Predictors of HIV-1 serostatus disclosure: a prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania

Male involvement in antenatal HIV counseling and testing: exploring men's perceptions in rural Malawi

Antenatal care can act as an excellent tool to improve access to HIV counseling and testing services. This paper investigates an issue that may weaken its potential, namely lack of male involvement. We explored married men's perceptions of HIV in pregnancy and male involvement in antenatal HIV testing and counseling in Southern Malawi through 11 focus group discussions and a cross-sectional survey (n=388). The main findings were that men were largely unaware of available antenatal HIV testing and counseling services, and perceived it overall problematic to attend female-oriented health care. Most men supported provision of antenatal HIV testing. They perceived husbands to participate in the process indirectly through spousal communication, being faithful during pregnancy, and supporting the wife if found HIV-positive. Involvement of husbands was compromised by men's reluctance to learn their HIV status and the threat that HIV poses on marriage. Men stressed the importance of prior spousal agreement of antenatal HIV testing and considered HIV testing without their consent a valid reason for divorce. We suggest that male involvement in antenatal HIV testing requires refocusing of information and health services to include men. To avoid negative social outcomes for women, comprehensive and early involvement of men is essential.

Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa

BACKGROUND

Access to free antiretroviral therapy in sub-Saharan Africa has been steadily increasing, and the success of large-scale antiretroviral therapy programs depends on early initiation of HIV care. However, little is known about the stage at which those infected with HIV present for treatment in sub-Saharan Africa.

METHODS

We conducted a cross-sectional analysis of initial visits to the Immune Suppression Syndrome Clinic of the Mbarara University Teaching Hospital, including patients who had their initial visit between February 2007 and February 2008 (N = 2311).

RESULTS

The median age of the patients was 33 years (range 16-81 years), and 64% were female. More than one third (40%) were categorized as late presenters, that is, World Health Organization disease stage 3 or 4. Male gender, age 46-60 years (vs. younger), lower education level, being unemployed, living in a household with others, being unmarried, and lack of spousal HIV status disclosure were independently associated with late presentation, whereas being pregnant, having young children, and consuming alcohol in the prior year were associated with early presentation.

CONCLUSIONS

Targeted public health interventions to facilitate earlier entry into HIV care are needed, as well as additional study to determine whether late presentation is due to delays in testing vs. delays in accessing care.

Differential disclosure across social network ties among women living with HIV

Women’s disclosure of their HIV serostatus across social network ties was examined in a sample of women living in Los Angeles (n = 234), using multivariate random intercept logistic regressions. Women with disclosure-averse attitudes were less likely to disclose, while women with higher CD4+ counts were significantly more likely to disclose, regardless of relationship type. Relative to all other types of relationships, spouses/romantic partners were greater than four times more likely to be the targets of disclosure. Women were more than 2.5 times more likely to disclose to a given network member if that target provided the woman with social support. Social network members whom women believed to be HIV-positive were more than 10 times more likely to be the targets of disclosure. The implications for how social roles and social identities are manifest in these results are discussed, including the implications such an interpretation has for future prevention research.

Disclosure outcomes, coping strategies, and life changes among women living with HIV in Uganda

An HIV diagnosis is a life-changing event. Disclosure of HIV test results might be related to developing effective coping strategies. We conducted qualitative, in-depth interviews with 30 HIV-infected women in Uganda to explore links between HIV disclosure and coping strategies. Many women experienced an evolution in their ability to cope from initial shame to eventual acceptance. Factors that facilitated adaptive coping included being healthy, feeling responsible for children, support group participation, forming supportive relationships, and low perceived stigma and discrimination. HIV disclosure was often the first step in this coping process. Overall, 80% of the women had disclosed, with most reporting positive outcomes. Development of adaptive coping strategies and HIV serostatus disclosure are closely related, as they allow women to develop support networks and begin coming to terms with their diagnosis. Strategies are needed to safely support women who want to disclose their HIV test results.

One year after ART initiation: psychosocial factors associated with stigma among HIV-positive Mozambicans

The pathways through which stigma is associated with psychological distress remains understudied in Africa. This study evaluates stigma among 277 Mozambicans who were on an antiretroviral therapy (ART) regimens for a full year. Using bivariate and multiple regression analyses, we examine psychosocial factors (disclosure decisions, perceived social support, and depression) associated with stigma, at ART initiation and 1 year later. We found 1 year after initiating ART, participants reported no change in stigma, a decrease in perceived social support, and an increase in depressive symptomology. Disclosing HIV status to friends (versus family or partner) was associated with lower levels of stigma. These findings suggest that HIV care in comparable settings should include counselling, support groups, and peer support, that includes stigma and disclosure concerns prior to and during the first year following diagnosis. Most importantly, assessment and treatment of depression should be incorporated into ongoing HIV care.

Stigma of People with HIV/AIDS in Sub-Saharan Africa: A Literature Review

The aim of this literature review is to elucidate what is known about HIV/AIDS and stigma in Sub-Saharan Africa. Literature about HIV/AIDS and stigma in Sub-Saharan Africa was systematically searched in Pubmed, Medscape, and Psycinfo up to March 31, 2009. No starting date limit was specified. The material was analyzed using Gilmore and Somerville's (1994) four processes of stigmatizing responses: the definition of the problem HIV/AIDS, identification of people living with HIV/AIDS (PLWHA), linking HIV/AIDS to immorality and other negative characteristics, and finally behavioural consequences of stigma (distancing, isolation, discrimination in care). It was found that the cultural construction of HIV/AIDS, based on beliefs about contamination, sexuality, and religion, plays a crucial role and contributes to the strength of distancing reactions and discrimination in society. Stigma prevents the delivery of effective social and medical care (including taking antiretroviral therapy) and also enhances the number of HIV infections. More qualitative studies on HIV/AIDS stigma including stigma in health care institutions in Sub-Saharan Africa are recommended.

