Beyond knowledge deficits: social visibility, family dynamics, and delayed initiation among people living with HIV in Southwestern China—a descriptive phenomenological study

BACKGROUND: Despite global recommendations for early antiretroviral therapy (ART) initiation and the well-established benefits of timely treatment, delayed ART initiation remains a concern in some settings. Previous studies have identified multiple barriers to ART initiation, including limited treatment knowledge, stigma, disclosure concerns, side-effect fears, and service-related barriers. Less is known, however, about how these factors become organized in everyday life into a sustained process of delay after diagnosis. This study explored how people living with HIV in southwestern China experienced delayed ART initiation, with attention to social visibility, family relationships, informal information, and changing perceptions of treatment urgency. METHODS: A descriptive phenomenological design was used. Semi-structured, in-depth interviews were conducted with 23 people living with HIV who had delayed ART initiation and were recruited from two HIV-designated hospitals in Yunnan Province, China. Interviews were audio-recorded, transcribed, and analyzed using Colaizzi's seven-step method. The analysis was primarily inductive, while an HIV-related stigma framework informed the research question, interview domains, and later interpretation. RESULTS: Four themes were identified. First, delayed ART initiation often began when treatment entry was experienced as a risk of being recognized, leading to concealment, stigma-related shame, and avoidance. Second, delay was sustained through family negotiation, informal information, symptom-free periods, concerns about side effects, and the normalization of waiting. Third, treatment initiation became more likely when family or significant-other support, continued healthcare-provider contact, symptoms, or complications changed participants' perceptions of risk. Fourth, cross-theme patterns showed that delayed ART initiation was experienced as unfolding from concealment and waiting toward treatment entry when support, symptoms, or changing perceptions of risk made continued delay less acceptable. The local context functioned primarily as a contextual condition shaping social visibility, mobility-related experience, informal information, and treatment urgency, rather than as a standalone mechanism. CONCLUSIONS: Delayed ART initiation in this study was not solely attributable to insufficient knowledge or poor treatment awareness. Participants described delay as an experience shaped by social visibility concerns, stigma-related shame, family negotiation, informal information, symptom experiences, and changing perceptions of risk. Efforts to promote timely ART initiation may need to address not only treatment knowledge, but also confidentiality concerns, stigma-sensitive support, family context, and the social conditions in which treatment decisions are made.