HIV-positive status disclosure in patients in care in rural South Africa: implications for scaling up treatment and prevention interventions

Young men's barriers to and facilitators of utilising HIV-testing services in South Africa

Background

In South Africa, men are less likely than women to use HIV-testing services (HTS). They are also unlikely to start and adhere to antiretroviral therapy until the virus has progressed to advanced AIDS stages.

Objectives

To explore young men's barriers to and facilitators of accessing and utilising HTS at the rural Driefontein and peri-urban Steadville Township in Ladysmith, KwaZulu-Natal (KZN) province, and to develop a comprehensive framework of care for young men to encourage and support them to utilise HTS at primary healthcare facilities.

Method

This exploratory-descriptive qualitative study entailed using semi-structured interviews conducted via WhatsApp and landline audio calls with 17 young men between 18 years and 30 years of age in Steadville and Driefontein communities in KZN in September 2021. Participants were purposively and conveniently sampled, and the data were analysed thematically.

Results

All participants were unmarried isiZulu African men experienced with HTS in the last 4 years. Fear of an HIV-positive test result, limited HTS knowledge, and stigma around HIV and AIDS were challenges linked to HTS utilisation. Unsafe sexual encounters, voluntary medical male circumcision, early virus-detection, having a significant other living with HIV, and HIV-status curiosity encouraged young men to utilise HTS.

Conclusion

Various barriers and facilitators to HTS utilisation, are key for consideration when deriving contextual interventions acceptable to young men as efforts to raise awareness and attract and retain men in care.

Prevalence and correlates of common mental disorders in people living with HIV in primary health care facilities in Ekurhuleni district

BACKGROUND

 There is paucity of data regarding the prevalence of common mental disorders (CMDs) in people living with HIV (PLHIV) in Ekurhuleni Health District (EHD), South Africa. Also, there is an association between CMDs and poor HIV treatment outcomes. Guidelines therefore recommend that healthcare practitioners screen for CMDs in PLHIV.

AIM

 To determine the prevalence and correlates of CMDs in PLHIV in primary health care facilities in Ekurhuleni district.

SETTING

 Seven primary health facilities in Ekurhuleni district.

METHODS

 A cross-sectional study was conducted in which data were collected from 403 randomly selected participants, using a questionnaire that incorporated the scores of the Patient Health Questionnaire (PHQ)-9, generalised anxiety disorder (GAD)-7 and substance use disorder (SUD) criteria of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5). The proportion screening positive for CMDs was calculated. 'R' statistical software was used for univariate and multivariate analysis, with a confidence interval (CI) of 95%.

RESULTS

 Most participants (63%) were female and the mean age was 43 ± 11 years. Forty per cent of participants screened positive for CMDs, 16.6%, 15.1% and 24.1% screened positive for depression, GAD and SUD, respectively. Common mental disorders were associated with poor adherence and HIV non-suppression, while increasing age and being female were associated with reduced risk of CMDs. The risk of severe SUDs in males was 11 times compared to females. During assessment, clinicians screened only 16%, 14% and 40% of the cohort for depression, GAD and SUDs, respectively.

CONCLUSION

 The prevalence of CMDs remains high. Adherence to recommendations to screen for CMDs in PLHIV is low.Contribution: This study reveals a low CMD screening rate, estimates the prevalence of CMDs in PLHIV in Ekurhuleni district, and its impact.

Positive Status Disclosure and Sexual Risk Behavior Changes among People Living with HIV in the Northern Region of Ghana

OBJECTIVE

To investigate sexual behavior changes adopted by People Living with Human Immunodeficiency Virus (PLHIV) on Antiretroviral therapy (ART) in the Northern Region of Ghana.

METHODS

We employed a cross-sectional survey with a questionnaire to collect data from 900 clients from 9 major ART centers within the region. Chi-square and logistic regression analyses were applied to the data.