Gender and HIV testing in Burkina Faso: an exploratory study

This study investigated the utilization of services around HIV testing in Burkina Faso through a survey that combined quantitative and qualitative data from 14 selected sites and 299 questionnaires. While some attitudes and behaviors towards HIV testing were similar for women and men, we found lower use of services by men, greater concerns about testing and disclosure on the part of women, and differences between men and women in motivations to test, and the experience of testing and its consequences. The results are discussed in the context of Burkina Faso and in terms of their implications for efforts to improve access to services around HIV.

The impact of HIV/AIDS on the living arrangements and well-being of elderly caregivers in rural Uganda

As the HIV/AIDS epidemic continues to devastate the sub-Saharan Africa region, the demand for care and support services to persons infected and affected by the disease is proliferating. Currently providing the bulk of this much-needed care and support are elderly persons. However, limited work has been done to examine how such care and support impacts the well-being of elderly caregivers. Using qualitative data from elderly respondents in two Ugandan districts, Kamuli and Luwero, this article examines changes in the household structure and living arrangements of older persons (50 years and above) after they take on caregiving responsibilities for persons suffering from AIDS-related illnesses and orphans and vulnerable children (OVC) affected by HIV/AIDS. The findings show that elderly caregivers face drastic disruptions of living arrangements, including prolonged travels and absences from their homes to care for the sick. There is also a sharp increase in their household size as they take on more OVC. The implications of such changes on the older persons' health and well-being are discussed.

Slow to share: social capital and its role in public HIV disclosure among public sector ART patients in the Free State province of South Africa

HIV serostatus disclosure to community members has been shown to have potential public and personal health benefits. This study examined the impact of bonding and bridging social capital (i.e. close and distant ties) on public disclosure and described the complex relationship between bonding and bridging social capital in the context of serostatus disclosure among AIDS patients enrolled in South Africa's public sector antiretroviral treatment (ART) program. Data were collected from a cohort of patients enrolled in the public sector ART program in the Free State province of South Africa. Semi-structured, face-to-face interviews were conducted with a random sample of 268 patients at three points in time (<6 months of ART, 6-12 months of ART, and 18-24 of months ART). The relationship between bonding and bridging social capital and the impact of different forms of social capital on public disclosure were determined using a fully cross-lagged regression model. The impact of bonding social capital (treatment and emotional buddy) on public disclosure was positive and invariant across time. The results from the cross-lagged regression indicated that bridging social capital (community health worker and support group) only encouraged public disclosure in the second year of treatment. At the start of treatment, bivariate analysis showed a strong negative association between bonding and bridging social capital, which diminished at follow-up and eventually disappeared in the second year of treatment. This study identified bonding social capital as a leverage to maximize potential benefits and minimize potential risks in order to shift the balance toward consistent public disclosure. Furthermore, the importance of bridging social capital initiatives is demonstrated, especially for the most vulnerable patients, those who cannot capitalize their bonding social capital by disclosing their HIV serostatus to family and friends at the start of treatment.

HIV SEROSTATUS DISCLOSURE PATTERN AMONG PREGNANT WOMEN IN ENUGU, NIGERIA

This study was carried out in two medical facilities in Enugu, Nigeria, from September to November 2007. An interviewer-administered questionnaire was used to collect data from HIV-positive pregnant women accessing PMTCT (prevention of maternal-to-child transmission) services at the two centres. Ninety-two women were interviewed: 89 (96.7%) had disclosed their status, while 3 (3.3%) had not. Of the 89 women who had disclosed, 84 (94.4%) had disclosed to partners, 82 (92.1%) to husbands, 2 (2.2%) to fiancés, 18 (20.2%) to sisters, 13 (14.6%) to mothers, 10 (11.2%) to brothers, 10 (11.2%) to fathers and 10 (11.2%) to priests. Fifty-two (58.4%) gave emotional support as the reason for disclosure and 46 (51.7%) gave economic and financial support as reasons. Fifty-six (62.9%) reported understanding from partner as a positive outcome and 44 (49.4%) reported financial support. Forty-six (51.7%) reported no negative outcome. Serostatus disclosure rate in this study was high with most women disclosing to their partners.

Male involvement in PMTCT services in Mbeya Region, Tanzania

Throughout all stages of programmes for the prevention of mother-to-child-transmission of HIV (PMTCT), high dropout rates are common. Increased male involvement and couples' joint HIV counselling/testing during antenatal care (ANC) seem crucial for improving PMTCT outcomes. Our study assessed male attitudes regarding partner involvement into ANC/PMTCT services in Mbeya Region, Tanzania, conducting 124 individual interviews and six focus group discussions. Almost all respondents generally supported PMTCT interventions. Mentioned barriers to ANC/PMTCT attendance included lacking information/knowledge, no time, neglected importance, the services representing a female responsibility, or fear of HIV-test results. Only few perceived couple HIV counselling/testing as disadvantageous. Among fathers who had refused previous ANC/PMTCT attendance, most had done so even though they were not perceiving a disadvantage about couple counselling/testing. The contradiction between men's beneficial attitudes towards their involvement and low participation rates suggests that external barriers play a large role in this decision-making process and that partner's needs should be more specifically addressed in ANC/PMTCT services.

Community support and disclosure of HIV serostatus to family members by public-sector antiretroviral treatment patients in the Free State Province of South Africa

Recent studies have indicated that the support of close relatives is fundamental in coping with HIV/AIDS and in accessing the emotional and material support necessary for sustained adherence to treatment. Because disclosure to family members is imperative to ensure their support, identifying tools or resources that can minimize the possible risks and maximize the potential benefits of disclosure should be useful in improving the lives of people living with HIV/AIDS. Where health systems require strengthening, engaging the community in HIV/AIDS care could potentially create an environment that encourages disclosure to family members. This study investigated the impact of community support initiatives (community health workers and treatment support groups), patient characteristics (age, gender, and education), and time since first diagnosis on the disclosure of serostatus to family members by a sample of 268 public-sector antiretroviral treatment patients in a province of South Africa between August 2004 and July 2007. Whereas gender, age, and education only weakly influenced disclosure, there was a strong and stable positive association between community support and disclosure to family members. The immediate and long-term impact of community support on the disclosure by seropositive patients to family members indicates that initiatives such as community health workers and HIV support groups run by people living with HIV/AIDS should be strengthened, especially for those patients who cannot disclose their status to immediate family and close friends.

