Strategies and outcomes of HIV status disclosure in HIV-positive young women with abuse histories

Attitudes Toward and Experiences With Discussing Pre-exposure Prophylaxis With Sexual Partners Among US Adolescents and Young Adults Living With HIV

PURPOSE

Sexual partners of youth living with HIV are a key population for pre-exposure prophylaxis (PrEP). Among youth engaged in HIV medical care, we examined awareness of PrEP and experiences with and attitudes toward discussing PrEP with sexual partners.

METHODS

We recruited 25 15-24-year olds from an adolescent/young adult HIV clinic to complete individual interviews. Interviews assessed demographics, PrEP knowledge, sexual behaviors, and experiences with, intentions toward, barriers, and facilitating factors to discussing PrEP with partners. Transcripts were analyzed using framework analysis.

RESULTS

Mean age was 18.2 years. Twelve participants were cis-female, 11 cis-male, and two transgender female. Seventeen participants (68%) identified as Black, non-Hispanic. Nineteen acquired HIV sexually. Of 22 participants who had ever had sex, eight reported condomless sex in the prior 6 months. Most youth (17/25) were aware of PrEP. Only 11 participants had discussed PrEP with a partner; 16 reported high intention to discuss PrEP with future partners. Barriers to discussing PrEP with partners included participant-related barriers (i.e., discomfort disclosing HIV status), partner-related barriers (i.e., not open to or unfamiliar with PrEP), relationship-related barriers (i.e., new relationship, lack of trust), and stigma about HIV. Facilitating factors included positive relationship factors, educating partners about PrEP, and partners being receptive to learning about PrEP.

DISCUSSION

Although many youth living with HIV were aware of PrEP, fewer had discussed PrEP with a partner. PrEP use by partners of these youth may be improved by educating all youth about PrEP and offering opportunities for partners to meet with clinicians to discuss PrEP.

"Keep It to Yourself": A Qualitative Study of HIV Disclosure Perspectives Among Older Adults Living With HIV in South Carolina Who Are Childhood Sexual Abuse Survivors

ABSTRACT

HIV disclosure is an important consideration for people living with HIV. The prevalence of childhood sexual abuse (CSA) may range from 16% to 22% among older adults living with HIV. There is a dearth of research on HIV disclosure among older CSA survivors. Therefore, the aim of this study was to qualitatively examine HIV disclosure among older CSA survivors living with HIV. Twenty-four CSA survivors living with HIV (aged 50-67 years) participated in in-depth, semistructured interviews. Data were analyzed thematically, and the iterative coding and analytic process included discussion of initial thoughts and key concepts, identification and reconciliation of codes, and naming of emergent themes. Four themes emerged: (a) secrecy/not planning to disclose HIV; (b) disclose HIV regardless; (c) disclose HIV depending on the person; and (d) disclose HIV depending on the circumstance. Lack of disclosure may be due to HIV-related stigma. HIV disclosure intervention programs may be beneficial for this population.

Stigma, coping strategies, and their impact on treatment and health outcomes among young men living with HIV in Vietnam: A qualitative study

BACKGROUND

Stigma affects persons living with HIV in myriad ways, including mental health, adherence to antiretroviral therapy, and retention in care, and may manifest at inter- and intra-personal levels. Youth are particularly vulnerable; those in vulnerable groups may experience multiple stigmas. In Vietnam, new HIV infections are rising among men in young age groups. To better understand the facets of stigma experienced by young men living with HIV in Vietnam, we conducted a qualitative study with youth and clinicians.

METHODS

We conducted in-depth interviews with ten youth and two clinicians in Hanoi, querying experiences of inter- and intra-personal stigma, coping strategies, and disclosure. As a framework for further research, we developed a conceptual model based on our findings and the published evidence base which portrays interactions among HIV-related stigma, coping strategies, and ART adherence, care engagement, and health outcomes.

RESULTS

Common themes that emerged from interviews with youth included extensive internalized/self-stigma and perceived stigma, yet limited experienced interpersonal stigma due to non-disclosure and avoidant coping strategies. Within different types of relationships or contexts, youth used different strategies. Non-disclosure with family, friends, and workplaces/school, and avoidance of romantic relationships and health care were common. Mental health and social support appeared to be mediating factors between coping strategies and health outcomes.

CONCLUSIONS

Validation of this model of mechanisms of the impact of stigma for youth will require further research with larger samples. In the meantime, public campaigns to increase public awareness related to HIV should be implemented in Vietnam. Critical support for youth and their mental health should involve approaches tailored to the individual, taking into account context and personal capacity, including adequate time to prepare psychologically for disclosure. Some strategies for safe and effective disclosure are suggested.

