Table 2.

Categories identified by participants regarding the risks and protective factors associated with ART initiation

Categories	Gender	Treatment decision	Representative quotation
Risk Losing health or beauty	F	Sustained refuser	QUOTE 1: “I [feel] very healthy. I found out in 2004 that I am HIV positive […] I was not understanding negative and positive. They said, ‘You are HIV positive,’ and I said, ‘I am not HIV positive.’ […] I told myself that I am beautiful and they say I am HIV positive. Are they sick? I said, “No, they are mad. How can they say that?” I am very healthy”
Risk Stigma associated with disclosure	F	Initial refuser	QUOTE 2: “In a rural area, it’s a small place even though you trust the nurses and stuff like that. People who are in the clinic, they know that you go to that door when you are HIV positive. You come in this way, so they will notice, “Wow, she is also HIV positive.” So they will start talking, I have got my ex’s in this area”
	F	Initial refuser	QUOTE 3: “I think the main thing is that you get it by having sex. That is the problem… so people think that when you are HIV positive you have been sleeping around, maybe you have been selling your body or something… you have been careless with your body. So people are scared that they are going to be labeled as a person who has been so selfish as someone who has been sleeping around. That’s why people are so scared to be known as being HIV positive”
Risk Increased financial burdens	F	False acceptor	QUOTE 4: “I even told [the counselor] that they had referred me to start taking ARV’s, but my problem is that sometimes I do not have food to eat at all. How can I take [ARVs] when I don’t have food to eat? So now that means that I will default, but if I knew that I had money then I would take them”
	F	False acceptor	QUOTE 5: “To tell you the truth, where I am currently staying, it’s difficult for me, to the point that there was an argument this past Saturday and…they told me I should go and look for a place to rent. Alright, I don’t buy food because I don’t work and they also complained about that. So you see, this thing is emotionally hurting me… I was even saying that if I was working, I would move out and live elsewhere and I would not go to bed on an empty stomach… I would be able to take my tablets… I don’t deny that I need to take ARV’s, but I am looking at my living conditions, and the fact that I might take them and then default”
Risk Religious mores	M	Initial refuser	QUOTE 6: “So, when I went to church with my brother, they discussed HIV as a disease, but there was an element to say that it is for promiscuous people and they push prayer more than they push ARVs… For people who are strong believers, [I believe] they can really be cured. I think with God - what is impossible with man- is possible with God”
Risk Role of traditional healers and alternative therapies	M	Sustained refuser	QUOTE 7: “I don’t use ART. I use the traditional herbs that I am used to, like ‘ingwe’ [an herbal remedy known as an immune booster]. It also tries to kill the virus. It also helps to maintain a healthy life and not lose weight. It boosts the immune system”
	M	Sustained refuser	QUOTE 8: “My mom went and brought me some medication that they sell for around three hundreds or four hundred rand at Clicks [a department store] - The ones that boost the immune system. I took them for about a week and I felt that they were not helping me. I told her that I don’t want medication…My father told me to keep on taking the medication…”
Protective Social support	M	True acceptor	QUOTE 9: Interviewer: “Who exactly have you told in your family?” Participant: “I told everyone, I first told my brother, and then my sister when I got home. I then called my Aunt. They said that I should accept [my HIV diagnosis] and take treatment” Interviewer: “Oh they told you that as long as you take treatment you will be okay?” Participant: “Yes, and there is nothing discriminating that they do since they know, like not allowing me to do certain things”
	M	True acceptor	QUOTE 10: “I come from a very supportive family, when you make mistakes they are supportive. And with other families, when [they learn you are HIV positive] they start to exclude you and tell neighbors, ‘Don’t see him like this. He has Z3 [slang reference for the three letters in the HIV acronym]- he has HIV.’ You get what I’m saying?”
	F	Sustained refuser	QUOTE 11: “I would like to meet some people who are in the same situation [living with HIV] - like support groups, stuff like that, so that I could get courage. And then I can see that I am not alone in that situation”
Protective Coping and resilience	F	Initial refuser	QUOTE 12: “In rural areas, we have fields where there is no one. I went there and I wrote a suicidal letter. It was addressed to my grandmother and my aunts. But then I thought of people who love me. I thought my teacher wouldn’t like this. She wouldn’t be proud of me, because she knows that I am a fighter. I am a hard- worker, and if I do this she will be disappointed. I just cried and cried and then I said, let me just pull myself together. I lost my mother. I got shot and I survived. So why am not going to survive this HIV thing?”
	F	True acceptor	QUOTE 13: “When I found out that I was HIV positive - you blame yourself…You feel like is your fault. Okay sometimes it is not your fault. Like myself I was married. My husband was gathering around with every girlfriend that he found. So I relied on myself saying, if I am faced with this, I am going to take whatever is coming at me. That is why today, I know how to stand up for myself. I am facing it…Whatever storm comes my way, I can take it”
Protective Positive messages from government or media	F	True acceptor	QUOTE 14: Interviewer: “What kind of information have you heard from our government about ARV’s?” Participant: “It’s that you have to start taking treatment with a CD4 of 350.” Interviewer: “Do you think that the media is also involved in terms of talking about ARV’s?” Participant: “Yes they are. I think that sometimes people need repetition. When you hear something over and over again, even if you don’t want to listen, you end up listening. It’s in your face and you can’t run away from it. Things like Soul City [a non-governmental organization that produces a television show focused on living with HIV in a poor community in South Africa] - everything is educating these days”
	M	True acceptor	QUOTE 15: “So I see that the HIV treatment is good, especially when I look at the statistics on TV. I can see that the babies are even protected, and I see that the rate is going down, and you can live a long time [on treatment]. Because there was this white guy who disclosed his status on TV, and said that he has been infected for 25 years. That’s when I became motivated and encouraged [to start ART]”
	M	Sustained refuser	QUOTE 16: “The media is always talking about antiretrovirals all the time. They tell us to take ARV’s so that we will live. Wherever you go, there are these people who are doing HIV testing on the streets, maybe on the radio and TV. They are always talking about antiretrovirals. I will not be influenced by the media. If I see something in my ear, hands, mouth or my genital area – it is only then that I will consider going to the clinic to initiate taking ARV’s, because by then I would be in a bad condition”
Role of healthcare providers			QUOTE 17: “The client was afraid to take treatment because [she believed] her sister was killed by treatment. I asked how the sister was killed by treatment and the client said that by the time the sister took treatment, she was very sick, and then she passed on. [The sister] had delayed, and refused. So it is because the sister passed away after starting ARV treatment [that the client now refused]. So I asked if the client found out if it is true that treatment can kill, and the client said the sister’s death was the evidence. So, I explained to the client about how the treatment works in a human body, and maybe the sister started it late… Since she was sick, helpless and had HIV symptoms, that is why she passed away. I advised the client to start treatment because of her low CD4 count” QUOTE 18: “There was a client who did not want to take treatment because of the bad attitude by the clinic staff. The client was not given any explanation before testing for HIV, and was told to start taking treatment because it is a matter of life and death, so there was no one to explain why the client has to take ARV’s. The clients were being shouted at for not using condoms. They were told that is why they got infected. So the clients would not take treatment because of the bad attitude they got”