Factors influencing disclosure of HIV positive status in Mityana district of Uganda

BACKGROUND

Disclosure of HIV positive sero-status to sexual partners, friends or relatives is useful for prevention and care. Identifying factors associated with disclosure is a research priority as a high proportion of persons living with HIV/AIDS (PHA) never disclose.

OBJECTIVE

To identify factors associated with disclosure among PHAs in Mityana district of Uganda.

METHODS

Using a case control design, we compared 139 PHAs who had disclosed to 139 PHA who had not disclosed regarding socio demographic characteristics, sexual behaviour, individual experiences and perceptions about disclosure, as well as on health facility/community correlates of disclosure.

RESULTS

The independent factors that favour disclosure are not fearing negative outcomes of disclosure adjusted odds ratio (AOR) 7.00, 95 % confidence interval (95% CI) 3.03-16.95, having communication skills to disclose (AOR 12.08, 95% CI 4.94-29.51), having initiated anti-retroviral therapy (AOR 7.51, 95% CI 3.42-16.49), not having tested for HIV during ante-natal clinic (AOR 5.07, 95% CI 1.95-13.10), receiving ongoing counselling (AOR 4.33, 95% CI 1.50-12.51) and having ever seen a PHA publicly disclose his/her HIV status AOR 2.73, 95% CI 1.24-6.02).

CONCLUSIONS

PHAs that have not initiated anti-retroviral therapy (ART), test for HIV in ante-natal clinic and fear negative outcomes need more help in disclosure. Measures that empower PHA to disclose such as those that lead to improved communication skills should be reinforced during ongoing counselling.

Disclosure of HIV status: Experiences of Patients Enrolled in an Integrated TB and HAART Pilot Programme in South Africa

The convergence between the tuberculosis (TB) and HIV epidemics has led to studies investigating strategies for integrated HIV and TB care. We present the experiences of a cohort of 17 patients enrolled in the first integrated TB and HIV treatment pilot programme, conducted in Durban, South Africa, as a precursor to a pivotal trial to answer the question of when to start antiretroviral treatment (ART) in patients co-infected with HIV and TB. Patients' experiences with integrated TB and HIV care can provide insight about the problems or benefits of introducing HIV treatment into existing TB care in resource-constrained settings, where stigma and discrimination are often pervasive and determining factors influencing treatment uptake and coverage. Individual interviews, focus group discussions, and observations were used to understand patients' experiences with integrated TB and HIV treatment. The patients described incorporating highly active antiretroviral therapy (HAART) into their daily routine as 'easy'; however, the patients experienced difficulties with disclosing their HIV status. Non-disclosure to sexual partners may jeopardise safer-sex practices and enhance HIV transmission. Being on TB treatment created a safe space for all patients to conceal their HIV status from those to whom they did not wish to disclose. The data suggest that the context of directly observed therapy (DOT) for TB may have the added benefit of creating a safe space for introducing ART to patients who would benefit most from treatment initiation but who are not ready or prepared to disclose their HIV status to others.

Intimate partner violence and correlates in pregnant HIV positive Nigerians

OBJECTIVE

To determine the prevalence, types and correlates of intimate partner violence (IPV) in pregnant Nigerian living with HIV.

DESIGN

Cross sectional study.

POPULATION

HIV positive pregnant women.

SETTING

A large HIV comprehensive treatment centre.

METHODS

A cross sectional study of 652 HIV positive pregnant Nigerians seen at Nigerian Institute of Medical Research, Lagos, Nigeria over a 24 months period.

MAIN OUTCOME MEASURES

Prevalence of intimate partner violence after HIV diagnosis.

RESULTS

Among the women interviewed, 423 (65.8%) reported abuse. In 74.0% of abused women, the abuse started after HIV diagnosis. Though having a HIV negative spouse and disclosure of HIV status were associated with abuse, only having a HIV negative partner retained its association with IPV (OR 3.1; CI 2.4-5.3) after controlling for confounding variables. Sixty-two (9.6%) women have not disclosed their HIV status because of fear of rejection. Verbal abuse (51.7%), threat of violence in 97 (22.9%) and sexual deprivation in 91 (21.5%) were the common forms of abuse reported.

CONCLUSION

IPV is common among HIV positive pregnant Nigerians; with a threefold increased risk in women in HIV serodiscordant relationship.

Follow-up survey of women who have undergone a prevention of mother-to-child transmission program in a resource-poor setting in South Africa

The aim of this study was to investigate the implementation of a prevention of mother-to-child transmission (PMTCT) program and to evaluate the uptake and adherence to single-dose nevirapine in a cohort sample that had undergone PMTCT in five public clinics in a resource-poor setting, Quakeni Local Service Area, O.R. Tambo District in the Eastern Cape, South Africa. Results indicated that 116 women (15.3% of the sample) were infected with HIV, 642 (84.7%) were uninfected, and 552 (42.1%) had an unknown HIV status. Almost all of the women had received information about HIV and HIV testing prenatally, but 552 (42%) had not been tested for HIV, and their HIV status was unknown. Only 66 (57%) of the HIV-infected pregnant women had been provided with nevirapine. It is recommended that the quality of HIV counseling be improved and the program of maternal self-medication with nevirapine tablets at onset of labor and maternal provision of nevirapine syrup to newborns be encouraged.

Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: implications for preventive programs

This study aimed to describe the prevalence and predictors for male partner participation in HIV voluntary counselling and testing (VCT) at two primary healthcare clinics in Moshi urban, Tanzania as well as the effect of partner participation on uptake of HIV perinatal interventions. Pregnant women (n = 2654) in their third trimester, participating in a prevention of mother to child tranmission (PMTCT) program between June 2002 and March 2004 were encouraged to inform and invite their partners for HIV-VCT. Trained nurses conducted pre-test counselling, interviews, clinical examinations and blood sampling from the participating women and their partners. Test results were presented and post-test counselling was conducted individually or in couples, depending on the wishes of the participants. Three-hundred-and-thirty-two male partners (12.5%) came for HIV-VCT. A high proportion (131; 40%) came after the woman had delivered. HIV-seropositive women whose partners attended were three times more likely to use Nevirapine prophylaxis, four times more likely to avoid breastfeeding and six times more likely to adhere to the infant feeding method selected than those whose partners didn't attend. Women were more likely to bring their partner for VCT if they collected their own test results, were living with their partner, had a high monthly income and had expressed at enrolment the intention to share HIV results with their partner. Although PMTCT programs are presumably a good entry point for male involvement in prevention of sexual and perinatal HIV transmission, this traditional clinic-based approach reaches few men. Given the positive influence male participation has on the acceptance of perinatal interventions, a different approach for promoting male participation in VCT is urgently required. Within PMTCT programs, counseling should emphasize the advantages of partner participation to encourage women to inform and convince male partners to come for VCT. Also, promotion of couple VCT outside antenatal settings in male friendly and accessible settings should be given priority.

Factors affecting disclosure in South African HIV-positive pregnant women

To provide understanding of social and psychological factors that affect disclosure of HIV status among women diagnosed HIV-positive in pregnancy, 438 HIV positive women attending antenatal al clinics in Pretoria, South Africa were invited to participate in a longitudinal study. A total of 293 (62%) women were enrolled from June 2003 to December 2004. Questionnaires assessing sociodemographics and psychological measures were administered during pregnancy and at 3 months postdelivery. At enrollment, 59% had disclosed to their partners and 42% to others. This rose to 67% and 59%, respectively, by follow-up. Logistic regression analysis identified being married (adjusted odds Ratio [AOR] 2.32; 95% confidence interval [CI] 1.20-4.47), prior discussion about testing (AOR 4.19; CI 2.34-7.49), having a partner with tertiary education (AOR 2.76; CI 1.29-5.88) and less experience of violence (AOR 0.48; CI 0.24-0.97) as factors associated with having disclosed to partners prior to enrollment. Better housing (AOR 1.26; CI 1.06-1.49), less financial dependence on partners (AOR 0.46; CI 0.25-0.85), and knowing someone with HIV (AOR 2.13; CI 1.20-3.76) were associated with prior disclosure to others. Increased levels of stigma at baseline decreased the likelihood of disclosure to partners postenrollment (AOR 0.91; CI 0.84-0.98) and increased levels of avoidant coping decreased subsequent disclosure to others (AOR 0.84; CI 0.72-0.97). These results provide understanding of disclosure for women diagnosed as HIV positive in pregnancy, and identify variables that could be used to screen for women who require help.

Burden of depression among impoverished HIV-positive women in Peru

OBJECTIVES

In resource-poor settings, the mental health burden among HIV-positive women is exacerbated by poverty. We sought to describe the extent, risk factors, and experience of depression among impoverished HIV-positive women living in Lima, Peru.

METHODS

This is a case series of 78 HIV-positive women in Lima, Peru. We measured depression, stigma, and social support and performed a multivariable analysis to identify factors associated with depression.

RESULTS

Among 78 HIV-positive patients, 68% were depressed. Depression and suicidal ideation were rarely diagnosed by providers. In multivariable analysis, HIV-related stigma and food scarcity were associated with depression.

CONCLUSIONS

In our cohort of HIV-positive women in Lima, Peru, poverty and socioeconomic vulnerability contributed to depression. Findings highlight the heavy burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral component of HIV care.

HIV disclosure among adults living with HIV

Research on disclosure among heterosexual adult person(s) living with HIV (PLH) was reviewed, omitting disclosure of parental HIV to children. Disclosure has been studied within five additional relational contexts: with partners, family members, friends, healthcare professionals and in work settings. Disclosure is higher among women than men, among Latino and white compared to African-American families, and among younger compared to older HIV-positive adults. Most PLH disclose to their sexual partners and family members, yet there is a significant minority who do not disclose. Similarly, rates of disclosure to employers range from 27-68%, suggesting broad variability in perceived consequences of employment disclosures. Of concern, 40% of PLH do not consistently disclose to their healthcare professionals. Rather than examine HIV disclosures in the context of relationships, it is possible to understand disclosures around personal identity. Disclosure decisions are often made to tell everyone (making HIV status a central attribute of one's identity), no one (requiring strategies for securing social support while remaining anonymous) or some people (requiring strategic decisions based on context). Given that disclosure decisions are central to personal identity, future data on disclosure and interventions designed to increase disclosure or comfort with disclosure must focus on communication strategies adopted by PLH to present a coherent identity.

Preventing Mother-to-Child HIV Transmission Among South African Adolescents

Although prevention of mother-to-child HIV transmission (PMTCT) programs are predicated on maternal behavior change, little is known about sociocultural factors affecting maternal—child care practices in this arena. The authors used narrative methods (key informant workshops, questionnaires, focus groups, and case study analysis) to explore how sociocultural context shapes adolescent mothers' ability to adhere to programmatic recommendations in rural and urban South Africa. The study aims were to understand the extent to which mothers' decisions are borne out in PMTCT-related practices and to identify contextual elements that affect the link between individual resolutions and action. The results revealed rural adolescents as less likely than urbanites to successfully implement most PMTCT-related practices. HIV stigma, family decision making, and cultural norms surrounding infant feeding hampered mothers' efforts to implement practices that would decrease the risk for infant infection. Barriers to behavior change were analyzed along four domains: history, culture, gender, and power. Methodological aspects and programmatic implications are discussed.

Acceptance of Voluntary Counselling, Testing and Treatment for HIV Among Pregnant Women in Kumasi, Ghana

SUMMARY BACKGROUND

Voluntary counselling and testing (VCT) for human immunodeficiency virus (HIV) and treatment of positive pregnant women can reduce mother to child transmission (MTCT) of HIV.

