Introduction

The HIV epidemic continues to be one of the most significant public health challenges after more than 40 years of its emergence. To date, people living with HIV (PLWH) face challenges related to HIV infection, even when they have had sustained antiretroviral therapy (ART) and they achieve suppression of viral load (VL) of HIV [1–3]; two of the three 95-95-95 important UNIADS targets for eradicating HIV pandemic [4–6]. From a clinical perspective, PLWH are confronted with the chronic nature of the infection, the long-term effects of ART and the associated challenges of adherence. They also experience the burden of non-infectious comorbidities [7]. In addition to these clinical demands, PLWH also face persistent stigma and discrimination. This should be understood as an additional challenge that compounds the complexity of living with HIV, rather than being a direct clinical manifestation [2]. Together, these clinical and social factors have a significant impact on perception of health and their QoL [8,9]. This impact is particularly pronounced in highly vulnerable groups, such as WLWH, who may encounter additional stressors during pregnancy, the postpartum period, and motherhood [10]. During these periods, pain and physical discomfort, combined with environmental factors, social relationships and personal beliefs, can exacerbate vulnerability and perpetuate stigma and discrimination. Consequently, perceptions of health status deteriorate, QoL declines and negative outcomes such as reduced self-care and diminished attention may ensue [11,12].

There are also significant associations between maternal postpartum health (both mental and physical) and the health of their children [13]. Therefore, a mother’s QoL could influence her children’s QoL as they grow up. It is known that even in non-complicated perinatal period important physical and emotional changes occurs, and factors such as age, parity, social and economic issues, obstetric complications, obesity, history of alcohol dependence, sleep difficulties, stress, anxiety and postnatal depression affect the mother QoL [13–15]. Furthermore, studies assessing QoL in mothers with chronic diseases have reported that their children also experience lowest QoL [13,16]. Another study evaluating health-related quality of life (HR-QoL) in mother-child pairs from low-income settings found that these children had poorer outcomes and behavioural disorders compared to children in the general population [17]. It is important to emphasise that the traditional approach to health has primarily focused on the clinical dimension, centered on the detection, treatment and cure of diseases. However, health cannot be reduced to the mere absence of illness as it permeates every aspect of a patient’s life, making this approach insufficient. Therefore, the assessment of QoL emerges as a valuable indicator of self-perceived well-being and health status, encompassing broader dimensions of QoL [18].

QoL has several definitions and instruments to assess it [18]. Furthermore, according to experts, the assessment of QoL should be evaluated with specialised and validated instruments for a population, especially if it involves a population with chronic diseases [19,20]. According to the World Health Organisation (WHO), QoL is the perception that a person has of their position in life, in the context of the culture and value system in which they live, and concerning their objectives, expectations, standards and concerns, and provides a QoL instrument for the PLWH [8].

Expert groups on HIV/AIDS have proposed to include the QoL evaluation in PLWH as a measure of therapeutic success, as well as a ‘fourth 95’ HIV target which should be achieved [8]. QoL is increasingly recognised as a key component of public health [21], guiding management strategies and informing the development of new health policies for PLWH. This approach is particularly important for vulnerable groups, such as WLWH, as it helps to improve medical care and address their specific needs [7,9,10].

Globally, WLWH represent 53% of all PLWH [22], and the majority are of reproductive age. This increases the likelihood of pregnancy and the risk of exposing their newborns to HIV vertical transmission [23]. Around 1.2 million WLWH become pregnant each year, and 84% of these (72–98%) receive ART to prevent mother-to-child-transmission (MTCT) [23]. Therefore, aligning with important United Nations Sustainable Development Goals, particularly the Goal 3: Good Health and Well-being, within the context of countries facing significant challenges related to social inequalities, is necessary.

