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

3 (64) 87.3(204) 82. College Station. HIV status) (Table 1).38) 8.0) 1.7 (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 84.3 (283) 43. TX).2 (409) 72.8 (0.4 (162) 80.5 (0.4 (171) 81.0 (1.7 (433) 31.8 (0.1 (75) 82. sex and wealth) and partner-related characteristics (co-habitation.2 (291) 53.9 (262) 82.7 (370) 41.26) 1.9 (547) 12.5 (222) 54.1 (283) 314 (50.0 (322) 46.6 (291) 76.001) 77.9 (175) 85.3 (197) 81..004) 2. socio-demographic variables (age.2 (466) 74.6 (228) 90.134 AIDS Behav (2012) 16:132–138 Data Analysis All analyses were carried out using STATA software version 11.0 (296) 83.00) 59.3 (442) 57.7 (155) 68.2 (0.9 (201) 9.8 (320) 31.5 (0.8 (339) 87.2 (0.7 (124) 72.0 (567) 10.6 (0.7 (46) 8.0 (176) 79.7(420) 76.5 (0.23) 2.0 (340) 46.3 (273) 56.27) 58.9 (40) 81.8 (0.5 (217) 34.2 (104) 90.0 (63) 65.84) 0.00) 2.0 (STATA Corp.3 (52) 50.5 (191) 95.4 (0. Variables significant at P \ 0.7 (358) 78. 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.8 (219) 32.4 (342) 33.2 (444) 85.0 (57) 0.0) 314 (50.6 (47) 84.3 (260) 31.3 (210) 66.3 (506) 19.9 (144) 0.7 (357) 85.1 (165) 80.10) 123 .3 (71) 80.9 (176) 32.00) 89 (0.3 (230) 79.14) 10.0) 79.0 (290) 81.1 (486) 22.

2 (0.6–1.3) 1.0) 2.3 (0.2) 7.2–5. About 8% of the sample was between 18 and 24.6) 3.2–2.9–1. OR odds ratio.4 (0.001.0)** 18% 2.6 (1.8–3.3 (1.8–2.9 (1.1 (3. with model selection done using a forward stepwise selection process.0 (0.) 25–34 35–44 45–61 Female Wealth (1st quintile = ref.5–7.3–8. *** P \ 0.3 (0.6)** 1.4) 1.05. 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. while controlling for potential confounding factors (Table 2).05.6 (1.08). *** P \ 0.5) 1.7 (1.6–6.2–4.7–2.8–1.6–2.2) 2.4–1.1–1.1 (1. ranging from 18 to 61 years old.8 (0.) 25–34 35–44 45–61 Female Wealth (1st quintile = ref.7)** 1.3)** 2.) 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 \ 0.7) 1.4) 0.3 (1.5)** 7.1 (0.4 (2.8 (1.0)*** 4.6–1.2 (0.9–2.3 (0.5–3.1–1.6 (0. ** P \ 0.1)*** 2.) 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 \ 0.9) 1.8) 1.9 (3.9) 1.1) 2.3)** 23% 1.6–1.5 (0. Study sites (five different clinics) were controlled in all analyses and P-value was determined based on the robust standard error.8)** 1.6–3.6) 1.7–2.1–4.8–6.1) 1.1 (0.3–1. ** P \ 0.4 (1.2–2. Based on this result.8 (3.01.1) N/a 1.4 (0. AOR adjusted odds ratio On ART for 1 year Pseudo R2 1.0 (0. the final model predicting HIV disclosure was stratified by the types of sex partner (Table 3).8)*** 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.5–5. 32% was between 35 and 44.9–3.1) 1.3 (0.6) 17% 1. Results Participants were mainly from the working-age group with a median age of 33.1–2.6) 1.1 (0.2) 1.9) 1.3)* 1.0–2.6–1.5)** 123 .8 (3.2 (0.5 (1.7 (0. AOR adjusted odds ratio On ART for 1 year Pseudo R2 1.6–1.4)*** 5.0) 1.0 (0.4–18.4–3.4 (0.1 (0.2 (0.001.9) 1.9–2.9 (1.1) 2. 51% was between 25 and 34.1) 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 (0.7–2.9 (0.2) 1.1–1.6)*** 7.5)** 1.01.9)** 1.8) 1.7 (0.6 (1.2–18.2 (0.8–2.AIDS Behav (2012) 16:132–138 135 assessed using logistic regression.6)** 1.6–1. OR odds ratio.2–3.5–3.4–39.5–5.6–4.7)*** 1.6 (0.7) 1.4–4.3 (1.0 (1. We then examined the potential interaction of types of sex partner and HIVrelated stigma (P = 0.

