HIV/AIDS and 'othering' in South Africa: the blame goes on

Compassionate Othering: the construction of refugee patients in medical students' narratives - a qualitative study using story completion

BACKGROUND

Refugees remain a marginalized population and are exposed to a variety of discriminatory processes, among them Othering which categorizes people as belonging or not-belonging according to certain ascribed characteristics. We explored how the narrative construction of refugee patients by medical students constitutes a form of Othering.

METHODS

Using story completion, 124 5th year medical students at the Martin- Luther- University Halle-Wittenberg in October 2019 wrote a fictional story in response to a story stem situated in a medical practice. In a comparative approach, one patient presenting with abdominal pain lacks further characterization (version A) and the other is a refugee (version B). The stories were coded using qualitative content analysis by Mayring with a focus on content and narrative strategies (plot structure and perspective).

RESULTS

We identified four themes: characters, medical condition, access to care and provision of substandard care. The stories were predominantly framed with a medical or an interaction-based plot structure and written from a process-oriented perspective. The themes in version B, supported by their use of narrative strategies, were largely contextualized within the patients' history of migration. An empathic depiction of patient B and the students' compassion for the patients facing substandard care were key motifs as well.

CONCLUSION

The perception of the version B patients predominantly as refugees establishes their construction as an Other. The students' compassion acts as a representation of societal inequalities and remains an inept response without the tools to counter underlying discriminatory structures. Based on a discourse of deservingness, compassion alone therefore perpetuates Othering and highlights the need for structural competency training in medical school.

Secondary distribution of HIV self-test kits from males to their female sexual partners in two fishing communities in rural Uganda

Secondary distribution of HIV self-test kits from females to their male partners has increased HIV testing rates in men but little evidence exists on the potential for HIV self-test kits distribution from males to their female partners. We assessed the acceptability of secondary HIV self-test kits distribution from males to their female sexual partners in a fishing community context. This secondary analysis used data from the PEer-led HIV Self-Testing intervention for MEN (PEST4MEN), a pilot interventional study in Buvuma and Kalangala districts in Uganda. At the baseline visit, in July 2022, data were collected from 400 men aged 15+ years who self-reported a HIV-negative or unknown HIV status. Enrolled men were asked to pick two oral fluid HIV self-test kits from a trained male distributor. At the first follow-up visit, in September 2022, men were asked about the number of kits that they received and if they gave kits to anyone, including to their female sexual partners. We used a modified Poisson regression model to determine the factors independently associated with giving kits to sexual partners. Data were analyzed using STATA version 16.0. Of 361 men interviewed at follow-up, 98.3% (355) received at least one kit; 79.7% (283) received two kits. Of those who received two kits, 64% (181) gave the second kit to anyone else; of these, 74.6% (132/177) gave it to a sexual partner. Being currently married (adjusted prevalence ratio [adj. PR] = 1.39; 95% confidence interval [95%CI]: 1.10, 1.75) and having difficulty in reading text prepared in the local language (adj. PR = 1.26; 95%CI: 1.03, 1.55) were significantly associated with men giving kits to their female sexual partners. Ninety-seven per cent (112/132) of the men reported that they knew their sexual partners' HIV self-test results. Of these, 93.7% (n = 105) reported that their partners were HIV-negative while 6.3% (n = 7) reported that they were HIV-positive. Only 28.6% (n = 2) of the HIV-positive sexual partners were reported to have initiated HIV care. Secondary distribution of HIV self-test kits from males to their female sexual partners is well accepted by women in the fishing communities, suggesting that distribution of kits through men in the fishing communities can help to improve HIV testing uptake among their female sexual partners.

Discourse, Difference, and Divergence: Exploring Media Representations and Online Public Sentiments toward Marginalized Urban Communities in Jamaica during the COVID-19 Pandemic

Despite lacking the resources to adequately adhere to public health protocols, urban residents belonging to impoverished communities in Kingston, Jamaica were prominently featured in local news reports that highlighted their breaches of social distancing. These reports generated an overwhelmingly prejudiced online social discourse, characterized by derogatory and dehumanizing remarks. This research aims to explore the ways media representations of calls for social distancing have unearthed latent social cleavages and contributed to the othering of Kingston’s poor. A thematic analysis was used to understand the nature of the public response to these news reports. The comments were manually coded, and emergent themes were classified based on the sentiments expressed. The comments generated evoked class, place, race, and political tensions, potentially perpetuating the public perception of vulnerable groups as the ‘threatening other’. These comments possibly represent deeper problems associated with the social divergence of Jamaican society. The lack of sensitivity exhibited shows a general disregard for the stark social realities commonly experienced by subaltern groups. These findings suggest media coverage promoting public safety, while important, may inadvertently lead to heightened social tensions and perpetuate social stigmas against marginalized groups, potentially stirring social divergence and countering efforts toward inclusiveness and integration.

How are we going to treat Chinese people during the pandemic? Media cultivation of intergroup threat and blame

This study integrates cultivation and intergroup threat theories to examine media cultivation effects during the COVID-19 pandemic. We argue that U.S. media have consistently portrayed China as a threat and target of blame. The cultivation of media has thus resulted in perceived threat of and blame on Chinese people for the COVID-19 pandemic. Results of a cross-sectional survey in two samples (MTurk: N = 375; college: N = 566) showed that the amount of media consumption predicted stronger perceptions that Chinese people were a health threat, and also predicted blame on Chinese people for the COVID-19 outbreak. Threat perception and blame were further associated with support of media content that derogated China, stronger intentions to attack, and weaker intentions to help Chinese people. The findings have profound implications for intergroup threat and cultivation research, and practical importance for intergroup relations, especially when the global community finds itself in a public crisis.

'I am Dying a Slow Death of White Guilt': Spiritual Carers in a South African Hospice Navigate Issues of Race and Cultural Diversity

Culturally appropriate spiritual care is increasingly recognised as a crucial component of spiritual care. As part of a larger study, we were interested in cultural and racial issues as experienced by spiritual carers in a hospice in Cape Town, South Africa. We conducted one-on-one interviews and focus group discussions with a cohort of spiritual care workers, who, being volunteers and relatively privileged South Africans, discussed their sensitivity to cultural issues, but also mentioned a host of political, racial and identity issues which profoundly affect their work. The data suggest that the concept of culturally appropriate care must be understood and acted on contextually. We note that the work of transformation of care cannot be separated from broader questions of social inequality and change.