Significant progress has been made in understanding the QoL of pregnant and postpartum WLWH in Latin America (LATAM), particularly in Brazil [24–26]. Nevertheless, important gaps remain that could be addressed by future research, particularly by moving beyond a purely medical perspective. There is a need for greater exploration of factors such as emotional impact, social stigma and support networks, as well as the population characteristics that shape these experiences. This is essential to better understand how these women navigate their condition and the demands of motherhood.

The objectives of this study were to describe the perception of QoL during postpartum period of Mexican WLWH and to determine its association sociodemographic and physiopathological factors.

Materials and methods

Results

Characteristics of the Mexican postpartum WLWH population in the study

The sample consisted of 75 postpartum WLWH with an average age of 29 ± 5.4 years. They reported several ART regimens as a part of their HIV clinical management during pregnancy and postpartum. Upon admission to prenatal care and delivery at INPer, most of them were in the third trimester of pregnancy, averaging 32 ± 8 gestational weeks. Among these women, 76% had completed nine years of education, 47% cohabited with their partners, 69% were housewives, and 92% resided in urban areas, as presented in Table 1. Monthly incomes ranged from USD $28.4 to USD $1705.55, placing 97% in the low-income classification according to the National Institute of Statistics and Geography (INEGI, Mexico) [31].

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Table 1. Demographic characteristics, obstetric history and sexual behavior of the Mexican postpartum WLWH.

https://doi.org/10.1371/journal.pone.0330790.t001

Regarding drug use during their current pregnancies, participants denied current consumption of alcohol, tobacco, or illegal substances. However, they reported alcohol consumption in 21%, illegal drug use in 8%, and minimal cases of combined use (6%) histories, as detailed in Table 1.

Concerning the partner’s drug addiction, 17% of woman denied knowledge of their current partner’s substance use. The remaining 83% of the woman reported smoking (3%), alcoholism (12%), illegal drug addiction (7%), combined alcohol and illegal drug use (14%), and a mix of alcohol, smoking, and illegal drugs (5%) among those aware of it. Regarding tattoos and piercings, 25% had tattoos, 5% had piercings, and 9% reported having both (Table 1).

In terms of sexual behavior, most of the participants initiated sexual activity in late adolescence, with a history of 3–5 sexual partners until the study period. Unfortunately, 9% reported having been sexually abused. They were multigravida, delivered by Caesarean section, and reported pregnancy loss (0.55 ± 1.04) based on their gynaecological and obstetric history (Table 1).

The percentage of our participants diagnosed with HIV during their current pregnancy was 32%, and most of these cases believed that it was sexually transmitted (Table 2).

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Table 2. Infectious history and ART management of the Mexican postpartum WLWH.

https://doi.org/10.1371/journal.pone.0330790.t002

All participants received ART immediately after the diagnosis and throughout their pregnancies with effective clinical management, as indicated by CD4 + levels and undetectable viral loads, preventing vertical transmission (Table 2). The most common ART regimen during prenatal care vs postpartum period in all WLWH included two reverse transcriptase inhibitors (NRTIs) plus integrase inhibitors (II) (66 and 65%) categorized as group C (Table 2). During birth, 76% of all participants received ART intrapartum as prophylaxis, based on clinical criteria and in accordance to the national guidelines for the care of WLWH [32]. Based on questionnaires applied during postpartum period, the adherence to ART was high (84%) and confirmed by medical records. One in three women reported perinatal complications. There are no clinical or medical reports related to the use of ART therapy in this study.

Perception of Quality of life in the postpartum period of the Mexican WLWH

In our study population, the WHOQoL-HIV-Bref instrument demonstrated excellent reliability (Cronbach’s index, α = 0.8). The total QoL median score was 15 [IQR:13–16], with the Physical health and Independence level domains scoring highest, 16 [IQR: 13–18 and 14–18, respectively], and the Spirituality, religion and personal beliefs domain scoring lowest, 13 [IQR: 10–16]. Psychological health and Environment median sores were 14 [IQR: 13–17 and 13–16, respectively] (Table 3).

