Background: In Ethiopia a little has been explored about the prevalence of, barriers to, outcomes and factors associated with HIV status disclosure among HIV positive pregnant women.

Objective: To assess factors of disclosing HIV sero-status to sexual partner among HIV positive pregnant women attending antenatal care in Addis Ababa public health centers, Ethiopia.

Method: An institution based Cross- sectional study was conducted using quantitative method among 665 HIV positive pregnant women who were attending antenatal care from May 1-30/2016. All sero-positive pregnant women of age >18 years were included in study by multistage sampling method. Data was collected using structured interviewer administered questionnaire and entered and analyzed by SPSS 20 version. Multivariate logistic regressions were applied to evaluate significant association between independent and outcome (HIV positive sero-status disclosure).

Result: a total of 665 HIV positive pregnant women, participated in the study with the response rate of 99%. The overall Prevalence of disclosure of HIV status among pregnant women is 80.6% and 51.7% disclosed to their current main sexual partner. However, 35.2% of disclosure to sexual partner was delayed and 13.5% didn’t know their participant HIV status. Disclosure of HIV status to sexual partner was associated with discussion about HIV testing with partner prior to test (OR, 2.594, 95%CI, 1.474-4.565) and knowing partner HIV status (having sero-positive partner) (OR, 0.409, 95% CI, 0.231-0.723).

Conclusion: nearly half of the women challenged to disclose their status due to lack of open discussion with their partners that might lead to limited ability to engage in preventive behaviors and to access support.

Keywords: HIV, sero-status, pregnant, disclosure, sexual partner

AIDS, acquired immune deficiency syndrome; ANC, antenatal care; AOR, adjusted odds ratio; ART, antiretroviral therapy; B+, using a single tablet fixed dose combination of tenofovir, lamivudine and efavirenz; CART, combined antiretroviral treatment; CARV, combined antiretroviral therapy; CD4, cluster of differentiations 4; CI, confidence interval; COR, crude odds ratio; HCT, HIV counselling and testing; HIV, human immune deficiency virus; OR, odds ratio; PLWHIV, people living with HIV; PMTCT, prevention of mother to child transmission; SD, standard deviation; SPSS, statistical package for social sciences; WHO, World health organization

The prevention of HIV infection depends on the success of strategies to prevent new infection and treat currently infected individuals. Prevention of mother to child transmission (PMTCT) and HIV counseling and testing (HCT) services are both a critical prevention and treatment tools in controlling HIV epidemics. Within PMTCT and HCT program emphasis is placed on the importance of HIV status disclosure among HIV infected clients, particularly their sexual partners.¹

Disclosure of HIV status to sexual partner is an important prevention goal emphasized by the WHO and centers for disease control and prevention in their protocols for HIV testing and counseling. Besides it offers a number of important benefits to the infected individual and the general public.^2–5 Some of potential benefits for the individual and public including increased opportunities for social support, improved access to necessary medical care (antiretroviral treatment), increased opportunities to discuss and implement HIV risk reduction with partners, and increased opportunities to plan for the future, motivating sexual partners to be tested, change bad behaviours, reduce vertical and sexual transmission risk.^7–12

Consequently, Women who disclose their HIV sero-status to their sexual partners may be more likely to participate in programmes for prevention of HIV transmission to their sexual partners as well as to their infants.¹³ in addition, it enables couples to make informed reproductive health choices that may ultimately lower the number of unintended pregnancies among HIV positive women and help them take ARV drugs properly and give it to the new born as recommended by physicians.¹⁴

Despite, all the mentioned benefits, HIV infected women may face a lot of potential risks following disclosure: including loss of economic support, blame, abandonment, physical and emotional abuse, discrimination and disruption of family relationships.^14,15 Fear of the above these risks identified as barriers to disclose their sero-status for immediate partners^16,17 that in turn lead to lost opportunities for the prevention of new infections and ability to access appropriate treatment, care and support services where they are available.^18,19 Despite the availability and scale up of life-saving interventions, in Ethiopia only 24% of pregnant women living with HIV are receiving the medication to prevent mother-to-child transmission of HIV.⁴ Because, the uptake and adherence to PMTCT programmes is difficult for women whose partners are unaware of their HIV status. This study was intended to assess issues of disclosing HIV sero-status among HIV positive pregnant women attending antenatal care in public health centres of Addis Ababa.

