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AIDS Behav (2012) 16:132138 DOI 10.

1007/s10461-010-9873-y

ORIGINAL PAPER

Disclosure of HIV Status to Sex Partners Among HIV-Infected Men and Women in Cape Town, South Africa
Lung Vu Katherine Andrinopoulos Catherine Mathews Mickey Chopra Carl Kendall Thomas P. Eisele

Published online: 1 January 2011 Springer Science+Business Media, LLC (outside the USA) 2010

Abstract This study examines factors inuencing HIV sero-status disclosure to sex partners among a sample of 630 HIV-infected men and women with recent sexual contact attending anti-retroviral therapy (ART) clinics in Cape Town, South Africa, with a focus on sex partner type, HIVrelated stigma, and ART as potential correlates. About 20% of the sample had not disclosed their HIV status to their most recent sex partners. HIV disclosure to sex partner was more likely among participants who had a steady sex partner [Adjusted odds ratio (AOR) = 2.7; 95% CI: 1.64.6], had a partner with known-HIV status [AOR = 7.8; 95% CI: 3.218.7]; perceived less stigma [AOR = 1.9; 95% CI: 1.22.9]; and were on ART [AOR = 1.6; 95% CI: 1.12.3]. Stratied analyses by the type of sex partner further reveals that stigma and ART were signicantly associated with HIV
L. Vu (&) HIV and AIDS Program, Population Council, 4301 Connecticut Avenue, NW, Suite 280, Washington, DC 20008, USA e-mail: lvu@popcouncil.org K. Andrinopoulos C. Kendall T. P. Eisele Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2200, New Orleans, LA 70112, USA e-mail: teisele@tulane.edu C. Mathews Health Systems Research Unit, Medical Research Council, Tygerberg, South Africa C. Mathews School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa M. Chopra Programme Division, UNICEF, 3 United Nations Plaza, New York, NY 10017, USA

disclosure within steady relationships but were not signicant correlates of HIV disclosure with casual sex partners. The ndings support a positive prevention strategy that emphasizes increased access to ART, and behavioral interventions to reduce casual sex partnerships for persons who are HIV-positive. Mitigating the inuence of HIV stigma on HIV status disclosure particularly within steady sex partnerships is also important and may be accomplished through individual and couple counseling. Keywords HIV disclosure HIV stigma Anti-retroviral therapy Partner type South Africa

Introduction South Africa has one of the worlds largest HIV epidemics. UNAIDS estimates that the number of people living with HIV and AIDS (PLWHA) in South Africa is 5.7 million, which constitutes 25 and 10% of the total number of PLWHA in sub-Saharan Africa and in the whole world, respectively [1]. Of those 5.7 million PLWHA, an estimated 900,000 are in need of anti-retroviral therapy (ART), and 400,000 of these people have initiated ART [2]. A critical issue in stemming transmission of HIV in South Africa, and other countries globally, is HIV serostatus disclosure to sex partners. In addition to being associated with a healthier psychological wellbeing for PLWHA [3, 4], and better adherence to ART [5, 6], studies demonstrates a link between HIV status disclosure to sex partners and condom use [711]. Models also suggest that status disclosure may contribute to the reduction of HIV transmission by as much as 41% [12]. HIV disclosure facilitates discussion between couples and provides potential sex partners of HIV-positives the opportunity for

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an informed choice about whether to use a condom or have sex at all. The process of HIV status disclosure may also serve as a mechanism to promote partner testing for HIV [8, 13]. In South Africa, PLWHA who have previously experienced stigma and discrimination were less likely to disclose their HIV status to their sex partners, and nondisclosure was later found to be associated with HIV-risk behavior [11, 14]. While there are numerous individual and population level benets to endorse HIV status disclosure as a rational public health priority, it is important to also recognize the social risks implicit in the decision to make public ones infection status. HIV is a complicated and stigmatized disease associated with sexual behaviors and drug use [1]. The decision to disclose may therefore be inuenced by fear of rejection from ones sex partner(s), families and friends, the fear of revelation of hidden sexual orientation, fear of losing ones job, and physical abuse [13, 15]. Type of sexual partnership may also be an important factor to consider. PLWHA may disclose their HIV status within one type of social relationship but not within another, because social risks of stigma and rejection are context and relationship specic [16, 17]. The duration of the relationship may also be important because the consequence of facing rejection from someone with whom there is an ongoing commitment may be perceived as more costly than that of a short acquaintance [17, 18]. Studies of the relationship between ART and HIV disclosure are rare, especially in developing countries with high HIV burdens [19]. Among the few studies that explore this relationship, the ndings are conicting. Menon and colleagues [20] found that entry into an ART program increased the likelihood of HIV disclosure to a sex partner, while Skogmar and Klitzman found no relationship between ART and HIV disclosure [19, 21]. Skogmars study was conducted among 114 PLWHA attending an HIV clinic in Johannesburg in 2003; it was found that 21% had not disclosed their HIV status to their sex partners and that there was no relationship between ART and disclosure after 8 weeks of follow up [21]. We present data on factors associated with HIV serostatus disclosure among 630 HIV-positive men and women attending the ve largest antiretroviral treatment clinics in Cape Town, South Africa. Previous analysis of these data showed that a signicant proportion of PLWHA did not disclose their HIV status to their sex partners (20%); and that those who disclosed their status were more likely to use condoms [9, 22]. Specically, we examine the relationship between self-perceived stigma and HIV sero-status disclosure with steady versus casual sex partners. We also explore the impact of starting ART on HIV status disclosure by different partnership types. These two lines of

