|Year : 2021 | Volume
| Issue : 2 | Page : 172-177
Human immunodeficiency virus status disclosure among people living with human immunodeficiency virus receiving care in Enugu, Nigeria: A mixed method study
Ifeoma Maureen Obionu1, Chinyere Cecilia Okeke1, Ikechukwu Eke-Okoro2, Emmanuel Nwabueze Aguwa1, Chika Nwanma Onwasigwe1
1 University of Nigeria Teaching Hospital Enugu, Ituku, Nigeria
2 College of Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri, USA
|Date of Submission||30-Nov-2020|
|Date of Decision||18-Feb-2021|
|Date of Acceptance||22-Apr-2021|
|Date of Web Publication||14-Jun-2021|
Chinyere Cecilia Okeke
University of Nigeria Teaching Hospital Enugu, Ituku
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Disclosure of human immunodeficiency virus (HIV) status has potential benefits for both the individual and society. Objectives: This study aimed to determine the disclosure rate and its associated factors in people living with HIV receiving care in Enugu, Nigeria. Methods: A cross-sectional study using mixed methods was carried out in 5 comprehensive treatment facilities in Enugu, Nigeria during March to August 2019. 300 participants for the quantitative aspect were selected using a simple random sampling method and 30 participants for the qualitative aspect were selected purposively. Interviewer administered questionnaire and focus group discussion were applied for data collection. The quantitative data was analyzed using Epi info version 7; Chi-square test and multivariable logistic regression were applied and a level of statistical significance was set at P < 0.05. The qualitative data were analyzed using thematic analysis. Results: Among 300 participants, 241 (80.3%) had voluntarily disclosed their status to someone within their social network. 228 respondents had sexual partners and 122 (52.4%) had disclosed to their sexual partners. Twenty-five (11.0%) disclosed to their partners on the day of diagnosis. Predictors of disclosure were being female, having a formal education and being 35 years or more. Conclusion: This study revealed high voluntary disclosure rate to someone within the social network, but lower and delayed disclosure rate to sexual partners.
Keywords: Acquired immunodeficiency syndrome, disclosure, human immunodeficiency virus, sero-status
|How to cite this article:|
Obionu IM, Okeke CC, Eke-Okoro I, Aguwa EN, Onwasigwe CN. Human immunodeficiency virus status disclosure among people living with human immunodeficiency virus receiving care in Enugu, Nigeria: A mixed method study. Indian J Public Health 2021;65:172-7
|How to cite this URL:|
Obionu IM, Okeke CC, Eke-Okoro I, Aguwa EN, Onwasigwe CN. Human immunodeficiency virus status disclosure among people living with human immunodeficiency virus receiving care in Enugu, Nigeria: A mixed method study. Indian J Public Health [serial online] 2021 [cited 2021 Aug 2];65:172-7. Available from: https://www.ijph.in/text.asp?2021/65/2/172/318359
| Introduction|| |
Human immunodeficiency virus (HIV) status disclosure in simple terms means revealing to someone or people that one is HIV positive. HIV status is usually disclosed voluntarily by the index person, but it can also be revealed by others with or without the index person's consent.
HIV status disclosure has been reported to be of great relevance in the prevention and control of HIV. Timely disclosure between sexual partners can enhance access to care and treatment services in case the partner/spouse is also affected. If uninfected, protection can be achieved through taking appropriate actions such as safer sex practices to prevent infection. In addition, disclosure may facilitate other health behaviors that may improve the management of HIV. For example, women who disclose their status to partners may be more likely to participate in programmes for the prevention of HIV transmission from mothers to infants.
Since the advent of HIV pandemics, disclosure of patient's serostatus to sexual partners has been the concern of HIV caregivers. Overall rates of disclosure vary between studies, but many studies indicate that disclosure does not occur in a substantial majority of sexual partnerships, perhaps 20%–50% in developed countries as opposed to developing countries where the rate of disclosure is said to be lower.
