Consultation Implications in Context

C O N C E P T A N A L Y S I S

HIV disclosure among HIV positive individuals: a concept analysis

Rosemary W. Eustace & Perla R. Ilagan

Accepted for publication 26 March 2010

Correspondence to R.W. Eustace:

e-mail: [email protected]

Rosemary W. Eustace PhD RN CFLE

Assistant Professor

College of Nursing and Health, Wright State

University, Dayton, Ohio, USA

Perla R. Ilagan PhD RN

Assistant Professor

College of Nursing and Health, Wright State

University, Dayton, Ohio, USA

E U S T A C E R . W . & I L A G A N P . R . ( 2 0 1 0 )E U S T A C E R . W . & I L A G A N P . R . ( 2 0 1 0 ) HIV disclosure among HIV positive

individuals: a concept analysis. Journal of Advanced Nursing 66(9), 2094–2103.

doi: 10.1111/j.1365-2648.2010.05354.x

Abstract Aim. This paper is a report of an analysis of the concept of HIV disclosure.

Background. There is a growing interest among healthcare providers and researchers

in HIV disclosure as an effective HIV prevention and early disease management ini-

tiative. However, the concept still remains unclear. Conceptual clarity is important for

providing an expanded theoretical definition and understanding of attributes of HIV

disclosure. This information is useful in constructing better HIV disclosure measures

in HIV/AIDS nursing practice and research.

Data sources. A computer search of the following databases was conducted to capture

the meaning and processes of HIV disclosure among HIV-positive individuals:

PubMed, CINAHL and PSYCINFO. Only English language journals were used.

Publication dates of the literature review ranged from 1999 to 2009. The following key

words were used: HIV disclosure, self-disclosure, disclosure and serostatus disclosure.

Methods. The Walker and Avant (2005) concept analysis model (Strategies for

Theory Construction in Nursing, Pearson Prentice Hall, River, NJ, 2005) was used to

guide the analysis process, which was completed in 2009.

Results. The concept analysis revealed that HIV disclosure is a complex process

characterized by the following attributes: experiencing an event, communicating

something, timing, and contextual environment, protecting someone, relationship

status and improving something or being therapeutic. In addition, the process of HIV

disclosure varies across time.

Conclusion. The proposed HIV disclosure attributes provide nursing scholars and

researchers with new directions on how to reframe research questions, develop mea-

surement tools to reflect better the diversity and fluidity of the process of HIV

disclosure among HIV-positive individuals. Policy implications include the need to

develop approaches that protect individual and public rights.

Keywords: concept analysis, HIV disclosure, HIV/AIDS, nursing, theoretical models

Introduction

Since the inception of the HIV epidemic in the early 1980s,

numerous HIV prevention programs and public health

measures have been underway. Countries around the world

continue to adopt effective strategies to prevent new HIV

infections and improve the quality of life of HIV-infected

individuals and their sexual and social networks. New

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J A N JOURNAL OF ADVANCED NURSING

strategies that promote early diagnosis and prevention of

HIV infection for HIV-positive individuals are now in place

(Hogben et al. 2007). Within these programs, there is also a

growing emphasis on HIV disclosure among HIV-infected

individuals as an effective prevention and early management

initiative (Pinkerton & Galletly 2007). HIV disclosure is

supported by empirical evidence indicating that a substantial

number of people report high levels of delayed or non-

disclosure by people living with HIV/AIDS (PLWH/A)

(Skogmar et al. 2006). Likewise, the evidence suggests that

HIV-positive individuals continue to engage in unsafe sexual

and drug-sharing behaviours without serostatus disclosure,

which hinders HIV prevention efforts (e.g. Simoni &

Pantalone 2004, Stirratt et al. 2006). To facilitate the

prevention of further HIV transmission and early access to

treatment, HIV/AIDS practitioners need to implement scien-

tific behavioural interventions that focus on HIV disclosure

among PLWH/A. However, to do so, it is important that

they develop a clear understanding of the concept of HIV

disclosure (Sullivan 2005, Greeff et al. 2008). Previous

personal experiences of working with HIV-positive clients

suggest that despite extensive training in HIV testing and

counselling and prevention, the majority of HIV/AIDS

counsellors/case managers are not clear about the underlying

attributes of the concept of HIV disclosure. As a result, it

becomes somewhat difficult to assist HIV positive clients

effectively through the disclosure process (Kalichman et al.