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Table 3. WHOQoL-HIV-Bref instrument scores in the Mexican postpartum WLWH.

https://doi.org/10.1371/journal.pone.0330790.t003

Financial resources, transport, recreation and leisure activities, forgiveness and blame, negative emotions, future concerns, death and dying, and cognitive skills were the sub-domains with the lowest scores (Table 3).

Using as a reference point the median of total QoL score 15 [IQR:13–16], the perception of QoL was categorised as low (<15), medium (15), and high (>15). Despite an overall medium QoL, 49% of the Mexican postpartum WLWH perceived a low total QoL (Fig 1). The results of the S1 Table indicate a statistically significant difference in the total QoL median scores among the ART regimens (Kruskal-Wallis, p = 0.039) and in the Physical health domain score (p = 0.008). These findings suggest that the treatment regimen is associated with variations in perceived QoL.

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Fig 1. The Quality of Life (QoL) median scores of the Mexican postpartum WLWH obtained with the WHOQoL-HIV-Bref instrument.

On the left-hand side, scores are presented on a 4–20 points scale. The percentage of postpartum WLWH with the QoL categorized is shown on the right-hand side. Instrument domains are defined as: I. Physical health, II. Psychological health, III. Independence level, IV, Social relationships, V. Environment, VI. Spirituality, religion and personal beliefs. Total QoL refers to the score obtained by the WHOQoL-HIV-Bref instrument. QoL categories: Scores below 15 points are considered low, score of 15 points is considered medium, and scores above 15 are considered high.

https://doi.org/10.1371/journal.pone.0330790.g001

Most participants had less than one year since their last obstetric event (73%). Significant differences in median Physical health (Mann-Whitney U, p = 0.035) and Social relationships (p = 0.011) domain scores were observed across postpartum time groups (S2 Table). Significant differences in median QoL scores across years of interview were observed in the Physical health domain (Kruskal-Wallis, p < 0.001), with scores showing a notable decline and reaching their lowest values in 2022. Likewise, significant differences were found in the Social relationships domain (p < 0.001) and in Spirituality, religion and personal beliefs (p = 0.017) (S2 Table).

ART is related to physical health, social relationships and overall perception of quality of life in Mexican postpartum WLWH

To determine the relationship between QoL instrument scores with demographic, nonpathological history, infectious history and ART management, obstetric history, and sexual behavior variables a Spearman’s correlation test was performed. There was a negative correlation between Physical health and ART therapy during prenatal care (r = −0.313, p = 0.007) and postpartum (r = −0.425, p < 0.001), and its category (prenatal care r = −0.330, p = 0.004; postpartum r = −0.378, p = 0.001 respectively). Additionally, ART during prenatal care positively correlated with Social relationships (r = 0.260, p = 0.025), while ART during postpartum and its category showed positive correlations with this same score (r = 0.294, p = 0.014, and r = 0.261, p = 0.03, respectively). Lastly, it was observed that ART category during prenatal care and postpartum were negatively correlated to the overall QoL (r = −0.272, p = 0.019; r = −0.289, p = 0.016, respectively) (Fig 2). This underlies the importance of the role of ART on the perception of QoL of the postpartum WLWH.

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Fig 2. ART is related to Physical health and Social relationships in the Mexican postpartum WLWH.

Heatmap of the Spearman correlation coefficients between demographic, nonpathological history, infectious history and ART management, obstetric history, and sexual behavior with QoL instrument scores. Instrument domains are defined as: I. Physical health, II. Psychological health, III. Independence level, IV, Social relationships, V. Environment, VI. Spirituality, religion and personal beliefs. Total QoL refers to the score obtained by the WHOQoL-HIV-Bref instrument. A p-value < 0.05 was considered statistically significant.