OBJECTIVE

This study was conducted to assess acceptance of HIV VCT and antiretroviral therapy (ART) by pregnant women in Kumasi, Ghana, before and after VCT and ART were available.

METHODS

Two cross-sectional studies were conducted among women in antenatal clinics. The first, in 2003 among 501 women, before VCT and ART were available in Kumasi. Women who were willing were counselled and tested for HIV. In 2005, after the introduction of VCT and ART by the Ghana Health Service, 675 pregnant women were surveyed regarding HIV/VCT acceptance and uptake.

RESULTS

In 2003, 98% of women accepted counselling and 97% accepted testing; 3.3% tested HIV positive. Multivariate analysis showed that women with secondary education were 88% less likely than those with no/primary education to accept testing (OR=0.12, CI=0.03-0.54,p=0.006). Women who had prior HIV testing were 95% less likely to accept testing (OR=0.05, CI=0.01-0.19, p=0.0001). Women who reported two sexual partners in the past year were 6 times as likely to be HIV positive than those reporting one sexual partner (OR=5.76. CI=1.53 - 21.69, p=>0.05). In 2005, 76% of women reported no prior HIV counselling and 78% no testing.

CONCLUSIONS

In 2003, there was wide uptake of VCT by prenatal women. However, in 2005 the majority of pregnant women were not accessing the available VCT services.

Processes and outcomes of HIV serostatus disclosure to sexual partners among people living with HIV in Uganda

Disclosure of HIV serostatus to sexual partners supports risk reduction and facilitates access to prevention and care services for people living with HIV/AIDS. To assess health and social predictors of disclosure as well as to explore and describe the process, experiences and outcomes related to disclosure of HIV-infected men and women in Eastern Uganda, we conducted a study among HIV-infected men and women who were clients of The AIDS Support Organization (TASO) in Jinja, Uganda. We enrolled TASO clients in a cross-sectional study on transmission risk behavior. Demographic and behavioral data and CD4 cell count measurements were collected. Among 1,092 participants, 42% were currently sexually active and 69% had disclosed their HIV serostatus to their most recent sexual partner. Multivariate logistic regression analysis showed that disclosure of HIV-status was associated with being married, having attended TASO for more than 2 years, increased condom use, and knowledge of partner's serostatus. From these clients, 45 men and women were purposefully selected and interviewed in-depth on disclosure issues. Positive outcomes included risk reduction behavior, partner testing, increased care-seeking behavior, anxiety relief, increased sexual communication, and motivation to plan for the future.

Disclosure experience and associated factors among HIV positive men and women clinical service users in Southwest Ethiopia

BACKGROUND

Disclosing HIV test results to one's sexual partner allows the partner to engage in preventive behaviors as well as the access of necessary support for coping with serostatus or illness. It may motivate partners to seek testing or change behavior, and ultimately decrease the transmission of HIV. The present study was undertaken to determine the rate, outcomes and factors associated with HIV positive status disclosure in Southwest Ethiopia among HIV positive service users.

METHODS

A cross-sectional study was carried out from January 15, 2007 to March 15, 2007 in Jimma University Specialized Hospital. Data were collected using a pre-tested interviewer-administered structured questionnaire.

RESULTS

A total of 705 people (353 women and 352 men), participated in the study of which 71.6% were taking ART. The vast majority (94.5%) disclosed their result to at least one person and 90.8% disclosed to their current main partner. However, 14.2% of disclosure was delayed and 20.6% did not know their partner's HIV status. Among those who did not disclose, 54% stated their reason as fear of negative reaction from their partner. Among those disclosures however, only 5% reported any negative reaction from the partner. Most (80.3%) reported that their partners reacted supportively to disclosure of HIV status. Disclosure of HIV results to a sexual partner was associated with knowing the partner's HIV status, advanced disease stage, low negative self-image, residing in the same house with partner, and discussion about HIV testing prior to seeking services.

CONCLUSION

Although the majority of participants disclosed their test results, lack of disclosure by a minority resulted in a limited ability to engage in preventive behaviors and to access support. In addition, a considerable proportion of the participants did not know their partner's HIV status. Programmatic and counseling efforts should focus on mutual disclosure of HIV test results, by encouraging individuals to ask their partner's HIV status in addition to disclosing their own.

Evolution of couples' voluntary counseling and testing for HIV in Lusaka, Zambia

BACKGROUND

: We describe promotional strategies for couples' voluntary HIV counseling and testing (CVCT) and demographic risk factors for couples in Lusaka, Zambia, where an estimated two thirds of new infections occur in cohabiting couples.

PRINCIPAL FINDINGS

: CVCT attendance as a function of promotional strategies is described over a 6-year period. Cross-sectional analyses of risk factors associated with HIV in men, women, and couples are presented. Community workers (CWs) recruited from couples seeking CVCT promoted testing in their communities. Attendance dropped when CW outreach ended, despite continued mass media advertisements. In Lusaka, 51% of 8500 cohabiting couples who sought HIV testing were concordant negative for HIV (MF) and 26% concordant positive (MF); 23% had 1 HIV-positive partner and one HIV-negative partner, with 11% HIV-positive man/HIV-negative woman (MF) and 12% HIV-negative man/HIV-positive woman (FM). HIV infection was associated with men's age 30 to 39, women's age 25 to 34, duration of union <3 years, and number of children <2. Even among couples with either 1 or 2 or no risk factors, HIV prevalence was 45% and 29%, respectively.

CONCLUSIONS

: Many married African adults do not have high-risk profiles, nor realize that only 1 may be HIV positive. Active and sustained promotion is needed to encourage all couples to be jointly tested and counseled.

Enrollment and retention of HIV discordant couples in Lusaka, Zambia

BACKGROUND

Biased enrollment and attrition compromise the power of clinical trials and limit generalizability of findings. We identify predictors of enrollment and retention for HIV-discordant couples enrolled in prospective studies in Zambia.

