] would separate my cup, plate, even clothes… and wash everything apart, as if I could easily infect them. It made me feel isolated in my own home, like I was no longer part of the family. Even simple daily things became a reminder of how people feared and misunderstood HIV during COVID-19.” (FGD 7, Young adult). “...judgment of women not only from people in the community but sometimes even from health workers who did not want to get close to mothers especially those that lacked masks on due to fear to contract COVID-19...” (KII 7, Midwife). COVID-19 restrictions, visibility, and social isolation Lockdown measures and movement restrictions further intensified fear of disclosure and reduced access to health services. Women feared being seen accessing care, as visibility was closely linked to community speculation about HIV status. Discreet ART delivery systems reduced stigma for some but also highlighted concerns about unintended disclosure. Social isolation during lockdown further weakened peer support and increased emotional distress. “During the lockdown, it became hard for us health workers to reach health facilities on time but even it became harder for women to access care especially if they had not disclosed their HIV status... Movement restrictions meant we had limited ways to reach the health facilities, and every trip outside felt like it could expose us”. (KII 10, clinical officer) “If a man came on a boda boda[motorcycle] and knocked at your door bringing medicine during COVID-19 lockdown, I feared people would start to wonder and talk. In the village, nothing goes unnoticed—neighbours are always watching. They would assume you are HIV positive, and gossip would start, bringing stigma even when you are only trying to take care of your health.”” (FGD 1, adult breast feeding). “Due to fear of disclosure of HIV status... they [health workers] gave me my medication in a small, plain package without any labels. When I carried it home, no one could tell what it is, so I didn’t feel embarrassed or ashamed. It allowed me to take my medicine quietly and continue my treatment without people in the community questioning or judging me.” (IDI 12, adult, breastfeeding) “During lockdown, I stayed alone most of the time. I could not meet my peer mothers or talk freely to anyone. I felt isolated and scared that if I went out, people would suspect my condition.” (IDI 19, adult, breastfeeding). Layered stigma Intersection of HIV and COVID-19 fears The coexistence of HIV and COVID-19 created compounded stigma that shaped maternal health-seeking behavior. Fear of infection, social labelling, and perceived risks within health facilities interacted to delay or prevent care. Health facilities were sometimes perceived as unsafe or associated with isolation and death, further discouraging service uptake. “Women were constantly afraid—not only of HIV stigma but also of getting COVID-19. These two fears mixed together and affected how they made decisions about seeking care. Sometimes they would avoid going to the clinic because they feared catching COVID-19...” (KII 24, facility in charge) “I had a cough when I was pregnant… my husband said if you go to the hospital for antenatal, you will die. He thought it was COVID… he stopped me from going because he feared they would quarantine me. I was isolated and slept in my own room… so I stayed home.” (FGD 3, Young adults) “Women became afraid of going to the health facility during COVID-19 because people said those places were where they could be isolated, or quarantined. That fear stayed with me...This fear made the postpone clinic visits...loss of patients to follow up was a very big problem... up to now we are still receiving women who disengaged from care due to COVI|D-19... we notice their viral load unsuppressed.” (KII 16, doctor, ART case manager) Stigma shaped by disability Women with disabilities faced compounded stigma during COVID-19 due to HIV, disability, and infection fears. Marginalization increased vulnerability, while dependence on caregivers risked involuntary disclosure. Mobility barriers limited access to care. Despite stigma and isolation, some remained resilient, relying on trusted caregivers and community health workers to continue treatment. “... a woman with disability... people already judge you, so adding HIV and COVID-19 made it worse. I depend on others to move, but I fear they may talk and expose my status. Still, I try to continue care because my life and my child depend on it.” (KII 16, CAB member, woman with disability) Stigma shaped by displacement Refugee women faced layered HIV and COVID-19 stigma shaped by displacement and poverty. Crowded settings increased visibility and fear of gossip, limiting clinic use. Language barriers and lockdowns reduced access. Despite this, some remained resilient, maintaining treatment through discreet services and support from trusted community health workers and peers. “As a refugee woman, life for a refugee woman is hard... already have no money... live in camps which are crowded...also have issues with language barrier...seeking care was difficult during lockdown. During COVID-19, if you went to the clinic often, they would start talking and say you have HIV or corona. Many women refugees feared being judged and isolated...they avoided health facilities...as their leader I delivered drugs to them at their homes” (KII 17, Refugee activist) Health system level Trust, privacy, and service adaptations Confidentiality, respectful care, and trust in health workers were critical enablers of service continuity. Women emphasized the importance of privacy in reducing stigma and supporting adherence. Health system adaptations such as telehealth, home delivery of ART, and community distribution improved access but sometimes increased visibility and stigma risks. “…I feared people gossiping about me…now I can pick my medication without anyone knowing…If I go and no one sees me, I feel safe to take my medication on time.” (IDI, 4 adults, pregnant) “As health workers, we have learned that privacy is very important in encouraging mothers to come for care. We should ensure services protect confidentiality so women are not seen or identified by community members when they visit the facility. When mothers feel safe from recognition and judgment, they are more likely to seek care early and continue treatment without fear.” (KII 12, facility in charge) Policy and community interventions Stigma reduction and resilience strategies Participants highlighted the importance of multi-level interventions including psychosocial support, emergency preparedness, community education, and peer-led approaches. Trusted community actors such as Village Health Teams, peer mothers, and community leaders played a central role in improving adherence and reducing misinformation. Mental health and psychosocial support for Health workers; women was suggested. “Integrate mental health and psychosocial support services for patients and health workers during epidemics…”. (KII 19, policy maker). C onfidential service delivery . Ensure privacy at health facilities and in service provision to reduce fear of being seen by community members. Potential Implementation should include . Private consultation rooms, anonymous check-in systems and discreet pharmacy pick-up. “…I used to fear people gossiping about me, and that fear made me uncomfortable seeking care openly. During COVID I could pick my medication quietly without anyone knowing. When I go and no one notices me, I feel safe and free to take my medication on time, without worrying about judgment or talk in the community.” (IDI, 10 adult, pregnant) D isguised ART distribution Deliver antiretroviral therapy (ART) in ways that conceal the purpose from others, reducing stigma. This can be done through home delivery in unmarked packages, medication pick-up points outside the clinic and multi-purpose packages with other health items. “Sometimes, they give me my medication in a small unmarked package. No one knows what it is, and I don’t feel ashamed.” (IDI 12, adult, breastfeeding) “I can swallow my medicine at home quietly…COVID showed me it’s better when no one is watching.” (IDI, 7, adult, pregnant) “We, as health workers, need to deliver antiretroviral therapy in ways that do not reveal its purpose. This includes unmarked home delivery, discreet pick-up points outside clinics, or combining ART with other health items. These approaches protect clients from stigma while ensuring uninterrupted treatment access.” (KII 11, medical officer) Emergency preparedness for Health facilities; patients “Enhance readiness for future epidemics by educating patients on financial and logistical preparedness and ensuring facility-level contingency plans.” (KII 14, HIV activist) Health rights and empowerment for Pregnant and breastfeeding women “Implement policies and initiatives that promote health rights, social protection, and economic empowerment of pregnant and breastfeeding women.” (KII 22, Youth activist) Continuous medical education (CME) for Health workers; facility leadership “Sustain regular training and refresher programs for health workers on epidemic preparedness, updated clinical guidelines, and quality patient care.” (KII 24, facility in charge) C ommunity sensitization education to reduce discrimination Conduct awareness campaigns to reduce myths, promote empathy, and normalize HIV care in the community through local radio programs, community dialogues led by trained health workers and testimonies from people living with HIV. “We, as health workers, need to strengthen community awareness to address HIV myths during pandemics. Through radio programs, community dialogues led by trained workers, and testimonies from people living with HIV, people can hear real experiences and accurate information, foster empathy and reducing stigma.” (KII 14, HIV activist) “When people see that many are on treatment and doing well, they stop talking badly about others.” (IDI 8, adult, breastfeeding) “Education helped my neighbors understand that HIV is not a death sentence and that we can all live normally.” (IDI 4, adult, pregnant) Patient education and communication for patients; caregivers; community members “Develop clear, culturally appropriate, and locally understandable health education materials on epidemics, treatment options, and preventive behaviors” (KII 13, Health manager) Community health workers and peer mothers Leveraging trusted community actors such as Village Health Teams (VHTs), peer mothers, local council leaders, and respected national figures. Health care workers should Coordinate with