Myths, misconceptions, othering and stigmatizing responses to Covid-19 in South Africa: A rapid qualitative assessment

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new strain of virus in the Coronavirus family that has not been previously identified. Since SARS-CoV-2 is a new virus, everyone is at risk of catching the Coronavirus disease 2019 (Covid-19). No one has immunity to the virus. Despite this, misconceptions about specific groups of people who are immune to Covid-19 emerged with the onset of the pandemic. This paper explores South African communities' misconceptions about who is most vulnerable to Covid-19. A rapid qualitative assessment was conducted remotely in Gauteng, KwaZulu-Natal and the Western Cape provinces of South Africa. Recruitment of study participants took place through established relationships with civil society organizations and contacts made by researchers. In total, 60 key informant interviews and one focus group discussion was conducted. Atlas.ti.8 Windows was used to facilitate qualitative data analysis. The qualitative data was coded, and thematic analysis used to identify themes. The results show a high level of awareness and knowledge of the transmission and prevention of SARS-CoV-2. Qualitative data revealed that there is awareness of elderly people and those with immunocompromised conditions being more vulnerable to catching Covid-19. However, misconceptions of being protected against the virus or having low or no risk were also evident in the data. We found that false information circulated on social media not only instigated confusion, fear and panic, but also contributed to the construction of misconceptions, othering and stigmatizing responses to Covid-19. The study findings bring attention to the importance of developing communication materials adapted to specific communities to help reduce misconceptions, othering and stigmatization around Covid-19.

The development of Maisha, a video-assisted counseling intervention to address HIV stigma at entry into antenatal care in Tanzania

HIV stigma has a profound impact on clinical outcomes and undermines the quality of life of people living with HIV (PLWH). Among HIV-negative individuals, misinformation and prejudicial attitudes about HIV can fuel stigma and contribute to discrimination against PLWH. Antenatal care (ANC), with its focus on universal HIV testing, provides a unique entry point to address HIV stigma. This study describes the development of a counseling intervention to address HIV stigma among women and their partners attending a first ANC appointment in Tanzania. Formative work to inform the intervention consisted of qualitative interviews with 32 pregnant and postpartum women (both women living with HIV and HIV-negative women) and 20 healthcare workers. Data were analyzed iteratively, using a thematic analysis approach, to identify intervention targets. The resulting intervention, Maisha (Swahili for "Life"), includes three sessions informed by the HIV Stigma Framework and Cognitive-Behavioral Therapy: a video and brief counseling session prior to HIV testing and, for those who test seropositive for HIV, two additional sessions building on the video content. A pilot test of the intervention is in process. Addressing HIV stigma at the first ANC visit can help individuals living with HIV to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can reduce stigmatizing attitudes among those who test negative for HIV.

Social Distancing to Mitigate COVID-19 Risks Is Associated With COVID-19 Discriminatory Attitudes Among People Living with HIV

BACKGROUND

Severe acute respiratory syndrome coronavirus-2, the virus that causes COVID-19, is an emerging pandemic with heightened concerns for people with compromised immune systems, including people living with HIV.

PURPOSE

In the absence of a vaccine, public health messaging to mitigate risks for COVID-19 primarily focuses on social distancing. Because people living with HIV commonly experience mistreatment associated with HIV, their response to social distancing may be complicated by psychosocial attitudes associated with COVID-19.

METHODS

To evaluate these relationships, we conducted a rapid-response, cross-sectional survey with people living with HIV (N = 149) to assess social distancing practices, COVID-19 discriminatory attitudes, COVID-19 xenophobic attitudes, HIV microaggressions, and concern over contracting COVID-19. Data were collected from participants enrolled in a larger ongoing study between March 30, 2020 and April 17, 2020.

RESULTS

Results indicated that choosing to socially distance to reduce COVID-19 exposure was associated with COVID-19 discriminatory attitudes, concerns of contracting COVID-19, and identifying as transgender. Likewise, social distancing imposed by others (e.g., cancelations and restrictions) was associated with concerns of contracting COVID-19.

CONCLUSIONS

Findings demonstrate that social distancing measures are related to concerns of contracting the virus and discriminatory attitudes toward those who are presumed to be living with COVID-19. These potentially negative psychosocial attitudes toward people perceived to have COVID-19 echo the discriminatory actions and attitudes that we continue to observe in HIV social sciences research.

Factors influencing sexually transmissible infection disclosure to male partners by HIV-positive pregnant women in Pretoria townships, South Africa: a qualitative study

Background Sexually transmissible infections (STI) may increase the risk of mother-to-child transmission (MTCT) of HIV. However, diagnostic testing and targeted treatment of STI (STI-TT) during pregnancy is not standard care in South Africa.

METHODS

A qualitative study was nested in a STI-TT intervention to investigate motivating and enabling factors associated with STI test results disclosure to sexual partners. A semi-structured interview protocol covered partner communication, HIV and STI disclosure, financial security and relationships dynamics. Interviews were conducted in participants' preferred language, audio-recorded, transcribed into English and analysed using a constant comparison approach. The study was conducted in two townships in Pretoria, South Africa.

RESULTS

Twenty-eight HIV-positive pregnant women were interviewed. Based on the interviews, two disclosure experiences for women were identified - those with vulnerable experiences and those with self-enabling experiences within their partnerships. Vulnerable women discussed intimate partner violence (IPV) and fear of relationship dissolution as factors influencing their test result disclosure. Self-enabled women discussed their ability to talk with their partners about STI and HIV infections and the influence of multiple concurrent partnerships in the acquisition of HIV/STIs. Both groups of women were concerned about men's health behaviours, and all cited the health and development of their unborn child as a key motivator for test result disclosure.

CONCLUSIONS

Improved counselling and support for pregnant women to disclose their STI test results to their partners may improve the impact of STI diagnostic testing during pregnancy by improving partner treatment uptake and thus reducing the risk of re-infection.