investigation provide important information for HIV interventions among positives, at a time when ART is increasingly accessible in resource poor settings, and there has been increased recognition of the role of multiple and their different types of sexual partnerships in HIV transmission.

Methods Study Design and Participants The data used for this analysis are from a 2007 sample of PLWHA attending the ve largest public HIV clinics in the Cape Town metropolitan area, South Africa, as described elsewhere [9, 22]. A total sample of 410 participants who had been on ART for 1 year and 548 participants waiting to initiate ART were interviewed using a standard questionnaire on a Personal Data Collection Toolset (PDACT). [ART participants were prospectively followed up for 1 year, from 2006 to 2007 (August to October); non-ART participants were cross-sectionally interviewed in 2007 (August to October)]. The questionnaire included items measuring sexual risk behaviors (condom use, type of sexual relationship, number of sex partner), HIV-related stigma, HIV disclosure, and socio-demographic characteristics. The dependent variable, HIV disclosure, was measured by asking Have you told your most recent sex partner that you are HIV positive. HIV-related stigma was measured through a 4-point likert scale with 13 items constructed from established measures adapted for use in South Africa as described previously (Chronbachs a = 0.79) [23]. Example items include I feel that other people might blame me for being HIV positive; I feel that people might avoid me because of my HIV status; I fear that my family will reject me if they learn about my illness. The index score was computed using principal component analysis and dichotomized at the median (high versus low) for this analysis. The number of sex partners was ascertained by asking: How many people have you had sex with in the past 4 weeks. The types of sexual partners, steady and casual, were assessed by asking: How would you describe your most recent sexual partner? A casual partner was described as someone you are not serious about/not on a regular basis and a steady partner was described as a steady partner/spouse. The dependent variable asked about HIV disclosure with the most recent sex partner, and most recent sex partner was dened as sex partner in the past month. Thus, we focused on participants who had sex in the past month, leaving a sample of 630 for this analysis [66% of the total sample; n = 273 (43%) on ART; n = 357 (57%) not yet on ART].

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Data Analysis All analyses were carried out using STATA software version 11.0 (STATA Corp., College Station, TX). Factors related to the outcome of HIV disclosure in our sample were identied
Table 1 HIV disclosure to most recent sex partner by socio-economic characteristics and sexual risk behaviors: bivariate relationship Variables

through bivariate analysis with chi-square was conducted on hypothesized correlates that included stigma, socio-demographic variables (age, sex and wealth) and partner-related characteristics (co-habitation, HIV status) (Table 1). Variables signicant at P \ 0.25 from the bivariate analysis were
Disclosed HIV status (n = 513) % (n) Total sample (n = 630) % (n) v2 (P-value)