peer educators to counsel mothers experiencing stigma during pandemic setting. “Peer mothers...Village Health Teams are like the first doctors in our communities—the people we run to before anyone else. They live among us, they understand our struggles, and they keep our secrets. Because of that closeness and trust, many people feel safer opening up to them than to anyone else.” (IDI 14, pregnant) “The Village Health Teams are the first community doctors. They can share the right information with the pregnant or breast-feeding mothers. People trust them more than anyone else.” (KII 14, HIV activist) “We have peer mothers… When someone listens to another person like them, they say, ‘If she has said it, then it is true...they can share their own experiences with mothers to cope with stigma.” (KII 20, Policy maker, MOH) “…Peer mothers should be strengthened and supported because they are close to us in the community…If they are involved more in follow-up and counselling, many women will feel more comfortable and less stigmatized in their care.” (KII 23, nurse) Expand peer support models “Strengthen networks of peer mothers and mentors to provide trusted health education and support treatment adherence, leveraging community trust in peers” (KII 21, CAB Member) Partner involvement and disclosure to Male partners; couples “Promote strategies that engage male partners in maternal and HIV care to support disclosure, adherence, and positive health outcomes.” (KII 15, Activist positive women with disability) Discussion In sub-Saharan Africa, where HIV prevalence is high and health infrastructure limited, maintaining ART continuity during lockdowns and mobility restrictions was a major concern (21). This study demonstrates that HIV- and COVID-19–related stigma intersects across multiple ecological levels to shape maternal health-seeking behavior in Uganda. At the individual level, internalized stigma, fear of infection, and anticipated judgment led to secrecy, delayed care, and psychological distress, but also motivated continued service use driven by maternal and child survival. These findings align with existing evidence that stigma operates not only as a social constraint but also as a psychosocial stressor influencing healthcare decisions and treatment adherence among pregnant women living with HIV (22). Jolle et al found that social rejection and public ridicule were dominant stigma experiences among HIV positive pregnant women in rural northern Uganda, significantly impacting their sense of self and social support networks (3). Such findings support our results showing that anticipated stigma and fear of gossip deterred women from disclosing their status and accessing care, reinforcing continuity challenges documented in other Ugandan maternal populations. The COVID-19 pandemic added new layers of fear and structural barriers that intensified existing HIV-related stigma among pregnant and breastfeeding women. Movement restrictions, fear of infection, and concern about being seen at health facilities heightened anxiety about unintended HIV status disclosure, as clinic attendance in many Ugandan communities is closely associated with illness and can trigger gossip, labeling, and social judgment. These socio-cultural dynamics made accessing care both physically and socially challenging, particularly for women who sought to protect their privacy and reputation. As fear of COVID-19 infection became intertwined with fear of HIV stigma, care-seeking behaviors were further constrained, leading to delayed or avoided service use. This is consistent with findings that COVID-19 restrictions in Uganda worsened transport, psychosocial, and structural barriers to HIV service engagement (23), highlighting how pandemic response measures inadvertently reinforced stigma and reduced continuity of care among vulnerable maternal populations. Fear of contracting COVID-19 at health facilities further complicated health-seeking behaviour, particularly among pregnant and breastfeeding women living with HIV. Within the socio-cultural context of Uganda, health facilities are not only spaces for treatment but also highly visible public arenas where attendance can be easily observed and interpreted by others. This visibility intensified concerns about HIV-related stigma, as women feared that being seen at clinics during the pandemic could lead to unintended disclosure of their HIV status, triggering gossip, labelling, and potential social exclusion within their communities. These fears were deeply embedded in existing cultural norms that place strong emphasis on privacy, reputation, and social standing, especially for women during pregnancy. In such contexts, maintaining confidentiality about one’s health condition is critical to preserving dignity and avoiding shame. Consequently, the combined fear of COVID-19 infection and anticipated HIV stigma created a dual burden that discouraged timely and consistent use of antenatal and HIV services. This echoes qualitative research on healthcare engagement during COVID-19 in Uganda, which found that stringent public health measures disrupted continuity of routine care and diverted attention away from chronic disease management, affecting both patient access and confidence in health services (24). Participants’ narratives of anxiety about labelling and avoidance of facilities illustrate how infection fear and stigma may jointly depress utilization of antenatal and HIV services. At the community level, pervasive gossip, labeling, and social exclusion reinforced both HIV and COVID-19 stigma, leading to concealment of health status, switching of health facilities, and avoidance of care. In many settings, community norms strongly influence disclosure decisions and shape how and when individuals seek health services, particularly for conditions associated with moral judgment and social shame such as HIV (25-27). Within this context, maintaining secrecy becomes a protective strategy to avoid discrimination, even when it compromises timely access to care. The COVID-19 pandemic further intensified these dynamics by introducing additional fear of contagion and enforced social isolation, which compounded existing stigma and heightened suspicion toward affected individuals and households. This is consistent with global reports documenting pandemic-related stigma, where individuals perceived as infected with COVID-19 experienced avoidance, discrimination, and social distancing beyond public health requirements (28, 29). Despite many obstacles faced during COVID-19 pandemic, intrinsic motivation (30-33) among health workers, peer supporters, and community volunteers was a strong force maintaining HIV service continuity. The literature aligns with other studies where both point to peer mother networks, expert patients, and community client groups that stepped in when formal systems were constrained (34, 35).These actors often worked without much external reward, driven by commitment to patient welfare. Such resilience suggests that investing in peer support, institutional recognition, and psychological support for front‑line workers could strengthen the health system’s preparedness for shocks. Furthermore, embedding differentiated service delivery models like multi‑month dispensing, decentralized ART distribution, and flexible facility operations into routine policy could ensure smoother responses in future crises. Interpersonal networks played a dual role in shaping health behavior. While some male partners restricted healthcare access due to fear and misinformation, peer mothers and community health workers provided critical emotional and informational support. This reflects broader evidence that social support systems can buffer the negative effects of stigma and improve adherence to HIV care during pregnancy (Kintu et al., 2021). The use of home-based ART delivery and peer support aligns with global findings. A study in Kenya found that community health workers and peer navigators played a key role in discreet ART delivery, especially among women who feared disclosing their HIV status (36). Similar to the current study, phone-based counselling (Twimukye et al, 2021 ) not only provided logistical support but also emotional reassurance, mitigating isolation during lockdowns (37). However, stigma concerns such as reluctance to receive home deliveries due to fear of being identified as HIV-positive were echoed (8, 38, 39) reinforcing that visibility in ART delivery methods can unintentionally reinforce stigma, showing fear of boda boda ( motorcycle) deliveries being associated with HIV. The role of Village Health Teams and peer networks highlights the importance of trusted community structures in sustaining maternal health services during crises. At the health system and policy level, adaptations such as telehealth, home delivery of antiretroviral therapy (ART), and community-based drug distribution improved continuity of care but sometimes inadvertently increased stigma due to visibility concerns. Similar findings have been reported during COVID-19, where decentralized ART delivery improved access but raised confidentiality challenges in resource-limited settings (1, 40). Despite these challenges, our findings highlight resilience among women driven by a strong desire to protect themselves and their children. This motivation resonates with broader literature showing that, even amid stigma and pandemic disruptions, personal agency and community support can sustain engagement with care. Additionally, participants identified practical stigma‑mitigating strategies like confidential ART delivery, telehealth, and peer support—that align with documented health system adaptations in Uganda during COVID‑19, such as mobile phone reminders and differentiated service delivery models to maintain ART access (41).These findings have important implications for maternal HIV care policy. Addressing dual stigma requires integrated, stigma‑sensitive interventions that combine confidential service delivery with community education and peer support. By aligning local stigma experiences with evidence on structural barriers exacerbated by COVID‑19, health systems can better tailor strategies to support pregnant and breastfeeding women living with HIV during and beyond public health emergencies. Overall, findings underscore the utility of the Social Ecological Model in explaining how stigma is produced and reproduced across interacting levels such as individual, interpersonal, community, and structural. Addressing these layered barriers requires integrated interventions that combine confidentiality-sensitive service