To address the challenges of demographic aging, governments and organizations encourage extended working lives. This study investigates how individual health- and age-related workplace factors contribute to preferred, expected and actual retirement timing, as well as to the congruency between preferences vs. expectations, and preferences vs. actual retirement. We used data from a representative Swedish longitudinal sample comprising 4058 workers aged 50–64, with follow-up data regarding actual retirement timing available for 1164 respondents. Multinomial logistic regression analyses suggest that later preferred, expected, and actual retirement timing were, to different extent, influenced by better health, an age-friendly workplace and feeling positive regarding the future at work. Emotional exhaustion, age-related inequalities at work and experiencing aging as an obstacle increased the likelihood of preferring to retire earlier than one expected to, over retiring at the time one expected to. Those with better health and positive work prospects were less likely to prefer retiring earlier than they expected to, and more likely to being “pulled toward working until 65 and beyond”, compared to being “pulled toward early retirement”. Experiencing aging as an obstacle decreased the chances of being “pulled toward working until 65 and beyond”. The results provide insights on how to facilitate extended working lives. Many countries are facing the issue of an aged society . While iUnderstanding the factors that hinder or stimulate longer working lives is therefore relevant for developing effective policies and interventions to increase the employability of older workers and encourage later retirement ,5. A weaWang and Shultz  clustereAddressing these voids, the present study investigates the relative contribution of health , psychological age climate at the workplace , and perceived future at work  to retirement decision making, in a large representative longitudinal sample of older workers in Sweden. We focused specifically on (1) preferred retirement timing, (2) expected retirement timing, (3) actual retirement timing, (4) the congruency between preferred and expected retirement timing, and (5) the congruency between preferred and actual retirement timing. We develop hypotheses that are theoretically and empirically grounded for investigating aims 1–4. However, regarding aim 5, research questions are framed instead, given the lack of earlier evidence.Sweden is an interesting context to study retirement decision making, considering the significant influence workers have in deciding their retirement timing, at least at a formal level . In SwedThere exists no single, distinct, and universal definition of retirement status  and therRetirement has been described as a decision-making process occurring over a period of time, starting with the preference to retire (thinking about retirement), continuing to the decision to retire (intention), and ending with actual retirement ,21. One Conceptualizing retirement as a decision-making process assumes that retirement decisions reflect a motivated choice . HoweverThe difference between preferred and expected retirement timing creates a motivational (mis)match reflected in three conditions: (1) “potential early retirees”, representing workers who prefer to retire before the expected age; (2) workers who prefer to retire when they expect to do so, and (3) “workers disposed to late retirement”, denoting those who prefer to retire later than they realistically expect to . With inFurthermore, few studies have longitudinally investigated the congruency between preferred retirement timing at one point in time and subsequent actual retirement. Steiber and Kohli’s  study isInstead of examining the discrepancy between preferred and actual retirement timing quantitatively , we adopted an alternative approach and investigated different combinations of preferences and actual retirement, based on the relative point of retirement timing  for preferred and actual retirement. By doing so, we focused on the quality of the congruency, rather than only on its direction  and magnitude. Using this categorization, we were able to investigate four categories of (in)congruencies between preferred and actual retirement timing: (1) those who were “pulled toward early retirement” ; (2) those who were “pushed to continue working” ; (3) those who were “pushed out of work” , and; (4) those who were “pulled toward working until 65 and beyond” .This study focuses on the contribution of health , psychological age climate at the workplace , and perceived future at work  to the retirement decision-making process.Health is a core individual resource which affects individuals’ work ability and the likelihood of a longer working life . The rolPoor health has consistently been associated with early retirement ,10, whilc = 0.20).Poor psychological health also contributes to labor market withdrawal, and its impact may be even more pervasive than poor physical health . HoweverIn Warr’s  perspectConsidering this background, we derive the following hypotheses (H) and research questions (RQ):H1: Better self-rated health increases the likelihood of later (a) preferred, (b) expected, and (c) actual retirement timing, while it (d) decreases the likelihood of preferring to retire earlier than one expects to.RQ1: How does self-rated health relate to different types of (in)congruencies between preferred and actual retirement timing?H2: Emotional exhaustion decreases the likelihood of later (a) preferred, (b) expected, and (c) actual retirement timing, while it (d) increases the likelihood of preferring to retire earlier than one expects to.RQ2: How does emotional exhaustion relate to different types of (in)congruencies between preferred and actual retirement timing?According to the model of successful aging , optimalRegarding the first aspect, perceived age-related inequalities or discrimination at work is a recognized push factor out of work, e.g., , as earlThe valorization of older workers’ experience at the workplace comprises the second psychological age climate aspect considered in this study. An age-friendly workplace is one where older workers are regarded as a valued resource and are respected within the organization , and orgH3: Perceived age-related inequalities at the workplace decreases the likelihood of later (a) preferred, (b) expected, and (c) actual retirement timing, while it (d) increases the likelihood of preferring to retire earlier than one expects to.RQ3: How do perceived age-related inequalities at the workplace relate to different types of (in)congruencies between preferred and actual retirement timing?H4: Perceived valorization of older workers’ experience at the workplace increases the likelihood of later (a) preferred, (b) expected, and (c) actual retirement timing, while it (d) decreases the likelihood of preferring to retire earlier than one expects to.RQ4: How does the perceived valorization of older workers’ experience at the workplace relate to different types of (in)congruencies between preferred and actual retirement timing?Older workers’ opportunities at work are an absolute condition for a longer working life  and the Concerning the first, older workers who experience ageist attitudes in the workplace may develop age-related anxiety, internalize negative age-related stereotypes , such asSecond, accompanying the profound changes in labor-market structures and pensions systems, particularly in the last two decades, the traditional unidirectional and linear career paths have gradually changed to more diverse and dynamic patterns  and two Third, while active aging policies for extending working lives rely on the assumption that the decision to remain in the organization is at disposal of the older workers, this is not always the case . OrganizAgainst this background, we derive the following hypotheses and research questions:H5: Experiencing aging as a future obstacle at work decreases the likelihood of later (a) preferred, (b) expected, and (c) actual retirement timing, while it (d) increases the likelihood of preferring to retire earlier than one expects to.RQ5: How do the experiences of aging as a future obstacle at work relate to different types of (in)congruencies between preferred and actual retirement timing?H6: Feeling positive regarding one’s future work prospects increases the likelihood of later (a) preferred, (b) expected, and (c) actual retirement timing, while it (d) decreases the likelihood of preferring to retire earlier than one expects to.RQ6: How do positive future work prospects relate to different types of (in)congruencies between preferred and actual retirement timing?H7: Perceived opportunities to work in the organization after retirement age increases the likelihood of later (a) preferred, (b) expected, and (c) actual retirement timing, while it (d) decreases the likelihood of preferring to retire earlier than one expects to.RQ7: How do perceived opportunities to work after retirement age relate to different types of (in)congruencies between preferred and actual retirement timing?The study sample was drawn from the Swedish Longitudinal Occupational Survey of Health (SLOSH), a longitudinal cohort survey originally representative of the Swedish working population, which focus on associations between work organization, work environment and health . All parThis study is based on data from 4548 respondents to the questionnaire for those in paid work (including self-employment) in 2010 (T1), aged 50–64 years. After excluding 490 participants with missing data on relevant variables, the valid sample at T1 comprised 4058 individuals with a mean age of 57 years (SD = 4). Of these, 35 percent were married/cohabiting women, 21 percent were single/not cohabiting women, 29 percent were married/cohabiting men, and 15 percent were single/not cohabiting men. The majority (63%) were white-collar workers.In 2016 (T2), 988 respondents (24%) had dropped out from the study. A total of 1895 (47%) answered to the questionnaire for those in paid work (of which 167 were aged 66 years or older) and 1175 (29%) answered to the questionnaire for those non-working . Among the 1027 participants who reported being retired in 2016, 30 respondents did not indicate the year at which they left paid work and were therefore excluded from the T2 sample because their actual retirement timing could not be determined. Among the remaining 997 participants, 443 (44%) had retired at age 64 or earlier, 338 (34%) at the age of 65, and 216 (22%) at age 66 or later. The 167 participants who were working in 2016 and aged 66 years or older were included in the latter group (as they would necessarily retire at age 66 or later), such that this group comprised a total of 383 respondents. Altogether, the sample at T2 comprised 1164 respondents.n = 3070) with those who responded at T1 but not at T2 (n = 988). Results from these analyses showed that compared to those who participated in both waves, dropouts included slightly younger employees (0.46 years)  and more individuals in the lowest income level , more individuals in blue-collar occupations , and more single women and men . Further, dropouts reported slightly poorer self-rated health (mean difference = 0.13) .Dropout analyses compared respondents participating in both waves (Single items were used to measure preferred retirement timing [“At what age do you want to retire (as things look today)?”] and expected retirement timing [“At what age do you expect to retire (as things look today)?”], both assessed at T1. The responses were given as full years, which were later coded into three categories  for analytic purposes. This categorization has been used in other studies on retirement preferences, e.g., .The congruency between preferred and expected retirement timing was computed by subtracting the expected retirement age from preferred retirement age at T1. The resulting values  were recoded into 3 categories .Actual retirement timing was collected at T2. For participants who responded to the questionnaire for those not working, reported were receiving a retirement pension, and indicated the year they left paid work, actual retirement timing was computed subtracting the year of birth from the year they reported to have left paid work. The resulting variable was coded in three categories:  (the latter including those still in paid work who were