Test and tell: correlates and consequences of testing and disclosure of HIV status in South Africa (HPTN 043 Project Accept)

Associations between social network characteristics and sexual minority disclosure concern among Black men who have sex with men living with and without HIV

In addition to the pervasive anti-Black racism faced by Black people in the United States, Black men who have sex with men (BMSM) face sexual minority stigma and, among BMSM living with HIV, HIV-related stigma. These multilevel social forces shape social networks, which are important sources of resources, support, and behavior regulation. This study quantitatively examined the relationship between social network characteristics and sexual minority stigma (e.g., homophobia, biphobia), assessed by reported concerns around disclosing one's sexual minority status, among BMSM in Baltimore, Maryland in 2014 (N = 336). A majority of participants (63.7%) reported experiencing medium or high levels of sexual minority disclosure concern. In a multiple linear regression model, participants with higher sexual minority disclosure concern reported lower network density and having fewer good friends who are gay or bisexual men. Stratifying the same multiple linear regression model by HIV status supports the importance of an intersectional understanding of sexual minority and HIV-related stigma. These findings can help health-related programs address the complex relationships between sexual minority stigma, social networks, and HIV status within this multiply-marginalized and high-priority population.

Community and health system factors associated with antiretroviral therapy initiation among men and women in Malawi: a mixed methods study exploring gender-specific barriers to care

BACKGROUND

Although community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women.

METHODS

We examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods.

RESULTS

Among women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; p<0.05) was associated with ART initiation. Two health system factors were associated with ART initiation among men and one for women: trust that accessing ART services would not lead to unwanted disclosure (women: AOR=4.51, p<0.01; men: AOR=1.71, p<0.01) and trust that clients were not turned away from ART services (men: 12.36, p=0.001).

CONCLUSIONS

Qualitative data indicate that men were concerned about unwanted disclosure due to engaging in ART services and long waiting times for services. Interventions to remove health system barriers to ART services should be explored to promote social support among men.

Early ART Initiation Improves HIV Status Disclosure and Social Support in People Living with HIV, Linked to Care Within a Universal Test and Treat Program in Rural South Africa (ANRS 12249 TasP Trial)

We investigated the effect of early antiretroviral treatment (ART) initiation on HIV status disclosure and social support in a cluster-randomized, treatment-as-prevention (TasP) trial in rural South Africa. Individuals identified HIV-positive after home-based testing were referred to trial clinics where they were invited to initiate ART immediately irrespective of CD4 count (intervention arm) or following national guidelines (control arm). We used Poisson mixed effects models to assess the independent effects of (a) time since baseline clinical visit, (b) trial arm, and (c) ART initiation on HIV disclosure (n = 182) and social support (n = 152) among participants with a CD4 count > 500 cells/mm³ at baseline. Disclosure and social support significantly improved over follow-up in both arms. Disclosure was higher (incidence rate ratio [95% confidence interval]: 1.24 [1.04; 1.48]), and social support increased faster (1.22 [1.02; 1.46]) in the intervention arm than in the control arm. ART initiation improved both disclosure and social support (1.50 [1.28; 1.75] and 1.34 [1.12; 1.61], respectively), a stronger effect being seen in the intervention arm for social support (1.50 [1.12; 2.01]). Besides clinical benefits, early ART initiation may also improve psychosocial outcomes. This should further encourage countries to implement universal test-and-treat strategies.

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.

[Factors associated with non-disclosure of HIV status among women attending prenatal clinics in Bangui]

INTRODUCTION

The failure of pregnant women to disclose their HIV serological status to the those around her, especially the father of the unborn child, can be a barrier to preventing mother-to-child transmission of HIV. In this context, the present study was designed to determine the proportion of women who failed to disclose their HIV status to their spouses and the factors associated with this non-disclosure.

PATIENTS AND METHODS

This cross-sectional, descriptive and analytical study was conducted from 1 February to 30 May 2017. The study population consisted of all pregnant and non-pregnant HIV-positive women followed in the three main mother and child health services in Bangui.

RESULTS

A total of 256 women were recruited, 76 (29.7%) of whom had not disclosed their HIV status to their spouse. The main factors associated with non-disclosure of HIV status were the spouse's young age, precarious employment status, and couples living separately.

CONCLUSION

In the light of the results of this study, efforts should be made to ensure more active involvement of partners in sexual and reproductive health programmes in general and PMTCT in particular. The general public also needs to be made aware of the dangers of stigma and the law on the protection of people living with HIV should be enforced.

Trajectories of HIV-related internalized stigma and disclosure concerns among ART initiators and non-initiators in South Africa

Background

HIV-related stigma among people living with HIV (PLHIV) is associated with worse health outcomes. We used longitudinal data from a multi-site cohort in South Africa to assess changes over time in stigma after HIV diagnosis and determine whether antiretroviral therapy (ART) initiation is associated with stigma reduction.

Methods

We administered the Internalized AIDS-Related Stigma Scale (IARSS, a six-item dichotomous scale questionnaire) at baseline, three months, and six months to newly diagnosed ART-eligible participants between 2014-2015. A confirmatory factor analysis indicated that the IARSS contained a four-item internalized stigma factor (α=0.80) and a two-item disclosure concerns factor (α=0.75). We fitted multiple logistic regression models specifying internalized stigma/disclosure concerns at six months as the outcome and ART initiation as the predictor of interest.

Results

Of the 500 participants (187 men and 313 women) enrolled, 308 (62%) initiated ART. Internalized stigma declined among people entering care (mean score, 1.0 to 0.7, p<0.01); however, disclosure concerns remained unchanged (percentage endorsing either disclosure concern item, 78% to 77%, p=0.23). These findings were similar between ART initiators and non-initiators. We estimated a statistically significant positive association between ART initiation and disclosure concerns at six months (OR=1.88; 95% CI, 1.20-2.94) but not between ART initiation and internalized stigma at six months (OR=1.15; 95% CI, 0.75-1.78).

Conclusions

Among ART-eligible South African PLHIV entering into HIV care, internalized stigma modestly declined over time but disclosure concerns persisted. PLHIV who initiated ART were more likely to have persistent disclosure concerns over time as compared with those who did not start ART.

