Among HIV-Infected South Africans, Nondisclosure Is Linked to Risky Behavior
In a South African study conducted primarily at clinics providing HIV services, roughly two in five HIV-positive men and women said they had recently had sex without disclosing their HIV status to their partner.1 In many cases, this sex was unsafe: Compared with respondents who had told all of their recent partners that they had HIV, those who had concealed their status at least some of the time were substantially more likely to have engaged in unprotected intercourse and other risky behaviors. They were also more likely to have experienced HIV-related discrimination, such as losing a job or a place to live because of being infected.
The researchers surveyed 1,055 HIV-positive men and women in Cape Town, most (77%) of whom were recruited at sites that provided support services or treatment; the remainder were recruited by word of mouth. The questionnaire assessed a range of demographic, health and behavioral variables, as well as respondents' experiences with disclosing their HIV status. Most respondents were black (67%), 35 or younger (73%), single (73%) and unemployed (72%). On average, they had first tested positive for HIV 2.7 years earlier and had six physical symptoms of HIV infection; half had been hospitalized at least once for an HIV-related problem.
In the three months prior to the survey, the vast majority of participants (90% of men, 81% of women) had had at least one sexual partner, and substantial proportions had had at least one HIV-negative partner (40% of men, 18% of women) or a partner of unknown HIV status (39% of both men and women). Although most participants had had no more than one partner during the three months, 25% of men and 11% of women had had three or more.
Among the 903 sexually active respondents, 42% said that they had disclosed their HIV status to all of their sexual partners during the past three months. Compared with respondents who had disclosed their status to all of their recent partners, those who had concealed it from at least one of their partners were more likely to be married (49% vs. 26%) and less likely to identify themselves as black (62% vs. 73%). They were also more likely to have engaged in a variety of behaviors that could transmit HIV. Respondents who had concealed their status were more likely than those who had disclosed it to have had sex with partners who were HIV-negative (69% vs. 28%) or were of unknown HIV status (85% vs. 17%), to have had two or more partners (43% vs 22%), to have had unprotected vaginal intercourse with a concordant (61% vs. 28%) or nonconcordant partner (55% vs. 10%), and to have had unprotected anal intercourse with a concordant (39% vs. 12%) or nonconcordant (38% vs. 2%) partner.
Although participants who had concealed their HIV status from their sex partners and those who had disclosed it often differed in their sexual behavior, the two groups were generally similar in their reluctance to reveal their status to friends and strangers. After adjustment for all relevant variables, those who had concealed their HIV status from sex partners were not significantly more likely than those who had disclosed it to agree that "it is difficult to tell people about my HIV infection " (63% vs. 64%) or that "there are people I have not told I am HIV positive because I am afraid of their reaction " (65% vs. 57%). However, those who had concealed their status from sex partners did have an elevated likelihood of reporting that their HIV status had caused them to lose a job or a place to stay (odds ratio, 2.2), which may have contributed to their reluctance to tell partners and others about their infection. In addition, they were less likely than those who had disclosed their status to feel certain that they could tell their sex partners that they had HIV (0.6).
The researchers noted that the study had several limitations, including its reliance on self-reported data and its focus on a single city that may not be representative of South Africa as a whole. In addition, the study grouped together individuals who had not revealed their HIV status to any recent sex partners with those who had disclosed their status to some partners but not others; at least one prior study suggests that "selective disclosers " are particularly likely to engage in risky behaviors. Nonetheless, the study's findings—in particular, that people who had concealed their HIV status from their partners had elevated rates of risky behavior but little confidence in their ability to reveal their status to partners—point to "the need for behavioural interventions to reduce the risks of HIV transmission among men and women living with HIV in South Africa " and "to assist them [in making] effective decisions on disclosure. "—P. Doskoch "
1. Simbayi LC et al., Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa, Sexually Transmitted Infections, 2007, 83(1):29–34.