Abstract
Background:
HIV status disclosure to sex partners potentially reduces the risk of sexually transmitting HIV. However, there is limited information on the associations between HIV status disclosure in types of sexual partnerships and ensuing sexual practices.
Methods:
We examined HIV status disclosure to sex partners among 205 men and women living with HIV and receiving diagnostic and treatment services for a co-occurring sexually transmitted infection (STI) in Cape Town, South Africa. Participants completed partner-by-partner sexual behavior interviews and provided permission to extract recurrent STI clinic visits over the subsequent 12-months.
Results:
Three groups were formed on the basis of HIV status disclosure to sex partners: (a) 22% reported only HIV same-status partners; (b) 26% had HIV negative or unknown HIV status (HIV different-status) sex partners to whom they had disclosed their HIV status; and (c) 52% had at least one HIV different-status partner to whom they had not disclosed. There were no associations between HIV status disclosure and demographic characteristics, sexual practices, or recurrent STI clinic visits. Undisclosed HIV to at least one HIV different-status sex partner was associated with greater alcohol use and less likelihood of receiving ART; participants who were least likely to disclosure their HIV status to partners drank more alcohol and were less likely to be taking antiretroviral therapy.
Conclusions:
High prevalence of partner non-disclosure and lack of significant correlates to HIV status disclosure indicate a need for further research with an eye toward identifying disclosure processes and mechanisms that may ultimately lead to effective interventions.
Keywords: HIV disclosure, HIV Prevention, HIV-STI Co-infection, HIV stigma
Introduction
Disclosing HIV status to sex partners potentially reduces HIV transmission risks by negotiating safer sex and sharing in sexual decision-making. HIV status disclosure to sex partners early in relationships may help prevent the forward transmission of HIV (1), with some mathematical models suggesting that HIV disclosure may reduce HIV transmission risks by as much as 41% (2). Evidence suggests that it is common for people with HIV to not disclose their HIV status to sex partners (3, 4). Relative to casual sex partners, there is a 6-fold greater likelihood of disclosing HIV status to stable (e.g., main) sex partners among men and a 2.5-fold greater likelihood among women (5). In a nationally representative sample of people living with HIV in South Africa, nearly one in four (23%) reported having not disclosed their HIV status to current sex partners (6). A prospective study of HIV positive adults in South Africa found that 91% had disclosed their HIV status over one year, but with most disclosures occurring to family members and only 34% of men and 29% of women disclosing their HIV status to sex partners (5). In the Eastern Cape of South Africa, for example, women are significantly more likely to disclose their HIV status to family members than sex partners (7, 8), with non-disclosure most common among younger women with poorer retention to HIV care and lower antiretroviral therapy (ART) adherence (9). One reason for greater disclosure to family members than sex partners is that individuals derive greater support from family who know their HIV status than from sex partners (10). Furthermore, disclosure to sex partners can entail considerable costs including threats of abandonment, loss of economic support, and potential violence (3).
The implications of HIV disclosure for HIV prevention may change in the context of ART and HIV suppression, where risks for HIV transmission are diminished (11). Similar to how anticipated HIV stigma is an impediment to HIV disclosure, stigma also poses barriers to ART uptake and adherence. Population-based research indicates that nearly half (48%) of people living with HIV in South Africa experience significant stigma, including 44% who have been rejected by their families (12). A majority of people living with HIV in South Africa experience high-levels of internalized, anticipated, and enacted stigma and all of these forms of stigma are robust impediments to HIV treatment and HIV disclosure (13–15).
Overall, non-disclosure of HIV to avoid stigma is a stronger predictor of ART non-adherence than depression and poor social support (16). Hiding medications, removing medication bottle labels and other actions intended to conceal HIV status are associated with poor ART adherence (17). Studies in South Africa show that one in three people with biomarker confirmed use of ART deny taking ART when interviewed in their homes (18). Men and women who have not disclosed their HIV status are also less likely to have initiated ART (1). In Ethiopia concealing HIV from family and friends places constraints on social support, and significantly impedes ART adherence (19). Because stigma manifests itself by impeding both ART initiation and HIV disclosure, people living with HIV who do not disclose their HIV status to partners may also be untreated, HIV unsuppressed and therefore infectious (11, 20). Furthermore, in the absence of ART, sexually transmitted infections (STI) amplify the forward sexual transmission of HIV (21, 22).
