4 formula feed, because of the fear of having their HIV status exposed: “When we tell them they have to choose as to what they are going to do with their baby, ‘Are you going to breastfeed your baby or are you going to bottle feed?’ You will hear they will say ‘I can’t give my baby [formula feed brand]. Why?’ Because people in the location know that if you give your baby [formula feed brand] you are HIV-positive.” (KI—PMTCT organisation) On the other hand, once diagnosed HIV-positive, men avoided seeking help, treatment, or support, for fear of stigma. Such behaviour was seen as related to the male “macho” culture of needing to be seen to be strong, while HIV was still seen as largely a “female thing,” and thus it was mainly women who attended support groups: “With men we’ve been having little success, but we’ve been trying to get them on board, and it’s a battle to get men involved, but also trying to make men aware that it’s not only a women’s issue, and they also need to be involved and come on board, so that’s a bit of a struggle.” (KI—Community Muslim AIDS support group) “Most of the time its females, because males, I don’t know whether they are scared, most of the support groups are female. Maybe the man, if he has a big problem or if he was sick for a long time, very, very sick, so he thinks now he must go to the support group . . . I think maybe it’s part of our culture, because I know actually men, they don’t cry out, maybe they keep it inside, most of them they prefer to keep it inside than to talk to someone.” (KI—National PLWHA organisation) “Gay men have been told for generations, because of homophobia and prejudice, that their sex is bad, you understand? So the element of shame around HIV infection interfaces very directly with a diagnosis of HIV-positive in gay men . . . we talk about the stigma of being HIV-positive, but before we label them as HIV-positive, they are human beings and socially they are labelled for being gay, so you need to address that one before you can address the HIV stigma.” (KI—Gay support NGO) Furthermore, for MSM, sexual orientation could add to existing stigma attached to being HIV-positive: Interestingly, according to KIs and focus group partici- pants, the levels of stigma and discrimination were decreas- ing and attitudes were shifting toward greater acceptance of PLWHA in local communities: “I think there are a lot of changes now within the community. You have to accept it [your HIV- positive status] ﬁrstly, and then others will too. People don’t isolate themselves like they used to.” (FGD—HIV-positive African women) AIDS Research and Treatment “In K [local predominantly African community] it’s diﬀerent than the other areas, because we’ve been talking about HIV from 1999 . . . so they [PLWHA] don’t really encounter more diﬃculties than a person who’s HIV-negative.” (KI—ARV counsellor coordinator) 3.1.2. Disclosure. Decisions about HIV disclosure are depen- dent on perceived AIDS-related stigma [27]. In this study, closely linked to stigma were issues of disclosure. Due to the persistent nature of AIDS-related stigma group participants expressed fears of disclosure that might lead to rejection by their families or partners, or losing their jobs: “For me it was fear of rejection that somebody should ﬁnd out that I’m positive, so for a long time I kept it to myself.” (FGD—HIV-positive white gay men) “The second thing is the disclosure, ‘I can’t disclose to my partner because he’s going to throw me out of the house, I can’t disclose to my family’.” (KI— AIDS training coordinator) Focus group participants described other manifestations of discrimination including being isolated and forced to use separate kitchen utensils, and keeping to “their own room”: “At the time that I told them [my family] they said they must buy me gloves so that when I cook food I must wear them . . . they said that it would be much better if I moved out of their house. I didn’t say anything, I took my belongings and I went to my own place.” (FGD—HIV-positive African women) “That thing of being discriminated against at your own home, just because they have found out that you are HIV-positive, they provide you with your own spoon and dish, they give you your own room, and there is no-one who wishes to come to your room, you sleep alone.” (FGD—HIV- positive African men) The insistence that the person living with HIV have their “own dish, spoon . . . everything that you are using . . . must be diﬀerent” demonstrates the imagined danger, which the person living with HIV poses to the rest of the family. Inaccurate beliefs about HIV transmission can lead to more fear and discrimination, which can further stigmatise people living with HIV [28]. In a study done in South African communities, results showed that participants who held traditional beliefs about the causes of AIDS were more likely to stigmatise people living with HIV [29]. Similar experiences of discrimination and AIDS-related stigma were reported in a study conducted in an urban informal settlement in Cape Town [30]. Manifestations of such discrimination were also reported in the ﬁrst nationally based HIV prevalence study in South Africa in which 26% of respondents revealed that they were unwilling to share a meal