Disclosure amongst adult HIV patients on antiretroviral therapy in Port Harcourt,Nigeria

Abstract

HIV transmission is still a public health concern in sub-Saharan Africa; disclosure is an effective tool for its prevention, contact tracing and treatment. We aimed to evaluate the disclosure behaviours of adult HIV-positive patients receiving antiretroviral therapy (ART) in University of Port Harcourt Teaching Hospital, and identify major challenges to disclosure in a bid to develop ways to improve this practice in the environment. Patients receiving ART in this centre were interviewed using an interviewer-administered questionnaire. A total of 250 clients were interviewed over three months. A majority of the patients were tested on account of ill health 143 (57.2%). They commenced ART within 8 ± 15.4 SD months of presentation. The mean period before disclosure was 4.75 ± 12.8 SD months of diagnosis. Thirty-six (14.4%) of the respondents had not disclosed their HIV status; the major barrier to disclosure was stigmatisation in 19 (36%).

Keywords

Disclosure partner notification HIV AIDS diagnosis sero-discordant Africa

Introduction

HIV infection and transmission still remains an important health concern in sub-Saharan Africa despite concerted effort by governmental and non-governmental organisations to control the transmission of the disease and to improve the quality of life of those already infected.

Voluntary counselling and testing for HIV affords individuals the opportunity to get correct information about the disease, modalities of care and where to go to obtain care. It also provides information for the non-infected individuals on how to stay negative and prevent exposure to HIV.

Sexual partner notification (PN) is an important public health strategy for the control of sexually transmitted infection (STI).¹ Disclosure amongst HIV patients and their partners serves many goals; first it may motivate the sexual partner to seek testing, change in behaviour and ultimately reduce the transmission of HIV. It also affords the individual the opportunity for social support, improved and prompt access to care, increased opportunity to discuss and implement HIV risk reduction and more opportunities to plan for the future with the informed partner.²

Despite the benefits of disclosure, this strategy has not been effectively utilised in some settings because of the concerns regarding privacy protection, social harm and apparent lack of community and political support.³ As a result, there have been significant reports of domestic violence and abuse amongst women that disclosed their HIV-positive status to their partners.^4,5 The most common barriers to status disclosure have been fear of loss of economic support, rejection and discrimination, fear of domestic violence, fear of accusation of infidelity and disappointment and upset by family members.² These notwithstanding, some studies have shown that PN can be effective in sub-Saharan Africa, and it is a useful tool for rapidly and efficiently expanding the HIV treatment and prevention effort in many communities.³

This study therefore aims to evaluate the disclosure-behaviours of adult HIV-positive patients receiving antiretroviral therapy (ART) in this University of Port Harcourt Teaching Hospital, Rivers State, Nigeria, and to identify major challenges in the status disclosure process in a bid to develop or adopt new interventions to improve this practice in our own environment.

Method

People diagnosed and treated for HIV at the ART clinic in the University of Port Harcourt Teaching Hospital were recruited for this study. This hospital serves as an Institute for Human Virology – Nigeria (IHVN) supported HIV testing and treatment centre. It is a 1000-bed facility and provides ART and care for about 11,000 clients, coming from Port Harcourt and its environs. HIV screening and diagnosis were done using rapid kits (Determine HIV I and II and Stat Pak), according to the WHO standard for low-resource countries.⁶ The clients provided consent, and the questionnaire was administered by the doctors in the research team. Patients provided information on their age, gender, number of sexual partners before and after diagnosis, partner’s status, and time of diagnosis, time of disclosure, who they disclosed to and we also sought to know if the patients saw disclosure as an important tool for transmission reduction.

The data were analysed using SPSS 17.0.

Result

A total of 250 participants were interviewed during this study; 180 (72%) of them were women, 179 (66.4%) were married. The median age was 35 years (interquartile range, 31–42 years). The majority (173 [69.2%]) of the respondents were between 20 and 39 years of age as shown in Figure 1. Eighty-four (33.6%) of the respondents had received tertiary education (Table 1), and most of the respondents were self-employed.

Figure 1.

Age distribution of the respondents.

Table 1.

Demographic characteristics of the 250 respondents.

Demographics	Frequency (%)
Age (Mean ± SD)	37.04 ± 8.8
Gender
Female	180 (72.0)
Male	70 (28.0)
Educational status
Primary	50 (20.0)
Secondary	112 (44.8)
Tertiary	84 (33.6)
None	4 (1.6)
Route of diagnosis
VCCT	52 (20.8)
ANC	35 (14.0)
Ill health	143 (57.2)
Number of sexual partners before diagnosis
0–5	226 (90.0)
6–10	10 (5.6)
>10	2 (0.8)
Not specified	8 (3.6)

Ten (4%) were involved in exposure-prone jobs, e.g. nursing, hairdressing and catering. A majority of the patients were tested on account of ill health 143 (57.2)%, while a smaller percentage came for Voluntary Counselling and Confidential Testing (VCCT; 52 [20.8%]); an even smaller group (10; 4%) came for testing as a result of a partner disclosing their HIV-positive status. Thirty-five (14%) of the women were diagnosed during Antenatal Care (ANC) and only 22 (62.9%) of them had PMTCT as in Figure 2.

