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JULY, 2012 ¢ THE JOURNAL OF THE NATIONAL BLACK NURSES ASSOCIATION A Volume 23 Number 1 Experiences of HIV-Positive African-American and African Caribbean Childbearing Women: A Qualitative Study Veronica Njie-Carr, PhD, RN, ACNS-BC Phyllis Sharps, PhD, RN, FAAN, CNE Doris Campbell, PhD, RN, FAAN Gloria Callwood, PhD, RN Acknowledgements: Funding was obtained from the Caribbean Export Center for Health Disparities (R24 MD001123- 02) and the Caribbean Exploratory NIMHD Research Center of Excellence (Grant # 5 P20MD002286), National Institute on Minority Health and Health Disparities /NIH, University of the Virgin Islands. Abstract This qualitative study examined the experiences of HIV-posi- tive African-American and African Caribbean childbearing women related to decisions about HIV testin gz, status disclo- sure, adhering to treatment, decisions about childbearing, and experiences in violent intimate relationships. Twenty-three women completed a 60-minute in-depth interview. Six themes emerged: perceived vulnerability to HIV infection; feelings about getting tested for HIV; knowledge, attitudes, and behaviors after HIV diagnosis; disclosure of HIV status; living with HIV (pos- itivity, strength, and prayer); and, experiences with physical and sexual violence. Three women (13%) reported perinatal abuse and 10 women (n = 23, 43.4%) reported lifetime abuse. Positive experiences and resilience were gained from faith and prayer. Most important to the women were the perceived ben- efits of protecting the health of their baby. Findings suggest that policies supporting early identification of HIV-positive child- bearing women are critical in order to provide counseling and education in forming their decisions for safety precautions in violent intimate partner relationships. Key Words: African-American, African Caribbean, childbear- ing, HIV/AIDS, intimate partner violence, women Introduction Human immunodeficiency virus (HIV) infection and interpersonal violence are global health issues dispro- portionately affecting childbearing women of African heritage. As a result, these women have the highest HIV/AIDS burden (Archibald, 2010; Brewer, Zhao, Metsch, Coltes, & Zenilman, 2007; CDC, 2010; Krishnan et al., 2008). Women of African heritage are more vulnerable because of inequities, inequalities, and partners who are involved in risky behaviors (Aral, Adimora, & Fenton, 2008; Adimo- ra et al., 2006; Centers for Disease Control and Prevention [CDC], 2010; Tillerson, 2008). Researchers have found that social inequities and inequalities such as poverty, social norms, and expectations make women vulnerable and at risk for violence (Tillerson, 2008). Background and Significance Intimate Partner Violence Interpersonal violence is the use of physical force or power, either threatened or actual, against another person that results in, or has a high likelihood of resulting in, injury, death, psychological harm, or deprivation (World Health Organization [WHO], 2002). Interpersonal violence against women, particularly intimate partner violence, has been linked to increased vulnerability to HIV, underscoring glob- al and public health implications in HIV-prevention efforts (Campbell et al., 2002; Dunkle et al., 2006; Gielen, Gan- dour, Burke, Mahoney, McDonnell, & O’Campo, 2007). In addition, intimate partner violence propagates HIV trans- mission (Sareen, Pagura, & Grant, 2009; Silverman, Decker, Saggurti, Balaiah, & Raj, 2008). It has been linked to power imbalances associated with women’s inability to negoti- ate safe sex, maintain strong financial support, and realize economic stability. Economic challenges such as poverty force women to engage in sexual relations with older men and multiple partners (Aral, Adimora, & Fenton, 2008; Lichtenstein, 2008), limiting their choices to negotiate safe sex with subsequent exposure to HIV infection (Roundtree & Mulrany, 2010). Exposure to HIV Being exposed to HIV, and getting infected, place child- bearing women in critical positions that require them to Veronica Njie-Carr, PhD, RN, ACNS-BC, is an Assistant Professor, University of Delaware School of Nursing, Newark, DE. Phyllis Sharps, PhD, RN, FAAN, CNE, is a Professor and Chair, Department of Community Public Health, Johns Hopkins University School of Nursing, Baltimore, MD. Doris Campbell, PhD, RN, FAAN, is a Professor Emerita, University of South Florida, Tampa, FL, and Visiting Professor, Caribbean Exploratory NCMHD Research Center, School of Nursing, University of the Virgin Islands, St. Thomas, United States Virgin Islands. Gloria Callwood, PhD, RN, is an Associate Professor and Director Caribbean