Characterizing the Patterns of HIV Disclosure to Clients Among South African Female Sex Workers in Port Elizabeth

Female sex workers (FSW) in South Africa are disproportionately affected by HIV, yet little is known about their HIV-status disclosure with clients. Among 410 FSW participating in a cross-sectional study, 213 were HIV positive and aware of their status prior to enrollment. Among FSW aware of their HIV-status, 35% (74/213) reported disclosing their HIV-status to paying clients, whereas 75% (118/158) of those with regular, non-paying partners disclosed to them. In a multivariable analysis, disclosure to clients was associated with more years of education, disclosure to non-paying partners, and meeting clients at established sex work venues, whereas a history of sexual violence was associated with less disclosure. There was also evidence of mutual disclosure with clients, however disclosure was not associated with condom use with clients or being on antiretrovirals. Safer working environments may improve FSW HIV disclosure practices, however disclosure must also be linked with protective behaviors in this population.

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

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

Mitigating intimate partner violence among South African women testing HIV positive during mobile counseling and testing

South African women continue to suffer disproportionately from the interlinked epidemics of HIV and intimate partner violence (IPV). Effective strategies are needed to mitigate HIV-related IPV, which often creates barriers to successful engagement along the HIV continuum of care. More information is needed on how IPV impacts women's safety following mobile HCT diagnosis, and the HIV IPV Risk Assessment & Safety-planning (HIRS) protocol was developed to address several related gaps in knowledge. The sample included 255 black South African women experiencing IPV and testing HIV+ during mobile HCT in Gauteng province. Outcomes were compared between a standard of care (SOC) group and an Experimental group with two dosage levels (D1, D2). Of the total sample and in the last year, 99.2% had experienced non-violent control, 40.7% physical abuse, 44.8% sexual abuse, and 67.3% physical or sexual abuse. There were no significant differences in pre/post safety scores, or for satisfaction or acceptability items. The overall linkage rate was 45.8% (M = 12.97 days), and the Experimental group had more links to care in certain age groups-the highest in those aged ≤23 years in D1 (70%). The lowest linkage rate was for those aged 33-43 years in the SOC (22.2%). Almost two thirds of participants reported using the safety plan (61.9%), with 80% reporting it was helpful, and 80% using ≥1 safety strategy. The Experimental group reported significantly less violence upon partner notification of serostatus, but all groups felt significantly less safe getting to medical appointments by post-test. Overall, the study indicates the HIRS protocol is safe and helpful, brief to administer, and may mitigate violence during partner notification of serostatus, but further investigation is needed before implementing it as a standard of care.

The Role of Relationship Dynamics and Gender Inequalities As Barriers to HIV-Serostatus Disclosure: Qualitative Study among Women and Men Living with HIV in Durban, South Africa

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

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.

The role of basic psychological need satisfaction, sleep, and mindfulness in the health-related quality of life of people living with HIV

Research has not yet examined the relationship between psychological need satisfaction, sleep, mindfulness, and health-related quality of life in people living with HIV. This cross-sectional study ( N = 101; 84% male; mean age = 45.48, SD = 12.75) found need satisfaction to relate positively to physical and mental health. Sleep quality fully mediated the association with physical health and partially mediated the association with mental health. Furthermore, mindfulness related to higher sleep quality through higher need satisfaction. Findings underscore the role of need satisfaction in determining health-related quality of life and sleep quality in people living with HIV and suggest that mindfulness may facilitate need satisfaction.

Factors associated with changes in uptake of HIV testing among young women (aged 15-24) in Tanzania from 2003 to 2012

Background

This study explored the factors associated with changes in HIV testing uptake among young women in Tanzania, based on an analysis of data from the 2003–2004 Tanzania HIV/AIDS Indicator Survey, and the 2007–2008 and 2011–2012 Tanzania HIV/AIDS and Malaria Indicator Surveys.

Methods

The study population consisted of young women aged 15–24 years at the time of the survey. Multivariate decomposition analysis was used to assess factors associated with changes in HIV testing uptake between the 2003–2004 and 2007–2008 surveys, and between the 2007–2008 and 2011–2012 surveys.

Results

HIV testing uptake among the study population was 7 % in 2003–2004, 31 % in 2007–2008 and 40 % in 2011–2012. The time period of the survey had a substantial effect on the uptake of HIV testing independent of other covariates. The characteristics that were significantly associated with a higher chance of HIV testing uptake across the surveys were age (20–24), education level (primary and secondary), ever being married, having at least one lifetime sexual partner, having a sexually transmitted infection or associated symptoms, and receiving antenatal care.

Conclusions

Changes in the study participants’ characteristics in the 2003–2004 survey compared with the 2007–2008 survey were associated with a decrease in HIV testing uptake. Comparing the 2007–2008 survey with the 2011–2012 survey shows that the changes in the participants’ characteristics contributed to 22 % of the changes in HIV testing uptake, while 78 % of the changes were attributed to coefficients.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0180-3) contains supplementary material, which is available to authorized users.

Disclosure appraisal mediating the association between perceived stigma and HIV disclosure to casual sex partners among HIV+ MSM: a path model analysis

HIV stigma is widely believed to be related to HIV disclosure. However, there is a dearth of studies examining the mechanisms that link stigma to disclosure. This is a specific study to assess the relationship between perceived stigma and HIV disclosure to casual sex partners based on a social cognitive theory. HIV+ men who have sex with men (MSM) from two US cities (N = 297) completed questionnaires administered using audio computer-assisted self-interviewing. Path modeling analysis was used to assess the theory-based structural relationships. Perceived stigma was negatively associated with attitudes, intention and behavior of HIV disclosure to casual sex partners. The association was fully mediated by disclosure appraisal, including disclosure outcome expectations, costs and self-efficacy. Findings of this study add new knowledge regarding HIV stigma and disclosure, and provide timely data supporting more effective behavioral interventions to encourage HIV disclosure among MSM.