Xenophobia as a determinant of health: an integrative review

Though xenophobia has become increasingly relevant in today's political climate, little is known about the impact of xenophobia on health. While some studies have shown that xenophobia, in local contexts, may contribute to worse mental health outcomes, none have attempted to review the published literature to integrate these findings. This integrative scoping review examines the strength of these publications, then synthesizes their findings to provide a global perspective on xenophobia. The results show that it is not merely a political threat, but also has real, negative impact on the health of individuals and their communities. Given the multiple negative effects on individual and community health, xenophobia warrants more attention from both a public health and political perspective. Policies that promote cultural integration and understanding are essential to improving community health.

A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

BACKGROUND

Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions.

METHODS

We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations.

RESULTS

Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes.

CONCLUSIONS

Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.

Stigma and Discrimination: Threats to Living Positively with Human Immunodeficiency Virus

Antiretroviral therapy and care advances have resulted in people with human immunodeficiency virus (HIV) living longer and enjoying a higher level of physical well-being. Despite such advances, individuals with HIV continue to confront challenges to living positively, including facing the secondary epidemic of stigma and discrimination. Following is a historical overview of the concept of stigma and an exploration of the causes and consequences of multilevel stigma for individuals with HIV. Strategies used by individuals and societies to manage stigma and avoid negative experiences also are examined.

Commentary: Just What is Critical Race Theory and What's it Doing in a Progressive Field like Public Health?

Gloria Ladson-Billings cautiously promotes the use of Critical Race Theory (CRT) to address racism's contribution to educational disparities. Nearly a decade ago, we issued a similar call to the multidisciplinary field of public health. Public health touts its progressive roots and focus on equity, but do those efforts draw on CRT? To answer this question, we define CRT, describe its origin in the field of law, and review the ways its use has grown in the field of public health. Public health interventions and policies rely heavily on evidence; therefore, we re-introduce the semi-structured research method we developed to facilitate empirical application of CRT, ie, the Public Health Critical Race Praxis (PHCRP).

Introducing visual participatory methods to develop local knowledge on HIV in rural South Africa

INTRODUCTION

South Africa is a country faced with complex health and social inequalities, in which HIV/AIDS has had devastating impacts. The study aimed to gain insights into the perspectives of rural communities on HIV-related mortality.

METHODS

A participatory action research (PAR) process, inclusive of a visual participatory method (Photovoice), was initiated to elicit and organise local knowledge and to identify priorities for action in a rural subdistrict underpinned by the Agincourt Health and Socio-Demographic Surveillance System (HDSS). We convened three village-based discussion groups, presented HDSS data on HIV-related mortality, elicited subjective perspectives on HIV/AIDS, systematised these into collective accounts and identified priorities for action. Framework analysis was performed on narrative and visual data, and practice theory was used to interpret the findings.

FINDINGS

A range of social and health systems factors were identified as causes and contributors of HIV mortality. These included alcohol use/abuse, gender inequalities, stigma around disclosure of HIV status, problems with informal care, poor sanitation, harmful traditional practices, delays in treatment, problems with medications and problematic staff-patient relationships. To address these issues, developing youth facilities in communities, improving employment opportunities, timely treatment and extending community outreach for health education and health promotion were identified.

DISCUSSION

Addressing social practices of blame, stigma and mistrust around HIV-related mortality may be a useful focus for policy and planning. Research that engages communities and authorities to coproduce evidence can capture these practices, improve communication and build trust.

CONCLUSION

Actions to reduce HIV should go beyond individual agency and structural forces to focus on how social practices embody these elements. Initiating PAR inclusive of visual methods can build shared understandings of disease burdens in social and health systems contexts. This can develop shared accountability and improve staff-patient relationships, which, over time, may address the issues identified, here related to stigma and blame.

HIV risk and barriers to care for African-born immigrant women: a sociocultural outlook

Background

Data from the Minnesota Department of Health (MDH) HIV/AIDS Surveillance Report 2015 show that African-born (AB) women continue to be disproportionately affected by HIV. In 2015, these women accounted for more than half (54%) of all new cases of HIV reported among females in Minnesota and 34% of all known female cases in the state. This study was a needs assessment for HIV pre-exposure prophylaxis (PrEP) in vulnerable subgroups within the AB population and adequacy of HIV care for AB persons. The primary objective of this study was to gain an insight into the strategies that will limit the spread of HIV infection and enhance HIV care among AB immigrants.

Methods

Community advocates, community-based organizations (CBOs), clinicians, and other HIV-related service providers were invited to participate in a focus group, structured interview or complete an assessment tool using the same questionnaire about HIV and PrEP among AB persons. A thematic analysis was then conducted on the open-ended questions addressing perceived barriers.

Results

Findings suggest the following gender-specific sociocultural factors that drive HIV transmission and constitute barriers to HIV treatment for AB women: domestic/intimate partner violence, gender-biased stigma, discriminatory cultural beliefs and normative values/expectations, unprotected sex with husbands who have sex with other men, gender discordance in health care (preference for female provider), and sexual/reproductive health illiteracy.

Recommendation

Based on recommendations, a community-based sexual and reproductive health education is being initiated with a curriculum that will be 1) broad (inclusive but not limited to HIV), 2) culturally sensitive/responsive, and 3) at appropriate literacy level for all women, including those who have little or no formal education.

"HIV Changed My Life Forever": An Illustrative Case of a Sub-Saharan African Migrant Woman Living with HIV in Belgium

Living with HIV and AIDS changes everything for people diagnosed with HIV and it can be the most difficult experience in life. Like most people who have chronic diseases, these individuals have to deal with living a normal and quality life. Globally, more women (51%) than men are HIV positive. The main aim of this paper was to describe a sub-Saharan African migrant woman’s lived experience, and also to use the individual’s story to raise questions about the larger context after a HIV diagnosis. A qualitative study consisting of a personal story of a HIV-infected sub-Saharan African living in Belgium was conducted. Data were analysed using thematic analysis. The main themes that emerged from the data included relational risks, personal transformation and the search for normality, anxiety, depression, fear of stigma, societal gender norms, and support. The participant reported that marriage was no guarantee of staying HIV-free, especially in a male-dominant culture. This case further illustrates that married and unmarried African women are often at high risk of HIV and also informs us how HIV could spread, not only because of cultural practices but also because of individual behaviour and responses to everyday life situations. The participant also emphasized that she is faced with physical and mental health problems that are typical of people living with HIV. The vulnerability of sub-Saharan African women to HIV infection and their precarious health-related environments wherever they happen to be is further elucidated by this case.