aged 66 or older).The variable congruency between preferred and actual retirement timing was based on the combination of the variables preferred retirement timing at T1 and actual retirement timing collected at T2. We first isolated the category “at age 64 or earlier” and merged the categories “at age 65” and “at age 66 or later” for each variable. The four resulting combinations of preferred vs. actual retirement timing were then: 1 = pulled toward early retirement , 2 = pushed to continue working , 3 = pushed out of work (those who preferred to retire at age 65 or later but retired at age 64 or earlier); 4 = pulled toward working until 65 and beyond .All independent variables were measured at T1.Self-rated health was assessed with a single item  scored on a 5-point rating scale, ranging from (1) “very good” to (5) “very poor”. The response scale was reversed such that a high value reflects better subjective health. Emotional exhaustion was measured with the 5-item exhaustion subscale of the Maslach Burnout Inventory-General Survey . All iteSingle items were used to measure age-related inequalities at the workplace  and valorization of older workers’ experience at the workplace (“Are elderly workers’ experience appreciated at your workplace?”). These single items are part of the Nordic Questionnaire for Monitoring the Age Diverse Workforce (QPSNordic-ADW)  and wereSingle items were also used to measure aging as a future obstacle at work (“Do you believe that the fact that you are getting older will cause you some problems at your work in the future?”) and positive work prospects (“Do you feel positive about how your work will develop in the future?), which were drawn from the Nordic Questionnaire for Monitoring the Age Diverse Workforce QPSNordic-ADW  and scorAll covariates were assessed at T1. SLOSH contains information obtained from register data about age (based on year of birth), gender , marital status , income , and occupational status . These variables have been found to relate to retirement preferences and behavior, e.g., 8,000 SEK,71, an iMultivariate multinomial logistic regression analyses were calculated using SPSS version 26 to investigate the associations of the independent variables and the covariates with the outcome variables. The odds ratios were estimated for each independent variable, fully adjusted for the other variables, relative to a reference category: “at age 64 or earlier” in predicting preferred, expected and actual retirement timing, “preferred to retire at the time one expected to” in predicting the congruency between preferred and expected retirement timing, and “pulled toward early retirement” in the prediction of the congruency between preferred and actual retirement timing. Collinearity diagnostics indicated that multicollinearity was not a concern.Descriptive statistics (not reported in any table) showed that most participants (57%) preferred to retire at age 64 or earlier, while 36 percent preferred to retire at age 65, and only 7 percent reported a preference to retire at age 66 or later. As concerns expected retirement timing, most participants (58%) expected to retire at age 65, 28 percent expected to retire at age 64 or earlier and 14 percent expected to retire at age 66 or later. Looking at the actual retirement timing, 38 percent of participants included in the T2 sample had retired at age 64 or earlier, 29 percent at age 65, and 33 percent retired at age 66 or later. In relation to the congruency between preferred and expected retirement timing, while most respondents preferred to retire at the time they expected to (53%), the proportion of “potential early retirees” (those participants who preferred to retire earlier than they expected to) was considerably large (44%), and only 3 percent expressed the preference for retiring later than they expected to. Finally, with regard to the congruency between preferred and actual retirement timing, 31 percent of participants in the T2 sample were “pulled toward early retirement”, 18 percent were “pushed to continue working” 8 percent were “pushed out of work”, and 44 percent were “pulled toward working until 65 and beyond”.The results of the multivariate multinomial logistic regression analyses are presented in In line with H1a, better self-rated health increased the likelihood of preferring to retire at age 66 or later relative to preferring to retire at age 64 or earlier. Self-rated health was, however, not significantly related to the odds of preferring to retire at age 65 over preferring to retire at 64 or earlier. The findings did not support H1b, as self-rated health was not significantly related to the odds of expecting to retire at later ages over expecting to retire at age 64 or earlier. Regarding actual retirement, H1c was partially supported, as those with better self-rated health were more likely to actually retiring at age 66 or later, but not at age 65, compared to retiring at age 64 or earlier. Better self-rated health was moreover related to a lower likelihood of preferring to retire earlier than one expected to, compared to preferring to retire at the time one expected to, which is in line with H1d. With regard to the congruency between preferred and actual retirement timing (RQ1), those with better health were more likely to being “pulled toward working until 65 and beyond” compared to being “pulled toward early retirement”.Emotional exhaustion, on the other hand, decreased the likelihood of preferring to retire at age 65 and at age 66 or later compared to preferring to retire at age 64 or earlier, which is in line with H2a. Contrary to H2b, however, those with higher levels of emotional exhaustion were more likely to expect to retire at age 66 or later compared to expecting to retire at age 64 or earlier. Emotional exhaustion did not predict the likelihood of actual late retirement over early retirement, as assumed in H2c. Consistent with H2d, emotional exhaustion increased the likelihood of preferring to retire earlier than one expected to, relative to preferring to retire at the time one expected to. Regarding RQ2, higher levels of emotional exhaustion were associated with a higher probability of being “pushed to continue working” relative to being “pulled toward early retirement”.Perceiving age-related inequalities at the workplace did not predict later preferred, expected, and actual retirement over early retirement, and therefore H3a-c were not supported by the findings. As predicted by H3d, this variable was associated with a higher likelihood of preferring to retire earlier than one expected to over preferring to retire at the time one expected to. Furthermore, with regard to RQ3, age inequalities at work did not explain the probability of falling in any of the categories of (in)congruencies between preferred and actual retirement timing relative to being “pulled toward early retirement”. The results did not support H4a-d, as the perception that older workers’ experience was valued at the workplace did not predict later preferred, expected, and actual retirement, neither the likelihood of preferring to retire earlier than one expected to over preferring to retire at the time one expected to. Concerning RQ4, this variable was not relevant in predicting the congruency between preferred and actual retirement timing.Experiencing aging as a future obstacle at work decreased the likelihood of preferring to retire at age 65 relative to preferring to retire at age 64 or earlier, in line with H5a. This variable, however, did not predict expected or actual retirement timing, and therefore H5b-c were not supported. Moreover, experiencing aging as a future obstacle at work was associated with a higher risk of preferring to retire earlier than one expected to compared to preferring to retire at the time one expected to, in line with H5d, but also with the preference to retire later than one expected to. With respect to the congruency between preferred and actual retirement timing (RQ5), experiencing aging as a future obstacle at work decreased the odds of being “pulled toward working until 65 and beyond”, relative to being “pulled toward early retirement”.In line with H6a-c, feeling positive regarding one’s work prospects increased the likelihood of preferring to, expecting to, and actually retiring at age 65 and at age 66 or later, relative, respectively, to preferring to, expecting to, and actually retiring at age 64 or earlier. Furthermore, consistent with H6d, positive work prospects decreased the risk of preferring to retire earlier than one expected to over preferring to retire at the time one expected to. With respect to the congruency between preferred and actual retirement timing (RQ6), feeling positive regarding one’s future work prospects was associated with a higher likelihood of being pulled toward working until 65 and beyond compared to being pulled toward early retirement.Finally, having the opportunity to work in the organization after retirement age was associated with a higher likelihood of preferring to, and expecting to retire at age 65 and at age 66 or later, compared to retiring at age 64 or earlier. These findings give support to H7a-b. However, opportunities to work after retirement did not predict later actual retirement relative to earlier retirement, neither the probability of preferring to retire earlier than one expected to, compared to preferring to retire at the time one expected to, and therefore H7c-d were not supported. With regard to RQ7, having the opportunity to work in the organization after retirement age was not associated with the probability of falling into any of the categories of (in)congruencies between preferred and actual retirement.Among the control variables, age increased the likelihood of preferring to, and actually retiring, at age 65 and at age 66 or later, compared to preferring to, and actually retiring at age 64 or earlier, respectively. Furthermore, higher age was related to a lower risk of preferring to retire earlier than one expected to, over preferring to retire at the time one expected to. Finally, age increased the odds of being “pushed to continue working”, “pushed out of work” and being “pulled toward working until 65 and beyond” compared to being “pulled toward early retirement”.Being a married/co-habiting woman (in comparison to be a married/co-habiting man) decreased the likelihood of preferring to, expecting to, and actually retiring at age 66 or later relative, respectively, to preferring to, expecting to, and actually retiring at age 64 or earlier. Furthermore, this group had a lower probability of being “pushed to continue working” and “pulled toward working until 65 and beyond”, over being “pulled toward early retirement”. In contrast, single woman (in comparison to married/co-habiting man) had a higher likelihood of preferring to retire at age 65 over preferring to retire at age 64 or earlier, as well as expecting to retire at age 65 and at age 66 or later relative to expecting to retire at age 64 or earlier.Regarding income, participants in the low and medium income levels (in comparison to those in the highest income level) were more likely to expect to retire at age 65 relative to expecting to retire at age 64 or earlier. People in medium income levels had moreover a higher probability of actually retiring at age 65 relative to retiring at age 64 or earlier, and of preferring to retire earlier than they expected to, over preferring to retire at the time they expected to. With respect to the associations between income and the congruency between preferred and actual retirement timing, those in the low and medium income levels (relative to those in the highest income level) were more likely to be “pushed to continue working” over being “pulled toward early retirement”, and those in the medium-income level had also a higher likelihood of being “pulled toward working until 65 and beyond”.Blue-collar workers, relative to white-collar workers, had a lower likelihood of preferring to and actually retiring at age 66 or later, compared, respectively, to preferring to, and actually retiring at age 64 or earlier.Demographic population changes and an aging workforce demand for longer working lives, and policy-makers and organizations may benefit from a better understanding of factors encouraging older workers to remain in employment. This study examined the relative importance of health , psychological age climate