https://doi.org/10.1371/journal.pone.0330790.g002

Other significant correlations were identified with the QoL scores summarized in Fig 2. In brief, Physical health negatively correlated with Year of interview (r = −0.286, p = 0.013), and Efavirenz during pregnancy (r = −0.275, p = 0.019). Psychological health positively correlated with Monthly income (r = 0.243, p = 0.038), Last CD4 count during pregnancy (r = 0.262, p = 0.031) and Age of the beginning of sexual life (r = 0.259, p = 0.028), while negatively with HIV symptoms (r = −0.230, p = 0.047), Current partner HIV status (r = −0.253, p = 0.031), and Tattoos and piercings (r = −0.280, p = 0.035). Independence level had a positive relationship with Gestations (r = 0.282, p = 0.014), and negative relations with Educational status (r = −0.233, p = 0.044), HIV symptoms r = −0.229, p = 0.048) and Number of sexual partners (r = −0.417, p < 0.001). Social relationships domain had a positive relation with the Year of interview (r = 0.826, p < 0.001), while a negative relation with Marital status (r = −0.237, p = 0.041), Time of postpartum (r = −0.440, p < 0.001), Gestational age at medical admission (r = −0.591, p < 0.001), Current partner HIV status (r = −0.260, p = 0.026), Caesarean sections (r = −0.230, p = 0.047), and Smoking habit (r = −0.325, p = 0.005). Lastly, Environment showed a positive relation with Sexual abuse history (r = 0.231, p = 0.047), Spirituality, religion and personal beliefs were negatively related to Tattoos, and piercings (r = −0.321, p = 0.015), and Total QoL was negatively related to Efavirenz during pregnancy (r = −0.263, p = 0.025). Complete correlation coefficients between variables are summarised in S3 Table.

Physical health, Independence level, and Spirituality, religion and personal beliefs predict a perception of high QoL in Mexican postpartum WLWH

With the purpose of identifying potential predictors of QoL in the Mexican postpartum WLWH, analyses were conducted as established in the methods. From all the variables tested by MLR and PCA, Age, Years since HIV diagnosis, Gestational age at medical admission, Abortions, Marital status, Domain I. Physical Health, Time of postpartum, Age of the beginning of sexual life, Gestations, Other chronic diseases, Domain III. Independence level, Domain IV. Social relationships, and Domain VI. Spirituality, religion and personal beliefs fulfilled the criteria for further evaluation as potential predictors of QoL. From the above, Domain I. Physical health, Domain III. Independence level, and Domain VI. Spirituality, religion and personal beliefs exhibited good AUC values when tested for high QoL (Fig 3, 0.86, p = 0; 0.83, p = 0; and 0.84, p = 0, respectively). Cutoff values were then calculated for these three domains by the Youden index with their corresponding 95% CI. Summary data regarding these three potential predictors of a perception of high QoL in postpartum WLWH are presented in Table 4.

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Table 4. Summary data of potential predictors of a perception of high QoL in the Mexican postpartum WLWH.

https://doi.org/10.1371/journal.pone.0330790.t004

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Fig 3. Physical health, Independence level and Spirituality, religion and personal beliefs may potentially predict a perception of high QoL in Mexican postpartum WLWH.

ROC curve analysis of domains I, III, and VI as markers of a perception of high QoL.

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Additionally, a PCA was performed separately in QoL categories low, medium, and high, to identify which variables accounted for most of the variance per category. Absolute loading values per variable (> 0.6), and the subcategories with the higher frequencies are reported in S4 Table. It is of notice that certain variables were shared between low, medium and high categories: Domain IV. Social Relationships (score of 15 vs 16, low QoL18.9% vs medium 26.7% and high 43.5%), Year of interview (2021 most frequent in high QoL 73.9%, vs medium 66.7% and low 56.8%), Gestations (2 vs 3, low 37.8% and medium 26.7% vs high 34.8%), and c group ART therapy by category during prenatal care (low QoL 78.4% vs medium 57.1% and high 56.5%) and during postpartum (low QoL 76.5% vs medium 53.8% and high 54.5%), suggesting the importance of further exploration of these variables in more extended cohorts.

