Abstract
In South Africa, the country with the world’s largest HIV epidemic, the clinical success of Antiretroviral Therapy (ART) is contingent on sustained adherence. Alcohol use is a documented barrier to adherence, particularly among women, who bear a disproportionate burden of the epidemic. While healthcare workers (HCWs) are central to treatment success, their interactions with Women Living with HIV (WLHIV) who consume alcohol can be complicated by stigma, creating a critical barrier to care that remains underexplored.
This study aimed to investigate the experiences and perceptions of WLHIV who consume alcohol regarding their interactions with HCWs in HIV care settings.
A qualitative secondary analysis was conducted using interview transcripts from 18 WLHIV who reported alcohol use in South Africa. The study was guided by a social constructionist theoretical framework and employed Reflexive Thematic Analysis to analyse the data.
Four central themes were extracted. First, alcohol use was shaped by social norms, functioning as a mechanism for both social conformity and coping with trauma and a lack of support. Second, the clinic was experienced as a site of social control, where HCWs used medical authority and moral judgment to frame alcohol as an unmitigated evil. Third, clinical encounters were characterised by constant power negotiations, where women navigated between trust and mistrust, with the fear of stigmatisation often leading to concealment of alcohol use. Fourth, the language used by HCWs fused medical facts with moral judgment (e.g., "wrong," "bad"), actively framing patient identity and leading women to internalise feelings of being "bad patients."
The findings reveal that disengagement from care is not merely a failure of individual adherence but a response to a healthcare environment where women’s social and emotional realities are invalidated. The stigmatising discourse within clinics can inadvertently exacerbate the cycle of distress and alcohol use. The study argues for a paradigm shift in clinical practice towards trauma-informed, non-stigmatising communication that embraces harm-reduction principles to better support this vulnerable population.