Antiretroviral therapy availability associated with increased HIV disclosure

Antiretroviral therapy availability and HIV disclosure to spouse in Rakai, Uganda: a longitudinal population-based study.

Haberlen SA, Nakigozi G, Gray RH, Brahmbhatt H, Ssekasanvu J, Serwadda D, Nalugoda F, Kagaayi J, Wawer MJ. J Acquir Immune Defic Syndr. 2015 Jun 1;69(2):241-7. doi: 10.1097/QAI.0000000000000600.

Background: A decade after the rollout of antiretroviral therapy (ART) in sub-Saharan Africa, the effects of this structural change on social aspects of HIV, such as rates of HIV disclosure to partners, remain largely unmeasured. We evaluated whether the introduction of ART was associated with disclosure of HIV diagnosis to spouses in Rakai, Uganda, using longitudinal, population-based data.

Methods: We identified individuals in marital/cohabitating unions who were newly diagnosed with HIV in Rakai Community Cohort Study surveys between 2000 and 2008, where ART was introduced in mid-2004. Using discrete-time survival analysis, we assessed the hazard of self-reported HIV disclosure to spouse after diagnosis pre-ART and post-ART rollout, adjusting for individual and union characteristics. Disclosure in the ART period was further stratified by ART initiation.

Results: The analysis included 557 married adults, 264 of whom were diagnosed with HIV before ART was available (2000-2004), and 293 diagnosed after ART was introduced (2005-2008). The cumulative incidence of self-reported disclosure was 75.2% in the post-ART period, compared with 58.3% before ART availability [P < 0.001, adjusted hazard ratio: 1.46 (95% confidence interval: 1.16 to 1.83)]. In the post-ART period, observed disclosure rates were 39% (72 of 184) among those not in HIV care, 65% (82 of 126) among those in pre-ART care, and 85% (64 of 75) among persons on ART (P < 0.001).

Conclusions: Treatment availability and use, especially ART initiation, was associated with increased self-disclosure of HIV diagnosis to partners. ART access may facilitate the prevention of transmission to uninfected partners and linkage to treatment for infected couples.

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Editor’s notes: For effective prevention of sexual transmission of HIV, it is important that individuals who are HIV positive disclose their status to their spouses and other sexual partners. However, anticipation of possible negative consequences of disclosure of HIV positive status can be a significant barrier to disclosure. Access to antiretroviral therapy (ART) has increased considerably in low- and middle-income countries since 2003. Longitudinal data on the effect of ART availability and HIV disclosure in general African populations is limited. This study investigated whether increased access to ART has had an impact on disclosure of newly diagnosed HIV infection to spouses by men and women in stable unions in Rakai, Uganda. Although the study population was relatively small, the investigators demonstrated availability of ART was associated with increased self-disclosure of HIV infection to a spouse. It is possible that some disclosures may have been unintended, as it would be difficult to conceal treatment, including frequent clinic visits, from a spouse or co-habiting partner. Even so, the increase in disclosures among both men and women was significant. Furthermore, the desire to access ART was documented as a motivating factor to disclose HIV diagnosis. Although a relatively high rate of disclosure was observed in this study, a substantial subset of adults had not shared their HIV diagnosis with their partners. This highlights the importance of supportive models of care, in addition to ART, to facilitate safe disclosure of HIV infection.      

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