HIV Serostatus Disclosure to Sexual Partners Among Sexually Active People Living with HIV in South Africa: Results from the 2012 National Population-Based Household Survey

This paper explores the prevalence and correlates of HIV seropositive status disclosure to sexual partners by people living with HIV (PLHIV) in South Africa. Secondary analysis of the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey was conducted on data obtained from 934 sexually active PLHIV aged 15 years and older who responded to the question about HIV seropositive status disclosure. Overall, a large majority of respondents (77.1 %) reported disclosing their HIV-positive status to all their current sex partners. Multiple regression analysis, after adjustments for sex, marital status and locality type, revealed that those who were living together, going steady, and those who were single were all 60 % [adjusted odds ratio (AOR) = 0.4, 95 % CIs 0.20-0.78; AOR = 0.4, 95 % CIs 0.24-0.77; and AOR = 0.4, 95 % CIs 0.19-1.00, all ps < 0.05] less likely to disclose their HIV positive status to their partners compared to those who were married. Those who lived in rural formal areas were 70 % less likely to disclose their HIV status to their partners compared to those who stayed in urban formal areas (AOR = 0.3, 95 % CI 0.17-0.69, p < 0.001). Those who had correct HIV knowledge and rejection of myths were 2.0 times more likely to disclose their HIV status to their partners compared to those who did not have correct HIV knowledge and rejection of myths (AOR = 2.0, 95 % CI 1.04-3.68, p < 0.05). In conclusion, intervention programmes which help improve HIV seropositive status disclosure are needed by PLHIV who are not married, live in rural formal areas, and have incorrect HIV knowledge and rejection of myths.

Exploring gender perceptions of risk of HIV infection and related behaviour among elderly men and women of Ga-Rankuwa, Gauteng Province, South Africa

The literature shows that there are important differences between women and men in the underlying mechanisms of transmission of HIV infection and AIDS, as well as in the social and economic consequences of HIV/AIDS. These stem from sexual behaviour and socially constructed 'gender' differences between women and men in roles and responsibilities. Despite the fact that numerous gender-related sociocultural factors influence HIV/AIDS protective behaviours, little gender specificity is included in HIV prevention among the elderly. In order to close this gap, this study explored gender-related perceptions of risk of HIV infection among elderly men and women of Ga-Rankuwa in Gauteng Province, South Africa. This qualitative study used purposive sampling to conduct three focus group interviews with 22 women and 10 men who were above 60 years of age. Findings revealed that both genders blame each other for the spreading of HIV/AIDS. Male participants displayed the tendency to have multiple partners, whereas females accepted that males are promiscuous. Mixed perceptions about disclosure of HIV status were found. Condom use was a challenge, as men did not know how to introduce it with their wives, and some female participants indicated that men are resistant to using condoms. The elderly men also believed that women will have sex in exchange for money. It is concluded that there is a need for substantial behaviour change among both elderly males and females, which should address gender power relations. More in-depth and extensive research in this area is recommended.

Adolescent goals and aspirations in search of psychological well-being: from the perspective of self-determination theory

According to self-determination theory, an individual’s goal content and the processes involved in goal setting often represent the status of the individual’s mental health and well-being. When examining the importance placed on goal setting, an individual’s goals and aspirations are often synonymous with mental health and well-being. Aspiring to achieve intrinsic life goals has been associated with greater psychological well-being in literature. This study therefore aimed to establish the relationships between goals and aspirations, mental health behaviour (interpersonal relations, stress management, and spiritual growth), and psychological well-being (measured by positive affect). A sample of 457 secondary school learners in the Overberg Educational District, Western Cape, South Africa, participated in the study. The results suggest a significant positive relationship between placing importance on intrinsic goals and aspirations, and psychological well-being (as indicated by positive affect). However, psychological well-being was not correlated with mental health behaviour. The results of the hierarchical regression analysis suggest that importance placed on intrinsic goals and aspirations predicts psychological well-being and accounts for 8% of the variance. The results highlight the role of intrinsic goals and aspirations in predicting the psychological well-being of adolescents. The findings are supported by the theoretical assumptions of self-determination theory.

Human Rights Violations among Men Who Have Sex with Men in Southern Africa: Comparisons between Legal Contexts

In 1994, South Africa approved a constitution providing freedom from discrimination based on sexual orientation. Other Southern African countries, including Botswana, Malawi, and Namibia, criminalize same-sex behavior. Men who have sex with men (MSM) have been shown to experience high levels of stigma and discrimination, increasing their vulnerability to negative health and other outcomes. This paper examines the relationship between criminalization of same-sex behavior and experiences of human rights abuses by MSM. It compares the extent to which MSM in peri-urban Cape Town experience human rights abuses with that of MSM in Gaborone, Botswana; Blantyre and Lilongwe, Malawi; and Windhoek, Namibia. In 2008, 737 MSM participated in a cross-sectional study using a structured survey collecting data regarding demographics, human rights, HIV status, and risk behavior. Participants accrued in each site were compared using bivariate and multivariate logistic regression. Encouragingly, the results indicate MSM in Cape Town were more likely to disclose their sexual orientation to family or healthcare workers and less likely to be blackmailed or feel afraid in their communities than MSM in Botswana, Malawi, or Namibia. However, South African MSM were not statistically significantly less likely experience a human rights abuse than their peers in cities in other study countries, showing that while legal protections may reduce experiences of certain abuses, legislative changes alone are insufficient for protecting MSM. A comprehensive approach with interventions at multiple levels in multiple sectors is needed to create the legal and social change necessary to address attitudes, discrimination, and violence affecting MSM.

'The mercurial piece of the puzzle': Understanding stigma and HIV/AIDS in South Africa

Although stigma and its relationship to health and disease is not a new phenomenon, it has not been a major feature in the public discourse until the emergence of HIV. The range of negative responses associated with the epidemic placed stigma on the public agenda and drew attention to its complexity as a phenomenon and concept worthy of further investigation. Despite the consensus that stigma is one of the major contributors to the rapid spread of HIV and the frequent use of the term in the media and among people in the street, the exact meaning of 'stigma' remains ambiguous. The aim of this paper is to briefly re-visit some of the scholarly deliberations and further interrogate their relevance in explaining HIV-related stigma evidenced in South Africa. In conclusion a model is presented. Its usefulness--or explanatory potential--is that it attempts to provide a comprehensive framework that offers insights into the individual as well as the social/structural components of HIV-related stigma in a particular context. As such, it has the potential to provide more nuanced understandings as well as to alert us to knowledge-gaps in the process.

