Discussion

HEALTH POLICY AND ETHICS

Facilitating HIV Disclosure

Facilitating HIV Disclosure Across Diverse Settings: A Review Carla Makhlouf Obermeyer, DSc, Parijat Baijal, MA, and Elisabetta Pegurri, MSc

HIV status disclosure is cen-

tral to debates about HIV be-

cause of its potential for HIV

prevention and its links to pri-

vacy and confidentiality as hu-

man-rights issues.

Our review of the HIV-dis-

closure literature found that

few people keep their status

completely secret; disclosure

tends to be iterative and to be

higher in high-income coun-

tries; gender shapes disclosure

motivations and reactions; in-

voluntary disclosure and low

levels of partner disclosure

highlight the difficulties faced

by health workers; the mean-

ing and process of disclosure

differ across settings; stigmati-

zation increases fears of disclo-

sure; and the ethical dilemmas

resulting from competing

values concerning confidenti-

ality influence the extent to

which disclosure can be facil-

itated.

Our results suggest that

structural changes, including

making more services avail-

able, could facilitate HIV dis-

closure as much as individual

approaches and counseling

do. (Am J Public Health. 2011;

101:1011–1023. doi:10.2105/

AJPH.2010.300102)

THE TOPIC OF HIV STATUS

disclosure is central to debates

about HIV, because of its links to confidentiality and privacy as hu- man-rights issues and its potential role in prevention.1 Disclosure is also considered a way to ‘‘open up’’ the HIV epidemic2 and hence is a crucial step toward ending stigma and discrimination against people living with HIV and AIDS (PLWHA). Recognizing its impor- tance, a number of researchers have reviewed the literature on disclosure by women,3 by men,4 or by parents to children.5 Others have reviewed what is known about the factors associated with disclosure, including the connec- tions among stigma, disclosure, and social support for PLWHA6; the links among disclosure, personal identity, and relationships7; and client and provider experiences with HIV partner counseling and referral.8 We sought to comple- ment existing reviews by including available information on low- and middle-income countries, which are poorly represented in all but 1 of the extant literature reviews, and by focusing on the role of health ser- vices and health care providers in HIV disclosure.

Recently, increased attention to transmission within serodiscordant couples has highlighted the po- tential role of disclosure as a way to encourage prevention.9 More- over, as countries scale up HIV

testing, counseling, and treatment, better evidence is needed to inform laws and policies, particularly re- garding how best to facilitate dis- closure while protecting medical confidentiality. Ongoing debates about mandatory disclosure to partners, health workers’ role in disclosing without patients’ consent, and the criminalization of HIV transmission raise important ques- tions about the place of disclosure in the fight against HIV and about the human-rights dimension of dis- closure policies. These debates also underscore the need for a careful review of the evidence on disclosure, an examination of in- dividual motivations and experi- ences around disclosure, an as- sessment of the role of health workers, and a better understand- ing of the societal determinants and consequences of disclosure in diverse settings.

METHODS

We conducted an electronic search of databases for journal articles and abstracts, focusing on HIV disclosure by adults living with HIV. Disclosure is defined here as the process of revealing a person’s HIV status, whether positive or negative. HIV status is usually disclosed voluntarily by the index person, but it can also be

revealed by others with or without the index person’s consent. We conducted the search in PubMed, PsychINFO, Social Sciences Cita- tion Index, and the regional data- bases of the World Health Orga- nization, including African Index Medicus, Eastern Mediterranean, Latin America, and Index Medicus for South-East Asia Region. The search used the keywords ‘‘disclo- s(ure), notif(ication)’’ and ‘‘HIV or AIDS.’’ The search retrieved a to- tal of 3463 titles published be- tween January 1997 and October 2008. After a scan of titles and abstracts, we retained 231 sources, including 15 abstracts from the 2008 International AIDS Confer- ence and 11 reviews or commen- taries.

We included sources in this re- view if they were original studies or literature reviews that had appeared in peer-reviewed publi- cations and if they reported on the levels or process of disclosure (to whom, when, and how), the de- terminants of and reasons for dis- closure, and the consequences of and incidents associated with dis- closure, such as life events, risk behavior, stigma, and discrimina- tion. Articles that focused exclu- sively on children’s HIV status were excluded, but we refer to children if their parents disclosed to them. We consulted the

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regional databases of the World Health Organization to find arti- cles about resource-limited set- tings. This review also drew on related reviews of the literature on HIV testing, stigma, treatment, and prevention by Obermeyer et al.10,11

Studies published after October 2008 were not included in the tabulations, although they may be cited in the discussion.

