During the past 10 years, the scaling-up of HIV testing and antiretroviral therapy (ART) has changed the face of the HIV/AIDS disease and epidemic in both high-income and low-income countries. The primary achievement has been a decline in AIDS-related mortality at the population level and longer lives for people living with HIV/AIDS (PLWHA) even in resource-limited settings.1 In sub-Saharan Africa heterosexual transmission remains the predominant mode of acquisition of adult HIV infection and most PLWHA living in stable relationships have a serodiscordant partner.2 Although considered as a key component of secondary prevention in reducing the risk of HIV transmission, disclosure of one's HIV-positive status to one's serodiscordant partner remains generally low in sub-Saharan Africa.3
In Cameroon, a national ART program was launched in 2001, based on the existing decentralized framework of the health care system.4 According to the new World Health Organization 2010 guidelines, the overall ART coverage among Cameroonian HIV-infected adults was 28% by the end of 2009.1 The ANRS 12-116 EVAL (Evaluation du programme camerounais d'accès aux traitements antirétroviraux - Impact sur la prise en charge et les conditions de vie de la population infectée par le VIH) study aimed at evaluating the extent to which decentralized HIV care in Cameroon increased access to ART and how the individual and structural factors influenced access to care and treatment after diagnosis.5,6 The study showed that approximately 78% of included patients were receiving ART at the time of the study and that access to ART encouraged disclosure to family members and relatives.7 Safe sex was shown to be the main reason for disclosing one's status to one's main partner, as declared by 86% of the HIV-infected women participating in the study. Multivariate analysis focusing on individual factors was able to identify a set of characteristics associated with serostatus disclosure as follows: younger age, being married, living with children, knowing the serostatus of one's main partner, and believing that ART can cure HIV.8 Data from large representative samples of PLWHA in resource-limited countries is sparse. The purpose of the present study was to use such a sample to identify the structural factors associated with HIV serostatus disclosure to one's steady partner in Cameroon, while taking into account individual factors.
The ANRS 12-116 EVAL survey was conducted from September 2006 to March 2007 and provided cross-sectional data for a large representative sample of 3151 PLWHA attending HIV facilities in one of 27 hospitals at the central, provincial, or district level, representative of the treatment centers throughout the whole country. PLWHA were randomly selected by health care workers. Patients signed an informed consent form to participate and answered a face-to-face questionnaire administered by a trained interviewer. The collected data included the following patient information: sociodemographic and socioeconomic characteristics; disease history; perception and adherence to ART and medical follow-up; health care expenditures for the previous month; perception of health status; and quality of life and social relationships. Data about the characteristics of the participating health care facilities and their medical staff were also collected. Further details on the full design of the survey are described elsewhere.6
Study Population and Variables Definitions
The present analysis focused on patients who had a main partner at the time of the survey (n = 1673). The variable “having a main partner” is defined in our analysis as living in a stable relationship with a regular partner, with or without sexual activity. Safe sex was defined as having a seropositive partner or reporting systematic condom use or no sexual relationships with one's main partner during the previous 3 months. Unsafe sex was defined as nonsystematic use of condoms with one's seronegative or unknown serostatus main partner at least once during the previous 3 months. The variable “gender and head of household” was computed by combining the gender of the patient with his/her social status (built in 2 categories: being a male or female head of the household vs. being a female but not the head of the household). The variable “circumstances of HIV testing” was computed by combining the variables “who initiated HIV testing?” and “what was the reason for your HIV-test?” (built in 2 categories: testing because of pregnancy and upon request of health staff vs. testing because of pregnancy upon patient's initiative or due to other circumstances and upon patient's or health staff initiative). This last variable was computed for evaluating its impact on women' disclosure to their main partner in a sensitivity analysis only targeting women.
Health Care Facilities Characteristics
The following characteristics of the 27 health care facilities were used in this study to identify structural factors associated with serostatus disclosure: the level of decentralization (central, provincial or district level) and the existence of psychosocial and/or economic support in the hospital where the patient was followed-up, including interventions such as individual interviews with a psychologist or a social worker, meetings between PLWHA, an available information center for the patient, and counseling or assistance with adherence.
We used Pearson χ2 and analysis of variance for bivariate analysis. Individual and health-system determinants correlated with serostatus disclosure to one's main partner were identified using a hierarchical logistic model, which allows the impact of contextual and individual factors on individual outcomes to be studied. To appropriately model the relationship between patient-level and hospital-level covariates on HIV disclosure simultaneously, we developed a 2-level hierarchical model which enabled us to take into account the correlation between individuals (level-1) within each hospital-level unit (level-2).9 This was performed with hierarchical logistic model 6 for Windows (Scientific Software International, Inc, Lincolnwood, IL).