RESULTS

More than 50% of PLHIV on ART use condoms, reduce sexual partners, practice abstinence, reduce unprotected sex with married/regular partners, and avoid casual sex. Fear of others getting to know patients' HIV-positive status (χ² = 7.916, p = 0.005), stigma (χ² = 5.201, p = 0.023), and fear of loss of family support (χ² = 4.211, p = 0.040) significantly predict non-disclosure of HIV-positive status among the participants. Change in sexual behavior is influenced by the following: "to avoid spreading the disease to others" (R² = 0.043, F (1, 898) = 40.237, p < 0.0005), "to avoid contracting other STIs" (R² = 0.010, F (1, 898) = 8.937, p < 0.0005), "to live long" (R² = 0.038, F (1, 898) = 35.816, p < 0.0005), "to hide HIV-positive status" (R² = 0.038, F (1, 898) = 35.587, p < 0.0005), "to achieve good results from ART treatment" (R² = 0.005, F (1, 898) = 4. 282, p < 0.05), and "to live a Godly life" (R² = 0.023, F (1, 898) = 20. 880, p < 0.0005).

CONCLUSIONS

High self-disclosure rate of HIV-positive status was identified, with participants disclosing to their spouses or parents. Reasons for disclosure and non-disclosure differed from person to person.

Incidence of HIV disclosure among HIV affected heterosexual partners using a community health worker led mechanism in rural Uganda; a quasi-experimental study

BACKGROUND

HIV disclosure is vital in HIV management. Community Health Workers (CHW) were reported to support partner disclosure among HIV affected heterosexual partners with disclosure difficulties. However, time to disclosure attributed to use of CHW led disclosure support mechanism was not documented. This study compared the incidence of sexual partner disclosure among adults living with HIV (ALHIV) with CHW support and those without in the greater Luwero region, Uganda.

METHODS

We conducted a quasi-experimental study with two arms allocated by geographically determined clusters and adjusted for between-group differences; among ALHIV in the greater Luwero region of Uganda who had never disclosed to their current primary sexual partners. We allocated study clusters to either a CHW-led intervention or control arm. In both arms, we consecutively recruited participants; those in the intervention arm received CHW disclosure support in addition to routine care. The overall follow-up was six months, and the primary outcome was disclosure to the partner. We used survival analysis with proportional hazard ratios to determine the time to partner disclosure in both arms.

RESULTS

A total of 245 participants were enrolled, and 230 (93.9%) completed the study; of these, 112 (48.7%) were in the intervention and 118 (51.3%) in the control arm. The mean age was 31 ± 8 years with a range of 18 to 55 years; the majority were females, 176 (76.5%). The cumulative incidence of disclosure was higher in the intervention arm, 8.76 [95% CI: 7.20-10.67] per 1,000 person-days versus 5.15 [95%CI: 4.85-6.48] per 1,000 person-days in the control arm, log-rank test, X2 = 12.93, P < 0.001. Male gender, aHR = 1.82, tertiary education, aHR = 1.51, and relationship duration of > six months, aHR = 1.19 predicted disclosure. Prior disclosure to a relative, aHR = 0.55, and having more than one sexual partner in the past three months, aHR = 0.74, predicted non-disclosure.

CONCLUSION

CHW-led support mechanism increased the rate of sexual partner disclosure among ALHIV with disclosure difficulties. Therefore, to achieve the global targets of ending HIV, near location CHW-led disclosure support mechanism may be used to hasten HIV disclosure in rural settings.

Factors associated with transmasculine adults recently engaging in sexual behavior with partners of unknown STI and HIV status

The sexual partnerships of transmasculine (TM) adults-those assigned female at birth who identify as transgender men or a masculine spectrum gender identity-and characteristics associated with STI/HIV risk behavior remains understudied. Participants in the current study were TM adults (n = 141) receiving care at a community health center in Boston, Massachusetts between March 2015 and September 2016. Using generalized estimating equations, we examined individual- and partnership-level factors associated with TM adults' odds of engaging in sexual behavior with a sexual partner of unknown STI/HIV status in the past 12 months. TM adults with casual sexual partnerships (vs. monogamous partnerships) and those in partnerships with cisgender men, other TM individuals, or transfeminine partners (vs. cisgender women) had statistically significantly higher odds of engaging in sexual behavior with a partner of unknown STI/HIV status in the past 12 months. Findings may inform future efforts to improve sexual health communication and STI/HIV disclosure between TM adults and their sexual partners.