Discussion

Notwithstanding, the compelling counsel proffered by numerous experts in the field, the 2030 95-95-95 targets established by UNAIDS notably exclude the ‘fourth 95’ target, which stipulates that 95% of people living with HIV (PLWH) should attain a QoL that is comparable to that of individuals who are HIV-negative. This target emphasises the identification of factors that reduce the perception of QoL and the establishment of strategies to address them and support progress toward its achievement [4–8].

Our participants received medical care at a tertiary medical institution in Mexico City, most of them were in the third trimester of pregnancy, average 32 gestational weeks (Table 1). In Mexico, delayed prenatal care remains a critical public health concern, disproportionately affecting vulnerable populations, such as WLWH. Disparities are most pronounced among women with lower educational attainment, those residing in rural areas, and individuals of lower socioeconomic status—inequities that were further exacerbated by the COVID-19 pandemic [33,34]. Our findings align with previous studies [24,29,30,35–39], showing that HIV/SIDA disproportionally affects the population in disadvantaged socioeconomic strata. Limited education restricts access to well-paid employment. These women reside in marginalised suburbs of Mexico City, where there is a deficiency in access to adequate, high-quality public transportation at an affordable price. Furthermore, the safety of these areas is compromised by the high crime rates that prevail. Women’s reliance on transport systems is fundamental to their economic participation and social integration. However, inadequate accessibility, spatial constraints, and pervasive safety concerns significantly restrict their mobility, producing forms of social exclusion. The absence of secure and reliable travel options not only shapes women’s perceptions of the urban public realm but also curtails their access to education, employment, and healthcare. Consequently, mobility and safety emerge as critical determinants of gender equity and broader societal inclusion (Table 1).

The significant differences in total QoL scores and in the Physical health domain across ART regimens suggest that treatment choice may influence patients’ perceived well-being. Most participants received ART regimen consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) and one integrase inhibitor (II), classified as group C. The predominance of this regimen reflects current clinical guidelines that prioritize II-based combinations due to their high efficacy, favourable resistance profile, and generally good tolerability [32]. During their pregnancy they perceived high adherence, which persisted until postpartum, as reported in their clinical files. Many also received intrapartum prophylactic ARTs according with the national guidelines for the care of WLWH [32], and underwent Caesarean sections (Table 2). Studies indicate a high adherence to ART during pregnancy, which decreases after delivery [36]. Pregnant WLWH prioritise adherence to prevent vertical transmission and ensure their health to care for their babies [37]. Most of the participants had a recent diagnosis, which may help patients remain physically well and focus on their ART, despite psychological distress [11].

In our sample, 75% of the participants are aware of their partners’ HIV status. It should be noted that some of these individuals are HIV-positive (Table 2) and disclosed their diagnosis only to current partners or close family, no extended relatives. This behaviour coincides with previous studies, where PLWH only tell their partners or immediate family members about their diagnosis. Extended family members, such as parents-in-law, siblings, and grandparents, are not informed due to stigmatization [25,40]. Parental support from partners during pregnancy has been linked to better adherence to ART [41].

The QoL instrument demonstrated excellent internal consistency, aligning with evidence from the English version validated in Ethiopia [30,38], as well as the Spanish version [28].