Exploratory NCMHD Research Center, School of Nursing, Universi- ty of the Virgin Islands, St, Thomas, United States Virgin Islands. Address Requests for Reprints and Correspondence to: Veronica N) jie-Carr, PhD, RN, ACNS-BC, Assistant Professor, University of Delaware School of Nursing, 25 N. College Avenue, McDowell Hall/Room 335, Newark, DE 19716. Email: vncarr@udel.edu 21 gq THE JOURNAL OF THE NATION L BLACK Nurses ASSOCIATIO make important life changing decisions. These decisions include HIV testing, HIV status disclosure, adhering to treatment regimens, and decisions about continuing the pregnancy and parenting their child. Decisions may involve multiple interrelated factors, including individual beliefs, relationship status, and social and economic factors (Roundtree & Mulrany, 2010). Decisions about their preg- nancy may be influenced by fear of disclosing their HIV status to intimate partners, family and/or friends (Peltzer, Chao, & Dana, 2008); and they fear that their experiences involving violence might increase, thus creating major barriers to accessing care services. Astudy involving HIV- positive Black women in four U.S. cities found that even though some women made the decision to have children, they expressed concern that if they got sick they would be unable to care for them and no one would take care of their children when they died (Kirshenbaum et al., 2004). Contrasting results related to childbearing women’s deci- sions were found in the literature (Craft, Delaney, Bautista, & Serovich, 2007; Cruskin, Ahmed, & Ferguson, 2008). Specifically, there were differences in results related to HIV-positive women’s decisions whether to continue with the pregnancy or to terminate it for reasons such as a strong desire to have children versus concerns for the child’s health and inability to care for the child when they were too ill. Kanniappan, Jeyapaul, and Kalyanwala (2008) found that women desired to keep the pregnancy, depend- ing on available social support. Craft et al., (2007) found that almost 75% of HIV-positive women did not desire pregnancy. Limited research has explored HIV-positive childbearing women’s feelings and abuse experiences (Peltzer, Chao, & Dana, 2008). yn @ JULY, 2032 0 Volume 23 Number 1 Purpose of the Study The purpose of this study was to describe and ex)’ African-American and African Caribbean women’s kn: edge, attitudes, beliefs, feelings, interpersonal experic: related to participating in voluntary counseling anc | ing (VCT), disclosing their HIV status, and their decis related to pregnancy care and parenting practices. The following two questions were explored: (a) are the knowledge, attitudes, beliefs, and abuse e>) ences of HIV-positive women? (b) What influe HIV-positive women’s decisions related to their pa pation in VCT, disclosure of HIV status, and contin their pregnancy and parenting practices? Methodology Conceptual Model The Health Belief Model (HBM) (Pender, Murdau Parsons, 2006) provided the conceptual backgrou! this study. The theory posits that decisions and b ioral outcomes are influenced by a confluen interrelated concepts of cognitive perceptual fact perceived control of health; perceived health statu ceived self-efficacy; and perceived benefits. Also imp in the HBM are the modifying factors related to graphic, biological, and individual character interpersonal influences, and behavioral factors. Per risks and benefits could block or facilitate progres ositive outcomes or favorable decisions. Figure’ trates the inter-relationships among, the study ther constructs of the HBM (see Figure 1). Figure 1. Model Tlustrating the Inter-relationships among Study Themes and Constructs of the Health Belief! Perceived vulnerability Perceived vulnerability to HIV infec relate partner & own Experiences with physical and ehavior sexual violence Motivated to test for HIV because of benefits to baby (Perceived benefits; Perceived “A control of health) Feelings about getting tested for HI Y / efficacy) Perceived social and personal risks motivated HIV disclosure (Perceived self- Disclosure of HIV status Health behavioral changes, spiritual and emotional response to HIV results (Perceived health status) Knowledge, attitudes, and behavi after HIV diagnosis Living with HIV: Positivity, streng and prayer 22 JuLy, 2012 ¢ THe JouRNAEL OF THE NATIONAL BLACK NURSES ASSOCIATION Be Volume 23 Number 1 Research Design, Setting and Sample Setting Reported through 2008 in Baltimore, there were 9,447 new cases of HIV; 667 were African-Americans and 348 were females. Total AIDS cases were 7,085; 421 were African-Americans and 191 were females. Baltimore women have a 37.6% prevalence rate (Baltimore