Studies in both rural and urban settings across sub-Saharan Africa have shown disclosure of HIV positivity to be associated with positive outcomes including increased social support, reduced internalized stigma, improved mental health, and safer sexual behaviors. The proportion of HIV-infected individuals accessing antiretroviral therapy (ART) has dramatically increased as the ART rollout has progressed in sub-Saharan Africa, yet only half of people living with HIV (PLWHIV) regionally are aware of their status, and PLWHIV find disclosing their status, a complex decision-making process.
A systematic review of HIV status disclosure revealed heterogeneous disclosure rates across diverse populations and settings in sub-Saharan Africa. Concealment of HIV positivity may expose HIV-negative partners to infection, increase re-infection among HIV-positive partners, and create missed opportunities for HIV care. Disclosure is an important part of HIV prevention and care and access to antiretroviral medications. Owing to its importance increasing numbers of countries worldwide have applied and implemented laws that criminalize HIV nondisclosure, exposure and transmission (Joint United Nations Programme on HIV/acquired immunodeficiency syndrome [AIDS]) (UNAIDS, 2011). These laws prosecute PLWHIV who have, or are believed to have, put others at risk of acquiring HIV. According to the Nigerian HIV/AIDS discrimination Act of 2014, any partner in a marriage or cohabiting relationship has the right to be informed of his or her partner's HIV status in a situation where he or she considers himself or herself at risk of being infected by a partner. 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.
To facilitate better outcomes for HIV-positive individuals and their partners, it is important to examine the pattern of disclosure and the factors that contribute to the decision to disclose or not.
In this context, the present study has been undertaken with the objectives of determining the disclosure rate and its associated factors in PLWHIV receiving care in Enugu, Nigeria.
| Materials and Methods|| |
This study was a cross-sectional study using mixed methods and was carried out in 5 comprehensive treatment facilities in Enugu Metropolis in Enugu State, Nigeria. Three hundred PLWHIV completed a quantitative survey, whereas qualitative data were obtained from 30 PLWHIV. The survey was carried out from March to August 2019.
Data were collected using a semi-structured interviewer administered questionnaire for quantitative part and focused group discussions (FGDs) for qualitative part. Eligible participants were PLWHIV who had received treatment for at least 1 year and were 18 years and above.
For the quantitative sample, proportional allocation was used to allocate the number of participants recruited at each facility and participants were recruited as they presented for their clinic appointments using a simple random sampling method. Using a ballot method, eligible participants in the clinic were selected until the desired sample size for each facility was obtained. The sample size of 300 was determined using the sample size estimation formula for cross-sectional studies and a HIV status disclosure prevalence of 76.0% obtained from a similar study., A level of statistical significance was set at P < 0.05 and regression analysis was carried out at a 95% confidence interval (CI). The quantitative data were analyzed using Epi info version 7.
For the qualitative sample, participants for the FGD were selected purposively as they attended their routine clinic appointments with the help of the health workers at the selected facilities. A total of 30 participants were selected and 4 FGDs were conducted; 2 groups involving female participants and 2 groups involving male participants and the 4 FGD were carried out by a trained moderator with the support of a note taker. The FGDs were carried out on weekends at one of the selected facilities, because its location was central and easily accessible. The researchers introduced the topic to the participants, informed them that the sessions will be recorded, and that the information will be kept confidential, and their consent was obtained. An electronic recorder was used to record the FGD sessions and the recordings were stored in a passworded computer afterwards. An observer was present to record nonverbal responses from the participants. Each session lasted for about 45 min. FGDs were carried out using a pretested interview guide and included questions which addressed reasons for disclosure, reasons for nondisclosure, and opinions on the most important person to disclose to.
Data from the FGD were analyzed using inductive thematic analysis, and conclusions were drawn from the evolving themes. The audio recordings were accurately transcribed and the text was coded (i.e., organized the data into groups that were alike) by reading the transcript repeatedly. The transcript was also given to a research assistant to read and confirm the coding was complete. From the codes, patterns were identified, phrases with similar meaning were brought together, and themes were generated. Knowledge generated from the content analysis was based on the unique views of participants.
Ethical clearance was taken from the Health Research and Ethics Committee of the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, while permission was obtained from the management of the selected facilities. Informed consent was obtained from every participant that met the inclusion criteria.