Do People Know I'm Poz?: Factors Associated with Knowledge of Serostatus Among HIV-Positive African Americans' Social Network Members

We examined how functional social support, HIV-related discrimination, internalized HIV stigma, and social network structure and composition were cross-sectionally associated with network members' knowledge of respondents' serostatus among 244 HIV-positive African Americans in Los Angeles. Results of a generalized hierarchical linear model indicated people in respondents' networks who were highly trusted, well-known to others (high degree centrality), HIV-positive, or sex partners were more likely to know respondents' HIV serostatus; African American network members were less likely to know respondents' serostatus, as were drug-using partners. Greater internalized stigma among respondents living with HIV was associated with less knowledge of their seropositivity within their social network whereas greater respondent-level HIV discrimination was associated with more knowledge of seropositivity within the network. Additional research is needed to understand the causal mechanisms and mediating processes associated with serostatus disclosure as well as the long-term consequences of disclosure and network members' knowledge of respondents' serostatus.

How reliable are self-reports of HIV status disclosure? Evidence from couples in Malawi

INTRODUCTION

The majority of research on human immunodeficiency virus (HIV) disclosure utilizes the perspective from a single individual, which cannot be substantiated in the absence of supporting data such as from a primary partner.

OBJECTIVES

The objectives of this study were to evaluate: (1) the extent to which self-reported HIV disclosure was confirmed by a primary partner; (2) individual and relationship-level predictors of self-reported versus confirmed disclosure; and (3) whether confirmed disclosure was a stronger predictor of correctly assessing a partner's HIV status compared to self-reported disclosure.

METHODS

As part of an 8-wave longitudinal study from 2009 to 2011 in southern Malawi, 366 individuals (183 couples) were interviewed about their primary relationship (wave 3), individually tested for HIV (wave 4), and then asked whether they disclosed to their primary partner (wave 5).

RESULTS

While 93% of respondents reported that they disclosed, only 64% of respondents had confirmed reports from their partner. Having communicated with partner about HIV was positively associated with self-reported disclosure; this association remained significant but became more precise in the models for confirmed disclosure. Confirmed disclosure, but not self-report, was a significant predictor of correctly assessing a partner's HIV status. Being male, having lower perceived partner infidelity, having higher relationship unity, and testing HIV-negative were positively and significantly associated with correct assessment. Dyadic data from two partners provide an improved measure of disclosure as compared to a single individual's self-report and could be used to identify behavioral and biomedical opportunities to prevent HIV transmission within couples.

Seek, Test and Disclose: knowledge of HIV testing and serostatus among high-risk couples in a South African township

OBJECTIVES

HIV testing and disclosure of results to partners is an important strategy in HIV prevention but is under-researched within heterosexual partnerships. To address this gap, we describe patterns of HIV testing, discrepancies between beliefs and biologically confirmed HIV status of each partner, and characteristics of mutually correct knowledge of HIV status among heterosexual couples in a high-prevalence community.

METHODS

The study recruited 290 high-risk heterosexual couples in stable relationships from a township in Cape Town, South Africa. Male patrons of shebeens (drinking establishments) were approached to participate with their main partner in an intervention designed to reduce substance use, violence and unsafe sex. All participants were tested for HIV at baseline and asked about their partner's past HIV testing and current status. Using the couple as the unit of analysis, we conducted logistic regression to identify partnership and individual characteristics associated with having mutually correct knowledge of partner's HIV status.

RESULTS

Half (52%) of women and 41% of men correctly knew whether their partner had ever been tested for HIV. 38% of women, 28% of men and in 17% of couples, both members reported mutually correct knowledge of their partner's HIV status. Correlates of correct knowledge included married/cohabitating (aOR 2.69, 95% CI 1.35 to 5.40), both partners HIV-negative (aOR 3.32 (1.38 to 8.00)), women's acceptance of traditional gender roles (aOR 1.17 (1.01 to 1.40)) and men's relationship satisfaction (aOR 2.22 (1.01 to 4.44)).

CONCLUSIONS

Findings highlight the need to improve HIV testing uptake among men and to improve HIV disclosure among women in heterosexual partnerships.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registration NCT01121692.

The impact of gender norms on condom use among HIV-positive adults in KwaZulu-Natal, South Africa

Critical to preventing the spread of HIV is promoting condom use among HIV-positive individuals. Previous studies suggest that gender norms (social and cultural constructions of the ways that women and men are expected to behave) may be an important determinant of condom use. However, the relationship has not been evaluated among HIV-positive women and men in South Africa. We examined gender norms and condom use at last sex among 550 partnerships reported by 530 sexually-active HIV-positive women (372) and men (158) who had sought care, but not yet initiated antiretroviral therapy in a high HIV-prevalence rural setting in KwaZulu-Natal, South Africa between January 2009 and March 2011. Participants enrolled in the cohort study completed a baseline questionnaire that detailed their socio-demographic characteristics, socio-economic circumstances, religion, HIV testing history and disclosure of HIV status, stigma, social capital, gender norms and self-efficacy. Gender norms did not statistically differ between women and men (p = 0.18). Overall, condoms were used at last sex in 58% of partnerships. Although participants disclosed their HIV status in 66% of the partnerships, 60% did not have knowledge of their partner's HIV status. In multivariable logistic regression, run separately for each sex, women younger than 26 years with more equitable gender norms were significantly more likely to have used a condom at last sex than those of the same age group with inequitable gender norms (OR = 8.88, 95% CI 2.95-26.75); the association between condom use and gender norms among women aged 26+ years and men of all ages was not statistically significant. Strategies to address gender inequity should be integrated into positive prevention interventions, particularly for younger women, and supported by efforts at a societal level to decrease gender inequality.