Difficulties facing healthcare workers in the era of AIDS treatment in Lesotho

Sub-Saharan Africa is most affected by the AIDS pandemic and Lesotho is no exception. In many countries, healthcare workers are at the forefront of the fight against AIDS. This study explores the difficulties facing healthcare workers in Lesotho using a combination of qualitative methods--focus group discussions and in-depth interviews. The findings suggest that healthcare workers are afraid of contracting HIV from their patients and this affects their delivery of services. In addition, the results revealed that poor infrastructure and shortage of supplies at the facilities hinder healthcare workers from performing their duties effectively. The other concern was the heavy workload and severe time constraints which puts enormous stress on healthcare workers. Stigma and discrimination emerged as major problems for healthcare workers. Addressing the challenges facing healthcare workers is essential in effectively managing the AIDS pandemic facing the continent.

HIV/AIDS-related stigma in South African alcohol-serving venues and its potential impact on HIV disclosure, testing and treatment-seeking behaviours

Alcohol-serving venues in South Africa are sites for high-risk behaviours that may lead to HIV transmission. Prevention and treatment interventions are sorely needed in these settings, but HIV-related stigma may limit their effectiveness. This study explored expressions of stigma among alcohol-serving venue patrons in Cape Town and examined the potential impact of stigma on HIV disclosure, testing and treatment-seeking behaviours. A total of 92 in-depth interviews with male and female, black and coloured patrons were conducted. Transcripts were analysed via memo-writing and diagramming techniques. Many participants mentioned knowing other patrons living with HIV/AIDS (PLWH), and this visibility of HIV impacted expressions of HIV-related stigma. Participants discussed four forms of HIV-related stigma in the venues: fearing PLWH, fearing HIV acquisition, blaming others for spreading HIV and isolating PLWH. HIV visibility and expressions of HIV-related stigma, particularly fear of isolation, influenced participants' willingness to disclose their status. HIV-related stigma in the venues also appeared to indirectly influence testing and treatment-seeking behaviour outside the venue. Results suggest that efforts to change norms and reduce expressions of HIV-related stigma in alcohol-serving venues are necessary to successfully deliver tailored HIV prevention interventions and increase uptake of HIV testing and care in this important social setting.

Obstacles to HIV prevention, treatment and care in selected public universities in South Africa

South Africa, like the rest of Southern Africa, is ravaged by AIDS. Higher education in South Africa has a significant role to play in the fight against the spread of HIV and AIDS. This article reports the factors contributing to the spread of HIV and AIDS in three selected public universities in South Africa. To achieve the stated aim, the study answered the following research question: What are the factors contributing to the spread of HIV and AIDS in South African public universities? The problem in this study stems from South Africa's HIV and AIDS infection rate, one of the highest in the world, especially in KwaZulu-Natal. A qualitative approach was adopted by conducting focus group interviews with the students. The data were analysed using axial coding and open coding, where dominant themes from the discussions were identified and discussed in detail. The findings show that barriers to HIV and AIDS prevention, care and treatment exist in the tertiary institutions under study. Social and economic interventions are needed to stem the spread of HIV and AIDS at tertiary institutions. A range of recommendations for halting the spread of HIV and AIDS in these institutions is provided.

HIV-infected People in Sudan Moving Toward Chronic Poverty: Possible Interventions

We sought to identify the socioeconomic impact on people living with HIV (PLWH) in Sudan. Focus group discussions were used to collect data and identify the most outstanding domains of HIV impact on PLWH and the survival mechanisms that may be common to a group of diverse HIV-infected persons (n = 30). The findings indicated that the most striking financial and social impacts were due to stigma associated with HIV in the conservative Sudanese society, which led to loss of work with all its consequences (e.g., children's education and health care expenses were affected). The socioeconomic impacts of HIV on infected populations are discussed, and suggestions for possible interventions to mitigate harmful impacts and stigma within the society, the workplace, and health care settings are highlighted. We concluded that HIV has intensified the existing problems of infected people, contributing to their vulnerability to poverty.

'If the doctors see that they don't know how to cure the disease, they say it's AIDS': How older women in rural South Africa make sense of the HIV/AIDS epidemic

South Africa, like other sub-Saharan African countries, is in the midst of the AIDS epidemic. Older women, here defined as aged 60 years and older, while at lower risk of infection than those aged 20-50, are amongst those deeply 'affected' by the epidemic. In rural areas, older women, who have always played central roles in social reproduction in South African households and families, bear the brunt of care giving for the sick and dying. For this reason, it is important to explore how these women understand the epidemic. In South Africa, the prominence of traditional healers and medicine alongside biomedicine has led to multiple ways of perceiving, explaining and treating illness. This paper explores the various discourses older women in rural South Africa employ to make sense of the HIV/ AIDS epidemic in their daily lives. The aim is to better understand how these women construct the epidemic and how this knowledge can be used to benefit education and treatment endeavours in similar contexts. This paper draws on interview data collected as part of the Gogo Project conducted in the Medical Research Council (MRC)/Wits Rural Public Health and Health Transitions Research Unit. Sixty women between the ages of 60 and 75 years living in the rural Agincourt sub-district participated in three in-depth, semi-structured interviews. The respondents in this study relied on a variety of discourses to make sense of the HIV/AIDS epidemic. They displayed a high level of knowledge based on biomedical education, however, they expressed ideas, often simultaneously, that seemed to contradict this education. Their ability to employ seemingly contradictory discourses represents the need to place the epidemic within familiar 'explanatory models' that are based on these women's life experiences and local knowledge.