delivery, community stigma reduction, and strengthened psychosocial and peer support systems. Such approaches are essential for improving maternal health-seeking behavior and resilience in contexts affected by overlapping epidemics such as HIV and COVID-19. Conclusion This study explores the intersecting stigmas of HIV and COVID-19 experienced by pregnant and breastfeeding women in Uganda and how these influenced disclosure, social interactions, and health-seeking behaviors. HIV-related stigma was reflected in internalized shame, anticipated discrimination, and social exclusion, which led some women to conceal their status and limit engagement with care. The COVID-19 pandemic further contributed to feelings of isolation and disrupted access to services, particularly during lockdowns when movement restrictions and changes in service delivery increased concerns about unintended disclosure. Together, these overlapping stigmas created additional barriers to care, including fears of infection, gossip, and labelling, which in some cases contributed to delayed or avoided use of health services. Despite these challenges, some women continued to engage with care, often motivated by concerns for their own health and that of their children. Strategies such as confidential service delivery, discreet ART distribution, telehealth communication, and peer support were reported as helpful in reducing stigma-related barriers and supporting continuity of maternal health services. Overall, the findings suggest a need for continued attention to stigma-sensitive approaches within integrated HIV and maternal health services. Study limitation The study has some limitations that should be considered when interpreting the findings. The relatively small number of male participants compared to female participants limited the depth and balance of male perspectives, particularly regarding couple dynamics and male involvement in maternal health decision-making. In addition, recruitment was conducted mainly in selected urban health facilities, which may not fully reflect the experiences of individuals in rural or hard-to-reach areas where access to services, social norms, and stigma may differ, thereby limiting the transferability of the findings across different contexts. The reliance on self-reported data may also have introduced recall bias, especially for past experiences during pregnancy, breastfeeding, and the COVID-19 lockdown period, as well as social desirability bias due to the sensitive nature of HIV status and related stigma. Furthermore, the qualitative design does not allow for estimation of the prevalence or magnitude of the reported experiences, meaning the findings are interpretive and not statistically generalizable. Finally, the focus on selected themes related to stigma and service access may have meant that other relevant influences, such as broader economic constraints or health system challenges, were not fully explored. Declarations Acknowledgements The author expresses her gratitude to the entire study participants. She is also grateful to the research assistants who supported data collection Dorothy Namugerwa, Nagasha Rebecca, Joseph Ssebulime, Emanuel Nkurunziza and Patricia Kelly Kalisa as well as to Muhimba Hillary, who assisted with data transcription. Funding This research was made possible through funding by the Royal Society of Tropical Medicine and Hygiene (RSTHM), ref; nihr 24208. The decision to publish was not influenced by the funder. Authors’ contributions All authors contributed to the study and approved the final manuscript. AT conceptualized the project and conducted literature review. ATcollected data,organized and integrated data collected from various sources. AT coded and analyzed data that was interpreted by COO, PG and CW. AT drafted the manuscript and all authors critically revised the draft. Availability of data and materials Data analyzed for this manuscript are available from the corresponding author upon request. Human protection All data collection methods and analysis were carried out in accordance with relevant Good clinical care practice (GCP) guidelines and regulations. Competing interests The authors declare that they have no competing interests. Author’s Affiliation 1. Department of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya. 2. Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda. 3. 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Twimukye A, Alhassan Y, Ringwald B, Malaba T, Myer L, Waitt C, et al. Support, not blame: safe partner disclosure among women diagnosed with HIV late in pregnancy in South Africa and Uganda. AIDS Res therapy. 2024;21(1):14. Nyblade L, Stockton M, Travasso S, Krishnan S. A qualitative exploration of cervical and breast cancer stigma in Karnataka, India. BMC Womens Health. 2017;17(1):58. Derose KP, Williams MV, Branch CA, Flórez KR, Hawes-Dawson J, Mata MA, et al. A community-partnered approach to developing church-based interventions to reduce health disparities among African-Americans and Latinos. J racial ethnic health disparities. 2019;6(2):254–64. Bagcchi S. Stigma during the COVID-19 pandemic. Lancet Infect Dis. 2020;20(7):782. Logie CH, Turan JM. How do we balance tensions between COVID-19 public health responses and stigma mitigation? Learning from HIV research. AIDS Behav. 2020;24(7):2003–6. Adams O, Hicks V, editors. Pay and non-pay incentives, performance and motivation. WHO’s Workshop on a Global Health Workforce Strategy, Annecy, France; 2000. Peters DH, Chakraborty S, Mahapatra P, Steinhardt L. Job satisfaction and motivation of health workers in public and private sectors: cross-sectional analysis from two Indian states. Hum Resour health. 2010;8(1):27. Kajubi P, Parkes-Ratanshi R, Twimukye A, Bwanika Naggirinya A, Nabaggala MS, Kiragga A, et al. Perceptions and Attitudes Toward an Interactive Voice Response Tool (Call for Life Uganda) Providing Adherence Support and Health Information to HIV-Positive Ugandans: Qualitative Study. JMIR Formative Res. 2022;6(12):e36829. Safo KS, Opoku D, Bonney RA, Serchim CK, Mensah KA. Potential effects of Whatsapp on maternal health services uptake during COVID-19: a cross-sectional study in Ghana. BMC Health Serv Res. 2025;25(1):72. Lambrou P, Kontodimopoulos N, Niakas D. Motivation and job satisfaction among medical and nursing staff in a Cyprus public general hospital. Hum Resour health. 2010;8(1):26. Kuvaas B, Dysvik A. Perceived investment in employee development, intrinsic motivation and work performance. Hum resource Manage J. 2009;19(3):217–36. Isiko I, Taremwa K, Nyegenye S, Mwesigwa A, Mutebi RM, Okoro LN, et al. Factors Associated With Feeling Ashamed of Disclosure of HIV-Positive Status Among Women Who Self‐Reported to Health Facilities for HIV Testing in Kenya: Analysis of 2022 Kenya Demographic and Health Survey. Health Sci Rep. 2024;7(12):e70234. Macchiarulo E, Branca F, Mallardi A, Costanza A, Amerio A, Aguglia A, et al. Telephone counselling in coping with the COVID-19 lockdown consequences: preliminary data. Acta Bio Medica: Atenei Parmensis. 2021;92(Suppl 6):e2021441. Mihret MS, Azene ZN, Kebede AA, Mengistu BA, Eriku GA, Asaye MM, et al. Risk factors of dropout from institutional delivery among HIV positive antenatal care booked mothers within one year postpartum in Ethiopia: a case–control study. Archives Public Health. 2022;80(1):69. Tesfay F, Javanparast S, Mwanri L, Ziersch A. Stigma and discrimination: barriers to the utilisation of a nutritional program in HIV care services in the Tigray region, Ethiopia. BMC Public Health. 2020;20(1):904. Adepoju A. Determinants of multidimensional poverty transitions among rural households in Nigeria. 2018. Izudi J, Kiragga AN, Okoboi S, Bajunirwe F, Castelnuovo B. Adaptations to HIV services delivery amidst the COVID-19 pandemic restrictions in Kampala, Uganda: A qualitative study. PLOS Global Public Health. 2022;2(8):e0000908. Additional Declarations No competing interests reported. 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Defined as negative attitudes, prejudice, and discriminatory practices directed toward individuals living with HIV, stigma affects disclosure, social relationships, and access to health services across diverse contexts. Uganda has made substantial progress in the HIV response, aligning with UNAIDS\u0026rsquo; \u0026ldquo;95 95 95\u0026rdquo; targets (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) as part of its national strategy to end the AIDS epidemic by 2030. This framework aims for 95% of people living with HIV to be aware of their status, 95% of those diagnosed to receive sustained antiretroviral therapy (ART), and 95% of individuals on ART to achieve viral suppression. While Uganda successfully reached the second target ahead of schedule, the emergence of COVID 19 in March 2020, accompanied by stringent lock-downs, curfews, transport bans, and closure of non-essential services, posed serious disruptions to HIV service delivery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Uganda, HIV stigma continues to shape the lived experiences of women, including pregnant and breastfeeding populations, by reinforcing secrecy, internalised shame, and social exclusion despite advances in antiretroviral therapy (ART) and prevention of mother-to-child transmission programs. Moralized narratives reinforced stigma, particularly toward pregnant, breastfeeding, and HIV-positive women, shaping behaviours such as social distancing, secrecy, and avoidance of health services. By combining reliable messaging with digital access, women can engage safely with maternal and HIV care despite persistent moralized narratives. Qualitative evidence from rural Uganda highlights that social rejection and public ridicule remain dominant stigma experiences among pregnant women living with HIV, limiting care engagement and psychosocial well-being(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll women diagnosed with HIV during pregnancy or breastfeeding require ART for life (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). They may face several challenges that hinder their ability to adhere to medication and maintain regular appointments for routine care. Factors such as stigma, access to health care play a significant role. By identifying these factors, we can tailor interventions to meet women\u0026rsquo;s unique needs. Stigma associated with HIV can lead to fear of disclosure and discrimination: Some women may turn to alternative or traditional healing methods, which could impact their adherence to prescribed medications: Lack of consistent follow-up by healthcare providers