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They make you feel the guilt … you feel that whatever you are getting is deserved. The negative health consequences, particularly health-seeking behaviours, related to internalised stigma were apparent in some of the narratives. Female SW respondents described situations in which nurses adopted a scolding tone, which caused feelings of embarrassment and shame, resulting in a reluctance to return to the clinic for treatment. Perceived and experienced stigma and discrimination within healthcare settings by Key Populations, particularly around sexual identity and sexual behaviour, led to internalised stigma which manifested in delayed care-seeking, travel to distant clinics and missed opportunities to receive appropriate services.

One female SW respondent explained that she defaulted on her antiretroviral treatment because of the judgemental attitude of healthcare workers, which made her scared of going to the clinic. This thing also makes me feel bad because I know that it is my life … They nurses just scold at you that you have come to irritate them. Key Population and healthcare worker respondents in both provinces described a context of discrimination at the interpersonal level. This interpersonal level discrimination in their communities was characterised by homoprejudice, discrimination and social exclusion experienced by Key Populations.

The following quote from a healthcare worker in the North West alludes to the denial of the existence of homosexuality in the community, and the belief that homosexuality is a mental illness that should be prevented.

This thing of same-gender sex usually appears in psychotic patients, patients who are … ill. Another healthcare worker from the North West described how discrimination towards gay and lesbian people extends beyond healthcare facilities, and is evident in the broader community and religious institutions. In Free State, one healthcare worker attributed the discrimination towards MSM and gay men to the ignorance of community members. People treat them in a different way like they are not human beings. If they get some sickness they say that they brought it on themselves which is not true.

A number of gay-identified MSM FGD respondents in Free State reported experiencing significant discrimination and rejection as a result of their sexual identity. We are actually choosing this type of life, this type of sexuality for ourselves … in my community I have experienced a lot of problems … I have to actually go out of my community to feel accepted. All the Key Population respondents reported having experienced verbal abuse and being called derogatory names in the general community, and by healthcare workers specifically.

Some of the gay-identified MSM respondents shared their experiences of homophobia and homoprejudice in their communities, manifested in actions such as being verbally abused, shunned and isolated.

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MSM described being called isitabane and moffie , offensive slang terms for homosexuals. The context of discrimination in the community was similar for PWUD, who were described by healthcare workers as being subject to stereotyping and assumptions of criminal and violent behaviour. People who use drugs also reported being called derogatory and offensive names and experienced a lack of trust from their families and friends because of their being perceived as untrustworthy and unreliable.

Respondents from the PWUD focus groups described instances in which they had been labelled as being mentally unstable.

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Children can run away because their parents tell them that this chap is mad. Various Key Population respondents described the way in which nurses, often middle-aged women, adopt moralising judgemental tones when providing services to them. The narratives from healthcare workers themselves suggested that their moralising, judgemental and homoprejudicial attitudes are a result of religious conviction:.

Several of the healthcare workers cited their religious beliefs and Christian values in explanation of their own judgemental attitudes and lack of acceptance of behaviours such as sex work and same-sex partnerships. Even if my religious belief does not allow me.

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Several of the Key Population respondents narrated their personal experiences of violence, harassment and physical and sexual assault. Female SW respondents described their sense of powerlessness and their lack of recourse to bring incidents of discrimination or violence to the authorities because of the criminalisation of sex work; they explained that their lack of access to police protection enhances their vulnerability to violence.

In addition to the fear of violence, respondents described their reluctance to disclose themselves as SW, MSM or PWUD to healthcare workers, or disclose their risk behaviours. Many of the Key Population respondents described their personal experiences of having their confidentiality breached by nurses in government clinics:.

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When you walk in they stare … the nurses will call their friends and tell them that you have an STI and they should come look. They tell you to undress.

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It will reach a point were you are scared of going to the clinic … they nurses call each other every time and about five of them would come. They would say come see, what is this thing? One SW respondent explained that as a consequence of the lack of confidentiality at the clinics, she chose to seek assistance instead from traditional herbalist healers to treat her STI symptoms. I can hear that this person is talking about me.

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There was no chance that I would go to the clinic because the Sisters talk about us … We are scared. We are terribly scared of nurses. Notably, some Key Population respondents commented that healthcare workers are not homogeneous, and some provide services without discrimination or judgement:. The sentiment that not all healthcare workers are unfriendly was echoed by some of the MSM respondents who explained that they had good relationships with healthcare workers and were open about being gay:. Even when I am sick I go there and the service is okay unless they wait for me to leave and speak behind my back.

People do that but I have not had such an experience. In addition to healthcare workers displaying judgemental attitudes, many of the Key Population respondents shared the view that healthcare workers in government facilities are not equipped with the knowledge and skills to provide them with appropriate services:. So she was busy writing and asking questions and stuff, then came the part where I had to take my clothes off. Did you have sex with your … anus? Structural barriers to accessing HIV-related commodities were also described by the Key Population respondents, such as the lack of access to clean injecting equipment for people who inject drugs.

One PWUD explained that the only way for them to get clean needles is to steal them from the health facility:.

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Some healthcare workers expressed the opinion that providing an injecting drug user with clean needles would serve to encourage and condone the behaviour, and thus they were not prepared to do so:. The physical environment of health facilities was also described as uninviting and non-inclusive of Key Populations, for example, the lack of informative and educational materials relating to Key Populations or their risk behaviours.

As a result of the judgemental and discriminatory attitudes of public sector healthcare workers, and the non-conducive clinic environments, Key Population respondents expressed a preference for health services delivered through community and outreach-based programmes, or by the private sector. These findings highlight the individual, interpersonal and structural barriers impeding access to healthcare for SWs, MSM and PWUD, and the delivery of health services in these two South African cities.

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