Stigma and HIV disclosure in the Cape Metropolitan area, South Africa

Disclosure rates of HIV-positive status remain low and are considered to be related to stigmatisation. Determining the factors that influence a person's decision to disclose a positive status is essential to understanding the process of and ways to improve disclosure rates. This study investigated the factors that influence the disclosure of a person's HIV-positive status and focused on socio-demographic factors, stigma and discrimination, religion, culture, fear of abandonment and rejection as well as knowledge of the disease that may all influence disclosure rates. A facility based descriptive cross-sectional research design with a quantitative approach was applied using convenience sampling. The sample comprised 150 individuals which was 12.5% of the study population. A self-administered questionnaire comprising mainly closed-ended questions, with a limited number of open ended questions was designed, tested and utilised. Statistical associations were determined between the demographic factors and responses to the questions. The open ended questions were analysed thematically by means of content analysis to extract meaning. The results revealed that fear of stigmatisation, especially among the male participants, was a major reason for delayed or non-disclosure. The results of the total study sample also showed that the level of education influenced the fear of stigmatisation; those with secondary school level education were most afraid of this (29%). There was a statistically significant association between fear of blame or discrimination and disclosure to the sexual partner. This fear was most often cited by the participants who had never married (19%). The participants who feared blame or discrimination the most reported having no income (23%). The findings of this study indicate that numerous factors influence HIV disclosure. Stigma of individuals who are HIV-positive remains a barrier to disclosure as well as fear of blame and discrimination. Recommendations were made to facilitate and increase disclosure rates. This should include community based support groups and advocating partners to attend voluntary counselling and testing together to minimise the fear of blame.

Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection

SETTING

Five primary health care clinics in Kinshasa, Democratic Republic of Congo.

OBJECTIVE

To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment.

DESIGN

Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm(3) or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100-350 cells/mm(3), or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤ 350 cells/mm(3) or patient has WHO Clinical Stage 4.

RESULTS

Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm(3)), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and non-disclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation.

CONCLUSION

Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.

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

A nuanced understanding of HIV-positive status disclosure is urgently needed to inform the implementation of prevention interventions, including TasP and PrEP. To provide such understanding for the high HIV-burden setting of rural KwaZulu-Natal, we conducted a prospective cohort study to characterize determinants and trends in HIV-positive status disclosure. 687 consenting HIV-positive individuals (73.2 % female; 60.3 % ART initiated) were enrolled. Reports of any incidence of disclosure to either a family member or sexual partner at enrollment and follow-up visits (median 4.4 months post-enrolment) were common (91.0 %); however, reports of disclosure specifically to sexual partners were relatively rare (34.1 %), especially in women (29.8 %). Participants not engaged in a stable partnerships, not ART-imitated, and/or who had disclosed to their family were at risk of non-disclosure to sexual partners. These data highlight both an urgent need to empower HIV-positive individuals, and the significant barriers to targeting sero-discordant couples for HIV prevention in this setting.

Disclosure of HIV test results by women to their partners following antenatal HIV testing: a population-based cross-sectional survey among slum dwellers in Kampala Uganda

BACKGROUND

Disclosure of HIV status by women to their partners is the backbone for prevention of HIV transmission among couples as well as promotion of the prevention of mother to child transmission of HIV interventions. The aim of this study was to determine the prevalence and factors associated with disclosure of HIV test results by women to their sexual partners following antenatal HIV testing in Kamwokya slum community, Kampala, Uganda.

METHODS

This was a population based cross-sectional study carried out from October to November 2011. A total of 408 randomly selected women aged 18-45 years, who had delivered a child within 2 years prior to the study, and had tested for HIV during antenatal care were recruited from Kamwokya community. A standardised interviewer- administered questionnaire was used to collect data. Data was entered into Epidata 2.1b and analysed using SPSS software version 16.0 and StatsDirect version 2.8.0.

RESULTS

Overall 83.8% (95% CI: 79.9- 87.1) of the women reported that they had disclosed their HIV status to their sexual partners. Disclosure was significantly higher among women whose partners had also tested for HIV (OR=24.86, 95% CI: 5.30 - 116.56). Other factors that were associated with disclosure were secondary education or above (OR=2.66, 95% CI: 1.34 - 5.30), having attended 3 or more antenatal care visits (OR=3.62, 95% CI: 1.70 - 7.72), being married/cohabiting (OR=8.76, 95% CI: 4.06 - 18.81) and whether or not they would opt not to disclose a family member's HIV status (OR=1.61, 95% CI: 1.003 - 2.58). Overall, stigma was not significantly associated with disclosure.

CONCLUSIONS

Disclosure of HIV test results to sexual partners in this group of women was relatively high. The results suggest that having a sexual partner who had also tested probably made it easier to disclose the woman's HIV status. Other predictors of disclosure were secondary education and above and having attended more antenatal care visits. These findings suggest the need for promotion of sexual partner HIV testing, improvement of literacy levels of women, and encouragement of women to attend antenatal care, as key factors in promoting disclosure of HIV results.

Perceived vulnerability and HIV testing among youth in Cape Town, South Africa

The importance of perceived vulnerability to risk-reducing behaviors, including HIV testing, is fairly established, especially among youth in sub-Saharan Africa. Yet, the majority of studies that examined this important relationship used cross-sectional data that inherently assume that perceived vulnerability does not change. While these studies have been useful, the assumption of perceived vulnerability as time invariant is a major flaw and has largely limited the practical usefulness of this variable in AIDS prevention and programing. Using longitudinal data and applying random-effects logit models, this study makes a major contribution to scholarship by examining if changes in perceived vulnerability associate with a change to test for HIV among 857 young people in Cape Town, South Africa. Results show that female youth who changed their risk perceptions were more likely to also change to test for HIV, but the effects were completely attenuated after controlling for theoretically relevant variables. No significant relationships were observed for males. Also, females who were virgins at wave 2 but had sex between waves were significantly more likely to have changed to test for HIV. Of most importance was that sexual behavior eliminated the effects of change in risk perceptions suggesting that a change in perception may have occurred as a result of changes in sexual behavior. AIDS prevention programs must pay particular attention to helping youth become aware of their vulnerability to HIV risks, especially as these have implications for risk-reducing behaviors, especially for females who are burdened.

Sociocultural factors influencing HIV disclosure among men in South Africa

In South Africa, more than 2 million people living with HIV are men aged 15 years and older, and heterosexual intercourse remains the predominant mode of HIV transmission. Knowledge of the sociocultural factors that influence men's decisions about whether, when, or how to disclose seropositive status remains incompletely understood. Using the PEN-3 cultural model as a guide, this study explored the sociocultural factors influencing HIV disclosure among men in South Africa. Four focus group discussions with 27 participants were used to determine the perceptions, enabling and nurturing factors that influence how men chose to reveal or conceal knowledge of their seropositive status. The results revealed that notions of male identity in the South African context, family, and community factors contribute to disclosure and nondisclosure of seropositive status among men living with HIV/AIDS. Future interventions should work to address these factors, as they are necessary with supporting disclosure among men living with HIV.