in the workplace , and perceived future at work  for older workers’ preferred, expected and actual retirement timing, as well as for the congruency between preferred vs. expected retirement timing and preferred vs. actual retirement timing, in a large representative longitudinal sample of older workers in Sweden.Participants showed a clear preference for early retirement, which is not in line with the current policy reforms toward increasing retirement ages. Moreover, most participants expected to retire at the age of 65, suggesting that expectations regarding retirement timing were largely framed by a “default” retirement age (65) that still seems to be regarded as the norm (at least in Sweden). A relatively high share of participants had a preference for retiring earlier than they expected to and, while the majority who had retired between waves did so around the preferred timing, a considerable proportion of participants actually retired later than they would have preferred, i.e., were pushed to continue working. Working longer than preferred may have negative consequences for health and well-being . It may The factors investigated in this study contributed differently to preferred, expected and actual retirement timing, in line with earlier research, e.g., ,11,24, aWe examined the contribution of self-rated health (H1a–d) and emotional exhaustion (H2a–d) in predicting (a) preferred, (b) expected, and (c) actual retirement timing, as well as (d) the congruency between preferred and expected retirement timing. Furthermore, two research questions (RQ1 and RQ2) were framed to investigate the role of self-rated health and emotional exhaustion, respectively, in explaining the congruency between preferred and actual retirement timing.Those with better self-rated health were more likely to prefer late retirement, over preferring to retire earlier, as expected in H1a. This finding may be discussed in the light of the COR theory , as thosHowever, contrary to the prediction in H1b, self-rated health did not predict late expected retirement timing, as also was the case in Beehr et al.’s  study. PWith regard to emotional exhaustion, our findings support the assumption that feelings of exhaustion increase the desire to leave the workforce. In fact, and in line with earlier research  and withIt may be that there is a reciprocal relationship between emotional exhaustion and feelings of being forced to continue working longer than preferred, which may in part be explained by perceiving a lack of opportunities to retire at the preferred timing, one of these being insufficient income. Our findings show that participants in the low and medium income levels, compared to those in the highest income level, had an increased risk of being “pushed to continue working” relative to be “pulled toward early retirement”. Earlier research  has showThis study investigated the role of two aspects of psychological age climate in the workplace—perceived age-related inequalities (H3a–d) and perceived valorization of older workers’ experience (H4a–d)—in predicting (a) preferred, (b) expected, and (c) actual retirement timing, along with (d) the congruency between preferred and expected retirement timing. Additionally, two research questions (RQ3 and RQ4) were formulated regarding the contributions of, respectively, perceived age-related inequalities and valorization of older workers’ experience to the congruency between preferred and actual retirement timing.Perceiving inequalities between younger and older workers—a proxy of age discrimination—was not a significant predictor of preferred, expected and actual late retirement timing, and, therefore, H3a–c were not supported. Some studies have also found a lack of associations between age discrimination and intended retirement timing  and actuSurprisingly, the perception that older workers’ experience was valued at the workplace was not associated with any of the outcomes, and therefore H4a-d were not supported. It may be that the referent used in the item—‘older workers’ in general instead of the respondent (him/her)self—made it less relevant to differentiate participants based on their preferred, expected and actual retirement timing. Armstrong-Stassen and Schlosser , for insWe investigated how experiencing aging as a future obstacle at work (H5a–d), feeling positive regarding one’s future work prospects (H6a–d), and perceiving opportunities for continuing working after retirement age (H7a–d) related to older workers’ (a) preferred, (b) expected, and (c) actual retirement timing, as well as (d) the congruency between preferred and expected retirement timing. Moreover, we examined how these factors contributed to the congruency between preferred and actual retirement timing .The experience of aging as a future obstacle at work decreased the odds of preferring to retire at 65 over preferring to retire at 64 or earlier, which is in line with H5a. This hypothesis was however only partially supported, as experiencing aging as an obstacle was not significantly associated with the likelihood of preferring to retire at 66 or later relative to preferring to retire at age 64 or earlier. Moreover, this variable did not predict expected neither actual retirement at 65, or at 66 or later, over earlier retirement, and therefore H5b-c were not supported. With respect to the congruency between preferred and expected retirement timing, experiencing aging as a future obstacle at work increased the likelihood of both preferring to retire earlier than one expected to and preferring to retire later than one expected to, over preferring to retire at the time one expected to. For some people, perceiving that aging will be an obstacle at work may increase the willingness to retire early, for instance because of internalized negative age-related stereotypes or perceiving/anticipating an age-related decline that was not sufficiently disabling though so that they realistically expected to retire that early. For other individuals, however, aging may be perceived as an unsurpassable obstacle in the future  due to, for example, health-related problems or impairments in work-ability hindering individuals’ potential for working in later ages and that they expect will eventually push them out of work earlier than they would prefer. Concerning the congruency between preferred and actual retirement timing, our longitudinal findings show in turn that experiences of aging as a future obstacle at work decreased the likelihood of being “pulled toward working until 65 and beyond” in comparison to being “pulled toward early retirement”.Feeling positive regarding one’s future work prospects was the only factor associated with all outcomes in this study, and seems an important contributor to a longer participation in the workforce. In line with previous literature ,64 and HPerceiving that the organization offered opportunities to work after retirement age was positively associated with the likelihood of preferring to, and expecting to retire at age 65 and at age 66 or later (over preferring and expecting to retire at 64 or earlier), in line with H7a–b. These findings suggest that the organizational openness to work after retirement may signal older employees that they are a valuable asset to the organization , encouraThis study has a number of methodological issues that should be considered. The first concerns the cross-sectional nature of the data used in the analyses to predict preferred and expected retirement timing and the congruency between preferred and expected retirement timing, as no causal inference between the independent and dependent variables can be drawn . HoweverSecond, issues regarding the generalizability of the findings should also be acknowledged. This study was conducted in Sweden, a European country with a relatively generous welfare system, where, at least at a formal level, people have a considerable decision latitude with regard to their retirement timing . SteiberThe third methodological issue concerns the exclusive use of self-report data, which may result in a source of uncontrolled measurement error due to common method variance . HoweverFourth, the use of single item measures may be considered a shortcoming of this study, which made use of SLOSH data that was not collected for the purposes of the present study. SLOSH has however the strength of being a large nationally representative cohort of people who are followed over time regardless of employment status at follow-up . MoreoveA fifth methodological question concerns potential sources of bias resulting from sample selection issues. Retirement age is not known for those who dropped out from the study between waves, and data on actual retirement timing used in the longitudinal analyses was not available for those participants who were either too young to have had the possibility to retire at T2, or had reached the possibility to retire but had not yet retired. In the latter case, we could only estimate actual retirement timing for those who were aged 66 and older, whereas for all others the retirement timing remained unknown. Furthermore, those participants with better health may be overrepresented in SLOSH, both at T1 and over time , which To respond to the challenges posed by population and workforce aging, governments worldwide have increased the statutory retirement age and established benefit increments for later retirement ,3. NeverThis study focused on how health- and age-related workplace factors associate with preferred, expected and actual retirement, as well as with the congruency between preferred vs. expected retirement timing and preferred vs. actual retirement timing in a large representative longitudinal sample of older workers in Sweden. The findings show a clear preference for early retirement, which is not in line with the extended working lives political agenda, and reinforce the importance of understanding factors associated with later retirement, that may inform the design of policies and practices that go beyond economic incentives to postpone retirement. Overall, better health, an age-friendly work environment and, principally, feeling positive regarding the future at work, contributed, although in different extents, to preferring, expecting and actually retiring at later ages.An important contribution of this study concerns the congruency between preferred and expected retirement timing, specifically, finding that a great share of participants preferred to retire earlier than they expected to. These individuals, at a particular moment, may feel that they are at risk of “job lock”, that is, of remaining involuntarily at the workforce, because they expect that they will not be able to retire as early as they wished, what may have negative consequences for both the individual and the organization over time. A better understanding of factors that contribute to older workers preferring to retire earlier than they expect to be able to, and which factors may decrease such a preference, may provide inputs for the design of interventions targeted at promoting well-being and positive work attitudes among older workers. The present study found that higher levels of emotional exhaustion, perceiving age-related inequalities at the workplace and experiencing aging as a future obstacle at work, contributed to a higher likelihood of preferring to retire earlier than one expected to, over preferring to retire at the time one expected to, while better self-rated health and feeling positive regarding one’s work prospects decreased the odds of preferring to retire earlier than one expected to.Few studies have longitudinally investigated the correspondence between preferred and actual retirement timing and this is another relevant contribution of this study. Better self-rated health and positive work prospects increased the likelihood of being “pulled toward working until 65 and beyond” over being “pulled toward early retirement”, while experiencing aging as a future obstacle at work decreased the likelihood of preferring to and actually working until 65 and beyond. Those reporting higher levels of emotional exhaustion, in turn, were more likely to remain involuntarily in work, that is, to be pushed to continue working relative to being pulled toward early retirement. The study findings provide insights for policy-makers and organizations wishing to encourage their older employees to extend their working life.


