'You feel like it's better to just die': Death-centric stereotypes and stigma contribute to suicide risk for adolescents living with HIV in Malawi.

Suicide is the second leading cause of death for adolescents worldwide. Adolescents living with HIV (ALWH) in Malawi are particularly at risk, due to stigmatization and a high comorbid prevalence of depression. Internalized stigma is an indicator of depression and suicidality, yet we have a limited understanding of the drivers and impacts of internalized stigma. In this analysis, we assessed how death-centric stereotypes and experienced stigma contribute to the development of internalized stigma and elevate suicide risk for ALWH in Malawi. This qualitative study recruited 68 total participants from three government healthcare facilities in Lilongwe, Malawi. We conducted 13 in-depth interviews and 10 focus group discussions with ALWH, caregivers of ALWH, adolescent peers without HIV, schoolteachers, HIV care providers, and mental health providers. We sought to understand how stigma manifests in key parts of an ALWH's life and contributes to internalized stigma and suicidal ideation. Guided by thematic analysis, we organized the relevant data into four themes: death-centric stereotypes, experienced stigma, internalized stigma, and suicidality. Death-centric stereotypes were identified as HIV's association with being a death sentence, obstructing one's future, and weak physical and mental capacity. From these stereotypes originate specific manifestations of experienced stigma, including insults and mockery, reduced social and economic prospects for adulthood, caregiver lack of investment in vital resources, and exclusion from community activities. Stereotypes and experienced stigma contribute to internalized stigma which manifests as low self-esteem, loss of future-oriented mindset, and self-isolation. This stigmatization process, particularly when perpetuated by family, increased suicide risk for ALWH. This study describes how death-centric stereotypes dominate the public discourse around ALWH, influence stigmatizing behaviors towards ALWH that disenfranchise them in their daily lives, and contribute to the development of internalized stigma and suicidality. Suicide screening and prevention programming, with attention to culturally sensitive stigma reduction, is urgently needed for ALWH.