Practice and perception of parental HIV disclosure to children in Beijing, China

The role of internalised HIV stigma in disclosure of maternal HIV serostatus to children perinatally HIV-exposed but uninfected: a prospective study in the United States

INTRODUCTION

Decisions to disclose HIV serostatus may be complicated by internalised HIV stigma. We evaluated the association of internalised HIV stigma in biological mothers living with HIV with disclosure of their serostatus to their children perinatally HIV-exposed but uninfected (CHEU).

METHODS

Mothers and their CHEU were enrolled in the United States (U.S.)-based Surveillance Monitoring for Antiretroviral Therapy (ART) Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study (PHACS), a longitudinal study of outcomes related to in utero exposure to HIV and ART among CHEU. Mothers completing at least one stigma and disclosure assessment starting at the child's age 11-, 13-, 15- and/or 17-year study visits between 16 August 2016 and 1 October 2020 were eligible. Stigma was measured with the 28-item Internalised HIV Stigma Scale (IHSS). Mean stigma scores were linearly transformed to a range of 0-100, with higher scores indicating greater levels of stigma. At each visit, mothers were asked if their child was aware of their HIV diagnosis and at what age the child became aware. The Kaplan-Meier estimator evaluated the cumulative probability of disclosure at each child age. Logistic regression models with generalised estimating equations to account for repeated measures were fit to examine the association between stigma and disclosure, controlling for relevant socio-demographic variables.

RESULTS

Included were 438 mothers of 576 children (mean age 41.5 years, 60% U.S.-born, 60% Black/African American and 37% with household income ≤$10,000). The prevalence of disclosure across all visits was 29%. Mothers whose children were aware versus not aware of their serostatus reported lower mean IHSS scores (38.2 vs. 45.6, respectively). The cumulative proportion of disclosure by age 11 was 18.4% (95% CI: 15.5%, 21.8%) and 41% by age 17 (95% CI: 35.2%, 47.4%). At all child ages, disclosure was higher among children of U.S.-born versus non-U.S.-born mothers. After adjusting for age, marital status and years since HIV diagnosis, higher IHSS scores were associated with lower odds of disclosure (OR = 0.985, 95% CI: 0.975, 0.995).

CONCLUSIONS

Providing support to women as they make decisions about serostatus disclosure to their children may entail addressing internalised HIV stigma and consideration of community-level factors, particularly for non-U.S.-born mothers.

Chinese mothers' intent to disclose the HIV status to their children: the role of outcome expectations and self-efficacy

The present study examined the association between outcome expectations, self-efficacy, and intention to disclose HIV status to children among HIV-positive women in China, and the moderating and mediating role of self-efficacy on the association between outcome expectations and intention to disclose. A cross-sectional survey was conducted among 179 HIV-positive mothers who had at least one living child aged >5 years and had not yet disclosed their HIV status to her oldest child. Results from hierarchical regressions revealed that after adjusting for socio-demographic and medical variables, negative outcome expectations had a negative association (β = -0.22), while disclosure self-efficacy had a positive association (β = 0.43) with an intention to disclose HIV. The moderation effect of self-efficacy on the association between outcome expectations and intention to disclose HIV was not significant. Results from structural equation modeling showed that self-efficacy mediated the association between negative/positive outcome expectations and intention to disclose HIV. Findings support the importance of outcome expectations and self-efficacy and also the mediating role of self-efficacy in HIV disclosure among HIV-positive mothers in the Chinese context.

An Integrated Approach to HIV Disclosure for HIV-Affected Families in Thailand

Disclosure of HIV status to family members could improve communication, relationship, and cohesion. We evaluated the impact of a family-centered program designed to increase the readiness/willingness of parents to disclose HIV status to their children. People living with HIV (PLWH) with children ≥8 years were surveyed regarding HIV knowledge, family relationship, attitudes, willingness/readiness to disclose, and they were then invited to participate in group education and family camps. Of 367 PLWH surveyed, 0.8% had disclosed, 14.7% had not yet disclosed but were willing/ready to disclose, 50.4% were willing but not ready, and 33.2% did not wish to disclose. The educational sessions and camps led to significant improvements of HIV knowledge and disclosure techniques, and readiness/willingness to disclose. Given the benefits of group education and family camps in supporting PLWH to improve their communication with their families and disclose their HIV status, these supporting activities should be included in HIV programs.

