title: Scaling up stigma? The effects of antiretroviral roll-out on stigma and HIV testing. Early evidence from rural Tanzania.
abstract: OBJECTIVE
  To investigate the interplay between antiretroviral therapy (ART) scale-up, different types of stigma and Voluntary Counselling and Testing (VCT) uptake 2 years after the introduction of free ART in a rural ward of Tanzania.
  
  
  METHODS
  Qualitative study using in-depth interviews and group activities with a purposive sample of 91 community leaders, 77 ART clients and 16 health providers. Data were analysed for recurrent themes using NVIVO-7 software.
  
  
  RESULTS
  The complex interplay between ART, stigma and VCT in this setting is characterised by two powerful but opposing dynamics. The availability of effective treatment has transformed HIV into a manageable condition which is contributing to a reduction in self-stigma and is stimulating VCT uptake. However, this is counterbalanced by the persistence of blaming attitudes and emergence of new sources of stigma associated with ART provision. The general perception among community leaders was that as ART users regained health, they increasingly engaged in sexual relations and "spread the disease." Fears were exacerbated because they were perceived to be very mobile and difficult to identify physically. Some leaders suggested giving ART recipients drugs "for impotence," marking them "with a sign" and putting them "in isolation camps." In this context, traditional beliefs about disease aetiology provided a less stigmatised explanation for HIV symptoms contributing to a situation of collective denial.
  
  
  CONCLUSIONS
  Where anticipated stigma prevails, provision of antiretroviral drugs alone is unlikely to have sufficient impact on VCT uptake. Achieving widespread public health benefits of ART roll-out requires community-level interventions to ensure local acceptability of antiretroviral drugs.
authors.affiliation: Centre for Population Studies, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK. maria.roura@lshtm.ac.uk
authors.forename: M
authors.initials: M
authors.lastname: Roura
authors.forename: M
authors.initials: M
authors.lastname: Urassa
authors.forename: J
authors.initials: J
authors.lastname: Busza
authors.forename: D
authors.initials: D
authors.lastname: Mbata
authors.forename: A
authors.initials: A
authors.lastname: Wringe
authors.forename: B
authors.initials: B
authors.lastname: Zaba
mesh_terms: D044966:Anti-Retroviral Agents / Q000600:supply & distribution* / Q000627:therapeutic use; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000523:psychology; D006801:Humans; D007407:Interviews as Topic; D007857:Leadership; D008297:Male; D010342:Patient Acceptance of Health Care / Q000523:psychology / Q000706:statistics & numerical data*; D011287:Prejudice; D045808:Refusal to Participate / Q000523:psychology; D019035:Rural Health Services / Q000706:statistics & numerical data*; D013636:Tanzania / Q000453:epidemiology
chemical_list: D044966:Anti-Retroviral Agents