The group of Mexican postpartum WLWH in this study had an intermediate total QoL median score (Table 3 and Fig 1) despite belonging to the lowest socioeconomic strata. Their undetectable viral load, adequate CD4 cell count, and adherence to ART contributed to an optimistic perception and HIV-free births. Nevertheless, the educational status, HIV-related symptoms, partner’s serostatus, and histories of sexual abuse intensify vulnerability, stigma and intersect as indicators of higher risk behavior impacting both mental and physical health; while treatment status, regimen type, and limited income further constrain coping capacity, influencing the perception of QoL (Fig 2). The above reflects the impact of socioeconomic constraints despite the high Human Development Index (HDI) of Mexico (HDI, 0.781) [42]. Vulnerable groups face limited access to essential services, lowering QoL scores [28]. A study in India [35], found higher QoL scores, among non-pregnant-WLWH, despite the poverty. The study attributes this result to a structured program for the distribution of ART, close monitoring of adherence, and strong community support. It is important to note that India has a lower HDI (0.644) compared with Mexico. In contrast, in Ethiopia (HDI, 0.492), Iran (HDI, 0.780), Brazil (HDI, 0.760), and even Spain (HDI, 0.911) [42], limited education, lack of community support, barriers to ART access due to gender, socioeconomic inequalities, stigma, and racism were related to low QoL, poor adherence, and severe health problems [24,28–30]. We suggest that HDI is not associated with the perception of QoL.

The total QoL comprises six domains (Fig 1) with global differences most evident in median scores. Our participants reported energy for daily tasks (Physical and Independence level domains) and satisfaction with their relationships due to partners, friends, or family support (Relationship domain), but are constrained by marital status, postpartum duration, clinical conditions. The findings indicate that postpartum duration was a significant factor affecting women’s QoL. The duration since childbirth has been shown to impact women’s perceived social support and relational well-being, with a time frame over one year being particularly notable. On the other hand, when the value is less than one year, the Physical health domain receives a low score [43,44]. The stigma surrounding their condition often led to secrecy, anxiety, and reduced QoL scores in the domains of psychological health and personal beliefs. According to a study in northern Mexico, stigma and a lack of societal acceptance of people living with HIV/AIDS (PLWH) discourage them from disclosing their status to family, friends, and coworkers [45].

Our postpartum WLWH expressed dissatisfaction with their living conditions due to insufficient services and transportation, as they live in the suburbs of Mexico City, in addition to financial constraints that limit access to health care and leisure activities, as reflected in a low Environment domain score (Table 3). Moreover, their wages were lower than men’s when they were employed; likewise, the low psychological health scores highlight ongoing stigma and discrimination, with perception of judgment tied to forgiveness and guilt, as reported in Spain [28], Ethiopia [30,38], Iran [39], Brazil [24], and India [35]. Also, we could say that the QoL perceptions varied according to cultural, traditional, and religious factors. In this respect, Haraldstat et al. (2019) concluded that the concept of QoL may vary across cultures, with unclear cross-cultural relevance. Further studies in Asian and non-Western cultures are needed to explore QoL and its cultural manifestations [18].

The present study also provides insight into the impact of the ART therapy on QoL domains. The evidence presented herein demonstrates the dual impact of ART during pregnancy and postpartum of WLWH. The negative correlation with the physical health domain suggests that treatment side effects or the burden of the treatment regimen may reduce perceived well-being. In contrast, the positive correlation with the Social relationships domain indicates that ART use enhances feelings of safety and strengthens interpersonal support. These findings underscore the importance of comprehensive care approaches that address physical discomfort while also fostering social inclusion in WLWH (Fig 2). These findings align with the conclusions of previous studies, which have indicated that women receiving long-term ART can expect to maintain a satisfactory QoL [35,38]. However, it is possible that specific antiretroviral regimens may have exerted a negative influence on outcomes. This is exemplified by the utilisation of efavirenz during pregnancy (Fig 2). As Xiao et al. (2023) and Law et al. (2020) have demonstrated, this antiretroviral drug has exerted a substantial deleterious effect on the Physical health domain. This is attributable to the fact that such agents have been associated with the occurrence of neuropsychiatric adverse events in PLWH, which frequently result in a diminution of QoL and a consequent decline in patient adherence [46,47].

