Adolescents, safer sex and HIV-status disclosure in South Africa

Sex and secrecy: how HIV-status disclosure affects safe sex among HIV-positive adolescents.

Toska E, Cluver LD, Hodes R, Kidia KK. AIDS Care. 2015 Dec;27 Suppl 1:47-58. doi: 10.1080/09540121.2015.1071775.

HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of one's HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight hundred and fifty eight HIV-positive adolescents (10-19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers. N = 128 (14.9%) of the total sample had ever had sex, while N = 109 (85.1%) of sexually active adolescents had boy/girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partner's status, and 35.5% had disclosed to their partners. For adolescents, knowing one's status was associated with safer sex (OR = 4.355, CI 1.085-17.474, p = .038). Neither knowing their partner's status, nor disclosing one's HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be ill-equipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex.

Abstract [1]  Full-text [free] access [2]

Editor’s notes: Ninety percent of the world’s adolescents living with HIV, live in sub-Saharan Africa.  Evidence illustrates high levels of condomless sex with other adolescents (27-90%) and low rates of disclosure to sexual partners. Negotiating safer sexual practices is particularly challenging for HIV-positive adolescents, exacerbated by HIV-associated factors, learning and accepting their status, and withholding or disclosing their HIV status to sexual partners. There is a dearth of evidence on associations between disclosure and negotiating safer sexual practices among adolescents. This study examines the extent to which disclosure to, and by, adolescents living with HIV is associated with safer sex.

This mixed-methods study employed an iterative approach whereby preliminary qualitative findings guided quantitative measures, particularly items on disclosure. Emerging quantitative findings framed the thematic focus of qualitative research. The study was conducted in the eastern Cape, South Africa. Some 858 adolescents aged 10-19 years were recruited for the quantitative arm of the study. Some 43 participants were included in the qualitative arm of the study. Data generation methods used were individual interviews, focus group discussions and direct observations.

The findings indicate that among adolescents living with HIV, knowledge of HIV-status was strongly associated with safer sex. Knowing one’s partner’s status or disclosing one’s status was not.  Qualitative findings suggest that fear of rejection, exposure, and stigma discouraged HIV-positive adolescents from disclosing to their partners as a strategy for negotiating safer sex. Disclosure counselling and support from healthcare professionals did not address these challenges. Guidelines on counselling HIV-positive adolescents should focus on promoting safer sex with all sexual partners as a first priority, rather than promoting disclosure to sexual partners. Disclosure counselling for HIV-positive adolescents could also be enhanced by improving patient confidentiality, addressing adolescent fears on the dangers of disclosure and by giving HIV-positive adolescents skills to negotiate safer sex.

Africa [10]
South Africa [11]
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