A mixed-methods assessment of disclosure of HIV status among expert mothers living with HIV in rural Nigeria.
ABSTRACT: BACKGROUND:Peer support provided by experienced and/or trained "expert" women living with HIV has been adopted by prevention of mother-to-child transmission of HIV (PMTCT) programs across sub-Saharan Africa. While there is ample data on HIV status disclosure among non-expert women, there is little data on disclosure among such expert women, who support other women living with HIV. OBJECTIVE:This study compared HIV disclosure rates between expert and non-expert mothers living with HIV, and contextualized quantitative findings with qualitative data from expert women. METHODS:We compared survey data on HIV disclosure to male partners and family/friends from 37 expert and 100 non-expert mothers living with HIV in rural North-Central Nigeria. Four focus group discussions with expert mothers provided further context on disclosure to male partners, extended family and peers. Chi square and Fisher's exact tests were applied to quantitative data. Qualitative data were manually analyzed using a Grounded Theory approach. RESULTS:Two-thirds of the 137 participants were 21-30 years old; 89.8% were married, and 52.3% had secondary-level education. Disclosure to male partners was higher among expert (100.0%) versus non-expert mothers (85.0%), p = 0.035. Disclosure to anyone (93.1% vs 80.8%, p = 0.156), and knowledge of male partners' HIV status were similar (75.7% versus 66.7%, p = 0.324) between expert and non-expert mothers, respectively. With respect to male partners, HIV serodiscordance rates were also similar (46.4% vs 55.6%, p = 0.433). Group discussions indicated that expert mothers did not consistently disclose to their mentored clients, with community-level stigma and discrimination stated as major reasons for this non-disclosure. CONCLUSIONS:Expert mothers experience similar disclosure barriers as their non-expert peers, especially regarding disclosure outside of intimate relationships. Thus, attention to expert mothers' coping skills and disclosure status, particularly to mentored clients is important to maximize the impact of peer support in PMTCT. CLINICAL TRIALS REGISTRATION:Clinicaltrials.gov registration number NCT01936753 (retrospective), September 3, 2013.
Project description:BACKGROUND:Serostatus disclosure may facilitate decreased HIV transmission between serodiscordant partners by raising risk awareness and heightening the need for prevention. For women living with HIV (WLWH), the decision to disclose may be influenced by culturally determined, community-level stigma and norms. Understanding the impact of community HIV stigma and gender norms on disclosure among WLWH in different countries may inform intervention development. METHODS:HPTN063 was a longitudinal, observational study of sexually active HIV-infected individuals, including heterosexual women, in care in Zambia, Thailand and Brazil. At baseline, a questionnaire measuring community HIV stigma and gender norms, anticipated stigma, demographic, partner/relationship characteristics, and intimate partner violence was administered. Longitudinal HIV disclosure to sexual partners was determined via audio-computer assisted self-interview (ACASI) at the baseline and quarterly during the one year following up. Logistic regression was conducted to identify the predictors of disclosure. RESULTS:Almost half (45%) of women living with HIV acknowledged perceived community HIV stigma (the belief that in their community HIV infection among women is associated with sex work and multiple sexual partners). Many women (42.9%) also acknowledged perceived community gender norms (the belief that traditional gender norms such as submissiveness to husbands/male sexual partners is necessary and that social status is lost if one does not procreate). HIV disclosure to current sex partners was reported by 67% of women. In multivariate analysis, among all women, those who were older [OR 0.16, 95%CI(0.06,0.48)], reported symptoms of severe depression [OR 0.53, 95%CI(0.31, 0.90)], endorsed anticipated stigma [OR 0.30, 95%CI(0.18, 0.50)], and were unmarried [OR 0.43, 95%CI(0.26,0.71)] were less likely to disclose to current partners. In an analysis stratified by marital status and cohabitation, unmarried [OR 0.41, 95%CI(0.20,0.82)] and non-cohabiting women [OR 0.31, 95%CI(0.13,0.73)] who perceived community HIV stigma were less likely to disclose to their sex partners. CONCLUSIONS:Perceived community level HIV stigma, along with individual level factors such as anticipated stigma, depressive symptoms, and older age, predict non-disclosure of HIV status to sexual partners among WLWH in diverse geographic settings. Interventions to promote disclosure among women in serodiscordant relationships should incorporate community-level interventions to reduce stigma and promote gender equality.