Barriers to timely disclosure of HIV serostatus: A qualitative study at care and treatment centers in Dar es Salaam, Tanzania

Introduction

Disclosure of Human Immunodeficiency Virus (HIV) status is important to prevent the spread of HIV and maintain the health of people living with HIV, their spouses, and the community. Despite the benefits of disclosure, many people living with HIV delay disclosing their status to those close to them thereby increasing the risk for disease transmission. This study aimed to determine the barriers to timely disclosure of HIV serostatus for people living with HIV in Dar es Salaam, Tanzania, and identify what motivated disclosure.

Methods

A qualitative descriptive study using in-depth individual interviews was conducted with10 participants attending HIV care and treatment centers in Dar es Salaam. The participants were people living with HIV who had delayed disclosing their serostatus for more than one month after diagnosis. Data was analyzed using qualitative content analysis.

Results

Three categories emerged from the analysis: Barriers hindering timely disclosure, motivation for disclosure of serostatus, and consequences of delayed disclosure. Barriers to timely disclosure included denial of one’s status, the fear of stigmatization, fear of being separated or divorced, the need to protect loved ones, and lack of adequate knowledge about the disease. Reasons that motivated disclosure included gaining social support, preventing disease transmission and wanting to be at peace.

Conclusion

Timely disclosure is hindered by stigma because HIV is negatively perceived by the public. People living with HIV prefer not to disclose to avoid the negative consequences of disclosure, especially because of fear of being discriminated against and losing their social status, which plays a major role in social status in Tanzania.

Trust and adequate counseling from health care workers helps prompt disclosure.

Factors influencing sexually transmissible infection disclosure to male partners by HIV-positive pregnant women in Pretoria townships, South Africa: a qualitative study

Background Sexually transmissible infections (STI) may increase the risk of mother-to-child transmission (MTCT) of HIV. However, diagnostic testing and targeted treatment of STI (STI-TT) during pregnancy is not standard care in South Africa.

METHODS

A qualitative study was nested in a STI-TT intervention to investigate motivating and enabling factors associated with STI test results disclosure to sexual partners. A semi-structured interview protocol covered partner communication, HIV and STI disclosure, financial security and relationships dynamics. Interviews were conducted in participants' preferred language, audio-recorded, transcribed into English and analysed using a constant comparison approach. The study was conducted in two townships in Pretoria, South Africa.

RESULTS

Twenty-eight HIV-positive pregnant women were interviewed. Based on the interviews, two disclosure experiences for women were identified - those with vulnerable experiences and those with self-enabling experiences within their partnerships. Vulnerable women discussed intimate partner violence (IPV) and fear of relationship dissolution as factors influencing their test result disclosure. Self-enabled women discussed their ability to talk with their partners about STI and HIV infections and the influence of multiple concurrent partnerships in the acquisition of HIV/STIs. Both groups of women were concerned about men's health behaviours, and all cited the health and development of their unborn child as a key motivator for test result disclosure.

CONCLUSIONS

Improved counselling and support for pregnant women to disclose their STI test results to their partners may improve the impact of STI diagnostic testing during pregnancy by improving partner treatment uptake and thus reducing the risk of re-infection.

Factors Associated with HIV Disclosure Status Among iENGAGE Cohort of New to HIV Care Patients

HIV disclosure is an important behavior with implications for HIV treatment and prevention but understudied among new to HIV care patients who face unique challenges adjusting to a new diagnosis. This study evaluated the factors associated with HIV disclosure status and patterns of HIV disclosure among new to HIV care patients. A cross-sectional study was conducted evaluating the iENGAGE (integrating ENGagement and Adherence Goals upon Entry) cohort. Participants were enrolled in this randomized behavioral trial between December 2013 and June 2016. The primary and secondary outcomes included HIV disclosure status (Yes/No) and patterns of disclosure (Broad, Selective and Nondisclosure), respectively. Logistic and Multinomial Logistic Regression were used to evaluate the association of participant factors with HIV disclosure and patterns of HIV disclosure, respectively. Of 371 participants, the average age was 37 ± 12 years, 79.3% were males, and 62.3% were African Americans. A majority of participants (78.4%) disclosed their HIV status at baseline, 63.1% were broad disclosers and 15.2% were selective disclosers. In multivariable regression, black race, emotional support, and unmet needs predicted any HIV and broad disclosure, whereas males, emotional support, active coping, and acceptance were associated with selective disclosure. Interventions to promote early disclosure should focus on coping strategies and unmet needs, particularly among black and male people living with HIV initiating care.