PRINCIPAL FINDINGS

A total of 1995 discordant couples were invited to enroll. Predictors of nonenrollment, loss to follow-up, and missed appointments were evaluated using multivariate models. MF couples were more likely to be eligible and to enroll and less likely to be lost to follow-up than FM couples. Substantial losses to follow-up occurred between testing and enrollment (21.3% of MF and 28.1% of FM) and between enrollment and the first follow-up visit (24.9% of MF and 30.5% of FM). Among MF and FM couples, residence far from the clinic, younger age, and women's age at first intercourse </=17 years were predictive of attrition. No income, </=2 lifetime sex partners, no history of sexually transmitted infection in women, and recent extramarital contact in their male partners predicted attrition in FM couples.

CONCLUSIONS

Discordant couples are critical to observational studies and clinical trials to prevent male-to-female and female-to-male transmission. Retention biases must be taken into account during analysis. Run-in designs that delay randomization may improve retention in clinical trials.

Regional differences in prevalence of HIV-1 discordance in Africa and enrollment of HIV-1 discordant couples into an HIV-1 prevention trial

BACKGROUND

Most HIV-1 transmission in Africa occurs among HIV-1-discordant couples (one partner HIV-1 infected and one uninfected) who are unaware of their discordant HIV-1 serostatus. Given the high HIV-1 incidence among HIV-1 discordant couples and to assess efficacy of interventions for reducing HIV-1 transmission, HIV-1 discordant couples represent a critical target population for HIV-1 prevention interventions and prevention trials. Substantial regional differences exist in HIV-1 prevalence in Africa, but regional differences in HIV-1 discordance among African couples, has not previously been reported.

METHODOLOGY/PRINCIPAL FINDINGS

The Partners in Prevention HSV-2/HIV-1 Transmission Trial ("Partners HSV-2 Study"), the first large HIV-1 prevention trial in Africa involving HIV-1 discordant couples, completed enrollment in May 2007. Partners HSV-2 Study recruitment data from 12 sites from East and Southern Africa were used to assess HIV-1 discordance among couples accessing couples HIV-1 counseling and testing, and to correlate with enrollment of HIV-1 discordant couples. HIV-1 discordance at Partners HSV-2 Study sites ranged from 8-31% of couples tested from the community. Across all study sites and, among all couples with one HIV-1 infected partner, almost half (49%) of couples were HIV-1 discordant. Site-specific monthly enrollment of HIV-1 discordant couples into the clinical trial was not directly associated with prevalence of HIV-1 discordance, but was modestly correlated with national HIV-1 counseling and testing rates and access to palliative care/basic health care (r = 0.74, p = 0.09).

CONCLUSIONS/SIGNIFICANCE

HIV-1 discordant couples are a critical target for HIV-1 prevention in Africa. In addition to community prevalence of HIV-1 discordance, national infrastructure for HIV-1 testing and healthcare delivery and effective community outreach strategies impact recruitment of HIV-1 discordant couples into HIV-1 prevention trials.

The utilization of testing and counseling for HIV: a review of the social and behavioral evidence

Against the background of debates about expanding HIV testing and counseling, we summarize the evidence on the social and behavioral dimension of testing and its implications for programs. The discrepancy between acceptance of testing and returning for results and the difficulties of disclosure are examined in light of research on risk perceptions and the influence of gender and stigma. We also summarize the evidence on the provision of testing and counseling, the implementation of practices regarding confidentiality and consent, and the results of interventions. We demonstrate that social factors have a considerable impact on testing, show that the services linked to testing are key determinants of utilization, and consider the implications of these findings for HIV testing programs.

Motivations and methods for self-disclosure of HIV seropositivity in Nairobi, Kenya

This study employed structured interviews with 307 people living with HIV (PLHIVs) in Nairobi, Kenya to investigate their serostatus disclosure with respect to four types of relationships in their lives: partners, friends, family members, and religious leaders/clergy. Regarding motivations for disclosure, it was found that a sense of duty and seeking material support motivated disclosure to family and partners, fear of loss of confidentiality inhibited disclosure to friends, and the need for advice encouraged disclosure to religious leaders. The method of disclosure most frequently mentioned was direct, with males less likely than females to use direct methods when disclosing to spouses or partners. Intermediated disclosure was common in partner/spouse relationships with around one-third of partners preferring to disclose through a third party. Methods used to disclose as well as reasons for doing so varied by relationship type.

The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review

Partner counseling and referral services (PCRS) are part of the spectrum of care for HIV-positive people and their sexual or needle-sharing partners. Referral includes notifying partners of exposure, after which they are (ideally) tested and receive prevention or risk reduction counseling or enter into care (if they test positive). Using The Guide to Community Preventive Services's methods for systematic reviews, the effectiveness of PCRS was evaluated, including partner notification, in identifying a population at high risk of HIV infection and in increasing testing in those populations. In this review, PCRS efforts using provider referral were found to be effective in reaching a population with a high prevalence of HIV. Nine studies qualified for the review. In these studies, a range of one to eight partners was identified per index case (a person newly diagnosed with HIV who has partners who should be notified); a mean of 67% of identified partners were found and notified of their potential exposure to HIV, and a mean of 63% of those notified were tested (previously known "positives" were not tested). Of those tested, a mean of 20% were HIV positive. Therefore, even given that not all partners could be found and notified and that some who could be found did not accept testing, 1% to 8% of people named as potentially exposed and not previously known to be HIV positive were identified as HIV positive through partner notification (although these people were not necessarily infected by the index case). Evidence was insufficient to determine whether PCRS, including partner notification, was also effective in changing behavior or reducing transmission because available studies did not generally report on these outcomes. Little empirical evidence was available to assess potential harm of the interventions, but current studies have not shown substantial harms. Based on Community Guide rules of evidence, sufficient evidence shows that PCRS with partner notification by a public health professional ("provider referral") effectively increases identification of a high-prevalence target population for HIV testing.