Study setting

Institution based cross sectional study was conducted among HIV+ pregnant women attending ANC service in selected public health centres that are providing PMTCT services in Addis Ababa. Addis Ababa is a capital city of Ethiopia. The city covers an area of 530.14 square kilometres that is divided into 10 sub-cities (“Kifle Ketema”) and 100 kebeles with an estimated population of 3,384,569.²⁰ There are about 29 hospitals, 82 health centres, 8 health stations and 116 health posts owned by public and private, of which 5 hospitals, 24 health centres and 8 health posts are governmental.

Inclusion and exclusion criteria

HIV positive pregnant women of age ≥18 years, who attended ANC follow up and undergone HIV counselling, testing and received their HIV test result before one month prior to study were included. However, those who were seriously ill and unable to communicate and those with age of <18 are excluded from the study.

Sample size and sampling procedures

The sample size was computed using Open Epi version 3 (Kelsy, et al) by considering the following assumptions: n=sample size, z=standard normal deviate set at 1.96 (for 95% confidence level), d=desired degree of accuracy (0.05) and by taking the proportion of sero status disclosure from Addis Ababa which was 73%⁵ and design effect of 2.

After identification of 78 HCs providing PMTCT service, health centres are clustered by sub-cities and one health centre was selected from each sub cities by simple random sampling and the sample size was distributed to study population of respective health centres. Finally, a total of 668 pregnant women were selected by systemic random sampling using PMTCT register book as sampling framework. All eligible participants were interviewed.

Data collection and analysis

Data were collected using structured and pre-tested interviewer questionnaire IN Amharic version accommodating: socio-demographic characteristics (age, income, education, religion and occupation), relationship factors (duration of relationship, fear of partner’s reaction and HIV status of partner), barriers to HIV Status disclosure (fear of abandonment, fear of confidentiality, and fear of accusation of infidelity) and Outcome of disclosure (acceptance, understanding, blame and violence). The collected data was cleaned, checked, coded, entered and then analysed by version 20 Statistical Package (SPSS) software. Bivariate and multivariate analysis was carried out to see the effect of each factor. Variables that showed significant association in the bivariate analyses were fitted in to a multiple logistic regression model to identify the independent contribution of each variable for HIV sero-positive status disclosure. Odds ratio with 95% confidence interval was calculated to assess both the association and measure the strength of the association between explanatory and outcome variables. P-Value 0.2 or less was taken as a cut-off point to include the variable in to the final model.

Ethical consideration

Ethical clearance was obtained from ethical review committee of Debre-markos University Medicine and Health science collage. Letter of agreement was obtained to Addis Ababa health bureau and Addis Ababa health bureau approved it to be continued. Informed consent was granted by individual respondent at the time of data collection. Privacy and confidentiality of participants were maintained throughout the study.

Socio demographic characteristics of the participants

A total of 665 pregnant women were interviewed making a response rate of 99%. Among all participants, 328 (49.3%) were in age group of 28-32 years, 228 (34.3%) Amhara by ethnicity, 345(51.9%) were of Orthodox religion, 202 (30.4%) were unable to read and write, 273(41.1%) house wife, 459(69%) were married and house hold income between 600-1600 were 313(47.1%) (Table 1).

Obstetric, Sexual and clinical characteristics of participants

Most pregnant mothers 435(65.4%) have early first trimester pregnancy, 224(33.7%) has ANC follow up more than 3 times, 473 (71.4%) know HIV positive pregnant women transmits the virus to her unborn baby, 505(75.9%) mothers know the existence of HIV transmission intervention, whereas 49(7.4%) mothers didn’t know the benefit of ART drugs.

As Table 2 shows, three hundred eighty (57.1%) claim disclosing their result to anyone could affect ANC follow up, 7(1.1%) mothers didn’t know it might affect or not. Among all participants, 148(22.3%) didn’t use condom because they found it difficult to discuss about condom with their sexual partner while 3(0.5%) found it difficult to put it on or use it properly.

HIV status disclosure

Among all respondents 536 (80.6%) indicated that they have disclosed their result to at least one individual. However; of those who disclosed 234 (35.2%) of women had sex with their partner before telling their result. Respondents reported disclosing most frequently to main partners (51.7%) followed by mother (20.2%), other family members (4.8%) (Table 3).