The limitation of this study was that it relied on self-reports from the respondents and it was not easy to ascertain that what was reported was true. This was mitigated by ensuring anonymity and strict confidentiality of the participants' responses and conducting interviews privately.
| Results|| |
Majority of the respondents were male, and the mean age of the respondents was 40.9 ± 10.1 years. Majority of the participants in this study had disclosed their status to someone within their social network 241 (80.3%). Of the 300 respondents studied, only 233 currently (at the time of data collection) had sexual partners, and out of this number, 122 (52.4%) had disclosed their status to their current sexual partners [Table 1].
Of 241 respondents who have voluntarily disclosed their HIV status, 228 had sexual partners as at the time their diagnosis of HIV was made. Only 25 (11.0%) disclosed to their partners on the same day of diagnosis, whereas 127 (55.7%) disclosed to their sexual partners after 1 month of testing positive. Two hundred and eighteen (72.7%) felt that it was important to disclose a positive HIV status to a sexual partner/spouse, while 55 (18.3%) felt it was not important and 27 (9.0%) did not know if it was important or not [Table 2].
|Table 2: Prevalence of HIV status disclosure to current sexual partners and knowledge of its importance|
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The factors associated with disclosure were having a formal education, being female and being aged 35 years or more [Table 3]. Following regression analysis, all three factors were also found to be associated with HIV status disclosure these include: Being female (adjusted odds ratios [AOR] 3.485, CI 1.744–6.963), having a formal education (AOR 4.449, CI 1.972–10.081), being aged 35 years or more (AOR 5.127 CI 2.548–10.316) [Table 4].
|Table 3: Factors associated with voluntary HIV status disclosure (n=300)|
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|Table 4: Multivariable logistic regression showing predictors of HIV status disclosure|
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Demographic characteristics of qualitative sample
There were thirty respondents with equal number of males and females. The mean age of the respondents was 38 ± 6. Most of the respondents (60%) had disclosed their HIV status to someone in their social network and 75% of them had a sexual partner at the time of data collection.
Reasons for disclosure of human immunodeficiency virus status
During the FGDs, most of the respondents gave various reasons why PLWHIV disclose their HIV status. These were classified into four themes which were desire to have uninfected children, nature of relationship with disclosure target, support and signs of worsening illness.
Most of the respondents expressed that the desire to have uninfected children was a reason for disclosure.
"We tell our spouses especially when we want to have children; in my own case I told my wife when she was pregnant for our first child. I didn't want my child to get it” (Age 39, male).
A few of the respondents believed that the nature of relationship with disclosure target was a reason for disclosure.
"If I am in a serious sexual relationship and it is one that will lead to marriage I have to tell her. But you cannot be telling every girl just like that (chuckles)" (Age 36, male).
A few respondents indicated that the signs of worsening illness were a reason for disclosure.
"I was losing a lot of weight, now you see me I am even fat! When it starts showing that you are sick you tell people. As for me, because of that, I had to tell my mother" (Age 40, female).
Nearly all respondents felt that to receive support was a reason for disclosure.
"Before, I didn't tell anyone because my drugs were free but they changed my drug and now I buy some. It is very very expensive and I know my family will help I told them so they can help me pay for medicine" (Age 34, male).
Reasons for nondisclosure of human immunodeficiency virus status
Reasons for nondisclosure of HIV-positive status were grouped into themes of slander/gossip, discrimination, upsetting people, especially family members and fear of negative outcome after disclosure.
Many respondents narrated gossip/slander as reasons why people do not disclose their status.
"I told mysister about my condition and I have been regretting it since. She told the whole neighborhood and every time I go out people will be saying horrible things about me. That's why it is difficult for people to tell” (Age 37, female).
Nearly all respondents expressed that they were discriminated against by some people in the society.
"Why should I tell people that I am infected? They will only start behaving somehow and avoiding you. My neighborhood association said I could not be their leader because of my illness” (Age 40, Male).
There were also concerns from nearly all respondents about upsetting close relatives.
"Family people worry a lot, my sister suspected I was positive, she told my mother and the next time my mother saw me she threw herself on the ground crying that I was going to die. I had to lie and tell her I am not sick. We don't want our people to worry" (Age 40, male).