Viral suppression among pregnant adolescents and women living with HIV in rural KwaZulu-Natal, South Africa: a cross sectional study to assess progress towards UNAIDS indicators and Implications for HIV Epidemic Control

BACKGROUND

South Africa has made significant progress in scaling up antiretroviral therapy (ART) to achieve the aspirational goal of HIV epidemic control. The aim of this study was to determine the prevalence of HIV, assess progress towards each of the Joint United Nations Programme on HIV/AIDS (UNAIDS) indicators and determine factors associated with achieving viral suppression among pregnant adolescents and women living with HIV in rural KwaZulu-Natal, South Africa.

METHODS

Pregnant adolescents and women, 12 years and older seeking antenatal care at six primary health care clinics were enrolled in a cross-sectional study. Following written informed consent, structured questionnaires were administered, and finger-prick blood samples were collected for HIV antibody testing and viral load measurement. Viral suppression was defined as HIV viral load of < 400 copies per mL.

RESULTS

Between Dec 2016 and March 2017, among the 546 enrolled participants, data for 545 were analysed. The overall HIV prevalence was 40.2% [95% Confidence Interval (CI) 36.1-44.3]. Age-stratified prevalence increased from 22.1% (95% CI, 15.9-30.0) in the 14-19 year age group to 63.9% (95% CI, 55.1-71.9) among women ≥ 30 years (Χ2 trend P < 0.0001). Of the HIV positive participants, 84.5% (95% CI, 79.0-88.8) knew their HIV positive status, 98.3% (95% CI 95.1-99.4) who knew their status were on ART, and of those on ART, 95.9% (95% CI 91.8-98.0) were virally suppressed. Among all HIV-positives 90.8% (95% CI, 86.3-94.0) had achieved viral suppression, whilst those in the 14-19 year age group were least likely to be virally suppressed at 82.8% (95% CI 65.5-92.4) compared to those in the older age groups. Married women compared to those unmarried were more likely to have achieved viral suppression (PRR) of 1.11 (95% CI 1.05-1.18), P < 0.001.

CONCLUSIONS

The proportion of HIV positive pregnant women achieving viral suppression was encouraging though far short of the target towards achieving epidemic control. Importantly, adolescent pregnant women were less likely to know their HIV status and to achieve viral suppression, underscoring the public health implications of sustained risk of HIV transmission. Thus, greater effort and strong social support are essential to improve HIV knowledge of status and care continuum towards the goal to achieving HIV epidemic control. To "fast-track" the response to achieve HIV epidemic control and end the AIDS epidemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set ambitious HIV testing and treatment targets for people living with HIV. Meeting these targets through scaling up testing for HIV, initiating and sustaining antiretroviral therapy (ART) to maintain viral suppression provides both therapeutic and preventive benefits with the potential to reduce HIV transmission. Viral suppression among pregnant adolescents and women living with HIV is crucial for the prevention of mother-to-child transmission of HIV including onward transmission to sexual partners. As a public health approach, in South Africa all pregnant women are offered routine HIV testing and immediate initiation of lifelong ART irrespective of CD4 cell count. It is, therefore, important to ascertain progress towards reaching the targets. The proportion of HIV positive pregnant adolescents and women achieving viral suppression was encouraging though far short of the target towards achieving epidemic control. Importantly, pregnant adolescents were less likely to know their HIV status and to achieve viral suppression, underscoring the public health implications of sustained risk of HIV transmission. Thus, greater effort and strong social support are essential to improve HIV knowledge of status and care continuum towards the goal to achieving HIV epidemic control.