Table 1 presents the character- istics of the studies included in this review. Of the 231 articles in- cluded, more than two thirds (157 studies) came from high-income countries, mainly the United States. Most studies in low- and middle-income countries (49 out of 76) were from sub-Saharan Africa. A total of 98 studies were conducted among heterosexual adults of both sexes, 49 specifi- cally among women, and 35

among men who have sex with men, of which 31 were conducted in the United States.

Most of these studies (134 of 231) were based on quantitative surveys, and they provide fre- quencies on different aspects of disclosure. However, a consider- able number (74 studies) used qualitative methods, including in-depth interviews and focus- group discussions, and some (11 studies) combined questionn- aires with qualitative methods, often to explore the relational context of disclosure and how individuals coped with their HIV status.

LEVELS AND PATTERNS OF DISCLOSURE

Table 2 summarizes the results of studies on levels and patterns of

disclosure in general as well as disclosure to specific categories of people, such as sexual partners, family members, and friends. Overall, a striking finding of this review was that the majority of people disclosed their HIV status to someone. The levels of reported disclosure to anyone, as shown in Table 2, ranged mostly from about two thirds to about three fourths of respondents, with a few lower rates in sub-Saharan Africa. Three studies explicitly refered to involuntary disclosure, but the rest were concerned with voluntary disclosure exist, suggesting that most people willingly disclosed their HIV status.

The frequencies summarized in Table 2 indicate that gender dif- ferences in levels and patterns of disclosure exist. Women (as mothers and sisters) were more

frequently mentioned than were men as recipients of disclo- sure. Only a few studies have in- vestigated gender differences in HIV-positive disclosure rates to partners, and the findings have been mixed. Some found no gender differences, as in Ethio- pia103,104 and Mali,105 or higher disclosure rates by HIV-positive men (84%) than HIV-positive women (78%).71 Several found higher rates by women, as in Burkina Faso and Mali,105 South Africa,73 and the United States.17

Regardless of whether there were significant gender differences in disclosure rates, most studies docu- mented substantial gender differ- ences in the contexts of, barriers to, and outcomes of disclosure.

Other differences in disclosure frequency had to do with HIV status and to whom status was

TABLE 1—Characteristics of Studies on Disclosure of HIV Status, January 1997–October 2008

Populations Sampled

Countries

Adults, Both

Genders

Heterosexual

Men Only

Men Who Have

Sex With Men

Women Only,

Including PMTCT

Injection

Drug Users

Parents’ Disclosure

to Children Total

High income

United States 41 6 a

31 a

22 10 23 133

United Kingdom 4 . . . 2 1 . . . . . . 7

Western Europeb 7 . . . . . . . . . 1 2 10

Australia 4 . . . . . . . . . . . . . . . 4

Canada 1 . . . . . . 1 . . . . . . 2

Saudi Arabia 1 . . . . . . . . . . . . . . . 1

Low and middle income

Sub-Saharan Africa 25 . . . 1 20 . . . 3 49

Asia 12 1 . . . 5 2 . . . 20

Eastern Europe 1 . . . . . . . . . . . . . . . 1

Latin America, Caribbean 2 1 1 . . . . . . . . . 4

Total 98 8 35 49 13 28 231c

Note. PMTCT = prevention of mother-to-child transmission. Ellipses indicate that no studies were reviewed from that country or region. aMarks and Crepaz12 includes both homosexual and heterosexual men. bWestern Europe does not include the United Kingdom. cMedley et al.3 covers both Africa and Asia; Grinstead et al.13 covers both Africa and Latin America.

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TABLE 2—Studies (n = 96) on Levels and Patterns of HIV Status Disclosure, January 1997–October 2008

Population (Location) No. of Studies Disclosure to Anybody, % Disclosure to Sexual Partners, % Disclosure to Family, % Disclosure to Friends, %

United States (n = 46)

Adults14–23 10 82 56–81 (casual partners 25;

main partners 74)

70–87 (77–79 to mothers;

47–65 to fathers)

26–88

Parent to children 24–34,a,b

11 30–75 to parents;

32–62 to children

Men 35–36

2 53–60

Women37–45 9 96–100 68–92 60–84 (66–81 to mothers;

25–51 to fathers)

28–83

MSM12,17,46–55,c 12 80–97 54–80 (38-42

casual partners)

50 (37–67 to mothers;

23–47 to fathers)

85

Injection drug users 56,57

2 61–86

Europe (n = 10)

Adults (France, 58–60

Russian Federation, 61

Sweden, 62

United Kingdom 63–65

)

8 85–97 88–97 53–77 57–79

Parent to children (Belgium66) 1 10 to children

Women (United Kingdom67) 1 81

Sub-Saharan Africa (n = 26)

Adults (Burkina Faso,68 Ethiopia,69 Kenya13,d,

Nigeria, 70

South Africa, 71–74

Uganda, 75

Tanzania, 76,77

Zambia 78

)

12 22–96 28–91 (65 by men;

