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.
Chakrapani et al. (Mon,) studied this question.