Disclosure of Same-Sex Behaviors to Health-care Providers and Uptake of HIV Testing for Men Who Have Sex With Men: A Systematic Review

To promote HIV-testing and offer optimal care for men who have sex with men (MSM), health-care providers (HCPs) must first be aware of their patients’ sexual behaviors. Otherwise, HCPs may overlook MSM’s risks for HIV infection and their special health-care needs. For MSM, reporting their same-sex behaviors to HCPs (disclosure to HCPs) may promote their linkage to HIV prevention and treatment cascade and improve their health outcomes. No literature review has been conducted to examine the relationship between disclosure to HCPs and uptake of HIV-testing among MSM. The current study reviewed and synthesized findings from 29 empirical studies published in English by 2016. We summarized the rates of MSM’s disclosure to HCPs, investigated the association between disclosure and HIV-testing among MSM, identified potential facilitators and barriers for disclosure, and discussed the implications of our findings in research and clinical practices. The disclosure rates varied across subgroups and study settings, ranging from 16% to 90% with a median of 61%. Disclosure to HCPs was positively associated with uptake of HIV-testing. African American MSM were less likely to disclose to HCPs. MSM who lived in urban settings with higher education attainment and higher income were more likely to disclose. MSM tended to perceive younger or gay-friendly doctors as safer targets of disclosure. Clinics with LGBT-friendly signs were viewed as safer contexts for disclosure. Having previous communications about substance use, sex, and HIV with HCPs could also facilitate disclosure. The main reasons for nondisclosure included lack of probing from HCPs, concerns on confidentiality breach and stigma, and perceived irrelevance with services. Providing appropriate trainings for HCPs and creating gay-friendly clinical settings can be effective strategies to facilitate disclosures of same-sex behaviors among MSM and meet their specific medical needs. Interventions to promote disclosure should give priorities to MSM from the most marginalized subgroups (e.g., MSM in rural areas, MSM of ethnic minorities).

Waiting for the doctor to ask: influencers of lesbian, gay, and bisexual identity disclosure to healthcare providers

Lesbian, gay, and bisexual (LGB) individuals encounter multiple barriers in healthcare, resulting in problematic care. Many LGB patients wrestle with whether to disclose their sexuality to healthcare providers. This article explored what influences LGB patients’ decision to disclose their sexuality to healthcare providers. Guided by Communication Privacy Management theory, the authors conducted in-depth interviews with 20 LGB patients. LGB patients heavily relied on boundary management when negotiating the disclosure of their sexuality. The findings suggest several factors influence LGB patients’ disclosure of sexuality: i) experience with family; ii) fear of gossip and connections; iii) concern for provider care refusal; iv) religion; v) age; and vi) level of trust with providers. Boundary turbulence can be created between patient and provider when there is uncertainty about if and when sexuality is considered private information. Additionally, a site of tension for LGB patients was their concern about providers sharing private information outside the clinic setting.

The role of enacted stigma in parental HIV disclosure among HIV-infected parents in China

Existing studies have delineated that HIV-infected parents face numerous challenges in disclosing their HIV infection to the children (“parental HIV disclosure”), and practices of parental HIV disclosure vary with individual characteristics, family contexts, and social environment. Using cross-sectional data from 1254 HIV-infected parents who had children aged 5–16 years in southwest China, the current study examined the association of parental HIV disclosure with mental health and medication adherence among parents and explored the possible effect of enacted stigma on such association. Multivariate analysis of variance revealed that parents who had experienced disclosure to children reported higher level enacted stigma, worse mental health conditions, and poorer medication adherence. Enacted stigma partially mediated the associations between disclosure and both mental health and medication adherence after controlling basic background characteristics. Our findings highlight the importance of providing appropriate disclosure-related training and counseling service among HIV-infected parents. In a social setting where HIV-related stigma is still persistent, disclosure intervention should address and reduce stigma and discrimination in the practice of parental HIV disclosure.

