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A multi-institutional, cross-sectional study on disclosure of HIV status to sexual partner(s) and associated factors among people living with HIV/AIDS attending selected hospitals in Kigali, Rwanda

Human Immunodeficiency Virus (HIV) is still a serious public health concern globally. Southern and Eastern Africa combined account for 45% of new HIV infections. HIV status disclosure remains an important aspect of epidemic control. Multiple benefits have been reported to HIV status disclosure. Chief among which, it has been reported that participants who reported disclosure to their partner had higher rates of condom use with their partner. This leads to the much-needed decline in new infections. However, worrying disclosure rates have been revealed in recent studies in sub-Saharan Africa (SSA). The disclosure rates identified in studies conducted in Southern Africa have ranged from 11 to 34% only. Nondisclosure has serious implications including lack of antiretroviral therapy (ART) medication initiation and adherence.


INTRODUCTION
Human Immunodeficiency Virus (HIV) is still a serious public health concern globally. 1 Southern and Eastern Africa combined account for 45% of new HIV infections. 1,2 HIV status disclosure remains an important aspect of epidemic control. Multiple benefits have been reported to HIV status disclosure. Chief among which, it has been reported that participants who reported disclosure to their partner had higher rates of condom use with their partner. 2 This leads to the much-needed decline in new infections. However, worrying disclosure rates have been revealed in recent studies in sub-Saharan Africa (SSA). The disclosure rates identified in studies conducted in Southern Africa have ranged from 11 to 34% only. 3 Nondisclosure has serious implications including lack of antiretroviral therapy (ART) medication initiation and adherence. 3 social support has been cited to be unrelated to disclosure. Where higher level of support was reported, higher odds of disclosure were also reported. The same study found that women in violence-prone relationships had higher proportion of disclosure compared to those not in such relationships; an unexpected finding. 5 In the Rwandan context, poor HIV status disclosure was associated with higher odds of poor quality of life. 6 Targeted research adapted to suit the various sociocultural contexts to support HIV disclosure among people living with HIV/AIDS (PLWH) is critical in attaining the 90-90-90 UNAIDS targets. 7 Worldwide, multi-organizational efforts have resulted in the successful HIV prevention programs being implemented. 8 These multi-organizational efforts are also true for Rwanda, however, with all these interventions, HIV transmission is not decreasing in a way that relates to the effort and resources devoted and spent. This has raised scrutiny among researchers to understand the factors that contribute to new HIV infections. HIV status disclosure to sexual partners remains a key area of interest to better understand the HIV epidemic in Rwanda. Major success has been reported in Rwanda, in ensuring access to antiretroviral therapy for PLWH. 9,10 However, for prevention interventions, HIV status disclosure particularly to sexual partner(s) plays a pivotal role. The present study aimed to investigate the proportion of and factors affecting divulging HIV positive status to among PLWH to their sexual partner(s) in Kigali, Rwanda.

Design, setting, study population
This study was a cross sectional study, with data collection at three health facilities in Kigali, Rwanda. One hospital was selected in each of the three districts in city of Kigali during the period June and August 2019. The target population was adults aged 18 and older as this age group is considered sexually active. The respondents were PLWH attending antiretroviral (ARV) clinics at these health facilities. For this study, the target population was PLWH attending selected hospitals in Kigali, Rwanda. One hospital was purposively selected with representation from each of the 3 districts. The selection is based on high number of clinic attendees. Study locations were Kibagabaga Hospital (Gasabo District), The University Teaching Hospital of Kigali (CHUK) (Nyarugenge District) and Rwanda Military Hospital (Kicukiro District). Participants were enrolled in the study using simple random sampling.

Data collection and analysis
Individual close-ended, self-administered questionnaires focusing on demographic characteristics, general health status, HIV-related risk behavior, HIV status disclosure and exploratory factors were used. The instrument tool has been adopted from a similar study conducted in Ghana. 11 Participants used either English or Kinyarwanda version. Quantitative data was summarized using mean and standard deviation) or median and range where appropriate. Qualitative data was summarized using frequency and percentages. All statistical analysis was conducted in SPSS version 25.0 statistical package. All statistical decisions were concluded at 5% level of significance.

Ethics approval and consent to participate
This study was approved by the University Teaching Hospital of Kigali Institutional Review Board (approval number: EC/CHUK/0130/2019). Permission was obtained from the Director General at Kibagabaga Hospital prior to conducting of this study. All study participants also signed an informed consent.

Demographic characteristics
A total of 384 participants were enrolled in the study. Of these 46% were male while 54% were female. The participants mean age was 36.5 with a standard deviation of 10.4. Only 7% had never attended school. Majority (69%) were of the Christian religion. More details on participants demographic characteristics are presented on Table 1.

HIV status disclosure
Of the participants, 66% reported having disclosed their HIV status with only 46% of these having disclosed to their sexual partners. The findings also reveal that 96% of the participants who disclosed their HIV positive status cited the need to get their partner's support as the main reason for disclosure ( Figure 1). Three reasons most cited as main reasons for non-disclosure were not wanting to worry sexual partner (93%), abandonment (81%) and rejection/ discrimination/ stigmatization (81%). Based on the findings of the study, fear of being killed and fear of legal implications were the least cited reasons. Fear of being killed and fear of legal implications for non-disclosure of HIV status were the least cited reasons with only 14% and 19% citing them respectively ( Figure 2). Bivariate analysis revealed that there was an association between knowledge of sexual partner's HIV status and HIV status disclosure (p<0.001). There was an association between satisfaction with counselling given after HIV status was made known to an individual and HIV status disclosure (p=0.008). There was an association between gender (p=0.009), sexual partner on ART (p=0.005), place get to know about HIV status (p<0.001) and HIV status disclosure ( Figure 3).   There was an association between age and disclosure status after adjusting for other study variables (p=0.035), the odds of disclosure reduce by 6% for a unit increase in age.
There was an association between being satisfied with counselling and disclosure status after adjusting for other study variables (p=0.017), the odds of disclosure among those not satisfied were 76% less that of individuals who were satisfied. There was an association between gender and disclosure status after adjusting for other study variables (p=0.030), the odds of disclosure among females were 5.5 times that of males. There was an association between education and disclosure status after adjusting for other study variables (p=0.041), the odds of disclosure among those with at least secondary education were 2.1 times that of individuals educated up to primary education ( Figure 4).