2007). In addition, most empirical studies on HIV disclosure

among PLWH/A subpopulations operationalize this disclo-

sure as simply a dichotomous ‘Yes’ or ‘No’ response (i.e.

disclosed/not disclosed), which does not capture the broader

meaning of the concept. Therefore, the aim of this paper is to

provide nurses with a basic understanding of the meaning

and usefulness of the concept of HIV disclosure by using the

Walker and Avant’s (2005) concept analysis approach.

Expectations of the analysis include proposing a theoretical

definition of HIV disclosure as well as raising awareness of

the attributes, antecedents and consequences of HIV disclo-

sure among nurses. This information will be useful in

constructing better HIV disclosure measures in advanced

HIV nursing practice and research.

Background

The concept of HIV disclosure has its roots in ‘self-

disclosure’. The concept of self-disclosure was originally

developed by Canadian Human Psychologist Sidney Jourard

(Jourard 1958, Jourard & Lasakow 1958), and was simply

understood as a communication approach that involved

sharing information about oneself. The concept has been

adopted in nursing and embedded in the humanistic commu-

nication theory developed by Dr Bonnie Duldt (Duldt 1991,

Duldt & Giffin 1985). According to the theory, self-disclosure,

trust and feedback are central tripods of the interpersonal

communication process. On the other hand, self-disclosure is

also viewed as a risky rejection in terms of telling how one

feels and thinks about certain life events (e.g. a diagnosis of

HIV/AIDS or cancer) (Duldt & Griffin). Unlike cancer,

self-disclosure of HIV/AIDS has enormous risks because of

the stigma that can occur due to blame, shame, fear

and scapegoating (Thorne et al. 2000). This makes the

HIV disclosure concept unique and at the same time

challenging.

Although several models of HIV disclosure have been

proposed, the majority offer a narrow perspective that does

not reflect the broader socio-economic and cultural perspec-

tive of the disclosure process (Zea et al. 2007). For instance,

some scholars have examined HIV/AIDS discourse in the

context of HIV-positive social relationships (Bairan et al.

2007), while others have focused on disease progression and

consequences (Serovich 2001, Serovich et al. 2008). The

disease progression theory suggests that some seropositive

individuals’ decisions to disclose their status occur when the

disease progresses to AIDS, because they can no longer hide

the disease or keep it secret. On the other hand, the

consequence theory suggests that an individual’s decision to

disclose their serostatus occurs after carefully analysing the

anticipated outcomes. Additionally, others have described

HIV/AIDS disclosure by examining the disclosure methods/

strategies (Serovich et al. 2005). For instance, Serovich et al.

(2005) developed a typology that depicted five primary

categories of HIV disclosure among men namely, point-blank

disclosure, indirect disclosure, stage-setting, buffering, and

seeking similar disclosure. Thus, it is apparent that the

validity of the theories and measures employed in HIV/AIDS

disclosure research raises further questions, making it difficult

for researchers and care providers to pursue potential clues

that are critical in supporting the disclosure needs of their

clients (Greeff et al. 2008).

Data sources

A computer search of the following databases was conducted

to find the meaning and processes of HIV disclosure

among HIV-positive individuals: PubMed, CINAHL and

PSYCINFO. Literature examining HIV disclosure from 1999

to 2009 was reviewed. The following key words were used in

the search: HIV disclosure, HIV self-disclosure, disclosure

and HIV serostatus disclosure. Papers describing the mean-

ing, uses, characteristics, antecedents, consequences, barriers,

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process and outcomes of HIV disclosure among HIV positive

individuals were included in the analysis.

Method

The Walker and Avant (2005) concept analysis model was

used to guide the analysis. The model has eight steps:

(1) selecting the concept, (2) determining the aims or purpose

of analysis, (3) identifying uses of the concept, (4) determin-

ing the defining attributes, (5) identifying a model case, (6)

identifying additional cases (e.g. alternative/borderline and

contrary case), (7) identifying antecedents and consequences

and (8) defining empirical referents. The first two steps have

already been covered in the introduction and background

sections above. The other steps are discussed below.

Results

Uses of self-disclosure and HIV/AIDS disclosure

The Merriam-Webster Online Dictionary (2010) describes

disclosure as simply an act or instance of disclosing or

making something known that was previously unknown or

concealed. The term disclosure has been used in the business

and medical literature as a policy tool to protect the public

and improve performance (Repetto 2005). In the medical

literature, disclosure is used to inform consumers about

healthcare issues such as medical errors and diseases/trau-

matic conditions (Bradley & Follingstad 2001, Webster et al.