respondents with partners with known-HIV status were 8 times more likely to disclose [AOR = 7. After controlling for potential confounders.1] and casual relationships [AOR = 7. As found elsewhere [28. and 14% had an HIV-negative partner.6. The bivariate analysis suggests that co-habitation status (P \ 0.5. HIV-related stigma (P \ 0. 19% of the study participants had not disclosed their HIV status to their most recent sex partner (n = 117). For example. 95% CI: 1. in the stratified analysis stigma only influenced disclosure among those with a steady partner. 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. and being on ART [AOR = 2. However.2–18. These results also demonstrate the importance of considering partner type on how stigma affects disclosure. and multiple sexual partnerships were not significantly associated with HIV status disclosure (Table 2). First.3].2–4. resulting in enhanced disclosure.5] and living with a spouse/sex partner [AOR = 2. Gender. 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. This finding. compared to having a partner with unknown-HIV status. is corroborated in a previous analysis of this population: ART positively alters sexual risk behavior [9. should recognize the importance of stigma on disclosure among those with steady partners. which is similar to non-disclosure found in other studies in this region [21. 29].9]. Second.0. There were twice as many females (67%) as males (33%) in the sample. (95% CI: 1.5%). although the same relationship was not found between these variables in casual partnerships.4–18. 95% CI: 1. 10% of the sample had multiple sex partners in the past month.0] were significantly associated with HIV disclosure. Individuals who perceived low levels of HIV-related stigma were twice as likely to disclose their HIV status [AOR = 1.4–4. gender and wealth.6–4. logistic regression showed individuals aged 25–44 were more likely to disclose their HIV status to their sex partner. 24]. These results suggest that interventions to increase disclosure. 39. 95% CI: 1.1. Participants with a steady sex partner were more likely to disclose their HIV sero-status compared to those with casual sex partners [AOR = 2.1–4. and bring more opportunities for sexual activities. which could increase HIV-risk 123 . HIV status of the sex partner (P \ 0. 95% CI: 3. 20% considered their most recent sex partner ‘‘casual’’ (Table 1). ART may improve the health of PLWHA [9].2–3. 22]. 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. especially among steady partners [25–28]. type of the sex partner (P \ 0. 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. and thereby facilitate more open condom negotiations at sex.3. We found 1 in 5 respondents had not disclosed their HIV status to their most recent sex partners. The study also finds a significant relationship between HIV disclosure and entry into an ART program. Nearly half reported having partners with unknown HIV status (46. This is of particular importance as there may also be issues related to having children and contraceptive use within a steady relationship.01). thus reducing a perceived or actual stigma. respectively]. About one-third (31%) of the sample was unemployed and a half of them lived with their spouse or sex partner.5]. Within steady relationships. coupled with perceived stigma of HIV. and ART (P \ 0. 95% CI: 1. About half of the sample self-reported good health (Table 1).8). resulting in more disclosure. 95% CI: 1.6) and 1.3]. wealth.3.136 AIDS Behav (2012) 16:132–138 was between 45 and 61. the effect of stigma on disclosure was mitigated by the type of sex partner.5] were associated with HIV status disclosure within casual but not steady sex partnerships (Table 3).1–2.1–1.3. co-habitation status.2–2. it may become more difficult to disclose as the relationship progresses over time and increases in intimacy and closeness.1) were associated with HIV status disclosure (Table 1). 95% CI: 1.4 (95% CI: 1. This study supports other literature indicating that HIVrelated stigma is an important barrier in disclosing one’s HIV status.8. with nearly a quarter (23%) reported that they did not use condom at last sex.7]. likely diminishes the likelihood of disclosing one’s HIV status to a steady partner.1–1. perceiving low stigma [AOR = 2. South Africa. fear of losing or damaging a steady relationship.5% had an HIV-positive partner. After controlling for age. the improvement in health could generate optimism in PLWHA. Although ART treatment optimism has been documented in developed country settings. Conversely. 95% CI: 1.3]. condom use at last sex. we hypothesize that if one does not disclose their HIV status to a sex partner initially. We offer a few possible explanations for this. in fact.8. Partner HIV status showed a strong association with HIV disclosure. counseling to build trust and understanding and to create a supportive environment among steady couples may facilitate HIV disclosure. 95% CI: 1. Additionally. being older [AOR 1. Lastly.001).4–39. 95% CI: 1.7.6]. as compared to the youngest group (18–24 years old) [Adjusted odds ratios (AOR) = 1.001).6.1–1.001).9. 95% CI: 3. being female [AOR = 2.