Perceived Stigma as a Contextual Barrier to Early Uptake of HIV Testing, Treatment Initiation, and Disclosure; the Case of Patients Admitted with AIDS-Related Illness in a Rural Hospital in South Africa

We explored the extent to which perceived HIV-related stigma influences the disclosure and concealment of HIV status to family among adult patients hospitalised for AIDS-related illness, and described reports of negative responses and enacted stigma following disclosure. We conducted interviews with a purposeful sample of 28 adult patients in a rural South African hospital. Data analysis was deductive and inductive and followed the thematic approach. We found evidence of delayed HIV diagnosis and initiation of treatment. There was delayed and selective disclosure as well as concealment of the HIV-positive status. The disclosure was delayed for months or even years. During that time, there was active concealment of the HIV status to avoid stigma from family, friends, and community. When disclosure occurred, there was selective disclosure to close family members who would keep the secret and respond favorably. Although the participants disclosed mostly to close family, some of their post-disclosure experiences included incidents of enacted stigma and discrimination. The fear of perceived stigma and self-stigma influenced the active concealment of their HIV status from others. Continuous concealment of one's HIV status and delayed disclosure limit the opportunities for support and care. There is a need to take into consideration the interaction between HIV-related stigma and disclosure to develop disclosure-counselling strategies in primary health care settings.

Understanding the determinants and consequences of HIV status disclosure in Manicaland, Zimbabwe: cross-sectional and prospective analyses

Few longitudinal studies have measured trends and effects of disclosure over ART scale-up in general-population samples. We investigated levels, determinants and outcomes of disclosure to relatives and partners in a large general-population cohort in Zimbabwe. Trends in disclosure levels from 2003 to 2013 were analysed, and multivariable logistic regression was used to identify determinants. Longitudinal analyses were conducted testing associations between disclosure and prevention/treatment-related outcomes. Disclosure to anyone increased from 79% to 100% in men and from 63% to 98% in women from 2003 to 2008; but declined to 89% in both sexes in 2012-2013. More women than men disclosed to relatives (67.8% versus 44.4%; p < 0.001) but fewer women disclosed to partners (85.3% versus 95.0%; p < 0.001). In 2012-2013,secondary/higher education, being single, and experience of stigma were associated with disclosure to relatives in both sexes. Partner characteristics and HIV-group attendance were associated with disclosure to partners for women. Reactions to disclosure were generally supportive but less so for females than males disclosing to partners (92.0% versus 97.4%). Partner disclosure was weakly associated (p < 0.08) with having had a CD4 count or taken ART at follow-up in females. To conclude, this study shows disclosure is vital to HIV prevention and treatment, and programmes to facilitate disclosure should be re-invigorated.

Patterns and Predictors of HIV Status Disclosure in the 12 Months After Diagnosis in Mozambique

BACKGROUND

HIV disclosure benefits people living with HIV, their partners, and HIV programs. However, data on the prevalence of disclosure and associated correlates have come largely from patients already in HIV care, potentially overestimating disclosure rates and precluding examination of the impact of disclosure on HIV care outcomes.

SETTING

We used data from an implementation study conducted in Maputo City and Inhambane Province, Mozambique. Adults were enrolled at HIV testing clinics after diagnosis and traced in the community 1 and 12 months later when they reported on disclosure and other outcomes.

METHODS

We examined patterns of participants' disclosure to their social networks (N = 1573) and sexual partners (N = 1024) at both follow-up assessments and used relative risk regression to identify correlates of nondisclosure.

RESULTS

Disclosure to one's social network and sexual partners was reported by 77.8% and 57.7% of participants, respectively, at 1 month and 92.9% and 72.4% of participants, respectively, at 12 months. At both time points, living in Inhambane Province, being single or not living with a partner, having high levels of anticipated stigma, and not initiating HIV treatment were associated with increased risks of nondisclosure to social networks. Nondisclosure to sexual partners at both follow-up assessments was associated with being women, living in Inhambane Province and in a household without other people living with HIV, and reporting that posttest counseling addressed disclosure.

CONCLUSIONS

Although reported disclosure to social networks was high, disclosure to sexual partners was suboptimal. Effective and acceptable approaches to support partner disclosure, particularly for women, are needed.