can result in missed appointments and poor treatment adherence. Insufficient counselling, fear of disclosing HIV status, stigma, and discrimination have been identified as factors that impact adherence to Antiretroviral Therapy (ART) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Addressing stigmas through education, and culturally sensitive interventions is essential to promote positive attitudes towards breastfeeding and support optimal infant feeding practices and good child care (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePregnant and breastfeeding women represent a particularly vulnerable group within the HIV epidemic due to biological, social, and structural factors that intersect to affect maternal and infant health outcomes. Stigma not only threatens personal well-being but also contributes to delayed initiation of care, suboptimal ART adherence, and increased risk of vertical transmission. In addition, studies in sub-Saharan Africa report HIV stigma\u0026rsquo;s negative effects on mental health, social support, and maternal health-seeking behaviours, underscoring the urgency of addressing stigma within maternal care services (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe emergence of the COVID-19 pandemic introduced additional psychosocial stressors and structural barriers that have reshaped health systems and care engagement worldwide (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). COVID-19-related stigma where individuals diagnosed or suspected of having the disease experience fear, avoidance, and discriminatory behaviors has been documented during the pandemic and linked to reduced utilisation of essential health services, including maternal care. Mitigation measures such as movement restrictions and fear of infection have further altered health-seeking patterns among pregnant women and mothers, contributing to anxiety, reduced facility attendance, and disruptions in continuity of care (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite growing evidence on HIV stigma and separately on COVID-19 impacts, research on how intersecting stigmas specifically HIV stigma and COVID-19-related fear simultaneously shape the lived experiences of pregnant and breastfeeding women is limited. Understanding this intersection is essential because dual stigma may exert compounded effects on disclosure, caregiving decisions, and utilisation of HIV and maternal health services. The socioecological model (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) explains how individual beliefs, relationships, community norms, and structural systems interact to shape human behavior and health outcomes across personal, social, cultural, and institutional levels, contexts worldwide. The social ecological model (SEM) provides a comprehensive framework for understanding how various contextual layers shape COVID-19 and HIV related stigma. By applying the SEM, this study aims to mapped out the multilevel factors influencing the individual experiences (e.g., fear of infection) interact with community norms (e.g., stigma around COVID-19). Healthcare policies (e.g., telehealth options) intersect with network support (e.g., family encouragement). Understanding these interactions is vital for designing effective interventions that support pregnant and breastfeeding women living with HIV to overcome stigma during this challenging time (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Uganda, where HIV prevalence remains high among women of reproductive age and maternal mortality indicators continue to challenge health systems, the combined burden of HIV and COVID-19 stigma may undermine progress toward effective maternal HIV care. However, there is a paucity of empirical evidence exploring how these intersecting stigmas influence health-seeking behaviour, treatment adherence, and social dynamics among pregnant and breastfeeding women living with HIV. This study seeks to fill that gap by examining the nature and consequences of intersecting HIV and COVID-19 stigma in Uganda\u0026rsquo;s maternal health context.\u003c/p\u003e"},{"header":"Setting and method","content":"\u003cp\u003eWe adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure transparent reporting of this qualitative study (13). A qualitative cross-sectional design was used, conducted in March to July 2025 in selected high-volume public and private-not-for-profit HIV care facilities in central Kampala and Wakiso districts, Uganda. Seven strategically selected sites, including the Infectious Diseases Institute Clinic Mulago, Komamboga, and Kasangati HCIV, were included. These facilities provide comprehensive HIV, maternal, and reproductive health services and also served as COVID-19 vaccination sites during the pandemic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA qualitative study was conducted in selected districts in Uganda. Data were collected using 12 focus group discussions (FGDs), 21 in-depth interviews (IDIs) among breast feeding and pregnant women living with HIV. \u0026nbsp;24 key informant interviews (KIIs) included: ART case managers (clinical officers, health managers, midwives, counsellors, social workers, peer mothers, and sociologists), HIV activists, community advisory board members, and policymakers involved in HIV care and pandemic response in Kampala and Wakiso, Uganda. Maximum variation sampling (14) was used to ensure diversity in role, facility type, and geographic location.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All interviews were conducted using an interview guides developed based on the socio-ecological model. The topic guides (Supplementary 1,2, \u0026amp;3) explored perspectives about HIV and antenatal seeking behaviours during COVID-19, care provision during the pandemic, HIV and COVID-19 stigma, their effects on maternal care-seeking, disclosure, and support systems, alongside community, health system, and pandemic-related barriers, coping strategies, and potential stigma-reduction interventions. FGDs and IDIs were conducted in local language-Luganda and lasted about 90 minutes. While most Key informant interviews lasted 20–60 minutes, one key informant interview was limited to approximately 20 minutes due to the participant’s restricted availability and time constraints. All interviews were audio-recorded with consent and translated as appropriate and transcribed verbatim for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality assurance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo maintain high data quality, the study implemented rigorous control procedures throughout and after fieldwork. All the FGDS, IDIs and KIIs were audio-recorded, then transcribed by the principal investigator with two trained research assistants to ensure consistency. The research adhered to Lincoln and Guba’s (1985) trustworthiness framework covering credibility, confirmability, dependability, transferability, and authenticity (15-18). Standard operating procedures (SOPs) and pre-tested topic guides were used to guide data collection. Quality assurance was further reinforced through regular team debriefings and spot checks. Transcriptions were done verbatim, preserving both meaning and context to support accurate and reliable qualitative analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor data analysis,first, the researcher familiarized herself with the data by transcribing audio recordings, reading through transcripts, and taking initial notes. Next,\u0026nbsp;she coded (16-18) the data by highlighting relevant text and assigning descriptive labels.\u0026nbsp;Data analysis was conducted using NVivo software (19). Two qualitative data analysts independently coded a subset of transcripts to ensure intercoder reliability. Thematic analysis (16) was conducted using both inductive and deductive approaches. A coding framework (20) was developed from initial readings of transcripts and refined iteratively and \u0026nbsp; a final code book \u0026nbsp;generated (supplementary 4). Emergent themes were discussed and synthesized across SEM levels: (individual, interpersonal, institutional, community, and policy) to identify patterns in HIVand COVID-19 stigma and health seeking barriers among stakeholders. Finally, the findings were presented in a written report, supported by relevant data excerpts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Makerere University School of Public Health Research and Ethics Committee (SPH-REC, Ref: SPH-2024-619) and the Uganda National Council for Science and Technology (UNCST, Ref: SS3219ES). Additional support was provided by the Institute of Anthropology, Gender and African Studies at the University of Nairobi. All participants provided written informed consent in accordance with the Declaration of Helsinki prior to participation. Anonymity and confidentiality were ensured, and participants were informed of their right to withdraw at any time. They were also compensated for their time. All data were stored securely and used solely for research purposes.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eSocio-demographic characteristics of stakeholders\u003c/h2\u003e\n\u003cp\u003eThe study included 136 participants across focus group discussions (FGDs), in-depth interviews (IDIs), and key informant interviews (KIIs). The majority of participants were female, reflecting the maternal health focus of the study population. The mean age was 32 years among IDI participants and 27 years among FGD participants. Most FGD and IDI participants had attained secondary-level education and were either married or cohabiting. A substantial proportion of women were pregnant or breastfeeding at the time of data collection. COVID-19 vaccination coverage among participants was 66.7%. Among IDI participants living with HIV, viral suppression was high (92.9%), indicating strong treatment adherence within this subgroup\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntersection of HIV- and COVID-19–related stigma and health care seeking barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings are presented using the Social Ecological Model to illustrate how intersecting HIV- and COVID-19–related stigma and fear shaped maternal health-seeking behavior among pregnant and breastfeeding women in Uganda across individual, interpersonal, community, health system, and policy levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndividual level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;Internalized stigma, fear, and resilience\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the individual level, women described internalized HIV stigma, fear of COVID-19 infection, and anxiety about pregnancy outcomes as major drivers of secrecy, emotional distress, and delayed care-seeking. Anticipated gossip and judgment reinforced concealment of HIV status, even when symptomatic, contributing to delayed or inconsistent engagement with antenatal and ART services. However, fear also functioned as a motivator for continued care, particularly when linked to maternal and child survival, with many women demonstrating resilience grounded in motherhood and responsibility for their unborn or breastfeeding children.