Stressors such as the COVID-19 pandemic, which disrupted healthcare access and daily routines. The significant differences observed in Social relationships and Spirituality, religion and personal beliefs domains (S2 Table) further suggest that Psychosocial dimensions of well-being were negatively affected, possibly due to restrictions on social interaction and reduced opportunities for community or spiritual support during this period [48,49]. Physical health domain was also negatively associated with year of interview suggesting pandemic-related influences on well-being (Fig 2 and S2 Table).

The global population experienced significant impacts from the SARS-CoV-2 (COVID-19) pandemic, including economic, social, psychological, environmental, and public health challenges. The disease posed life-threatening risks and immense psychological stress worldwide. The relationship between the perception of vulnerability (e.g., unemployment, food, job insecurity, and illness) and low QoL is widely accepted [50]. Teotonio et al. reported that females presented worse QoL than males, due to predominantly manage family food purchases, meal preparation, and household decisions. During social distancing, women bore most domestic chores, childcare, education, and professional responsibilities, adversely affecting their QoL [50]. Mexican postpartum WLWH were not the exception, they had reduced scores in the physical health domain in 2022 compared to 2020–2021 scores (S2 Table). In accordance with other studies [50–56] also the increased stress, isolation, gender inequities, and reduced physical activity during lockdown, exacerbated vulnerability and wellness perceptions among WLWH.

For WLWH, the post-lockdown era signifies more than a mere return to normality during pregnancy and postpartum. The situation is still significantly impacted by a combination of ongoing psychosocial, structural, and HIV-related factors, and efforts have been made to address their emotional and psychological well-being and persistent stigma [43,44,48].

The correlations across QoL domains (Fig 2) highlight the interplay of medical, social, and cultural factors in WLWH during the postpartum period. As demonstrated in preceding studies, the consequences primarily encompass physical health, psychological well-being, independence levels, and relationships [24,25,28–30,35,38,39,40,41,57–65].

The principal component analysis (PCA) across low, medium, or high QoL categories revealed that several variables consistently contributed to variance, underscoring their relevance as potential determinants of the perception of QoL in Mexican postpartum WLWH. Social relationships domain emerged as a shared factor across all categories, highlighting the central role of interpersonal support in shaping well-being. Evidence shows that social support fosters psychological well-being, self-esteem, and resilience, translating into healthier coping and reduced stress responses [63]. Similarly, the year of the interview suggests that temporal or contextual factors, such as evolving health policies or social support structures, may have influenced QoL outcomes. This was indeed the case, as the study was conducted between 2020 and 2022—the years of the SARS-CoV-2 pandemic and the lockdown— with the consequences for this population previously described [50–56]. Furthermore, the gestational history also appeared across categories, reflecting the influence of maternal experience on resilience and self-perceived QoL. The notion that repeated maternal experiences may enhance self-reliance and confidence in managing daily life has been postulated by Puente Ferreira and Hernando (2023) and Lima et al. (2022). These researchers concluded that the experience of motherhood can boost the confidence and self-assurance of women living with HIV, allowing them to reaffirm their feminine identity, normalise their lives and overcome the social stigma associated with the disease. The advent of medical advances has rendered it feasible for women to have healthy children, thereby empowering them to prioritise their own well-being and demonstrate a commitment to their health [62,66]. The use of ART therapy during prenatal and postpartum care was more prevalent among women with low QoL scores, suggesting that treatment regimens may contribute to differences in perceived health and functioning. ART is an essential component of viral suppression; however, it can also contribute to adverse effects or treatment-related discomfort, which can negatively influence the perceived physical well-being of these women. It is important to note that certain antiretroviral regimens may have had a detrimental effect on physical outcomes, and this discomfort can impede WLWH participation in social activities. The aforementioned points are in accordance with previous studies [8,35,37,38,46,47]. These findings emphasize the need for further exploration of these variables in larger cohorts to clarify their predictive value and inform targeted clinical interventions.