Gender perspective of risk factors associated with disclosure of HIV status, a cross-sectional study in Soweto, South Africa

Background

Human Immunodeficiency Virus (HIV) status disclosure has been shown to provide several benefits, both at the individual and societal levels.

Aim

To determine risk factors associated with disclosing HIV status among antiretroviral therapy (ART) recipients in South Africa.

Setting

A cross-sectional study on risk factors for viremia and drug resistance took place at two outpatient HIV clinics in 2008, at a large hospital located in Soweto, South Africa.

Methods

We conducted a secondary data analysis on socio-economic characteristics and HIV status disclosure to anyone, focusing on gender differences. Descriptive and multivariable logistic regression analyses were performed to model the associations between risk factors and HIV status disclosure. Additionally, descriptive analysis was conducted to describe gender differences of HIV status disclosure to partner, parents, parents in law, partner, child, family, employer, and other.

Patients

A total of 883 patients were interviewed. The majority were women (73%) with median age of 39 years.

Results

Employed patients were less likely to disclose than unemployed (odds ratio (OR) 0.36; 95% confidence interval (CI) 0.1–1.0; p = 0.05)). Women with higher income were more likely to disclose (OR 3.25; 95% CI 0.90–11.7; p = 0.07) than women with lower income, while men with higher income were less likely (OR 0.20; 95% CI 0.02–1.99; p = 0.17) than men with lower income. Men were more likely than women to disclose to their partner (p<0.01), and to partner and family (p<0.01), women were more likely than men to disclose to child and family (p<0.01), to child, family and others (p = 0.01).

Conclusion

Being employed imposed a risk factor for HIV status disclosure, additionally we found an interaction effect of gender and income on disclosure. Interventions designed to reduce workplace discrimination and gender-sensitive interventions promoting disclosure are strongly recommended.

Disclosure in times of ART: a relational analysis of social practices

The reach of HIV counseling and testing has grown rapidly since the 2000s, particularly since 2007 when provider-initiated counseling and testing was implemented alongside voluntary counseling and testing and testing for the prevention of mother-to-child transmission. Nevertheless, we still know little about the attendant practices of disclosing HIV-positive status. Persistently high rates of non-disclosure raise difficult ethical, public health and human rights issues. The articles in this special issue show that disclosure practices in Africa not only follow the public health rationality but are shaped by fears of stigma that favor secrecy. They show how practices of disclosure are embedded in social relationships. More specifically, they present disclosure practices at the intersection of five social spaces: international norms, national legislation and public health recommendations; household and family settings; couples' relationships; parental relationships; and relationships between health workers and PLWHA. The authors describe how people pursue strategies of disclosure in one or more of these social spaces, which sometimes allows them to avoid barriers (for instance when they choose to disclose only partially to certain 'significant others' in the household). One important finding is that counselors often do not support PLWHA to disclose their HIV status. Counselors themselves may be influenced by divergent logics and experience conflicts in values; they may also lack sufficient knowledge and skills to discuss sensitive issues based on rapidly changing medical data and public health recommendations.

[HIV disclosure in polygamous settings in Senegal]

In Senegal, where HIV prevalence is less than 1% and stigma remains important, 40% of marriages are polygamic. The purpose of this article is to describe and analyze the motivations, benefits and constraints related to HIV disclosure, and to explore specific situations related to polygamy. Data were collected through qualitative research based on in-depth repeated interviews on the experience of antiretroviral therapy and its social effects, conducted over a period of 10 years with people on antiretroviral treatment and their caregivers. Health professionals encourage people to disclose their HIV status, especially in certain circumstances such as preventing mother-to-child transmission of HIV. Nevertheless they are aware of the social risks for some patients, particularly women. Some health workers insist on disclosure, while others do not interfere with women who do not disclose to their partner, while highlighting their ethical dilemma. Interviews trace the changing attitudes of caregivers regarding disclosure. The majority of married women begin by sharing their HIV status with their mother, waiting for her to confirm that the contamination is not due to immoral behavior and to participate in implementing a strategy to maintain secrecy. In polygamous households, women try to disclose to their partner, keeping the secret beyond the couple. Some women fear disclosure by their husbands to co-spouses, whose attitudes can be very diverse: some stories relate collective rejection from the household; sometimes disclosure is made in a progressive way following the hierarchy of positions of each person in the household; another person reported the solidarity shown by her co-spouses who kept her HIV status a secret outside the household. The article shows the diversity of situations and their dynamics regarding both disclosure practices and their social effects.

Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis

INTRODUCTION

Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence.

METHODS

We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies.

RESULTS

Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants' ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ (2)=7.7; p=0.005).

CONCLUSIONS

We found that HIV-related stigma compromised participants' abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.

Individual- and school-level correlates of HIV testing among secondary school students in Kenya

The policy framework guiding Kenya's response to the AIDS epidemic identifies voluntary counseling and testing as crucial to risk reduction and HIV-preventive activities. Yet in Kenya, as in most sub-Saharan countries, voluntary testing rates are low, especially among young people. Using hierarchical linear models, we identify both individual- and teacher/school-level factors that affect voluntary HIV testing among secondary school students in Kenya. Results indicate that adolescents are more likely to test for HIV serostatus when they are knowledgeable about testing, have been involved in HIV/AIDS activities in primary school, have been provided with HIV information in secondary school, perceive themselves as at high risk of contracting HIV or know of someone infected with or who has died from HIV/AIDS, and have ever engaged in sexual intercourse. Barriers include fear of going to testing centers and being perceived as HIV-positive. Teacher/school-level characteristics are relevant for explaining rates of HIV testing, especially among girls. To encourage testing, policymakers should attend to teacher/school-level factors as well as individual characteristics of students.

The social and gender context of HIV disclosure in sub-Saharan Africa: a review of policies and practices

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.

