摘要：Disclosure of HIV status is an essential part of behavior modification and access and adherence to treatment in people infected with HIV. We conducted interviews in 2 South African communities of similar ethnic mix but with very different rates of disclosure of HIV status and found that disclosure was the catalyst for access to a variety of important and often essential resources. In the community with high rates of disclosure of HIV infection, disclosure led to greater access to formal institutional support and opportunities to take positive leadership roles in the community. Our findings highlight the prominence of wider sociopolitical contexts for disclosure decisionmaking and the need for HIV interventions to increase levels of disclosure of HIV infection. The sheer scale of the HIV/AIDS epidemic in sub-Saharan Africa has finally led to an expanded global response. South Africa, a nation in which more than 5 million people are estimated to be infected with HIV/AIDS, 1 has established large-scale prevention and treatment programs. However, the uptake and effectiveness of many of these interventions remain suboptimal and are only having a marginal impact on the trajectory of the epidemic. 1 We believe that effective public policy can be fostered through an understanding of the issues surrounding the disclosure of HIV infection and of the environments that enable disclosure at the individual and community levels. There is increasing recognition that voluntary testing and counseling are important first steps for the modification of behaviors required to reduce the incidence of HIV infection. For example, a study in South Africa found that knowing someone infected with HIV was positively associated with condom use at last sexual contact and negatively associated with multiple and casual sexual partners. 2 Further, in Thailand it was found that those with histories of contact with people living with HIV/AIDS were more tolerant of the disease in general as well as of those infected. 3 However, community benefits such as the reduced incidence of HIV infection and reductions in stigma and discrimination cannot be realized without disclosure by HIV-positive individuals. At the individual level, disclosure of HIV infection can enable the activation of family or community support networks and reduce morbidity through better psychosocial management of the illness. Disclosure is also fundamental to the management of HIV infection; it has become an entry criterion for many treatment programs in resource-constrained settings and is crucial to adherence to complex treatment regimens in which treatment “buddies” and support can be accessed. For example, HIV-positive people have reported that they sometimes skip doses of their prescribed medications because they cannot take them without being observed doing so. 4 Access to other forms of care such as home-based care, nongovernmental organization (NGO) support, and specific social grants also depend on the disclosure of HIV status. From a health policy perspective, then, effective response across all levels centers on the creation of an enabling environment for disclosure of HIV infection. Although there are clear benefits to increased rates of disclosure of HIV infection at the individual and community levels, levels of disclosure remain low, especially in developing countries. 5 Dominant explanations for this issue focus on the role of stigma. Stigma is a social construction that dramatically affects the lives and experiences of individuals living with HIV infection, as well as their partners, families, and friends. 6 Disclosure of HIV infection can be an extremely difficult process because it makes one vulnerable to the perceived stigma of friends, family, or the community. 7 Stigma thus makes HIV-positive individuals reluctant to become identified and seek appropriate care, which ultimately results in a lack of access to important sources of family and social support. 8 The decision to disclose HIV status is therefore presented as the outcome of a calculation of the immediate benefits and risks of such an action. However, traditional definitions underplay the role of stigma as a social and political construction that facilitates the domination of certain social groupings, especially in the context of competition for scarce resources. 9 This conceptualization of stigma introduces the wider social, cultural, and economic environment as another determinant in decisions related to disclosure of HIV infection. Despite the plethora of explanatory theories related to disclosure of HIV infection, empirical evidence of the actual strategies individuals use to negotiate and counter the fear of rejection and isolation is scarce. Most studies examining disclosure have been conducted in Western contexts. 4 , 10 , 11 There is a dearth of research on the complex process of disclosure of HIV infection in sub-Saharan African nations, especially when the prevalence rates in the region one considers. We could find no analytic studies from Africa that attempted to identify the determinants of HIV disclosure. As increasing numbers of Africans test positive for HIV, an understanding of the disclosure process is essential to effective public policy and programming. Describing and analyzing the decisionmaking process before disclosure of HIV infection, as well as the event itself within the wider sociopolitical context, is an essential step in designing effective interventions that will facilitate increases in disclosure rates. We describe the realities of disclosure of HIV infection in 2 South African communities of similar ethnic mix but with very different overall levels of HIV disclosure. We sought to discern key factors that would encourage greater disclosure in both communities and have the potential for policy implications at the national and regional levels.