One of the earliest examples of the exploitation of groundwater to sustain human civilization is the aqueduct system of ancient Rome. Although some of the aqueducts were fed by surface water, most of them were supplied by springs, usually augmented by tunneling to increase the flow of groundwater.Natural History, Pliny the Elder (23 to 79 AD) touted the aqueducts of Rome as a “marvel” that was “unsurpassed”  ranked the aqueducts as one of “the three most magnificent works in Rome,” the other two being paved roads and sewers. The aqueducts were a testament to the “greatness of the Roman empire,” because of their usefulness and the expense of constructing them . Vitruvius was an engineer and architect who worked with both Julius Caesar and Augustus. Around 30 BC, he authored De Architectura (On Architecture), a work that has been more‐or‐less in continuous print for more than 2000 years.The most important primary sources that inform our knowledge of the water supply of ancient Rome are inscriptions, the physical ruins of the system, and the writings of Frontinus and Vitruvius. Sextus Julius Frontinus (c. 40 to 103 AD) was appointed It is tempting to equate the Roman system with modern accomplishments in hydraulic engineering and sanitation. Yet as redoubtable as their accomplishments were, the Romans nevertheless lagged far behind modern standards of health and hygienics. Life in ancient Rome was very different from that in modern times.The Romans were not the first to construct an aqueduct. Nor does it seem reasonable to regard the aqueduct itself as a novelty of any magnitude. There is nothing difficult about envisioning an artificial channel for conveying water.Among the notable predecessors of the Roman water system was the aqueduct at Jerwan constructed by Sennacherib (reigned 704 to 681 BC), king of Assyria. Sennacherib's aqueduct was part of a regional water supply system consisting of several canals designed to supply the city of Nineveh . During the Republican period, three more aqueducts were built: the Anio Vetus (272 to 269 BC), Aqua Marcia (144 to 140 BC), and Aqua Tepula (126 to 125 BC)  Bruun , 298.Aqua Julia (33 BC), the Aqua Virgo (19 BC), and the Aqua Alsietina (2 BC). According to Frontinus, Agrippa also “rebuilt the nearly ruined aqueducts of Appia, of Anio, and of Marcia,” and “supplied the city with a large number of ornamental fountains”  marked a period of renewed refurbishment and construction Forbes , 670. InAnio Novus and the Aqua Claudia initiated by his predecessor, Caligula (AD 12 to 41). The waters of the Aqua Claudia were derived from a spring and praised by Frontinus for their purity. The waters of the Anio Novus, like its predecessor, the Anio Vetus, were sourced from the Anio River. Despite the installation of a settling tank, water from the Anio Novus often reached Rome “in a discolored condition whenever there are heavy rains” (Frontinus Aqua Traiana began in AD 109 during the reign of Trajan (AD 53 to 117). The last of the 11 aqueducts of ancient Rome, the Aqua Alexandrina was built in AD 226.In AD 52, the Emperor Claudius (10 BC to AD 54) completed the It is not entirely clear that the average citizen of ancient Rome obtained most of their daily water supply from the aqueducts. Wells and cisterns were major sources of water Niebuhr . CertainAqua Appia in 312 BC, Frontinus informs us that “from the foundation of the city for 441 years, the Romans were content with the use of waters which they drew, either from the Tiber, or from wells, or from springs” (Frontinus lacus) in first century Rome , caldarium (hot room), tepidarium (warm room), and frigidarim (cold room). The hot baths were heated by means of a hypocaust, an under‐the‐floor central heating system. Lavish decorations included marble and mosaic floors, paintings, fountains, and sculptures , reportedly cut off aqueduct water “running or carried into any private building” Livius , 347. Prfistulae) practical and safe. Vitruvius acknowledged the poisonous properties of lead and argued that “water from clay pipes is much more wholesome than that which is conducted through lead pipes”  mentions a siphon pipe laid underneath the Anio River that supplied a villa owned by the patrician Manilius Vospiscus . A modern estimate is that a pipe with a diameter of one quinaria will discharge 40 m3 in 24 h .Rarely has a sewer been the subject of literary adoration. Yet when Barthold Georg Niebuhr (1776 to 1831) described the Cloaca Maxima was originally constructed as a drainage channel, a “monumental, open‐air, fresh‐water canal”  who in turn peddled feces as agricultural fertilizer  warned that “bathing, before the wound is pure, is one of the very worst things that can be done: for it makes it humid and foul, and then gangrene is usually the consequence” . Overflow was both deliberate and necessary. Frontinus argued “there must necessarily be some overflow from the delivery tanks, this being proper not only for the health of the city, but also for use in the flushing of the sewers” . Although the aqueduct system supplied ancient Rome with abundant fresh and flowing water, sanitary conditions in ancient Rome were nevertheless severely lacking by modern standards. “The Roman world was indeed not as clean as modern audiences have come to believe” Rogers , 40. ToiAncient Romans evidently lacked a full comprehension of the dangers inherent in handling human waste. Human excrement contains organisms capable of causing “diarrhea, bacillary dysentery, infectious hepatitis, salmonella infection, and many other illnesses” Scobie , 407. CoSanitary Report in The modern concept of hygiene dates from the middle nineteenth century Jansen . From RoAqua Virgo was functioning with any reliability. The other aqueducts, “patchily repaired after being frequently cut, and improperly maintained, leaked and formed marshes under their junctions” (Llewellyn In 537 AD the Goths lay siege to Rome. According to Procopius (c. 500 to 565 AD), the Goths “tore open all the aqueducts, so that no water at all might enter the city from them”  initiated the restoration of the ury Long . By 1630ury Long , 4. The  Martini , 564. Th55 initia Martini , 226.Although today we tend to associate the aqueducts of ancient Rome with the Roman prowess in civil engineering and monumental construction, the fact that most aqueducts drew their water from springs is a testament to the importance of groundwater in sustaining human civilization. Groundwater remains a vital human resource today. As of 2015, the US Geological Survey estimated that 325 million people in the United States daily withdrew 321 billion liters of groundwater for public and domestic water supply, irrigation, watering of livestock, aquaculture, mining, industrial purposes, and thermoelectric power (Dieter et al.