Risk factors were screened for inclusion in the multivariate model by testing each of them independently for a significant association with disclosure, using a liberal P value of 25% threshold in the univariate analysis. The variables achieving that criterion were considered for inclusion in the multivariate model. Stepwise backward selection procedures were used to select only the significant individual characteristics with a 5% threshold. Mixed models were estimated using the restricted maximum likelihood method with Stata software (StataCorp. 2005. Stata Statistical Software: Release 9. StataCorp LP, College Station, TX).10 Once the model identified, a sensitivity analysis was performed by running this model only on women and testing the significance of additional women-specific variables.
Among the 3488 PLWHA randomly selected among eligible patients, 3170 agreed to participate and 3151 filled out the questionnaire completely (global response rate: 90%). Slightly more than half (n = 1673, 53.1%) of the survey's participants declared having a main partner at the time of the survey (study sample). These respondents were primarily female (n = 1014, 61%), with a median (IQR) age of 36 years (31-43). The majority had no education or a low education level (91%), were living with a main partner (70%) and with children (87%), and were living below the poverty line (75.5%)—defined as a monthly household income of 20,000 CFA Francs or less per adult equivalent (ie, US $1.3 per day). Half (49.5%) of them were heads of households.
Concerning clinical characteristics, median (IQR) time since diagnosis was 21(10-40) months although median (IQR) CD4 cell count at the time of the survey was 341(214-452) cells per cubic millimeter. A high proportion of patients (77%) reported receiving ART at the time of the survey, whereas 30% had already progressed to CDC stage C of the disease. Regarding sexual behavior during the previous 3 months, 84% of patients declared having safe sex that is, systematic condom use or no sexual relations with their main partner, whereas 16% engaged in unsafe sex. A majority (59%) thought that ART could cure HIV. The distribution of patients with respect to the HIV care level was as follows: approximately 41% attended a facility at a central level, 29% at a provincial, and 30% at a district level. Last, most patients (92%) reported receiving psychosocial and/or economic support in the hospital.
Factors Associated With HIV Disclosure to the Main Partner
Among the 1673 patients included in this study, 1429 (85%) reported having disclosed their serostatus to their main partner. The following factors did not seem to be significantly associated with disclosure: education level, time since diagnosis, ART receipt at time of study, CD4 cell count, and finally, clinical stage of the disease. Univariate and multivariate analyses based on multilevel modeling approaches showed that the following individual factors were significantly associated with disclosure (Table 1): living with one's steady partner; living with children; reporting no sexual risk with one's steady partner (defined as systematic condom use or being sexually abstinent), and not living below the poverty line. Moreover, PLWHA who knew other HIV-infected persons in their familial and social circles were significantly more likely to disclose their serostatus than those who had not. A gender-related factor seemed to be associated with disclosure when jointly considering the gender and head of household status. Women were more inclined than men to disclose their serostatus to their steady partner if they were not heads of households (P < 0.04). The sensitivity analysis performed only on women confirmed the model identified and the only additional variable found significantly associated with the outcome was "testing during pregnancy upon health staff request [odds ratio (95% confidence interval): 3.8 (1.7 to 8.4), P = 0.001]. Results concerning structural factors showed that variables such as attending national health facilities in Yaoundé or Douala and having access to psychosocial or economical support interventions in hospital were significantly associated with disclosure.
This study reports a high level of serostatus disclosure to one's steady partner (85.4%) among a national representative sample of PLWHA attending HIV care facilities at the different levels of the health care system (central, provincial and district) in 6 of the 10 provinces of Cameroon. This proportion is comparable with those reported in studies conducted in other West and East African countries,11-13 but higher than those described in South Africa14,15 and Zambia.16 As the EVAL survey was directly carried out in HIV care units, it is possible that in terms of the general population of PLWHA, those who concealed their serostatus might have been underrepresented in the sample, as they may have been less likely to seek HIV care. However the decentralization of the Cameroonian health care system might have limited any such effect because it has been shown to increase HIV care accessibility for PLWHA.17
Disclosure was significantly associated with safe sex, defined as systematic condom use or nonsexual relations with one's main partner. In terms of sexual behavior, safe sex was reported by half of the participants, whereas one-third reported being sexually abstinent to avoid HIV transmission. The high rate of abstinence might be explained by the fact that it was promoted during counseling to PLWHA by health care and social workers.18,19 As in several other studies in Africa, unsafe sex, defined in this study as inconsistent condom use with one's main partner, was shown to be associated with concealment of one's seropositivity.20-23 We observed no per se gender-related factor associated with disclosure. Only HIV-infected women who were not heads of households were more likely to have disclosed their serostatus to their steady partner. These women might be more economically dependent on their partner than those who are heads of households. A low socioeconomic status was associated with partner notification among HIV-infected pregnant women.24,25 Men or/and women who are heads of households have to assume important responsibilities toward their family, and this might represent a barrier to disclosure and a fear of rejection and stigmatization. PLWHA who are heads of households are also more likely to be economically independent of their partners, and as such are not obliged to disclose their serostatus to obtain financial support for their health expenditures or their survival. This was confirmed by the fact that PWLHA having a better economic status were more likely to disclose their serostatus than those living below the poverty line. Furthermore a previous analysis of patients followed up in the public hospitals in Yaoundé showed that financial difficulties were significantly associated with lower adherence to ART and with lower CD4 counts.5 These results reinforce the need not only for economic interventions at the individual level but also for public health policies which provide free access to HIV care and treatment to the whole population, especially the poor ones.