Perceived benefits and costs of disclosing HIV diagnosis to family members among people living with HIV in Southern China: an application of a decision-making framework

ABSTRACT People living with HIV (PLWH) would decide whether to disclose their HIV serostatus to others based on the weight of perceived benefits and costs for the disclosure. Using cross-sectional data from 1254 PLWH in Guangxi, China, the study aimed to examine a framework of disclosure decision-making in the context of disclosure to family members (parents and siblings) through exploring the associations between disclosure and perceived benefits and costs of disclosure at individual and interpersonal levels. Univariate and multivariate regression analyses showed that HIV disclosure was associated with perceived benefits at both individual level (stress relief and social support) and interpersonal level (educating others and promoting family stability), but was not associated with perceived costs at either individual level (stigma and confidentiality breaching) or interpersonal level (family conflicts and concerns). Our findings suggest that perceived benefits rather than costs are associated with disclosure to family and play an important role in disclosure decision-making. These results may refine and expand the existing framework on decision-making of HIV disclosure focusing on PLWH's weight of individual benefits and costs. Future interventions highlighting the benefits for their family and other members of their social network may be an effective strategy to promote HIV disclosure to family members.

HIV Disclosure to Family Members and Medication Adherence: Role of Social Support and Self-efficacy

Although antiretroviral therapy (ART) is vital to people living with HIV (PLWH) by suppressing the virus and in turn preventing onward HIV transmission and reducing AIDS-related morbidity and mortality, the rates of optimal ART adherence continuously remain low. Disclosure of HIV status is considered to be a critical predictor of ART adherence. However, few studies have explored the mechanisms underlying the association between disclosure and medication adherence. The current study aims to examine the mediating role of social support and self-efficacy underlying the relationship between HIV disclosure to family members and ART adherence. PLWH in China provided data on HIV disclosure, ART adherence, perceived social support on medication adherence, adherence self-efficacy, and social-demographic information. The path analyses revealed that disclosure to family members had significant indirect effects on adherence via social support and self-efficacy. Our findings suggested that HIV disclosure might positively affect ART adherence through two psychosocial pathways: social support and self-efficacy. Future intervention to improve medication adherence among PLWH should consider targeting these two factors.

Self-Disclosure of HIV Status Among Youth Living with HIV: A Global Systematic Review

Self-disclosure of HIV serostatus by youth has been considered an essential component of HIV prevention and medication adherence efforts. Therefore, a comprehensive investigation of disclosure goals, processes, and outcomes is warranted. We conducted a global systematic review in accordance with the 2015 Preferred Items for Reporting Systematic Reviews and Meta-Analysis tool to assess HIV self-disclosure among youth ages 13-24. We identified 5881 articles during our initial search. After screening titles and abstracts and examining articles in greater detail, 33 studies (35 articles) were included in the synthesis. The disclosure process model was used to highlight antecedent goals to self-disclosure including common avoidance goals such as fear of rejection and isolation. While disclosure was associated with negative and positive emotional outcomes and improved medication adherence, there remain concerns regarding the impact of self-disclosure on sexual behaviors. Implications for practice and future directions for research are presented.PROSPERO registration number: CRD42018097250.

Effects of multiple types of stigma on the probability of HIV disclosure to sex partners: a systematic review

Previous review studies explored factors related to the process of HIV disclosure. However, none of these review studies specifically focused on the effects of stigma on HIV disclosure to sex partners. A comprehensive systematic review of empirical studies on the effects of stigma on HIV disclosure to sex partners was conducted until December 2014. Twenty-seven articles published in English-language journals were selected, and study characteristics and findings were evaluated. Inconsistent findings in the assessment of impacts of stigma on HIV disclosure to sex partners were documented. Three underlying plausible reasons were identified, and these included: (1) different types of stigma may have different effects on HIV disclosure to sex partners; (2) studies used different measurement strategies; and (3) varied personal backgrounds and health factors that can mitigate, facilitate or moderate the effect of stigma on HIV disclosure to sex partners. Studies with precise definition measurements of specific types of stigma used them appropriately in a matching context to provide more consistent research results. This review identifies the need for further investigation into how the HIV disclosure process is shaped by particular types of stigma, types of sex partners and demographic characteristics of people living with HIV/AIDS.

