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Correlates of HIV Status Nondisclosure by Pregnant Women Living With HIV to Their Male Partners in Uganda: A Cross-Sectional Study

Bulterys, Michelle A. MPHa,b; Sharma, Monisha PhDb; Mugwanya, Kenneth PhDa,b; Stein, Gabrielle MPHb; Mujugira, Andrew PhDa,b; Nakyanzi, Agnes BScMc; Twohey-Jacobs, Lorraine MSb; Ware, Norma C. PhDd; Heffron, Renee PhDa,b; Celum, Connie MD, MPHb

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: April 1, 2021 - Volume 86 - Issue 4 - p 389-395
doi: 10.1097/QAI.0000000000002566
  • Free



In sub-Saharan Africa (SSA), the success of prevention of mother-to-child transmission (PMTCT) of HIV programs is improved when pregnant women living with HIV (PWLHIV) disclose their HIV status to their male partners. Studies have shown that HIV status disclosure is associated with higher likelihood of adhering to antiretroviral therapy (ART),1 achieving viral suppression on ART, receiving social support, safer sexual behaviors, and improved child health outcomes.2–4 High fertility rates in SSA coupled with high antenatal care (ANC) attendance (98.4% in Uganda) has resulted in most women receiving HIV testing and care during ANC.5,6 A systematic review of more than 570 studies found that fear of status disclosure and stigma were the most frequently cited barriers overall and across time for using PMTCT programs.7 Qualitative studies show that PWLHIV fear being seen taking medications or attending PMTCT services.8,9 The detrimental consequences of nondisclosure during pregnancy are well documented: a lack of disclosure is associated with higher likelihood of infant HIV acquisition, ART nonadherence for both the mother and infant, and increased maternal loss to follow-up from ART care.10–12 A case–control study found that mothers living with HIV who had uninfected infants were 14 times more likely to have disclosed their status to their male partners than mothers with HIV-infected infants.13 Similarly, a national survey in Kenya found that nondisclosure during pregnancy was associated with 12.8 times higher odds of MTCT of HIV.14 The 2019 Uganda Population-Based HIV Impact Assessment (UPHIA) identified the improvement of disclosure as a critical unmet need in the strive to achieve its 90-90-90 targets.6

Studies evaluating relationship and sociodemographic factors as predictors of female status disclosure in PMTCT settings have found that factors significantly associated with disclosure include being married/cohabitating, being in a longer-duration relationship, having an individual income, adhering to ART, knowing the HIV-positive status of male partner, current contraceptive use, and male involvement in pregnancy.9,10,15,16 Furthermore, low levels of education and living below the poverty line ($2/day) were associated with nondisclosure.10,17 Because PWLHIV with male partners of unknown status are less likely to disclose to their partners, studies evaluating this subset of HIV-infected pregnant women can provide additional insights into factors associated with nondisclosure.

We sought to identify relationship factors associated with nondisclosure of HIV status by PWLHIV to their male partners among women accessing ANC in Kampala, Uganda. The findings can inform tailored counseling messages and interventions to facilitate HIV status disclosure to their partners and improved women's retention in care.


Study Population

The current study was nested within an ongoing randomized clinical trial (RCT) among PWLHIV being conducted at the Kitebi Health Center, a public ANC clinic in Kampala, Uganda (Obumu, NCT03484533). The primary aims of the Obumu study are to evaluate the effect of secondary distribution of HIV self-test (HIVST) kits from PWLHIV on (1) male partner's testing and linkage to pre-exposure prophylaxis (PrEP) or ART, depending on his status and (2) women's postpartum ART continuation and viral suppression at 12 months postpartum. Eligibility criteria included PWLHIV, regardless of their date of diagnosis, age ≥18 years, participating in PMTCT B+ programs in Kampala, having a male partner of unknown HIV status, and being at a low risk of intimate partner violence (IPV). Health care workers assessed women's IPV risk after the World Health Organization's standardized screening tool for clinical diagnosis of IPV.18 Women were randomized in a 2:1 ratio to receive an HIVST kit or invitation letter to give to their partner for fast-track testing at the antenatal clinic. Recruitment for this study was completed in February 2020, and participating women are being followed for 12 months postpartum.

Study Design

Using baseline enrollment data from the Obumu clinical trial, we conducted a cross-sectional study to assess women's self-reported nondisclosure of HIV status to male partners and factors associated with nondisclosure.