Age 1824 2534 3544 4561 Gender Male Female Job situation Unemployed Employed (at least part-time) Wealth 1st quintile 2nd quintile 3rd quintile Self-rated health status Not good Good Co-habilitation status Not living with spouse/sex partner Living with spouse/sex partner Type of sex partner Steady Casual (not serious about) HIV status of the sex partner Unknown Known Number of sex partner (past month) 1 partner C2 partners Condom use at last sex Yes No Plan to get or get partner pregnant No Yes Stigma Low level High level ART-group Had been on ART for 1 year Not yet on ART 84.3 (230) 79.3 (283) 43.3 (273) 56.7 (357) 85.6 (291) 76.5 (222) 54.0 (340) 46.0 (290) 81.2 (444) 85.3 (64) 87.9 (547) 12.1 (75) 82.2 (466) 74.6 (47) 84.2 (409) 72.2 (104) 90.0 (567) 10.0 (63) 65.5 (191) 95.0 (322) 46.2 (291) 53.8 (339) 87.3 (442) 57.3 (71) 80.3 (506) 19.7 (124) 72.6 (228) 90.1 (283) 314 (50.0) 314 (50.0) 79.9 (175) 85.0 (176) 79.4 (162) 80.0 (296) 83.5 (217) 34.8 (219) 32.9 (176) 32.3(204) 82.7 (358) 78.7 (155) 68.7 (433) 31.3 (197) 81.4 (171) 81.4 (342) 33.3 (210) 66.7(420) 76.9 (40) 81.9 (262) 82.1 (165) 80.7 (46) 8.3 (52) 50.8 (320) 31.9 (201) 9.0 (57)

0.8 (0.84)

0.0 (1.0)

1.4 (0.23)

2.7 (0.26)

1.2 (0.27) 58.7 (370) 41.3 (260) 31.8 (0.00)

59.6 (0.00)

89 (0.00)

2.2 (0.14)

10.5 (0.001) 77.1 (486) 22.9 (144) 0.8 (0.38)

8.5 (0.004)

2.5 (0.10)

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assessed using logistic regression, with model selection done using a forward stepwise selection process. The Hosmer Lemeshow test of goodness of t was used to determine model t of the logistic regression models to assess factors associated with HIV disclosure, while controlling for potential confounding factors (Table 2). We then examined the potential interaction of types of sex partner and HIVrelated stigma (P = 0.08). Based on this result, the nal model predicting HIV disclosure was stratied by the types of sex partner (Table 3). Study sites (ve different clinics)

were controlled in all analyses and P-value was determined based on the robust standard error.

Results Participants were mainly from the working-age group with a median age of 33, ranging from 18 to 61 years old. About 8% of the sample was between 18 and 24, 51% was between 25 and 34, 32% was between 35 and 44, and 9%

Table 2 Factors affecting HIV disclosure (n = 628)

Variables

Disclosed HIV status OR (95% CI) AOR (95% CI)

Age (1824 years old = ref.) 2534 3544 4561 Female Wealth (1st quintile = ref.) 2nd quintile 3rd quintile Living with spouse/sex partner Sex partner is considered steady Knowing sex partners HIV status Having multiple sex partners Having a low level of HIV stigma Note * P \ 0.05; ** P \ 0.01; *** P \ 0.001; OR odds ratio; AOR adjusted odds ratio On ART for 1 year Pseudo R2 1.4 (0.92.3) 1.0 (0.61.6) 3.4 (2.25.4)*** 5.1 (3.38.0)*** 4.9 (3.66.8)*** 0.6 (0.31.2) 1.8 (1.22.7)** 1.4 (0.92.1) N/a 1.3 (0.82.2) 1.1 (0.81.6) 1.7 (0.93.1) 2.7 (1.64.6)*** 7.8 (3.218.7)*** 1.6 (1.02.4) 1.9 (1.22.9)** 1.6 (1.12.3)** 23% 1.4 (0.72.7) 1.4 (0.72.9) 1.3 (0.53.1) 1.2 (0.61.5) 1.3 (1.11.6)** 1.4 (1.11.8)** 1.3 (0.91.8) 1.3 (0.82.1)

Table 3 Factors affecting HIV disclosure: stratied by the types of sex partner

Variables

Disclosure among steady partner (n = 504) AOR (95% CI)

Disclosure among casual partner (n = 124) AOR (95% CI)

Age (1824 = ref.) 2534 3544 4561 Female Wealth (1st quintile = ref.) 2nd quintile 3rd quintile Living with spouse/sex partner Knowing sex partners HIV status Having multiple sex partners Having a low level of HIV stigma Note * P \ 0.05; ** P \ 0.01; *** P \ 0.001; OR odds ratio; AOR adjusted odds ratio On ART for 1 year Pseudo R2 1.0 (0.61.7) 1.1 (0.61.9) 1.6 (0.83.2) 7.8 (3.418.1)*** 2.1 (0.86.1) 2.3 (1.24.3)** 2.1 (1.14.0)** 18% 2.9 (1.55.6)** 1.2 (0.53.0) 2.5 (1.44.5)** 7.6 (1.439.3)* 1.2 (0.72.0) 1.2 (0.62.4) 0.8 (0.41.6) 17% 1.1 (0.61.9) 1.5 (0.63.6) 1.3 (1.11.5)** 1.0 (0.61.8) 1.9 (0.57.1) 1.2 (0.43.9) 1.7 (0.55.2) 2.0 (1.23.5)**