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I felt so ashamed to go for medication during Covid- 19… my peers would say I was going to give birth to a child who is HIV positive because i missed drugs—I was so stressed and scared.”\u003c/em\u003e\u0026nbsp; (IDI 7, adult, pregnant)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“I had a cough but did not tell anyone because I feared gossip and judgment. In my community, people quickly assume the worst, whisper, and distance themselves. I worried they would see me as a danger to my child, so I stayed silent even when I needed support.” “\u003c/em\u003e(IDI 8, adult breast feeding)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“A mother’s instinct to protect life becomes stronger than shame… women continue care because their children’s survival gives them strength.”\u003c/em\u003e (KII 14, HIV activist)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNon-disclosure and disrupted continuity of care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-disclosure of HIV status was common and largely driven by fear of stigma and COVID-19-related labelling. Women often concealed their status even when symptomatic, which disrupted continuity of care and reduced opportunities for timely clinical support. Health workers also noted challenges in providing care to women who had not disclosed, necessitating adapted and discreet service delivery approaches.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I kept my HIV status to myself because I feared how people would label me, especially during COVID-19. If I showed any symptoms, they would quickly... I had both illnesses. Because of that fear, I chose silence, even when I was not feeling well due to pregnancy. It made it hard to for me to go for antenatal consistently...”\u003c/em\u003e (IDI 18, breastfeeding)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e“Pregnant women living with HIV who had not disclosed their status were difficult to support openly because it risked exposing them. We adapted by using motorcycles for discreet delivery and making quiet, low-profile visits. This allowed us to continue their care while protecting privacy and reducing community stigma.\u0026nbsp;\u003c/em\u003e(KII 3, clinical officer)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eInterpersonal level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFamily control, partner influence, and peer support\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the interpersonal level, partner and family dynamics significantly shaped care-seeking behavior. Some male partners restricted clinic attendance due to fear of stigma and community gossip, resulting in delayed care. In contrast, peer mothers and community health workers provided emotional support, reassurance, and shared lived experiences that strengthened adherence and reduced isolation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHe[spouse] refused to let me go for testing, saying people would notice and start talking—that they would know his wife is HIV positive. In our community, gossip spreads quickly, and it brings shame not just to me but to the whole family. Because of that fear, my health had to wait, and I was left worrying in silence.”\u003c/em\u003e (FGD 7, Young adult).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“As midwives, we noticed that peer mothers and community health workers played a very important role in reducing stigma during COVID-19. They would sit with the mothers, encourage them, and share their own experiences, which made the women feel less alone. This emotional support helped mothers stay on treatment and continue attending care, even when they were worried or afraid.”\u003c/em\u003e (KII 6, Midwife)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth worker level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Fear of infection and enacted stigma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers’ fear of COVID-19 infection influenced interactions with clients, particularly in HIV care settings. Cautious behaviors such as distancing, reduced physical contact, and shortened consultations were common and, although intended for protection, were often perceived as discrimination, thereby reinforcing HIV-related stigma and weakening patient–provider trust. Health workers also experienced stigma within their households, where they were viewed as potential sources of infection.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“During the COVID-19 period…health workers were also afraid of getting infected… we became more cautious in how we handled clients, especially those coming for HIV services… our fear made us keep distance or rush interactions, and patients could feel it. Some interpreted this as rejection, which affected their trust and willingness to return for care.”\u0026nbsp;\u003c/em\u003e(KII 3, clinical officer)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“At home, things changed during COVID-19. My family became afraid of me because I worked in the hospital. They would ask me to stay away from the children and even change before entering the house. It was painful because I felt like I was bringing danger instead of care, even though I was only doing my job.”\u003c/em\u003e (KII 11, medical officer)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cem\u003eNorms, gossip, and social surveillance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity norms strongly reinforced stigma through gossip, labeling, and social surveillance. Attendance at health facilities and ART access were highly visible and often interpreted negatively, discouraging disclosure and promoting concealment. Household stigma was also evident through segregation practices, while anticipated stigma discouraged women from seeking care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“In our community, people watch everything you do. If someone goes frequently to the clinic, others start talking and guessing. During COVID-19, this became worse because even small signs made people suspect....”\u003c/em\u003e (KII 15, CAB member)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They [family members] would separate my cup, plate, even clothes… and wash everything apart, as if I could easily infect them. It made me feel isolated in my own home, like I was no longer part of the family. Even simple daily things became a reminder of how people feared and misunderstood HIV during COVID-19.”\u003c/em\u003e (FGD 7, Young adult).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“...judgment of women not only from people in the community but sometimes even from health workers who did not want to get close to mothers especially those that lacked masks on due to fear to contract COVID-19...”\u003c/em\u003e (KII 7, Midwife).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eCOVID-19 restrictions, visibility, and social isolation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLockdown measures and movement restrictions further intensified fear of disclosure and reduced access to health services. Women feared being seen accessing care, as visibility was closely linked to community speculation about HIV status. Discreet ART delivery systems reduced stigma for some but also highlighted concerns about unintended disclosure. Social isolation during lockdown further weakened peer support and increased emotional distress.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“During the lockdown, it became hard for us health workers to reach health facilities on time but even it became harder for women to access care especially if they had not disclosed their HIV status... Movement restrictions meant we had limited ways to reach the health facilities, and every trip outside felt like it could expose us”.\u003c/em\u003e (KII 10, clinical officer)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e“If a man came on a boda boda[motorcycle] and knocked at your door bringing medicine during COVID-19 lockdown, I feared people would start to wonder and talk. In the village, nothing goes unnoticed—neighbours are always watching. They would assume you are HIV positive, and gossip would start, bringing stigma even when you are only trying to take care of your health.””\u003c/em\u003e (FGD 1, adult breast feeding).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“Due to fear of disclosure of HIV status... they [health workers] gave me my medication in a small, plain package without any labels. When I carried it home, no one could tell what it is, so I didn’t feel embarrassed or ashamed. It allowed me to take my medicine quietly and continue my treatment without people in the community questioning or judging me.”\u003c/em\u003e (IDI 12, adult, breastfeeding)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“During lockdown, I stayed alone most of the time. I could not meet my peer mothers or talk freely to anyone. I felt isolated and scared that if I went out, people would suspect my condition.”\u003c/em\u003e (IDI 19, adult, breastfeeding).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLayered stigma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cem\u003eIntersection of HIV and COVID-19 fears\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe coexistence of HIV and COVID-19 created compounded stigma that shaped maternal health-seeking behavior. Fear of infection, social labelling, and perceived risks within health facilities interacted to delay or prevent care. Health facilities were sometimes perceived as unsafe or associated with isolation and death, further discouraging service uptake.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Women were constantly afraid—not only of HIV stigma but also of getting COVID-19. These two fears mixed together and affected how they made decisions about seeking care. Sometimes they would avoid going to the clinic because they feared catching COVID-19...”