Reasons for disclosure and/or non-disclosure

The first motivating reason for disclosure of their HIV status reported by participants was seeking support from their partner 102(29.1%).While 64(18.3%) of respondents disclosed their test result to keep free their partner. Having a close relationship (usual to tell him every secret thing), spiritual responsibility and fear of legal accusation were the other motivators of disclosure. On other sides, reasons for non-disclosure among those respondents who did not disclose their test results to their partner, were fear of physically being hurt by partner 170(25.6%), separation/divorce 163(31.8%), fear of labelling as bad person 5 (1.0%), he might be afraid of risk of HIV infection from me 9(1.8%), my partner might get angry with me 16(3.2%), and other reasons depicted in Table 4.

Reaction main partners towards HIV status disclosure among HIV positive women

As represented in Table 5, 25.3% anticipated that their partner would be supportive and actually 27.4% of partners were supportive towards disclosure. However, some of the partners reacted with unwanted reaction such as anger 15(2.3%), confused 131(19.7%) and leave the relationship 1(0.2%). Even though there were eight participants who anticipated physical violence, there was only three individual physically harmed.

Determinants of sero-status disclosure

As shown in Table 6, in bivariate analysis some of the variables were found to be significantly associated with HIV status disclosure of pregnant women. Among socio-demographic characteristics those having smooth relationship with partners and expecting long lasting relationship were significantly associated with disclosure of their status. Whereas educational status, marital status and employment status was not significantly associated. Besides, some of service related factors were found to be associated with disclosure. Participants, who discussed about HIV prior to test, talking about testing together, know partners HIV status and having relationship for more than four years were variables more likely to disclose their result to partners than those who didn’t.

Multiple logistic regressions was employed to control potential confounders. Important variables bivariate P-value 0.2 or less was included to the model. In the multiple logistic regression analysis models two variables were found to be independent predictors of disclosure to a partner (Table 7). Those participants who didn’t know their partners HIV status were 59.1% less likely to disclose their sero-status than those who know their partners result (having seropositive partner) (OR, 0.409, 95%CI, 0.231-0.723). Individuals who have prior discussion about HIV testing with partner were 2.5 times more likely to disclose their status than those who didn’t have discussion previously(OR,2.594,95%CI, 1.474-4.565).

The study focused on identifying factors of HIV status disclosure to sexual partner among HIV positive pregnant women in Addis Ababa public health centres. The overall prevalence of disclosure (told to at least one person) in this study was 80.6%, which is less as compared to findings of study conducted in south west Ethiopia and Hawassa referral hospital (94.5%) and (92.2%) women disclosed their result to at least one person respectively.^16,21 This difference may be due to those studies were carried out among all sero positive clients and among ART clinic customers. Because, whatever the result becomes they accepted it easily than those participants found in this study. However, participants of this research went to clinic to know the health of their unborn child as well as their own and they didn’t intend to be tested if PMTCT protocol not influences them to be tested.

The overall rate of disclosure is in line with study conducted in Uganda in that 83.8% had disclosed their sero-status to at least one person,²² study of South Africa (80.0%) disclosed to one of their family²³ and Kenyan study (83%).²⁴

However it is higher than the rate (59%) found in a study conducted in South African HIV positive pregnant women.² Still much higher than in Tanzania (60%) of those pregnant women interviewed had disclosed to significant others.¹ Similarly it’s quite higher than the finding of study in Southwest Ethiopia (69%).¹⁸ It’s higher than that of study of Zimbabwe (65.9%),¹⁷ also higher than that of Addis Ababa study (75%),⁷ and it’s greater than result of Togo’s study (60.9%).²⁵ The basic predicators of the variation in rate disclosure of this study in relation of the above mentioned ones could be the time of study because some were conducted a decades ago; difference in size of samples; and setting of study.

Despite the encouraging result found in this study, substantial proportion (35.2%) of the disclosures were delayed, these individuals had at least one sexual contact with their untold sexual partner before disclosure. It raises the possibility of transmission risk if condoms were not used and may limit the beneficial aspect of disclosure, making negotiating safer sex difficult and perhaps putting the untold partner at risk of acquiring the infection or risk of re-infection for the couples. This estimate of delayed disclosure is somewhat higher than, reported in South west Ethiopia (14.2%),¹⁶ in Addis Ababa (12.8%);⁷ in Wolidia (29%);¹⁹ in Tanzania (15.1%).²⁶ Though significant number of participants concealed their HIV status for some times after knowing their test results, it may not be surprising due to high sample size of this study in relation to quoted ones because the sample size of our study very huge in comparison to cited findings.

