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AIDS Behav (2012) 16:132–138 DOI 10.



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 Ó Springer Science+Business Media, LLC (outside the USA) 2010

Abstract This study examines factors influencing 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: 1.6–4.6], had a partner with known-HIV status [AOR = 7.8; 95% CI: 3.2–18.7]; perceived less stigma [AOR = 1.9; 95% CI: 1.2–2.9]; and were on ART [AOR = 1.6; 95% CI: 1.1–2.3]. Stratified analyses by the type of sex partner further reveals that stigma and ART were significantly associated with HIV
L. Vu (&) HIV and AIDS Program, Population Council, 4301 Connecticut Avenue, NW, Suite 280, Washington, DC 20008, USA e-mail: K. Andrinopoulos Á C. Kendall Á 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: 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 significant correlates of HIV disclosure with casual sex partners. The findings 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 influence 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 Á HIV stigma Á Anti-retroviral therapy Á Partner type Á South Africa

Introduction South Africa has one of the world’s 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 [7–11]. 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


families and friends. 22]. and physical abuse [13. The questionnaire included items measuring sexual risk behaviors (condom use. HIV disclosure. South Africa. We also explore the impact of starting ART on HIV status disclosure by different partnership types. HIV is a complicated and stigmatized disease associated with sexual behaviors and drug use [1]. Specifically. was measured by asking ‘‘Have you told your most recent sex partner that you are HIV positive’’. [ART participants were prospectively followed up for 1 year. We present data on factors associated with HIV serostatus disclosure among 630 HIV-positive men and women attending the five largest antiretroviral treatment clinics in Cape Town. Studies of the relationship between ART and HIV disclosure are rare. because social risks of stigma and rejection are context and relationship specific [16. especially in developing countries with high HIV burdens [19]. The dependent variable asked about HIV disclosure with the most recent sex partner. we examine the relationship between self-perceived stigma and HIV sero-status disclosure with steady versus casual sex partners. Previous analysis of these data showed that a significant proportion of PLWHA did not disclose their HIV status to their sex partners (20%). Skogmar’s study was conducted among 114 PLWHA attending an HIV clinic in Johannesburg in 2003. we focused on participants who had sex in the past month. steady and casual. While there are numerous individual and population level benefits to endorse HIV status disclosure as a rational public health priority. 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’’. and socio-demographic characteristics. Example items include ‘‘I feel that other people might blame me for being HIV positive’’. The types of sexual partners. Type of sexual partnership may also be an important factor to consider. type of sexual relationship. 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 (Chronbach’s a = 0. HIV disclosure. 21]. 17]. HIV-related stigma. the fear of revelation of hidden sexual orientation. 15]. it is important to also recognize the social risks implicit in the decision to make public one’s infection status. The number of sex partners was ascertained by asking: ‘‘How many people have you had sex with in the past 4 weeks’’. while Skogmar and Klitzman found no relationship between ART and HIV disclosure [19. 14]. non-ART participants were cross-sectionally interviewed in 2007 (August to October)]. at a time when ART is increasingly accessible in resource poor settings. The dependent variable. South Africa. leaving a sample of 630 for this analysis [66% of the total sample. from 2006 to 2007 (August to October). The process of HIV status disclosure may also serve as a mechanism to promote partner testing for HIV [8. Thus. The decision to disclose may therefore be influenced by fear of rejection from one’s sex partner(s). 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). Menon and colleagues [20] found that entry into an ART program increased the likelihood of HIV disclosure to a sex partner. 13]. n = 273 (43%) on ART. and nondisclosure was later found to be associated with HIV-risk behavior [11. PLWHA may disclose their HIV status within one type of social relationship but not within another. Among the few studies that explore this relationship. 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].79) [23]. 22]. 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.AIDS Behav (2012) 16:132–138 133 an informed choice about whether to use a condom or have sex at all. These two lines of investigation provide important information for HIV interventions among positives. Methods Study Design and Participants The data used for this analysis are from a 2007 sample of PLWHA attending the five largest public HIV clinics in the Cape Town metropolitan area. as described elsewhere [9. and there has been increased recognition of the role of multiple and their different types of sexual partnerships in HIV transmission. ‘‘I fear that my family will reject me if they learn about my illness’’. the findings are conflicting. fear of losing one’s job. 123 . PLWHA who have previously experienced stigma and discrimination were less likely to disclose their HIV status to their sex partners. ‘‘I feel that people might avoid me because of my HIV status’’. and that those who disclosed their status were more likely to use condoms [9. n = 357 (57%) not yet on ART]. 18]. In South Africa. and most recent sex partner was defined as sex partner in the past month. number of sex partner). The index score was computed using principal component analysis and dichotomized at the median (high versus low) for this analysis.