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was between 45 and 61. There were twice as many females (67%) as males (33%) in the sample. About one-third (31%) of the sample was unemployed and a half of them lived with their spouse or sex partner. About half of the sample self-reported good health (Table 1). 19% of the study participants had not disclosed their HIV status to their most recent sex partner (n = 117). Nearly half reported having partners with unknown HIV status (46.5%), 39.5% had an HIV-positive partner, and 14% had an HIV-negative partner. 10% of the sample had multiple sex partners in the past month, with nearly a quarter (23%) reported that they did not use condom at last sex. 20% considered their most recent sex partner casual (Table 1). The bivariate analysis suggests that co-habitation status (P \ 0.001), type of the sex partner (P \ 0.001), HIV status of the sex partner (P \ 0.001), condom use at last sex, HIV-related stigma (P \ 0.01), and ART (P \ 0.1) were associated with HIV status disclosure (Table 1). After controlling for age, gender and wealth, logistic regression showed individuals aged 2544 were more likely to disclose their HIV status to their sex partner, as compared to the youngest group (1824 years old) [Adjusted odds ratios (AOR) = 1.3; (95% CI: 1.11.6) and 1.4 (95% CI: 1.11.8), respectively]. Partner HIV status showed a strong association with HIV disclosure; respondents with partners with known-HIV status were 8 times more likely to disclose [AOR = 7.8; 95% CI: 3.218.7], compared to having a partner with unknown-HIV status. Participants with a steady sex partner were more likely to disclose their HIV sero-status compared to those with casual sex partners [AOR = 2.7; 95% CI: 1.64.6]. Individuals who perceived low levels of HIV-related stigma were twice as likely to disclose their HIV status [AOR = 1.9; 95% CI: 1.22.9]. Lastly, those who had been on ART for 1 year were one and half times more likely to disclose their HIV status to their sex partners [AOR = 1.6; 95% CI: 1.12.3]. Gender, wealth, co-habitation status, and multiple sexual partnerships were not signicantly associated with HIV status disclosure (Table 2). A stratied analysis by sex partner type showed that knowing a sex partners HIV status remained signicantly associated with HIV status disclosure within both steady [AOR = 7.8; 95% CI: 3.418.1] and casual relationships [AOR = 7.6; 95% CI: 1.439.3]. Within steady relationships, being older [AOR 1.3; 95% CI: 1.11.5], perceiving low stigma [AOR = 2.3; 95% CI: 1.24.3], and being on ART [AOR = 2.1; 95% CI: 1.14.0] were signicantly associated with HIV disclosure, although the same relationship was not found between these variables in casual partnerships. Conversely, being female [AOR = 2.0; 95% CI: 1.23.5] and living with a spouse/sex partner [AOR = 2.5; 95% CI: 1.44.5] were associated with HIV

status disclosure within casual but not steady sex partnerships (Table 3).

Discussion We examined the factors associated with HIV disclosure among a sample of PLWHA who had been on ART for a year or were waiting to start ART attending the ve largest ART clinics in the Cape Town metro area, South Africa. We found 1 in 5 respondents had not disclosed their HIV status to their most recent sex partners, which is similar to non-disclosure found in other studies in this region [21, 24]. After controlling for potential confounders, participants with higher self perceived HIV-related stigma were less likely to disclose their HIV status to their sex partner than those with low levels of perceived stigma. However, the effect of stigma on disclosure was mitigated by the type of sex partner; in the stratied analysis stigma only inuenced disclosure among those with a steady partner. This study supports other literature indicating that HIVrelated stigma is an important barrier in disclosing ones HIV status, especially among steady partners [2528]. These results also demonstrate the importance of considering partner type on how stigma affects disclosure. As found elsewhere [28, 29], fear of losing or damaging a steady relationship, coupled with perceived stigma of HIV, likely diminishes the likelihood of disclosing ones HIV status to a steady partner. Additionally, we hypothesize that if one does not disclose their HIV status to a sex partner initially, it may become more difcult to disclose as the relationship progresses over time and increases in intimacy and closeness. These results suggest that interventions to increase disclosure, and thereby facilitate more open condom negotiations at sex, should recognize the importance of stigma on disclosure among those with steady partners. For example, counseling to build trust and understanding and to create a supportive environment among steady couples may facilitate HIV disclosure. This is of particular importance as there may also be issues related to having children and contraceptive use within a steady relationship. The study also nds a signicant relationship between HIV disclosure and entry into an ART program. We offer a few possible explanations for this. First, ART may improve the health of PLWHA [9], thus reducing a perceived or actual stigma, resulting in enhanced disclosure. Second, the improvement in health could generate optimism in PLWHA, and bring more opportunities for sexual activities, resulting in more disclosure. This nding, in fact, is corroborated in a previous analysis of this population: ART positively alters sexual risk behavior [9, 22]. Although ART treatment optimism has been documented in developed country settings, which could increase HIV-risk