\u003c/em\u003e (KII \u0026nbsp;24, facility in charge)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I had a cough when I was pregnant… my husband said if you go to the hospital for antenatal, you will die. He thought it was COVID… he stopped me from going because he feared they would quarantine me. I was isolated and slept in my own room… so I stayed home.”\u003c/em\u003e (FGD 3, Young adults)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Women became afraid of going to the health facility during COVID-19 because people said those places were where they could be isolated, or quarantined. That fear stayed with me...This fear made the postpone clinic visits...loss of patients to follow up was a very big problem... up to now we are still receiving women who disengaged from care due to COVI|D-19... we notice their viral load unsuppressed.”\u003c/em\u003e (KII \u0026nbsp;16, doctor, ART case manager)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStigma shaped by disability\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWomen with disabilities faced compounded stigma during COVID-19 due to HIV, disability, and infection fears. Marginalization increased vulnerability, while dependence on caregivers risked involuntary disclosure. Mobility barriers limited access to care. Despite stigma and isolation, some remained resilient, relying on trusted caregivers and community health workers to continue treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“... a woman with disability... people already judge you, so adding HIV and COVID-19 made it worse. I depend on others to move, but I fear they may talk and expose my status. Still, I try to continue care because my life and my child depend on it.”\u0026nbsp;\u003c/em\u003e(KII 16, CAB member, woman with disability)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStigma shaped by displacement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRefugee women faced layered HIV and COVID-19 stigma shaped by displacement and poverty. Crowded settings increased visibility and fear of gossip, limiting clinic use. Language barriers and lockdowns reduced access. Despite this, some remained resilient, maintaining treatment through discreet services and support from trusted community health workers and peers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“As a refugee woman, life for a refugee woman is hard... already have no money... live in camps which are crowded...also have issues with language barrier...seeking care was difficult during lockdown. During COVID-19, if you went to the clinic often, they would start talking and say you have HIV or corona. Many women refugees feared being judged and isolated...they avoided health facilities...as their leader I delivered drugs to them at their homes”\u003c/em\u003e (KII 17, Refugee activist)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth system level\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;Trust, privacy, and service adaptations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConfidentiality, respectful care, and trust in health workers were critical enablers of service continuity. Women emphasized the importance of privacy in reducing stigma and supporting adherence. Health system adaptations such as telehealth, home delivery of ART, and community distribution improved access but sometimes increased visibility and stigma risks.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“…I feared people gossiping about me…now I can pick my medication without anyone knowing…If I go and no one sees me, I feel safe to take my medication on time.”\u003c/em\u003e (IDI, 4 adults, pregnant)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e“As health workers, we have learned that privacy is very important in encouraging mothers to come for care. We should ensure services protect confidentiality so women are not seen or identified by community members when they visit the facility. When mothers feel safe from recognition and judgment, they are more likely to seek care early and continue treatment without fear.”\u003c/em\u003e (KII 12, facility in charge)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003ePolicy and community interventions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;Stigma reduction and resilience strategies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants highlighted the importance of multi-level interventions including psychosocial support, emergency preparedness, community education, and peer-led approaches. Trusted community actors such as Village Health Teams, peer mothers, and community leaders played a central role in improving adherence and reducing misinformation. Mental health and psychosocial support for Health workers; women was suggested.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Integrate mental health and psychosocial support services for patients and health workers during epidemics…”.\u0026nbsp;\u003c/em\u003e(KII 19, policy maker).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eC\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eonfidential service delivery\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnsure privacy at health facilities and in service provision to reduce fear of being seen by community members. Potential Implementation should include\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003ePrivate consultation rooms, anonymous check-in systems and discreet pharmacy pick-up.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“…I used to fear people gossiping about me, and that fear made me uncomfortable seeking care openly. During COVID I could pick my medication quietly without anyone knowing. When I go and no one notices me, I feel safe and free to take my medication on time, without worrying about judgment or talk in the community.”\u003c/em\u003e (IDI, 10 adult, pregnant)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eD\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eisguised ART distribution\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeliver antiretroviral therapy (ART) in ways that conceal the purpose from others, reducing stigma. This can be done through home delivery in unmarked packages, medication pick-up points outside the clinic and multi-purpose packages with other health items.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Sometimes, they give me my medication in a small unmarked package. No one knows what it is, and I don’t feel ashamed.”\u003c/em\u003e(IDI 12, adult, breastfeeding)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I can swallow my medicine at home quietly…COVID showed me it’s better when no one is watching.”\u003c/em\u003e (IDI, 7, adult, pregnant)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e“We, as health workers, need to deliver antiretroviral therapy in ways that do not reveal its purpose. This includes unmarked home delivery, discreet pick-up points outside clinics, or combining ART with other health items. These approaches protect clients from stigma while ensuring uninterrupted treatment access.”\u003c/em\u003e (KII 11, medical officer)\u003c/p\u003e\n\u003cp\u003eEmergency preparedness for Health facilities; patients\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Enhance readiness for future epidemics by educating patients on financial and logistical preparedness and ensuring facility-level contingency plans.”\u003c/em\u003e (KII 14, HIV activist)\u003c/p\u003e\n\u003cp\u003eHealth rights and empowerment for Pregnant and breastfeeding women\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Implement policies and initiatives that promote health rights, social protection, and economic empowerment of pregnant and breastfeeding women.”\u003c/em\u003e (KII 22, Youth activist)\u003c/p\u003e\n\u003cp\u003eContinuous medical education (CME) for Health workers; facility leadership\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Sustain regular training and refresher programs for health workers on epidemic preparedness, updated clinical guidelines, and quality patient care.”\u003c/em\u003e (KII 24, facility in charge)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eC\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eommunity\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003esensitization\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eeducation to reduce discrimination\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Conduct awareness campaigns to reduce myths, promote empathy, and normalize HIV care in the community through local radio programs, community dialogues led by trained health workers and testimonies from people living with HIV.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“We, as health workers, need to strengthen community awareness to address HIV myths during pandemics. Through radio programs, community dialogues led by trained workers, and testimonies from people living with HIV, people can hear real experiences and accurate information, foster empathy and reducing stigma.”\u0026nbsp;\u003c/em\u003e(KII 14, HIV activist)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When people see that many are on treatment and doing well, they stop talking badly about others.”\u0026nbsp;\u003c/em\u003e(IDI 8, adult, breastfeeding)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Education helped my neighbors understand that HIV is not a death sentence and that we can all live normally.”\u0026nbsp;\u003c/em\u003e(IDI 4, adult, pregnant)\u003c/p\u003e\n\u003cp\u003ePatient education and communication for patients; caregivers; community members\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Develop clear, culturally appropriate, and locally understandable health education materials on epidemics, treatment options, and preventive behaviors”\u003c/em\u003e (KII 13, Health manager)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommunity health workers and peer mothers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeveraging trusted community actors such as Village Health Teams (VHTs), peer mothers, local council leaders, and respected national figures. Health care workers should Coordinate with peer educators to counsel mothers experiencing stigma during pandemic setting.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Peer mothers...Village Health Teams are like the first doctors in our communities—the people we run to before anyone else. They live among us, they understand our struggles, and they keep our secrets. Because of that closeness and trust, many people feel safer opening up to them than to anyone else.”