Living with one's main partner and having children in one's household were factors associated with disclosure. These factors were also associated with disclosure in a study conducted in Mali and Burkina Faso, although having children was specifically associated with disclosure by women.11 Moreover, we showed that HIV testing of pregnant women upon the request of health care providers was associated with disclosure to one's main partner. As in many other studies conducted in developing countries, women represent the majority of participants (60.6% of our sample) and this might explain the importance of pregnancy and motherhood as a key factor in disclosure.8,26 All these results reinforce the need to develop interventions which encourage PLWHA to disclose their status to their serodiscordant partners and the need to involve these partners in prevention interventions (eg, couple counseling) and in support for adherence to ART. In this way, efficient HIV-positive prevention strategies can be developed,13,27,28 and HIV-related stigma decreased,14,29 allowing PLWHA greater access to social and/or material support15,30 which in turn provide physical and mental health benefits.12,24 Moreover, the involvement of the partner in supporting treatment adherence can potentially improve quality of life through enhanced response to ART.7
Apart from individual factors, our study provided evidence that some structural factors were significantly associated with disclosure to the steady partner. A previous analysis described the structural characteristics of the HIV care facilities participating in the ANRS12-116 EVAL survey and pointed out that access to ART is less likely in larger district hospitals (>150 beds) but also in national or provincial units with higher workload for medical staff and little or no task-shifting from physicians to nurses.17 Psychosocial and economic support interventions for PLWHA lead to better adherence to ART, are beneficial at the individual level, and are of strong interest in deciding on public health policies.31 Our results showed that patients seeking HIV care at the national level and in services providing psychosocial and/or economical support for PLWHA were more likely to disclose their serostatus to their main partner. These results strengthen the argument for the introduction and/or development of psychosocial and economic interventions at all levels of organization in Cameroonian hospitals as an important component of health system strengthening in public health policies for those living with HIV. Community support initiatives, such as treatment support groups run by PLWHA, also play a key role in disclosure to family members.32 Where health system strengthening is needed, engaging the community in HIV care might be a condition to ensure the development and success of positive prevention strategies.
The authors would like to thank all the patients and medical staff for their participation in the study. We would also like to thank Jude Sweeney for revising and editing the English version of the article.
1. UNAIDS. Report on the global AIDS epidemic. Geneva, Switzerland: United Nations Programme on HIV/AIDS
2. Eyawo O, de Walque D, Ford N, et al. HIV status in discordant couples in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Infect Dis
3. Pinkerton SD, Galletly CL. Reducing HIV transmission risk by increasing serostatus disclosure
: a mathematical modeling analysis. AIDS Behav
4. Gruenais M. Changing a health system: the case of Cameroon. Bulletin de I'APAD,
2001;21 (online November 25, 2005). Available at: http://apad.revues.org/26.
5. Boyer S, Marcellin F, Ongolo-Zogo P, et al. Financial barriers to HIV treatment in Yaounde, Cameroon: first results of a national cross-sectional survey. Bull World Health Organ
6. Marcellin F, Boyer S, Protopopescu C, et al. Determinants of unplanned antiretroviral treatment interruptions among people living with HIV in Yaounde, Cameroon (EVAL survey, ANRS 12-116). Trop Med Int Health
7. Marcellin F, Bonono CR, Blanche J, et al. Higher risk of unsafe sex and impaired quality of life among patients not receiving antiretroviral therapy in Cameroon: results from the EVAL survey (ANRS 12-116). AIDS
. 2010;24(suppl 1):S17-S25.
