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AIDS Behav (2012) 16:132–138 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 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: lvu@popcouncil.org 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: 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 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

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

8 (219) 32.9 (176) 32.6 (47) 84.3 (273) 56..5 (222) 54.2 (0.8 (339) 87.3 (230) 79.5 (191) 95. College Station.3 (52) 50.2 (291) 53.00) 2.0 (STATA Corp.7 (0.7 (357) 85.001) 77.3(204) 82.004) 2.3 (260) 31.3 (71) 80.00) 89 (0.4 (0.8 (0.0) 314 (50.9 (40) 81.25 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 84.5 (217) 34.3 (64) 87.3 (506) 19.2 (444) 85.9 (175) 85.9 (262) 82.23) 2.6 (0.10) 123 .3 (283) 43.8 (0.7 (155) 68. TX).4 (162) 80.9 (144) 0.8 (0. socio-demographic variables (age.5 (0.27) 58.0) 79.9 (547) 12. sex and wealth) and partner-related characteristics (co-habitation. Variables significant at P \ 0.84) 0.14) 10.0 (290) 81.7 (433) 31.4 (342) 33.4 (171) 81.5 (0.0 (57) 0.2 (409) 72.1 (165) 80.0 (340) 46.3 (210) 66.26) 1.0 (322) 46.9 (201) 9. HIV status) (Table 1).8 (320) 31.1 (486) 22.0 (296) 83.7 (370) 41.1 (75) 82.134 AIDS Behav (2012) 16:132–138 Data Analysis All analyses were carried out using STATA software version 11.0 (63) 65.38) 8. 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.7 (124) 72.3 (442) 57.0 (567) 10.6 (291) 76.00) 59.2 (104) 90.7(420) 76.7 (358) 78.5 (0.0 (176) 79.6 (228) 90.3 (197) 81.2 (0.0 (1.0) 1.1 (283) 314 (50.7 (46) 8.2 (466) 74.

6 (1.6 (0. 32% was between 35 and 44.7 (1.0 (0.) 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 \ 0.3–1.3 (1.8 (3.0 (0.4) 0. *** P \ 0.1) N/a 1. AOR adjusted odds ratio On ART for 1 year Pseudo R2 1. Based on this result.0 (1.5)** 123 .6)** 1.) 25–34 35–44 45–61 Female Wealth (1st quintile = ref.9–2.8–3.7–2.6–2.1–1.01.001.9)** 1.4 (1.8) 1. 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.0 (0.8)*** 0. ** P \ 0.5–3.1–4.0)** 18% 2.2–2.001.4 (0.4 (0.3–8.9) 1.2–3.2) 1.1 (0.7 (0.5–5.0)*** 4.2 (0.8)** 1.1) 2.8 (0.3 (1.4 (0.4–1.2 (0.08).0–2. ranging from 18 to 61 years old.9 (1.01.3) 1.6–1.5 (0. About 8% of the sample was between 18 and 24.8) 1. ** P \ 0.6–6.6 (1. the final model predicting HIV disclosure was stratified by the types of sex partner (Table 3).9–1.05.05.2) 2.5)** 1.2–5.7)** 1.6–3.6) 1.3 (0.4) 1. OR odds ratio.6)** 1.8–6.6 (1.6–1.7)*** 1.8 (3.1) 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.2 (0.1 (3.1)*** 2.4 (2.1) 2.6–1.8–2.1–1.2) 7.5)** 7.3)** 2.4–18.1 (1.7) 1.6 (0.2 (0.3 (1.6) 1.4 (0. *** P \ 0.7–2.8–1. Results Participants were mainly from the working-age group with a median age of 33.1 (0.3 (0. 51% was between 25 and 34.9–2.2) 1. We then examined the potential interaction of types of sex partner and HIVrelated stigma (P = 0.2–2.1 (0.1–2.2 (0.AIDS Behav (2012) 16:132–138 135 assessed using logistic regression.0) 1.1 (0. 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.5) 1.3 (0.8 (1.5–5.9) 1. AOR adjusted odds ratio On ART for 1 year Pseudo R2 1.5–3.3 (0.1–1.5 (1.6–4. with model selection done using a forward stepwise selection process.) 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 \ 0.2–18.9) 1.6)*** 7.6–1. OR odds ratio. Study sites (five different clinics) were controlled in all analyses and P-value was determined based on the robust standard error.6) 3.6–1.4–4.8–2.4)*** 5.9 (1.0) 2.4–39.1) 1.9 (3.2–4.7–2.9) 1.9–3.3)* 1.6) 17% 1.7 (0.3)** 23% 1. while controlling for potential confounding factors (Table 2).1) 1.5–7.6–1.7) 1.4–3.) 25–34 35–44 45–61 Female Wealth (1st quintile = ref.9 (0.