Research conducted in the US has found an association between diagnosis with co-occurring STI and non-disclosure of HIV status to HIV negative and unknown status (e.g., different-status) sex partners (23). However, we are not aware of previous research examining HIV status disclosure to sex partners among people living with HIV and being treated for sexually transmitted co-infections in southern Africa, the region of the world with the vast majority of HIV infections. The purpose of this study is to fill this gap by examining factors associated with HIV status disclosure to sex partners among people living with HIV. We examined participant characteristics (e.g., gender, age, alcohol use, recurrent STI clinic visits, receiving ART) among those who disclose their HIV status to HIV positive and HIV different-status sex partners. We hypothesized that people living with HIV who were receiving treatment for an STI would be significantly more likely to have disclosed their HIV status to main sex partners than to their casual and one-time partners. We also hypothesized that participants who had disclosed their HIV status to different-status sex partners would engage in lower-rates of condomless intercourse, higher-rates of condom use, and would be more likely to be treated with ART than their counterparts who had not disclosed their HIV status to HIV different-status partners.
Methods
Procedures
We conducted a cross-sectional study with 205 people who self-identified as having tested HIV positive from a larger sample of 1050 patients receiving treatment for an STI at a clinic located in an economically impoverished Cape Town community. Participants were enrolled in a behavioral intervention trial to prevent contracting a new STI. This study utilizes data collected at the baseline assessments conducted between June, 2014 and August, 2017, prior to the intervention exposure.
We invited all individuals 18 years of age and older who were diagnosed with an STI at the clinic to participate. Recruitment occurred in the clinic waiting area on the day of their STI diagnosis. Participants were given the option to participate the day of recruitment, or at most 2 days afterwards. After providing informed consent, participants completed a face-to-face interview that included collecting participant demographic and health characteristics, and sex behaviors elicited partner-by-partner. Interviews were conducted by two female bachelors-level research assistants with extensive training and weekly supervision provided by the project manager. We used female interviewers because of the generally higher response rates found with female interviewers in sex research (24). Participants had the option to complete interviews in English or isiXhosa. In addition, participants provided consent for the researchers to access their electronic clinical records over the subsequent 12-months in order to code clinic visits and extract new STI visits.
Measures
Participant characteristics.
Participants reported their demographic characteristics including age, sex, education, marital status, and whether they had children. Participants also reported their substance use, HIV testing and treatment history, and history of STI symptoms and diagnoses. To assess alcohol use, participants reported how often and how much they typically drink (frequency and quantity) using the Alcohol Use Disorders Identification Test consumption scale [AUDIT-C (25, 26)]. Participants also reported their use of cannabis, amphetamines and other drugs (e.g., dagga, tik etc.). The HIV testing history component asked about when participants had been tested for HIV and the results of their most recent HIV test. Responses to these questions were used to identify HIV positive participants for inclusion in this study. STI symptoms included genital ulcerations, discharge, and pain as well as experiencing genital bleeding during sexual intercourse (coital bleeding). In addition, using electronic medical records we identified whether participants returned to the clinic for treatment of a new STI over the subsequent 12-months.
Sexual relationships and sexual behaviors.
Participants were asked to identify, by first name or nickname, up to five sex partners during the prior 3-months. Names were recorded on a response form by the interviewer along with responses to detailed questions regarding partner characteristics, relationship history, and sexual behaviors. Participants were asked to define each partner as: main (‘someone you have sex with on a regular basis and you feel close to’); casual (‘someone you have sex with on a regular basis who is not a main partner’); or one-time (‘someone who you may have only had sex with once or twice, not someone you have sex with on a regular basis’). Responses to these partner questions were used to classify partners into categories.