Data Collection

Data were collected by trained study nurses through case report forms and visit summaries and entered into the study's Research Electronic Data Capture (REDCap) database using laptops and tablets during the enrollment visit. Interviewer-administered questionnaires included questions about demographics, sexual behavior, relationship characteristics and dynamics, and HIV and medical history. Participants were reimbursed for time and/or travel based on local standards. We asked women whether they perceived themselves to be in a polygamous relationship, as defined by being in a union of one man with multiple women, who often reside in the same household and together with their children. This relationship does not need to be characterized by formal marriage, nor does it include short-term extramarital relations.

Data Analysis

Descriptive statistics were tabulated to summarize participant characteristics. Univariate and multivariate log-link binomial regression models were conducted to evaluate the association between sociomeasures of relationship stability and HIV status disclosure. We report estimates as prevalence ratios (PRs) with 95% confidence intervals (CIs). Final models included adjustment for age, employment status, education level, and having an individual income, based on a priori knowledge of the effect of these factors on HIV status disclosure. In addition, we considered other potential explanatory variables and included them in the final model if we observed a change in the effect estimate of 10% or greater. If two variables were collinear, we included only the most influential variable in our model.

Ethical Approvals

This study was approved by the University of Washington Human Subjects Review Committee (STUDY00002257), the Ugandan National HIV/AIDS Research Committee (NARC 200), and the Uganda National Council for Science and Technology (SS 4501). All participants provided written informed consent.


Description of Study Population

Between May 2018 and February 2020, 500 PWLHIV with a partner of unknown status were enrolled into the study (Table 1). Approximately two-thirds of the study population (68.2%) had not disclosed their HIV status to their partners by the time of study enrollment. Over half of all study participants had completed primary school. Most women were younger than their male partners. Over half (57.4%) of all study participants started ART before learning about their current pregnancy, and 42.6% started ART during their current pregnancy. Half of the study participants were in their third trimester, 44.0% were in their second trimester, and 5.2% were in their first trimester.

TABLE 1. - Sociodemographics, Relationship Characteristics, and HIV History of PWLHIV Who Have and Have Not Disclosed Their HIV Status to Their Male Partner of Unknown Status, at the Time of Study Enrollment
Disclosed (N = 159) Undisclosed (N = 341)
  18–24 55 (34.6) 116 (34.0)
  25–29 56 (35.2) 120 (35.2)
  30–34 31 (19.5) 65 (19.1)
  35+ 17 (10.7) 40 (11.7)
 Highest education level
  Primary education 52 (32.7) 115 (33.7)
  Secondary education 78 (49.1) 159 (46.6)
  Tertiary education 29 (18.2) 67 (19.7)
 Employment status
  Unemployed 82 (51.5) 155 (45.5)
  Salaried 9 (5.7) 31 (9.1)
  Self-employed 51 (32.1) 126 (36.9)
  Regular hourly work 9 (5.7) 23 (6.7)
  Irregular hourly work 8 (5.0) 6 (1.8)
 Has an individual income 48 (30.2) 70 (20.5)
 No. of household members (including self)
  1 3 (1.9) 18 (5.3)
  2–4 128 (80.5) 282 (82.7)
  5+ 28 (17.6) 41 (12.0)
 Possible clinically significant depression* 0 (0.0) 12 (3.5)
HIV and antenatal history
 No. of previous live births
  0 22 (13.8) 67 (19.7)
  1–2 86 (54.1) 190 (55.7)
  3+ 51 (32.1) 84 (24.6)
 Knew she was HIV+ in last pregnancy
  Yes 83 (52.2) 127 (37.2)
  No 45 (28.3) 112 (32.9)
  No answer 31 (19.5) 102 (29.9)
 Knew she was HIV+ when she became pregnant with this baby 107 (67.3) 185 (54.3)
 Time since starting ART
  Less than a year ago 68 (42.7) 178 (52.2)
  1–3 yrs ago 36 (22.7) 78 (22.9)
  4+ yrs ago 52 (32.7) 77 (22.6)
  Missing 3 (1.9) 8 (2.3)
 Started ART before learning about this pregnancy 106 (66.7) 181 (53.1)
 Current pregnancy trimester
  Third trimester 81 (50.9) 171 (50.1)
  Second trimester 66 (41.5) 154 (45.2)
  First trimester 12 (7.5) 16 (4.7)
 Currently on ART 156 (98.1) 322 (94.4)
 Self-reported ART adherence
  Poor to fair 30 (18.9) 56 (16.4)
  Good to excellent 122 (76.7) 235 (68.9)
  No answer 7 (4.4) 50 (14.7)
 Most people who know her status provide support to her adherence
  Agree 130 (81.8) 192 (56.3)
  Disagree 28 (17.6) 130 (38.1)
  No answer 1 (0.6) 19 (5.6)
Relationship characteristics
 Age difference (yrs)
  She is older than him or they are the same age 16 (10.1) 51 (15.0)
  He is 1–4 yrs older than her 47 (29.6) 109 (32.0)
  He is 5–9 yrs older than her 52 (32.7) 79 (23.1)
  He is 10+ yrs older than her 32 (20.1) 56 (16.4)
  Missing 12 (7.5) 46 (13.5)
 Length of relationship (yrs)
  <1 17 (10.7) 48 (14.1)
  1–4 70 (44.0) 199 (58.4)
  5–9 51 (32.1) 69 (20.2)
  10+ 21 (13.2) 25 (7.3)
 Being married 151 (95.0) 285 (83.6)
 Relationship is:
  Monogamous 122 (76.7) 213 (62.5)
  Polygamous 33 (20.8) 114 (33.4)
  No answer 4 (2.5) 14 (4.1)
 Reports that partner has had a HIV test in the past
  Yes 70 (44.0) 63 (18.5)
  No 52 (32.7) 137 (40.2)
  Do not know 37 (23.3) 141 (41.3)
 Experiences at least one form of abuse in relationship 24 (15.1) 37 (10.9)
 Experiences physical abuse 15 (9.4) 20 (5.9)
 Experiences verbal abuse 19 (11.9) 23 (6.7)
 Experiences economic abuse 4 (2.5) 8 (2.3)
 Partner has more power than her on whether to use condoms 90 (56.6) 150 (44.0)
*Presents symptoms suggestive of depression as calculated using a mental health score, defined as having reported little interest or pleasure in doing things, feeling down, depressed, and hopeless. The mental health score was calculated using the Patient Health Questionnaire version 9 (PHQ-9) depression screening tool.32.
Experiencing abuse was defined as having reported at least one of the following: verbal abuse, economic abuse, being threatened, kicked, slapped, or forced into sex.

