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.
Conclusion: 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.
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Funding: This study was funded by the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) and the Welcome Trust.
Competing interests: None.
Ethics approval: Ethics approval was provided by the LSHTM Ethics Committee and the Tanzanian Medical Research Coordinating Committee.
Patient consent: Obtained.
MR developed the substudy with community leaders, conducted the analysis, trained fieldworkers and wrote the first draft of the paper; MU, director of the whole cohort study, provided overall advice, facilitated the coordination of fieldwork and contributed to drafting the paper; JB provided technical advice, helped train fieldworkers and assisted in drafting the paper; DM contributed to data collection and analysis; AW developed the substudy with PLHA and health providers, created a sampling framework and facilitated the recruitment of ART clients; BZ, technical advisor for the whole cohort study, provided advice and contributed to drafting the paper.
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