For each partner, participants indicated whether they were aware of the partner’s HIV status and whether they had informed that partner of their own HIV positive status. Participants also reported the number of times they had vaginal and anal intercourse as well as the number of times participants had used alcohol in the context of a sexual encounter with each partner over the previous 3-months. Condom use was assessed with a continuous 100-point rating scale representing the percent of time condoms were used; no condom use-to-condoms used every time, coded as 0% to 100% condom use. This measure was modeled after a validated 100-point rating scale that has become standard in estimating HIV treatment adherence (27)
Classifying HIV status and disclosure status in sexual partnerships
For each partner in the partner-by-partner interview, participants were asked whether they knew if the partner had been tested for HIV, and if they had been tested what their HIV test results were. Not knowing whether a partner had been tested was coded as HIV different-status as was knowing that a partner had tested HIV negative. Likewise, for each partner we asked if participants had disclosed their HIV status to that partner. Using the intersection of partner status and disclosure status, participants were classified into partner-disclosure groups. Specifically, we formed three groups of participants: (a) those who only reported having sex partners known to also be HIV positive (same-status partners); (b) participants who reported at least one HIV different-status partner to whom they had disclosed their HIV status; and (c) participants who reported at least one HIV different-status partner to whom they had not disclosed their HIV status. The sero-partnership groups were conceptualized hierarchically, such that the HIV same-status partner group did not have any HIV different-status partners and were therefore not at risk for transmitting HIV to an uninfected partner. For the participants with HIV different-status partners, we formed the other two groups: those who had disclosed their HIV status to all HIV different-status partners, and those who had at least one HIV different-status partner to whom they had not disclosed their HIV status. This classification scheme resulted in 46 participants who only reported HIV same-status partners, 54 participants who reported different-status partners that had been disclosed to, and 105 participants who had at least one HIV different-status partner to whom they had not disclosed their HIV status.
Statistical analyses
Data analyses were performed at the participant level. We compared the three sero-partnership groups on demographic and health characteristics using contingency table chi-square (X2) tests for categorical variables and one-way analyses of variance (ANOVA) for continuous variables. Comparisons between groups for numbers of sex partners and counts of sexual behaviors were conducted using generalized linear modeling (GLM). Specifically, we used Poisson regression to model predictors of counts with robust estimators. We included participant gender and gender X sero-partnership group interactions as controls in all models. Statistical significance was defined by p < .05 for all analyses.
Results
Among the 205 people living with HIV being treated for a co-occurring STI, 159 (78%) had at least one HIV different-status sex partner in the previous 3-months. For the 52 men in the study, 27 (49%) had not disclosed their HIV status to at least one partner. Similarly, among the 153 women, 78 (51%) had not disclosed their HIV status to at least one partner. Thus, 46 (22%) participants reported only HIV same-status partners, 54 (26%) participants had HIV different-status partners that they had disclosed their HIV status to, and 105 (52%) participants had at least one HIV different-status partner to whom they had not disclosed their HIV status. In total, these 105 participants reported 206 sex partners in the past 3-months with whom HIV testing was never discussed and to whom their own HIV status was not disclosed.
Demographic characteristics and substance use.
Table 1 shows the demographic and health characteristics of the three HIV sero-partnership groups. Uni-variable analyses indicated significant differences between groups. With respect to demographic characteristics, participants who had not disclosed to different-status partners were less likely to be married and less likely to have children than the other two groups, which did not differ from each other. In terms of substance use, individuals with non-disclosed to different-status partners were significantly more likely to report alcohol use, including greater quantity and frequency of drinking.
Table 1.