Unable to be a Human Being in Front of Other People: A Qualitative Study of Self-Isolation Among People Living with HIV/AIDS in China

In China, acute stigma accompanying an HIV diagnosis can lead to self-isolation. In a cultural setting where family relationships are highly valued and contribute critically to well-being, such self-isolation can thwart HIV self-management and engagement in medical care, and so heighten risk for health disparities. To understand this phenomenon, we conducted individual in-depth interviews with 34 persons living with HIV/AIDS (PLwHA) in Shanghai and Beijing. Inductive content analysis revealed a range of forms of self-isolation motivation, beliefs, and behaviors influenced by: 1) internalized stigma and desire to avoid discrimination; 2) HIV-related factors such as HIV knowledge and disease progression; and 3) familial factors such as a sense of responsibility and family members' reactions. Based on a proposed framework centering on dialectical family influences (whereby PLwHA are pushed away from, yet pulled toward the family fold), implications for provision of multidisciplinary care in medical settings are considered, including culturally appropriate strategies to decrease health disparities.

Disclosure of Parental HIV Status to Children: Experiences of Adults Receiving Antiretroviral Treatment at an Urban Clinic in Kampala, Uganda

Limited data are available on the experiences of parental HIV disclosure to children in Uganda. We conducted a qualitative study comprising sixteen in-depth interviews and four focus group discussions with parents receiving highly active antiretroviral therapy. Analysis was done using Atlas.ti qualitative research software. Back-and-forth triangulation was done between transcripts of the in-depth interviews and focus group discussions, and themes and subthemes were developed. Barriers to parents' disclosure included perceptions that children are too young to understand what HIV infection means and fears of secondary disclosure by the children. Immediate outcomes of disclosure included children getting scared and crying, although such instances often gave way to more enduring positive experiences for the parents, such as support in adherence to medical care, help in household chores, and a decrease in financial demands from the children. Country-specific interventions are needed to improve the process of parental HIV disclosure to children and this should encompass preparation on how to deal with the immediate psychological challenges associated with the parent's disclosure.

A Systematic Review and Narrative Synthesis of Interventions for Parental Human Immunodeficiency Virus Disclosure

INTRODUCTION

Disclosure of parental human immunodeficiency virus (HIV) infection to their children remains a difficult process for parents living with HIV (PLWH). In order to identify the best strategies to facilitate parental HIV disclosure, it is necessary to examine the efficacy of existing interventions designed to help PLWH parents with the disclosure process to their children.

OBJECTIVES

To systematically review the efficacy of interventions designed to assist PLWH disclose their HIV status to their children.

METHODS

We conducted a systematic review and narrative synthesis of interventions designed to assist PLWH disclose their HIV status to their children. MEDLINE/PubMed, PsycINFO, Embase, Global Health, and Web of Science were searched.

RESULTS

Studies were eligible for inclusion if they evaluated an intervention for parental HIV disclosure. Five studies published between 2001 and 2015 met the inclusion criteria. The interventions were conducted in South Africa, China, and the United States. Three of the studies used two-arm randomized controlled trials, in which the intervention group was given enhanced care while the control group received standard care. Four of the five studies included a theoretically informed intervention and three were limited to mothers. Results showed that four of the interventions increased parental HIV disclosure.

CONCLUSION

The findings suggest that parental HIV disclosure interventions are successful in assisting parents with the disclosure process and can be adapted in different cultural context. Future parental HIV disclosure interventions should include fathers in order to assist men with parental HIV disclosure.

Issues around childhood disclosure of HIV status - findings from a qualitative study in West Bengal, India

INTRODUCTION

Informing the children living with HIV (CLH) about their disease (disclosure) is important from the perspective of disease treatment and overall psychosocial development. There are no published studies that qualitatively explored HIV disclosure-related issues among CLH in India. Our aim was to provide insights into the perceptions of informal caregivers of CLH regarding childhood disclosure.

METHODS

Children were defined as those aged <16 years. In-depth interviews were conducted with 34 primary caregivers of CLH aged 8 to 15 years old who were residing in West Bengal, India. The participants were recruited with the help of a community-based organization that provides need-based services to people living with HIV.

RESULTS

We obtained caregivers' perspectives on the motivators and barriers of childhood disclosure. Health benefits such as medication adherence emerged as an important motivator, while distress caused by disclosure and potential for stigma were identified as barriers. Health care providers were the preferred disclosers for most caregivers, followed by the caregivers themselves. Some caregivers wanted their child to learn about his/her HIV status by him/herself. There was no consensus among the caregivers about the ideal age for disclosure. Many preferred to wait until the child attained maturity or was of marriageable age.