Project description:BACKGROUND: In Africa, women tested for HIV during antenatal care are counselled to share with their partner their HIV test result and to encourage partners to undertake HIV testing. We investigate, among women tested for HIV within a prevention of mother-to-child transmission of HIV (PMTCT) programme, the key moments for disclosure of their own HIV status to their partner and the impact on partner HIV testing. METHODS AND FINDINGS: Within the Ditrame Plus PMTCT project in Abidjan, 546 HIV-positive and 393 HIV-negative women were tested during pregnancy and followed-up for two years after delivery. Circumstances, frequency, and determinants of disclosure to the male partner were estimated according to HIV status. The determinants of partner HIV testing were identified according to women's HIV status. During the two-year follow-up, disclosure to the partner was reported by 96.7% of the HIV-negative women, compared to 46.2% of HIV-positive women (chi(2) = 265.2, degrees of freedom [df] = 1, p < 0.001). Among HIV-infected women, privileged circumstances for disclosure were just before delivery, during early weaning (at 4 mo to prevent HIV postnatal transmission), or upon resumption of sexual activity. Formula feeding by HIV-infected women increased the probability of disclosure (adjusted odds ratio 1.54, 95% confidence interval 1.04-2.27, Wald test = 4.649, df = 1, p = 0.031), whereas household factors such as having a co-spouse or living with family reduced the probability of disclosure. The proportion of male partners tested for HIV was 23.1% among HIV-positive women and 14.8% among HIV-negative women (chi(2) = 10.04, df = 1, p = 0.002). Partners of HIV-positive women who were informed of their wife's HIV status were more likely to undertake HIV testing than those not informed (37.7% versus 10.5%, chi(2) = 56.36, df = 1, p < 0.001). CONCLUSIONS: In PMTCT programmes, specific psychosocial counselling and support should be provided to women during the key moments of disclosure of HIV status to their partners (end of pregnancy, weaning, and resumption of sexual activity). This support could contribute to improving women's adherence to the advice given to prevent postnatal and sexual HIV transmission.
Project description:BACKGROUND:Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women. METHODS:A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014-2016, all (34,637) mothers attending 54 under-5 clinics with their 4-26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were excluded. Data collected included socio-demographics, partner disclosure, maternal ART uptake, and adherence. Between 2016-2017, in-depth interviews and focus group discussions were conducted with adult mothers (n = 53) and their spouse/cohabiting partners (n = 19), adolescent mothers (n = 13), lost-to-follow up (LTFU) mothers (n = 22), community leaders (n = 23) and healthcare workers (n = 154). RESULTS:Of 3153 known HIV-infected mothers, 2882 (91.4%) reported having a spouse/cohabiting partner. Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART (aOR 4.7; 95%CI 2.5-8.8), suboptimal treatment adherence (aOR 1.8; 95%CI 1.1-2.8) and MTCT (aOR 2.1; 95%CI 1.1-4.1). Women's fear of blame by partners was central to decisions not to disclose within couples and when starting new relationships. LTFU mothers struggled to accept and disclose their status, hindering treatment initiation; some were unable to hide ART and feared involuntary disclosure. CONCLUSION:Partner disclosure seems to play an important role in women's decisions regarding ART initiation and adherence. Inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence and MTCT.