5] and living with a spouse/sex partner [AOR = 2. For example. 95% CI: 1. Conversely. 10% of the sample had multiple sex partners in the past month.1–1. 95% CI: 1.1) were associated with HIV status disclosure (Table 1). After controlling for potential confounders.6–4. in fact.9].2–4. condom use at last sex.001). coupled with perceived stigma of HIV.5%). thus reducing a perceived or actual stigma. logistic regression showed individuals aged 25–44 were more likely to disclose their HIV status to their sex partner. ART may improve the health of PLWHA [9].1.1–2.5% had an HIV-positive partner. After controlling for age.5]. and thereby facilitate more open condom negotiations at sex.136 AIDS Behav (2012) 16:132–138 was between 45 and 61. Individuals who perceived low levels of HIV-related stigma were twice as likely to disclose their HIV status [AOR = 1. 95% CI: 1.3.6]. although the same relationship was not found between these variables in casual partnerships. These results also demonstrate the importance of considering partner type on how stigma affects disclosure. These results suggest that interventions to increase disclosure. and 14% had an HIV-negative partner. which is similar to non-disclosure found in other studies in this region [21.7]. is corroborated in a previous analysis of this population: ART positively alters sexual risk behavior [9. However.3. with nearly a quarter (23%) reported that they did not use condom at last sex. First.001). and multiple sexual partnerships were not significantly associated with HIV status disclosure (Table 2). 29].5.1–4. Partner HIV status showed a strong association with HIV disclosure. co-habitation status. The study also finds a significant relationship between HIV disclosure and entry into an ART program.5] were associated with HIV status disclosure within casual but not steady sex partnerships (Table 3). respectively]. (95% CI: 1.1] and casual relationships [AOR = 7.9. HIV status of the sex partner (P \ 0. 24]. 95% CI: 3. As found elsewhere [28. being female [AOR = 2.6. and ART (P \ 0.001). Participants with a steady sex partner were more likely to disclose their HIV sero-status compared to those with casual sex partners [AOR = 2. gender and wealth. Additionally. which could increase HIV-risk 123 .8). About half of the sample self-reported good health (Table 1). the improvement in health could generate optimism in PLWHA.6. HIV-related stigma (P \ 0. counseling to build trust and understanding and to create a supportive environment among steady couples may facilitate HIV disclosure. 95% CI: 1. Although ART treatment optimism has been documented in developed country settings.01). 95% CI: 1. 20% considered their most recent sex partner ‘‘casual’’ (Table 1). type of the sex partner (P \ 0. 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. Gender. resulting in enhanced disclosure. wealth. 39. 22]. respondents with partners with known-HIV status were 8 times more likely to disclose [AOR = 7. This finding. compared to having a partner with unknown-HIV status.4–18. Second. We found 1 in 5 respondents had not disclosed their HIV status to their most recent sex partners. 95% CI: 1. About one-third (31%) of the sample was unemployed and a half of them lived with their spouse or sex partner. This is of particular importance as there may also be issues related to having children and contraceptive use within a steady relationship. the effect of stigma on disclosure was mitigated by the type of sex partner. The bivariate analysis suggests that co-habitation status (P \ 0.3]. likely diminishes the likelihood of disclosing one’s HIV status to a steady partner. as compared to the youngest group (18–24 years old) [Adjusted odds ratios (AOR) = 1.1–1. 95% CI: 1.3.2–18. it may become more difficult to disclose as the relationship progresses over time and increases in intimacy and closeness.0. 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 = 7.2–3.1–1. 95% CI: 3. 95% CI: 1.3]. fear of losing or damaging a steady relationship.6) and 1.4–4.4 (95% CI: 1.3].2–2. and being on ART [AOR = 2. We offer a few possible explanations for this. should recognize the importance of stigma on disclosure among those with steady partners. in the stratified analysis stigma only influenced disclosure among those with a steady partner. 19% of the study participants had not disclosed their HIV status to their most recent sex partner (n = 117).8. especially among steady partners [25–28].4–39. being older [AOR 1. There were twice as many females (67%) as males (33%) in the sample. we hypothesize that if one does not disclose their HIV status to a sex partner initially. and bring more opportunities for sexual activities. This study supports other literature indicating that HIVrelated stigma is an important barrier in disclosing one’s HIV status. 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. Lastly. Within steady relationships. resulting in more disclosure.7.0] were significantly associated with HIV disclosure. 95% CI: 1. perceiving low stigma [AOR = 2. South Africa. 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. Nearly half reported having partners with unknown HIV status (46.8.

