"They Call Us Amaphara (Junkies)": Intersectional Tuberculosis, Alcohol, and Drug Stigma in South Africa.

Stigma acts as a barrier to the diagnosis and effective treatment of tuberculosis (TB). Individuals with TB who also use alcohol or drugs (AODs), including methamphetamine, may experience intersectional stigma. Further, the nature and intensity of these intersecting stigmas may be compounded by co-morbidities like HIV and marginalized social status. Despite this, AOD use stigma has rarely been studied in the context of TB and other co-occurring conditions. We examined the perceptions and experiences of AOD use-related stigma among individuals who were previously diagnosed with TB or were at increased risk of TB based on their close contacts, in a rural community in the Western Cape, South Africa. We analyzed qualitative data collected by two studies (study 1: five focus groups (n=34), study 2: ten focus groups (n=84)). Findings highlighted that study participants who use AODs experienced intersectional stigma from multiple sources. AOD use- and TB-related stigma were experienced from friends, family, healthcare providers, and the broader community, particularly for those who used illicit drugs. Participants discussed stigma's effects on their health and well-being. The negative effects of AOD use stigma were particularly salient among female participants. Findings indicate that intersecting stigmas exist at multiple levels for people who use AODs with/at risk of TB, and that these stigmas hinder healthcare utilization in this rural setting. Future interventions to improve TB service uptake need to address intersectional AOD use and TB stigma.