Navigating HIV Prevention within Relationships Shaped By Stigma and Power: A Qualitative Study of Adolescents and Young Adults Living with HIV In Eastern Uganda

Background

Adolescents and young adults (AYAs) living with HIV play a critical role in preventing onward transmission, particularly within intimate relationships. While biomedical prevention strategies such as pre-exposure prophylaxis (PrEP), condom use, and treatment as prevention are available, less is known about how AYAs navigate these options within relationships shaped by stigma, unequal power, and uncertainty about partner HIV status.

Methods

Between June and July 2025, we conducted five focus group discussions with 33 AYAs (aged 15–29 years) living with HIV and receiving antiretroviral therapy (ART) at the Youth HIV clinic, Mbale Regional Referral Hospital, and Bukedi Prevention Institute in eastern Uganda. Ethical approval was obtained from the Mbale ethics review board and the principal investigator’s affiliated university, and all participation was voluntary. Groups included male-only, female-only, and mixed-gender participants (6–7 per group). Data were audio-recorded, transcribed, and analyzed using thematic analysis. Findings were interpreted using a social-ecological lens, with particular attention to relationship power dynamics in shaping prevention decision-making.

Results
AYAs described HIV prevention as a dynamic and negotiated process within intimate relationships rather than a fixed set of behaviors. Limited understanding of PrEP and confusion between prevention options constrained informed decision-making. At the interpersonal level, disclosure of HIV status emerged as a central challenge, shaped by unequal relationship power. Participants, particularly young women, described fears of abandonment, blame, or loss of support, which often led to concealment of HIV status and reduced opportunities for partner testing and PrEP use. Condom negotiation was similarly influenced by power imbalances, with some participants reporting limited ability to insist on protection when partners refused. Stigma, both anticipated and enacted, reinforced secrecy and further constrained prevention choices. In response, AYAs adopted adaptive strategies, including selective disclosure, modifying medication-taking practices to avoid detection, and, in some cases, relying on partners’ PrEP use. However, gaps in counseling on partner protection and limited youth-friendly prevention support hindered effective prevention.

Conclusions
HIV prevention among AYAs living with HIV is deeply embedded in relational power dynamics and broader social contexts. Interventions that focus solely on individual behavior change are insufficient. There is a need for integrated, youth-centered approaches that address disclosure support, relationship power imbalances, stigma reduction, and access to partner-focused prevention options such as PrEP. Social work-informed interventions are critical to support AYAs in navigating prevention within complex and unequal relationship environments.