“Protecting ourselves in silence”: a qualitative study of HIV risk perception and prevention among women in Sierra Leone

Women in Sierra Leone navigate HIV vulnerabilities shaped by gender inequities, economic dependence, and post-conflict dynamics. Despite a disproportionate burden (2.2% among women versus 1.1% among men), limited research has explored how women perceive and respond to HIV risk in low-prevalence West African settings. This qualitative study examined risk perception, vulnerability drivers, and prevention strategies through semi-structured interviews with 90 women across three districts (Western Area Urban, Bo, Kenema), including women living with HIV (n = 40), women with elevated vulnerability (n = 30), and community health workers (n = 20). Thematic analysis guided by the AIDS Risk Reduction Model identified three themes: barriers to risk recognition through psychological distancing and moral othering; factors influencing commitment, shaped by self-worth, relationship power, economic dependence, and solidarity networks; and prevention in practice, encompassing testing access, condom negotiation constraints, limited pre-exposure prophylaxis (PrEP) awareness, and substance use intersections. Psychological distancing appeared reinforced by low HIV visibility, with stronger distancing in Bo and Kenema than Freetown. Economic dependence emerged as a pervasive constraint across the risk navigation process. Findings suggest effective prevention may require addressing structural preconditions for protective action, with attention to district-level variation in HIV visibility and network dynamics. Further research is needed to test these implications.