8. Loubiere S, Peretti-Watel P, Boyer S, et al. HIV disclosure and unsafe sex among HIV-infected women in Cameroon: results from the ANRS-EVAL study. Soc Sci Med
9. Rice N, Jones A. Multilevel models and health economics. Health Econ
10. Rabe-Hesketh S, Skrondal A. Multilevel and Longitudinal Modeling Using Stata
. 2nd ed. College Station, TX: Stata Press; 2008.
11. Ndiaye C, Boileau C, Zunzunegui MV, et al. Gender-related factors influencing HIV serostatus disclosure
in patients receiving HAART in West Africa. World Health Popul
12. Medley AM, Kennedy CE, Lunyolo S, et al. Disclosure outcomes, coping strategies, and life changes among women living with HIV in Uganda. Qual Health Res
13. Kairania R, Gray RH, Kiwanuka N, et al. Disclosure of HIV results among discordant couples in Rakai, Uganda: a facilitated couple counselling approach. AIDS Care
14. Simbayi LC, Kalichman SC, Strebel A, et al. Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa. Sex Transm Infect
15. Wong LH, Rooyen HV, Modiba P, et al. Test and tell: correlates and consequences of testing and disclosure of HIV status in South Africa (HPTN 043 Project Accept). J Acquir Immune Defic Syndr
16. Bond VA. “It is not an easy decision on HIV, especially in Zambia”: opting for silence, limited disclosure and implicit understanding to retain a wider identity. AIDS Care
. 2010;22(suppl 1):6-13.
17. Loubiere S, Boyer S, Protopopescu C, et al. Decentralization of HIV care in Cameroon: increased access to antiretroviral treatment and associated persistent barriers. Health Policy
18. Moatti JP, Prudhomme J, Traore DC, et al. Access to antiretroviral treatment and sexual behaviours of HIV-infected patients aware of their serostatus in Cote d'Ivoire. AIDS
. 2003;17(suppl 3):S69-S77.
19. Kiene SM, Bateganya M, Wanyenze R, et al. Initial outcomes of provider-initiated routine HIV testing and counseling during outpatient care at a rural Ugandan hospital: risky sexual behavior, partner HIV testing, disclosure, and HIV care seeking. AIDS Patient Care STDS
20. Kiene SM, Christie S, Cornman DH, et al. Sexual risk behaviour among HIV-positive individuals in clinical care in urban KwaZulu-Natal, South Africa. AIDS
21. Protopopescu C, Marcellin F, Preau M, et al. Psychosocial correlates of inconsistent condom use among HIV-infected patients enrolled in a structured ART interruptions trial in Cote d'Ivoire: results from the TRIVACAN trial (ANRS 1269). Trop Med Int Health
22. Olley BO, Seedat S, Stein DJ. Self-disclosure of HIV serostatus in recently diagnosed patients with HIV in South Africa. Afr J Reprod Health
23. Kalichman SC, Ntseane D, Nthomang K, et al. Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS
in Botswana. Sex Transm Infect
24. Antelman G, Smith Fawzi MC, Kaaya S, et al. Predictors of HIV-1 serostatus disclosure
: a prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania. AIDS
25. Farquhar C, Mbori-Ngacha DA, Bosire RK, et al. Partner notification by HIV-1 seropositive pregnant women: association with infant feeding decisions. AIDS
26. Brou H, Djohan G, Becquet R, et al. When do HIV-infected women disclose their HIV status to their male partner and why? A study in a PMTCT programme, Abidjan. PLoS Med
27. Bunnell R, Mermin J, De Cock KM. HIV prevention for a threatened continent. Implementing positive prevention in Africa. JAMA
28. Desgrees-du-Lou A, Orne-Gliemann J. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa. Reprod Health Matters
29. Vu L, Andrinopoulos K, Mathews C, et al. Disclosure of HIV status to sex partners among HIV-infected men and women in Cape Town, South Africa. AIDS Behav
30. Ssali SN, Atuyambe L, Tumwine C, et al. Reasons for disclosure of HIV status by people living with HIV/AIDS
and in HIV care in Uganda: an exploratory study. AIDS Patient Care STDS
31. Boyer S, Clerc I, Bonono CR, et al. Non-adherence to antiretroviral treatment and unplanned treatment interruption among people living with HIV/AIDS
in Cameroon: individual and healthcare supply-related factors. Soc Sci Med
32. Wouters E, van Loon F, van Rensburg D, et al. Community support and disclosure of HIV serostatus to family members by public-sector antiretroviral treatment patients in the Free State Province of South Africa. AIDS Patient Care STDS