Dear Readers, “The ball is round, and a game lasts 90 minutes.” (Sepp Herberger). And we know what to do. We have no choice. We throw everything forward. Every woman, every man. Even if we are acting defensively and time is running out. We go all in – we almost completely blow our cover. We know what to do: nearly anything – really anything. “The round thing has to go into the square thing.” (Sepp Herberger). It's that simple. With this clarity, concentration and stormy composure, thousands of scientists, health and nursing professionals, doctors and members of many other healthcare professions are currently working – no fighting the battle against a much smaller opponent – a tiny one: the new coronavirus 2019-nCoV [https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd]. In Wuhan, people are cautiously hesitant to leave their shelters again, while in other places they are waiting in fear – with reports from Spain and Italy breathing down their necks – for the first offshoots of the great wave of sick and respirator-dependent people. We are all preparing ourselves – bracing ourselves for the unknown. We have one of the best healthcare systems. We are well educated. Faced with the current situation, it is simply unthinkable to write a medical text without making a reference to this pandemic. Too much suffering, too many exhausted helpers, too many overwhelming experiences. 375,498 confirmed cases and 16,362 deaths in 195 countries and territories have been recorded according to the latest WHO statistics (as of 25.03.2020; [Without wanting to overtax the power of association: This issue, too, reflects part of a mosaic of many thousands of individual conceptual and scientific achievements which, taken together, will help us to overcome – and I am sure we will overcome – this current crisis. The scope of this issue ranges from interactive learning methods for improved knowledge acquisition in microscopic anatomy , the conYes, they are. As if that were not enough, I am putting you through even more today. Because at the moment, in view of the many deaths caused by the corona crisis, all the stress on the helpers and the social insecurity in society, it is hard to name and believe: the corona crisis will be far eclipsed by another crisis: the climate crisis. The Lancet Countdown on health and climate change  has madeWe are unable to see the virus. But we can all feel the rising temperature, we can all see the effects of rising sea levels, we can all hear the reports of droughts. Yet these issues are underrepresented in our medical curricula . Here toStay healthy, everyone, Yours, Christoph NikendeiThe author declares that he has no competing interests.


Women in the U.S. have been earning more education than their male peers since the mid-1990’s. High power career positions that have historically been dominated by men are increasingly being filled by women. At the same time, since 2000, the U.S. workforce participation rate for women aged 25 – 55 has leveled off and begun to fall. Called the “mommy-wars” in the media, a heated debate has ensued between those women who feel that the role of mother should preempt seemingly selfish desires to engage in career work, while others firmly believe that it is possible to have it all; work, marriage and family. The purpose of this research project is to determine the health implications of each lifestyle for women later in life. Using the Health and Retirement Study, I compare self-rated health trajectories for the subset of women who are married, have children, and have attended college – those who are most likely to have the option to “opt-out” of the workforce for a stay-at-home mother lifestyle. Controlling for income and childhood health, and using growth curves and multivariate regression, preliminary results indicate that educated, married women who work full-time and raise children are the healthiest after age 50, while educated, married women who stay home with their children and do not work are the least healthy. In addition, these health trajectories have changed little since the 1950’s, even as cultural expectations for women have shifted.


Public health programming often frames HIV status disclosure as a means to negotiate condom- and abstinence-based prevention or to involve intimate partners in HIV care to garner treatment adherence support. HIV treatment can be used to ensure viral suppression and prevent onward transmission, which provides strong evidence to encourage disclosure. The ideological shift towards HIV treatment as prevention is expected to facilitate disclosure.There is a lack of research on how the scale-up of universal HIV testing and treatment influences disclosure practices in high burden settings. In this manuscript, we aim to address this gap.To this end, we conducted a two-phased narrative performative analysis of the disclosure scripts of 15 women living with HIV in three communities of Western Cape, South Africa where the HPTN 071 (PopART) HIV prevention trial implemented a universal HIV testing and treatment model as part of the intervention. The women were part of a larger cohort nested in the trial. We use Goffman’s dramaturgical metaphor, which understands social interactions as ‘performances’ by ‘actors’ (people) guided by ‘scripts’ , to explore how women living with HIV manage their status disclosure.We describe how these women perform HIV status disclosure (or deliberate non-disclosure) to retain, reaffirm or redefine existing social scripts with partners. Their performances reveal priorities other than those imagined by public health programmes driving HIV disclosure (or non-disclosure): establishing trust, resenting betrayal and ensuring self-preservation while simultaneously (re)constructing self-identity. None of the women engaged with the concept of treatment as prevention in their disclosure narratives, either to facilitate disclosure or to ‘justify’ non-disclosure. HIV prevention, in general, and treatment adherence support were rarely mentioned as a reason for disclosure. To date, there has been a missed opportunity to ease and support disclosure in health programmes by tapping into existing social scripts, impeding potential patient and public health benefits of universal HIV testing and treatment. Evidence from health settings in South Africa has shown that the message of treatment as a means of preventing HIV transmission has not being explicitly advocated, and authors have noted that it will be difficult to implement and will require appropriate resources at every step in the HIV care continuum.11 In addition, research from trial settings has shown that despite ART availability to all PLHIV, ART coverage is undermined by suboptimal linkage to care.13 We suggest that messages of HIV treatment as a form of prevention might ease and facilitate more disclosure among PLHIV in intimate relationships and encourage linkage to care. However, there is a lack of empirical data on how, or if, the offer of universal access to testing and treatment (UTT) and messages surrounding treatment as prevention are filtering into the disclosure practices of people in high burden settings. To understand the motivations behind and pathways of HIV disclosure in the context of UTT, we conducted a performative analysis14 of the narratives of women living with HIV in South Africa, the country with the most PLHIV.15Globally, there have been efforts to scale-up access to ART (WHO 2018)16 that has to be managed ‘both clinically and socially’.17 The historical association of HIV with sex, promiscuity and death18 means that it is a highly stigmatized condition20 and that for many PLHIV, their diagnosis is positioned as a private condition.22 As is the case for other chronic illnesses, the act of disclosure (or deliberate non-disclosure) often means more than just revealing health information, but rather, signifies the performance of broader underlying interpersonal processes and the reconciling of self and identity,23 where ‘self’ can be understood as the sense of who one is in relation to others.24 The aim of this article is to explore how women living with HIV negotiate disclosure (or non-disclosure) of their HIV status with their sexual partners through social scripts and performances.For PLHIV, a positive diagnosis has both biological and social implications. HIV has been described as ‘an epidemic of signification’25 increased social support26 and safer sexual practices among intimate partners.28 As a result, status disclosure is generally regarded as an important part of HIV treatment adherence and is actively promoted in many settings.2 As HIV is transmitted mainly through sex in South Africa,29 researchers need to focus on whether individuals decide to disclose in sexual relationships, or not. HIV status disclosure in intimate sexual relationships is subject to various dynamics, including perceived relationship quality and type, decisions around childbearing, knowledge of others who have disclosed their status, HIV knowledge and individuals’ self-esteem.31Studies have found that HIV status disclosure is associated with an increased likelihood of ART initiation and adherence,32 while non-disclosure is associated with internalized and anticipated stigma.33 Intertwined with these factors are broader social processes, including gender roles and power dynamics.35 For example, fears around intimate partner violence17 render disclosure problematic. Abdool Karim et al.36 found that lower rates of HIV status disclosure by women to their sexual partners are ‘suggestive of significant gender-power imbalance within couples . . . [highlighting the] fear of enacted stigma and gender-based violence as significant barriers to disclosure’. Against this background, we explore how South African women in heterosexual relationships ‘perform’ HIV status disclosure (or non-disclosure).Disclosure is further complicated by associations with enacted stigma,37 social interactions between people, including health status disclosures, are similar to theatrical performances. Goffman employs stage metaphors of actors and audiences ; roles and scripts ; the front stage (where persons ‘do’ performances for others) and the backstage  to understand how persons operate and sustain accepted/normative social interactions or scenarios. Goffman highlights how performances are key in constructing and maintaining self-identity. Building on Goffman’s work, Brissett and Edgley38 noted that the self is ‘established by its activity and the activity of others with respect to it . . . [and] selves are outcomes, not antecedents, of human interaction’. Performances, in addition to being mechanisms of maintaining accepted social scripts, are thus instrumental in constructing identity. Goffman noted that people are constantly negotiating impression management whereby, to preserve positive self-identities, individuals attempt to shape favourable impressions of themselves and avoid embarrassment or social discomfort.According to Goffman,23 noted that illness, especially a chronic illness, can be understood as a ‘biological disruption’, as it upends the structures of everyday life. By carefully crafting how, when and to whom they disclose their status, people with chronic illnesses create ‘bounded impressions’ or ‘scripts’ of themselves through which they attempt to regulate others’ reception of the information