DISCUSSION

Disclosure of HIV status to children is an emotional issue, both for the caregiver and the child. Like most low-or middle-income countries, no standardized, age-appropriate disclosure guidelines exist in India. Our findings advocate adoption of a multi-faceted approach, including increased availability of social and familial support, for childhood HIV disclosure.

Family relations in the context of HIV/AIDS in Southwest China

In China, an estimated 780,000 people have been infected with HIV (China AIDS, 2012 ). Even as this stigmatized population rapidly grows, with the majority of reproductive age (20-40 years old), information about their daily experiences in the domestic sphere has been scarce. Because the family remains a central unit of social and ethical organization in China, the current qualitative study examines family relations among people living with HIV (PLWH) with the goal of identifying the effect of HIV on family relations and, conversely, the effect of family relations on those with HIV. We analyzed data from 90 in-depth interviews with PLWH and people around them (i.e., their children, health care providers, other community members) in southwest China (Guangxi province). Through analyzing the families' experiences with illness, three themes emerged: how individuals with HIV interact with their community; how they cope with stigma alongside and against their family; and how families can support those with HIV. Our data ultimately showed the critical role of family in the quality of PLWH's well-being. Because concealment of their serostatus was the primary coping strategy, stigma manifestation was most obvious in the domestic spheres. Yet, when help was received, PLWH regarded family support as the most helpful, as those who received empathy from their families remained more optimistic. Thus, there is an urgent need for developing efficacious intervention programs that could lead to maximize family support, involving the families of PLWH, with a particular attention to family dynamics in daily interactions. Despite our awareness of the significance of family in China, this study reveals a particular kind of role of family that has rarely been considered, namely the role of family in healing and sustaining social bonds within the context of stigmatization, when those bonds might otherwise be broken.

AIDS impact special issue 2015: interpersonal factors associated with HIV partner disclosure among HIV-infected people in China

HIV partner disclosure may facilitate social support, improve psychological well-being among HIV-infected individuals, and promote HIV testing and HIV prevention among their sexual partners. A growing literature emphasizes the critical role of interpersonal factors may play in decision-making and practice regarding HIV partner disclosure. However, there is a dearth of empirical studies that investigate how interpersonal factors may be associated with HIV partner disclosure. Using cross-sectional data collected from 791 HIV-infected people in Guangxi China, we examined the associations between these two interpersonal factors (quality of relationship with partner and family communication) and HIV partner disclosure. Descriptive analysis, t-test analysis, and gender stratified GLM analysis were conducted. We find that disclosing HIV status to partners was significantly related to better quality of relationship with partners and open and effective family communication. Gender and partner HIV status might moderate the associations between interpersonal factors and HIV partner disclosure. Our findings suggest the importance of considering relationship quality and enhancing open and comfortable family communication in HIV disclosure interventions. Gender difference and partner HIV status should be also considered in HIV disclosure intervention to address the diverse needs of HIV-infected people.

A Mixed-Methods Study Supporting a Model of Chinese Parental HIV Disclosure

Parents who are HIV-positive confront difficult decisions regarding whether, when, and how to disclose their HIV status to their children. In China, a setting of acute HIV stigma where family harmony is culturally valued, limited research has been conducted on parental disclosure. We aimed to develop a model of parental disclosure that accounts for the cultural context in China based on a mixed-methods study. In our individual, in-depth interviews (N = 24) as well as survey data (N = 84) collected from parents living with HIV in Shanghai and Beijing, we found the primary barriers to disclosure were stigma, fear of exposing the mode by which they acquired HIV, psychologically burdening the child, rejection by the child, and negative social consequences for the family. Parents concurrently cited many motivations for disclosure, such as disease progression, ensuring safety of the child, gaining assistance, and fulfilling their parental responsibility. Most parents had not actively disclosed their HIV status (68 %); many parents reported some form of partial disclosure (e.g., sharing they have a blood disease but not labeling it HIV), unplanned disclosure, or unintentional disclosure to their children by other people. Findings informed the development of a Chinese Parental HIV Disclosure Model, with primary components accounting for distal cultural factors, decision-making (balancing approach and avoid motivations), the disclosure event, and outcomes resulting from the disclosure. This model highlights the cultural context of the Chinese parental disclosure process, and may be useful in guiding future observational research and intervention work.