Exploring the Impact of Childhood Abuse on HIV Social and Attitudinal Factors Among Adults With and Without this History in Sub-Saharan Africa: Findings from NIMH Project Accept (HPTN 043)

Using data from four sites in three African countries, this community randomized study examined the association between childhood sexual and/or physical abuse (CSA and/or CPA) and HIV disclosure, HIV-related stigma, stress, and social support among adults with and without a history of abuse. A history of abuse among men was associated with higher levels of adult-reported stress and HIV-related stigma, and with significantly lower rates of HIV test result disclosure to current partners. Women with a history of CSA and/or CPA had significantly higher perceived stigma, discrimination and stress. Although childhood abuse was significantly associated with adult stress and stigmatization, participants with histories of CSA and/or CPA also reported significantly higher perceived social support compared to people without such experiences. These findings may reflect support received in response to disclosure of CSA or CPA or emotional ambivalence in relationships that have been found to be associated with child abuse. We conclude that it is critical for HIV prevention interventions to advocate for the primary prevention of child abuse, for early identification of adolescents and adults who report experiencing childhood abuse, and to address stigma and stress-related attitudinal, behavioral and relationship difficulties experiences as an aftermath of early abuse that increase their risk of HIV.

Another Way to Talk: Exploring Photovoice as a Strategy to Support Safe Disclosure Among Men and Women With HIV

HIV status disclosure can reduce stigma and facilitate medication adherence and safer sex among people living with HIV (PLH). Effective disclosure interventions are limited, however, and new strategies are necessary. We conducted a pilot Photovoice-based project with 38 PLH in four cities in the Midwest and Northeast U.S. and explored how the project affected disclosure perspectives and experiences. Participants attended three group Photovoice sessions, one individual session, and an optional photo exhibit. Qualitative strategies of theme and narrative analysis of photos and session transcripts revealed that participants discussed three categories of disclosures to others: fearful, reluctant, and open. The project supported all disclosure types, helping fearful participants manage their emotions, reluctant participants plan for more effective disclosures, and open participants share their HIV status. Pilot findings suggest that Photovoice should be further developed and studied as a safe and powerful strategy to improve disclosure and subsequent health and prevention outcomes among PLH.

Intimate relationships in young adults with perinatally acquired HIV: a qualitative study of strategies used to manage HIV disclosure

An increasing number of children born with perinatally acquired HIV (PAH) are surviving into late adolescence and early adulthood. At this developmental stage, forming and sustaining intimate relationships is important. Young adults with PAH face both normative challenges and additional, HIV-related, relationship stressors. One key issue is the decision about whether and how to share their HIV status with others. Being able to disclose one's HIV status to sexual partners may reduce the risk of onward HIV transmission but is associated with the fear of rejection. There has been little research on how young people with PAH manage such disclosure-related stressors in intimate relationships. This study examined how disclosure challenges are managed by young adults with PAH in the UK within their intimate relationships. Seven participants (five females and two males) currently or previously in an intimate relationship, aged 18-23 years, were recruited from a UK hospital clinic. The majority of participants were of sub-Saharan African origins. They took part in in-depth interviews, with data analysed according to the principles of interpretative phenomenological analysis. Four themes were elicited: (1) decisions about starting, continuing or resuming relationships shaped by disclosure, (2) disclosing early to avoid the pain of future rejection, (3) using condoms to avoid disclosure and (4) testing likely partner reactions to disclosure. The study revealed the significant extent to which HIV disclosure affected the experience of relationships in this population. Interventions to support adolescents and young adults with PAH to disclose to their partners should be developed alongside guidance for professionals. Future research should include older samples of adults with PAH and studies in sub-Saharan African settings.

Effectiveness of interventions promoting HIV serostatus disclosure to sexual partners: a systematic review

Disclosure of HIV serostatus to sexual partners is mandated within certain states in the United States and other countries. Despite these laws implemented and public health efforts to increase disclosure, rates of disclosure to sexual partners among people living with HIV (PLWH) remain low, suggesting the need for interventions to assist PLWH with the disclosure process. We conducted a systematic review of studies testing whether HIV serostatus disclosure interventions increase disclosure to sexual partners. We searched six electronic databases and screened 484 records. Five studies published between 2005 and 2012 met inclusion criteria and were included in this review. Results showed that three of the HIV serostatus disclosure-related intervention studies were efficacious in promoting disclosure to sexual partners. Although all three studies were conducted in the United States the intervention content and measurements of disclosure across the studies varied, so broad conclusions are not possible. The findings suggest that more rigorous HIV serostatus disclosure-related intervention trials targeting different populations in the United States and abroad are needed to facilitate disclosure to sexual partners.

