DISPLACED BUT NOT FORGOTTEN: EXPLORING AND ASSESSING INTERSECTIONAL STIGMA, HIV TESTING BEHAVIORS, AND THE ACCEPTABILITY OF HIV SELF-TESTING AMONG REFUGEE WOMEN IN WESTERN UGANDA.

Abstract

The intersection of population mobility, conflict, and health remains a critical public health issue in sub-Saharan Africa, where a large proportion of the world’s displaced populations reside. In Uganda, which hosts approximately 1.9 million refugees and has an HIV prevalence of 5.1%, refugee women face heightened vulnerability to HIV due to intersecting structural, social, and gendered factors. These include exposure to sexual and gender-based violence, limited access to healthcare, and socio-cultural norms that constrain autonomy in health-related decision-making. Despite these challenges, limited research has examined how HIV-related stigma and social support shape HIV testing behaviors among refugee women, particularly in the context of HIV self-testing (HIVST).Grounded in intersectionality, social support theory, and the Theory of Gender and Power, this dissertation employed a qualitative approach with prolonged field engagement to examine HIV-related stigma and testing behaviors among refugee women in Nakivale Refugee Settlement, Uganda. The study addressed two aims: (1) to explore how refugee women experience and navigate HIV-related stigma and how these experiences influence HIV testing decisions, and (2) to co-design an HIV self-testing intervention using Community-Based Participatory Research (CBPR) and Human-Centered Design (HCD) approaches. Data collection included semi-structured interviews with refugee women, key informant interviews with stakeholders, and contextual observation. Reflexive thematic analysis was used to identify patterns and themes related to stigma, social support, and testing behaviors. Findings revealed that HIV testing decisions were shaped by multilevel factors, including structural barriers within the healthcare environment, interpersonal dynamics such as fear of disclosure, and individual concerns related to privacy, emotional readiness, and trust in testing methods. HIV self-testing emerged as a conditional alternative to facility-based testing, offering increased privacy and autonomy while also introducing concerns related to accuracy, emotional support, and linkage to care. Building on these findings, a co-creation process involving refugee women and stakeholders was conducted to develop a contextually grounded HIVST intervention. This process ensured that the intervention was responsive to community priorities, culturally appropriate, and feasible within the settlement context. This dissertation contributes to public health knowledge by advancing understanding of how intersecting structural and social factors shape HIV testing behaviors among refugee women. It also demonstrates the value of integrating qualitative inquiry with participatory and design-based approaches to develop interventions for marginalized populations. The findings provide actionable insights for improving HIV testing strategies and reducing disparities among displaced populations in sub-Saharan Africa.