However, In Ethiopia knowing the partner´s HIV status was a facilitator for disclosure^18,16,21,27 and it was observed that knowing partners HIV status and talked about HIV testing prior to test with partner were independent and significant predictors of HIV status disclosure this study. In the presence of high rate of HIV status disclosure, significant proportion (53.4%) of the respondents did not know their partner’s HIV status. The silence of the partners could be either acknowledging that he is already infected or emotional rejection to the partner. This finding is lower than the result of study in Kenya in which 66% reported the partner had not tested or did not know whether he had been tested.⁹ This might be due to participants of our study are directly involved from ANC and that of Kenyan study were enrolled until their postpartum period that may increase recall bias. In contrast the result of this study is much higher that some studies conducted in Addis Ababa (32.7%),⁷ in South west Ethiopia 20.6%,¹⁶ in Axum 12.4%²⁷ did not know their partner's HIV status. The most probable reason for the variation of result could be these studies accommodated both sexes of adult groups who particularly know the status before.

The reasons given for nondisclosures were fear of separation/divorce, fear of being labelled as bad person; he might be afraid of risk of HIV infection from me, my partner might get angry with me, and fear of breach of confidentiality. Indeed, feelings of uncertainty about how partner would react to their status were mentioned by most of the participants. This was in agreement with other studies.¹⁶ This implies that individuals who know their partner’s HIV status at least had a discussion time about HIV testing, and these would help them to anticipate their partner’s reaction towards disclosure.

Besides, discussion with partner before test had been identified as facilitating factor of disclosure of HIV status for their intimate partners.^28–30 Even though it is as such important, 14.5% of participants among discussed did not disclose their result. Consistent with other studies communicating with partner about testing prior to seeking service was found to be a predictor to disclosure.¹⁸ This might help individuals to anticipate partner’s reaction and would give them an opportunity to raise the issue again and tell their result.

In this analysis it was observed that there was high agreement between anticipated and actual positive outcomes of disclosure among participants who anticipated supportive outcome to disclosure while 92% received support and assurance from their partner. From those (14%) anticipated their partner would assure them and in actual terms 21.7% received assurance from their partners. However, some of the partners reacted with unwanted reaction such as anger 2.3%, confused 19.7% and leave the relationship 0.2%.

Even though there were eight participants who anticipated physical violence, there were only three individuals physically harmed. There was high agreement observed between anticipated and actual positive outcome of disclosure those individual who anticipated supportive outcome to disclosure who received support and assurance from their partner. In contrast there was no agreement between anticipated and actual negative outcomes of disclosure.

Finally in this study 2.1% of HIV positive women live in discordant relation and 8.1% of these couples do not mutually know their HIV status. Disclosure has paramount importance in curbing the infection. I suggest that HIV prevention should target HIV status disclosure and further behavioural change. Unless HIV positive individuals mutually know their HIV status it is difficult to use protective methods to prevent further transmission. In addition in this study substantial proportion of HIV infected individuals continue to have unprotected sex. This cross-sectional study is conducted in institutional basis and limits the ideas of those who were in their home during data collection which is considered as limitation of the study.

This study indicated that the outcomes of disclosure are encouraging but it is not that much satisfactory. The rate of HIV positive status disclosure to partner in this study is almost comparable with rate seen in other developing countries in recent years. Knowing partner’s HIV status, couple counselling, discussing with partner about HIV and talking about HIV testing with partner prior to test were found to be main predictors for HIV status disclosure to partner. However, fear of partner’s reaction, anticipated physical violence as a result of disclosure identified as a main barriers to disclosure of their status. Thus, due emphasis should be given to awareness creation and counselling on mutual disclosure, couple communication about HIV testing and legal support for women. Further, more multi-centred research on disclosure is needed to assess the context of disclosure in more detail.

First and for most we give honour to God and next the deepest gratitude could be given to Dr. Tegbar Yegzaw, Mr. Teklu Lemma, and Mr. Kassahun Bedlu for their willingness to encourage and support us through the process of this study. At last but least, our deepest gratitude goes to all who assisted us in providing relevant literature references in particular the Bole 17 health centre delivery ward staffs, mother support groups and librarians in AIDS resource centres.

None.

The authors declare that they have no competing interests.

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