Nachimson D. 31]. In addition. We also found that in the case of those who had casual sex partners. child support. PLWHA may feel concerned about their partner’s health and thus feel responsible for protecting their partners. to withstand this revelation. GA. especially given that South Africa has high levels of HIV-related stigma and discriminations [24. Dolezal C. PLWHA tend to disclose their HIV status to a steady and committed partner rather than to a casual partner. which could be useful for counselors and health workers in HIVrisk reduction interventions. 1999. responses were likely subject to social-desirability bias. 5. In many situations. thus they were obligated to go through counseling to increase ART adherence and decrease risk behaviors. Stirratt MJ. There are a number of important study limitations. especially when HIV is generalized across different population groups. Collins NL. in a steady relationship. couple counseling and testing may help PLWHA to disclose their HIV status to significant other. which makes it difficult for them to conceal their HIV status. UNAIDS. This implies that safe sex negotiation skills. PLWHA might live in the same house with the steady partner. Psychol Bull. 31]. 2. Apr 2008. 123 . the issues related to care for children. 34]. which would have influenced disclosure. more negative impact of HIVrelated stigma among steady sex partners was found. This suggests that gender inequity in a relationship might prevent women from asking the HIV status of their male partners. Krieger D. we believe it is less likely the case for this population. Republic of South Africa. 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. Remien RH. However. 4. We found the proportion of HIV disclosure to a steady sex partner is 2.7 times higher than casual sex partners. which likely educed the possibility that ‘‘commercial sex’’ has confounded the ‘‘casual sex’’ category. we were unable to distinguish whether a casual sex partner was a sexual encounter with a commercial sex worker. which prevented us from understanding more complex disclosure issues. females were twice as likely as males to disclose. Switzerland.AIDS Behav (2012) 16:132–138 137 behaviors [30.116(3):457–75. regardless of the partner’s HIV status. This relationship remains highly significant in the stratified analysis across the two partner types. It also suggests that discussion about one’s partner HIV status is important for facilitating disclosure. 67% of this study population was female. This may be due to a lower sense of responsibility to casual sex partners [25]. AIDS epidemic update 2009. we did not measure the reasons why PLWHA choose to disclose or not to disclose their HIV status. 2006. 18(3):281–7. 1994. irrespective of the use of assisted self interview techniques on PDAs. possibly resulting in unprotected sex and furthering the epidemic. ISBN 9789291738328. First. or males do not feel obligated to disclose to their female partners. and to the men and women of Cape Town (South Africa) for participating in the study. Acknowledgments The authors would like to thank the Centers for Disease Control and Prevention (Atlanta. In addition. In addition. Self-efficacy and disclosure of HIV-positive serostatus to sex partners. Miller LC. Another major implication is that HIV disclosure is a complex phenomenon that varies among different types of sexual relationships. References 1. including knowing partners’ HIV status is vital for everyone. Progress report on declaration of commitment on HIV and AIDS: reporting period: January 2006– December 2007. Kalichman SC. It also supports that reducing HIV-related stigma is important in HIV prevention. Health Psychol. USA) for funding. Copeland OQ. South Africa. the other would not answer [33. Finally. the study population was either on ART or about to start ART. Self-disclosure and liking: a meta-analytic review. The study supports the importance of ART in reducing HIV-risk behaviors of PLWHA in poor socioeconomic settings by increasing HIV disclosure. it gives the counselors the sense of what is important for disclosing one’s 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. especially when one was out of work due to illness [16]. The role of HIV serostatus disclosure in antiretroviral medication adherence. Finally. These results are therefore likely not representative of PLWHA outside the ART system. Nov 2009. 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. Fear of partner’s negative reactions and stigma prevents PLWHA from disclosing their HIV status to the sex partner. in a steady relationship. Third. leading to more disclosure [32]. Smith A. One possible explanation is that knowing someone’s HIV status requires discussions about one’s own HIV status among the couples before sex. and seeking economic support may facilitate disclosure to a steady sex partner. potentially leading to more disclosure. the steady sex partner is more likely to be one’s confidant for disclosure [16]. 3. AIDS Behav.10(5):483–93. If one does not ask. It may also be that the relationship is solid enough. 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]. Second. The study also shows that PLWHA tend to disclose their HIV status to sex partners whose HIV status they know. Geneva.

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