73 by women)

60–75 6–43

Parent to children (South Africa, 79

Uganda 80

) 2 44–50 e

Women (Burkina Faso, 81,82

Côte d’Ivoire, 83

Kenya,84,85 Malawi,86 South Africa,87–89

Tanzania90–92)

12 22–94

(46 HIV + ; 97 HIV–)

17–90 (64 HIV + ;

80 HIV–)

20–22 15

Asia (n = 8)

Adults (China,93 India94–96,f) 4 (35 involuntary;

65 voluntary)

70 (100 by women;

65 by men)

78 7

Men (Taiwan 97

) 1 72

Women (India, 98

Thailand 99

) 2 37–84 34 family or friends 34 family or friends

Injection drug users (Vietnam 100

) 1 0 (no respondents

disclosed)e

Caribbean (n = 1)

Adults (French Antilles/Guyana101) 1 70 85 56

Reviews (n = 5)

Adults 7,8,102

3 68–97 22–86 (70-92 LIC; 44–67 HIC) 61–86

Men 4

1 67–88

Women 3

1 17–86

Note. HIC = high-income countries; LIC = low-income countries; MSM = men who have sex with men. For multiple studies on a country or population, the table presents the range of disclosure rates (minimum and maximum) reported in the studies. aEmlet also reported that adults aged 50 years or older disclosed their HIV status to those in their social networks less frequently than younger adults did.34 b Two statistics are included: the percentage of parents who reported disclosing to children and the percentage of children who were told by their parents.

c The study by Marks and Crepaz of HIV-positive men (homosexual, bisexual, and heterosexual) is counted under MSM, who represent the majority of the study sample.

12 Similarly, the Weinhardt

et al. study of MSM, women, and heterosexual men is counted under MSM, who represent the majority of the study sample. 17

dGrinstead et al. covers Kenya, Tanzania, and Trinidad, but it is listed under Africa and counted once under Kenya.13 eIncludes data from studies with fewer than 25 participants. fIn Mulye et al., patients’ spouses (23%) and relatives (2%–12%) knew patients’ HIV status after it was disclosed to patients in their presence.94

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disclosed. Studies that included information on HIV status almost always reported that disclosure was lower when HIV status was positive. Disclosure to relatives was higher than was disclosure to friends. Partner disclosure varied greatly, but it was generally lower with casual partners than it was with steady partners.

Some studies explored sociode- mographic factors that influence disclosure, principally residence and ethnicity. For example, re- search in South Africa found higher disclosure rates in urban settings than in rural settings.106 In the United Kingdom, studies found that African men were less likely than were White men to tell their partners about their HIV infection (66% vs 86%, respectively63) and were less likely than were White men to disclose to relatives, part- ners, or work colleagues.64 Simi- larly, a study in French Antilles and French Guyana found that non- French citizens were less likely to disclose to a steady partner than were French citizens,101 and studies in the United States found that African Americans disclosed less often than did European Americans.34,107

Such results suggest that indi- viduals from racial/ethnic minor- ity groups have greater concerns about stigmatization if they dis- close their status. Socioeconomic factors and access to resources also appear to play an important role. In the South African study mentioned earlier,106 urban com- munities with higher disclosure rates had more institutional sources of support, including nongovern- mental organizations and hospitals. Research from Nigeria and among migrants from Africa in Sweden

revealed that more educated re- spondents disclosed more often than did their less educated coun- terparts.62,70 Similarly, a study from India found a higher rate of disclosure to partners by literate respondents compared with illiter- ate respondents (86% vs 44%, re- spectively96). Conversely, low-wage employment and economic vul- nerability reduced disclosure by Tanzanian women,91 Dominican male sex workers,108 and Canadian female sex workers.109 Such results suggest that economic and social disadvantage make disclosure more difficult. This finding is consistent with the frequencies in Table 2, which tended to be higher in higher-income countries (the United States and Europe), whereas levels in developing countries of Africa, Asia, and the Caribbean showed much greater variation.

VARIATIONS IN THE CONCEPT AND PROCESS OF DISCLOSURE

We found that different pro- cesses have been subsumed under the concept of disclosure, under- scoring the need for researchers to clarify more consistently how dis- closure is measured. Quantitative studies have shown large differ- ences in disclosure frequencies depending on what information was given and by whom, whether HIV status was positive or nega- tive, and whether that status was disclosed to 1 or more persons, to anyone, to sexual partners, to friends, or to family. Qualitative studies, on the other hand, have raised questions about the multi- ple dimensions and meanings of disclosure.