Figure 2.

Chart showing reasons for which respondents had HIV testing.

The respondents reported having a mean of 2.24 ± 2.39 SD, (a range of 0–15) sexual partners before diagnosis and a mean of 0.89 ± 0.831 SD (0–7) after diagnosis. There was a statistically significant reduction in the number of sexual partners after diagnosis of HIV in the respondents, (p < 0.001).

There was a high level of sero-discordance amongst sexual partners; 71 (28.4%) were sero-discordant couples. However, 85 (34%) of the patients reported not knowing the HIV sero-status of their sexual partners. Of the 71 sero-discordant couples, 10 (14.1%) had not disclosed their status to their partners. The respondents were more likely to disclose their status to family members (parents and siblings) in 128 (60.1%), spouses in 97 (45.4%), friends in 16 (7.5%) and pastors in 11 (5.2%).

From the study, 36 (14.4%) of the respondents had not disclosed their HIV status to anyone. The major reasons for non-disclosure in this group were fear of discrimination in 19 (52.8%), feeling of shame in 12 (33.3%), marital insecurity in 4 (11.1%) and 2 (5.5%) partner violence. Some of this group of respondents, 10 (27.8%) felt their partners may be willing come for testing if notified.

There was no statistically significant difference between the disclosure behaviour of the male and female respondents, p = 0.745, χ²= 0.105, OR = 1.14; (Table 2). The majority of the respondents who did not disclose their status were married people (27; 75%), and had not attained tertiary education (30; 83.3%). Some of the respondents in this group (19; 52.7%) did not use a condom regularly.

Table 2.

Association between gender of respondents and disclosure behaviour.

	Disclosure status
	Yes	No	Total
Gender
Males	61	9	70
Females	154	26	180
Total	215	35	250
	X²= 0.105	p = 0.745	OR = 1.14

Many of the respondents (141; 56.4%), did not know how they got the infection; however, 79 (31.6%) admitted that it most likely was from casual sex. Most (229; 91.2%) agreed that unsafe sex can lead to the transmission of HIV and 180 (73.2%) of the respondents believed that disclosure and PN will help to reduce the transmission of HIV.

Discussion

PN has long been a cornerstone to control the spread of STI and HIV.⁷ It is an important prevention goal emphasised by the WHO⁸ and CDC⁹ in their protocols for HIV testing and counselling. PN serves three main purposes – epidemiology, ethics and case-finding.¹⁰ The epidemiological component of this tool helps the health worker to track the socio-geographic scope of the spread or transmission of HIV; the health worker also fulfils his ethical role as he counsels individuals who are exposed of their risk, and the last component which is case-finding that provides a means of identifying, diagnosing and treating people who have come in contact with infected individuals.

Disclosure is an important tool in HIV control as it may help to encourage behavioural change. It is the role that the person infected with HIV plays to help reduce the burden of HIV in his community. It is evident from literature that risk behaviours change dramatically among couples where both partners are aware of their HIV status.¹¹

In spite of the fact that disclosure is a very important tool in the prevention of transmission of HIV, there are some potential risks from disclosure. Especially, for HIV-infected women, there is the risk of losing economic support, blame, abandonment, physical and emotional abuse, discrimination and disruption of the family relationship.¹² In our study, the reasons were similar, which include fear of discrimination, shame and marital insecurity.

In this study, it took the clients a mean duration of 4.75 ± 12.8 SD months (interquartile range of 1 to 2 months) to disclose their status to anyone.

The potential for social harm is a key concern in PN programmes.³ Disclosure was mostly to spouses (in married couples), family members (parents and siblings) and friends. Some, 21 (8.4%), disclosed to their other sexual partners, family members and not to their spouses; this is similar to a report from Jos, Nigeria.¹³ This may be due to the concern that if their spouses were aware of their HIV status, they may become violent, physically abusive and may disrupt the family relationship.

In this study, 14.4% had not disclosed their status; this is lower than a report from a centre in Lagos, Nigeria 32.2%.¹⁴ This would be a major cause for transmission of the virus amongst sero-discordant couples and a major cause of resistance to ART for those who have commenced treatment. As seen in this study, more than half of those who have not disclosed their status do not use condoms during sexual intercourse; this is also a risk for HIV transmission and resistance to ART for the person on therapy.

Prevention of transmission of HIV in sero-discordant partnerships is an important HIV prevention strategy. In our study, 71 (28.4%) of the respondents were sero-discordant. This is slightly lower than the reports from East and Southern Africa.¹⁵ The majority of the people who reported discordance were women (27; 75%). This is in support of the result of a meta-analysis by Eyawo et al.¹⁶ in India.

There is need, as is evident from this study, to adopt more proactive measures towards initiation of disclosure. It can be introduced during the pre-test counselling, after diagnosis and by returning to the issue on a regular basis during follow-up counselling.¹⁷ There is also the need to train more health workers in the process of PN, especially in regions with high prevalence of HIV and a low disclosure rate as seen in this study.

Conclusion

Disclosure is an effective tool for prevention, contact tracing and treatment. Our results underscore the need to improve PN and disclosure among adults HIV patients, more so those that are on ART this will help to reduce risky behaviours and thus reduce transmission of HIV especially among sero-discordant couples.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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