4 (0.7 (370) 41.0 (1.14) 10.2 (466) 74.2 (104) 90.7 (0.3 (273) 56.3 (197) 81.2 (0.25 from the bivariate analysis were Disclosed HIV status (n = 513) % (n) Total sample (n = 630) % (n) v2 (P-value) Age 18–24 25–34 35–44 45–61 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 84.9 (175) 85.4 (342) 33.0) 314 (50.5 (0.4 (171) 81.7 (155) 68.9 (176) 32. TX).7 (357) 85.23) 2.00) 2.8 (0.5 (217) 34.2 (0.5 (0.3 (260) 31.10) 123 .4 (162) 80. sex and wealth) and partner-related characteristics (co-habitation.84) 0.0) 79.8 (219) 32.3 (506) 19.8 (0.3 (210) 66.134 AIDS Behav (2012) 16:132–138 Data Analysis All analyses were carried out using STATA software version 11.1 (486) 22.00) 89 (0.7 (124) 72.0) 1.2 (409) 72.3(204) 82.2 (444) 85. HIV status) (Table 1).3 (71) 80.7(420) 76.0 (63) 65.7 (46) 8.3 (64) 87.27) 58.5 (222) 54.7 (358) 78.6 (228) 90. socio-demographic variables (age. Variables significant at P \ 0.5 (0.0 (290) 81.0 (STATA Corp.26) 1.3 (52) 50.0 (340) 46.9 (201) 9.6 (0.8 (0.1 (75) 82.7 (433) 31.0 (567) 10.1 (165) 80.9 (547) 12.9 (144) 0.3 (442) 57. Factors related to the outcome of HIV disclosure in our sample were identified 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.004) 2. College Station.38) 8.0 (296) 83.0 (57) 0.6 (47) 84.9 (262) 82..001) 77.3 (283) 43.6 (291) 76.8 (320) 31.0 (322) 46.00) 59.1 (283) 314 (50.3 (230) 79.8 (339) 87.0 (176) 79.5 (191) 95.2 (291) 53.9 (40) 81.

