Background: Sub-Saharan African health workers are looked up to as knowledgeable professionals and leaders. This assigned professional status may heighten feelings of shame, guilt or worthlessness stemming from the acceptance, or internalisation, of negative attitudes about HIV, making it harder for this group to reveal an HIV-positive status. We explore the prevalence of internalised, or ''self'', stigma amongst Zambian and South African health workers living with HIV (HW-LWH) and implications for accessing care.
Methods: Health facility (n=963), community health workers (n=281), and trial-specific community health workers (n=631) across 21 urban health facilities linked to a cluster randomised trial HTPN071 (PopART) completed a self-administered survey in 2015. Questions included self-reported HIV status, ART status, and reported internalised stigma for HW-LWH. Fifty HW-LWH were then interviewed about their experiences in 2016-17.
Results: Of all health workers, 87.8% self-reported their HIV status. Across the health worker cadres, reports of positive HIV status ranged from 15.3% to 28.5% in Zambia, and from 8.3% to 19.6% in South Africa. Compared to South Africa, all Zambian HW-LWH cadres reported higher internalised stigma, particularly health facility workers, with 25% agreeing with one of three internalised stigma items, and 10.5% reporting not taking ART.
In qualitative data, the term ''stigma'' was often aligned with ''self-stigma''. Health facility workers discussed fearing gossip, co-workers using their status against them, and client reactions. Community health workers (both types) were more open about living with HIV, drawing on their experiences to support clients. They were also more likely to access HIV clinic services at the local clinic. If health facility workers accessed ART at their workplace, they employed tactics to ''fast-track'' care and avoid identification. Experienced stigma, youth and pregnancy heightened internalised stigma. Interviews evoked poignant stories of HW-LWH dying rather than risking their professional reputation. Participant strategies to navigate internalised stigma included “acceptance” of status, avoiding identification, covert social support, and sometimes public testimony and challenging stigma.
Conclusions: Most health workers reported their HIV status. HW-LWH reported concerning levels of internalised stigma, particularly Zambian health facility workers. Interventions are required to support those at the heart of HIV service delivery.

 Health facility workers n %Zambia Community health workers n %CHiPs n %Health facility workers n %South Africa Community health workers n %CHiPs n %
Sample: Those who self-reported their HIV status Living with HIVn = 620 95 15.3n = 123 35 28.5n = 377 105 27.9n = 222 27 12.2n = 112 22 19.6n = 193 16 8.3
Sample: Those living with HIV Not currently taking ARV drugsn = 95 10 10.5n = 35 0 0.0n = 105 4 3.8n = 27 3 11.1n = 22 4 18.2n = 16 1 6.2
Sample: Those living with HIV who answered all three internalized stigma questions Agreed or strongly agreed with one of the three items reflecting internalised stigman = 88 22 25.0n = 35 7 20.0n = 102 19 18.6n = 26 3 11.5n = 20 2 10.0n = 15 2 13.3
[: Internalised stigma and ARV drug adherence among health care workers living with HIV in Zambia and South Africa]