Project description:BACKGROUND:Men who have sex with men (MSM) and transgender women (TGW) are disproportionately impacted by HIV and may face barriers to HIV status disclosure with negative ramifications for HIV prevention and care. We evaluated HIV status disclosure to sexual partners, HIV treatment outcomes, and stigma patterns of MSM and TGW in Abuja and Lagos, Nigeria. METHODS:Previously-diagnosed MSM and TGW living with HIV who enrolled in the TRUST/RV368 cohort from March 2013 to August 2018 were asked, "Have you told your (male/female) sexual partners (MSP/FSP) that you are living with HIV?" In separate analyses, robust Poisson regression models were used to estimate risk ratios (RRs) and 95% confidence intervals (95% CIs) for characteristics associated with HIV status disclosure to MSP and FSP. Self-reported stigma indicators were compared between groups. RESULTS:Of 493 participants living with HIV, 153 (31.0%) had disclosed their HIV status to some or all MSP since being diagnosed. Among 222 with FSP, 34 (15.3%) had disclosed to some or all FSP. Factors independently associated with disclosure to MSP included living in Lagos (RR 1.58 [95% CI 1.14-2.20]) and having viral load <?50 copies/mL (RR 1.67 [95% CI 1.24-2.25]). Disclosure to FSP was more common among participants who were working in entertainment industries (RR 6.25 [95% CI 1.06-36.84]) or as drivers/laborers (RR 6.66 [95% CI 1.10-40.36], as compared to unemployed) and also among those married/cohabiting (RR 3.95 [95% CI 1.97-7.91], as compared to single) and prescribed ART (RR 2.27 [95% CI 1.07-4.83]). No differences in self-reported stigma indicators were observed by disclosure status to MSP but disclosure to FSP was associated with a lower likelihood of ever having been assaulted (26.5% versus 45.2%, p?=?0.042). CONCLUSIONS:HIV status disclosure to sexual partners was uncommon among Nigerian MSM and TGW living with HIV but was associated with improved HIV care outcomes. Disclosure was not associated with substantially increased experiences of stigma. Strategies to encourage HIV status disclosure may improve HIV management outcomes in these highly-marginalized populations with a high burden of HIV infection.
Project description:<h4>Background</h4>Sub Saharan Africa continues to be the epicenter of HIV with 70% of people living with HIV globally. Women form nearly 60% of those living with HIV. Studies have shown disclosure of one's HIV status is important in HIV prevention, in increasing partners who are tested and getting into care early as well as in improving retention in PMTCT and ART programs. This study aimed to determine the prevalence, factors and outcomes of HIV status disclosure to partners among HIV-positive women attending HIV care-and-treatment clinics (CTCs) at Kilimanjaro region, northern Tanzania.<h4>Methods</h4>A cross-sectional study was conducted from January to June 2014 in 3 out of the 7 districts of Kilimanjaro region. The study population was HIV-positive women aged 15-49, who were attending for routine HIV care at 19 selected clinics. Face-to-face interviews were conducted with consenting women to collect necessary information. Multivariate logistic regression analyses were used to determine the independent predictors of HIV status disclosure to partner.<h4>Results</h4>A total of 672 HIV-positive women in Moshi municipal, Hai and Mwanga districts were enrolled. Of them, 609 HIV-positive women reported to have a regular partner. Prevalence of serostatus disclosure to partners was 66%. Of the 400 who had disclosed; 56% did so within the first month of knowing their HIV status. In a multiple logistic regression model, HIV serostatus disclosure was higher among women who: were married/cohabiting (AOR = 4.16, 95% CI: 2.39-7.25; p<0.001), currently on ART (AOR = 2.06, 95% CI: 1.11-3.82; p = 0.020), and who reported had ever communicated with partners on number of children (AOR = 1.85, 95% CI: 1.15-2.98; p = 0.010) and contraceptives use (AOR = 2.01, 95% CI: 1.27-3.20; p = 0.208). Most of the women (81%) who disclosed their HIV status to did not reported negative outcomes.<h4>Conclusion</h4>In this setting still a third of the HIV-positive women (34%) fail to disclose their HIV- serostatus to partners. Interventions to impart skills in communication and negotiation between partners may help in improving disclosure of HIV. Efforts to involve men in general sexual and reproductive health including couple counseling and testing will contribute in improving disclosure and communication on HIV among partners.