0 (0.1–1.AIDS Behav (2012) 16:132–138 135 assessed using logistic regression.6)*** 7.5) 1.5)** 1.3)** 2.9–2. AOR adjusted odds ratio On ART for 1 year Pseudo R2 1.2–3.3 (0.2) 1.7–2.9–1.8 (0.4–3.4 (0.) 25–34 35–44 45–61 Female Wealth (1st quintile = ref.9) 1.7–2.8 (3.6–1.8)** 1.2) 2.01.6) 1.8)*** 0.4) 0.0 (0.2–4.1) Table 3 Factors affecting HIV disclosure: stratified 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 (18–24 = ref.4)*** 5.6–2. and 9% Table 2 Factors affecting HIV disclosure (n = 628) Variables Disclosed HIV status OR (95% CI) AOR (95% CI) Age (18–24 years old = ref.2 (0.1–1.8–2.6–1.6)** 1. while controlling for potential confounding factors (Table 2). We then examined the potential interaction of types of sex partner and HIVrelated stigma (P = 0. Based on this result.) 2nd quintile 3rd quintile Living with spouse/sex partner Sex partner is considered steady Knowing sex partner’s HIV status Having multiple sex partners Having a low level of HIV stigma Note * P \ 0.6–1.4–1.3) 1.9–2.1 (0.08).8 (3.5–3.5 (1.1–2. About 8% of the sample was between 18 and 24.6) 3.9–3.3 (1.1 (0.4) 1.6 (1.8–6.9)** 1.2–5.0 (0.4–39.2) 1.1 (3.1) 2.4 (1.0)** 18% 2.) 25–34 35–44 45–61 Female Wealth (1st quintile = ref.3)* 1.3 (0.8 (1.6–1.01.2–2.3 (1. ** P \ 0.3–8. 51% was between 25 and 34.6) 1.5–7.6 (0.4 (0.5–3.2 (0. ** P \ 0.1) N/a 1.7 (1.2–18.5)** 123 .6 (1.6–4.0) 2.3 (0.2–2. The Hosmer– Lemeshow test of goodness of fit was used to determine model fit of the logistic regression models to assess factors associated with HIV disclosure.1 (0.8) 1.7–2.1)*** 2.6–1.1 (1.2 (0.2 (0.4 (0. *** P \ 0.0 (1.4 (2.4 (0.05. ranging from 18 to 61 years old.8–2.1–4. OR odds ratio.7) 1.4–18.9 (1. 32% was between 35 and 44.0–2. *** P \ 0.05.5–5.2 (0.6 (1.6–3. Study sites (five different clinics) were controlled in all analyses and P-value was determined based on the robust standard error. the final model predicting HIV disclosure was stratified by the types of sex partner (Table 3).5 (0.9) 1.001. AOR adjusted odds ratio On ART for 1 year Pseudo R2 1.8) 1.6 (0.4–4.7) 1.6–1.5–5. OR odds ratio. with model selection done using a forward stepwise selection process.5)** 7.6) 17% 1.7 (0.9 (0.3–1.7)*** 1.0) 1.3 (1.2) 7.1) 1.9) 1.3)** 23% 1. Results Participants were mainly from the working-age group with a median age of 33.8–1.8–3.3 (0.1) 1.7)** 1.001.1 (0.1) 2.0)*** 4.) 2nd quintile 3rd quintile Living with spouse/sex partner Knowing sex partner’s HIV status Having multiple sex partners Having a low level of HIV stigma Note * P \ 0.9) 1.6)** 1.9 (1.1–1.6–6.7 (0.9 (3.