2009). In nursing, self-disclosure has been used in relation to

therapeutic relationships, especially in mental health nursing

practice (Ashmore & Banks 2002). As a concept, it is defined

as self-awareness (Burnard & Morrison 1992, Newshan,

1998) and may be associated with either a loss (stressor) or

gain (opportunity of) (Chandra et al. 2003b). As an oppor-

tunity, an individual can increase their quality of life through

social, financial, emotional and behaviour gains. As a

stressor, disclosure may be associated with discrimination,

abandonment and stigmatization (Chandra et al. 2003a,

Kalichman et al. 2003). The above-mentioned outcomes of

self-disclosure of HIV serostatus have been conceptualized

through disease progression and consequence theories (Sero-

vich 2001). Empirically, however, these theories continue to

lack explanatory and predictive powers because they have

not been adequately tested among various HIV subpopula-

tions (Simoni & Pantalone 2004).

Thus, HIV disclosure can be defined theoretically as a

complex and multifaceted process of making a voluntary or

involuntary decision about whom to inform about one’s

serostatus, why, when, where and how. Individual factors

(such as self-esteem, self-efficacy, sex, age), relational factors

(e.g. family, partner and community–dyadic relationships)

(Serovich 2001, Simoni & Pantalone 2004) and cultural

factors are critical variables and need to be considered in this

process (Greeff et al. 2008, Mutchler et al. 2008). Theoret-

ical constructs such as perceived antecedents, type of

relationship and positive outcome/expectations about dis-

closing are also important (Sullivan 2005). The literature

describes some unique characteristics or attributes that make

up the concept of HIV disclosure among HIV-positive

individuals. These attributes are summarized in the following

section.

Attributes of HIV disclosure

In summary, the characteristics of HIV disclosure include: (1)

experiencing an event, (2) communicating something, (3)

timing, (4) contextual environment, (5) protecting someone,

(6) relationship status and (7) improving something or being

therapeutic.

Experiencing an event

Disclosure happens when a certain life event is experienced

that influences the feeling(s) or thought(s) of disclosing or not

disclosing it to others. In the case of HIV, the person is faced

with a diagnosis that is seen as shameful and life-threatening

and needs to decide how, when, where, what and to whom to

disclose or not to disclose.

Communicating something

Disclosures cannot happen if there is no communication.

Therefore, the attribute of communication in HIV disclosure

includes the act of telling someone about a life-threatening

and shameful disease that nobody is aware of or suspecting. It

includes the release of a burning issue (Winstead et al. 2002).

Others have defined this process as catharsis, or the oppor-

tunity to ventilate feelings by talking to someone (Derlega

et al. 2004). Making the decision to communicate is a diffi-

cult and personal process. The process of communicating a

sensitive topic such as HIV seropositivity is influenced by

individual and social factors. For the most part, HIV-positive

individuals who intend to communicate their serostatus may

actually decide not to disclose because they lack the strength,

motivation or will-power to do so (Sullivan 2005). This may

happen to people who have low self-esteem or low self-effi-

cacy. Other factors include race/ethnicity, gender and age

(Sullivan 2005), personal childhood experiences with family

secrets and parental silence (Lester et al. 2002), the mode of

transmission (Ko et al. 2007) and medium of communication

(Serovich et al. 2005). For instance, African American and

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Latina HIV-positive individuals are less likely to disclose their

status than their White counterparts (Sullivan 2005, Rice

et al. 2009). Moreover, research indicates that men who have

sex with men (MSM) tend to disclose their HIV status to

friends immediately after obtaining the test result, while

heterosexual men tend to disclose their seropositive status to

family members a few days after the test results are received.

Additionally, injecting drug users (IDUs) have been said to

have the most difficulties in disclosing HIV to others (Ko

et al. 2007). As for the medium of communication, point-

blank and direct disclosures have been the most commonly

used strategies (Serovich et al. 2005).

Timing

The timing of HIV disclosure refers to the social meaning of

when and why individuals decide to disclose their serostatus

to others. HIV-positive individuals may become more

accepting or open about their illness over time but struggle

when it comes to whom and when to tell (Winstead et al.