The act of telling: South African women's narratives of HIV status disclosure to intimate partners in the HPTN 071 (PopART) HIV prevention trial

BACKGROUND

Public health programming often frames HIV status disclosure as a means to negotiate condom- and abstinence-based prevention or to involve intimate partners in HIV care to garner treatment adherence support. HIV treatment can be used to ensure viral suppression and prevent onward transmission, which provides strong evidence to encourage disclosure. The ideological shift towards HIV treatment as prevention is expected to facilitate disclosure.

PURPOSE

There is a lack of research on how the scale-up of universal HIV testing and treatment influences disclosure practices in high burden settings. In this manuscript, we aim to address this gap.

METHODS

To this end, we conducted a two-phased narrative performative analysis of the disclosure scripts of 15 women living with HIV in three communities of Western Cape, South Africa where the HPTN 071 (PopART) HIV prevention trial implemented a universal HIV testing and treatment model as part of the intervention. The women were part of a larger cohort nested in the trial. We use Goffman's dramaturgical metaphor, which understands social interactions as 'performances' by 'actors' (people) guided by 'scripts' (anticipated dialogues/interactions), to explore how women living with HIV manage their status disclosure.

CONCLUSION

We describe how these women perform HIV status disclosure (or deliberate non-disclosure) to retain, reaffirm or redefine existing social scripts with partners. Their performances reveal priorities other than those imagined by public health programmes driving HIV disclosure (or non-disclosure): establishing trust, resenting betrayal and ensuring self-preservation while simultaneously (re)constructing self-identity. None of the women engaged with the concept of treatment as prevention in their disclosure narratives, either to facilitate disclosure or to 'justify' non-disclosure. HIV prevention, in general, and treatment adherence support were rarely mentioned as a reason for disclosure. To date, there has been a missed opportunity to ease and support disclosure in health programmes by tapping into existing social scripts, impeding potential patient and public health benefits of universal HIV testing and treatment.

HIV Status Disclosure and Sexual Transmission Risks Among People Who Are Living With HIV and Receiving Treatment for Non-HIV Sexually Transmitted Infections, Cape Town, South Africa

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: (1) 22% reported only HIV same-status partners, (2) 26% had HIV-negative or unknown HIV status (HIV different status) sex partners to whom they had disclosed their HIV status, and (3) 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 status to at least one HIV different-status sex partner was associated with greater alcohol use and less likelihood of receiving antiretroviral therapy; participants who were least likely to disclose their HIV status to partners drank more alcohol and were less likely to be taking antiretroviral therapy.

CONCLUSIONS

High prevalence of partner nondisclosure 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.

Disclosure of HIV status among patients new to HIV care in Southern Ethiopia: role of perceived social support and other factors

Reports from Sub-Saharan Africa, with a large HIV-infected population, vary widely in how often HIV status is disclosed to others, including spouses and other partners. We surveyed 1799 Ethiopian HIV patients newly enrolled in care within the previous 3 months at one of 32 local hospitals and health centers about disclosure of HIV status and two perceived social support domains: emotional/informational (EI) and tangible assistance (TA) support. Disclosure to another person was reported by 1389 (77%) persons. Disclosure rates to specific persons were: spouses or other partners = 74%; mothers = 24%; fathers = 16%; children = 26%; other family members = 37%; friends = 19%, and neighbors/other community members = 13%. Disclosure to another person was associated with higher social support scores on both EI and TA domains, marriage, and a longer time knowing HIV status. In multivariate adjusted models, disclosure to any person, as well as disclosure specifically to a spouse or partner, were associated with higher EI and higher TA social support scores. Provision of knowledgeable and emotionally supportive assistance can be an important factor in facilitating HIV disclosure. Helping persons with HIV decide who to disclose to and how to do so in the most positive manner is an essential component of HIV care and support.