City, 2009; CDC, 2009). AIDS cases were at 37.7 cases /100,000 pop- ulation. HIV prevalence among African-Americans declined up to 10% in the previous 10 years, yet, African- Americans are eight times more likely to die from HIV and related diseases. Cumulative data for females in Bal- timore diagnosed with HIV were 3,662, and with AIDS, 2,512 (Baltimore City, 2009). United States Virgin Islands (USVI) has the second high- est per capita rate for AIDS and the third highest per capita rate for HIV in the United States and five territories (CDC, 2009). At the end of 2010, the estimated numbers of per- sons living with HIV was 252; AIDS was 281 (Virgin Islands Department of Health [VIDOH], 2010). Six females were reported as HIV-infected and 5 women were reported with AIDS during 2010 (VIDOH, 2010). In communication with the Director of HOPE, INC., the cumulative numbers of females diagnosed with HIV since data was collected is 135 women; and 209 women have been diagnosed with AIDS (March 16, 2010). Study Design and Sample This in-depth qualitative design study was a compo- nent of a larger mixed methods study. The quantitative study included demographic data and the use of ques- tionnaires to obtain information on attitudes, knowled ge, beliefs, decisions related to testing and disclosure, health and parenting practices; as well as questionnaires related to depression, and self-esteem. A total of 67 women were recruited and consent was obtained for the parent study. Inclusion criteria were: African-American and African Caribbean women clinically diagnosed as HIV-positive; pregnant or having infants 12 months or younger; receiv- ing pre-natal care; self-reported interpersonal violence currently, or within 12 months prior to the pregnancy; residing in Baltimore and the USVI. Exclusion criteria were: not meeting any of the above criteria or medically diagnosed with mental or psychiatric illness. Data and findings presented here are from the 23 women (N = 23) who agreed to participate in the qualitative study. Institutional Review Board Approval Institutional Review Board approval was obtained from the Johns Hopkins University and the USVI before par-' ticipant recruitment and data collection began. A total of 67 women included in this study had given consent for the larger study. The 23 women described in the qualita- tive study reported here volunteered to complete the in-depth interviews and signed an additional consent form. Recruitment and Data Collection Flyers were posted at data collection sites. In-depth inter- views of approximately 60-minutes were conducted using a structured interview guide. Interviewers used probe questions to direct the focus of the interviews. Questions included demographic information such as age, years of formal education, pregnancy health history, decisions about HIV testing, learning about their diagnosis, preg- nancy and parenting practices, disclosure of HIV status, behaviors and changes in intimate relationships related to HIV test results, and partner relationships. Women were interviewed until no new information was generated, sug- gesting that data saturation was reached. Instrumentation The in-depth interview guide was designed by the research team to obtain data about the women’s beliefs, feelings, and attitudes that may be influenced by their HIV/AIDS status and related stigma experiences. The research team formulated the content for the questions based upon previous studies examined, as well as gaps in what has been studied. The open-ended questions for the interview were designed to allow the women to tell their “story” using “their own words.” Questions includ- ed: HIV testing status; how the decision was made about testing; attitudes, beliefs, and feelings after they learned of their HIV status; disclosure of their HIV status to whom and when; after disclosure, changes in their relationships with partners (i.e., conflict, physical, sexual and/or men- tal violence /abuse); family, friends (i.e., cutoff/isolation, conflict, physical, sexual and/or mental violence/abuse); since learning their status had they changed anything they did or said in relation to their HIV status; after becoming aware of their status had it changed their beliefs, feelings and attitudes related to parenting; other questions were also asked about sources and types of social support. The in-depth interviews lasted approximately 45-60 minutes. Ensuring Scientific Rigor and Trustworthiness For credibility and confirmability, the interview guide reflected questions that generated information related to the childbearing women’s HIV and interpersonal experi- ences. The guide was first reviewed by a nurse scholar