Trajectories of HIV management among virally suppressed and unsuppressed female sex workers in the Dominican Republic: A comparative qualitative analysis

Figures & data

Figure 1. Overview of parent study sampling design.

Table I. Participant information.

Viral Suppression (<400 copies per cubic millilitre)	#	%
Yes	10	50
No	10	50
Ages	#	%
21-28	3	15
29-36	3	15
37-44	10	50
45-53	4	20
Years living with HIV	#	%
<5	3	15
6-9	4	20
10-14	6	30
15-20	4	20
>21	2	10
unclear	1	5
Acquired HIV from:	#	%
Spouse or steady partner	9	45
Sex work client	2	10
Mother-to-Child Transmission	1	5
Participant is not sure	4	20
Participant did not describe	4	20
Number of living children and financially dependent grandchildren	#	%
1	4	20
2	8	40
3	7	35
4	1	5

Table II. Key themes in participant narratives.

Theme	Description	Illustrative Quote
Mental health challenges	Participants’ experiences of depression, grief, and emotional distress concerning their HIV status. These challenges often centred around fears of death, concerns for their children’s future, and guilt over transmission to others.	I lost all of those pounds because I was not eating, I had a relationship with a person and I was thinking, I was saying and that this person had his wife, and so I blamed myself, I did not know, I didn’t know anything about anything and I say “my God!” in thinking about this other person, I was thinking about my children, when I would see my children, I would say that they are going to be left alone and such [continues sobbing] and maybe this is why I feel so good. (unsuppressed)
Denial of diagnosis	Participants’ rejection of their HIV diagnosis, as well as their more general unwillingness to accept their condition.	Before I was not really taking responsibility, I wasn’t taking it in, I wasn’t understanding what was happening to me, eh I used to take the medication but it wasn’t having an effect on me, I would go to talks at places, and I would listen, or rather I would hear what they were saying but I wouldn’t give any importance to the advice, I didn’t give any importance to what they were saying to me, because I was thinking that I didn’t have anything. (virally suppressed)
ART side effects	Fears and actual experiences with ART side effects and the impact of both on treatment initiation and adherence.	I cried a lot because thinking that … I thought that I was going to die, because the people were saying that it was not very advisable to take those medications, that sometimes instead of making you feel better they would put you in a worse condition. (virally suppressed)
Conflicts and tension	Lack of support, arguments, and rejection from family members, friends, or neighbours that affected participants’ HIV management.	Participant: Because in June was when she [her daughter] left and I kicked [her ex-partner] out more or less in May, I left him in May more or less around then […] Interviewer: So before that you were fine and from there that was when you got worse? Participant: Yes, because from there that was where I started to think more about it […] to neglect caring for myself. I didn’t want to comb my hair, because I, I recognized it, one day I recognized: “I am falling into a depression.” I didn’t want to comb my hair, I didn’t want to put on makeup, I didn’t want to. (virally suppressed)
Loss of loved ones	Participants’ experiences of caretaking for ill family members or grieving the passing of partners or family members, which affected their mental health and HIV treatment adherence.	Interviewer: And why did you stop the medications? Participant: The neglect and also the worry for [her husband who passed away], for taking care of him, I was not going to my house, I was taking everything there including even what I would be eating, as he was almost not eating, I would divide the same food for him and we would both eat, the few things that he was eating, because he was just tasting food, he was not eating anything … ”(unsuppressed)
Social support	Emotional, financial, and logistical support from friends, family members, healthcare providers, or support group facilitators that aided participants’ commitment and ability to manage HIV.	I left until one day they found me and called me at where I was working and they tell me that I was needing to go, that if I was gambling with my health […] and etcetera, until I went, then I renewed treatment, I started again from zero, and from there I started going appointment after appointment, appointment after appointment, until I met [a counsellor for the support group], she brought me here. Here I have shared a lot. (unsuppressed)
Internal reflection processes	Psychological processes to accept their HIV status and improve management, including reflections on their desire to be present for their children, understanding that HIV is a manageable condition, and empowerment to take initiative in managing their health.	Everyone that used to see me, I don’t know, they would say that it was tuberculosis too, ay but she is going to die, she is going to die, and one day I stood up and I said, “who is going to die, me?” And I stood up from my bed […] and here I am 100% moving forward. (virally suppressed)
Acceptance of HIV status	Participants’ expressions of accepting and making peace with their HIV status after initially denying or lamenting their diagnosis.	… and about my health condition, the truth is that I feel well because I have tried to overcome, and I have tried to accept myself, you know that when one accepts themselves, things change because one can fight illnesses with the mind, when one does not accept it, you already have to go and what else is there to say (laughs) … (virally suppressed)
Pro-active self-care	Participants’ efforts to prioritize their health and wellbeing including healthy nutrition, sleep habits, and avoidance of drug use, among other behaviours.	Interviewer: Have you ever stopped taking the medications? Participant: “Never, it can happen to me that I can miss a few hours because I go out, sometimes I think that I have it in my pockets or I have it in the wallet and I don’t have it, but immediately when I arrive, I take it, and I haven’t missed picking up my medications either, I do not mess around with that.” (virally suppressed)
Prioritizing mental health to improve ART adherence	Participants highlighted the importance of maintaining a positive attitude and resisting HIV stigma to maintain optimal ART adherence.	that I have strengthened myself mentally, or rather that I am not allowing anything to affect me, that nothing and nobody affects me (virally suppressed)
Improved adherence	Participants’ improvements in following their ART regimen and attending regular medical appointments since their HIV diagnosis.	No, nothing, now I have to take them for all my life because now for me to have HIV is better than to have cancer […] because cancer kills a person more quickly and HIV at least has medication and I drink my medication as prescribed, it is not going to kill me, I can die from something else, but from HIV no. (unsuppressed)
Not thinking about HIV	Participants’ efforts to live a “normal life” as if they did not have HIV.	Well, my tranquillity that after I come to the program, I have been more stable, calm I don’t think much about that which, or I don’t give thought to the virus in my body. (unsuppressed)
Economic instability	Psychological and logistical barriers to managing HIV that participants experienced due to their economic situation. Examples included food insecurity, cost of transportation or medications, housing instability, and demands of sex work that compromised adherence and health.	“Fast” means that when I don’t have money, I become like a “desperate person,” […] I would go out to look for money and I would forget, and the pills would stay in the house. (unsuppressed)
HIV stigma	Participants’ fears of being rejected by family and friends due to their HIV status, as well as their lived experiences of discrimination. This theme also captured internalized stigma, or participants’ feelings of shame and low self-esteem because of their HIV status.	Interviewer: What would happen that you would get that way that you did not want to take the pills? […] Participant: Sometimes one thinks about why they have [HIV], sometimes one gets focused on “ay why do I have that, I am not a good person,” or many people when they think that a person has it they ignore the person, sometimes it gets into the person’s head. One time I wanted to take my own life. (unsuppressed).