Almost all respondents had of fears concerning the possible outcome of disclosure as many had experienced or heard about the negative reaction from people after disclosure.
"You heard from others about how people they have told are treating them, somebody said his family chased him away, some have even said they were beaten. I don't want that to happen to me too" (Age 36, male).
"My husband left me after I told him. He also took the result of my test and showed all our family people telling them I was useless” (Age 37, female).
Most important person to disclose human immunodeficiency virus status to
Response from the discussions generated two themes. One was a female family member and the other was a sexual partner. Majority of the respondents believed that the most important person to disclose to was a female family member.
"The most important person to tell is either your mother or your sister. They will take care of you when you are sick. Women are more caring" (Age 36, male).
Only few respondents recognized the importance of the main disclosure target being a sexual partner.
"I think a husband or wife so you do not give them or your children the disease…" (Age 38, female).
| Discussions|| |
The findings on the overall voluntary disclosure rate of respondents to someone in their social network was found to be low, 80.3% in this study when compared with the findings from other developing countries such as Kenya where general disclosure rate to members of social networks was 92%. However, this differed a lot more than the disclosure rate of 17% observed for other developing countries like Northern Ethiopia in 2015. This high difference may be because of the gap in time as more interventions have been put in place in recent times to enhance and promote disclosure of HIV status such as the use of partner notification services.
Disclosure rate to main current sexual partners was 52.4%, similar to that found in Ogun State in Nigeria (50.9%). This similarity may be because most of the respondents in both studies were married. Higher disclosure rates were found in Ethiopia where 76.7% had disclosed to their sexual partners, although it was not said if it was past or current sexual partners. Studies have also shown that stigma and discrimination are the challenges in the care and treatment of persons with HIV infection worldwide and fear of negative social consequences often causes persons with HIV/AIDS to keep their infection secret, resulting in negative psychological and physical outcomes and continued spread of the disease.
In this study, majority of the respondents took more than a month to disclose their status to their sexual partners, this was similar to that documented in previous research works such as that carried out in Ethiopia where among those who disclosed their HIV status, 58% of them told their partner after 1 month after diagnosis and in Tanzania, disclosure to sexual partners increased from 22% within 2 months to 40% after nearly 4 years; however, different findings were seen in another study in Sagamu Nigeria, where almost half (49.3%) disclosed to other people immediately. This difference may have been because the study in Sagamu Nigeria was assessing the time it took respondents to disclose to someone, while this study assessed the time it took respondents to disclose to their sexual partners only. Responses from the FGD supported this finding of delayed disclosure as many commonly responded that telling people such things take time as one has to get used to and accept ones positive serostatus first.
Respondents who had received a formal education were found to be about three times more likely to disclose their status than those who had no formal education. This interestingly differs from a study in Ethiopia where a person who is literate was 60% less likely to disclose their sero-positive status to sexual partner than those who are illiterate (AOR = 0.4, 95% CI 0.17–0.92) this occurrence may be because of the social and geographical differences in the study settings. This study also indicated that there is a relationship between sex and disclosure, and a similar study has identified gender differences in disclosure of HIV status with men disclosing more than women, although this was not statistically significant. These findings may be due to the gender inequalities in the region which make women vulnerable and scared of the possible negative outcome of disclosure and research has shown that many women have reported experiencing a violent reaction from a partner following disclosure. Therefore, empowering women living with HIV may improve disclosure rates within this population. Being 35 years or more was also found to be a predictor of disclosure in this study. This finding was not surprising as it is expected that an older person is more likely to understand the implications of nondisclosure, may also be in a more stable sexual relationship, and feel more responsibility toward protecting the health of their partners and children than the younger respondents. Therefore, more emphasis should be put into sensitization and counseling on the importance and benefits of disclosure in the younger population.
| Conclusion|| |
The findings from this study revealed that voluntary disclosure of HIV status to anyone within the social network was high. However, voluntary disclosure to sexual partners was much lower and delayed. It is therefore important that voluntary counseling and testing services scale up partner notification services and ensure support services are available for those who may face negative consequences of disclosure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Iwelunmor J, Sofolahan-Oladeinde Y, Airhihenbuwa CO. Sociocultural factors influencing HIV disclosure among men in South Africa. Am J Mens Health 2015;9:193-200.
