Host countries often lack the capacity or commitment to deliver adequate, culturally-sensitive care to refugee women, who must navigate unfamiliar healthcare systems during resettlement with limited support (5, 7). Many arrive with histories of trauma, including violence and displacement, which profoundly impact their physical and mental health (5). The United States, historically a leading refugee resettlement destination, has limited and fragmented research on the intersection of HIV and refugee women’s health, leaving critical gaps in understanding. Addressing these gaps requires tailored trauma-informed care (TIC) programs that integrate refugees’ unique vulnerabilities and social determinants of health, particularly in HIV prevention and care (5, 8). Such programs must address language barriers, limited educational opportunities in refugee camps, and the challenges of securing employment and housing in host countries. Culturally sensitive care respects and incorporates patients’ cultural beliefs, values, and experiences, ensuring services are adapted to diverse populations (10). Cultural considerations are often inconsistently applied and measured, as a 2011–2021 review found only 12% of HIV interventions were culturally sensitive (11) Understanding these overlapping challenges is essential to dismantling the systemic and structural obstacles to HIV equity for this population.

Intersectional stigma provides a powerful framework for analyzing and addressing the barriers encountered by refugee women. This theory highlights that stigmatization does not occur in isolation but rather as a complex web of intersecting societal oppressions (12). For example, a refugee woman living with HIV may simultaneously face HIV-related stigma, characterized by fear of ostracism within her community; gender stigma, which limits her autonomy in healthcare decision-making; racial stigma, manifesting as discrimination within healthcare systems; and migrant stigma, driven by fears of being perceived as a burden or outsider in the host country, as some are often accused of importing HIV in the host countries (13). The literature shows that African immigrants and refugees have HIV infection rates six times higher than any other minority group in the U.S. (14). Migrant stigma related to HIV is particularly pronounced in refugee populations, as they are often scapegoated for bringing the virus into host communities (3, 9). This discriminatory perception can further leads refugees to neglecting their health needs, while survival priorities—such as securing food, safety, and shelter—frequently take precedence over seeking healthcare, delaying HIV testing and treatment (3, 5, 15). Moreover, language barriers and cultural stigma further exacerbate these issues, leading to delayed care initiation and poor treatment retention (5, 7, 16). These overlapping stigmas compound to erode trust in healthcare providers, delay testing, and reduce engagement in care (15–17). Furthermore, historical exclusionary policies related to HIV have deepened these fears, leaving a legacy of mistrust that persists even after policy changes (3). Additionally, refugees often reside in crowded living conditions where inadvertent disclosure of HIV status can lead to social exclusion or discrimination (18). This fear is particularly acute for women, who may experience compounded stigma. These cultural dynamics intersect with additional structural and systemic barriers, making healthcare access even more challenging. Intersectional stigma theory helps to explain how these overlapping stigmas magnify the challenges of accessing HIV testing and care as women navigate a healthcare system that often lacks culturally sensitive approaches.

The status-neutral model offers a novel framework for the HIV continuum of care integrating both PWH and those at risk of HIV (19). Beginning with an HIV test, the model divides into two pathways: “HIV Primary Prevention Engagement” for those testing negative and “HIV Treatment Engagement” for those testing positive. Both pathways share a common goal: sustained engagement in clinical care to minimize HIV transmission or acquisition risk. The model emphasizes that preventive and quality care services require continuous collaboration between patients and providers to sustain engagement in care or treatment.

Applying the status-neutral model to refugee women, requires addressing the intricate interplay of factors across multiple levels (Figure 1):

Acknowledging and addressing these interconnected factors is critical to improving outcomes and ensuring the success of this initiative (Figure 1).

Historically, public health responses to the needs of refugee women have been scarce. Existing TIC efforts in the US primarily focused on addressing issues such as intimate partner violence (IPV), domestic abuse, and child abuse, with a limited number of interventions or research reflecting HIV and TIC among refugee women highlighting the need for tailored interventions for that vulnerable group (17, 24). Moreover, existing, efforts are often hampered by logistical challenges, under-resourced health systems, and a lack of targeted interventions that consider the specific needs of displaced women (3, 7).

