Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.
Department of Sociology and Social Anthropology, Stellenbosch University, Stellenbosch, South Africa.
Womens Health (Lond). 2021 Jan-Dec;17:1745506521998204. doi: 10.1177/1745506521998204.
Public health programming often frames HIV status disclosure as a means to negotiate condom- and abstinence-based prevention or to involve intimate partners in HIV care to garner treatment adherence support. HIV treatment can be used to ensure viral suppression and prevent onward transmission, which provides strong evidence to encourage disclosure. The ideological shift towards HIV treatment as prevention is expected to facilitate disclosure.
There is a lack of research on how the scale-up of universal HIV testing and treatment influences disclosure practices in high burden settings. In this manuscript, we aim to address this gap.
To this end, we conducted a two-phased narrative performative analysis of the disclosure scripts of 15 women living with HIV in three communities of Western Cape, South Africa where the HPTN 071 (PopART) HIV prevention trial implemented a universal HIV testing and treatment model as part of the intervention. The women were part of a larger cohort nested in the trial. We use Goffman's dramaturgical metaphor, which understands social interactions as 'performances' by 'actors' (people) guided by 'scripts' (anticipated dialogues/interactions), to explore how women living with HIV manage their status disclosure.
We describe how these women perform HIV status disclosure (or deliberate non-disclosure) to retain, reaffirm or redefine existing social scripts with partners. Their performances reveal priorities other than those imagined by public health programmes driving HIV disclosure (or non-disclosure): establishing trust, resenting betrayal and ensuring self-preservation while simultaneously (re)constructing self-identity. None of the women engaged with the concept of treatment as prevention in their disclosure narratives, either to facilitate disclosure or to 'justify' non-disclosure. HIV prevention, in general, and treatment adherence support were rarely mentioned as a reason for disclosure. To date, there has been a missed opportunity to ease and support disclosure in health programmes by tapping into existing social scripts, impeding potential patient and public health benefits of universal HIV testing and treatment.
公共卫生规划常将 HIV 状况披露视为协商使用避孕套和禁欲预防措施，或让亲密伴侣参与 HIV 护理以获得治疗依从性支持的一种手段。HIV 治疗可用于确保病毒抑制和防止传播，为鼓励披露提供了有力证据。向 HIV 治疗即预防的理念转变预计将促进披露。
在高负担环境中，普遍开展 HIV 检测和治疗对披露实践的影响的研究相对较少。本研究旨在弥补这一空白。
为此，我们对南非西开普省三个社区的 15 名 HIV 感染者的披露剧本进行了两阶段叙述性表现分析，这些社区都参与了 HPTN 071（PopART）HIV 预防试验，试验实施了普遍 HIV 检测和治疗模式，作为干预措施的一部分。这些妇女是作为试验中嵌套的更大队列的一部分。我们使用戈夫曼的戏剧隐喻，将社会互动理解为“演员”（人）根据“剧本”（预期的对话/互动）进行的“表演”，以探讨 HIV 感染者如何管理其状况披露。
我们描述了这些女性如何通过表演来披露（或故意不披露）HIV 状况，以维持、重申或重新定义与伴侣的现有社会剧本。她们的表演揭示了公共卫生计划推动 HIV 披露（或不披露）背后的优先事项：建立信任、反感背叛、确保自我保护，同时（重新）构建自我认同。在披露叙述中，没有一位女性提到治疗即预防的概念，无论是为了促进披露还是为了“证明”不披露的合理性。HIV 预防，一般来说，以及治疗依从性支持，很少被提及作为披露的原因。迄今为止，通过利用现有社会剧本，在卫生规划中为披露提供便利和支持的机会被错失，阻碍了普遍 HIV 检测和治疗的潜在患者和公共卫生效益。