and maintain a positive identity.39 Interactions are, therefore, structured around actors’ mutual understandings of the accepted ‘scripts’ for social scenarios. When people disclose their illness status, it is feasible that they want to convey a certain message (or performance) and hold the expectation that their partner will adhere to an anticipated script or react in predictable ways.39In relation to health conditions, Bury40 Accordingly, HIV status disclosure is framed as a means of transferring knowledge of a diagnosis to make informed, and by implication, better future  health decisions. However, research has shown that HIV status disclosure has repercussions for intimate partners that PLHIV consider when deciding if, why and how to share their status. HIV status disclosure is related to the anticipated reactions from significant others41 and has been linked to strengthening identity and intimate relationships,42 while non-disclosure has been linked to fear, mistrust and anticipated stigma.41 We explore how HIV status disclosure is framed by women in South Africa at this stage of the HIV epidemic where treatment is available for all PLHIV.The public health ‘script’ for HIV status disclosure has focused mainly on the so-called ‘logico-scientific reasoning’ approach, whereby inferences are made from pragmatic empirical evidence as opposed to an intuitive narratives approach, where subjective experiences form the basis of knowledge.43 Through a cadre of community-based health workers, community members were offered door-to-door testing and a package of HIV prevention interventions consisting of condoms, STI screenings, referrals for medical male circumcision, and, in communities randomized to receive the full intervention, early access to ART to PLHIV (ART regardless of CD4 count). The aim of the trial was to measure the impact of universal access to HIV testing and treatment on HIV incidence. The trial was conducted in 9 communities in the Western Cape Province of South Africa and 12 communities across Zambia. This analysis is based on the data we collected with 89 households participating in a longitudinal qualitative cohort study nested in the 9 trial communities in South Africa. Households were recruited through referrals by community health workers and during structured community observations.The data for this analysis were drawn from the social science component of a cluster-randomized HIV prevention trial referred to as HPTN 071 (or PopART).21We conducted bimonthly household visits over an 18-month period between 2016 and 2018. Researchers worked in pairs, usually a man and a woman, with at least one researcher fluent in the participants’ home language. We used participatory research methods and completed thematized discussion guides arranged by modules with family members, either as one-on-one interviews or as group discussions, depending on the topic and household structure. Modules focused on household composition; income and expenditure; love, sex and romance; health access; and hopes, dreams and fears. Households were recruited to ensure diversity across age, gender, composition and HIV status (including participants who self-reported as living with or not living with HIV).44).For this analysis, we included all cisgender women living with HIV in the three South African intervention communities receiving early access to ART and who participated in the qualitative cohort (n = 15)  of HIV status disclosure of each participant. In phase one, we collated data collected across all research modules for each of the 15 women to construct a cohesive case description of each participant, including their kinship maps, housing arrangements, economic prospects, romantic relationships, illness narratives and health access history. Data included verbatim translated transcripts of in-depth interviews, field notes, photos and detailed reflective notes. Second, we focused on the specific speech sections where participants described the act(s) of disclosing  their HIV status to their sexual partners. We then identified overarching themes46 for the various types of performances of (non)disclosure. Through narrative analysis, we engage with several ‘lenses’ in considering the way that participants construct events, including language (word choices), the narrative process (sentence structures), context (in which events take place) and moments (identifying key events).47The analysis was informed by performance theoryFrom the analyses, we describe key ‘moments of disclosure’ narrated by participants during the extended course of data collection. We present these disclosure narratives with supporting longitudinal data from each participant where they described their intimate sexual relationships in detail.Approval was provided by the London School of Hygiene and Tropical Medicine Ethics Committee, Stellenbosch University Research Ethics Committee, and the Bio-medical Research Ethics Committee at the University of Zambia . All participants signed written informed consent and continually reconfirmed over time. Pseudonyms are used throughout for reporting purposes.48)In our findings, we present data from 15 women aged 19–45 years, from 12 households. In terms of demographic representation, nine of the women were Black African, Xhosa-speaking, and six women were coloured, Afrikaans-speaking community members see . served a purpose beyond relaying biomedical information to inform sexual practices or for accessing HIV treatment support. Disclosure narratives were constructed according to broader scripts specifically performed to convince the audience or co-actors (intimate partner in this case) of the woman’s intentions or position. We grouped these performances into three categories: cementing relationships, betrayal, and anger, and ensuring self-preservation.For several women, HIV disclosure was positioned as a productive next step towards affirming their intimate relationship with their sexual partners. Dora (aged 30 years) was diagnosed by the PopART intervention team in 2015 and, with the support of her close-knit family, initiated early treatment  soon thereafter. When we spoke to her, Dora was in an on-again, off-again relationship with her neighbour, Hector (55). Dora described how Hector made her feel special and that he took good care of her: ‘he does everything for me . . . he is a good person’. For Dora, the act of disclosure was positioned around the intention of ‘being honest’ with her partner, and in so doing, cementing their relationship.[Hector] asked me, ‘how’s it going?’ And, ‘are you okay?’ Then I said, ‘no, give me another hug’. Then [Hector] said, ‘it’s going to be fine’. And then he asked, ‘what’s it about?’ I said, ‘I’m going to talk with you later’ [pause] and then later I told him.During one of our discussions with Dora she described how, on seeing PopART community health workers (CHWs) who conduct door-to-door HIV testing in her neighbourhood, she preemptively engaged in a performance to assess Hector’s reaction to the possibility that she might need health support. In this prelude, Dora positioned herself as vulnerable and in need of care. In her account, Hector’s initial response to potentially distressing news assured her of his preservation of their relational script casting him as supportive partner which led to her disclosing her HIV status later that day:Although the preliminary conversation gave Dora sufficient confidence that Hector would react supportively to her HIV status disclosure, the excerpt below illustrates just how tenuous the moment of disclosure can be,ResearcherWhat did he say?DoraHe was upset and so on. Then I told him, if he’s not happy with me, then he must say ‘no’. I’ll take my things and leave, I’ll move [end the relationship]. Then he said, ‘no, it’s good’ I told him, and I was honest with him. And then he also said now [disclosed his HIV-positive status].ResearcherHe also told you about himself [his HIV status]? [Dora nods] And how did you feel that he didn’t tell you about it earlier?DoraI wasn’t angry. Now if I was negative, then I would’ve been angry. But because I’m now already positive [it is okay]. We sat and spoke now  and after that time, then everything was okay again.When asked why she had disclosed, Dora explained to us that they were ‘at that stage of their relationship’, indicating that, for her, status disclosure was expected when a relationship had reached a certain level of seriousness. Dora’s status disclosure was thus a carefully constructed performance, guided by the intention to strengthen their bond. When it seemed that Hector might be going ‘off-script’ and not reciprocating her investment in the relationship, Dora threatened to end the relationship. However, with Hector’s acceptance and unexpected co-disclosure of also being HIV-positive, the status of their relationship was reaffirmed. In addition, through Dora’s disclosure, she cast herself in the positive framing of an ‘honest’ partner. In this disclosure dance, the parties co-constructed a script that championed their relationship above whatever social and health-related issues that come with living with HIV. To note, according to her account, at no point during their mutual disclosure did Dora, or Hector, mention the health-related aspects of HIV (treatment and transmission) or benefits of having disclosed (adherence support).While HIV disclosure is often carefully planned and scripted, as indicated above, reactions from partners that do not adhere to expected scripts are disruptive and threaten the discloser’s identity and relationship with their partner. Lana (aged 28 years), for instance, went through careful measures to conceal her HIV status from others, including hiding her ART in the ceiling of the home she shared with her group of friends. She was diagnosed with HIV by the PopART intervention CHWs in 2015. During our interview in 2016, Lana was in a new relationship with one of the men in her social group, Simon (aged 28 years). Lana told us that she had told Simon about her diagnosis because ‘I always trusted him, see, I could talk to him. Other people close to me aren’t like that’. However, when asked about Simon’s reaction, Lana described the following:ResearcherWhat did he say [about your status]?Lana[extended pause] It is another story.ResearcherWhen did you tell him?LanaWhen the two of us tested.ResearcherWere you and Simon together when you tested? [Lana nods] And so you tested positive [Lana nods] And he? [Lana nods]. So, you were positive already? [Lana nods] So you tested again with Simon?LanaYes, but then Simon was positive already [knew his status prior to this test].ResearcherOh, he also knew? [Lana nods] And so what did he say− [Lana interrupts]Lana−I did not know.ResearcherWhat happened then?LanaBecause I did not know about him [pause]. I just told him, but  I did not know about him [pause], and he is not one who freaks out [overreacts]. He is just calm, but I have not . He did not tell me about himself .ResearcherAnd was he ugly [mean/rude] towards you?LanaNo, he [pause] he knew about himself.ResearcherHe told you he knew already [about his own status]?LanaNo, he did not tell me. I found out at the clinic [inaudible]. I was getting angry, because I told him about me [my status] but he has not told me about himself [his status].Lana described how she used the opportunity of retesting for HIV