Disclosure is not always volun- tary, an issue raised primarily (though not exclusively) in studies conducted outside Europe and the United States. Varga et al.88

reported that in South Africa, 32% of disclosure to family members was involuntary. Similarly, in India, 35% of male and female respon- dents reported that their HIV status had been disclosed without con- sent,95 and relatives sometimes found out a person’s HIV status when it was disclosed in their pres- ence by someone else.94

Research has found large vari- ations in the amount of informa- tion that people reveal. For exam- ple, only about half of respondents in a study from India disclosed the exact nature of their illness to those around them; others pre- ferred partial disclosure or re- ferred to a less stigmatizing illness, such as fever, heart problems, or general illness.95 A US study found that 54% of respondents reported having received full disclosure.15

Parents tended to disclose partially to their young children and more fully to their adolescent children.110

Rather than being a one-time event, as it is sometimes assumed to be, disclosure is often a gradual process of disclosing to an in- creasing number of others in one’s networks over time. For example, a study among homosexual and bisexual men in the United King- dom found that immediately after diagnosis, respondents were more likely to opt for nondisclosure, but later they used disclosure as a mechanism for coping with the disease.111 In a study in South Africa, many HIV-positive men and women waited substantial periods of time before disclosing to their

partners, including 15% who waited more than a year.71 Among a sample of gay Latino men in the United States, half disclosed to someone on the day they found out, and another 15% disclosed within a few days, but about 20% did not tell anyone for 1 year or more.54

Among a sample of HIV-positive pregnant women in Tanzania, dis- closure to a partner increased from 22% within 2 months of diagnosis to 40% after nearly 4 years.91

Other studies among heterosexual men and women, young people, and attendees of an outpatient HIV clinic found that disclosure had a positive association with the length of time since diagno- sis15,20,34,65,112 and with disease progression.19,74,113

Some qualitative studies ex- plored differences among those who disclose and those who do not, such as the criteria motivating decisions, the process of commu- nication, and coping styles. The results of these studies tended to converge around certain key points: selective disclosure is the most frequent strategy, a minority of people fall in the ‘‘never dis- close’’ or ‘‘always disclose’’ cate- gories, disclosure decisions have to be made repeatedly, and dis- closure decisions change over time.7,41,114---117 Other qualitative studies have provided insight into the process whereby individuals weigh the risks (fear of abandon- ment and discrimination) and ben- efits (need for support) of disclosure before making a decision.118 These studies underscore the importance of relationships, trust, emotions, perceptions of self, and perceptions of HIV status. Most of these studies were conducted in the United

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States, tended to emphasize the psychological aspects of disclosure, and focused on individual factors and processes, but some considered the social context of disclosure in Africa,77,106 and others analyzed the connections between the choices made by individuals and the ethical debates and social poli- cies around HIV disclosure.119

ATTITUDES, REACTIONS, AND BEHAVIORS AFTER DISCLOSURE

Much has been written about the stigma associated with disclo- sure of HIV-positive status. Fear of stigma is thought to discourage disclosure, and disclosure has of- ten been considered a proxy measure for stigma, because peo- ple living with HIV are more likely to disclose in low-stigma contexts, where they expect fewer nega- tive consequences.120 Conversely, there is a vast literature on dis- crimination (sometimes defined as enacted stigma) faced by those whose HIV status is disclosed by others, often without their consent. Women are thought to face spe- cial barriers related to fears of stigma, as documented in numerous sources.3,41,42,76,84,90,92,99,115,121---123

Research has drawn attention to negative consequences of disclosure, such as disrupted relationships with families and communities124,125; isolation, criticism, and ostracism by family members68,126; abuse, violence, divorce, or separation from partners; and rejection by friends.43,84,89,127

However, it has been difficult to document the causal link between HIV disclosure and adverse events, in part because baseline

rates of negative experiences such as violence are often unknown, and because HIV-positive individ- uals who eventually face negative reactions often come from disad- vantaged groups that are already at high risk for violence.128 For example, although some evidence suggests that women with risk fac- tors such as a history of drug use are more likely to experience neg- ative social and physical conse- quences when their infection be- comes known,43,129 violence was not significantly higher among a sample of HIV-positive women compared with demographically and behaviorally similar HIV-negative women in the United States.130

Nevertheless, evidence indicates that fear of stigma, discrimination, and violence decreases willingness to disclose HIV status in many settings.3,115,121,125,131---138

Reviews of the literature have shown that reactions to disclosure ranged from negative to neutral to supportive, and that negative re- actions from family, friends, em- ployers, and the community were relatively low––about 3% to 15% of cases.3,8,43,96,129 Studies in di- verse contexts have documented high levels of supportive reactions to HIV-positive persons.68,119,139,140

