# Magnitude of Prompt HIV-Seropositive Status Disclosure to Partner and Associated Factors among Adult Clients on ART at Holeta Health Center, Central Ethiopia, 2020

Authors: Guta Kebede; Adugna Dufera; Tufa Kolola; Teka Girma; Daniel Belema
Journal: Advances in Public Health
 (2022)

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## Abstract

Background. Disclosure of HIV-seropositive status is important for HIV prevention and maintenance of health for people living with HIV and the community at large. Most of the disclosure in our country and elsewhere were after putting the partner at risk of contracting HIV/AIDS. This study aimed to assess prompt HIV-seropositive status disclosure to partner and its associated factors among people living with HIV and attending care and treatment at a health center, in central Ethiopia. Methods. A cross-sectional study was carried out from September 15, 2019, to March 15, 2020, among 438 people living with HIV who were more than 18 years old and had sexual partner attending ART clinic at Holeta Health Center, central Ethiopia. The data were collected through face-to-face interviews using a structured questionnaire. The data were entered into Epi data version 3.1 and exported to SPSS version 21 for analysis. Descriptive analysis was conducted to determine the magnitude of prompt HIV seropositive status disclosure to partner and multivariable logistic regression analysis was computed to identify factors associated with prompt HIV seropositive status disclosure. Results. A total of 434 study participants took part in this study giving a response rate of 99%. Three hundred thirteen (72.1%) respondents disclosed their seropositive status to their partners promptly. Being married (AOR = 2.99, 95% CI = 1.09–8.21), less than 24-months duration on treatment (AOR = 0.185, 95% CI = 0.076–0.454), discouraging response of partner about the test (AOR = 0.34, 95% CI = 0.0149–0.780), knowing serostatus of one’s own partner (AOR = 10.42, 95% CI = 4.19–25.19), and using condom always with a partner (AOR = 11.44, 95% CI = 3.37–38.79) were factors significantly associated with prompt HIV seropositive status disclosure to partner. Conclusion. The proportion of prompt disclosure of HIV seropositive status to partner was low when compared to the overall partner disclosure rate. Being in marriage, less than 24 months duration on treatment, discouraging response of partner about the test, knowing serostatus of one’s partner, and using condom always with a partner were identified as predictors of prompt HIV seropositive status disclosure to partner.


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## Body

## 1. Background

Globally, 38 million people were living with HIV and 1.7 million of them were new infections in 2019. An estimated 32.2 million adults aged 15–49 years worldwide are living with HIV [1, 2]. These increments in the number of patients resulted because of continuing new infections, living longer with HIV. and population growth [2]. In 2019, sub-Saharan Africa, the hardest-hit region, is home to nearly 54% of people living with HIV, 1.1 million children living with HIV, 300,000 AIDS-related deaths, and 730,000 new infections [3]. Ethiopia also has a large and very vulnerable population that there were more than half-million (671,941) HIV-positive population, 14,405 new HIV infections, and 24, 813 deaths in 2016 [4]. A common concern within HIV prevention is that HIV-positive individuals do not disclose their HIV status to their partners who are thus at increased risk for HIV infection [5]. HIV disclosure to sexual partners is an important HIV prevention strategy and is associated with a reduced risk of HIV transmission by 18% to 41% [6]. HIV discordance among couples considerably contributes to the HIV epidemic and represents an unmet HIV prevention need in sub-Saharan Africa. In East Africa, less than 10% of HIV-seropositive individuals know their partners’ status and only about 20% of the couples know that they are living in a discordant relationship [7–9]. On-time disclosure makes the partner either look to be diagnosed and adhere to ART or to be prevented from infection or reinfection with new strains [6]. It also helps the couples to discuss their reproductive health and their future of having a child which would have great success in reducing vertical transmission of HIV/AIDS [10, 11]. Furthermore, intervention programs will be in accordance with the scenarios as a seroconcordant should be put for the same interventions (ART or prevention packages) while in the case of serodiscordant, the negative partner should be engaged in effective HIV prevention (condom and PrEP) and test while the other should initiate ART [12].Apart from the overall HIV-seropositive disclosure status [13–17], the study finding specifically on prompt HIV-seropositive disclosure status to the sexual partner is limited in Ethiopia including our study area. Therefore, this study aimed to assess the proportion of prompt HIV-seropositive status disclosure to their partner and associated factors among adult clients on ART at a health centre, in central Ethiopia.