Nurse-delivered counselling intervention for parental HIV disclosure: results from a pilot randomized controlled trial in China

OBJECTIVE

The objective of this study was to design and conduct a preliminary evaluation of an intervention to assist parents in decision-making about disclosure of their HIV diagnosis to their children.

DESIGN

This was a pilot randomized controlled trial (RCT) with blinded assessment. Participants were randomized to intervention or treatment-as-usual (TAU) arms.

SETTING

The study occurred at an outpatient HIV primary care centre in Shanghai, China.

PARTICIPANTS

Participants were 20 HIV-positive outpatients with at least one child (13-25 years old) who was unaware of the parent's HIV diagnosis.

INTERVENTION

The nurse-delivered intervention involved three, hour-long, individual sessions over 4 weeks. Intervention content comprised family assessment, discussion of advantages and disadvantages of disclosure, psycho-education about cognitive, social and emotional abilities of children at different developmental stages, and disclosure planning and practicing via role-plays.

MAIN OUTCOME MEASURE(S)

Primary study outcomes for intervention versus TAU arms were self-reported disclosure distress, self-efficacy, and behaviours along a continuum from no disclosure to full disclosure and open communication about HIV.

RESULTS

In all cross-sectional (Wald tests) and longitudinal (general estimating equations) analyses, at both postintervention (4 weeks) and follow-up (13 weeks), effects were in the hypothesized directions. Despite the small sample size, most of these between-arm comparisons were statistically significant, with at least one result for each outcome indicating a 'large' effect size.

CONCLUSION

Our results suggest that nurses are able to deliver a counselling intervention in a clinic setting with the potential to alleviate parental distress around HIV disclosure to their children. Findings warrant future trials powered for efficacy.

Factors influencing the decision-making of parental HIV disclosure: a socio-ecological approach

OBJECTIVES

Using the socio-ecological approach, the current study aims to identify facilitators and barriers to decision-making regarding parental HIV disclosure or nondisclosure at intrapersonal, interpersonal, and sociocultural levels; and examine the unique contribution of factors at different level of influences to the decision of disclosure or nondisclosure.

DESIGN

A cross-sectional survey was conducted among people living with HIV in Guangxi, China. A sub-sample of 1254 participants, who had children aged 5-16 years, was included in the data analysis in the current study.

METHODS

Multivariate models using hierarchical logistic regression were employed to assess the association of parental decision regarding HIV disclosure to children with various factors at intrapersonal, interpersonal, and sociocultural levels controlling background characteristics, and detect the level-specific influence on disclosure decision.

RESULTS

Positive coping with HIV infection and a good parent-child relationship facilitated parental HIV disclosure; whereas high level of resilience and fears of parental HIV disclosure impeded their decisions to talk about HIV status to their children. In addition, the current study recognized specific contribution of multiple ecological levels to parental decisions regarding disclosure to children.

CONCLUSION

The socio-ecological model is a promising theoretical framework to guide further studies and interventions related to parental HIV disclosure. Directions for further studies using socio-ecological approach were also discussed.

The role of social relationship in HIV healing and its implications in HIV cure in China

HIV is both a biomedical disease and a social phenomenon that is constructed in particular cultural contexts. A successful and humane HIV cure requires not only the science of eradicating pathogens, but also the art of healing to restore harmony between mind and body. Healing in the context of HIV cure will be both personal and interpersonal, biological and social, and will involve rebuilding connections between HIV patients and their social environment. Social conceptions of healing have been highlighted in many regions with rich non-biomedical healing traditions, including China. Based on an adapted theoretical model on social relationships and health, we address the essential role of social relations for HIV healing in Chinese cultural context, and propose several recommendations for reforming practices and policies regarding HIV healing. In general, family is still a core social unit in HIV patients' medical journey from diagnosis to treatment. A positive patient-physician relationship based on mutual respect and trust also has critical impact on patients' physical and mental health. Physicians may become a key or the main source of social support in circumstances when families are not actively engaged in healing. Reconnecting HIV patients with their communities should be a necessary component of HIV cure, as this will help patients engage more fully in the HIV healing process. We call for a family-centered approach in HIV healing intervention to strengthen patient-family ties; a series of policies to build up and sustain positive patient-physician ties; and multi-level strategies to empower patients and rebuild their bonds to community and larger society. We also call for more empirical research on how non-biomedical healing approaches in various cultural settings could (directly or indirectly) inform HIV cure research.