2002). Empirical evidence indicates that disclosure becomes

easier the longer someone has been living with HIV, because

they become more open and comfortable with the HIV status

or can no longer hide the symptoms (Serovich 2001,

Winstead et al. 2002, Batterham et al. 2005). For example,

the longer it takes to disclose, the more risky it might be in

terms of maintaining trusting relationships. When partners

feel betrayed, they are more likely to end the relationship.

Concerns over timing of disclosure and sexual activity,

however, are still unclear (Simoni & Pantalone 2004). How

does this work for HIV-positive individuals? Do they engage

in safer sex before or after disclosure? Surprisingly, delaying

disclosure may also be beneficial to HIV-positive individuals

because it may give them more time to know the other people

involved and thus anticipate possible reactions and conse-

quences to disclosure (Rutledge 2007).

Contextual environment

The contextual environment is critical in HIV disclosure/non-

disclosure. It describes the setting and potential contextual

factors under which disclosure is more or less likely to occur.

Seropositive individuals, their families and communities, as

well as their socio-cultural and political norms, constitute the

environment. If HIV stigma is present, HIV-positive indi-

viduals are less likely to disclose (Wouters et al. 2009).

Conversely, disclosure can occur only if the person feels

secure, in control and in a comfortable environment

(Rutledge 2007). For example, personal disclosure is more

likely to occur in the person’s own home rather than that of

their sexual partner’s because this affords a greater sense of

security. Silent communications through the presence of other

evidence of seropositivity such as medications (e.g. taking or

displaying medications in the open), brochures (support

groups) are more likely to occur at home and hence facilitate

disclosure. For some individuals, however, this may also

become difficult to accomplish and anonymous disclosure

over the internet or through another person is desirable,

because the process is easier and rejection is less obvious

(Rutledge 2007). However, anonymous sexual contexts such

as public sexual venues may also affect disclosure because of

fear of being detected (Simoni & Pantalone 2004). Other

contextual factors may include substance abuse, income and

other socio-cultural factors (Simoni & Pantalone 2004). As

far as taking highly active retroviral treatment (HAART) is

concerned, there is a possibility that this may influence the

process of disclosure in both negative and positive ways. This

finding, however, is not conclusive (Klitzman et al. 2004).

Protecting someone

HIV-positive individuals choose to disclose/not disclose their

status because they feel a sense of responsibility to protect

their partners and social networks (personal vs. shared

responsibility) (Jeffe et al. 2000, Winstead et al. 2002,

Sullivan 2005), and in some sense to protect themselves

(Gorbach et al. 2004). This can be described as another-

focused reason (Chandra et al. 2003a). This sense of pro-

tection can occur in many different ways. Some may choose

to go ahead and tell their partners about their status so that

they can decide what they want to do. To some, this is a

moment of fulfilling the need to educate (Emlet 2008). Others

may realize that their partners have the right to know but

choose not to disclose because they believe that, as long as

they have protected sex, the partners do not need to know

(Winstead et al. 2002). For some individuals, serosorting may

be another option (Wong et al. 2009). This is a new strategy

that involves commitment and checking whether a partner is

indeed positive before sexual encounters. If a partner is per-

ceived as HIV-positive, then the seropositive individual is

more likely to disclose. As for self-protection, if people con-

sider themselves to have a low viral load (which may reduce

possibility of transmission), they are less likely to disclose

(Gorbach et al. 2004, Simoni & Pantalone 2004).

Relationship status

The disclosure process to others has its own patterns and

limitations. The attribute of relationship status is character-

ized by a selective disclosure process to preserve privacy.

Some HIV-positive individuals are secretive about who they

disclose to and may not disclose to everyone (Kalichman

et al. 2003). Often, HIV-positive people will disclose their

status to some friends and family members, healthcare

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workers, employers, others in the community and/or some-

times to their partners. As for sexual partners, disclosure is

more likely to occur in longer romantic relationships than

casual relationships (one-night stands, anonymous partners,

group scene, etc.) (Batterham et al. 2005, Rutledge 2007).

Most people feel that if they have a romantic relationship

they would be more inclined to disclose than when they are in

a casual sexual relationship. For some individuals, however,

disclosure may be a strategy to excusing oneself from getting

to know another person, especially in situations where there

is lack of attraction (i.e. also known as ‘cop outing’) (Rutl-

edge 2007).