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. respondents with partners with known-HIV status were 8 times more likely to disclose [AOR = 7.9].6) and 1. 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 five largest ART clinics in the Cape Town metro area. These results suggest that interventions to increase disclosure. HIV-related stigma (P \ 0.3].1–2.001). coupled with perceived stigma of HIV. is corroborated in a previous analysis of this population: ART positively alters sexual risk behavior [9. which could increase HIV-risk 123 .0] were significantly associated with HIV disclosure. and ART (P \ 0. likely diminishes the likelihood of disclosing one’s HIV status to a steady partner. 29].6].1. HIV status of the sex partner (P \ 0. and being on ART [AOR = 2. (95% CI: 1. Participants with a steady sex partner were more likely to disclose their HIV sero-status compared to those with casual sex partners [AOR = Individuals who perceived low levels of HIV-related stigma were twice as likely to disclose their HIV status [AOR = 1. A stratified analysis by sex partner type showed that knowing a sex partner’s HIV status remained significantly associated with HIV status disclosure within both steady [AOR = 7. condom use at last sex. ART may improve the health of PLWHA [9].1–1. 95% CI: 1. co-habitation status. and thereby facilitate more open condom negotiations at sex. 95% CI: 1. should recognize the importance of stigma on disclosure among those with steady partners.4–4. After controlling for age. Within steady relationships. The study also finds a significant relationship between HIV disclosure and entry into an ART program.1–4. Nearly half reported having partners with unknown HIV status (46. However. the improvement in health could generate optimism in PLWHA.1–1. being female [AOR = 2. 20% considered their most recent sex partner ‘‘casual’’ (Table 1). This is of particular importance as there may also be issues related to having children and contraceptive use within a steady relationship. 10% of the sample had multiple sex partners in the past month. Gender.1–1. The bivariate analysis suggests that co-habitation status (P \ 0.3]. although the same relationship was not found between these variables in casual partnerships. 95% CI: 1. and 14% had an HIV-negative partner. counseling to build trust and understanding and to create a supportive environment among steady couples may facilitate HIV disclosure. we hypothesize that if one does not disclose their HIV status to a sex partner initially. and bring more opportunities for sexual activities.4–18. resulting in more disclosure.3]. We found 1 in 5 respondents had not disclosed their HIV status to their most recent sex partners. as compared to the youngest group (18–24 years old) [Adjusted odds ratios (AOR) = 1. perceiving low stigma [AOR = 2. Conversely. There were twice as many females (67%) as males (33%) in the sample. especially among steady partners [25–28]. 95% CI: 1.6.5]. 39. Additionally.8. Second.1] and casual relationships [AOR = 7.001). it may become more difficult to disclose as the relationship progresses over time and increases in intimacy and closeness.5.3. These results also demonstrate the importance of considering partner type on how stigma affects disclosure. As found elsewhere [28. type of the sex partner (P \ 0. with nearly a quarter (23%) reported that they did not use condom at last sex.5] were associated with HIV status disclosure within casual but not steady sex partnerships (Table 3).4–39. thus reducing a perceived or actual stigma. respectively].4 (95% CI: 1. First.01). and multiple sexual partnerships were not significantly associated with HIV status disclosure (Table 2).6–4. which is similar to non-disclosure found in other studies in this region [21. 19% of the study participants had not disclosed their HIV status to their most recent sex partner (n = 117).3.0. in fact. For example. being older [AOR 1. resulting in enhanced disclosure. 95% CI: 1. South Africa. the effect of stigma on disclosure was mitigated by the type of sex partner.5%). 95% CI: 3.2–3. compared to having a partner with unknown-HIV status. 24]. wealth.5] and living with a spouse/sex partner [AOR = 2. 95% CI: 1.8). 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 = 1.8.2–18. Partner HIV status showed a strong association with HIV disclosure. 22]. Lastly.2–4.1) were associated with HIV status disclosure (Table 1). 95% CI: 1.2–2. 95% CI: 1. in the stratified analysis stigma only influenced disclosure among those with a steady partner. 95% CI: 1.5% had an HIV-positive partner. About one-third (31%) of the sample was unemployed and a half of them lived with their spouse or sex partner. 95% CI: 3. About half of the sample self-reported good health (Table 1).136 AIDS Behav (2012) 16:132–138 was between 45 and 61. We offer a few possible explanations for this. After controlling for potential confounders.7.001). This study supports other literature indicating that HIVrelated stigma is an important barrier in disclosing one’s HIV status. This finding. logistic regression showed individuals aged 25–44 were more likely to disclose their HIV status to their sex partner. Although ART treatment optimism has been documented in developed country settings.7]. gender and wealth. fear of losing or damaging a steady relationship.

