title: 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: BACKGROUND
  Stigma 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.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  Findings 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.
  
  
  CONCLUSIONS
  We 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.
authors.affiliation: University of California, San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA. kagan.sarah@gmail.com.
authors.forename: Sarah
authors.initials: S
authors.lastname: Treves-Kagan
authors.affiliation: University of California, San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA. wayne.steward@ucsf.edu.
authors.forename: Wayne T
authors.initials: WT
authors.lastname: Steward
authors.affiliation: University of Washington, International Training and Education Center for Health (ITECH) - South Africa, Pretoria, South Africa. lntswane@itech-southafrica.org.
authors.forename: Lebogang
authors.initials: L
authors.lastname: Ntswane
authors.affiliation: University of California, San Francisco, Global Health Sciences, San Francisco, CA, USA. robinhaller07@gmail.com.
authors.forename: Robin
authors.initials: R
authors.lastname: Haller
authors.affiliation: University of Washington, International Training and Education Center for Health (ITECH) - South Africa, Pretoria, South Africa. jay@globalactionconsulting.com.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Gilvydis
authors.affiliation: University of Washington, International Training and Education Center for Health, Seattle, WA, USA. harnikg@uw.edu.
authors.forename: Harnik
authors.initials: H
authors.lastname: Gulati
authors.affiliation: University of Washington, International Training and Education Center for Health, Seattle, WA, USA. sbht@uw.edu.
authors.forename: Scott
authors.initials: S
authors.lastname: Barnhart
authors.affiliation: University of California, San Francisco, Center for AIDS Prevention Studies, San Francisco, CA, USA. sheri.lippman@ucsf.edu.
authors.forename: Sheri A
authors.initials: SA
authors.lastname: Lippman
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003153:Community Health Services; D003695:Delivery of Health Care; D017144:Focus Groups; D015658:HIV Infections / Q000188:drug therapy* / Q000517:prevention & control* / Q000523:psychology; D006801:Humans; D008297:Male; D011287:Prejudice; D012424:Rural Population / Q000706:statistics & numerical data*; D012938:Social Perception; D057545:Social Stigma; D013019:South Africa / Q000453:epidemiology
chemical_list: D044966:Anti-Retroviral Agents
references.citation: AIDS. 2015 Jan 2;29(1):83-90
references.pmid: 25268886
references.citation: PLoS Med. 2005 Aug;2(8):e247
references.pmid: 16008508
references.citation: Trop Med Int Health. 2010 Jun;15 Suppl 1:70-5
references.pmid: 20586963
references.citation: Am J Community Psychol. 2014 Mar;53(1-2):146-58
references.pmid: 24477769
references.citation: South Afr J HIV Med. 2017 Jul 27;18(1):694
references.pmid: 29568630
references.citation: AIDS Behav. 2012 Apr;16(3):564-70
references.pmid: 22080386
references.citation: Ann Behav Med. 2013 Dec;46(3):285-94
references.pmid: 23690283
references.citation: Soc Sci Med. 2009 Jun;68(12):2271-8
references.pmid: 19394121
references.citation: AIDS Behav. 2009 Dec;13(6):1160-77
references.pmid: 19636699
references.citation: Glob Public Health. 2017 Sep;12(9):1122-1140
references.pmid: 26414798
references.citation: J Int AIDS Soc. 2013 Nov 13;16(3 Suppl 2):18734
references.pmid: 24242268
references.citation: AIDS Behav. 2010 Oct;14(5):1115-23
references.pmid: 20049520
references.citation: SAHARA J. 2011;8(2):82-8