Do support groups members disclose less to their partners? The dynamics of HIV disclosure in four African countries

BACKGROUND

Recent efforts to curtail the HIV epidemic in Africa have emphasised preventing sexual transmission to partners through antiretroviral therapy. A component of current strategies is disclosure to partners, thus understanding its motivations will help maximise results. This study examines the rates, dynamics and consequences of partner disclosure in Burkina Faso, Kenya, Malawi and Uganda, with special attention to the role of support groups and stigma in disclosure.

METHODS

The study employs mixed methods, including a cross-sectional client survey of counselling and testing services, focus groups, and in-depth interviews with HIV-positive individuals in stable partnerships in Burkina Faso, Kenya, Malawi and Uganda, recruited at healthcare facilities offering HIV testing.

RESULTS

Rates of disclosure to partners varied between countries (32.7% - 92.7%). The lowest rate was reported in Malawi. Reasons for disclosure included preventing the transmission of HIV, the need for care, and upholding the integrity of the relationship. Fear of stigma was an important reason for non-disclosure. Women reported experiencing more negative reactions when disclosing to partners. Disclosure was positively associated with living in urban areas, higher education levels, and being male, while being negatively associated with membership to support groups.

CONCLUSIONS

Understanding of reasons for disclosure and recognition of the role of support groups in the process can help improve current prevention efforts, that increasingly focus on treatment as prevention as a way to halt new infections. Support groups can help spread secondary prevention messages, by explaining to their members that antiretroviral treatment has benefits for HIV positive individuals and their partners. Home-based testing can further facilitate partner disclosure, as couples can test together and be counselled jointly.

A documentation policy development proposal for clinicians caring for people living with HIV/AIDS

In Canada, nondisclosure prosecutions against people living with HIV/AIDS (PHAs) have increased. Nurses who provide services to PHAs could become involved in such criminal cases because they (a) elicit sensitive information about their clients' sexual practices, and (b) adhere to documentation standards. Currently, HIV documentation policies do not exist for clinicians working with PHAs in Canada or abroad. Sexual assault nursing, which includes documentation guidelines, may offer guidance in the creation of a PHA care policy because sexual assault nursing and PHA care both intersect with the justice system. A PHA care policy may have several benefits: It can increase clinician confidence in patient interactions and documentation by clarifying roles and scope of responsibilities, reduce inconsistencies in practice, diminish conflict among professionals, and reduce the stress involved in clinical practice. The outcome of these improvements could be an increase in PHAs' level of comfort with nurses knowing that policies exist.

Impact of HIV comprehensive care and treatment on serostatus disclosure among Cameroonian patients in rural district hospitals

This work aimed to analyze the rate of disclosure to relatives and friends over time and to identify factors affecting disclosure among seropositive adults initiating antiretroviral therapy (ART) in rural district hospitals in the context of decentralized, integrated HIV care and task-shifting to nurses in Cameroon. Stratall was a 24-month, randomized, open-label trial comparing the effectiveness of clinical monitoring alone with laboratory plus clinical monitoring on treatment outcomes. It enrolled 459 HIV-infected ART-naive adults in 9 rural district hospitals in Cameroon. Participants in both groups were sometimes visited by nurses instead of physicians. Patients with complete data both at enrolment (M0) and at least at one follow-up visit were included in the present analysis. A mixed Poisson regression was used to estimate predictors of the evolution of disclosure index over 24 months (M24).The study population included 385 patients, accounting for 1733 face-to-face interviews at follow-up visits from M0 to M24. The median [IQR] number of categories of relatives and friends to whom patients had disclosed was 2 [1]-[3] and 3 [2]-[5] at M0 and M24 (p-trend<0.001), respectively. After multiple adjustments, factors associated with disclosure to a higher number of categories of relatives and friends were as follows: having revealed one's status to one's main partner, time on ART, HIV diagnosis during hospitalization, knowledge on ART and positive ratio of follow-up nurse-led to physician-led visits measuring task-shifting. ART delivered in the context of decentralized, integrated HIV care including task-shifting was associated with increased HIV serological status disclosure.

Prevalence and correlates of non-disclosure of HIV serostatus to sex partners among HIV-infected female sex workers and HIV-infected male clients of female sex workers in India

This study examines non-disclosure of HIV serostatus to sex partners among HIV-infected adults involved with transactional sex in Mumbai, India. Surveys were conducted with HIV-infected female sex workers (n = 211) and infected male clients (n = 205) regarding HIV knowledge, awareness of sex partners' HIV serostatus, alcohol use, transactional sex involvement post-HIV diagnosis and non-disclosure of HIV serostatus. Gender-stratified multiple logistic regression models were used for analysis. Non-disclosure of one's serostatus to all sex partners was reported by almost three-fifths of females and two-fifths of males. Predictors of non-disclosure included lack of correct knowledge about HIV and no knowledge of sex partners' HIV serostatus. Among females, recent alcohol consumption also predicted non-disclosure. Among males, 10 + paid sexual partners in the year following HIV diagnosis predicted non-disclosure. Secondary HIV prevention efforts in India require greater focus on HIV disclosure communication and integrated alcohol and sexual risk reduction.

The impact of structured support groups for pregnant South African women recently diagnosed HIV positive

The authors of this study evaluated a structured 10-session psychosocial support group intervention for newly HIV-diagnosed pregnant South African women. Participants were expected to display increases in HIV disclosure, self-esteem, active coping and positive social support, and decreases in depression, avoidant coping, and negative social support. Three hundred sixty-one pregnant HIV-infected women were recruited from four antenatal clinics in Tshwane townships from April 2005 to September 2006. Using a quasi-experimental design, assessments were conducted at baseline and two and eight months post-intervention. A series of random effects regression analyses were conducted, with the three assessment points treated as a random effect of time. At both follow-ups, the rate of disclosure in the intervention group was significantly higher than that of the comparison group (p<0.001). Compared to the comparison group at the first follow-up, the intervention group displayed higher levels of active coping (t=2.68, p<0.05) and lower levels of avoidant coping (t=-2.02, p<0.05), and those who attended at least half of the intervention sessions exhibited improved self-esteem (t=2.11, p<0.05). Group interventions tailored for newly HIV positive pregnant women, implemented in resource-limited settings, may accelerate the process of adjusting to one's HIV status, but may not have sustainable benefits over time.