## 2. Methods

### 2.1. Study Area and Period

The study was carried out in Holeta Health Centre, central Ethiopia from September 2019 to March 2020. Holeta Health Centre is found in Holeta town which is located 29 km to the west of Addis Ababa. There are 2 public health centres, 8 health posts, one primary hospital under construction, and 14 private clinics in the town. Holeta Health Center was the only antiretroviral therapy site in the town.The health centre (HC) ART clinic started the provision of antiretroviral drugs in 2007 and currently gives follow-up and treatment services for about 1079 HIV/AIDS patients out of which 996 were adults.


### 2.2. Study Design and Study Population

A cross-sectional study design was carried out. All people living with HIV/AIDS (PLWHA) attending the ART clinic in Holeta Health Center were our source population. All PLWH on ART at Holeta HC ART clinic who were above 18 years old and had a sexual partner were the study population (n = 438) for this study.


### 2.3. Data Collection Tool, Quality Control, and Measurements

A structured, interview-administered questionnaire was prepared in English and translated into Afan Oromo. The tool was adapted from the previous literature in different parts of the world and modified according to the local context [14, 18–20]. Two nurses were recruited as data collectors. The data collectors were then trained for one day on how to collect data before the actual data collection started. Moreover, a pretest was performed on 5% of the study participants and the necessary adjustment was made on some items of the questionnaire based on pretest results.


### 2.4. Operational Definition

Prompt disclosure: disclosing HIV-positive status to partner on the day of diagnosis before having sexual intercourse with a partner.Seroconcordant is a couple with both partners having the same result (HIV-positive or HIV-negative).Serodiscordant is a couple with one partner HIV-positive and the other HIV-negative.


### 2.5. Data Processing and Analysis

Before data entry, the questionnaire was checked for its completeness. The data were entered into Epi data version 3.1 and then exported to SPSS version 21 for further analysis. The descriptive analysis such as the frequency with its percentage and mean were calculated. The bivariate binary logistic regression analysis was used to identify associations between variables. Effects of confounders were controlled through multivariable logistic regression analysis entering variables in similar categories such as sociodemographic, magnitude, and reasons of nondisclosure characteristics together in their order. The variables that had ap value ≤ of 0.05 in the bivariate analysis were transferred to multivariable logistic regression models. The adjusted odds ratio with its 95% confidence interval was computed for variables entered into the multivariable model. Variables that had a p value <0.05 were considered statistically significant in a multivariable model.


## 2.1. Study Area and Period

The study was carried out in Holeta Health Centre, central Ethiopia from September 2019 to March 2020. Holeta Health Centre is found in Holeta town which is located 29 km to the west of Addis Ababa. There are 2 public health centres, 8 health posts, one primary hospital under construction, and 14 private clinics in the town. Holeta Health Center was the only antiretroviral therapy site in the town.The health centre (HC) ART clinic started the provision of antiretroviral drugs in 2007 and currently gives follow-up and treatment services for about 1079 HIV/AIDS patients out of which 996 were adults.


## 2.2. Study Design and Study Population

A cross-sectional study design was carried out. All people living with HIV/AIDS (PLWHA) attending the ART clinic in Holeta Health Center were our source population. All PLWH on ART at Holeta HC ART clinic who were above 18 years old and had a sexual partner were the study population (n = 438) for this study.