with the CHWs to inadvertently ‘reveal’ her status to Simon. When she tested positive, Lana explained, she told Simon that she had known she was living with HIV for a few months. Lana wanted to disclose to Simon because she thought of him as kind and trustworthy. Since Lana viewed Simon as supportive, she expected that her disclosure would be met with acceptance, even though he tested positive. Lana cast both herself and Simon as trustworthy. However, according to Lana, she inadvertently found out at the clinic that Simon had long been aware of his positive status, leaving her feeling betrayed. In this instance, the ‘disclosure script’ unfolded positively, and as expected, however the broader ‘relational script’ appears to have been fractured by Simon’s decision not to disclose his status earlier on in their relationship. While status disclosure presented a challenge to our participants’ relational scripts, it also revealed an opportunity to cement relationships especially when both partners were living with HIV. However, the disclosure process was, ultimately, influenced by the partner’s HIV status and their willingness reciprocates disclosure.tjommies [buddies] . . . when they hear that a friend is HIV-positive, then they move their company [friendship] away.Before the two of us were bound [had sex], I already opened up to him. He is my friend and I sat with him. We share everything with each other, as friends. We help each other . . . I opened up to him. I told him what I’d been through. I spoke to him about myself, that I have HIV so he would know, as a friend. I don’t have other friends. But I didn’t know how he is going to be [react] and how he’s going to speak to me. Is he going to be upstairs [looking down on] towards me? Many For others, like Chantelle (aged 31 years), HIV status disclosure was described as an affirmation of trust in her long-term childhood friend, neighbour and eventual boyfriend, Bradley (aged 27 years). Prior to her relationship with Bradley, Chantelle had been in several abusive relationships and had struggled with substance use. She described her disclosure to Bradley:Bradley said, ‘it’s not about being contagious. You just have to know how to avoid it [HIV transmission]. You won’t have clean [condom-less] sex, [you need to know what to do] if you have cuts’. Furthermore, the two of us, we understand each other. He understands me and I understand him. He accepts what I have been through.As in the previous disclosure narratives, Chantelle described the angst and uncertainty she felt about disclosing to Bradley. Unlike with other participants, Bradley maintained Chantelle’s script and turned the conversation towards a discussion on HIV transmission and safe sex. Chantelle explained,Bradley goes to the clinic, or he asks his friends [for condoms]. Then they want to know, why he’s asking for condoms. Then he says, ‘it’s for CD discs, to clean them’. [laughing] He tells them . . . you get the oil from the condoms and you rub it on [the cd]. He [tells them]: you can put it on your skin too. ‘I need those things [condoms] for that , not for women [sex], I mean, do you know me?’Maintaining a script of trust and understanding and managing Chantelle’s identity in their larger social group led Bradley to procure condoms without raising suspicions of Chantelle’s HIV status. Together, the couple engaged in a wider social script:For Chantelle, her status disclosure was meant to cement her relationship with Bradley. When Bradley also engaged in an elaborate act to conceal Chantelle’s HIV status from their friends, we see how the couples’ script bleeds into a wider script they both ascribe to in their social group. In this wider social script implied by Bradley’s rhetorical adage , safe sex (and HIV by implication) is positioned as outside of the norm for their group. Although the initial disclosure led to a discussion on safe sex practices, the logico-scientific information served to carve out a script both parties could ascribe to – one where HIV is not part of their socially performed personas – rather than being the centre around which other scripts revolve. It is important to note that neither Chantelle nor Bradley were aware of ART as a form of HIV prevention, despite living in a community where universal access to ART and door-to-door HIV testing was available.23 By disclosing their HIV status, some participants articulated a break in trust and disruption in their relationships, while others used the opportunity to force their partners to acknowledge infidelity and disclose their own HIV-positive status in an attempt to stitch the threads of their relationships together. Where the preexisting script was irreversibly spoilt, the women had to reevaluate their relationships and create new scripts based on new self-identities and impressions of their partners, shaped by the unwelcome introduction of HIV into their relationship.For other women, the act of disclosure was the aftermath of an unanticipated HIV-positive diagnosis. For these women, disclosure was part of a process of confrontation and acknowledgement of physical and emotional betrayal by their partners. In the moment of an unexpected HIV diagnosis, existing relational scripts came undone. This follows Bury’s observations that an unexpected illness diagnosis ‘brings individuals, their families, and wider social networks face to face with the character of their relationships’.Millie (aged 45 years) had been married to James (aged 47 years) for several years. She described her relationship with James as tumultuous – with James often drinking too much alcohol, taking drugs and disappearing for days at a time. However, Millie also describes herself as being deeply in love, and, every time James returned home, she would allow him to stay. Millie explained that she had unexpectedly tested positive for HIV during a routine household visit by the PopART intervention CHWs. James was out at the time, but her three children (from her previous marriage) were at home. The diagnosis was especially difficult for Millie, she explained because she was deeply religious. After reflecting on her diagnosis, she suggested that it must have been God who sent the CHWs so that she could become aware of her status and start medication. However, it was difficult for her to reconcile the romantic and emotional bonds she shared with James, with the realization that he had betrayed her and that he had been unfaithful. She recounted how she confronted James about her HIV status, conveying her anger, betrayal and shock:MillieIt was tense [emphasis]. He walked out, then he came back the night again.ResearcherDid he then get in bed? [Millie confirms]. How did you feel that time? No anger, no emotions?MillieMaybe.ResearcherWe− [Millie interrupts]Millie−maybe in my insides, sore, heartbroken and such things. [Whispering] I didn’t expect something like that, that it would happen. It also came back to me. Okay so maybe that was what [he] wanted to talk to me about. [He] said there is something that [he] wanted to tell me, but [he] didn’t know how I would accept it.ResearcherSo he had already wanted to tell you something? Do you think he knew about it [his positive status]?MillieMaybe. Yes, but he never talked about it . . . I said to him, ‘you gave it to me’. I said, I just said, ‘ok, fine it is how it is’.I wasn’t expecting it you know. But, as the time passes [you think], why would someone you love, you really love [stops mid-sentence]. That’s why I was saying, if he loves me, why would he hurt me in this way, you know? I told him, ‘tell me, if you feel you don’t want to be with me, because, I can talk to you openly about how I feel’. But he said I won’t understand him because we won’t be speaking the same language. So, I asked him, ‘just tell me if you don’t want to be in my life anymore, [if you] can’t take this’. He didn’t want to talk. He said I won’t understand him. I said, ‘so what does this mean? Where does this end? So, you think this must go on and on and on and I must just be at ease with you coming and going?’She continued to explain her shock and disappointment and how disclosure led to exposing other issues in the relationship:he doesn’t want to be with her), she also sketches new boundaries in which their relationship must exist. In Millie and James’ relationship, the act of disclosure was not associated with accessing treatment support or supporting other health-related decisions, but rather, the conversation was used as a way for Millie to recast a script in which underlying issues in their relationship would be averted and in which trust could, perhaps, be reestablished.Millie description shows how the preexisting scripts where the couple was cast as committed, loyal and loving, had been ruined by James. Despite this, she attempted to recreate a new script in which she will no longer ‘be at ease with [James] coming and going’. Although Millie positions herself as subject to James’ choice to take the lead in ending the relationship  is a shy woman who lives in a small informal home with 10 other extended family members and friends. When she was in high school, she had a sexual relationship with a taxi driver in his late 20s. Although occurring long after the relationship ended, she confronted him after being diagnosed with HIV:In telling Rebecca that she is ‘sick’, the taxi driver engaged in a nonchalant disclosure performance. For Rebecca, the former boyfriend is the target of her anger, but the betrayal she experienced at her diagnosis appeared to be directed towards herself. That is, she appears to rebuke herself for being naïve and ‘dumb’. By confronting the taxi driver, Rebecca appears to be recreating a script and identity in which she is wiser and regains agency, up to where she is able to reprimand the older man to ‘stop denying’ that he has HIV. Rebecca’s act of disclosure conveyed several intentions. While Millie and Rebecca’s anger towards their intimate partner was partly related to the impact of acquiring an incurable condition, it was the implicit betrayal that was being relayed. For these women, an HIV diagnosis signified that their partner was either dishonest or deceitful and the act of disclosure was a means to elicit a confession or to highlight other shortcomings in the relationship.For some women, not disclosing their HIV status to their intimate partner was a calculated decision. To conceal their HIV status, these women presented particular performances, aimed at maintaining the boundaries of privacy . For instance, Cebisa (aged 19 years), who became HIV-positive through vertical transmission, chose not to disclose her status to her boyfriend as an act of self-preservation. She described to us how she had been on HIV treatment ‘her entire life’, but only started questioning her mother about the medication when she was about 12 years old. Her mother was her main source of health support, as both her brothers were HIV negative – one born before her mother contracted HIV and the other after treatment for pregnant women became available. Cebisa has disclosed her HIV status to only one close friend, whom she describes as caring and loyal. She conceals her treatment and her diagnosis from everyone else. Cebisa spoke about her first serious boyfriend, Xola, whom she met in school when she was 16 and he was 18. She explained her feelings towards