Experience in international clinical research: the HIV Prevention Trials Network

The HIV Prevention Trials Network (HPTN) is supported by the NIH to conduct randomized clinical trials to assess the efficacy of HIV prevention strategies and technologies to reduce HIV transmission between adults. A special focus of attention is on the use of antiretroviral drugs to prevent HIV transmission, both by reducing infectiousness among HIV-infected persons taking combination antiretroviral therapy (cART) and also by reducing susceptibility among HIV-uninfected persons taking antiretrovirals for pre-exposure prophylaxis. Studies may be developmental in nature to assess novel ideas for interventions or for assessing trial feasibility. However, pivotal efficacy trials to test HIV-specific prevention strategies and technologies are the main HPTN priority. Examples include a major protocol investigating the impact of expanded testing and linkage to care on HIV surveillance indicators in the USA (HPTN 065). Another protocol is addressing similar issues while also investigating how combinations of prevention approaches are best deployed to make a community-level impact in southern Africa (HPTN 071). HPTN 068 is evaluating a novel conditional cash transfer structural intervention to increase school completion rates in young girls and thereby reduce their HIV risk. Studies outside the US address the epidemic in most at-risk populations and include an assessment of opiate agonist therapy to reduce risk of HIV seroconversion among injection drug users (HTPN 058), methods to increase HIV testing rates (HTPN 043), as well as methods for reducing high-risk behaviors, and increasing adherence to cART in HIV-infected individuals (HPTN 062 and HPTN 063, respectively). The recent HPTN 052 study demonstrated that a 96% reduction in HIV transmission could be achieved between serodiscordant sexual partners by providing the infected partners with cART at a CD4(+) cell count (350-550/µl) above the level that would usually qualify them for therapy in low- and middle-income countries. The immediate relevance to public health policy showcased in these trials is a paradigm for the HPTN: design and conduct of clinical trials using available licensed tools that can be rapidly translated for implementation ('Prevention NOW!').

What works to meet the sexual and reproductive health needs of women living with HIV/AIDS

It is critical to include a sexual and reproductive health lens in HIV programming as most HIV transmission occurs through sexual intercourse. As global attention is focusing on the sexual and reproductive health needs of women living with HIV, identifying which interventions work becomes vitally important. What evidence exists to support sexual and reproductive health programming related to HIV programmes?

This article reviews the evidence of what works to meet the sexual and reproductive health needs of women living with HIV in developing countries and includes 35 studies and evaluations of eight general interventions using various methods of implementation science from 15 countries. Data are primarily from 2000-2009. Searches to identify effective evaluations used SCOPUS, Popline, Medline, websites and consultations with experts. Evidence was ranked using the Gray Scale.

A range of successful and promising interventions to improve the sexual and reproductive health and rights of women living with HIV include: providing contraceptives and family planning counselling as part of HIV services; ensuring early postpartum visits providing family planning and HIV information and services; providing youth-friendly services; supporting information and skills building; supporting disclosure; providing cervical cancer screening; and promoting condom use for dual protection against pregnancy and HIV. Provision of antiretrovirals can also increase protective behaviours, including condom use.

While many gaps in programming and research remain, much can be done now to operationalize evidence-based effective interventions to meet the sexual and reproductive health needs of women living with HIV.

HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention

BACKGROUND

Sexual partners of persons with newly diagnosed HIV infection require HIV counseling, testing and, if necessary, evaluation for therapy. However, many African countries do not have a standardized protocol for partner notification, and the effectiveness of partner notification has not been evaluated in developing countries .

METHODS

Individuals with newly diagnosed HIV infection presenting to sexually transmitted infection clinics in Lilongwe, Malawi, were randomized to 1 of 3 methods of partner notification: passive referral, contract referral, or provider referral. The passive referral group was responsible for notifying their partners themselves. The contract referral group was given seven days to notify their partners, after which a health care provider contacted partners who had not reported for counseling and testing. In the provider referral group, a health care provider notified partners directly.

RESULTS

Two hundred forty-five index patients named 302 sexual partners and provided locator information for 252. Among locatable partners, 107 returned for HIV counseling and testing; 20 of 82 [24%; 95% confidence interval (CI): 15% to 34%] partners returned in the passive referral arm, 45 of 88 (51%; 95% CI: 41% to 62%) in the contract referral arm, and 42 of 82 (51%; 95% CI: 40% to 62%) in the provider referral arm (P < 0.001). Among returning partners (n = 107), 67 (64%) of were HIV infected with 54 (81%) newly diagnosed.

DISCUSSION

This study provides the first evidence of the effectiveness of partner notification in sub-Saharan Africa. Active partner notification was feasible, acceptable, and effective among sexually transmitted infections clinic patients. Partner notification will increase early referral to care and facilitate risk reduction among high-risk uninfected partners.

Disclosure of HIV status between spouses in rural Malawi

Disclosure of HIV status after HIV voluntary counseling and testing has important implications for the spread of the HIV epidemic and the health of individuals who are HIV positive. Here, we use individual and couples level data for currently married respondents from an ongoing longitudinal study in rural Malawi to (1) examine the extent of HIV status disclosure by HIV serostatus; (2) identify reasons for not sharing one's HIV status with a spouse; and (3) evaluate the reliability of self-reports of HIV status disclosure. We find that disclosure of HIV status is relatively common among rural Malawians, where most have shared their status with a spouse, and many disclose to others in the community. However, there are significant differences in disclosure patterns by HIV status and gender. Factors associated with non-disclosure are also gendered, where women who perceive greater HIV/AIDS stigma and HIV positive are less likely to disclose HIV status to a spouse, and men who are worried about HIV infection from extramarital partners are less likely to disclose their HIV status to a spouse. Finally, we test the reliability of self-reported HIV status disclosure and find that self-reports of HIV-positive men are of questionable reliability.

Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world

There have been dramatic increases in access to antiretroviral therapy (ART) across the developing world, and growing public health attention has focused on the possibility of utilizing ART as a means of slowing the global HIV epidemic. The preventive impact of ART will likely depend on decreasing levels of sexual risk behaviors following treatment initiation. The current review study examines the impact of wider access to ART on sexual risk behaviors among HIV-infected individuals in the developing world. The observational studies to date demonstrate that ART is associated with a significant reduction in unprotected sex following treatment initiation. Although data on the impact of ART on possible risk compensation are rapidly expanding across the developing world, more evidence is still needed before we can safely conclude expanded treatment will result in durable decreases in sexual risk behaviors.