## 2.3. Data Collection Tool, Quality Control, and Measurements

A structured, interview-administered questionnaire was prepared in English and translated into Afan Oromo. The tool was adapted from the previous literature in different parts of the world and modified according to the local context [14, 18–20]. Two nurses were recruited as data collectors. The data collectors were then trained for one day on how to collect data before the actual data collection started. Moreover, a pretest was performed on 5% of the study participants and the necessary adjustment was made on some items of the questionnaire based on pretest results.


## 2.4. Operational Definition

Prompt disclosure: disclosing HIV-positive status to partner on the day of diagnosis before having sexual intercourse with a partner.Seroconcordant is a couple with both partners having the same result (HIV-positive or HIV-negative).Serodiscordant is a couple with one partner HIV-positive and the other HIV-negative.


## 2.5. Data Processing and Analysis

Before data entry, the questionnaire was checked for its completeness. The data were entered into Epi data version 3.1 and then exported to SPSS version 21 for further analysis. The descriptive analysis such as the frequency with its percentage and mean were calculated. The bivariate binary logistic regression analysis was used to identify associations between variables. Effects of confounders were controlled through multivariable logistic regression analysis entering variables in similar categories such as sociodemographic, magnitude, and reasons of nondisclosure characteristics together in their order. The variables that had ap value ≤ of 0.05 in the bivariate analysis were transferred to multivariable logistic regression models. The adjusted odds ratio with its 95% confidence interval was computed for variables entered into the multivariable model. Variables that had a p value <0.05 were considered statistically significant in a multivariable model.


## 3. Results

A total of 438 study subjects were recruited for this study, of which 434 responded making a response rate of 99%. The mean age of the respondents was 39 years with SD ± 10.03 years. Slightly more than half of the respondents (229, 52.8%) were females. Concerning occupational status, 120 (27.6%) of the respondents were daily laborers while 46 (10.6%) were government employees. Out of four hundred thirty-four respondents, 95 (21.9%) had completed secondary education while 172 (39.6%) were not educated (Table1).Table 1
Sociodemographic characteristics of adult clients on ART at Holeta Health Center, central Ethiopia, 2020.
VariableCategoriesFrequencyPercentSexMale20547.2Female22952.8Age18–24184.125–29429.730–357116.4>3530369.8ReligionOrthodox29367.5Muslim61.4Wokefata61.4Protestant12929.7EthnicityOromo33777.7Amhara7717.7Tigre133Gurage71.6Marital statusSingle235.3Married34479.3Divorced419.5Widowed173.9Separated92Educational statusUnable to read and write17239.6Primary school12929.7Secondary school9521.9College and above388.8ResidenceRural11426.3Urban32073.7Income<1500 ETB27663.6≥1500 ETB15836.4OccupationGovernment employee4611Merchant5412.4Housewife10925.1Daily laborer12027.6Private employee266.0Farmer6715.4Other∗122.8∗NGO employed, students, and prisoners.The overall seropositive status disclosure rate to sexual partner was 378 (87.1%). Prompt HIV-seropositive status disclosure to sexual partner was 313 (72.1%). However, 65 (17.2%) of the study participants disclosed their seropositive status after committing sexual intercourse (Table2).Table 2
Magnitude of prompt disclosure to partner among clients on ART at Holeta Health Center, central Ethiopia, 2020.
VariablesCategoriesFrequencyPercentDid you tell your partner that you were living with HIV any time before sexual intercourse?Yes31372.1No12127.9If no, did you tell your partner that you were living with HIV after sexual intercourse?Yes6517.2No5612.9Did your partner currently know that you are HIV-positive?Yes37887.1No5612.9