The proportion of women who started ART before their current pregnancy was higher among women who had disclosed than among those who had not (66.7% vs. 53.1%, respectively). Approximately 24% of women had an individual income, which was higher among those who had disclosed compared with those who had not disclosed (30.2% vs. 20.5%, respectively). Women who had not disclosed were more likely to be in their first pregnancy, newly diagnosed with HIV, on ART for a shorter amount of time or not on ART, have poorer self-reported ART adherence, and report less social support from people who know their status compared with those who had disclosed. Women who had not disclosed their status who were younger than 20 years were less likely to report knowing their partner's age.

Correlates of HIV Status Nondisclosure

In multivariate regression, higher likelihood of HIV status nondisclosure was significantly associated with being in a relationship for less than a year [adjusted prevalence ratio (aPR) = 1.25; 95% CI: 1.02 to 1.54], being in a polygamous relationship (aPR = 1.21; 95% CI: 1.07 to 1.36), and not being married (aPR = 1.20; 95% CI: 1.07 to 1.35) (Table 2). Women who reported that their partners had never been HIV tested were 46% less likely to disclose their status (95% CI: 1.20 to 1.77), and women who did not know whether their male partners had ever been tested for HIV were 55% less likely to disclose (95% CI: 1.28 to 1.88) compared with women who reported knowing that their partners had previously tested for HIV. Women who reported not receiving social support from people who were aware of her status were 32% less likely to disclose compared with women receiving social support (95% CI: 1.18 to 1.49).

TABLE 2. - Relationship Characteristics and Associations With HIV Status Nondisclosure
Frequency of Nondisclosure PR (95% CI) P Adjusted PR* (95% CI) P
Length of relationship (yrs)
 <1 48/65 (73.8) 1.30 (1.07 to 1.59) 0.008 1.25 (1.02 to 1.54) 0.001
 1–4 199/269 (74.0) 1.31 (1.12 to 1.52) <0.001 1.29 (1.11 to 1.50) 0.037
 5+ 94/166 (56.6) Ref Ref
Relationship type
 Married 285/436 (65.4) Ref Ref
 Live-in partner or other 56/64 (87.5) 1.34 (1.01 to 1.78) <0.001 1.20 (1.07 to 1.35) 0.002
Relationship is:
 Monogamous 213/325 (65.5) Ref Ref
 Polygamous 114/147 (77.6) 1.22 (1.08 to 1.37) 0.001 1.21 (1.07 to 1.36) 0.002
 No answer 14/18 (77.8) 1.22 (0.94 to 1.59) 0.13 1.12 (0.84 to 1.47) 0.45
Reports that partner has had a HIV test in the past
 Yes 63/133 (47.4) Ref
 No 137/189 (72.5) 1.53 (1.25 to 1.87) <0.001 1.46 (1.20 to 1.77) <0.001
 Do not know 141/178 (79.2) 1.67 (1.38 to 2.03) <0.001 1.55 (1.28 to 1.88) <0.001
Partner has more power than her on whether to use condoms
 Yes 150/240 (62.5) Ref Ref
 No 191/260 (73.5) 1.18 (1.04 to 1.33) 0.009 1.17 (1.04 to 1.31) 0.008
Knew she was HIV+ in last pregnancy
 Yes 127/210 (60.5) Ref Ref
 No 112/157 (71.3) 1.18 (1.02 to 1.37) 0.028 1.07 (0.92 to 1.24) 0.365
 No answer 102/133 (76.7) 1.27 (1.10 to 1.46) 0.001 1.17 (1.01 to 1.36) 0.038
She receives adherence support from people aware of her status
 Agree 192/322 Ref Ref
 Disagree 130/158 1.38 (1.10 to 1.72) <0.001 1.32 (1.18 to 1.49) <0.001
 No answer 19/20 1.59 (0.99 to 2.55) <0.001 1.56 (1.36 to 1.78) <0.001
*Adjusted for age, employment status, education level, individual income, and for each other.