A model for understanding the relationship between stigma and healthcare-seeking behaviour among people living with HIV/AIDS in sub-Saharan Africa

People living with HIV or AIDS (PLHIV) in sub-Saharan Africa sometimes have care-seeking behaviours that result in a suboptimal quality of life. This paper seeks to examine the role of stigma in the care-seeking behaviour of PLHIV. We hypothesise that stigma relates to the behaviour of PLHIV themselves and with societal reactions, including those of healthcare professionals. From a literature review, we identified the following as important correlates of care-seeking behavior: beliefs about pathways of HIV infection and people infected with HIV, social reactions, coping strategies, knowledge of HIV and AIDS, and self-efficacy in finding care and treatment in addition to coping with the disease. Poverty, gender, age, religion and policy were found to be moderating variables. The Precede-Proceed model was adapted to build an explanatory model of healthcare-seeking behaviour among PLHIV and particularly to explore the role of stigma in the non-utilisation of healthcare institutions.

Experiences of emotional abuse among women living with HIV and AIDS in Malawi

Our aim for this study was to describe emotional abuse as it is experienced by women living with HIV and AIDS in Malawi. The study was conducted in the Lilongwe district in Malawi and used a descriptive phenomenological approach. Twelve women from two public health care clinics under the Lilongwe District Health Office were interviewed. Violating experiences that scarred the personhood and inherent value of being human were found to be the essence of their emotional abuse. Their husbands, family, and community members were responsible for the humiliation, abandonment, and blaming that caused them to feel hopeless.

Perceptions about the acceptability and prevalence of HIV testing and factors influencing them in different communities in South Africa

HIV counselling and testing (HCT) is considered important because it is an entry point to a comprehensive continuum of care for HIV/AIDS. The South African Department of Health launched an HCT campaign in April 2010, and this reached 13,269,746 people by June 2011, of which 16% tested HIV positive and 400,000 of those were initiated into antiretroviral treatment. The overall objective of this project was to gain insight into the general perceptions about HIV testing in the different South African communities. Factors influencing testing in these communities were also explored. Discussions with twelve focus groups (FG) of 8-12 participants each were conducted with male and female participants recruited from both urban formal and informal communities in Cape Town and Durban. Participants included four racial groups represented by different age groups as follows: adolescents (12-17 years), youth (18-24 years) and adults (25 years and older). Data were analyzed using thematic coding. Among the key themes that emerged from the findings were the inaccurate perception of risk, fear of testing HIV positive, stigma and discrimination. Participants from both African and Indian FGs reported being less likely to do self-initiated HIV testing and counselling, while those from the FG consisting of young whites were more likely to learn about their HIV status through blood donations and campus HIV testing campaigns. Most FGs said they were likely to test if they understood the testing process better and also if the results are kept confidential. The present findings reiterate the importance of spreading positive messages and ensuring confidentiality for HIV testing in a society where there is still some stigma associated with people living with HIV/AIDS. This can partly be accomplished by the continuation of the national HCT campaign, which has been a considerable success in the fight against HIV/AIDS in South Africa during the past two years.

Different dimensions of HIV-related stigma may have opposite effects on hiv testing: evidence among young men and women in South Africa

Although HIV-related stigma in general is known to deter HIV-testing, the extent to which different dimensions of stigma independently influence testing behaviour is poorly understood. We used data on young black men (n = 553) and women (n = 674) from the 2009 Cape Area Panel Study to examine the independent effects of stigmatising attitudes, perceived stigma and observed enacted stigma on HIV-testing. Multivariate logistic regression models showed that stigma had a strong relationship with HIV-testing among women, but not men. Women who held stigmatising attitudes were more likely to have been tested (OR 3, p < 0.01), while perceived stigma (OR 0.61, p < 0.1) and observed enacted stigma (OR 0.42, p < 0.01) reduced the odds significantly of women having had an HIV test. Our findings highlight that different dimensions of stigma may have opposite effects on HIV testing, and point towards the need for interventions that limit the impact of enacted and perceived stigma on HIV-testing among women.

Terms used for people living with HIV in the Democratic Republic of the Congo

For this study we conducted in-depth interviews with 29 youth living with HIV (YLWH) and key informant interviews with 8 HIV care/support providers. We describe terms used to portray people living with HIV (PLWH) in Kinshasa, Democratic Republic of the Congo. Labels commonly used, mostly derogatory, described PLWH as walking corpses, dangers to others, or people deserving to die before others get infected. Blame and other accusations were directed at PLWH through anchoring or objectification. Being labeled sometimes made these youth suffer in silence, afraid to disclose their status, or avoid performing actions in public, preferring to let others do them. YLWH need psychosocial support to mitigate the harmful effects of these labels and strengthen their coping skills, whereas community, institutional, and national efforts are needed for stigma reduction.

Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions

OBJECTIVE

This paper reviews available studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors.

METHODS

We search electronic databases and conducted a thematic analysis of empirical studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors. Studies were mapped to describe their methods, target population and the health behaviors or health outcomes studied. Forty-five studies met the inclusion criteria.

RESULTS

The studies reviewed used the PEN-3 model as a theoretical framework to centralize culture in the study of health behaviors and to integrate culturally relevant factors in the development of interventions. The model was also used as an analysis tool, to sift through text and data in order to separate, define and delineate emerging themes. PEN-3 model was also significant with exploring not only how cultural context shapes health beliefs and practices, but also how family systems play a critical role in enabling or nurturing positive health behaviors and health outcomes. Finally, the studies reviewed highlighted the utility of the model with examining cultural practices that are critical to positive health behaviors, unique practices that have a neutral impact on health and the negative factors that are likely to have an adverse influence on health.

DISCUSSION

The limitations of model and the role for future studies are discussed relative to the importance of using PEN-3 cultural model to explore the influence of culture in promoting positive health behaviors, eliminating health disparities and designing and implementing sustainable public health interventions.