### 3.1. Reasons for Prompt Disclosure

The main reasons for prompt disclosure of HIV-seropositive status to sexual partner were feeling of obligation to tell the partner (56.8%), not wanting to put the partner at more risk (22.6%), and letting others learn from (7.7%) (Table3).Table 3
Reason for disclosure and nondisclosure by the client on ART at Holeta Health Center, central Ethiopia, 2020.
Variables = 434CategoryFrequencyPercentReasons for not disclosed promptly/not disclosed totallyFear of abandonment4033Fear of stigma or rejection3126Fear of break-in confidentiality2621Other∗2420Reason for disclosing your HIV-seropositive status to partner promptlyI felt obligated to tell this person17856.8I did not want to risk anymore7122.6To let others learn from247.7Other∗∗4012.6Is it your duty to disclose your seropositive status to this partner?Yes26160No17340∗Fear of accusation of infidelity, client skill, and psychology;∗∗Religious motives, to adhere to treatment.


### 3.2. Factor Associated with Prompt HIV-Seropositive Status Disclosure

In bivariate analysis, educational status, relationship duration, marital status, duration of treatment, telling partner when went to get test service, response of partner about the test, knowing serostatus of own partner, and frequency of condom use with the partner were found significant atp value <0.05. After adjusting variables in the multivariate logistic regression analysis, marital status, duration of treatment, response of partner about the test, knowing serostatus of own partner, and frequency of condom use with the partner were significantly associated with prompt HIV-seropositive status disclosure at a p value <0.05.Respondents in marriage were about 3 times more likely to disclose their HIV-positive status to their partner promptly as compared to respondents out of marriage (AOR = 2.99, 95% CI: 1.09, 8.21). Respondents whose duration of treatment was <24 months were 81% less likely to disclose their HIV-positive status to their partner promptly as compared to respondents >24-months duration of treatment (AOR = 0.185, 95% CI: 0.076, 0.454). Respondents who were discouraged about the test by their partner were 66% less likely to disclose their HIV-positive status to their partners promptly as compared to respondents who were encouraged about the test by their partners (AOR = 0.341, 95% CI 0.0149, 0.780). Respondents who had known serostatus of their partner were 10 times more likely to disclose their HIV-positive status to their partner promptly as compared to those who had not known serostatus of their partners (AOR = 10.42, 95% CI 4.19, 25.19). Respondents who had used condoms always with their partners were 11 times more likely to disclose their HIV-positive status to their partner promptly as compared to those who had never used condoms (AOR = 11.44, 95% CI 3.37, 38.79) (Table4).Table 4
Factor associated with prompt HIV-seropositive status disclosure to the partner among clients on ART at Holeta Health Center, central Ethiopia, 2020.
VariablesAlternativePrompt disclosureCOR (95% CI)AOR (95% CI)p valueYesNoEducational statusUnable to read and write1066611Primary school98311.97 (1.18, 3.27)0.62 (0.25, 1.52)0.29Secondary school81143.60 (1.89, 6.87)0.50 (0.14, 1.80)0.28College and above28101.74 (0.80, 3.82)0.65 (0.18, 2.37)0.51Relationship duration<48 months200901≥48 months113311.64 (1.03, 2.62)1.581 (0.66, 3.78)0.3Marital statusOut of marriage573311In marriage256881.68 (1.03, 2.76)2.99 (1.09, 8.21)∗0.03Duration on treatment≥24 months2217311<24 months92480.63 (0.41, 0.981)0.18 (0.08, 0.45)∗0.001Did you tell your partner when went to get tested?No1316711Yes182541.72 (1.13, 2.63)1.09 (0.54, 2.22)0.79Response of your partnerEncouraging282611Neutral10120.77 (0.29, 2.09)0.60 (0.17, 2.09)0.42Discouraging40780.48 (0.25, 0.92)0.34 (0.15, 0.78)∗0.001Knowing serostatus of own partnerNo1929711Yes121242.55 (1.54, 4.20)10.42 (4.19, 25.91)∗0.001Frequency of condom use with partnerNever used622711Always101133.38 (1.62, 7.04)11.44 (3.37, 38.79)∗0.001Some times150810.81 (0.48, 1.36)0.98 (0.39, 2.48)0.97