\u0026nbsp;\u003c/em\u003e(IDI 14, pregnant)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The Village Health Teams are the first community doctors. They can share the right information with the pregnant or breast-feeding mothers. People trust them more than anyone else.”\u003c/em\u003e (KII 14, HIV activist)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We have peer mothers… When someone listens to another person like them, they say, ‘If she has said it, then it is true...they can share their own experiences with mothers to cope with stigma.”\u003c/em\u003e (KII \u0026nbsp;20, Policy maker, MOH)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“…Peer mothers should be strengthened and supported because they are close to us in the community…If they are involved more in follow-up and counselling, many women will feel more comfortable and less stigmatized in their care.”\u0026nbsp;\u003c/em\u003e(KII 23, nurse)\u003c/p\u003e\n\u003cp\u003eExpand peer support models\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Strengthen networks of peer mothers and mentors to provide trusted health education and support treatment adherence, leveraging community trust in peers”\u003c/em\u003e (KII 21, CAB Member)\u003c/p\u003e\n\u003cp\u003ePartner involvement and disclosure to Male partners; couples\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Promote strategies that engage male partners in maternal and HIV care to support disclosure, adherence, and positive health outcomes.”\u003c/em\u003e (KII 15, Activist positive women with disability)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn sub-Saharan Africa, where HIV prevalence is high and health infrastructure limited, maintaining ART continuity during lockdowns and mobility restrictions was a major concern (21). This study demonstrates that HIV- and COVID-19–related stigma intersects across multiple ecological levels to shape maternal health-seeking behavior in Uganda. At the individual level, internalized stigma, fear of infection, and anticipated judgment led to secrecy, delayed care, and psychological distress, but also motivated continued service use driven by maternal and child survival. These findings align with existing evidence that stigma operates not only as a social constraint but also as a psychosocial stressor influencing healthcare decisions and treatment adherence among pregnant women living with HIV (22). Jolle et al found that social rejection and public ridicule were dominant stigma experiences among HIV positive pregnant women in rural northern Uganda, significantly impacting their sense of self and social support networks (3). Such findings support our results showing that anticipated stigma and fear of gossip deterred women from disclosing their status and accessing care, reinforcing continuity challenges documented in other Ugandan maternal populations.\u003c/p\u003e\n\u003cp\u003eThe COVID-19 pandemic added new layers of fear and structural barriers that intensified existing HIV-related stigma among pregnant and breastfeeding women. Movement restrictions, fear of infection, and concern about being seen at health facilities heightened anxiety about unintended HIV status disclosure, as clinic attendance in many Ugandan communities is closely associated with illness and can trigger gossip, labeling, and social judgment. These socio-cultural dynamics made accessing care both physically and socially challenging, particularly for women who sought to protect their privacy and reputation. As fear of COVID-19 infection became intertwined with fear of HIV stigma, care-seeking behaviors were further constrained, leading to delayed or avoided service use. This is consistent with findings that COVID-19 restrictions in Uganda worsened transport, psychosocial, and structural barriers to HIV service engagement (23), highlighting how pandemic response measures inadvertently reinforced stigma and reduced continuity of care among vulnerable maternal populations.\u003c/p\u003e\n\u003cp\u003eFear of contracting COVID-19 at health facilities further complicated health-seeking behaviour, particularly among pregnant and breastfeeding women living with HIV. Within the socio-cultural context of Uganda, health facilities are not only spaces for treatment but also highly visible public arenas where attendance can be easily observed and interpreted by others. This visibility intensified concerns about HIV-related stigma, as women feared that being seen at clinics during the pandemic could lead to unintended disclosure of their HIV status, triggering gossip, labelling, and potential social exclusion within their communities. These fears were deeply embedded in existing cultural norms that place strong emphasis on privacy, reputation, and social standing, especially for women during pregnancy. In such contexts, maintaining confidentiality about one’s health condition is critical to preserving dignity and avoiding shame. Consequently, the combined fear of COVID-19 infection and anticipated HIV stigma created a dual burden that discouraged timely and consistent use of antenatal and HIV services. This echoes qualitative research on healthcare engagement during COVID-19 in Uganda, which found that stringent public health measures disrupted continuity of routine care and diverted attention away from chronic disease management, affecting both patient access and confidence in health services (24). Participants’ narratives of anxiety about labelling and avoidance of facilities illustrate how infection fear and stigma may jointly depress utilization of antenatal and HIV services.\u003c/p\u003e\n\u003cp\u003eAt the community level, pervasive gossip, labeling, and social exclusion reinforced both HIV and COVID-19 stigma, leading to concealment of health status, switching of health facilities, and avoidance of care. In many settings, community norms strongly influence disclosure decisions and shape how and when individuals seek health services, particularly for conditions associated with moral judgment and social shame such as HIV (25-27). Within this context, maintaining secrecy becomes a protective strategy to avoid discrimination, even when it compromises timely access to care. The COVID-19 pandemic further intensified these dynamics by introducing additional fear of contagion and enforced social isolation, which compounded existing stigma and heightened suspicion toward affected individuals and households. This is consistent with global reports documenting pandemic-related stigma, where individuals perceived as infected with COVID-19 experienced avoidance, discrimination, and social distancing beyond public health requirements \u0026nbsp;(28, 29). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite many obstacles faced during COVID-19 pandemic, intrinsic motivation (30-33) among health workers, peer supporters, and community volunteers was a strong force maintaining HIV service continuity. The literature aligns with other studies where both point to peer mother networks, expert patients, and community client groups that stepped in when formal systems were constrained (34, 35).These actors often worked without much external reward, driven by commitment to patient welfare. Such resilience suggests that investing in peer support, institutional recognition, and psychological support for front‑line workers could strengthen the health system’s preparedness for shocks. Furthermore, embedding differentiated service delivery models like multi‑month dispensing, decentralized ART distribution, and flexible facility operations into routine policy could ensure smoother responses in future crises.\u003c/p\u003e\n\u003cp\u003eInterpersonal networks played a dual role in shaping health behavior. While some male partners restricted healthcare access due to fear and misinformation, peer mothers and community health workers provided critical emotional and informational support. This reflects broader evidence that social support systems can buffer the negative effects of stigma and improve adherence to HIV care during pregnancy (Kintu et al., 2021). The use of home-based ART delivery and peer support aligns with global findings. A study in Kenya found that community health workers and peer navigators played a key role in discreet ART delivery, especially among women who feared disclosing their HIV status (36). Similar to the current study, phone-based counselling (Twimukye et al, 2021 ) \u0026nbsp; \u0026nbsp;not only provided logistical support but also emotional reassurance, mitigating isolation during lockdowns (37). However, stigma concerns such as reluctance to receive home deliveries due to fear of being identified as HIV-positive were echoed (8, 38, 39) reinforcing that visibility in ART delivery methods can unintentionally reinforce stigma, showing fear of boda boda ( motorcycle) deliveries being associated with HIV. The role of Village Health Teams and peer networks highlights the importance of trusted community structures in sustaining maternal health services during crises.\u003c/p\u003e\n\u003cp\u003eAt the health system and policy level, adaptations such as telehealth, home delivery of antiretroviral therapy (ART), and community-based drug distribution improved continuity of care but sometimes inadvertently increased stigma due to visibility concerns. Similar findings have been reported during COVID-19, where decentralized ART delivery improved access but raised confidentiality challenges in resource-limited settings (1, 40). Despite these challenges, our findings highlight resilience among women driven by a strong desire to protect themselves and their children. This motivation resonates with broader literature showing that, even amid stigma and pandemic disruptions, personal agency and community support can sustain engagement with care. Additionally, participants identified practical stigma‑mitigating strategies like confidential ART delivery, telehealth, and peer support—that align with documented health system adaptations in Uganda during COVID‑19, such as mobile phone reminders and differentiated service delivery models to maintain ART access (41).These findings have important implications for maternal HIV care policy. Addressing dual stigma requires integrated, stigma‑sensitive interventions that combine confidential service delivery with community education and peer support. By aligning local stigma experiences with evidence on structural barriers exacerbated by COVID‑19, health systems can better tailor strategies to support pregnant and breastfeeding women living with HIV during and beyond public health emergencies.