HIV testing is a critical entry point for the implementation of the status-neutral HIV service delivery model. The Center for Diseases Prevention and Control (CDC) recommends routine opt-out HIV screening for refugees and immigrants as part of post-arrival healthcare (3). However, data on adherence to these guidelines and implementation outcomes remain limited. For testing to occur, women must be aware of their HIV risk, have access to primary care, sexually transmitted infection (STI) clinics, or other healthcare settings, and consult with culturally sensitive health providers. Studies looking at refugee women’s Knowledge, Attitudes, and Practices (KAP) reveal that many women have low knowledge and perception of their own HIV risk due to cultural or contextual factors, further reducing testing rates (19, 21, 25). Structural barriers such as lack of insurance, transportation challenges, and fragmented healthcare systems significantly limit access to care and contribute to the low rates of HIV testing and counseling among refugee and immigrant women (23). Additionally, intersectional stigma—stemming from the interplay of race, ethnicity, gender, HIV status, forced displacement, and refugee identity—creates fear and hesitancy around seeking testing (mistrust in how asylum host countries may use this information and difficulty in maintaining confidentiality in refugee settings) (3, 18).

Prenatal care presents another critical opportunity, as HIV testing is mandated during pregnancy. However, studies have identified missed opportunities, as refugee status has been associated with the late presentation of HIV (26). While women testing positive during prenatal care can be linked to care with good outcomes, those testing negative often receive minimal counseling on HIV prevention. Language barriers exacerbate these issues, as limited English proficiency hinders effective communication with healthcare providers. Compounding these challenges is the frequent lack of trauma-informed and culturally responsive care, as many healthcare providers are not trained to address the unique needs and lived experiences of refugee populations. Strategies that increase the ease of accessing HIV testing will likely result in decreased morbidity, mortality, and transmission of disease among this population. Paramount to that, gaps in KAP should be addressed, as studies showed inadequate knowledge of HIV transmission and inconsistencies between knowledge of HIV acquisition and behaviors relating to HIV-positive individuals, which may indicate HIV-associated stigma among refugee women (19, 25).

Despite these challenges, several strategies have shown promise in improving HIV testing and reducing the stigma around it. Studies on social support and its impact on HIV testing and adherence among refugee populations showed that informational support encouraged refugees to test for HIV (27).

Prevention strategies for HIV among refugee women must be culturally sensitive and context-specific, recognizing the unique challenges faced by this population. A review of various HIV prevention interventions highlights the importance of integrating cultural beliefs and experiences into program designs to improve their effectiveness (28). This is particularly crucial for refugee women who may have different social norms and barriers to health care access. Educational interventions hold great promise as a study by Cianelli et al. showed that increased HIV knowledge positively correlates with self-efficacy in HIV prevention, meaning women with more knowledge are more confident in their ability to adopt HIV prevention measures (29).

Culturally tailored programs that engage community members as peer leaders have proven effective in promoting HIV prevention strategies. Such participatory approaches not only enhance knowledge but also build social capital, which is critical for facilitating access to health services among refugee populations (9, 11, 16). Programs must provide information about available health services within refugee settlements, ensuring that women are aware of their options for prevention and treatment (5).

Furthermore, it is essential to incorporate strong social and psychological support systems from families, communities, and healthcare providers to improve adherence to HIV care within these settings (5). Promoting awareness and education among men and boys regarding sexual and reproductive health and gender equity is another critical component of HIV prevention strategies (3). By fostering gender equity, interventions can reduce stigma and discrimination, thereby facilitating more effective HIV prevention efforts for refugee women.

Research on the HIV continuum of care for refugee women in the U.S. remains limited, but studies from other countries provide valuable insights into the challenges these women face in engaging with HIV care. Pregnancy often serves as a pivotal entry point and represent the first sustained interaction with formal healthcare services, as it necessitates medical attention for maternal and child health needs (26, 30, 31). However, recent studies suggest that the prevalence of HIV among refugee women is typically higher than that of pregnant women in host countries, underscoring the urgency of targeted interventions (30). Furthermore, research indicated that refugee women who access antenatal visits face an increased risk of delayed HIV diagnosis due to their migrant background, which can jeopardize the health of both the mother and the unborn baby (26). High HIV prevalence in this population is further associated with severe maternal morbidity, emphasizing the importance of early and consistent HIV testing as a life-saving measure (31).