For example, nearly half of the HIV- positive women in the often-cited study from Tanzania90 reported that their partners were supportive, as did 73% of women in a Kenyan study.84 Studies in South Africa found that reactions to disclosure included trust, support, and under- standing,74 and that 19% of disclo- sures resulted in kindness and 70% in no change of attitude.89 A posi- tive correlation between disclosure and social support has been

documented in a meta-analysis6 as well as in studies from contexts as varied as Greece, Kenya, South Africa, Tanzania, Trinidad, and the United States.13,18,44,71,90,139,141

However, these results must be interpreted in light of differences in types of populations and levels of disclosure. Reactions of support are more likely where HIV-positive in- dividuals are not seen as responsi- ble for getting HIV, whereas those seen as having been infected be- cause of their own behavior may face negative reactions. In addition, low disclosure and high support may indicate that individuals are careful not to disclose their HIV status if they expect negative re- actions.92

Studies have also examined the behavioral outcomes of disclosure, including its possible effect on safer sex. Disclosure of HIV-posi- tive status to partners has been associated with safer sexual prac- tices in the United States,17,21,142,143

France,60 and Cameroon.144 Simi- larly, a study in South Africa found that condom use was higher (57%) among women who disclosed their status than it was among those who did not (38%).73 Unprotected sex was also more frequent among groups of men who have sex with men, heterosexual men, and women who did not disclose than it was among those in each cate- gory who did.145 Other risk be- haviors, such as having multiple sexual partners, have also been associated with nondisclosure, as documented in a review.4 Studies among injection drug users and men who have sex with men in the United States revealed that sexual risk behaviors were highest among inconsistent disclosers, followed by

nondisclosers; consistent disclosers reported fewer sexual risk behav- iors, although the evidence was not always unequivocal.51,56

Indeed, not all studies have found an association between disclosure and safer behav- iors.12,22,50,55,146,147 The difficulties of documenting effects and estab- lishing the direction of causality are common to studies of prevention in general, and we found a literature review on disclosure that reported contradictory results, with positive effects sometimes limited to a sub- group of participants, such as HIV- negative partners or nonprimary partners.148 These inconsistent re- sults may be partly attributable to confounding factors such as alcohol or drug consumption, which in- crease risk-taking regardless of dis- closure. In addition, because safer sex requires explicit discussions be- yond simply disclosing HIV sta- tus,35 the effect of disclosure needs to be considered in relation to other behaviors and attitudes.

DISCLOSURE, HEALTH SERVICES, AND HEALTH PROVIDERS

The influence of health services on disclosure has not been sys- tematically examined, but we can piece together information on 3 interrelated questions: first, whether staff at health facilities contribute to reducing stigma and discrimination, thus normalizing HIV; second, whether they en- courage disclosure by HIV-posi- tive persons and promote testing and referral of partners and family members; and third, whether they are prepared to counsel and sup- port those who are tested, to

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facilitate voluntary disclosure and support.

The extent to which health fa- cilities promote disclosure de- pends in part on whether they provide a supportive context for the difficult experience of being HIV positive. Evidence suggests that health facilities sometimes fall short in this regard. Discrimination against HIV-positive individuals was reported to occur when health workers treat them differently, use excessive precautions, or withhold appropriate care.149---151

Fears of being treated poorly were reported more frequently by women than men. In Australian health facilities, more women than men reported fearing discrimina- tion in the form of avoidance of treatment, extra precautions, and confidentiality problems, and in Kenyan maternity wards, health workers expressed anxiety when caring for women who may have been HIV positive and admitted that they used ‘‘extra care’’ in han- dling them; such situations contrib- uted to delays and suboptimal care, such as reluctance to take HIV tests or to give birth at health facilities.152---154 These studies also reported that stigma and discrimi- nation are declining.

Another indication of how dis- closure is linked to health services comes from studies that examined its connection with adherence to antiretroviral therapy. Initiatives to provide antiretroviral therapy sometimes require that patients disclose to a supportive individual in their network, on the basis of a large body of evidence indicating that disclosure facilitates initiation of and adherence to antiretro- viral therapy, whereas worries

about disclosure contribute to se- crecy and missed medica- tions.88,155---160 Most studies on the subject focus on adherence, and more information is needed about the process of disclosure when it is a condition for antiretroviral therapy.

Health facilities are often ill equipped to reassure PLWHA that they will be treated well, and health workers may not have the training to counsel patients or the competence to judge how to dis- close patients’ HIV status or to whom it should be disclosed.161,162

For example, a study from Vietnam found that health workers felt so uncomfortable discussing HIV with patients that they avoided giving women their HIV test results di- rectly; instead, they relied on the official notification system, which informs local district officials about the HIV status of people living in their catchment area without pa- tients’ consent.163 This nonconfi- dential process sometimes has seri- ous social, economic, and health consequences for HIV-positive women and their children.