"It Was as Though My Spirit Left, Like They Killed Me": The Disruptive Impact of an HIV-Positive Diagnosis among Women in the Dominican Republic

An HIV diagnosis may be associated with severe emotional and psychological distress, which can contribute to delays in care or poor self-management. Few studies have explored the emotional, psychological, and psychosocial impacts of an HIV diagnosis on women in low-resource settings. We conducted in-depth interviews with 30 women living with HIV in the Dominican Republic. Interviews were audio-recorded, transcribed, and analyzed using the biographical disruption framework. Three disruption phases emerged (impacts of a diagnosis, postdiagnosis turning points, and integration). Nearly all respondents described the news as deeply distressful and feelings of depression and loss of self-worth were common. Several reported struggling with the decision to disclose—worrying about stigma. Postdiagnosis turning points consisted of a focus on survival and motherhood; social support (family members, friends, HIV community) promoted integration. The findings suggest a need for psychological resources and social support interventions to mitigate the negative impacts of an HIV diagnosis.

Identification of serodiscordant couples, their clinical and laboratory characteristics, and vulnerabilities of HIV transmission risk in Northeastern Brazil in the era of pre-exposure prophylaxis (PrEP)

Objectives: To evaluate the frequency of HIV serodiscordants couples and their seronegative partners who were candidates for pre-exposure prophylaxis (PrPE), and the knowledge about behavioural measures to reduce virus transmission. Methods: The research was performed in Northeastern Brazil, from February 2016 to March 2017. Ninety HIV-positive individuals (Index) and their HIV-serodiscordant partners (n = 17) were submitted for epidemiological, clinical, and laboratory questionnaires, and for rapid laboratory tests for syphilis, hepatitis B and C. Results: High frequencies of HIV-syphilis (34.4%) and HIV-HBV (3.3%) coinfection were detected in the HIV-positive individuals. Three new HIV cases were detected in partners. Most participants in both groups (85.6%, Index; 94.1%, Partners) had an excellent degree of knowledge regarding HIV transmission, although nine seronegative HIV partners with a high risk of HIV infection were identified (53%). HIV-positive individuals had a high frequency of HIV-syphilis co-infection and 10% of them did not use antiretroviral by personal option. Conclusions: Adoption of PrEP and other preventive measures to prevent HIV transmission in serodiscordants couples should be studied and evaluated.

Impact of HIV-Status Disclosure on HIV Viral Load in Pregnant and Postpartum Women on Antiretroviral Therapy

BACKGROUND

HIV-status disclosure is widely encouraged by counseling services, in part because it is thought to improve antiretroviral therapy (ART) adherence and thus HIV viral suppression. However, few longitudinal studies have examined the impact of disclosure on HIV viral load (VL) during pregnancy and postpartum.

METHODS

We explored these associations among 1187 women living with HIV, enrolled between March 2013 and June 2014 in Cape Town, South Africa.

RESULTS

Among women who tested HIV-positive before pregnancy, we observed no association between disclosure and VL at entry into antenatal care among those already on ART, nor at delivery and 12 months postpartum among those initiating ART. Among women who tested HIV-positive during pregnancy and initiated ART subsequently, disclosure to a male partner was associated with a reduced risk of VL ≥50 copies/mL at delivery (adjusted risk ratio: 0.56; 95% confidence interval: 0.31 to 1.01). After stratification by relationship status, this association was only observed among women who were married and/or cohabiting. In addition, disclosure to ≥1 family/community member was associated with a reduced risk of VL ≥50 copies/mL at 12 months postpartum (adjusted risk ratio: 0.69; 95% confidence interval: 0.48 to 0.97) among newly-diagnosed women.

CONCLUSIONS

These findings suggest that the impact of disclosure on VL is modified by 3 factors: (1) timing of HIV diagnosis (before vs. during the pregnancy); (2) relationship to the person(s) to whom women disclose; and (3) in the case of disclosure to a male partner, relationship status. Counseling about disclosure may be most effective if tailored to individual women's circumstances.