whose area of expertise is women, maternal and child health. Second, the four investigators independently con- ducted manual analysis, constantly comparing the raw data to transcribed interviews in an iterative process to be certain both were comparable. Using multiple analysts (triangulation) for qualitative analyses is desirable and strongly recommended by qualitative scholars to strength- en credibility of the results (Polit & Beck, 2012). Third, themes and exemplars were compared across research team members. Differences in wording of the themes were fully explored (Patton, 2002). One investigator conduct- ed a computer analysis using NVivo and coding of themes, which were confirmed by another investigator. Relevant discussions during conferences, transcribed interviews, raw data, and notes of activities during data collection can be traced through an audit trail ensuring auditabili- 23 a THE JOURNAL OF THE NATIONAL BLACK NuRSES ASSOCIATION ® JULY, 2012 ty. Returning themes to participants for validation is a desirable step in some phenomenological approaches. The Giorgi approach does not require this step (Polit & Beck, 2012). Data Analysis Data were analyzed using qualitative content analysis (Patton, 2002; Polit & Beck, 2012; Sandelowski, 2008). Gior- gi’s phenomenological approach included identifying significant statements from each transcribed interview, forming meanings, and then organizing the common pat- terns in clusters of themes in an iterative process constantly comparing them with the raw data to ensure accuracy. Results Demographic Results Although 24 women consented to participate in the qual- itative study, one woman was lost to follow-up and only 23 women completed the interview. The 23 women ranged in age from 18 to 38 years and were recruited and inter- viewed from February, 2008, to January, 2010. Seventeen women lived in Baltimore and six in the USVI. Ten to 15 participants is an adequate sample size to reach data sat- uration in qualitative studies (Sandelowski, 2008). Of the 23 women, 20 were pregnant and three were parenting with an infant that was less than 12 months of age. Those who were pregnant had gestational ages ranging from 15 to 39 weeks. Time since diagnosis of HIV ranged from one month to nine years, with an average of 2.5 years. Three women (13%) reported abuse experiences during preg- nancy and 10 (43.4%) reported lifetime abuse, Six themes were identified. Themes The six themes identified are consistent with the HBM constructs: perceived vulnerability to HIV infection; feel- ings about getting tested for HIV, knowledge, attitudes, and behaviors after HIV diagnosis; disclosure of HIV sta- tus; living with HIV: positivity, strength, and prayer; and, experiences with physical and sexual violence. Pseudo- nyms were used to protect the women’s identities. Theme 1: Perceived Vulnerability to HIV Infection The women were interviewed during pre-natal visits when they had the HIV testing done. Women reported a perceived vulnerability to HIV infection prompted by the acknowledgement of their own and their partners’ risky behaviors. Women described risks related to their part- ner’s risk status, such as drug use or multiple partners, and their risk or vulnerability related to unprotected or forced sex, sexual activities with a partner known to bea drug user, or to have had multiple partners. As Kenya noted, “Twas mentally prepared because I knew Iwas at risk. My partner then was an intravenous drug user. I was not surprised because at the time I was living a most- ly risky and unhealthy lifestyle ...” Volume 23 Number 1 Some women knew that they could get infected with HIV, yet failed to take action to prevent infection. Per- ception of low risk prevented them from taking the necessary precautions to protect themselves. One Virgin Islander was HIV-positive as a result of vertical trans- mission from her mother and the others were previously diagnosed as positive prior to this pregnancy. Theme 2: Feelings about Getting Tested for HIV This theme described women’s experiences related to the decision to get tested, and what might have influenced their decisions to get tested. The decision to get tested for HIV for the majority of women was voluntary, even though the women could have opted out of getting tested. Some were unaware about their option to opt-out, and instead. reported that they were given laboratory forms to have what they believed were “normal pregnancy” blood tests. After the testing was completed, they were informed of the results and they realized that HIV testing was includ- ed. Therefore, it seemed that the majority of the women in this sample did not make a deliberate decision