\u003c/p\u003e\n\u003cp\u003eOverall, findings underscore the utility of the Social Ecological Model in explaining how stigma is produced and reproduced across interacting levels such as individual, interpersonal, community, and structural. Addressing these layered barriers requires integrated interventions that combine confidentiality-sensitive service delivery, community stigma reduction, and strengthened psychosocial and peer support systems. Such approaches are essential for improving maternal health-seeking behavior and resilience in contexts affected by overlapping epidemics such as HIV and COVID-19.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study explores the intersecting stigmas of HIV and COVID-19 experienced by pregnant and breastfeeding women in Uganda and how these influenced disclosure, social interactions, and health-seeking behaviors. HIV-related stigma was reflected in internalized shame, anticipated discrimination, and social exclusion, which led some women to conceal their status and limit engagement with care. The COVID-19 pandemic further contributed to feelings of isolation and disrupted access to services, particularly during lockdowns when movement restrictions and changes in service delivery increased concerns about unintended disclosure. Together, these overlapping stigmas created additional barriers to care, including fears of infection, gossip, and labelling, which in some cases contributed to delayed or avoided use of health services. Despite these challenges, some women continued to engage with care, often motivated by concerns for their own health and that of their children. Strategies such as confidential service delivery, discreet ART distribution, telehealth communication, and peer support were reported as helpful in reducing stigma-related barriers and supporting continuity of maternal health services. Overall, the findings suggest a need for continued attention to stigma-sensitive approaches within integrated HIV and maternal health services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy limitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The study has some limitations that should be considered when interpreting the findings. The relatively small number of male participants compared to female participants limited the depth and balance of male perspectives, particularly regarding couple dynamics and male involvement in maternal health decision-making. In addition, recruitment was conducted mainly in selected urban health facilities, which may not fully reflect the experiences of individuals in rural or hard-to-reach areas where access to services, social norms, and stigma may differ, thereby limiting the transferability of the findings across different contexts. The reliance on self-reported data may also have introduced recall bias, especially for past experiences during pregnancy, breastfeeding, and the COVID-19 lockdown period, as well as social desirability bias due to the sensitive nature of HIV status and related stigma. Furthermore, the qualitative design does not allow for estimation of the prevalence or magnitude of the reported experiences, meaning the findings are interpretive and not statistically generalizable. Finally, the focus on selected themes related to stigma and service access may have meant that other relevant influences, such as broader economic constraints or health system challenges, were not fully explored.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe author expresses her gratitude to the entire study participants. She is also grateful to the research assistants who supported data collection Dorothy Namugerwa, Nagasha Rebecca, Joseph Ssebulime, Emanuel Nkurunziza and Patricia Kelly Kalisa as well as to Muhimba Hillary, who assisted with data transcription.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was made possible through funding by the Royal Society of Tropical Medicine and Hygiene (RSTHM), ref; nihr 24208.\u0026nbsp;The decision to publish was not influenced by the funder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study and approved the final manuscript.\u0026nbsp;AT conceptualized the project and conducted literature review. \u0026nbsp;ATcollected data,organized and integrated data collected from various sources. AT coded and analyzed data that was interpreted by COO, PG and CW.\u0026nbsp;AT drafted the manuscript and all authors critically revised the draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analyzed for this manuscript are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman protection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data collection methods and analysis were carried out in accordance with relevant Good clinical care practice (GCP) guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Affiliation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1.\u0026nbsp;\u003c/sup\u003eDepartment of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003csup\u003e2.\u0026nbsp;\u003c/sup\u003e Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3.\u0026nbsp;\u003c/sup\u003e Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.\u003c/p\u003e\n\u003cp\u003e4. Department of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNAIDS. HIV and Stigma and Dicrimination. UNAIDS; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabami J, Owaraganise A, Beesiga B, Okiring J, Kakande E, Chen Y-H, et al. Effect of the COVID-19 lockdown on the HIV care continuum in Southwestern Uganda: a time series analysis. PLoS ONE. 2023;18(8):e0289000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJolle J, Kabunga A, Okello TO, Kadito EO, Aloka J, Otiti G, et al. HIV-related stigma experiences and coping strategies among pregnant women in rural Uganda: a qualitative descriptive study. PLoS ONE. 2022;17(10):e0272931.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Acta Bio Medica: Atenei Parmensis. 2021;92(Suppl 6):e2021441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMihret MS, Azene ZN, Kebede AA, Mengistu BA, Eriku GA, Asaye MM, et al. Risk factors of dropout from institutional delivery among HIV positive antenatal care booked mothers within one year postpartum in Ethiopia: a case\u0026ndash;control study. Archives Public Health. 2022;80(1):69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTesfay F, Javanparast S, Mwanri L, Ziersch A. Stigma and discrimination: barriers to the utilisation of a nutritional program in HIV care services in the Tigray region, Ethiopia. BMC Public Health. 2020;20(1):904.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdepoju A. Determinants of multidimensional poverty transitions among rural households in Nigeria. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIzudi J, Kiragga AN, Okoboi S, Bajunirwe F, Castelnuovo B. Adaptations to HIV services delivery amidst the COVID-19 pandemic restrictions in Kampala, Uganda: A qualitative study. PLOS Global Public Health. 2022;2(8):e0000908.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV, COVID-19, stigma, breast feeding, pregnant, women, Uganda, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-9457639/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9457639/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStigma and fear associated with HIV/AIDS and COVID-19 remain major barriers to healthcare access, particularly for pregnant and breastfeeding women. These intersecting social processes may undermine health-seeking behavior, treatment adherence, and maternal health outcomes. The study explored experiences of HIV stigma, COVID-19\u0026ndash;related fear, and health-seeking barriers among pregnant and breastfeeding women, healthcare workers, and community stakeholders in Uganda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative study was conducted in selected districts in Uganda in March-July 2025. Data were collected using 12 focus group discussions (FGDs), 24 in-depth interviews (IDIs), and 21 key informant interviews (KIIs). Participants included pregnant and breastfeeding women, healthcare workers, and community stakeholders, selected purposively. Interviews were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis using Nvivo version 12 software guided by the Social Ecological Model.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eHIV stigma was pervasive, expressed through gossip, discrimination, secrecy, and moral judgment, shaping disclosure and access to care. COVID-19\u0026ndash;related fear intensified social isolation, movement restrictions, and unintended disclosure of HIV status. The coexistence of both conditions created layered stigma that disrupted antenatal attendance, ART adherence, and household relationships. Despite these barriers, participants demonstrated resilience driven by child protection and survival. Coping strategies included discreet ART delivery, peer support, telehealth communication, and community sensitization. Trust in healthcare workers and confidentiality were central to service utilization.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIntersecting HIV and COVID-19 stigma and fear appeared to contribute to barriers in maternal health-seeking among women in Uganda. These influences may be reduced through targeted approaches such as confidential service delivery, peer-led support, and community education. Integrating stigma-sensitive practices into maternal and HIV care services could help strengthen trust, support service use, and improve maternal health outcomes during concurrent public health challenges.\u003c/p\u003e","manuscriptTitle":"Community and healthcare provider perspectives on HIV- and COVID-19–related stigma, fear and health-seeking barriers among pregnant and breastfeeding women in Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-06 11:26:42","doi":"10.21203/rs.3.rs-9457639/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-06T18:02:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88707260333890844556296197773108611604","date":"2026-04-28T05:52:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T05:46:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-22T12:55:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-21T18:25:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-21T18:14:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be2a0e0a-bb74-4405-98c0-5fb1080896ac","owner":[],"postedDate":"May 6th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-06T18:02:51+00:00","index":16,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T11:26:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-06 11:26:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9457639","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9457639","identity":"rs-9457639","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}