to withstand this revelation.7 times higher than casual sex partners. 67% of this study population was female. In addition. 2. In addition. In many situations. which prevented us from understanding more complex disclosure issues. Second. GA. This may be of particular benefit 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]. Stirratt MJ. This finding indicates that it is not the HIV status that affects one’s own decision to disclose but rather the knowledge of the partner’s HIV status. Self-efficacy and disclosure of HIV-positive serostatus to sex partners. In addition. We also found that in the case of those who had casual sex partners. PLWHA might live in the same house with the steady partner. 34]. which could be useful for counselors and health workers in HIVrisk reduction interventions. thus they were obligated to go through counseling to increase ART adherence and decrease risk behaviors. Smith A. There are a number of important study limitations. especially when HIV is generalized across different population groups. Finally. Counselors are able to create an environment where couples are informed about the possible benefit versus the negative consequences if ones disclose their HIV status. AIDS epidemic update 2009. which would have influenced disclosure. Finally. Republic of South Africa. The role of HIV serostatus disclosure in antiretroviral medication adherence. PLWHA may feel concerned about their partner’s health and thus feel responsible for protecting their partners. Fear of partner’s negative reactions and stigma prevents PLWHA from disclosing their HIV status to the sex partner. 123 . First. 31]. This suggests that gender inequity in a relationship might prevent women from asking the HIV status of their male partners. especially when one was out of work due to illness [16]. Kalichman SC. the steady sex partner is more likely to be one’s confidant for disclosure [16]. These results are therefore likely not representative of PLWHA outside the ART system. and seeking economic support may facilitate disclosure to a steady sex partner. the other would not answer [33. 4. The study also shows that PLWHA tend to disclose their HIV status to sex partners whose HIV status they know. females were twice as likely as males to disclose. Miller LC. South Africa. we believe it is less likely the case for this population. AIDS Behav. Remien RH. more negative impact of HIVrelated stigma among steady sex partners was found. It may also be that the relationship is solid enough. In addition.AIDS Behav (2012) 16:132–138 137 behaviors [30. One possible explanation is that knowing someone’s HIV status requires discussions about one’s own HIV status among the couples before sex. the study population was either on ART or about to start ART. 18(3):281–7. or males do not feel obligated to disclose to their female partners. the issues related to care for children. References 1. responses were likely subject to social-desirability bias. irrespective of the use of assisted self interview techniques on PDAs. 2006. Progress report on declaration of commitment on HIV and AIDS: reporting period: January 2006– December 2007. It also supports that reducing HIV-related stigma is important in HIV prevention. Switzerland. 3. Krieger D. Dolezal C.10(5):483–93. UNAIDS. This may be due to a lower sense of responsibility to casual sex partners [25]. Acknowledgments The authors would like to thank the Centers for Disease Control and Prevention (Atlanta. Third. However. 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). which makes it difficult for them to conceal their HIV status. The study supports the importance of ART in reducing HIV-risk behaviors of PLWHA in poor socioeconomic settings by increasing HIV disclosure. PLWHA tend to disclose their HIV status to a steady and committed partner rather than to a casual partner. we were unable to distinguish whether a casual sex partner was a sexual encounter with a commercial sex worker. This relationship remains highly significant in the stratified analysis across the two partner types. and to the men and women of Cape Town (South Africa) for participating in the study. 5. This implies that safe sex negotiation skills. Geneva. which likely educed the possibility that ‘‘commercial sex’’ has confounded the ‘‘casual sex’’ category. Copeland OQ. we did not measure the reasons why PLWHA choose to disclose or not to disclose their HIV status. Nov 2009. in a steady relationship. regardless of the partner’s HIV status. USA) for funding. Psychol Bull. We found the proportion of HIV disclosure to a steady sex partner is 2. in a steady relationship. Self-disclosure and liking: a meta-analytic review. Nachimson D. potentially leading to more disclosure. Another major implication is that HIV disclosure is a complex phenomenon that varies among different types of sexual relationships. ISBN 9789291738328. it gives the counselors the sense of what is important for disclosing one’s HIV status. including knowing partners’ HIV status is vital for everyone. Collins NL. possibly resulting in unprotected sex and furthering the epidemic. couple counseling and testing may help PLWHA to disclose their HIV status to significant other. especially given that South Africa has high levels of HIV-related stigma and discriminations [24. Apr 2008. child support. 1999. Health Psychol. 1994. If one does not ask. leading to more disclosure [32].116(3):457–75. It also suggests that discussion about one’s partner HIV status is important for facilitating disclosure. 31].

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