Studies exploring ART use among pregnant refugee women with HIV highlight significant factors influencing non-adherence. Late initiation of prevention of mother to child transmission (PMTCT) services in the third trimester reduces the time available for viral suppression, psychological adjustment, and treatment adherence. Additionally, women not requiring partner or family permission for PMTCT services exhibited lower adherence, likely reflecting insufficient social support (13). Negative attitudes from healthcare providers further diminished adherence, emphasizing the need for better training and support for service providers to foster trust and engagement.

The intersection of pregnancy, HIV and the cultural and systemic challenges of resettlement compounds the vulnerability of refugee women, who often conceal their HIV diagnosis due to stigma (32). Social support plays a crucial role in mitigating these challenges. For example, a study by Rouhani et al. in Southwestern Uganda demonstrated the dual importance of emotional support, which helps individuals cope with HIV diagnoses, and instrumental support, which facilitates ART adherence (27). Refugee women living with HIV also acted as agents of change by educating their social networks promoting testing, and accompanying others to testing sites. These findings underscore the importance of involving refugee women living with HIV in the design and implementation of programs to improve testing and treatment access for their social network.

Trauma-informed care for refugee women addresses the profound effects of trauma stemming from experiences during displacement, conflict, or resettlement. Refugee women face unique challenges, including high rates of sexual and intimate partner violence during migration, leading to mental health issues such as post-traumatic stress disorder (PTSD) (5, 33, 34). Women with lifetime trauma are more likely to report PTSD, depression, anxiety, and substance use, which negatively impact their quality of life and adherence to antiretrovirals (35). This care model emphasizes creating a safe, trusting healthcare environment that focuses on cultural sensitivity and patient empowerment (36). Such models should aim to avoid re-traumatization and facilitate healing through comprehensive, interdisciplinary approaches. TIC is particularly relevant for HIV care, as trauma is prevalent among people with or at risk for HIV and contributes to HIV acquisition, morbidity, and mortality. NASTAD’s Trauma-Informed Approaches Toolkit is a valuable resource that offers guidelines for healthcare providers on implementing TIC within HIV care systems. The toolkit emphasizes the importance of healing-centered care, recognizing that achieving viral suppression is just one aspect of comprehensive HIV treatment (36).

Few studies have examined the impact of TIC interventions on HIV care outcomes among this population. However, recent findings suggest that a trauma-informed approach to developing interventions may help to improve treatment outcomes, such as engagement in care and adherence to antiretrovirals (37). Research shows that social support is essential in reducing feelings of isolation and improving healthcare access for refugee women (5). Interventions like the “Tree of Life” for women with HIV have shown potential in helping refugee women identify personal strengths and qualities that enabled them to cope and build their resilience by empowering them to re-author their life narratives (38).

Despite its significance, the implementation of TIC faces considerable challenges, including systemic barriers such as limited access to mental health services, cultural stigma surrounding mental health, and language barriers that can complicate communication between providers and refugee women (33, 39, 40). Additionally, inadequate training among healthcare professionals in trauma-specific practices can hinder effective care delivery, underscoring the necessity for ongoing education and policy advocacy to support this population (22, 41).

We propose applying the Consolidated Framework for Implementation Research (CFIR) to guide the systematic implementation of TIC for refugee women living with or at risk of HIV (42). The CFIR framework allows for a structured approach to identifying and addressing individual, organizational, and policy-level determinants influencing the implementation process (Table 1). The CFIR was chosen for its multi-level approach, considering individual, organizational, and policy factors in implementing TIC (43). Unlike frameworks focused solely on behavior change or readiness, CFIR systematically assesses barriers and facilitators, making it ideal for complex interventions like trauma-informed, status-neutral HIV care for refugee women. However, its main limitation is the lack of guidance on adapting interventions based on identified factors.

The co-design of a tailored action plan, informed by the needs assessment, should actively engage refugee women and key stakeholders to ensure cultural relevance and stakeholder buy-in. Developing implementation outcomes, such as engagement in prevention and care programs, is crucial for evaluating success. Continuous quality improvement can enhance fidelity and sustainability by enabling ongoing adaptation to systemic, organizational, and policy environments. This evidence-based approach ensures that TIC implementation is robust, scalable, and effective in meeting the needs of refugee women.