Status and associated characteristics of HIV disclosure among people living with HIV/AIDS in Liangshan, China: A cross-sectional study

Human immunodeficiency virus (HIV) disclosure is a prerequisite to get access to antiretroviral therapy (ART) and social support. Increased disclosure of HIV status has been shown to reduce mother-to-child transmission and high-risk sexual behaviors. Limited studies were conducted to get an insight into HIV disclosure among people living with HIV/acquired immune deficiency syndrome (AIDS) (PLWHA) in Liangshan.Our study aimed to investigate the status and associated characteristics of HIV disclosure among PLWHA in Liangshan.We conducted a cross-sectional study using a stratified, convenience sampling method from August to December in 2017. All of the participants were from Liangshan, a typical impoverished mountainous area which also has a long history of drug production and drug trade. Each participant completed a structured questionnaire including HIV disclosure status, demographic and HIV-related characteristics, social support, and perceived HIV-related stigma. We performed a binary regression analysis to detect associated characteristics of HIV disclosure among PLWHA in Liangshan.A final sample size of 318 participants was included in this study. The overall prevalence of HIV disclosure was 83.6% (266/318). In binary logistic regression analysis, PLWHA who had higher educational levels, and got infected by sexual transmission were less likely to disclose their HIV status (both P < .05). HIV nondisclosure was correlated with a higher level of perceived HIV-related stigma (P < .01).The prevalence of HIV disclosure was relatively low in Liangshan. Healthcare workers are suggested to conduct more counseling and education to promote safe sexual behaviors and reduce perceived stigma among PLWHA, then enhance HIV serostatus disclosure.

Understanding the Time Needed to Link to Care and Start ART in Seven HPTN 071 (PopART) Study Communities in Zambia and South Africa

To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.

Patterns and Predictors of HIV-Status Disclosure Among Pregnant Women in South Africa: Dimensions of Disclosure and Influence of Social and Economic Circumstances

HIV-status disclosure may improve psychosocial health and adherence to antiretroviral therapy (ART), but existing insights suffer from methodological limitations. We explored disclosure over time during pregnancy and postpartum among 1347 HIV-positive women in Cape Town. Among 995 women diagnosed HIV-positive before the pregnancy and entering antenatal care (median age 30 years), 95% had disclosed to ≥ 1 individual. In Mokken scale analysis, we observed two separate dimensions of disclosure: disclosure to a male partner, and disclosure to family/community members. Among 352 women diagnosed during the pregnancy and initiating ART (median age 27 years), 61% disclosed to a male partner and 71% to a family/community member by 12 months after diagnosis. Relationship status modified the impact of pregnancy intentions and poverty on disclosure to a male partner. These unique data provide important insights into dimensions of disclosure during pregnancy and postpartum, and suggest that women's social and economic circumstances are central determinants of disclosure.

HIV status disclosure to male partners among rural Nigerian women along the prevention of mother-to-child transmission of HIV cascade: a mixed methods study

BACKGROUND

HIV status disclosure to male partners is important for optimal outcomes in the prevention of mother-to-child transmission of HIV (PMTCT). Depending on timing of HIV diagnosis or pregnancy status, readiness to disclose and disclosure rates may differ among HIV-positive women. We sought to determine rates, patterns, and experiences of disclosure among Nigerian women along the PMTCT cascade.

METHODS

HIV-positive women in rural North-Central Nigeria were purposively recruited according to their PMTCT cascade status: pregnant-newly HIV-diagnosed, pregnant-in care, postpartum, and lost-to-follow-up (LTFU). Participants were surveyed to determine rates of disclosure to male partners and others; in-depth interviews evaluated disclosure patterns and experiences. Tests of association were applied to quantitative data. Qualitative data were manually analysed by theme and content using the constant comparative method in a Grounded Theory approach.

RESULTS

We interviewed 100 women; 69% were 21-30 years old, and 86% were married. There were 25, 26, 28 and 21 women in the newly-diagnosed, in-care, postpartum, and LTFU groups, respectively. Approximately 81% of all participants reported disclosing to anyone; however, family members were typically disclosed to first. Ultimately, more women had disclosed to male partners (85%) than to family members (55%). Rates of disclosure to anyone varied between groups: newly-diagnosed and LTFU women had the lowest (56%) and highest (100%) rates, respectively (p = 0.001). However, family (p = 0.402) and male partner (p = 0.218) disclosure rates were similar between cascade groups. Across all cascade groups, fear of divorce and intimate partner violence deterred women from disclosing to male partners. However, participants reported that with assistance from healthcare workers, disclosure and post-disclosure experiences were mostly positive.