## 3.1. Reasons for Prompt Disclosure

The main reasons for prompt disclosure of HIV-seropositive status to sexual partner were feeling of obligation to tell the partner (56.8%), not wanting to put the partner at more risk (22.6%), and letting others learn from (7.7%) (Table3).Table 3
Reason for disclosure and nondisclosure by the client on ART at Holeta Health Center, central Ethiopia, 2020.
Variables = 434CategoryFrequencyPercentReasons for not disclosed promptly/not disclosed totallyFear of abandonment4033Fear of stigma or rejection3126Fear of break-in confidentiality2621Other∗2420Reason for disclosing your HIV-seropositive status to partner promptlyI felt obligated to tell this person17856.8I did not want to risk anymore7122.6To let others learn from247.7Other∗∗4012.6Is it your duty to disclose your seropositive status to this partner?Yes26160No17340∗Fear of accusation of infidelity, client skill, and psychology;∗∗Religious motives, to adhere to treatment.


## 3.2. Factor Associated with Prompt HIV-Seropositive Status Disclosure

In bivariate analysis, educational status, relationship duration, marital status, duration of treatment, telling partner when went to get test service, response of partner about the test, knowing serostatus of own partner, and frequency of condom use with the partner were found significant atp value <0.05. After adjusting variables in the multivariate logistic regression analysis, marital status, duration of treatment, response of partner about the test, knowing serostatus of own partner, and frequency of condom use with the partner were significantly associated with prompt HIV-seropositive status disclosure at a p value <0.05.Respondents in marriage were about 3 times more likely to disclose their HIV-positive status to their partner promptly as compared to respondents out of marriage (AOR = 2.99, 95% CI: 1.09, 8.21). Respondents whose duration of treatment was <24 months were 81% less likely to disclose their HIV-positive status to their partner promptly as compared to respondents >24-months duration of treatment (AOR = 0.185, 95% CI: 0.076, 0.454). Respondents who were discouraged about the test by their partner were 66% less likely to disclose their HIV-positive status to their partners promptly as compared to respondents who were encouraged about the test by their partners (AOR = 0.341, 95% CI 0.0149, 0.780). Respondents who had known serostatus of their partner were 10 times more likely to disclose their HIV-positive status to their partner promptly as compared to those who had not known serostatus of their partners (AOR = 10.42, 95% CI 4.19, 25.19). Respondents who had used condoms always with their partners were 11 times more likely to disclose their HIV-positive status to their partner promptly as compared to those who had never used condoms (AOR = 11.44, 95% CI 3.37, 38.79) (Table4).Table 4
Factor associated with prompt HIV-seropositive status disclosure to the partner among clients on ART at Holeta Health Center, central Ethiopia, 2020.
VariablesAlternativePrompt disclosureCOR (95% CI)AOR (95% CI)p valueYesNoEducational statusUnable to read and write1066611Primary school98311.97 (1.18, 3.27)0.62 (0.25, 1.52)0.29Secondary school81143.60 (1.89, 6.87)0.50 (0.14, 1.80)0.28College and above28101.74 (0.80, 3.82)0.65 (0.18, 2.37)0.51Relationship duration<48 months200901≥48 months113311.64 (1.03, 2.62)1.581 (0.66, 3.78)0.3Marital statusOut of marriage573311In marriage256881.68 (1.03, 2.76)2.99 (1.09, 8.21)∗0.03Duration on treatment≥24 months2217311<24 months92480.63 (0.41, 0.981)0.18 (0.08, 0.45)∗0.001Did you tell your partner when went to get tested?No1316711Yes182541.72 (1.13, 2.63)1.09 (0.54, 2.22)0.79Response of your partnerEncouraging282611Neutral10120.77 (0.29, 2.09)0.60 (0.17, 2.09)0.42Discouraging40780.48 (0.25, 0.92)0.34 (0.15, 0.78)∗0.001Knowing serostatus of own partnerNo1929711Yes121242.55 (1.54, 4.20)10.42 (4.19, 25.91)∗0.001Frequency of condom use with partnerNever used622711Always101133.38 (1.62, 7.04)11.44 (3.37, 38.79)∗0.001Some times150810.81 (0.48, 1.36)0.98 (0.39, 2.48)0.97