DISCUSSION
From this current study, 66% of the participants reported disclosure, with only 46% of these to their sexual partner(s). In Ethiopia, a study reported a proportion of 57.4% with 58.0% of them informing their partner within four weeks of initial positive test result. 12 The findings of Genet et al study was lower on the overall disclosure rate but higher on disclosure to sexual partners. An Ethiopian cross sectional survey demonstrated that 85.7% of the participants (women) reported disclosure to their sexual partners. 13 Another study also done in Addis Ababa revealed that the disclosure proportion to the sex partners stood at 93.1%. 14 It further noted that among the people who disclosed, 74.5% were accepted, while 10.8% faced minor challenges or suspicion of the results and the last 7.8% reported physical abuse, as well as blame 14. These findings were higher than those obtained in the current study. The findings of the study, which was carried out in Nigeria indicated that 97.5% overall disclosure rate with 36.8% of these disclosing to their spouses. 15 A rate of 60.9% to sexual partners was reported in Togo. 16 In Tanzania, Yonah et al indicated that the overall prevalence of the serostatus disclosure stood at 93.3%. 17 Another cross-sectional study done in Nigeria concluded a disclosure rate of 95.0%. 18 Out of this 50.4% had revealed to sex partners. A separate study conducted in Northern Ethiopia indicated a slightly lower rate of disclosure of 63.8%. 19 A study done in South West Nigeria established that 75.6% disclosed to their sex partner. 20 Elsewhere in Addis Ababa, results indicated a higher proportion of 82.5%. 2 The current study findings contribute to the body of knowledge on the prevalence of HIV status disclosure to sexual partner(s) and associated factors among PLWH in Kigali, Rwanda. Less than half of the participants who reported HIV status disclosure had disclosed to their sexual partner in the present study. This finding is a public health concern as vast literature has shown poor health outcomes for couples engaging in sex with an infected partner. Moreover, PLWH who do not disclose to their sexual partner will not obtain the much-needed support from their partners affecting components of HIV care and treatment such as adherence to treatment.
Several studies have also explored factors associated with divulging a positive HIV status to sexual partner(s). In the study, which was carried out in Ethiopia, the findings revealed that some of the main factors which hinder HIV status disclosure to sexual partner(s) include fear of both abandonment and ending a relationship as well as the fear of stigma. 13 In another study also done in Ethiopia some of the notable factors, which affected disclosure to sexual partners include the fear of divorce (32%), fear of stigma as well as discrimination (32%) and the general fear of physical abuse (16%). 14 Level of education, gender, satisfaction with counselling and age were reported as factors associated in this current study. The findings of the study carried out in Nigeria demonstrated that there was a significant link between education level and status disclosure. 18 A study in Togo noted the same findings. 16 According to a Nigerian study, knowledge of the partner's HIV status is associated with disclosure. 19 This conforms with work by Ethiopian scholars. 13 This finding underscores the need to have proper counselling messages that facilitate disclosure.
In this current study it was determined that age was associated with HIV status disclosure. The odds of disclosure reduce by 6% for a unit increase in age. In line with these findings, published literature shows that younger persons are more prone to disclose their HIV status to their sexual partner/family members than their older counterparts. According to Medley, women younger than 24 were more prone to disclose to their sexual partners than their older counterparts. 21 However, different findings were reported in Uganda. 22 Results presented by O'Brien et al. in Nigeria, showed individuals older than 22 disclosed more often to sexual partners. 23 This pattern of mixed results warrants further research into how age influences HIV status disclosure and age group targeted health education to improve disclosure rates.
There was an association between being satisfied with counselling and disclosure status. This is consistent with findings from Nigeria. 19 The importance of proper HIV status disclosure counselling cannot be overemphasized. The current study found an association between sex and disclosure status. This is aligning with results from Fifield et al. 5 Other studies have also highlighted similar findings. 24 There is need for male-targeted health education messages to improve disclosure. There was an association between education and disclosure status after adjusting for other study variables. This conforms to earlier work. 4,16,25 It has been established that learning can bring about a change in behavior. Health education is also a vital tool to bring about behavioral change in addition to formal education.

CONCLUSION
There is need to improve rates of HIV status disclosure among PLWH in Kigali, Rwanda. Various efforts should be put in place to ensure that there is increased promotion of disclosure of HIV serostatus in Rwanda through health education as well as through awareness for both HIV infected individuals and the general community. Actors in the HIV prevention programs ought to strengthen counselling efforts aimed at ensuring that there is mutual disclosure of HIV test results through encouraging discussion, minimization of stigma, for better disclosure as well as for continuing care. Besides, HIV status disclosure should be encouraged after diagnosis due to its significance, mainly among couples. Further, gender difference, as well as partner HIV status also ought to be taken into consideration in HIV disclosure intervention in order to effectively address the different needs of HIVinfected individuals.

Limitations
Cross sectional studies by nature are not able to demonstrate causality. Further, the findings may not be generalized for the entire population. Finally, the research relied on self-reported data for HIV status disclosure.