“As an older person my thoughts do not focus on one thing”: a qualitative exploration of the experiences of intersectional stigma and living with HIV among older people in Cape Town, South Africa

In South Africa, HIV prevalence among people over 50 exceeds 18.5%, yet research and interventions for older people living with HIV (OPLWH) remain limited. Evidence links HIV stigma to poor health outcomes, but little is known about OPLWH's experiences in resource-limited settings. This study explores how OPLWH understand and experience intersecting stigmas, and how these shape engagement in care. Using a qualitative exploratory design, we conducted semi-structured in-depth interviews, body mapping and social network analyses with 30 OPLWH from three clinics. Data were transcribed, translated and thematically analysed using a stigma framework. While structural stigma was limited, participants described intersecting stigmas related to age, gender and sexuality. Historically enacted stigma, linked to the pre-ART era, had declined as HIV became normalised. However, community and anticipated stigma continued to influence disclosure and coping strategies, often leading to concealment. Internalised stigma initially hindered care engagement and caused isolation, but support and time fostered resilience. Financial insecurity, co-morbidities and family roles amplified stigma's effects, yet participants developed coping strategies that strengthened psychological resilience. Despite stigma, OPLWH demonstrated strategies to ensure mitigation and agency and self-efficacy, highlighting the need for multi-level interventions addressing stigma within broader social and economic contexts.