The moral-behavioural logic of silence: gender, stigma, and disclosure among long-term HIV survivors

Silence, the deliberate non-disclosure of HIV status - remains an overlooked yet central aspect of long-term antiretroviral therapy (ART) survivorship. While disclosure is promoted as empowerment, such framings may neglect the gendered, relational, and institutional contexts in which non-disclosure occurs. We conducted in-depth interviews with 21 long-term ART users (10-22 years on treatment) in Tamil Nadu, India, and analysed narratives using stigma, social identity, emotion work, spiritual reframing, and institutional betrayal lenses. Silence emerged not as absence, but as a moral-behavioural strategy. Women's silence reflected care-based labour aimed at protecting children and preserve family integrity; while men often framed silence as endurance, restraint, or sacrifice. Participants sustained concealment through spiritual meaning-making and, over time, selectively withdrew from systems experienced as stigmatising or confidentiality-compromising. We identified four interlinked patterns - of emotional rupture, strategic non-disclosure, moral reframing, and institutional withdrawal - highlighting silence as an adaptive, gendered survival strategy. HIV care systems should depathologize silence and redesign counselling approaches to centre dignity, caregiving, and emotional safety.