ART roll-out in Uganda accompanied by increased rates of HIV disclosure to spouses

Roll-out of
antiretroviral treatment (ART) has been accompanied by an increase in the
proportion of people living with HIV disclosing their status to spouses,
investigators from Uganda report in the 1 June edition of the Journal of Acquired Immune Deficiency
Syndromes. The authors monitored rates of disclosure in married/co-habiting
couples in periods before and after ART was introduced.

“We found a
significant increase in disclosure of HIV infection to a spouse (from 63% to
78% among men, and from 55% to 73% among women) after the introduction of an
ART programme in a rural African community,” write the authors. “To our
knowledge, these are the first disclosure estimates reported from a general
population in sub-Saharan Africa that directly quantify the change in
disclosure after ART rollout.”

Research conducted
before ART became widely available in sub-Saharan Africa suggested that only
49% of people living with HIV disclosed to their partner. HIV treatment started
to become widely available in the region in the middle of the last decade, and
studies carried out since then have shown disclosure rates are now as high as
79%. But the findings of these studies are limited because they have a
cross-sectional – or snap-shot – design.
Investigators from the Rakai Health Services Program wanted to remedy this
limitation and establish a better understanding of the impact of ART roll-out on
disclosure rates. They therefore designed a longitudinal, population-based
study involving 557 married/co-habiting individuals who were newly diagnosed
between 2000 and 2008. ART first became available in Rakai – a rural region of
Uganda – in 2004 and access was widespread by 2005. The investigators compared
disclosure rates in the eras before (2000-2004) and after (2005-2008) ART
introduction. They also analysed disclosure rates in the ART era according to
use of HIV services and HIV treatment.

Study participants were
asked about disclosure at their first three follow-up visits (a period covering
approximately five years).

Two hundred and
sixty-four (47%) individuals were diagnosed before ART was introduced, the
other participants in the ART era. The characteristics of people diagnosed in the two
periods were broadly comparable.

Disclosure rates
increased from approximately 58% in the pre-ART era to 75% after ART roll-out.
This increase was highly significant (p < 0.001) and was observed in both
men and women, but disclosure rates in both periods were higher among men.

The odds of
disclosure were 46% higher post-ART availability compared to the pre-ART era
(aHR = 1.46; 95% CI, 1.16-1.93; p < 0.001). Women were approximately 20%
less likely to disclose than men (p = 0.046).

Longer duration of
relationship and the presence of AIDS-associated symptoms were associated with
increased odds of disclosure, whereas alcohol use and higher levels of
education were associated with decreased chances.

In the period
after ART roll-out, there was a clear relationship between disclosure and use of
HIV services. Only 36% of individuals not in HIV care disclosed, increasing to
65% for those in care but not on ART, and 85% among people on HIV treatment.

“In the ART era,
enrollment in ART or pre-ART care was strongly associated with disclosure to a
spouse,” comment the investigators. “Operations research in Rakai documented
the desire to access ART as a motivating factor to disclose one’s HIV status
to one’s spouse.”

The authors
conclude that ART availability was associated with disclosure to spouses,
facilitating “linking infected partners to care, accessing prevention of
mother-to-child transmission and preventing sexual transmission to uninfected
partners through sexual risk reduction and treatment-centred prevention
approaches.”

References