Title: The role of unintended pregnancy in internalized stigma among women living with HIV
in Kenya
Version: 2 Date: 09 Dec 2020
Reviewer's report:
This well-written manuscript addresses the important topic of internalized HIV-related stigma
and how it may be related to unintended pregnancy among women living with HIV (WLWH) in
Kenya. The authors report on data from a cross-sectional survey of WLWH of reproductive age
(N=1116) in southwestern Kenya conducted as baseline data collection for a FP/HIV integration
intervention study. The key finding is a significant association between the last pregnancy being
reported by the woman as unintended (unwanted or mistimed) and internalized HIV-related
stigma, after adjusting for other potential predictors. There are some limitations of the study
that make the results hard to interpret, chiefly the lack of data on the timing of the intended
pregnancy in relation to the timing of HIV diagnosis. The directionality of the relationships is
unclear due to the cross-sectional nature of the data, and that should be further acknowledged
and explored by the authors. Specific comments by section are given below.
Introduction:
1. Page 3, line 17:  In general, it is best to avoid the term HIV/AIDS and use HIV when you are
talking about HIV in general, and only AIDS when you are referring to progression to AIDS.
A woman could not transmit AIDS to her infant.
2. Page 3-4:  It seems relevant to bring in more background about the current promise of PLWH
having children safely due to effective PMTCT and Safer Conception strategies.  More and more
couples living with HIV are able to fulfill their desires to have children.
3. Page 4, lines 42-43:  I think there is now a large body of international literature showing an
association between internalized HIV-related stigma and sub-optimal ART adherence, working
through different psychosocial mechanisms.
4. Page 4, lines 52-53:  Given the cross-sectional nature of the data, it seems like the authors
should be very careful about suggesting directionality of the relationship between unintended
pregnancy (UP) and internalized stigma (IS).  It is perfectly plausible that internalized HIV-
related stigma could cause someone to experience an unintended pregnancy (if it makes them
less likely to use health services, such as RH/FP services) or report a pregnancy as unintended.
Thus, it would be better to refer to it as an association throughout and acknowledge this possible
other direction of causality in the Discussion.
Methods:
5. Page 4, line 59:  It would be helpful to briefly summarize any differences in the two districts
included in the study, given the significantly different results.  Is one more urbanized?  Have
better access to health care?  Anything else that might explain the differences (besides sample
size)? Why was the sample so much larger in one district compared to the other?
6. Page 5, line 85:  The authors should state their rationale for dichotomizing internalized stigma.
Much existing research uses this sub-scale as a continuous variable.  Are results the same/similar
when a continuous outcome variable (mean of the items) is used?
7. Page 6, lines 104-105.  Is it possible that HIV-related discrimination and/or violence
are mediating variables on the pathway between UP and IS?  For example, a woman who
experiences an UP may experience violence from her partner, which could cause her to
internalize stigma related to HIV. If so, it would not be appropriate to adjust for these variables
in analyses.  This possibility could also be acknowledged in the Discussion.
8. Page 6, lines 118-120: Other variables that have been found to be associated with internalized
stigma in the literature include mental health (depression), lack of social support, lack of
disclosure, and being in a polygynous relationship (husband has more than one wife).  Were
these variables measured or considered?
Results:
9. Page 7, lines 146-147:  It would be useful to see the distributions on all four of the
discrimination items in a small table, as well as each of the 3 violence items.  I am wondering
if any of these are more common and which may have driven the overall summary variables.
Discussion:
10.  Page 12, lines 208-215:  It does seem crucial to know the timing of the unintended pregnancy
in relation to the woman’s HIV diagnosis.  Many women who are successfully virally suppressed
on ART want to become pregnant.  Pregnant women who newly find out that they have HIV
after becoming pregnant tend to struggle more with stigma, disclosure, and engagement in HIV
care (see for example Cichowitz et al., AIDS & Behav, 2019).  In the current study the timing
of the unintended pregnancy is completely unknown (could have been years ago) making the
results difficult to interpret.
11. Page 12, lines 229-231:  In addition to the one DR study mentioned, there are studies in the
US that have found that experienced stigma (discrimination) leads to internalized stigma (see
for example Kay et al, JAIDS, 2018).
12. Page 13, line 254:  Another important limitation is the cross-sectional nature of the data and
thus inability to understand directionality or causality.