## 4. Discussion

The proportion of prompt HIV-seropositive status disclosure to partner is 72.1% (95% CI: 67.7–76.7) which is higher than the studies conducted in Mekele Hospital (58%) [13] and Sagamu of Nigeria (49.3%) [21]. These differences may be due to differences in study periods and study areas. In the study conducted in Ambo, 84% of the participants disclosed their HIV-seropositive status immediately after diagnosis which is higher than the finding from the current study [22]. This could be because the study conducted in Ambo reported the disclosure to partner or other family members.Study participants who were in marriage were about 3 times more likely to disclose promptly to their sexual partners compared with their counterparts which is consistent with studies conducted in Ambo Hospital [22] and Axum [23], Ethiopia. Respondents who were on treatment for less than 24 months were 81% less likely to disclose their HIV-positive status to partner promptly as compared to respondents who stayed ≥24 months duration of treatment which is agreed with studies conducted in Mekele [17] and Ambo Hospital [22]. This may be since the client stayed longer on HAART treatment and was counselled repeatedly to become stable, assured more, and become more comfortable which can increase their social relationship and disclosure. This study showed that respondents who were discouraged by their partner when they asked about their need for a test were 66% less likely to disclose their HIV-positive status to their partner promptly. This finding is in line with a study conducted in Kemissie, northern Ethiopia [15]. This might be due to the fact that discussing HIV/AIDS openly and test results with a partner might help the individual to be strong to disclose their result.Furthermore, knowing the serostatus of their partner is significantly associated with prompt HIV-seropositive status disclosure to their partner. Respondents who knew the serostatus of their partner were more likely to disclose promptly when compared with respondents who did not know the serostatus of their partners. A consistent finding was reported by other studies conducted in Jimma [18], Hawassa [14], Mekele [13], Ambo [22], Axum [23], Kemissie [15], and Bale [16].Similarly, respondents who had always used a condom with their partner were 11 times more likely to disclose their HIV-seropositive status to their partner promptly as compared to those who had never used a condom. This may be due to the fact that using condoms regularly is safe for partners and as far as the partner was not put at risk of getting HIV-positive, disclosing may not be frustrating so that the one who disclose may not feel guilt. The finding was in line with studies conducted in Addis Ababa [24].


### 4.1. Limitation and Strength of the Study

As far as a cross-sectional study is a snapshot, respondents were expected to remember information retrospectively at that moment. Recall and interviewer bias were the potential limitations of this study. However, several scientific procedures have been employed to minimize the possible effects. To reduce the recall bias, for instance, only about the recent partner was asked for the respondents frequently changed their partner. The study was also cost-effective and versatile.


## 4.1. Limitation and Strength of the Study

As far as a cross-sectional study is a snapshot, respondents were expected to remember information retrospectively at that moment. Recall and interviewer bias were the potential limitations of this study. However, several scientific procedures have been employed to minimize the possible effects. To reduce the recall bias, for instance, only about the recent partner was asked for the respondents frequently changed their partner. The study was also cost-effective and versatile.


## 5. Conclusion and Recommendation

The proportion of prompt disclosure of HIV seropositive status to partners was low as compared to the overall partner disclosure rate of the national target of the country. Being in marriage, having less than 24-months duration on treatment, discouraging response of partner about the test, knowing serostatus of one’s partner, and using a condom always with a partner were identified as predictors of prompt HIV-seropositive status disclosure to partner. Thus, counsellors and respective health care providers in collaboration with concerned stakeholders should focus on treatment adherence, partner testing, regular condom use, and partners’ open discussion so that they in turn affect the prompt serostatus disclosure among partners.



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