Ssali SN, Atuyambe L, Tumwine C, Segujja E, Nekesa N, Nannungi A, et al.
Reasons for disclosure of HIV status by people living with HIV/AIDS and in HIV care in Uganda: An exploratory study. AIDS Patient Care STDS 2010;24:675-81.
Coates TJ, Richter L, Caceres C. Behavioural strategies to reduce HIV transmission: How to make them work better. Lancet 2008;372:669-84.
Betancourt TS, Abrams EJ, McBain R, Fawzi MC. Family-centred approaches to the prevention of mother to child transmission of HIV. J Int AIDS Soc 2010;13 Suppl 2:S2.
Titilope AA, Adediran A, Umeh C, Akinbami A, Unigwe O, Akanmu AS. Psychosocial Impact of disclosure of HIV Serostatus in heterosexual relationship at the Lagos University teaching Hospital, Nigeria. Niger Med J 2011;52:55-9.
] [Full text]
Maeri I, El Ayadi A, Getahun M, Charlebois E, Akatukwasa C, Tumwebaze D, et al.
“How can I tell?” Consequences of HIV status disclosure among couples in eastern African communities in the context of an ongoing HIV “test-and-treat” trial. AIDS Care 2016;28:59-66.
Obermeyer CM, Baijal P, Pegurri E. Facilitating HIV disclosure across diverse settings: A review. Am J Public Health 2011;101:1011-23.
Bott S, Obermeyer CM. The social and gender context of HIV disclosure in sub-Saharan Africa: A review of policies and practices. SAHARA J 2013;10 Suppl 1:S5-16.
Salako AA, Sholeye OO, Amoran OE. Disclosure of HIV Status among Clients Accessing Care at A Tertiary Health Facility in Sagamu, Southwestern Nigeria. Curr Res J Biol Sci 2016;8:18-23.
Onwasigwe CN. Principles and Methods of Epidemiology. 2nd
ed. Enugu: EL Damak Publications; 2010. p. 147.
Berhane Alema H, Awoke Yalew W, Bedimo Beyene M, Gebremedhin Woldu M. HIV positive status disclosure and associated factors among HIV positive adults in Axum health facilities, Tigray, Northern Ethiopia. Sci J Public Heal 2015;3:61-6.
Amoran OE. Predictors of disclosure of sero-status to sexual partners among people living with HIV/AIDS in Ogun State, Nigeria. Niger J Clin Pract 2012;15:385-90. [Full text]
Erku TA, Megabiaw B, Wubshet M. Predictors of HIV status disclosure to sexual partners among people living with HIV/AIDS in Ethiopia. Pan Afr Med J 2012;13:87.
Sowell RL, Phillips KD. Understanding and responding to HIV/AIDS stigma and disclosure: An international challenge for mental health nurses. Issues Ment Health Nurs 2010;31:394-402.
Gultie T, Genet M, Sebsibie G. Disclosure of HIV-positive status to sexual partner and associated factors among ART users in Mekelle Hospital. HIV/AIDS - Res Palliat Care 2015;7:209.
Kiula ES, Damian DJ, Msuya SE. Predictors of HIV serostatus disclosure to partners among HIV-positive pregnant women in Morogoro, Tanzania. BMC Public Health 2013;13:433.
Deribe K, Woldemichael K, Njau BJ, Yakob B, Biadgilign S, Amberbir A. Gender differences regarding barriers and motivators of HIV status disclosure among HIV-positive service users: Original article. Sahara J Soc Asp HIV/AIDS Res Alliance J Soc Asp HIV/AIDS Res Alliance 2010;7:30-9.
Medley A, Gracia-Moreno C, Scott McGill SM. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: Implications for prevention of mother-to-child transmission programmes Amy. Bull World Health Organ 2004;82:299-307.
[Table 1], [Table 2], [Table 3], [Table 4]