The multinomial linear regression (MLR analysis) identified several demographics, clinical, and psychosocial variables as potential predictors of QoL of WLWH in postpartum. In the present study, three domains—Physical health, Independence level, and Spirituality—were identified as the strongest predictors of elevated QoL scores. Each domain demonstrated a high discriminative capacity (Fig 3). The predictive value of the Physical Health domain emphasises the significance of effective symptom management and treatment-related adverse effects in determining overall well-being. The Independence domain is indicative of the role of self-reliance and functional autonomy, both of which are critical for coping with the demands of postpartum life. Finally, the domain Spirituality, religion, and personal beliefs demonstrate the protective influence of cultural and existential frameworks in sustaining resilience. The aforementioned supports the results here obtained and are consistent with previous studies [8,35,38,40,46,47,61,64,66–73], which together with these findings emphasize the necessity of comprehensive interventions that integrate clinical care with psychosocial and cultural dimensions to increase QoL in this population.

No single instrument can fully evaluate all QoL factors. WHOQoL-HIV-Bref, although robust, does not fully assess barriers, such as mental illness and addictions or specific aspects related to ART (e.g., adherence, duration and type). More research should use specialised tools to assess adherence to ART and mental health. It is important to stablish that this instrument assesses the QoL and includes two questions about self-perceived QoL and health status, which score we called overall QoL and general health (Table 3).

This study had several limitations. First, obtaining a large sample of postpartum WLWH was challenging due to the specificity of their characteristics and vulnerability. Second, the cross-sectional design prevented the establishment of causality between variable associations. Third, ART adherence was obtained through clinical interviews rather than specialized instruments. Fourth, perception and behavior of QoL may have been influenced by the lockdown and post-pandemic period of the SARS-CoV-2 (COVID-19) pandemic.

Despite its limitations, this study provides valuable information on highly vulnerable populations such as postpartum WLWH and their QoL scores. The sample size is representative of Mexican postpartum WLWH who were treated at the antenatal care at INPer. The participants are from Mexico City and its suburbs (the Estado de México).

Nevertheless, the analysis conducted enabled the identification of significant sociodemographic and clinical variables that contribute to the assessment of QoL, and the identification of three predictors of a high QoL. The emphasis is on the identification and mitigation factors influencing the perception of QoL in PLWH, specially in high vulnerability groups as a WLWH during pregnancy and postpartum, with the aim of proposing strategies for medical attention and therapeutic success, and for the promotion of overall well-being. Furthermore, the call is made for the inclusion of QoL evaluation in WHO strategies, the fourth 95 target, and government and societal efforts to reduce stigma, foster acceptance, and improve environments for WLWH, future generations, and exposed newborns.

Conclusions

HIV/AIDS has a detrimental impact on the perception of QoL of Mexican postpartum WLWH and potentially their infants. Despite poverty, stigma, and discrimination, they remain motivated, especially when their child is born HIV-free. Mexican postpartum WLWH perceived their QoL as moderate, largely influenced by dual impact of ART regimens during pregnancy and postpartum, along with low-income. Clinical factors, particularly undetectable viral load, obstetric history, and the absence of symptoms due to HIV infection, have been found to be closely linked to improve their perception of QoL. The domains Physical health, Independence level, and Spirituality, religion and personal beliefs scores are strongest predictors of elevated total QoL scores. These findings underscore the significance of formally incorporating QoL assessment as the ‘fourth 95’ target in WHO strategies for the most vulnerable among PLWH, WLWH and their children.

Supporting information

Acknowledgments

The authors are also deeply grateful to all the women who participated in this work, and we hope that our efforts will improve their quality of life in all respects. The authors thank to their colleagues, Estela Y. Godínez-Martínez, Virginia E. Santillán-Palomo, María del Pilar Meza-Rodríguez, Carmen Flores-Cisneros, Cecilia Mota-González, Rosa Georgina Rodríguez-Delgado, and Edgar Bonilla-Reyes, for their excellent technical assistance, interest in this work, and helpful discussions.