Measurement of Stigma in Men Who Have Sex with Men in Hanoi, Vietnam: Assessment of a Homosexuality-Related Stigma Scale

Objective. To develop and assess a homosexuality-related stigma scale among men who have sex with men (MSM) in Hanoi, Vietnam. Methods. We conducted a cross-sectional study using respondent-driven sampling in Hanoi, Vietnam, in 2011. We used a cross-validation approach. Factor analysis was performed, and interitem correlation matrices were constructed to identify the latent factor structures, examine the goodness of fit, and assess convergent and discriminant validity of the determined scales. Internal consistency checks were performed in split samples and whole sample, and separately for each determined factor. Results. The findings were consistent in split samples. Three homosexuality-related stigma factors were identified: enacted homosexual stigma, perceived homosexual stigma, and internalized homosexual stigma. The fit indices of the confirmatory factor analysis in both split samples supported the hypothesized three-factor structures (in subsamples A and B: χ²/degrees of freedom ratio = 1.77 and 1.59, nonnormed fit index = 0.92 and 0.94, comparative fit index = 0.93 and 0.95, and the root mean square of approximation = 0.06 and 0.05, resp.). The interitem correlation supported the convergent and discriminant validity of the scales. The reliability of the three scales indicated good consistency (Cronbach's alpha: 0.79–0.84) across split samples and for the whole data. Conclusion. Our scales have good psychometric properties for measuring homosexuality-related stigma. These comprehensive and practical tools are crucial not only to assess stigma against MSM and its consequence, but also to guide the development of interventions targeting MSM, as well as to evaluate the efficacy of existing stigma reduction efforts in Vietnam and other countries with similar settings.

Correlates of social exclusion and negative labeling and devaluation of people living with HIV/AIDS in rural settings: evidence from a General Household Survey in Zambézia Province, Mozambique

Background

Increased HIV/AIDS knowledge and access to antiretroviral treatment (ART) have been hypothesized to decrease HIV stigma. However, stigma persists as a barrier to HIV services uptake. We studied the relationship between stigma, knowledge and attitudes towards HIV and its treatment, and confidence in the legal system (legal rights certitude).

Methods

We analyzed data from a household survey of 3749 randomly sampled female heads of households in 259 enumeration areas across 14 districts of Zambézia Province, Mozambique. The questionnaire included questions about beliefs, attitudes and behavior towards PLWHA, HIV transmission knowledge, treatment-related beliefs, and legal rights certitude. Factor analysis distinguished two stigma constructs: Negative labeling and devaluation (NLD) and social exclusion (SoE). Multivariable linear regression was used to determine the association between stigma, knowledge of HIV/AIDS, treatment-related beliefs, and legal rights certitude, while controlling for variance in socio-demographics.

Results

A 4-point increase in knowledge about HIV transmission was associated with more than a 3 unit decrease in NLD and SoE stigma scores (p<0.001). Given HIV transmission knowledge, a 25-point increase in legal rights certitude was associated with a 4.62 unit drop in NLD stigma (p<0.001); we did not detect an association between legal rights certitude and SoE stigma. Knowing at least one HIV positive person was associated with lower SoE (−3.17, 95% CI: −5.78, −0.56); no association with NLD (p = 0.1) was detected. ART efficacy belief was associated with higher NLD and lower SoE (2.90 increase and 6.94 decrease, respectively; p≤0.001).

Conclusion

Increasing knowledge about HIV transmission and access to ART are likely to reduce stigma, but neither of the two is a panacea. Raising community awareness of the legal rights of PLWHA might improve the efficacy of stigma reduction efforts. Strategies that focus on specific domains of stigma might be more effective than generic stigma reduction strategies.

Malicious whites, greedy women, and virtuous volunteers: negotiating social relations through clinical trial narratives in South Africa

As clinical trial research increasingly permeates sub-Saharan Africa, tales of purposeful HIV infection, blood theft, and other harmful outcomes are widely reported by participants and community members. Examining responses to the Microbicide Development Programme 301-a randomized, double-blind, placebo-controlled microbicide trial-we investigate the ways in which these accounts embed medical research within postcolonial contexts. We explore three popular narratives circulating around the Johannesburg trial site: malicious whites killing participants and selling their blood, greedy women enrolling in the trial solely for financial gain, and virtuous volunteers attempting to ensure their health and aid others through trial participation. We argue that trial participants and community members transform medical research into a meaningful tool that alternately affirms, debates, and challenges contemporary social relations.

Silencing women's sexuality: global AIDS policies and the case of the female condom

INTRODUCTION

The female condom is the only evidence-based AIDS prevention technology that has been designed for the female body; yet, most women do not have access to it. This is remarkable since women constitute the majority of all HIV-positive people living in sub-Saharan Africa, and gender inequality is seen as a driving force of the AIDS epidemic. In this study, we analyze how major actors in the AIDS prevention field frame the AIDS problem, in particular the female condom in comparison to other prevention technologies, in their discourse and policy formulations. Our aim is to gain insight into the discursive power mechanisms that underlie the thinking about AIDS prevention and women's sexual agency.

METHODS

We analyze the AIDS policies of 16 agencies that constitute the most influential actors in the global response to AIDS. Our study unravels the discursive power of these global AIDS policy actors, when promoting and making choices between AIDS prevention technologies. We conducted both a quantitative and qualitative analysis of how the global AIDS epidemic is being addressed by them, in framing the AIDS problem, labelling of different categories of people for targeting AIDS prevention programmes and in gender marking of AIDS prevention technologies.

RESULTS

We found that global AIDS policy actors frame the AIDS problem predominantly in the context of gender and reproductive health, rather than that of sexuality and sexual rights. Men's sexual agency is treated differently from women's sexual agency. An example of such differentiation and of gender marking is shown by contrasting the framing and labelling of male circumcision as an intervention aimed at the prevention of HIV with that of the female condom.

CONCLUSIONS

The gender-stereotyped global AIDS policy discourse negates women's agency in sexuality and their sexual rights. This could be an important factor in limiting the scale-up of female condom programmes and hampering universal access to female condoms.