Project description:This qualitative study investigated gender power inequalities as they contribute to relationship dynamics and HIV-serostatus disclosure among men and women living with HIV in Durban, South Africa. HIV serodiscordance among men and women within stable partnerships contributes to high HIV incidence in southern Africa, yet disclosure rates remain low. Given the emphasis on prevention for HIV-serodiscordant couples, this research supports the urgent need to explore how best to support couples to recognize that they are part of this priority population and to access appropriate prevention and treatment.Thirty-five in-depth individual interviews were conducted with 15 HIV-positive men and 20 HIV-positive women (not couples) receiving care at public-sector clinics near Durban. A structured coding scheme was developed to investigate men's and women's attitudes toward HIV-serostatus disclosure and behaviors of sharing (or not sharing) HIV serostatus with a partner. Narratives were analyzed for barriers and facilitators of disclosure through the lens of sociocultural gender inequality, focusing on reasons for non-disclosure.Among 35 participants: median age was 33 years (men) and 30 years (women); average years since HIV diagnosis was 1 (men) and 1.5 (women). Four themes related to gender inequality and HIV-serostatus disclosure emerged: (1) Men and women fear disclosing to partners due to concerns about stigma and relationship dissolution, (2) suspicions and mistrust between partners underlies decisions for non-disclosure, (3) unequal, gendered power in relationships causes differential likelihood and safety of disclosure among men and women, and (4) incomplete or implicit disclosure are strategies to navigate disclosure challenges. Findings illustrate HIV-serostatus disclosure as a complex process evolving over time, rather than a one-time event.Partner communication about HIV serostatus is infrequent and complicated, with gender inequalities contributing to fear, mistrust, and partial or implicit disclosure. Relationship dynamics and gender roles shape the environment within which men and women can engage successfully in the HIV-serostatus disclosure process. Integrated interventions to reduce barriers to trustful and effective communication are needed for HIV-affected men and women in partnerships in which seeking couples-based HIV counseling and testing (CHCT) is challenging or unlikely. These data offer insights to support HIV-serostatus disclosure strategies within relationships over time.
Project description:HIV sero-status disclosure among people living with HIV (PLWH) is an important component of preventing HIV transmission to sexual partners. Due to various social, structural, and behavioral challenges, however, many HIV-infected opioid-dependent patients do not disclose their HIV status to all sexual partners. In this analysis, we therefore examined non-disclosure practices and correlates of non-disclosure among high-risk HIV-infected opioid-dependent individuals. HIV-infected opioid-dependent individuals who reported HIV-risk behaviors were enrolled (N?=?133) and assessed for HIV disclosure, risk behaviors, health status, antiretroviral therapy (ART) adherence, HIV stigma, social support and other characteristics. Multivariable logistic regression was used to identify significant correlates of non-disclosure. Overall, 23% reported not disclosing their HIV status to sexual partners, who also had high levels of HIV risk: sharing of injection equipment (70.5%) and inconsistent condom use (93.5%). Independent correlates of HIV non-disclosure included: being virally suppressed (aOR 0.19, p?=?0.04), high HIV-related stigma (aOR 2.37, p?=?0.03), and having multiple sex partners (aOR 5.87, p?=?0.04). Furthermore, a significant interaction between HIV-related stigma and living with family/friends suggests that those living with family/friends were more likely to report not disclosing their HIV status when higher levels of perceived stigma was present. Our findings support the need for future interventions to better address the impact of perceived stigma and HIV disclosure as it relates to risk behaviors among opioid-dependents patients in substance abuse treatment settings.
Project description:Globally, there are 3.3 million children < 15 years of age living with HIV infection. About 95% of HIV infected children have acquired infection from their mothers. Although new pediatric HIV infection in Tanzania has declined by 48% and Prevention of Mother to Child Transmission (PMTCT) coverage of highly active anti-retroviral therapy (HAART) has increased to 77%, the MTCT rate remains high (15%). Poor male partner involvement in PMTCT services is one of the factors contributing to reduced effectiveness of the PMTCT and hence failure to achieve the elimination of maternal to child transmission of HIV. This study examined the predictors of male involvement in PMTCT services in Mwanza Region, Tanzania from perspectives of the mother.A cross sectional study involving selected health facilities was conducted in Mwanza urban from October 2013 through January 2014. HIV positive pregnant women attending ante-natal clinic (ANC) were interviewed using a semi structured questionnaire. Univariate analysis was used to describe the study respondents where bivariate and logistic regression was used to determine predictors of male involvement.A total of 300 HIV positive mothers attending ANC with the mean age of 27.5 + 5.6 were interviewed. Few mothers (24.7%) had their male partners involved in PMTCT. Predictors of male partner involvement in PMTCT were mothers being proactive (Adjusted Odds Ratio (AOR) 28.6; Confidence Interval (CI) 7-116), perceived partners knowledge on PMTCT (AOR 24.6, CI 5.9-102.8), exposure to TV/Radio announcements on PMTCT (AOR 4.6, CI 1.5-14) and married status of the mother (AOR 3.7, CI 1.5-9). Mothers who never wanted to be escorted by their male partners and busy partners were associated with reduced odds of male involvement into PMTCT (AOR 0.07, CI 0.007-0.68) and (AOR 0.46 CI 0.21-0.99) respectively. Male partner involvement was associated with 98% reduced odds of violence (Crude Odds Ratio 0.018 CI 0.002-0.14).Male partner involvement in PMTCT is still low in Mwanza Region. Proactive mothers, partner's knowledge on PMTCT and announcements from television/radio were the major facilitating factors for male involvement in PMTCT as perceived by mothers. Busy male partners and mothers who did not want to be escorted by their partners were a hindrance to male involvement in PMTCT services. These factors highlight the importance of women role in promotion of PMTCT male involvement.