Factors leading to self-disclosure of a positive HIV diagnosis in Nairobi, Kenya: people living with HIV/AIDS in the Sub-Sahara

Understanding why, how, and to whom people living with HIV/AIDS disclose their diagnosis to others is a critical issue for HIV prevention and care efforts, but previous investigations of those issues in sub-Saharan Africa have been limited to one or two questions included in quantitative studies of social support or stigma. Instruments and findings on serostatus disclosure based on U.S. populations are likely to be at best only partially relevant because of Africa's primarily heterosexual transmission vectors and highly communalistic social structures. This qualitative analysis of two male and two female focus groups comprised of persons living with HIV/AIDS (PLWHAs) in Nairobi, Kenya, revealed several HIVstatus disclosure patterns that appear distinctive to Africa. These include (a) intermediaries as vehicles for disclosure to family, (b) indirectness as a communication strategy, and (c) church pastors as common targets for disclosure.

Disclosure of HIV among black African men and women attending a London HIV clinic

Little research has focused specifically on disclosure among HIV+ Black Africans living in the UK; however, the available evidence suggests that this population may be reluctant to disclose to significant others. Forty-five HIV+ Black African men and women were recruited from a London HIV clinic. Semi-structured interviews gathered information on: disclosure, social support, mental and physical health, medication adherence, acculturation and the perceived prevalence of stigma. Both qualitative and quantitative analyses were conducted. The majority of the participants had disclosed to one significant other and there was an inverse association between perceived stigma and disclosure. Disclosure could not be predicted by any of the respondent characteristics identified in the study; rather, disclosure decisions were reasoned, interpersonal in nature and many of the motivations were specific to the individual. There was little evidence to suggest that those who disclosed to more than one other gained additional benefits in physical or mental well-being. Clinicians seeking to assist members of this population to disclose need to assess the specific reasons for and barriers against disclosure for that individual.

Influence of the involvement of partners in the mother class with voluntary confidential counselling and testing acceptance for Prevention of Mother to Child Transmission of HIV Programme (PMTCT Programme) in Cambodia

The National Maternal and Child Health Center in Phnom Penh, Cambodia commenced PMTCT services as the first site of the National PMTCT programme of Cambodia in November 2001. However, the acceptance of voluntary confidential counselling and testing (VCCT) in the PMTCT services was not as high as expected. The aim of this study was to evaluate influence of partner participation in the mother class to the PMTCT services. During the first visit to antenatal care, all women were invited to the class, where information on PMTCT was provided. From July 2002, when partner participation started, to May 2005, the acceptance rate to the pre-test counselling of those who attended the class alone was 18.7% (3,234/17,340), while that of the attendees with their partner was 85.1% (2,908/3,417) (p <0.001). All of the couples accepted couple counselling and disclosure of their results to their partners. In conclusion, a strong association was observed between acceptance and partner involvement. However, we should consider also other strategies for future programme improvement.

HIV-disclosure in the context of vertical transmission: HIV-positive mothers in Johannesburg, South Africa

HIV-disclosure among childbearing women remains poorly understood, particularly in sub-Saharan Africa. This paper chronicles disclosure experiences of 31 women attending prevention of mother-to-child HIV transmission services in Johannesburg. Data collection entailed repeat in-depth interviews over a nine-month period. Virtually all women (93.5%) had told at least one person (usually a partner), most voluntarily and within a week of the test result. Secondary disclosure was most likely with female family members, through indirect means and involuntary. Confidentiality breach by primary targets likely contributed to the observed high rates of involuntary secondary disclosure and negative secondary disclosure experiences. For most mothers, voluntary disclosure was driven by the desire to ensure adequate infant care and avoid vertical HIV transmission. The impact of disclosure was not always clear-cut. While most primary disclosure experiences were ultimately constructive, secondary disclosure more likely led to rejection, stigmatization and the withholding of financial support. Our data illustrate the influence of social contextual factors on disclosure patterns and impact. For these mothers, socio-cultural norms, the current media and political environment surrounding HIV/AIDS, household composition and social networks and childbearing status shaped disclosure experiences; sometimes constraining disclosure circumstances and sometimes creating a safe space to disclose. Programmatic implications are also discussed.

Factors correlated with disclosure of HIV infection in the French Antilles and French Guiana: results from the ANRS-EN13-VESPA-DFA Study

OBJECTIVES

To determine the rate, patterns and predictors of HIV disclosure in the French Antilles and French Guiana.

METHODS

A cross-sectional survey was carried out among a 15% random sample (n=398) of the hospital caseload in hospitals providing HIV care. Determinants of disclosure to a steady partner and other members of the individual's social network were analysed using logistic regression.

RESULTS

From the time of diagnosis, 84.6% of those in a couple (n=173) disclosed their HIV-positive status to their steady partner, 55.6% disclosed to others, and 30.3% did not tell their status to anyone. Disclosure within a steady partnership was less likely among non-French individuals [Haitians: adjusted odds ratio (AOR) 0.11, 95% confidence interval (CI) 0.02-0.72; other nationalities: AOR 0.13, 95% CI 0.02-0.68]; and among those diagnosed with HIV after 1997 (AOR 0.21, 95% CI 0.05-0.86). Determinants of disclosure to others were found to be sex (women: AOR 2.04, 95% CI 1.24-3.36), age at diagnosis (>or=50 versus<30 years: AOR 0.42, 95% CI 0.19-0.90), nationality (Haitians versus French: AOR 0.39, 95% CI 0.19-0.77), transmission route (non-sexual versus sexual: AOR 3.38, 95% CI 1.12-10.23) and hospital inpatients (hospitalized versus non-hospitalized patients: AOR 1.98, 95% CI 1.17-3.37). After disclosing, social and emotional support from confidants was common and discrimination was infrequent.

CONCLUSION

One third of PLWHA had kept their HIV status secret. Interventions targeting the general population and social institutions, and support for PLWHA by healthcare staff are needed to improve the situation.

