Structural drivers of mental health among pregnant and postpartum women living with HIV: Implications for collaborative care models in Kenya

Pregnant and postpartum women living with HIV (PPWLH) experience disproportionately high rates of common mental disorders compared with both HIV-negative women and men living with HIV. Structural vulnerabilities, including poverty, gender inequality, and stigma, create overlapping constraints that compound the healthcare burdens PPWLH face as they navigate HIV care, pregnancy, and mental health needs. This study examined how structural vulnerabilities contribute to mental distress among PPWLH in southwestern Kenya and their preferences for mental health services. Between January and September 2024, we conducted six Focus Group Discussions with 48 PPWLH, clinic staff, and lay health worker ‘mentor mothers’, alongside 20 Key Informant Interviews with local health-sector representatives. Guided by the structural vulnerability framework, thematic analysis revealed that structural drivers of mental health, including poverty, gender disparities, and stigma, converged to produce mental distress among PPWLH and impede access to healthcare. Amid synergistic and multiplicative structural concerns, patients' service delivery preferences were fairly specific. Many emphasized privacy, face-to-face interaction, and continuity of support, and both patients and providers favored integrating mental health services into HIV and maternal care. For collaborative care models to be sustained, providers suggested infrastructural investment, drugs and commodity availability, and balancing short-term patient needs (particularly around transport for multiple clinic visits) with longer-term sustainability. Collaborative care for mental health in resource-limited settings will require programs that actively address structural drivers. Without this shift, interventions may reinforce rather than challenge health inequities, which will be salient for the care of pregnant and postpartum groups living with HIV.