Variables that were not significantly associated with nondisclosure univariately included partner's age, currently living with one's partner, whether a woman was currently on ART, trimester of current pregnancy, and number of previous live births. Age difference between women and their male partners and starting ART during the current pregnancy were associated with higher likelihood nondisclosure univariately but were no longer significant after adjustment for other variables. Women's awareness of their HIV status during her last pregnancy was associated with lower likelihood of nondisclosure univariately, but because this was the first pregnancy for some women in the sample, this variable was not included in the multivariate model.


In this study among 500 PWLHIV in Kampala, Uganda, higher likelihood of nondisclosure was associated with being in the relationship for less than a year, being in a polygamous relationship, and not being married. Furthermore, women who reported not receiving social support from others regarding their HIV status were less likely to have disclosed to their male partners. These relationship characteristics represent barriers to HIV status disclosure by PWLHIV. This knowledge can be leveraged by health care providers and lay counselors to provide targeted HIV testing and disclosure counseling messages in clinic visits and disclosure support groups.

This is the first study, to the best our knowledge, to assess rates of nondisclosure specifically among women whose male partners are of unknown HIV status. A study in Kenya found that women who did not know their male partners' HIV status had 4.23 higher odds of nondisclosure than women who knew their partners' status.10 Because none of the women in our sample knew their partner's HIV status, we could not assess this association. However, in this study, women who did not know if their partner had ever been tested for HIV were less likely to disclose their status. Qualitative studies show that a male partner's unwillingness to test and/or disclose his HIV status are barriers to a woman's disclosure of her HIV infection, in part reflecting fear from both men and women of being blamed for bringing the virus into the relationship.19 These findings suggest that interventions to increase HIV testing among male partners may help facilitate women's disclosure. One potential strategy to increase men's testing uptake is HIVST, which can serve as a discreet alternative to facility-based testing. HIVST may overcome men's barriers to facility testing, including time and transport costs, stigma, and confidentiality concerns. A study in Malawi found that HIVST was reported as the most preferred option for future HIV testing by men.20

In particular, secondary distribution of HIVST kits from pregnant women to male partners is a strategy that can be implemented in antenatal settings to increase the proportion of partners who learn their HIV status. In a study in Kenya, 91% of pregnant women attending ANC reported successfully distributing HIVST kits to their partners, which increased couples testing and disclosure as well as safer sexual behaviors.21 However, HIV testing outcomes among men in this study were ascertained by self-report through their female partner. Furthermore, most of the women were HIV-negative so disclosure of their HIV status was not a barrier to delivery of HIVST to their partners. More studies are needed to evaluate HIVST distribution and male testing outcomes among women living with HIV.

Our finding that women who do not have their own income are less likely to disclose their HIV status is consistent with previous studies.2,10 Women are particularly vulnerable during pregnancy because relationship separation, physical and financial abuse, economic vulnerability, and social stigma could severely impact their well-being and ability to care for their children.19 Women who earn their own income may be less concerned with potential loss of financial security in the case of relationship dissolution and therefore may be more likely to disclose. Messaging that ART restores one's health and eliminates transmission to sexual partners when used with high adherence, such as “U = U or undetectable is uninfectious” may reduce the probability of relationship dissolution by alleviating men's concerns that they may become infected with HIV from their female partner. This can facilitate women's disclosure and increase men's support of their partners' ART adherence. However, there remains a widespread lack of awareness of the U = U concept across SSA.22 In a qualitative study conducted in Kenya, many health providers reported lacking confidence to counsel people on the U = U concept and also feared it would encourage people to engage in multiple sexual partnerships.22 In our previous and ongoing qualitative work among HIV-positive pregnant women and their male partners in Uganda, both men and women reported concerns about relationship dissolution associated with HIV status disclosure and expressed a lack of trust and understanding that ART adherence can prevent transmission to one's partner (unpublished data).23,24 Strategies to help health care providers, individuals, and communities understand the protection from viral suppression are needed to optimize the effectiveness of U = U messaging. Furthermore, implementing peer support groups for women to gain insights into effective strategies they used to disclose their HIV status can increase women's confidence and motivation to share their HIV status with their partner. Peer support groups have been shown improve retention in care, ART access, ART adherence, HIV-related somatic and mental health symptoms, and have become a hallmark of successful PMTCT programs.25