Demographic and health characteristics of HIV positive adults receiving co-occurring STI treatment services in three HIV status partner groups.
| Same Status Partners N=46 |
Disclosed to HIV Different Status Partners N=54 |
Non-Disclosed HIV Different Status Partners N=105 |
|||||
|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | X2 | |
| Participant gender | |||||||
| Women | 32 | 70 | 43 | 80 | 78 | 75 | 1.3 |
| Men | 14 | 30 | 11 | 20 | 27 | 25 | |
| Men with male | |||||||
| sex partners | 1 | 1 | 4 | 7 | 5 | 4 | n/a |
| Participant race | |||||||
| Black | 46 | 100 | 54 | 100 | 99 | 94 | n/a |
| White | 0 | 0 | 2 | 2 | |||
| Bi-racial | 0 | 0 | 4 | 4 | |||
| Married status | 6 | 13 | 11 | 20 | 5 | 5 | 9.3** |
| Women engaged in sex work | 0 | 2 | 1 | 1 | 1 | n/a | |
| Has at least one child | 37 | 80 | 47 | 87 | 72 | 69 | 7.3* |
| Current alcohol use | 27 | 59 | 38 | 70 | 84 | 80 | 7.5* |
| Any current drug use | 6 | 13 | 8 | 15 | 20 | 19 | 1.0 |
| Currently receiving ART | 25 | 54 | 31 | 59 | 33 | 32 | 12.1** |
| Current STI Symptoms | |||||||
| Genital ulcer | 12 | 26 | 22 | 41 | 29 | 28 | 3.4 |
| Genital discharge | 31 | 67 | 34 | 63 | 73 | 69 | 0.5 |
| Genital pain | 24 | 52 | 31 | 57 | 71 | 68 | 3.7 |
| Any one current STI symptom | 27 | 68 | 28 | 60 | 54 | 57 | 1.3 |
| Coital bleeding | 10 | 22 | 15 | 28 | 32 | 34 | 2.2 |
| New STI visit over 12-months | 8 | 17 | 7 | 13 | 11 | 10 | 1.3 |
| M | SD | M | SD | M | SD | F | |
| Participant age | 32.6 | 6.3 | 33.7 | 6.9 | 31.1 | 7.3 | 1.6 |
| AUDIT-C score | 3.5 | 3.4 | 3.6 | 3.0 | 4.6 | 3.2 | 4.9** |
Note: ART = antiretroviral therapy, STI = sexually transmitted infection, AUDIT-C = Alcohol Use Disorders Identification Test – Consumption Scale,
p < .05,
p < .01, n/a cells too sparse for statistical testing
Sexual health.
More than half of participants were experiencing genital discharge and genital pain associated with their current STI, with more than one in four reporting genital ulcers (see Table 1). In addition, more than one in three participants with non-disclosed different-status partners reported coital bleeding in the past 3-months. Examination of electronic medical records over the subsequent year showed that 26 (12.6%) participants had a clinic visit for a new STI over the 12-month observation period. There were no significant differences between groups for any of the STI symptoms and no difference for new STI visits. Finally, 116 (56%) participants were currently not receiving ART, with those who had not disclosed to different-status partners significantly less likely to be receiving ART than the other two groups, which did not differ from each other.
Sex partners.
Overall, 96 (47%) participants reported two or more partners in the previous three-months (see Table 2). Among the 205 participants in the study, there was a total of 386 partners reported in the previous 3-months; 181 main partners, 130 casual partners, and 75 one-time partners. Furthermore, a total of 264 partners were of a different HIV status (e.g., HIV negative or unknown status) and 112 partners were not aware of the participants’ HIV positive status. Generalized linear models controlling for participant gender indicated that there were no differences between the three partner-relationship type groups for total number of sex partners in the past 3-months, Wald X2 = 1.82, p > .1; number of main sex partners, Wald X2 = 2.44, p > .1; number of casual partners, Wald X2 = 3.26, p > .1; or number of one-time sex partners, Wald X2 = 4.24, p > .1.
Table 2.