In addition, health workers sometimes communicate test re- sults to individuals other than HIV-positive patients, as docu- mented in numerous settings. For example, in a comparative study in India, Indonesia, the Philippines, and Thailand, 34% of HIV-posi- tive respondents reported that health care workers had revealed their HIV status to someone else without their consent.151 One In- dian study found that 61% of women reported that family mem- bers were given test results without the patient being consulted164; an- other found that 35% of

respondents (male and female) reported that their HIV status was disclosed to friends or relatives without their consent (in 75% of cases the disclosure was made by health workers).95 Similarly, a study in China found that health pro- viders often informed family mem- bers of an HIV diagnosis before informing the patient.165 One study suggested that privacy breaches by health workers in India were more frequent for female clients and in the private sector.161

Involuntary disclosure by health workers has been attrib- uted in part to circumstances at health facilities, which often lack private spaces and where it is difficult to manage patient files without compromising confidenti- ality. More importantly, however, the issue of involuntary disclosure by health workers highlights the difficulty of balancing medical confidentiality with the need to facilitate disclosure to those around an HIV-positive person. Health workers are supposed to encourage testing of partners and family members and to promote disclosure to mobilize support for treatment and prevention, but these objectives are often incom- patible with guaranteeing absolute patient confidentiality.

The difficulty of promoting partner disclosure is manifested in the low rates of partner refer- ral.21,82,90,166 A review of 15 studies from sub-Saharan Africa and Asia found that partner disclosure by HIV-positive women ranged from 17% to 80%, with lower rates generally reported by women tested during antenatal care, com- pared with women undergoing voluntary HIV testing and

counseling.3 This finding suggests that the mode of testing makes a difference to HIV disclosure, but also that women’s vulnerability during pregnancy increases their reluctance to disclose.11 For exam- ple, only 23% of partners of HIV- positive women attending a pro- gram on prevention of mother-to- child transmission in Côte d’Ivoire were subsequently tested for HIV.83 Only 17% of HIV-positive pregnant women in a study in Tanzania reported their test results to their partners.92 The fact that 69% of partners who agreed to test were seropositive under- scores the missed opportunity for prevention.

Some studies suggest that HIV- positive health workers find dis- closure difficult because they worry that they may be stigma- tized or that a positive diagnosis will mean they have failed as a role model. These fears may hamper their own ability to be tested, to disclose, and to promote testing, as documented among health workers in Kenya162 and Malawi.167

Despite these difficulties, some studies have shown that health workers can help people cope with disclosure and its aftermath. In Sweden, contact with counselors increased the probability of disclo- sure by immigrant African families, filling a gap in their disrupted social network.62 In a study in China, good relations between patients and providers led to positive health outcomes after disclosure, particu- larly when families were unsup- portive because of HIV-related stigma.165 More evidence is needed to demonstrate how health workers can support HIV disclosure.

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SOCIAL CONTEXT OF DISCLOSURE

Although frequencies and sta- tistical associations provide useful information about levels of dis- closure and their possible deter- minants, they also raise questions about differences in the meaning of disclosure, the consequences of disclosure, and the roles of health providers in different sociocultural settings. The evidence suggests that social context influences key dimensions of disclosure, in par- ticular the notion of support, the role of the family, and the values surrounding disclosure.

Qualitative studies that examine individual experiences have shown that disclosure is closely related to expectations of support. These studies have also shown that disclosure is higher when in- dividuals hope to receive help from those around them, and it is lower when they expect blame and discrimination. As a lengthy, potentially fatal illness, HIV infec- tion represents a possible rupture of the rules of reciprocity that are the basis of social interactions, and a potential drain on resources for those around the ill person.168

That is why, in diverse contexts–– such as the Dominican Republic, Malawi, and Tanzania––individuals thinking about disclosure try to predict how others will react, based on the disclosers’ perceived responsibility for the infection and on the quality of their relationships with those around them.76,77,86,133

Emotional support is important everywhere, but in low-resource settings where services are defi- cient and individuals need mate- rial support from their families and

communities, there are stronger in- centives to disclose. At the same time, however, there are also more risks in disclosing in these settings, precisely because PLWHA are explicitly or implicitly making im- mediate or future demands on those around them. Hence, a sub- tle difference can be discerned when comparing both qualitative and quantitative studies in re- source-rich settings to those in re- source-poor settings. Respondents in resource-rich settings, such as the United States and France, tended to describe disclosure as a way to obtain psychological sup- port and relief from the stress of harboring a secret,18,58,102 whereas those in resource-poor settings, such as China, India, Kenya, Nigeria, and South Africa, mentioned ex- pectations of financial and social support,70,72,169 emotional and ma- terial support,95 and help with medical care and counseling.93