Prevalence and correlates of HIV serostatus disclosure: a prospective study among HIV-infected postparturient women in Barbados

This study was undertaken to determine the prevalence of self-disclosure of HIV status among the postparturient HIV-infected women and to describe the correlates of disclosure in this population. Subjects for this study include all known HIV-infected postparturient women in Barbados who delivered during 1997 through 2004. Sociodemographic data are routinely collected from all HIV-infected postparturient women. Data on disclosure were collected through one-to-one interview of the consenting women included in this study. One hundred thirtynine women were studied. Forty women (28.8%) had self-disclosed their HIV status to other people including their current sex partner. Among women who did not disclose their HIV status to anybody, 30 (30%) gave fear of stigmatization as the reason for nondisclosure, while 23 (23%) did not disclose their status as they feared abnormal reaction from their current sex partner and possible violence directed at them. Women who had disclosed their HIV status were more likely to use condoms during all sexual encounters, less likely to have had subsequent pregnancy from a different sex partner, were more likely to have a partner who had been tested for HIV, and were themselves more likely to be attending the centralized HIV clinic for follow-up and care compared to those who did not disclose. A substantial proportion of HIV-infected postparturient women never disclosed their result to a partner or a close relative. Lack of disclosure may have limited their ability to engage in preventive behaviors or to obtain the necessary emotional support for coping with their serostatus or illness.

Domestic violence and prevention of mother-to-child transmission of HIV-1

OBJECTIVES

To determine the prevalence of life-time domestic violence by the current partner before HIV-1 testing, its impact on the uptake of prevention of mother-to-child transmission (PMTCT) interventions and frequency after testing.

DESIGN

A prospective cohort.

METHODS

Antenatally, women and their partners were interviewed regarding physical, financial, and psychological abuse by the male partner before HIV-1 testing and 2 weeks after receiving results.

RESULTS

Before testing, 804 of 2836 women (28%) reported previous domestic violence, which tended to be associated with increased odds of HIV-1 infection [univariate odds ratio (OR) 1.7, 95% confidence interval (CI) 1.3-2.2; P < 0.0001, adjusted OR 1.2, 95% CI 0.9-1.6; P = 0.1], decreased odds of coming with partners for counseling (adjusted OR 0.7, 95% CI 0.5-1.0; P = 0.04), and decreased odds of partner notification (adjusted OR 0.7, 95% CI 0.5-1.1; P = 0.09). Previous domestic violence was not associated with a reduced uptake of HIV-1 counseling, HIV-1 testing, or nevirapine. After receiving results, 15 out of 1638 women (0.9%) reported domestic violence. After notifying partners of results, the odds of HIV-1-seropositive women reporting domestic violence were 4.8 times those of HIV-1-seronegative women (95% CI 1.4-16; P = 0.01). Compared with women, men reported similar or more male-perpetrated domestic violence, suggesting a cultural acceptability of violence.

CONCLUSION

Domestic violence before testing may limit partner involvement in PMTCT. Although infrequent, immediate post-test domestic violence is more common among HIV-1-infected than uninfected women. Domestic violence prevention programmes need to be integrated into PMTCT, particularly for HIV-1-seropositive women.

Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission

To determine effect of partner involvement and couple counseling on uptake of interventions to prevent HIV-1 transmission, women attending a Nairobi antenatal clinic were encouraged to return with partners for voluntary HIV-1 counseling and testing (VCT) and offered individual or couple posttest counseling. Nevirapine was provided to HIV-1-seropositive women and condoms distributed to all participants. Among 2104 women accepting testing, 308 (15%) had partners participate in VCT, of whom 116 (38%) were couple counseled. Thirty-two (10%) of 314 HIV-1-seropositive women came with partners for VCT; these women were 3-fold more likely to return for nevirapine (P = 0.02) and to report administering nevirapine at delivery (P = 0.009). Nevirapine use was reported by 88% of HIV-infected women who were couple counseled, 67% whose partners came but were not couple counseled, and 45%whose partners did not present for VCT (P for trend = 0.006). HIV-1-seropositive women receiving couple counseling were 5-fold more likely to avoid breast-feeding (P = 0.03) compared with those counseled individually. Partner notification of HIV-1-positive results was reported by 138 women (64%) and was associated with 4-fold greater likelihood of condom use (P = 0.004). Partner participation in VCT and couple counseling increased uptake of nevirapine and formula feeding. Antenatal couple counseling may be a useful strategy to promote HIV-1 prevention interventions.

Psychosocial consequences of early diagnosis of HIV status in vertically exposed infants in Johannesburg, South Africa

Mother-to-child transmission (MTCT) is the most common source of HIV infection in children. One topic that has received virtually no attention in MTCT-related research and programming is the psychosocial consequences among parents and families of receiving a definitive diagnosis of infant HIV status. This study explored experiences of HIV-infected mothers in Johannesburg, South Africa, regarding infant testing and diagnosis. Data collection entailed a key informant workshop and repeat interviews with a convenience sample of 31 HIV-infected mothers. While early testing was desirable, diagnosis had both beneficial and detrimental psychosocial effects, especially in instances of serodiscordance. Programmatic implications are discussed.

Factors influencing acceptability of voluntary counselling and HIV-testing among pregnant women in Northern Tanzania

Guided by the conceptual framework of the Health Belief Model, this study aimed to identify factors associated with pregnant women's expressed willingness to accept voluntary counselling and HIV-testing (VCT). A cross-sectional interview survey of 500 pregnant women, complemented by focus group discussions, was conducted in the Kilimanjaro region of Tanzania. Constructs derived from the Health Belief Model explained 41.7% of women's willingness to accept VCT. Perceived high personal susceptibility to HIV/AIDS, barriers related to confidentiality and partner involvement, self-efficacy regarding alternative feeding methods and religion were all shown to be associated with willingness to accept VCT. The women's acceptance of VCT seems to depend upon their perceiving that VCT and alternative feeding strategies provide clear benefits, primarily for the child. Whether a positive attitude to VCT and alternative feeding strategies are transformed into actual behaviour depends on a set of complicated decisions in which several potential psychological consequences are assessed. Sharing the diagnosis with partners may not have the intended effect if there is a lack of sensitivity to the women's fear of blame and rejection. If pregnant women are to fully participate in and benefit from mother-to-child-transmission prevention efforts, their partners must be committed and involved in the process.