Sexual partners and sexual behaviors among HIV positive adults receiving co-occurring STI treatment services in three HIV status partner groups.
| Same Status Partners N=46 |
Disclosed to HIV Different Status Partners N=54 |
Non-Disclosed HIV Different Status Partners N=105 |
|||||
|---|---|---|---|---|---|---|---|
| Sex partners in the past 3-months | N | % | N | % | N | % | Wald X2 |
| Number of main sex partners | 2.44 | ||||||
| 0 | 1 | 2 | 5 | 9 | 15 | 16 | |
| 1 | 45 | 98 | 48 | 90 | 74 | 78 | |
| 2+ | 0 | 1 | 1 | 6 | 6 | ||
| Median | 1 | 1 | 1 | ||||
| Mean | 0.9 | 0.9 | 0.9 | ||||
| SD | 0.2 | 0.3 | 0.4 | ||||
| Number of casual sex partners | 3.26 | ||||||
| 0 | 28 | 61 | 34 | 63 | 43 | 45 | |
| 1 | 14 | 30 | 15 | 28 | 34 | 36 | |
| 2+ | 4 | 9 | 5 | 9 | 17 | 18 | |
| Median | 0 | 0 | 0 | ||||
| Mean | 0.5 | 0.5 | 0.8 | ||||
| SD | 0.9 | 0.8 | 1.0 | ||||
| Number of one-time sex partners | 4.24 | ||||||
| 0 | 41 | 92 | 44 | 83 | 71 | 76 | |
| 1 | 2 | 4 | 5 | 9 | 15 | 16 | |
| 2+ | 2 | 4 | 4 | 8 | 8 | 9 | |
| Median | 0 | 0 | 0 | ||||
| Mean | 0.2 | 0.5 | 0.4 | ||||
| SD | 0.5 | 2.2 | 0.9 | ||||
| Frequencies of sexual behaviorsa | |||||||
| Vaginal sex | 3.33 | ||||||
| Median | 11 | 10 | 11 | ||||
| Mean | 20.5 | 18.8 | 27.9 | ||||
| SD | 24.3 | 24.6 | 50.5 | ||||
| Percent condom use – vaginal sex | |||||||
| Median | 52.5 | 50.0 | 50.0 | ||||
| Mean | 53.4 | 48.7 | 42.5 | 2.40 | |||
| SD | 38.4 | 37.0 | 35.6 | ||||
| Anal intercourse | 3 | 6 | 3 | 5 | 13 | 12 | n/a |
| Median | 0 | 0 | 0 | ||||
| Mean | 0.1 | 0.1 | 0.5 | ||||
| SD | 0.6 | 0.6 | 1.8 | ||||
| Percent condom use – anal sex | |||||||
| Median | 100 | 0.0 | 75.0 | ||||
| Mean | 75.0 | 7.2 | 29.1 | n/a | |||
| SD | 50.0 | 16.1 | 39.3 | ||||
| Total vaginal + anal sex | 3.52 | ||||||
| Median | 11 | 10 | 12 | ||||
| Mean | 20.7 | 18.9 | 28.4 | ||||
| SD | 24.2 | 24.6 | 50.5 | ||||
| Alcohol use in sex context | 16 | 35 | 21 | 39 | 44 | 42 | 0.69 |
| Median | 0 | 0 | 0 | ||||
| Mean | 0.5 | 0.6 | 0.7 | ||||
| SD | 0.8 | 1.0 | 1.0 | ||||
Note:
Assessed partner-by-partner over the previous 3-months; n/a cells too sparse for statistical testing; all participants in each relationship type engaged in vaginal and therefore total sex in the past 3-months.
Sexual behaviors.
Participants reported an average of 28.7 (SD = 80.3) vaginal intercourse occasions in the previous 3-months across partners, with an average 46% (SD = 36.58) of vaginal intercourse acts protected by condoms. The average frequency of anal intercourse was .32 (SD = 1.4). Among the 19 participants reporting anal intercourse, the average use of condoms was 30% (SD = 41.4). A total of 81 (40%) participants reported alcohol use in the context of a sexual occasion in the past 3-months. Analyses showed no differences between partnership status groups for rates and frequencies of engaging in any sexual behaviors (see Table 2).