Exploring the relative costs of contact tracing for increasing HIV case finding in sub-Saharan countries

BACKGROUND

Contact tracing (CT) has rarely been used to improve HIV case finding in sub-Saharan Africa because of concerns regarding privacy protection and possibly high costs.

METHODS

We estimate the relative cost of identifying an undiagnosed HIV infection through CT compared with client-initiated voluntary counseling and testing (VCT) and door-to-door provider-initiated testing (PIT). We used data from the Likoma Network Study, a study of sexual networks and HIV infection conducted on the small island of Likoma in northern Malawi, to inform these calculations.

RESULTS

In Likoma, the probability that partners of HIV index cases could be traced and that they would consent to HIV testing and counseling was high and varied by partner type. HIV prevalence ranged from 48.1% to 66.7% among the partners who were tested. Per newly diagnosed infection, CT is rarely a cheaper case finding approach than VCT in populations with HIV prevalence > 5%. In populations with HIV prevalence < 5%, CT is an attractive case-finding approach relative to VCT when few HIV-infected individuals are aware of their status. Compared with door-to-door PIT, CT is almost always preferred when the population prevalence is below 10%, unless CT costs are prohibitively high. When HIV prevalence is >10%, providing CT for current spouses of index cases remains an attractive approach to HIV case finding.

CONCLUSIONS

CT could complement client-initiated VCT or door-to-door PIT in a large number of sub-Saharan populations affected by generalized epidemics of varying magnitudes.

HIV surveillance in a large, community-based study: results from the pilot study of Project Accept (HIV Prevention Trials Network 043)

Background

Project Accept is a community randomized, controlled trial to evaluate the efficacy of community mobilization, mobile testing, same-day results, and post-test support for the prevention of HIV infection in Thailand, Tanzania, Zimbabwe, and South Africa. We evaluated the accuracy of in-country HIV rapid testing and determined HIV prevalence in the Project Accept pilot study.

Methods

Two HIV rapid tests were performed in parallel in local laboratories. If the first two rapid tests were discordant (one reactive, one non-reactive), a third HIV rapid test or enzyme immunoassay was performed. Samples were designated HIV NEG if the first two tests were non-reactive, HIV DISC if the first two tests were discordant, and HIV POS if the first two tests were reactive. Samples were re-analyzed in the United States using a panel of laboratory tests.

Results

HIV infection status was correctly determined based on-in country testing for 2,236 (99.5%) of 2,247 participants [7 (0.37%) of 1,907 HIV NEG samples were HIV-positive; 2 (0.63%) of 317 HIV POS samples were HIV-negative; 2 (8.3%) of 24 HIV DISC samples were incorrectly identified as HIV-positive based on the in-country tie-breaker test]. HIV prevalence was: Thailand: 0.6%, Tanzania: 5.0%, Zimbabwe 14.7%, Soweto South Africa: 19.4%, Vulindlela, South Africa: 24.4%, (overall prevalence: 14.4%).

Conclusions

In-country testing based on two HIV rapid tests correctly identified the HIV infection status for 99.5% of study participants; most participants with discordant HIV rapid tests were not infected. HIV prevalence varied considerably across the study sites (range: 0.6% to 24.4%).

Trial Registration

ClinicalTrials.gov registry number NCT00203749.

HIV disclosure patterns, predictors, and psychosocial correlates among HIV positive women in Zimbabwe

Disclosure of positive HIV status in Sub-Saharan Africa has been associated with safer sexual practices and better antiretroviral therapy (ART) adherence, but associations with psychosocial function are unclear. We examined patterns and psychosocial correlates of disclosure in a Zimbabwean community. Two hundred HIV positive women at different stages of initiating ART participated in a cross-sectional study examining actual disclosures, disclosure beliefs, perceived stigma, self-esteem, depression, and quality of life. Ninety-seven percent of the women disclosed to at least one person, 78% disclosed to their current husband/partner, with an average disclosure of four persons per woman. The majority (85-98%) of disclosures occurred in a positive manner and 72-95% of the individuals reacted positively. Factors significantly correlated with HIV disclosure to partners included being married, later age at menses, longer duration of HIV since diagnosis, being on ART, being more symptomatic at baseline, ever having used condoms, and greater number of partners in the last year. In multivariate analysis, being married and age at menses predicted disclosure to partners. Positive disclosure beliefs, but not the total number of disclosures, significantly correlated with lower perceived stigma (ρ = 0.44 for personalized subscale and ρ = 0.51 for public subscale, both p<0.0001), higher self-esteem (ρ = 0.15, p=0.04), and fewer depressive symptoms (ρ = -0.14, p=0.05). In conclusion, disclosure of positive HIV status among Zimbabwean women is common and is frequently met with positive reactions. Moreover, positive disclosure beliefs correlate significantly with psychosocial measures, including lower perceived stigma, higher self-esteem, and lower depression.

HIV disclosure in rural China: predictors and relationship to access to care

This study examined the main reasons and predictors of HIV disclosure and its relationship to access to care among people living with HIV (PLH) in a rural area of China. A sample of 88 PLH from three counties was interviewed in 2009. In our sample, the rates of disclosure were higher within and outside family. Trust (31%), needing help (28%), and close relationships (26%) were the three main reasons of selecting the person to disclose by a PLH. Using a multivariate analysis, level of HIV disclosure to partners and members within the community was only significantly associated with use of antiretroviral treatment (ART) (β = 2.76; 95% Confidence Interval (CI): 0.77, 4.74). After adjusting for demographics, time since HIV diagnosis and ART, we found HIV disclosure (β = 0.07; 95% CI: 0.01, 0.13) was a significant predictor for access to care. In order to improve PLHs' access to health services and care, future intervention programs should consider both the potential benefits and risks associated with HIV disclosure (intentional and unintentional), and assist PLHs to prepare for HIV disclosure and reduce potential negative impacts that come with it.