Implementing an intimate partner violence (IPV) screening protocol in HIV care

HIV and intimate partner violence (IPV) epidemics propagate and interact in a syndemic fashion contributing to excess burden of disease and poorer health outcomes. In order to understand the impact of IPV on HIV disease management, a universal screening program was implemented in the Southern Alberta Clinic in May 2009. We evaluated our IPV screening protocol and made recommendations for its usage in HIV care. IPV data obtained from patients were evaluated, supplemented with responses from a subset of in-depth interviews. 35% of 1721 patients reported experiencing IPV. Prevalence was higher among females (46%), Aboriginal Canadians (67%), bisexual male/females (48%), and gay males (35%). Of 158 patients interviewed, only 22% had previously been asked about IPV in any health care setting. Patients were responsive to routine IPV screening emphasizing that referral services need to be easily accessible. 23% of patients disclosing IPV subsequently connected to additional IPV resources after screening. We recommend that universal IPV screening be incorporated within regular HIV clinic care. The IPV survey should be given after trust has been established with regular follow-up every 6-12 months. A referral process to local agencies dealing with IPV must be in place for patients disclosing abuses.

Examining the role of serostatus disclosure on unprotected sex among people living with HIV

Given the increasing prevalence of HIV, it is important to identify factors associated with safer sex behaviors between people living with HIV and their partners. Utilizing a diverse sample of 242 HIV-infected adults [n=69 men who have sex with men (MSM); n=68 men who have sex with women (MSW); n=105 women who have sex with men (WSM)], we examined the association between serostatus disclosure and unprotected anal or vaginal intercourse (UAVI) and the moderating effect of sexual behavior group on this association. Overall, 88.7% disclosed to their current partner. Approximately 18.8% of MSM, 17.7% of MSW, and 29.5% of WSM reported UAVI. Controlling for age, time since diagnosis, and partner serostatus, we found main effects on UAVI for disclosure and sexual behavior group; specifically, disclosure was inversely related to unprotected sex [AOR=0.09, 95% CI (0.02, 0.43), p<0.001], and MSM were less likely to engage in UAVI relative to WSM [AOR=0.11, 95% CI (0.17, 0.82), p<0.05]. However, the relationship between disclosure and UAVI was not moderated by sexual behavior group. Future strategies that aim to increase disclosure to partners may consider focusing on its value as a means by which to reduce sexual risk behavior.

Implementation of HIV prevention interventions in resource limited settings: the partner project

Evidence-based HIV prevention interventions have been translated to a variety of contexts across sub-Saharan Africa. Non-specialized community health center (CHC) staff members have been successfully engaged to deliver the interventions, which can be integrated into pre-existing HIV service programs in community-based health care delivery sites. This manuscript describes the process of implementing the Partner Project, a couples HIV risk reduction intervention, and examines the ability of CHC staff to achieve risk reduction outcomes comparable to those of the highly-trained research staff. The Partner Project was implemented within the HIV Counseling and Testing program in 6 urban community health clinics in Lusaka, Zambia. One hundred ninety-seven HIV-seroconcordant and -discordant couples were sequentially enrolled to the control group or to receive the intervention from partner research or CHC staff members. Couple members completed assessments on condom use, alcohol use, and intimate partner violence (IPV) at baseline, 6, and 12 months follow-up. Sexual barrier use outcomes achieved by the CHC staff were comparable to or better than those achieved by the Partner Project research staff, and both were superior to the control group. A reduction in IPV was observed for the entire sample, although no change in alcohol use was observed. Implementation of HIV prevention interventions at the community level should take advantage of existing resources available within the CHC staff. This is especially relevant in resource limited settings as consideration of the financial and clinical requirements of intervention programs is essential to the achievement of successful program implementation.

An expressive therapy group disclosure intervention for women living with HIV improves social support, self-efficacy, and the safety and quality of relationships: a qualitative analysis

Women living with HIV (WLHIV) face high rates of morbidity and mortality. HIV disclosure interventions have been identified as a promising but under-evaluated approach for WLHIV to improve their health and well-being. The Medea Project is an expressive therapy group intervention that was first developed to help incarcerated women develop the confidence and skills to tell their stories publicly in theatrical performances. The intervention was subsequently adapted as a community-based disclosure intervention for WLHIV. Our study describes an analysis of the impact of the Medea Project on the lives of the WLHIV who participated. All participating WLHIV publicly disclosed their HIV status during the performances. Five impact themes emerged from the data: sisterhood, catharsis, self-acceptance, safer and healthier relationships, and gaining a voice. Our study identifies a voluntary, effective, and broadly beneficial disclosure intervention for women living with HIV.