to be tested for HIV, however, they welcomed the opportunity to be tested for their overall health. In spite of this, per- ceived benefits for the baby were an important and significant motivator for women to get tested for their health in general when given the choice to be tested. Anna noted, “Tt was not optional to me. For the health of my baby and myself,” and Chris said, “... more concerned about the baby versus me.” Theme 3: Knowledge, Attitudes and Behaviors after HIV Diagnosis This theme described the emotions and feelings that the women recalled when they first learned of their HIV sta- tus. Many of the women who participated in this study learned of their status before their current pregnancy, which was not what the investigators had anticipated. ‘Women reported a wide range of emotional experiences after they were informed of their HIV status, ranging from shock, anger, disbelief, fears and fear of dying, both for themselves and their unborn child. A few women had more positive responses to learning about their HIV-pos- itive status and they described how their knowing their status had influenced their subsequent health practices. These emotions started with an initial shock and disbe- lief, Chris said, “Oh my God, Iam going to die,” “Baby [will] die.” “More afraid than anything, angry, concerned about baby versus me. Afraid, angry, and devastated.” The anguish that some women felt after learning of their HIV status prompted concerns about the welfare of their children. As Anna reported, “Lam going to die. Lam going to leave my kids - who am I going to leave them with? Just about my kids.” Other women had positive attitudes and were making positive health-promoting steps to adhere to HIV treat- ments as well as adopting healthy lifestyles. Lizzy reported, 24 JuLy, 2012 ¢ THE JOURNAL OF THE NATIONAL BLACK NURSES ASSOCIATION Ee Volume 23 Number 1 “Yes, I watch what I eat. lam more conscious ... I stay healthy, Tai am taking my medicines.” Theme 4: Disclosure of HIV Status This theme demonstrated how women made decisions about disclosing. their HIV-positive status, who they dis- closed to, their o feelings about disclosure, as well as how those to whom they disclosed responded to them. Women were found to disclose their HIV status to fami- ly members first, lowed by disclosing to friends. Cecilia reported, “My friend Tasha. She hugged me and we cried togeth- er. She has not changed as my best friend ... She told me everything t would be alright.” n experienced feelings of anguish, sad- ness, and isolation from the reactions they received from family and friends. Kenya said, id not provide specific reasons for dis- closing to family members first. It was clear that the women fi fam members or friends knew they Theme 5: Living wit iV: Positivity, Strength, and Prayer Some women expressed their: strong reliance on spiri- tual beliefs and faith in God to help them through the experience. They believed the situation was beyond their control, so they placed their fate in a higher power, demon- strating the women’s acceptance and strength in their faith. Chris reported, 7 “It is scary, but at the same ime, y you have to have faith, believe in yourself; have courage and pray.” “Spir- itual faith ts strong — [Lam] more mature. [I] appreciate life more, little things. Pray every day for a cure.” Clara noted that some women felt a sense of worth and increased confidence when they were pregnant and felt a sense of accomplishment. This renewed sense of self-worth lifted their depression, “My depression got much better during the pregnan- cy because the baby gave me a lot to think about and alot toplanand! was not depressed at all. I was happy. It was amazing .. The majority of the een Island women expressed strong beliefsin God but did not believe the church or the community would understand or be supportive, so they did not disclose their status to these groups. Maggie noted, “Tt is very difficult here with the community about the HIV ... they make a big deal about it.” Theme 6: Experiences with Physical and Sexual Vio- lence This theme captured the women’s descriptions of trau~ matic events in their childhood and adulthood, which included a pervasive prevalence of interpersonal violence, potentially placing them at risk for HIV infection. One of the participants was raped by her boyfriend’s father, who was HIV positive. This demonstrated a strong link between sexual violence and HIV infection. Kenya reported, “When I was younger ... I got raped at 8 years ...” A related story was from Erica, who reported, “T got HIV at 12, raped by my boyfriend's father who was HIV-infected ...” Anna reported emotional and sexual abuse even