Furthermore, family and friendship functioning is critical

in the disclosure process. In many cases, family size or social

network densities are not statistically significant predictors of

HIV disclosure (Kalichman et al. 2003). There has been a

consistent pattern of disclosure which suggests that women

are more likely to disclose than men (Kalichman et al. 2003,

Shaffer et al. 2001, Wouters et al. 2009). In addition,

disclosure is more likely to occur among friends, mothers

and sisters than fathers and brothers (Kalichman et al.

2003). Cultural differences are also vital in selective disclo-

sure, with HIV-positive individuals being more likely to

disclose to friends in the West than in countries such as those

in Africa and India, where family is most important. For

instance, Kalichman et al. (2003) found that friends were

disclosed to most often and were perceived as most

supportive among people in the United States of America

(USA). Likewise, the literature on disclosure to children

reveals unique patterns, with more disclosure among chil-

dren aged 10 years and older (Lester et al. 2002, Asander

et al. 2009). Other relational factors affecting HIV disclo-

sure/non-disclosure include number of sexual partners and

sexual orientation. HIV-positive individuals who have a

greater number of sexual partners are less likely to disclose,

compared to those with fewer partners (Sullivan 2005). In

addition, homosexual men have been reported to disclose

more than bisexual and heterosexual individuals (Sullivan

2005). These findings, however, are not conclusive because

of non-representative samples (Batterham et al. 2005). In

terms of sexual orientation, heterosexual individuals, in

particular women face unique challenges associated with

HIV disclosure. Some of these may be influenced by their

roles in society and the power imbalance within their

relationships. Semple et al. (1993) identified stressors in a

sample of 31 HIV-positive, mostly White, heterosexual

women with no reported history of intravenous drug use.

The researchers identified self-disclosure of HIV status to

children, concern about having infected children, caring for

an infected child, and making alternative arrangements for

caring for children as important stressors in the lives of

women who had children. In addition, race/ethnicity has

been found to play a key role in HIV disclosure. A study by

Elford et al. (2008) indicated that Black African heterosexual

men and women were less likely to tell their current partners

about their HIV infection than White or ethnic minority gay

men. Moreover, African American and Latino men leading

double lives by engaging in both heterosexual and homo-

sexual relations are less likely to disclose their HIV status to

female partners, and are also more likely to engage in

unprotected sex (Mutchler et al. 2008).

Improving something or being therapeutic

The therapeutic effect of disclosure has been commonly cited

as a reason for disclosing serostatus (Chandra et al.2003a).

Disclosure to significant others is important for coping with

HIV/AIDS and gaining social support among HIV-positive

individuals (Chandra et al. 2003a, Greeff et al. 2008).

Empirical evidence suggests that disclosure to significant

others can help increase social support as well as initiation

and adherence to HIV treatment and medications (Serovich

2001, Winstead et al. 2002, Stirratt et al. 2006). Disclosure

to friends has been reported to be most likely and friends

have been found to be very supportive (Kalichman et al.

2003). In addition, disclosures to mothers and sisters have

been reported more often than fathers and brothers, and are

perceived as the most supportive family members. The

extended family, on the other hand, is viewed as more

supportive than all immediate family members with the

exception of mothers (Kalichman et al. 2003).

Cases

Model case

Walker and Avant (2005) suggest that providing a model case

as an example of the concept will demonstrate all its defining

attributes. The following is a constructed example of a model

case. Patient A saw an advertisement about a local commu-

nity health project offering free HIV testing and decided to

get a test. She was somehow not very sure if she was at risk,

but knew that she had experienced unprotected sex with

multiple partners. After taking the test she was given a pre-

liminary positive result, and this was later confirmed at the

local health department. With the help of the counsellor,

Patient A decided to disclose her status to her mother

6 months later after learning her diagnosis. She disclosed to

her during a nurse practitioner follow-up visit. She believed

that her mother would be more accepting and supportive,

and that she deserved to know more about HIV transmission,

prevention and management.

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Alternative/borderline case

An alternative case is designed to demonstrate a situation

where some of the defining attributes antecedents or conse-

quences are present. Patient B was admitted to the hospital

with high fever, body malaise and vomiting. He had been out

of work for a while because of being ill. He had lost a lot of

weight, as he had not been eating well. He had been involved

in unsafe sexual activity and had being speculating that he

might have HIV. He had told his best friend J because he was

very accepting and non-judgmental. His friend requested that

he get tested. It took him a while to finally do so. The test

result indicated that he was HIV-negative. Patient B is an

example of an alternative case because he possessed some of

the attributes of HIV disclosure, with exception that he was

not HIV-positive, and thus did not need to disclose anything

(i.e. HIV status).