references.pmid: 23237685
references.citation: AIDS Patient Care STDS. 2007 Aug;21(8):584-92
references.pmid: 17711383
references.citation: Soc Sci Med. 2008 Oct;67(8):1225-35
references.pmid: 18599171
references.citation: BMC Public Health. 2007 Apr 25;7:63
references.pmid: 17459154
references.citation: S Afr Med J. 2009 Sep;99(9):653-60
references.pmid: 20073292
references.citation: J Int AIDS Soc. 2013 Nov 13;16(3 Suppl 2):18881
references.pmid: 24242269
references.citation: J Int AIDS Soc. 2012 Jun 14;15 Suppl 1:1-9
references.pmid: 22713354
references.citation: Soc Sci Med. 2014 May;108:166-74
references.pmid: 24641881
references.citation: Am J Public Health. 2005 Jan;95(1):53-9
references.pmid: 15623859
references.citation: AIDS Care. 2009 Jan;21(1):87-93
references.pmid: 19085224
references.citation: J Int Assoc Provid AIDS Care. 2013 Mar-Apr;12(2):103-9
references.pmid: 22282878
references.citation: Ann Behav Med. 2014 Aug;48(1):26-37
references.pmid: 24500077
references.citation: Global Health. 2011 May 15;7:13
references.pmid: 21575149
references.citation: Am J Public Health. 2003 Jun;93(6):970-9
references.pmid: 12773364
references.citation: Afr J AIDS Res. 2016;15(1):67-75
references.pmid: 27002359
references.citation: J Int AIDS Soc. 2010 Feb 09;13:6
references.pmid: 20181124
references.citation: Sex Transm Infect. 2009 Aug;85(4):308-12
references.pmid: 19036776
references.citation: Lancet. 2001 Aug 4;358(9279):404-9
references.pmid: 11502340
references.citation: PLoS One. 2014 Jul 16;9(7):e102904
references.pmid: 25028976
references.citation: AIDS Behav. 2013 Nov;17(9):2845-63
references.pmid: 23934267
references.citation: Am J Public Health. 2003 May;93(5):724-31
references.pmid: 12721133
references.citation: Lancet. 2011 Jun 11;377(9782):2031-41
references.pmid: 21641026
references.citation: Lancet. 2009 Jan 3;373(9657):48-57
references.pmid: 19038438
references.citation: AIDS Behav. 2011 Nov;15(8):1764-75
references.pmid: 21301948
references.citation: BMC Health Serv Res. 2008 Jan 23;8:19
references.pmid: 18215313
references.citation: J Int AIDS Soc. 2009 Aug 06;12:15
references.pmid: 19660113
references.citation: Trop Med Int Health. 2011 Jul;16(7):828-9
references.pmid: 21418449
references.citation: AIDS Educ Prev. 2003 Feb;15(1):49-69
references.pmid: 12627743
references.citation: Soc Sci Med. 2003 Jul;57(1):13-24
references.pmid: 12753813
references.citation: PLoS One. 2014 Feb 20;9(2):e88235
references.pmid: 24586310
references.citation: Sex Transm Infect. 2003 Dec;79(6):442-7
references.pmid: 14663117
references.citation: AIDS Behav. 2015 Apr;19(4):704-14
references.pmid: 25304330
references.citation: AIDS Care. 2008 Nov;20(10):1217-23
references.pmid: 18608082
references.citation: Prev Sci. 2009 Sep;10(3):260-9
references.pmid: 19353267
references.citation: AIDS Behav. 2005 Jun;9(2):135-43
references.pmid: 15933833
references.citation: PLoS One. 2013 Aug 09;8(8):e71778
references.pmid: 23951245
references.citation: PLoS Med. 2013 Nov;10(11):e1001557
references.pmid: 24319400
references.citation: Am J Public Health. 2008 Oct;98(10):1865-71
references.pmid: 18703447
references.citation: Bull World Health Organ. 2004 Apr;82(4):299-307
references.pmid: 15259260
references.citation: BMC Public Health. 2013 Mar 11;13:220
references.pmid: 23497196
references.citation: Lancet. 2009 Sep 12;374(9693):921-33
references.pmid: 19709731
references.citation: J Int AIDS Soc. 2013 Nov 13;16(3 Suppl 2):18640
references.pmid: 24242258
references.citation: AIDS. 2008 Aug;22 Suppl 2:S67-79
references.pmid: 18641472
references.citation: BMC Public Health. 2010 Jul 01;10:387
references.pmid: 20594326