before her pregnancy, “,.. yes, before I was HIV, he abused me, we did not use protection during sex, no use of safe sex practices. Calls me names, puts me down and humiliates me.” Discussion This study contributes to nursing knowledge by pro- viding additional evidence about the experiences of HIV-positive African-American and African Caribbean pregnant and parenting women. This study represents one of the first studies that included childbearing women of the USVI. This is particularly important as women of the USVI frequently travel to the mainland (USA) and receive care in that health-care system. Although the goal was to compare and contrast the women’s experiences from the two different settings, it was found that the women shared similar experiences. The findings from the study suggest that the women experienced complex and diverse situations regardless of the setting. It was found that across the settings, women who acknowledged their partners’ high risk behaviors dis- closed to them immediately. These study findings are similar to those who found the highest disclosure was to partners (51.7%; n = 116) (Peltzer, Chao, & Dana, 2008). Women may have felt that if their partners were engaged in risky behaviors, then they were the reason they got infected. Other women who discloséd to family members and close friends expected positive social support, moti- vating them to disclose their HIV status. Women’s knowledge about HIV and available treatment options seemed to be most influential in their participa- tion in testing. Twenty-two of the 23 women had at least one child before the current pregnancy and none felt the need to terminate the pregnancy, which is consistent with the findings of Kisakye, Akena, and Kaye (2010). All the women in this study received care in comprehensive clin- ics, which prepared them for healthy pregnancy and delivery experiences and may have resulted in the women having better emotional outlooks for their babies. Women 25 gg Tae Jounnat oF THE NATIONAL BAS Nurses AssociAt’© reported that their decision to adhere to HIV treatment was strongly motivated by perceived benefits to their baby. Getting tested was important in order to enable them fo start antiretroviral treatment early. Similar findings were reported by Craft et al., (2007), who found young, pres” nant women to be particularly concerned about transmitting the HIV to their unborn children. Other researchers have found similar results (Minnie, Klopper, & Walt, 2008). Even though the current study did not explore stigma experiences, some women reported. perceived feelings of isolation and fear that prevented them from disclosing. African Caribbean women were particularly aware of the stigmatization of people living, with HIV/AIDS in the USVI and were reluctant to disclose their status to per sons other than close family, friends, or health-care providers. Archibald (2010) reported. similar findings in church-going African Caribbean people living inthe Unit- ed States. The Virgin {slander women more frequently reported family, church, and community stigma related to HIV. Fear and stigma were the reasons that the older African-American adult participants in the southern Unit- ed States failed to disclose their HIV infection (Foster & Gaskins, 9009). These results demonstrated that 13% (n = 3) of the women reported perinatal abuse and 43% (1 = 10) reported lifetime abuse. The 13% reported in this study falls within the range of 0.9 — 20.1% reported by Coker, Sanders, and Doug (2004). These results are con” sistent with a population-based study that reported. lifetime abuse at 8.9% (11 = 6,790) among women (Coker et al., 2002). Limitations of the Study The study has limitations. First, the study targets the experiences of childbearing African-American and African Caribbean women. Therefore, the findings cannot be gen- eralized to non-childbearing women and other ethnic or racial groups. Second, some of the HIV-positive women were particip ating in comprehensive pre enancy pro grams, which may have influenced their feelings, their experi- ences about testing, about continuing the pregnancy, an treatment and health practices. These women may not represent the universe of other childbearing HIV-infect- ed women. Third, the women resided in urban areas of the United States and the USVI, and their experiences may not represent the experiences of other HIV-positive child- bearing women. Fourth, the women were of low socioeconomic status, and were not representative of women from diverse socioeconomic status. Even with these limitations, the findings provide insights into the experiences of HIV-infected low-income childbearing, African-American