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behaviors [30, 31], we believe it is less likely the case for this population. We conducted an additional analysis examining treatment optimism and found that it was almost absent: over 95% of the sample stated that they could still infect others when on ART (result not shown). We found the proportion of HIV disclosure to a steady sex partner is 2.7 times higher than casual sex partners. This may be due to a lower sense of responsibility to casual sex partners [25]. In addition, in a steady relationship, PLWHA may feel concerned about their partners health and thus feel responsible for protecting their partners, leading to more disclosure [32]. It may also be that the relationship is solid enough, in a steady relationship, to withstand this revelation. In addition, the issues related to care for children, child support, and seeking economic support may facilitate disclosure to a steady sex partner, especially when one was out of work due to illness [16]. In many situations, PLWHA might live in the same house with the steady partner, which makes it difcult for them to conceal their HIV status. In addition, the steady sex partner is more likely to be ones condant for disclosure [16]. We also found that in the case of those who had casual sex partners, females were twice as likely as males to disclose. This suggests that gender inequity in a relationship might prevent women from asking the HIV status of their male partners; or males do not feel obligated to disclose to their female partners. The study also shows that PLWHA tend to disclose their HIV status to sex partners whose HIV status they know. This relationship remains highly signicant in the stratied analysis across the two partner types. One possible explanation is that knowing someones HIV status requires discussions about ones own HIV status among the couples before sex, potentially leading to more disclosure. If one does not ask, the other would not answer [33, 34]. This nding indicates that it is not the HIV status that affects ones own decision to disclose but rather the knowledge of the partners HIV status. This implies that safe sex negotiation skills, including knowing partners HIV status is vital for everyone, especially when HIV is generalized across different population groups. There are a number of important study limitations. First, the study population was either on ART or about to start ART, thus they were obligated to go through counseling to increase ART adherence and decrease risk behaviors. These results are therefore likely not representative of PLWHA outside the ART system. Second, irrespective of the use of assisted self interview techniques on PDAs, responses were likely subject to social-desirability bias. Third, we did not measure the reasons why PLWHA choose to disclose or not to disclose their HIV status, which prevented us from understanding more complex disclosure issues. Finally, we were unable to distinguish whether a

casual sex partner was a sexual encounter with a commercial sex worker, which would have inuenced disclosure. However, 67% of this study population was female, which likely educed the possibility that commercial sex has confounded the casual sex category. The study supports the importance of ART in reducing HIV-risk behaviors of PLWHA in poor socioeconomic settings by increasing HIV disclosure. It also supports that reducing HIV-related stigma is important in HIV prevention, especially given that South Africa has high levels of HIV-related stigma and discriminations [24, 31]. Fear of partners negative reactions and stigma prevents PLWHA from disclosing their HIV status to the sex partner, possibly resulting in unprotected sex and furthering the epidemic. Another major implication is that HIV disclosure is a complex phenomenon that varies among different types of sexual relationships. PLWHA tend to disclose their HIV status to a steady and committed partner rather than to a casual partner. In addition, more negative impact of HIVrelated stigma among steady sex partners was found, which could be useful for counselors and health workers in HIVrisk reduction interventions; it gives the counselors the sense of what is important for disclosing ones HIV status. It also suggests that discussion about ones partner HIV status is important for facilitating disclosure, regardless of the partners HIV status. Finally, couple counseling and testing may help PLWHA to disclose their HIV status to signicant other. Counselors are able to create an environment where couples are informed about the possible benet versus the negative consequences if ones disclose their HIV status. This may be of particular benet to PLWHA who may be in danger of violence and negative consequences if they disclose their HIV status without the presence of a counselor [34].
Acknowledgments The authors would like to thank the Centers for Disease Control and Prevention (Atlanta, GA, USA) for funding, and to the men and women of Cape Town (South Africa) for participating in the study.

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