Social context also shapes the extent to which disclosure deci- sions are made by others beyond the individual, as documented in both quantitative and qualitative research. In settings where ade- quate health services and social services are lacking and kinship bonds continue to be strong, fam- ilies and communities may be seen as having responsibilities toward ill individuals and therefore as having a right to be informed about an HIV-positive result.93,125,147 If, as in India, close involvement of the family is thought to be in the best interest of the patient, then a health worker’s breach of confi- dence can be seen as choosing to conform to local social norms rather than to national stan- dards.161 In many settings,

physicians are thought to have the authority to decide on disclosure, as documented in a comparative study in Asia and the Middle East, where 80% of Saudi physicians reported that they would disclose a patient’s HIV status to their family without his or her consent.170 Practitioners often think they know better than poor or uneducated clients, partic- ularly women, and they involve families as a way of recognizing hierarchies within families that lead some members to make health de- cisions on behalf of others.95,171 A qualitative study from Lesotho found that when health workers kept patients’ HIV status strictly confidential, family caregivers sometimes lacked crucial informa- tion needed to secure appropriate medical care.172

Thus, the social context of dis- closure may define 2 competing sets of values: those designed to respect patients’ privacy and con- fidentiality, and those meant to assist and protect those around the patient. Health workers may be caught between these conflicting values and may feel that they should provide information to family members, either to rally support for an HIV-positive per- son or because they feel some responsibility to those around that person if patients themselves re- fuse to disclose.173

The legal context also influ- ences the extent of disclosure and its consequences. A number of countries have enacted laws or formulated policies to encourage disclosure or to mandate disclo- sure to partners. This has hap- pened in the United States,174,175

Canada,176 Singapore,177 and countries of west and central

Africa.178,179 In addition, manda- tory premarital HIV testing and so- called ‘‘beneficial disclosure,’’ which allows health workers to disclose patients’ status without their con- sent, are being discussed in African countries.180,181 Elsewhere, as in some countries of the Middle East and north Africa, the majority of HIV testing appears to be manda- tory, with no guidance on disclo- sure.182 These situations raise a number of ethical and legal issues that are beyond the scope of this article and about which much has been written. Here, it is important to note that the legal context has an impact on institutional support for disclosure at health facilities in the form of guidelines, protocols, pro- grams, and other resources that enable health workers to help around disclosure. The legal con- text also affects individuals’ per- ceived incentives and motivations for disclosure.

As a process of sharing infor- mation about a sensitive topic, HIV status disclosure takes on different meanings in different contexts. The absence of exact equivalents for the term ‘‘disclo- sure’’ in languages other than English testifies to the different connotations it can have (e.g., re- vealing a secret, admitting guilt, or simply stating a medical fact). These complex meanings are linked to moral and ethical valua- tions. The ethical and moral di- mensions of deeply personal choices around sex and dis- closure have been highlighted in a thoughtful US study,119 and com- parable analyses are sorely needed to better understand the reality of moral challenges and how they are addressed in other settings. It has

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been claimed that a policy focused on individual rights, confidentiality, and professional counseling dis- tances the family and community from their role in providing HIV support173 and may be incompati- ble with traditional notions of col- lective family responsibility.165

The tension between the ethics of individualism and communal- ism is beyond the scope of this article, but it is clear that the difficulties of disclosure reflect the potential conflict between com- peting ethical values. Some au- thors argue that the right of sexual partners to be informed and pro- tected is as important as the pri- vacy of PLWHA183 and that when respect for confidentiality increases the risks to third parties, then rou- tine third-party disclosure may be the lesser of the evils.184 Managing the value conflict underlying rec- ommendations about disclosure rep- resents an important challenge for all the actors involved––individual partners, health workers, and policymakers.41

CONCLUSIONS

The studies on disclosure that we have reviewed here show that, first, although disclosure is diffi- cult, few people keep their HIV status completely secret. Levels of disclosure are generally high, but lower levels are documented among certain populations, partic- ularly women tested during pre- natal care. This finding suggests that attention should be directed to these groups to better under- stand circumstances that favor or hinder disclosure. Second, not all studies on disclosure disaggregate results by respondents’ HIV status;

but this information is essential, because HIV-positive status is consistently linked to lower dis- closure rates, a point that under- scores the prevention implications of lower disclosure among those more likely to transmit the infec- tion. Third, disclosure is more uniformly high in the high-income countries of Europe and the United States, and frequency var- iations are wider in low- and mid- dle-income countries. These dif- ferences likely reflect differential availability of and access to re- sources to deal with HIV and its consequences. Fourth, women appear to disclose, and to receive disclosure, more frequently than do men, but married and preg- nant women encounter special difficulties with partner disclo- sure. Further research should seek to identify those specific gender-related factors that may facilitate disclosure and mitigate its negative consequences.