CONCLUSION

In our study cohort, although disclosure to male partners was overall higher, family members appeared more approachable for initial disclosure. Across cascade groups, male partners were ultimately disclosed to at rates > 75%, with no significant inter-group differences. Fear appears to be a major reason for non-disclosure or delayed disclosure by women to male partners. Augmentation of healthcare workers' skills and involvement can mediate gender power differentials, minimize fear and shorten time to male partner disclosure among women living with HIV, regardless of their PMTCT cascade status.

TRIAL REGISTRATION

Clinicaltrials.gov registration number NCT 01936753 , September 3, 2013 (retrospectively registered).

'Test and Treat' Among Women at High Risk for HIV-infection in Kampala, Uganda: Antiretroviral Therapy Initiation and Associated Factors

Data on implementation of 'Test and Treat' among key populations in sub-Saharan Africa are still limited. We examined factors associated with prompt antiretroviral therapy/ART (within 1 month of HIV-positive diagnosis or 1 week if pregnant) among 343 women at high risk for HIV infection in Kampala-Uganda, of whom 28% initiated prompt ART. Most (95%) reported paid sex within 3 months prior to enrolment. Multivariable logistic regression was used to determine baseline characteristics associated with prompt ART. Sex work as main job, younger age and being widowed/separated were associated with lower odds of prompt ART; being enrolled after 12 months of implementing the intervention was associated with higher odds of prompt ART. Younger women, widowed/separated and those reporting sex work as their main job need targeted interventions to start ART promptly after testing. Staff supervision and mentoring may need strengthening during the first year of implementing 'test and treat' interventions.

Prevalence, patterns, and correlates of HIV disclosure among TB-HIV patients initiating antiretroviral therapy in Lesotho

Disclosure of HIV-positive status has important implications for patient outcomes and preventing HIV transmission, but has been understudied in TB-HIV patients. We assessed disclosure patterns and correlates of non-disclosure among adult TB-HIV patients initiating ART enrolled in the START Study, a mixed-methods cluster-randomized trial conducted in Lesotho, which evaluated a combination intervention package (CIP) versus standard of care. Interviewer-administered questionnaire data were analyzed to describe patterns of disclosure. Patient-related factors were assessed for association with non-disclosure to anyone other than a health-care provider and primary partners using generalized linear mixed models. Among 371 participants, 95% had disclosed their HIV diagnosis to someone other than a health-care provider, most commonly a spouse/primary partner (76%). Age, TB knowledge, not planning to disclose TB status, greater perceived TB stigma, and CIP were associated with non-disclosure in unadjusted models (p < .1). In adjusted models, all point estimates were similar and greater TB knowledge (adjusted odds ratio [aOR] 0.59, 95% confidence interval [CI] 0.39-0.90) and CIP (aOR 0.20, 95% CI 0.05-0.79) remained statistically significant. Among 220 participants with a primary partner, 76% had disclosed to that partner. Significant correlates of partner non-disclosure (p < .1) in unadjusted analyses included being female, married/cohabitating, electricity at home, not knowing if partner was HIV-positive, and TB knowledge. Adjusted point estimates were largely similar, and being married/cohabitating (aOR 0.03, 95% CI 0.01-0.12), having electricity at home (aOR 0.38, 95% CI 0.17-0.85) and greater TB knowledge (aOR 0.76, 95% CI 0.59-0.98) remained significant. In conclusion, although nearly all participants reported disclosing their HIV status to someone other than a health-care provider at ART initiation, nearly a quarter of participants with a primary partner had not disclosed to their partner. Additional efforts to support HIV disclosure (e.g., counseling) may be needed for TB-HIV patients, particularly for women and those unaware of their partners' status.

Cascade of Refusal-What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa?

Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.