Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa

Abstract

BackgroundStigma is a known barrier to HIV testing and care. Because access to antiretroviral therapy reduces overt illness and mortality, some scholars theorized that HIV-related stigma would decrease as treatment availability increased. However, the association between ART accessibility and stigma has not been as straightforward as originally predicted.MethodsWe conducted a “situational analysis”—a rapid, community-based qualitative assessment to inform a combination HIV prevention program in high prevalence communities. In the context of this community-based research, we conducted semi-structured interviews and focus groups with 684 individuals in four low-resource sub-districts in North West Province, South Africa. In addition to using this data to inform programming, we examined the impact of stigma on the uptake of services.ResultsFindings suggested that anticipated stigma remains a barrier to care. Although participants reported less enacted stigma, or hostility toward people living with HIV, they also felt that HIV remains synonymous with promiscuity and infidelity. Participants described community members taking steps to avoid being identified as HIV-positive, including avoiding healthcare facilities entirely, using traditional healers, or paying for private doctors. Such behaviors led to delays in testing and accessing care, and problems adhering to medications, especially for men and youth with no other health condition that could plausibly account for their utilization of medical services.ConclusionsWe conclude that providing access to ART alone will not end HIV-related stigma. Instead, individuals will remain hesitant to seek care as long as they fear that doing so will lead to prejudice and discrimination. It is critical to combat this trend by increasing cultural acceptance of being seropositive, integrating HIV care into general primary care and normalizing men and youths’ accessing health care.

The Life Circumstances of Hiv-Positive Women: The Case of Magunje Township, Zimbabwe

“…The inevitability of one's death will be hovering at the back of one's mind, as the body gradually succumbs to the opportunistic infections as a result of the infection. This finding is in line with previous research, which shows that sometimes people cannot envisage a healthy identity when they are HIV positive, a situation which other researchers have labelled a "spoiled identity" (Aransiola, Imoyera, Olowookere & Zarowsky, 2014;Treves-Kagan, Steward, Ntswane, Haller, Gilvydis, Gulati, Barnhart & Lippman, 2016).…”

“…From the participants' stories it emerged that VCT in Zimbabwe seems to be focused mainly on living positively with HIV and that disclosure appears to have been relegated to the background. It is true that a positive mind is essential in order to live longer with HIV, but HIV/AIDS status disclosure is also needed in order to curb the rate of HIV infections in Africa, where the rate is alarmingly high, since it is this silence that helps to fuel the spread of the epidemic (Aransiola et al, 2014;Tharao, Massaquoi & Teclom, 2006;Treves-Kagan et al, 2016).…”

“…There is also a need for these awareness campaigns to tackle stigma, because stigma is one of the factors affecting disclosure (Aransiola et al, 2014;Treves-Kagan et al, 2016;Tshuma, 2016;Woolett, 2013).…”

Acceptability of HIV Testing and Counseling Services among Persons Visiting a funeral home in a regional referral hospital in Western Kenya, 2014-2015

“…Acceptability rates among ANC women in Africa are generally higher than those seen in previous years; 69% (35%-95%) (Cartoux M et al,1998). This could be attributed to increasing availability of ART and destigmatization of HIV infection (Treves-Kagan S et al,2016).…”

Traditional health practitioners’ management of HIV/AIDS in rural South Africa in the era of widespread antiretroviral therapy

“…As of 2016, South Africa is initiating ART with all patients testing HIV positive regardless of CD4 count, in line with the recommendations by the World Health Organization (WHO) [12]. However, other studies have suggested that, on their own, biomedical interventions are not enough to deal with the epidemic [18–21]. Structural and sociobehavioural factors have been considered major barriers to ART initiation [22,23].…”