Analyses of disclosure as a pro- cess show that decisions regarding what information to disclose, to whom, and when are iterative and selective, such that partial and gradual disclosure to a growing number of people is more com- mon than is one-time full disclo- sure to all; also, disclosure to sexual partners is often more dif- ficult than to others. The implica- tions of these results are clear: partner disclosure deserves special attention, given its consequences for transmission; initiatives to support disclosure need to be on- going, rather than focusing on a single point in time; and coun- seling cannot be the same at all stages but should consider evolving motivations and consequences.

A main goal of this review was to assess the extent to which health facilities and health work- ers facilitated disclosure. We found that health worker facilita- tion of disclosure was limited by the potential for discrimination at health facilities, the limited coun- seling abilities of many health workers, and health workers’ own fears and concerns regarding HIV. The relatively high frequencies of health workers disclosing peo- ple’s HIV status without their consent and the low levels of partner disclosure, particularly in less developed countries, testify to the difficult balance between en- couraging disclosure and keeping HIV status confidential. Health workers on the front lines need support as they negotiate these complicated situations.

At the same time, however, a number of reports indicate that health workers can help with dis- closure, provided that they are supported in multiple ways. There have been calls to give nurses a role in assisting women with their disclosure decisions,115 to support community- or home-based HIV care programs,185 to facilitate couple counseling, and to promote disclosure while reducing the risk of discrimination and violence against women. The successes reported by some programs suggest promis- ing possibilities, such as strength- ening health workers’ communica- tion skills and increasing their perceived self-efficacy, providing ongoing support for women working through disclosure deci- sions, and mediating disclosure through counselors in the clinic or through friends or family mem- bers outside the clinic.186 In

Rwanda, a package of strategies–– including systematic couple coun- seling and community-based cam- paigns––seems to have overcome some barriers to disclosure and has increased the uptake of HIV testing by male partners of pregnant women from 7% in 1999 to 84% in 2009.187 Further evidence is needed to identify the optimal combination of interventions that would support health workers’ ef- forts to facilitate disclosure while ensuring that disclosure is used as the basis for mobilizing support for those who need it.

We also found differences in the meaning of disclosure across settings. Although emotional fac- tors related to relationships and trust influenced motivations to disclose everywhere, respon- dents from resource-rich settings put a somewhat greater emphasis on psychological relief, whereas those in resource-poor settings more often referred to needs for material support and caregiving as a reason for disclosing. These mo- tivations may change with in- creased access to free treatment, however, as individuals have less need to disclose to their families to obtain material support and have greater access to support groups. Thus, the meaning of disclosure may shift from divulging a secret to sharing a new identity built on serostatus.

The ethical dilemmas resulting from competing values––the con- fidentiality of patient informa- tion versus the need to inform and protect others around the PLWHA––are especially marked in contexts in which family and community remain important structures and in which relatives

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and community members are expected to play a major role in medical decision-making, care giving, and material support for PLWHA. Cross-cultural compari- sons of what constitutes commu- nities and of the values attached to consent and confidentiality show a great deal of variation.188---190 A better understanding of how confi- dentiality is perceived in different cultural contexts can help identify areas of flexibility that can be used to facilitate disclosure where appropriate. Support for disclosure cannot wait for a resolution of the ethical dilemmas around confi- dentiality, but the debates around disclosure and the policies that are formulated to promote it should, at a minimum, be in- formed by evidence on how in- dividuals in the field address these situations.

Research also confirms the re- ciprocal connections among stigma, social support, and disclo- sure. Expectations of support are a crucial factor in the decisions of PLWHA to disclose, and reactions to these disclosures are, in part, influenced by the sacrifices that may be required from those around them. Stigmatization in- creases these potential sacrifices, and support services reduce them. Thus, fears around disclosure re- flect available levels of resources and social support. Taken to- gether, these results suggest that structural changes––including making more services available to support PLWHA, their families, and communities––could be as important as individual ap- proaches or the provision of counseling. j

About the Authors Carla Makhlouf Obermeyer is with the Department of HIV/AIDS, World Health Organization, Geneva, Switzerland. Parijat Baijal is with the Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland. Elisabetta Pegurri is with UNAIDS, Geneva, Switzerland.

Correspondence should be sent to Carla Makhlouf Obermeyer, Department of HIV/AIDS, World Health Organization, 20 Ave Appia, 1211 Geneva, Switzerland (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the ‘‘Reprints/Eprints’’ button.

This article was accepted December 9, 2010.

Note. The views expressed here are those of the authors and do not represent those of the World Health Organization; the Global Fund to Fight AIDS, Tuberculosis and Malaria; or UNAIDS.

Contributors C. M. Obermeyer conceptualized the study, coordinated the analyses, and led the writing of the article. P. Baijal and E. Pegurri conducted the searches, summa- rized the results, and participated in writing the article.

Human Participant Protection No protocol approval was necessary be- cause the study did not involve any human research participants.

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