High levels of bisexual behavior and factors associated with bisexual behavior among men having sex with men (MSM) in Nigeria

Nigerian men who have sex with men (MSM) have a high burden of HIV infection and are known to engage in bisexual behavior. This study presents the first data on characteristics and correlates of Nigerian men having sex with men and women (MSMW) in three Nigerian cities. Five hundred and fifty-seven MSM who engaged in anal sex with men completed a behavioral survey; 48.1% of these MSM also engaged in sex with women in the previous 2 months. MSMW displayed high levels of risky sexual behavior with female sex partners; casual (56.0%) and multiple female partners were common (69.0%) and 66.0% had unprotected vaginal sex. As much as 45.1% MSMW had anal sex with female partners of which 74.0% did not use protection in the 2 months prior. In bivariate analyses, bisexual behavior was associated (p<0.05) with being married or living with a women (OR 5.0, 95% CI = 2.6-9.4), less education (OR 2.0, 95% CI = 1.4-3.0), bisexual/straight identity (OR 2.3, 95% CI = 1.6-3.2), being an insertive partner (OR 3.0, 95% CI = 1.9-4.5), being HIV-negative (OR 1.6, 95% CI = 1.1-2.5), living in Lagos (OR 2.3, 95% CI = 1.7-2.2), being Muslim (OR 1.7, 95% CI = 1.1-2.5), and being away from home (OR 1.5, 95% CI = 1.0-2.1). In the multivariate model, being married to or living with a woman (AOR = 5.1; 95% CI = 2.5-10.3), bisexual/straight identity (AOR = 2.2; 95% CIs = 1.5-3.3), being an insertive partner (AOR = 3.0; 95% CI = 1.9-4.9), being away from home (AOR = 1.6; 95% CI = 1.1-2.3) and living in Lagos (AOR = 1.7; 95% CI = 1.0-2.8) remained significant (p< 0.05). High levels of bisexual behavior exist among Nigerian MSM, and these men engage in risky sexual behaviors with both male and female sex partners. While decriminalization of same-sex behavior in Nigeria will promote access to HIV prevention programs, current MSM interventions must incorporate information on safe sex with both male and female sex partners.

Why culture matters in health interventions: lessons from HIV/AIDS stigma and NCDs

Theories about health behavior are commonly used in public health and often frame problems as ascribed or related to individuals' actions or inaction. This framing suggests that poor health occurs because individuals are unable or unwilling to heed preventive messages or recommended treatment actions. The recent United Nations call for strategies to reduce the global disease burden of noncommunicable diseases like diabetes requires a reassessment of individual-based approaches to behavior change. We argue that public health and health behavior intervention should focus more on culture than behavior to achieve meaningful and sustainable change resulting in positive health outcomes. To change negative health behaviors, one must first identify and promote positive health behaviors within the cultural logic of its contexts. To illustrate these points, we discuss stigma associated with obesity and human immunodeficiency virus and acquired immune deficiency syndrome. We conclude that focusing on positive behaviors and sustaining cultural and personal transformations requires a culturally grounded approach to public health interventions, such as that provided by the PEN-3 model.

Perceptions of sexual risk compensation following posttrial HIV vaccine uptake among young South Africans

Concerns about the impact of risk compensation on advances in biomedical human immunodeficiency virus (HIV) prevention technologies have been documented. We conducted an exploratory qualitative study using focus group discussions with young South African men and women (aged 18 to 24 years) to explore perceptions of risk compensation with regard to a hypothetical posttrial HIV vaccine. During the discussions, participants expressed their disquiet about the potential for risk compensation and the manner in which this might manifest among young people. Discussions specifically focused on reductions in condom use, an increase in multiple partners, and increased frequency of sex. The discussions also revealed contradictory feelings about HIV vaccines: appreciation for their development tempered by concerns about loss of control and undermining morality. Women were particularly concerned with the possibility of increased partner concurrency and infidelity. We suggest that concerns in HIV vaccine target populations about the impact of possible risk compensation be incorporated into strategies for vaccine introduction once vaccines move from the hypothetical to reality.

Levels and correlates of internalized homophobia among men who have sex with men in Pretoria, South Africa

This study examines levels and correlates of internalized homophobia among men who have sex with men (MSM) in Pretoria, South Africa. Using respondent-driven sampling, we recruited 324 MSM from February to August 2009. Results were adjusted using RDSAT analysis to yield population-based estimates. High levels of internalized homophobia exist among South African MSM: 10-15% reported "often/very often" and over 20% reported "sometimes" having feelings of internalized homophobia. A greater level of internalized homophobia was significantly associated with a lower level of education [Adjusted Odds Ratio = 2.2; 95% CI = 1.1-4.9], a higher level of HIV misinformation [AOR = 2.7; 95% CI: 1.3-5.3], bisexual identity (vs. homosexual) [AOR = 5.5; 95% CI: 2.5-12.0], and HIV-related conspiracy beliefs [AOR = 2.4; 95% CI: 1.02-5.8]. These findings contribute valuable information to our understanding of internalized homophobia in South Africa, highlighting the need to empower the gay community, promote self-acceptance of homosexual identity, and address conspiracy beliefs among MSM to reduce internalized homophobia and increase access to HIV prevention interventions.

HIV and tuberculosis: the construction and management of double stigma

Mitigation of the tuberculosis (TB) and HIV syndemic is undermined by critical clinical, operational and social challenges of which the social aspects have been least explored. This paper examines the lived experience of TB disease and HIV from the perspective of affected individuals to analyze how they may think about their dual illness; how they understand their illness with TB in relation to HIV, and vice versa; and how they characterize their (stigmatized) experiences in the context of their perceptions and identities. From February-August 2009, qualitative, semi-structured interviews were conducted with 40 adults with HIV and TB disease at three ambulatory clinics in KwaZulu-Natal, South Africa. Subjective meanings of illness experience were analyzed using modified grounded-theory. Emergent themes on illness perception and disclosure revealed how patients constructed dichotomous identities associated with TB and HIV through social constructs of moral susceptibility and (im)permanence. Each identity was associated with relatively disparate degrees of stigma as a product of labeling, negative stereotyping and discrimination. HIV bore the least desirable identity and invoked the greatest stigma. However, the confluence of the two epidemics rendered TB symbolic and symptomatic of HIV, and enhanced the visibility of AIDS. Dual illness thus introduced a paradox to patients' identity constructions, and produced a unique, overlapping double stigma. This facilitated new forms of stigma against TB, and aggravated existing stigma against HIV. It also conferred visibility to some forms of extra-pulmonary TB. Patients managed their double stigmas through novel forms of information sharing that relied on segregating their dual illness identities. Patients deflected the dominant stigma of HIV through concurrent processes of HIV 'othering' - their symbolic distancing from persons affected by HIV, and 'covering' - their selective disclosure of illness (and identity associated) with TB over that of HIV. Findings call for greater consideration to the complex role of stigma in the delivery of TB/HIV healthcare.