Contrary case

Walker and Avant (2005) defines a contrary case as a clear

example of what is ‘not the concept’. Patient C is admitted

to the hospital with high fever, fatigue and loss of appetite.

He has been experiencing unexplained weight loss in the last

2 months. He has now officially learned that he has cancer.

He does not want to tell his wife about the diagnosis but

shows an interest in telling his boss at work. He believes

that his boss is very supportive and will make sure he

continues to receive health insurance coverage. This case

demonstrates some attributes of disclosure, but not HIV

disclosure.

Antecedents of HIV disclosure

The antecedents of HIV disclosure can be summarized in two

categories, namely before and after HIV diagnosis, and may

include individual, familial, community and social factors.

Post-diagnosis factors may include disease acceptance and

desire to protect others and gain support (Greeff et al. 2008).

Death of a loved one, partner or child has also been reported

as a factor leading to disclosure (Greeff et al. 2008). Some of

the determinants of disclosure among HIV positive individ-

uals include the act of maintaining secrets because of age-

related factors, social economic status (SES), the need of

privacy and the time-lag between knowing about HIV status

and deciding to disclose (Wouters et al. 2009). It has been

reported that HIV-positive individuals who disclose are on

average older, higher in SES and aware of their HIV status

longer than those who have not told their sexual partner(s)

(Demas 2000). Denial and breaching confidentiality may be

other reasons for not disclosing, as well as fear of negative

consequences for the family (Greeff et al. 2008). Another

important antecedent of disclosure is the presence of

community support initiatives. In their study to determine

the impact of a community support initiative on disclosure to

relatives, Wouters et al. (2009) concluded that the safe

environment created by the support of community health

workers or HIV support groups reduced fear of stigmatiza-

tion and rejection and encouraged disclosure among PLWH/

A. These findings support consequence theory as an expla-

nation of whether an individual decides to continue keeping

the secret or to disclose by considering the cost and rewards

of the decision (Serovich 2001). Overall, we can conclude

that, depending on the relationship target, the perception of

HIV-related stigma shapes people’s positive or negative

concerns about what might happen if they disclose (Derlega

et al. 2004). Other factors may include knowledge of the

disease (Skogmar et al. 2006), race/ethnicity (Fekete et al.

2009), and quality of communication, family functioning,

gender and sexual orientation (Lester et al. 2002).

Consequences of HIV disclosure

The consequences of HIV disclosure may be categorized as

either negative or positive in relation to the family, sexual

partners, friends and community. Negative consequences

include anxiety because of an uncertain outcome. HIV

disclosure generates fear of rejection for sex, loss of

romance, separation, divorce, and negative labels such as

handicap or sickness, as well as stigma and death sentence

(Skogmar et al. 2006, Calin et al. 2007, Rutledge 2007,

Wong et al. 2009). HIV disclosure is regarded as one of the

triggers of HIV stigma (Sandelowski et al. 2004, Greeff et al.

2008). Other negative consequences may include loss of

social support and abandonment assault/violence and impris-

onment. For instance, many states in the USA now consider

HIV transmission associated with non-serostatus disclosure

as ‘criminal transmission’. An individual can be taken to

court if their sexual partners or social networks think that

they contracted the disease because the individual did not

disclose their status (Simoni & Pantalone 2004). Moreover,

HIV disclosure to children may result in problem behaviour

and negative family functioning, especially among adoles-

cents (Li et al. 2007). Potential negative outcomes for

children include poor academic achievement, lack of pro-

social behaviours (e.g. cooperation, helping, trust), sexual

risk-taking, substance abuse (Delaney et al. 2009), fear of

the unknown, fear of death or separation, and denial or loss

of social relationships (Winstead et al. 2002). HIV disclosure

in the community has also been reported to result in denial

due to distrust toward seropositive individuals who disclose

because of their physical appearance (not thin/ill) and the

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thought that they are doing this for monetary gain (Greeff

et al. 2008).

As for positive consequences, disclosure is commonly

associated with reports of consequent safer sexual behaviour

and greater social support. It has been found that individuals

who disclose are more likely to report more frequently or

always using condoms, reducing the number of sexual

partners and/or becoming monogamous, increased social

support, with families providing the most support (Demas

2000, Wong et al. 2009). Other possible variables in relation

to the benefits of mothers’ disclosure to their children include

reduced worry, increased parental self-efficacy and improved

parent-child relationships (Winstead et al. 2002, Li et al.