Discussion
The current study contributes to the growing literature on the role of HIV status disclosure to sex partners in the prevention of forward HIV transmission. We found that 50% of participants had not disclosed their HIV status to HIV different-status partners, a rate of non-disclosure that is similar to that reported in previous research (28). In contrast to past studies, however, we did not find significant differences between men and women in their HIV status disclosure (29, 30). Results also failed to confirm our hypotheses regarding the association between different disclosure rates across different partner types. We also did not find significant differences in condomless or condom protected sex across HIV status disclosure groups. However, we did confirm our hypothesis that participants who had not disclosed their HIV status to HIV different status partners were significantly less likely to be taking ART. This difference occurred within a context of only half of participants being treated with ART, despite the STI clinic in which this study was conducted also serving as an ART dispensary. We anticipated HIV treatment would be lower in participants who had not disclosed their HIV status to partners given that stigma concerns likely underlie both non-disclosure and not being engaged in HIV care. Only slightly more than half of people with HIV who did disclose their HIV status were receiving ART. This rate of ART among people who know their HIV status falls far below the UNAIDS target of 90%, and ART uptake was even lower among those who had not disclosed to partners. Furthermore, the high-rate of recurrent STI clinic visits in conjunction with untreated HIV will facilitate the forward transmission of HIV (31).
We also found that participants who had not disclosed their HIV status to HIV different-status partners reported greater alcohol use. The difference occurred with respect to overall alcohol use, whereas the difference in alcohol use in sexual contexts was not significant. Thus, our study does not support a stress-alcohol association specific to sexual situations, as would be predicted by a cognitive-escape hypothesis of substance use and sexual risks (32). High-rates of alcohol use have been reported among people living with HIV in South Africa, and drinking is commonly associated with contracting STI (33) and not engaging HIV treatment (34), characteristics of our sample. Thus, additional research is needed to understand how alcohol use in general, rather than sexual situation-specific drinking, may be associated with HIV status disclosure.
There are limitations that should be considered when interpreting the current study findings. Our sample was one of convenience recruited at a single STI clinic and cannot therefore be taken as representative of people living with HIV and receiving STI treatment. The relatively small number of men in our sample is also a limitation and may have contributed to the lack of observed gender differences. We also relied on self-report measures of sexual behavior, HIV disclosure and other social and behavioral characteristics. Sexual behaviors assessed in interviews may be under reported, even when using state-of-the-science measures and procedures (35, 36). Our study was also limited by not including possible explanatory mechanisms for disclosure and non-disclosure. Our findings highlight the importance of first determining reliable relationships between HIV status disclosure and sexual behaviors in same-status and different-status relationships prior to identifying potential mechanisms of disclosure. With these limitations in mind, we believe that the current study has implications for addressing HIV status disclosure in interventions for people living with HIV who are diagnosed with co-occurring STI.
Communication skills building and HIV disclosure decision-making interventions have been found effective in facilitating safer HIV status disclosure among people living with HIV and can be adapted for use in sub-Saharan Africa (37, 38). Evidence to date suggests that interventions for increasing HIV status disclosure to sex partners in sub-Saharan Africa have had mixed results. A review of 14 studies that had tested interventions to increase HIV status disclosure, all in southern Africa, found that few trials demonstrated effects, with the most rigorously designed trials reporting the least positive outcomes (39). One reason for these disappointing intervention outcomes may be a lack of understanding for the dynamics at play in HIV status disclosure in sub-Saharan Africa. Findings such as those reported in the current study suggest a need for additional research to identify the processes and mechanisms underlying disclosure of HIV status in this context. We did not assess reasons for disclosure and nondisclosure, and such data are critical for moving interventions forward. Finally, the low-level of ART coverage observed in the current sample points out a significant need for removing barriers to treatment, perhaps most importantly stigma-related barriers. Increasing HIV treatment coverage, adherence and HIV suppression will be key to reducing HIV transmission and will yield immediate prevention benefits that are not dependent on HIV status disclosure.
Acknowledgments
This work was supported by the National Institute of Child Health and Development (NIH/NICHD) R01HD074560.
Footnotes
Disclosure statement. The authors declare no conflicts of interest.
Data availability statement. Data from this study are available upon request from the authors.
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