116(3):457–75. Krieger D. In addition. Geneva. 2. There are a number of important study limitations. One possible explanation is that knowing someone’s HIV status requires discussions about one’s own HIV status among the couples before sex. leading to more disclosure [32]. The study also shows that PLWHA tend to disclose their HIV status to sex partners whose HIV status they know. This relationship remains highly significant in the stratified analysis across the two partner types. ISBN 9789291738328. regardless of the partner’s HIV status. which could be useful for counselors and health workers in HIVrisk reduction interventions. Switzerland. Third. This may be due to a lower sense of responsibility to casual sex partners [25]. Second. potentially leading to more disclosure. especially when one was out of work due to illness [16]. more negative impact of HIVrelated stigma among steady sex partners was found. The role of HIV serostatus disclosure in antiretroviral medication adherence. 31]. Self-disclosure and liking: a meta-analytic review. 2006. which prevented us from understanding more complex disclosure issues. It also suggests that discussion about one’s partner HIV status is important for facilitating disclosure. Finally. or males do not feel obligated to disclose to their female partners. 3. we believe it is less likely the case for this population. possibly resulting in unprotected sex and furthering the epidemic. In many situations. AIDS Behav. If one does not ask. USA) for funding. South Africa. Nov 2009. we were unable to distinguish whether a casual sex partner was a sexual encounter with a commercial sex worker. the steady sex partner is more likely to be one’s confidant for disclosure [16]. Self-efficacy and disclosure of HIV-positive serostatus to sex partners. Progress report on declaration of commitment on HIV and AIDS: reporting period: January 2006– December 2007. Apr 2008. Stirratt MJ. females were twice as likely as males to disclose. It also supports that reducing HIV-related stigma is important in HIV prevention. However. We found the proportion of HIV disclosure to a steady sex partner is 2. which would have influenced disclosure. UNAIDS. especially when HIV is generalized across different population groups. Nachimson D. which makes it difficult for them to conceal their HIV status. 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. This implies that safe sex negotiation skills. 1999.10(5):483–93. to withstand this revelation. PLWHA tend to disclose their HIV status to a steady and committed partner rather than to a casual partner. child support. the other would not answer [33. AIDS epidemic update 2009. Finally. Psychol Bull. 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. The study supports the importance of ART in reducing HIV-risk behaviors of PLWHA in poor socioeconomic settings by increasing HIV disclosure. In addition. 123 . including knowing partners’ HIV status is vital for everyone. Smith A. in a steady relationship. Kalichman SC. We also found that in the case of those who had casual sex partners. especially given that South Africa has high levels of HIV-related stigma and discriminations [24. Another major implication is that HIV disclosure is a complex phenomenon that varies among different types of sexual relationships. couple counseling and testing may help PLWHA to disclose their HIV status to significant other. PLWHA may feel concerned about their partner’s health and thus feel responsible for protecting their partners. it gives the counselors the sense of what is important for disclosing one’s HIV status. we did not measure the reasons why PLWHA choose to disclose or not to disclose their HIV status. responses were likely subject to social-desirability bias. Copeland OQ. irrespective of the use of assisted self interview techniques on PDAs. 4.7 times higher than casual sex partners. and to the men and women of Cape Town (South Africa) for participating in the study. in a steady relationship. 67% of this study population was female. 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]. GA. These results are therefore likely not representative of PLWHA outside the ART system. First. which likely educed the possibility that ‘‘commercial sex’’ has confounded the ‘‘casual sex’’ category. 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). In addition. Acknowledgments The authors would like to thank the Centers for Disease Control and Prevention (Atlanta. It may also be that the relationship is solid enough. 5. the issues related to care for children. Fear of partner’s negative reactions and stigma prevents PLWHA from disclosing their HIV status to the sex partner. Miller LC. This suggests that gender inequity in a relationship might prevent women from asking the HIV status of their male partners. the study population was either on ART or about to start ART. Remien RH. and seeking economic support may facilitate disclosure to a steady sex partner. 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