2007). Disclosure may also lead to improved medication

adherence (Mellins et al. 2002).

Empirical referent

Following the model case, it is clear that empirical referents

should incorporate assessment of HIV testing and diagnosis,

timing of testing and disclosure, communication patterns and

types, context of disclosure, relationships types and social

support. These factors, together with the antecedents and

consequences, yield useful information that can offer new

research directions in HIV disclosure, in particular instru-

ment development.

Discussion

The proposed attributes and definition of HIV disclosure

were developed based on empirical evidence and earlier

efforts to understand the HIV disclosure process among HIV

positive individuals. The analysis offers a conceptual map for

further research to develop a middle-range theory of HIV

disclosure. Although the research evidence reviewed for this

analysis has generated many important and consistent find-

ings on some aspects of disclosure, such as the relational and

therapeutic (support) factors, many gaps remain. There is a

need for more data about HIV disclosure in order to develop

a more inclusive model. Each of the potential factors within

the proposed major categories (attributes, antecedents and

consequences/outcomes) needs further exploration.

Moreover, majority of the findings in this analysis are

based on cross-sectional and comparative research designs,

which yield limited information about the process of

disclosure over time and across various HIV subpopulations.

In addition, it is imperative to note that very few researchers

have examined HIV disclosure using randomized controlled

trials (Serovich et al. 2009). As a result, it is still difficult to

understand the complex patterns and consequences of

disclosure on HIV-positive individuals’ well-being. There-

fore, any new theoretical consideration of the process of

HIV disclosure should address relationship and therapeutic

needs, as well as the timing, protective, communicative and

contextual factors influencing disclosure. For instance,

future researchers should compare how HIV-positive indi-

viduals and their sexual/social networks perceive the impact

of HIV disclosure on their relationships (Winstead et al.

2002).

Conclusion

The major challenge offered in this analysis concerns how

scholars can enrich theoretical conceptualizations of HIV

disclosure. The concept has major implications for advanced

HIV nursing practice through the application of various

What is already known about this topic

• A significant amount of HIV/AIDS prevention literature provides support for HIV disclosure among

HIV-positive individuals.

• Healthcare providers are encouraged to be aware of any implications associated with HIV disclosure in

order to effectively support and meet the needs for

people living with HIV/AIDS.

• There literature does not offer a clear understanding of the concept of HIV disclosure as it reflects the

complex realities of HIV positive individuals.

What this paper adds

• A theoretical definition of the concept of HIV disclosure. • Major attribute categories of HIV disclosure are:

experiencing an event, communicating something,

timing, contextual environment, protecting someone,

relationship status and improving something or being

therapeutic.

• The process of HIV disclosure varies across time.

Implications for practice and/or policy

• Develop a HIV disclosure measurement tool for seropositive individuals.

• Offer effective services for people living with HIV/AIDS utilizing the defining attributes, antecedent and

consequences of HIV disclosure.

• Train health care providers on the process of HIV disclosure assistance.

R.W. Eustace and P.R. Ilagan

2100 � 2010 The Authors. Journal compilation � 2010 Blackwell Publishing Ltd

theories such as the humanistic communication theory and

interpersonal theories. The analysis offers nurses a guiding

tool on how to reframe research questions and practical

activities in order to reflect the diversity and fluidity of the

process of disclosure among people with HIV. Both qualita-

tive and quantitative research designs and methods should be

used in shedding light on the complex patterns of relationship

changes and interactions that can explain the process of HIV

disclosure. Socio-cultural norms and attitudes about HIV

should be considered and researched to further the under-

standing of HIV disclosure. Randomized trials, longitudinal

studies and multilevel models that evaluate HIV disclosure

interventions are also valuable designs in this process. The

key attributes of HIV disclosure offer nurses a base for

developing multiple level counselling and psychosocial inter-

ventions to help support HIV-positive individuals through the

disclosure process. Policy implications include the need to

develop better assessment, referral and follow-up approaches

that protect the rights of individuals and the public.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

RWE and PRI were responsible for the study conception and

design. RWE and PRI performed the data analysis. RWE and

PRI were responsible for the drafting of the manuscript. RWE

and PRI made critical revisions to the paper for important

intellectual content. PRI supervised the study.

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