him:CebisaYho! [Exclamation]. The problem is, I loved him very muchResearcherWhat is it you loved about him?CebisaYho! Even him, the way he was [Cebisa smiling], the way he was speaking, everything about him I loved it [laughs]. He was a right/good person [smiling].Cebisa explained that she had a sexual relationship with Xola, and how she negotiated condom use without revealing her status:ResearcherSo sometimes you would use protection sometimes you would not use a protection?CebisaNo, I never used it when I first slept [had sex] with him [brief pause], because I didn’t know what to say. I wanted protection for him because he trusted me. I also trusted him but then now I deceived him. I said that I don’t inject the needle [contraceptive injection]. So [inhales loudly], we must use condoms, then he agreed.ResearcherSo then would he agree to have a condom? [Cebisa nods] You were on [family] planning at the time?CebisaYes, I was on [family] planningCebisa explained that she cared for her partner, and to protect him, she orchestrated the scene where condom use was presented as a way of preventing pregnancy, not HIV transmission. For Cebisa, condom use for pregnancy prevention, despite already using another form of pregnancy prevention (Depo-Provera injection), was a more acceptable scripted performance than revealing that she was living with HIV. This alternative script is exemplified by Cebisa’s admitting to ‘deceiving’ Xola. Her non-disclosure is purposefully orchestrated as self-preservation, in addition to the perceived preservation of the relationship:ResearcherDo you ever say, look this is what is happening and disclose [your status]?CebisaNo never. [I] don’t do that thing, I have never done it [disclosed].ResearcherWhy?CebisaNo, yho ResearcherWhy Cebisa?CebisaNo.ResearcherWhy, [are] you afraid?CebisaYes, I’m afraid.ResearcherWhat are you afraid [of]? That he would dump you? He would beat you?CebisaYes, I’m afraid [of] those things, maybe he dumps me.The couple dated for 2 years, but Cebisa ended the relationship after she heard that he had ‘cheated on her’. Somewhat ironically, Cebisa explained that trust in relationships is very important to her and that you cannot have two girls from the same school dating the same boy.Ntombi (aged 40 years) became sick in 2014 and was diagnosed with HIV at the clinic. She started on ART in 2015 as part of the PopART trial, prior to the changes in HIV treatment national guidelines. When asked why she decided to access ART, she explained that she did not want to ‘be behind’ and continued: ‘I wanted to know where I stand. I must know myself’. When we spoke to Ntombi, she was in a relationship and living with Chikhu. The couple shared Chikhu’s house, and Ntombi ran a small business selling alcohol from their home. Although Ntombi was fond of Chikhu, she complained that he no longer satisfied her sexually, and that she had another casual partner (Esihle) that she met at a tavern. Neither of these men were aware of Ntombi’s HIV status. When asked why she did not want to disclose to Chikhu, Ntombi explained:NtombiMy reasons for me not wanting him to know is that, I see that he is rude. And he is as rude as he is proud. He is proud. Too much. He is full of himself. And he doesn’t take nonsense, you see? When a person loves, [they] will be there. Even if it means to die with you. But him, no.ResearcherThis guy?NtombiYes. It is about three times now, [he was] throwing me out of the house. I also told myself that no, there’s no need to show him who I am. Let me just keep it this way and continue the way we are. Because then from the very start when I met him, we used a condom. And he doesn’t take a risk. If it’s not there, it’s not there, simple .When you see it’s too windy, you leave. So, before you do that thing, you have to see first that it is okay. If I pour sugar, how sweet will this sugar taste? I realised, okay fine. We are in love. Everything is nice the way things are happening. I don’t want to tell him. Let’s just keep it this way. If we are already using condoms, we are right on that side. Because I don’t know what will happen in the end.Ntombi emphasizes that she hides her true self from Chikhu. Ntombi’s internal script of what it means ‘to love someone’, to ‘be there even if it means to die with you’, has been violated on at least three occasions by Chikhu, without her disclosing her HIV status. As such, she performs according to alternative script both to conceal ‘who she is’ and to protect herself from a potentially ‘rude’ reaction from Chikhu. Ntombi described her relationship with Esihle as casual, although she did start having more serious feelings towards him at one stage. She told us that she enjoyed his company, and they were having sex, but, when we last spoke to her, she did not foresee a long-term relationship. Ntombi employed several metaphors to explain why she did not disclose her status to him:Ntombi provided three reasons for her non-disclosure: disclosure might be disruptive for the relationship (cause wind/turbulence); if she discloses, the consequences are unknown ; and as they were already using condoms, there was no need to disclose. For Ntombi, fear of the unknown consequences of disclosure was presented as the reason for non-disclosure. Non-disclosure is also seen as a justifiable performance ( ‘on the right side’) as she insists on using condoms. In addition, Ntombi also appears to be relatively powerless in her relationship with Chikhu, on whom she relies for a place to stay and run her shop. She does not foresee any possibility of creating a script in which Chikhu reacts in a supportive way following disclosure. An unsure future with Esihle meant that Ntombi decided not to disclose her status to him either. However, it appears Ntombi is fully aware of the risks of HIV and has managed to both refrain from unprotected sex and maintain a script in which her HIV status goes unquestioned by her partners.We found that HIV status disclosure (and deliberate non-disclosure) is part of a carefully scripted performance, where the end product is not the sharing of biomedical information but rather to communicate underlying social intentions and to affirm social- and self-identities. Some women disclosed their HIV status to convey their trust in their partners and to cement their relationships. In preparing for disclosing, these women anticipated certain positive (scripted) reactions from their partners – acceptance, support and understanding. However, as we show, partner performances were at times discordant with women’s expectations, leading to tension in relationships. For others, disclosure was in reaction to receiving an (mostly unanticipated) HIV-positive diagnosis. For these women, disclosure was instrumental in conveying anger and betrayal. More than blaming their partners for transmitting a sexual infection, these women wanted to express their anger/anguish because of the breakdown of the relationship and the partner’s assumed sexual transgressions. Other women participated in different performances to avoid telling their partners about their HIV status, either as a form of self-preservation or for the preservation of the relationship. Performances included engaging in more acceptable social scripts and acts, such as condoms for pregnancy prevention, rather than HIV prevention. In disclosing, women engaged in (re)constructing their identities as PLHIV in intimate relationships – either as good/honest partners strengthening relationships; as betrayed partners reevaluating relationships or as women who were claiming agency and ensuring self-preservation. HIV prevention, in general, and treatment adherence support overall, was rarely mentioned as a reason for disclosure – and never as the primary driver for HIV disclosure. At the time of our research, the message of HIV treatment as form of prevention had not yet filtered down into the intimate disclosure narratives of women who had access of treatment regardless of CD4 count. It is plausible that scale-up of UTT has, to date, missed an opportunity to support disclosure thereby impeding the potential patient and public health benefits of this approach.42 Bury noted that acquiring an illness diagnosis, and in effect, decisions around disclosure are ‘disruptions in explanatory systems normally used by people, such that a fundamental re-thinking of the person’s biography and self-concept is involved’.23 We suggest that, in selected (non-)disclosures, women living with HIV try to maintain their relationship scripts with the intention of avoiding further disruptions to their lives. Wekesa and Coast49 noted that ‘incorporating HIV . . . into one’s identity also involves multiple phases of identity transition, including diagnosis, (non-)disclosure, positive living and attempts at repair and normalcy’. Others have suggested that considerations of disclosure are driven by potential social gains in support or evasion of negative reactions.41 In highlighting the complexities of disclosure, it is worth noting that, while public health messaging might be focused on HIV prevention and treatment adherence, HIV is not a standalone condition but is often nested in the complexities of intimate relationships.50Similar to other research focusing on HIV disclosure practices, we highlight that the process of revealing one’s HIV status is simultaneously a test of intimate relationships and a reconciling of self-identity.21). As an additional strength, the analyses were informed by the experiences of the primary authors who were involved in the conceptualization, design and data collection of the project and received input from an experienced multi-disciplinary research team familiar with the HIV landscape in South Africa.By drawing on rich longitudinal data set, we were able to support accounts of disclosure with additional longitudinal data on intimate relationships.51 However, through longitudinal data collection, we are able to supplement once-off narratives of disclosure with broader and repeated life narratives and in doing so, present comprehensive and informed accounts.As a limiting factor, we were only able to analyze the disclosure narratives presented to us by participants. As such, we present an analysis of the retelling of women’s performances, rather than the disclosure performance itself. Participants could also have viewed the researchers as another type of audience, where retelling their disclosure stories allowed them to ‘construct themselves and others as particular kinds of moral agents’.21 It is in these spaces where effective HIV counselling could be instrumental in facilitating disclosure processes by simultaneously providing interpersonal relationship support and engaging couples in the personal and public health benefits of ART adherence.We have shown that HIV status disclosure happens in context of tensions and overlapping priorities, such as relationship dynamics and identity formation. In addition, there are apparent competing disclosure principles: public health systems are focused on treatment adherence and transmission prevention while women living with HIV are focused on the dynamics of interpersonal relationships. In addition to other stresses in high-burden, low-resource communities, PLHIV often have challenges in preserving confidentiality, as the decisions around disclosure are complicated by a lack of private spaces.