We find that women in polygamous relationships were less likely to disclose than women in monogamous relationships, which may indicate that women feel less secure in a polygamous relationship, and warrants further research. The association between polygamy and HIV incidence is not well studied in Africa, where polygamy is legal in several countries. In Uganda, where this study was conducted, there are no restrictions to the number of wives a man can have in a union.26,27 Approximately 30% of our study population of PWLHIV reported being in a polygamous relationship (over triple the national average of 8%),28 suggesting that polygamy may be a contributing factor for HIV infection in addition to concurrent or extramarital relations, and further research is needed to evaluate this potential association.29

Limitations of this study include the cross-sectional analysis of baseline data, which limit causal inferences and assessment of temporality between HIV status disclosure and explanatory variables. In addition, women in this sample were recruited from a clinical trial and may not be fully representative of the general population of PWLHIV. The study enrolled pregnant women with a partner of unknown status, so these observations are not generalizable to women who know their partner's status. Women at risk of IPV were excluded from participation, and thus it is not possible to assess the association of past HIV status disclosure with IPV. Data on the timing of disclosure, whether study participants had disclosed their HIV status before or during the current pregnancy, were not collected. Furthermore, women were not questioned if their partner had tested before or after she was diagnosed with HIV, or whether women who had disclosed their status to their partner had intentionally disclosed or if it was accidental or otherwise made known without her consent. In addition, we cannot assess the generalizability of our findings to women with a moderate or high risk of IPV. However, because pregnant women in SSA are at higher risk of IPV and HIV-positive status is associated with a higher risk of IPV during pregnancy, additional studies are needed to understand the barriers and facilitators to HIV status nondisclosure in this vulnerable population to inform tailored interventions.30,31 HIV disclosure may need to be facilitated by providers to support women in relationships in which IPV has occurred. We found that women who had disclosed experienced more imbalance of condom decision-making power than women who have not disclosed; this might be because women who disclose their HIV status to their male partner may be at higher risk of power imbalances in the relationship, including imbalance regarding condom negotiation. Because this is a cross-sectional study, we cannot determine the direction of this association, but it highlights the needs for couples counseling and support to facilitate disclosure and maintain strong and healthy partnerships.

In conclusion, we found that relationship characteristics, including duration of relationship and polygamy, as well as a lack of knowledge about partner's HIV testing history were associated with higher likelihood of HIV status nondisclosure. Because nondisclosure by PWLHIV can lead to poorer clinical outcomes for both mothers and infants,10 it is crucial to assess factors associated with disclosure to inform targeted interventions for PWLHIV in PMTCT programs. However, disclosure of HIV status is a complex challenge, and some PWLHIV may not realistically be able to disclose their status to their male partners because of relationship power imbalances, economic dependency, and fear of abandonment. Interventions to promote HIV status disclosure should monitor for adverse events, including IPV and relationship dissolution, and proactively involve counseling support from HCWs to mitigate potential negative impacts of HIV status disclosure. Further qualitative research is needed to understand how to develop strategies acceptable to both women and men to improve disclosure, PMTCT uptake, male HIV testing uptake, and linkage to prevention in serodiscordant couples. Interventions that facilitate male partner testing and mutual disclosure, messaging to prevent relationship dissolution in serodiscordant couples (ie, U = U), and provision of peer support groups or peer leaders may provide women tools to safely disclose.


The authors thank the Obumu trial study team and the study participants. The authors gratefully acknowledge Dr. Karusa Kiragu, the Country Director of The Joint United Nations AIDS Program (UNAIDS) in Uganda, for providing her insight and expertise. The authors also acknowledge Dr. Ann Chao, Senior Advisor for the National Cancer Institute Center for Global Health, for her guidance on this paper's statistical analyses.


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HIV status disclosure; pregnant women; HIV self-testing; PMTCT

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