and African Caribbean women and may be useful for informing practice and providing future directions for research. Implications for Midwifery Practice The insight gained from this study may be useful for midwifery care practices. The philosophy of midwifery _ oe ne Juby, 2012 ______ Volume 23 Numb er 1 care embraces respect for human dignity, individu and diversity among, women receiving care, provin;; Jete and accurate information to assist women in ny informed decisions and involvement of the women’ ignated family members in all health-care experi (American College of Nurse Midwives [ACNM], The model of care promotes a partnership with thew acknowledging her life experiences and knowled Midwifery care begins with comprehensive assess which should also include the women’s lifetime experiences as well as current relationship status an ner abuse. Such assessments could occur during all of the women’s healthcare and is important for b trust and the women’s feelings of safety in disclosin status to midwives. Midwifery care that offers | counseling to provide women with accurate info! about HIV testing and treatment options is import findings from this study suggested that women ' knowledge opted to get tested. Women also indic: once knowing their status, they were motivated ate treatment, which was perceived as beneficia babies. Counseling could provide strategies to social networks and empower women to safely their HIV status and initiate HIV care and treatm ventions early. The positive social support that the women they received from family and friends could have their motivation to perform health-promoting | which is supported in the HBM. Also import need for midwives to integrate the women beliefs and faith in motivating them to perfo! promoting behaviors. As this study demonstrat relied on their faith for strength to deal with the they faced, as demonstrated in other studies (Mi per, & Walt, 2008). Midwives can also be active advocates for care policies that make comprehensive reproc available for all women. In an economy that th to entitlement programs and other women’s vices, midwives can continue to advoca as screening for intimate partner violence, and and counseling, as part of women’s healthea follow-up care for appropriate treatment op critical given the high percentage of women that reported lifetime abuse and who ma unknowingly exposed to HIV. Implications for Future Resea™ There are gaps in knowledge about wh health practices of HIV-infected childbeariss ticularly women of African roots. Research identifies the heterogeneity of beliefs, cull that influence the experiences of women } ing, disclosure, continuing pregnancy, ans treatment and parenting practices. Additic needed with diverse groups of women fre groups to explore more in-depth fear anc as other negative and positive experience _——-- a JULY, 2012 @ THE JOURNAL OF THE NATIONAL BLACK NURSES ASSOCIATION | Volume 23 Number 1 There is a need for more prevention interventions that simultaneously address the complex interactions between interpersonal violence and HIV among childbearing women. Studies that include supportive cultural compo- nents, practices that promote positivity and prayer, and echo the voices of women in this study are warranted. Research that investigates what is required to support the women’s ability to safely disclose HIV status to partners and family members is also needed; as well as how to safe- ly engage the support network in a manner that supports HIV treatment and reproductive care. ooo Conclusions The women in this study expressed a variety of expe- riences related to their HIV and interpersonal violence status. Their experiences related to getting tested for HIV was contingent upon their perceived vulnerability to HIV infection and perceived benefits to their unborn chil- dren. After getting tested, they faced many challenges related to disclosing their status. Disclosure considera- tions such as: when; to whom, and the risks, were influenced by knowledge of their partner’s risky behav- iors, as well as the social support they received. Through all these experiences, the women found that strong spir- itual beliefs: and positive attitudes gave them strength and resilience to cope with the complex situations they experienced related to their HIV status and interpersonal violence in their relationships. : oe ; References Adimora, A. A., Schoenbach, V. J., Martinson, E.E., Coyne- Beasley, T., Doherty, I., Stancil, T.R., et al. (2006). Heterosexually transmitted HIV infection among African Americans in North Carolina. Journal of Acquired Immune Deficiency Syndrome, 415), 616-623. 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