Project description:BACKGROUND:HIV testing male partners of pregnant women may decrease HIV transmission to women and promote uptake of prevention of mother-to-child HIV transmission (PMTCT) interventions. However, it has been difficult to access male partners in antenatal care (ANC) clinics. We hypothesized that home visits to offer HIV testing to partners of women attending ANC would increase partner HIV testing. METHODS:Women attending their first ANC were enrolled, interviewed using smartphone audio-computer-assisted self-interviews and randomized to home visits or written invitations for male partners to come to clinic, if they were married or cohabiting, unaccompanied by partners and had no prior couple HIV counselling and testing (CHCT). Enrolled men were offered CHCT (HIV testing and mutual disclosure). Prevalence of CHCT, male HIV seropositivity, couple serodiscordance and intimate partner violence, reported as physical threat from partner, were compared at 6 weeks. RESULTS:Among 495 women screened, 312 were eligible, and 300 randomized to clinic-based or home-based CHCT. Median age was 22 years (interquartile range 20-26 years), and 87% were monogamous. CHCT was significantly higher in home-visit than in clinic-invitation arm (n = 128, 85% vs. n = 54, 36%; P < 0.001). Home-arm identified more HIV-seropositive men (12.0 vs. 8.0%; P = 0.248) and more HIV-discordant couples (14.7 vs. 4.7%; P = 0.003). There was no difference in intimate partner violence. CONCLUSION:Home visits of pregnant women were safe and resulted in more male partner testing and mutual disclosure of HIV status. This strategy could facilitate prevention of maternal HIV acquisition, improve PMTCT uptake and increase male HIV diagnosis.
Project description:BACKGROUND:Social concerns about unintentional HIV status disclosure and HIV-related stigma are barriers to pregnant women's access to prevention of mother-to-child transmission of HIV (PMTCT) care. There is limited quantitative evidence of women's social and emotional barriers to PMTCT care and HIV disclosure. We aimed to investigate how social concerns related to participation in PMTCT care are associated with HIV status disclosure to partners and relatives among pregnant women living with HIV in western Kenya. METHODS:A cross-sectional study, including 437 pregnant women living with HIV, was carried out at enrolment in a multicentre mobile phone intervention trial (WelTel PMTCT) in western Kenya. Women diagnosed with HIV on the day of enrolment were excluded. To investigate social concerns and their association with HIV disclosure we used multivariable-adjusted logistic regression, adjusted for sociodemographic and HIV-related characteristics, to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS:The majority (80%) had disclosed their HIV status to a current partner and 46% to a relative. Older women (35-44?years) had lower odds of disclosure to a partner (OR?=?0.15; 95% CI: 0.05-0.44) compared to women 18-24?years. The most common social concern was involuntary HIV status disclosure (reported by 21%). Concern about isolation or lack of support from family or friends was reported by 9%, and was associated with lower odds of disclosure to partners (OR?=?0.33; 95% CI: 0.12-0.85) and relatives (OR?=?0.37; 95% CI: 0.16-0.85). Concern about separation (reported by 5%; OR?=?0.17; 95% CI: 0.05-0.57), and concern about conflict with a partner (reported by 5%; OR?=?0.18; 95% CI: 0.05-0.67), was associated with lower odds of disclosure to a partner. CONCLUSIONS:Compared to previous reports from Kenya, our estimated disclosure rate to a partner is higher, suggesting a possible improvement over time in disclosure. Younger pregnant women appear to be more likely to disclose, suggesting a possible decreased stigma and more openness about HIV among younger couples. Healthcare providers and future interventional studies seeking to increase partner disclosure should consider supporting women regarding their concerns about isolation, lack of support, separation, and conflict with a partner. PMTCT care should be organized to ensure women's privacy and confidentiality.