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Try out PMC Labs and tell us what you think. Learn More. Obermeyer conceptualized the study, coordinated the analyses, and led the writing of the article. Baijal and E. Pegurri conducted the searches, summarized theand participated in writing the article. HIV status disclosure is central to debates about HIV because of its potential for HIV prevention and its links to privacy and confidentiality as human-rights issues. Our review of the HIV-disclosure literature found that few people keep their status completely secret; disclosure tends to be iterative and to be higher in high-income countries; gender shapes disclosure motivations and reactions; involuntary disclosure and low levels of partner disclosure highlight the difficulties faced by health workers; the meaning and process of disclosure differ across settings; stigmatization increases fears of disclosure; and the ethical dilemmas resulting from competing values concerning confidentiality influence the extent to which disclosure can be facilitated.
Our suggest that structural changes, including making more services available, could facilitate HIV disclosure as much as Casual encounters Switzerland approaches and counseling do. Recognizing its importance, a of researchers have reviewed the literature on disclosure by women, 3 by men, 4 or by parents to children. Recently, increased attention to transmission within serodiscordant couples has highlighted the potential role of disclosure as a way to encourage prevention. These debates also Casual encounters Switzerland the need for a careful review of the evidence on disclosure, an examination of individual motivations and experiences around disclosure, an assessment of the role of health workers, and a better understanding of the societal determinants and consequences of disclosure in diverse settings.
We conducted an electronic search of databases for journal articles and abstracts, focusing on HIV disclosure by adults living with HIV. Disclosure is defined here as the process of revealing a person's HIV status, whether positive or negative. HIV status is usually disclosed voluntarily by the index person, but it can also be revealed by others with or without the index person's consent. After a scan of titles and abstracts, we retained sources, including 15 abstracts from the International AIDS Conference and 11 reviews or commentaries.
We included sources in this review if they were original studies or literature reviews that had appeared in peer-reviewed publications and if they reported on the levels or process of disclosure to whom, when, and howthe determinants of and reasons for disclosure, and the consequences of and incidents associated with disclosure, such as life events, risk behavior, stigma, and discrimination.
Articles that focused exclusively on children's HIV status were excluded, but we refer to children if their parents disclosed to them. We consulted the regional databases of the World Health Organization to find articles about resource-limited settings. This review also drew on related reviews of the literature on HIV testing, stigma, treatment, and prevention by Obermeyer et al. Table 1 presents the characteristics of the studies included in this review. Of the articles included, more than two thirds studies came from high-income countries, mainly the United States.
Most studies in low- and middle-income countries 49 out of 76 were from sub-Saharan Africa. A total of 98 studies were conducted among heterosexual adults of both sexes, 49 specifically among women, and 35 among men who have sex with men, of which 31 were conducted in the United States. Ellipses indicate that no studies were reviewed from that country or region. Most of these studies of were based on quantitative surveys, and they provide frequencies on different aspects of disclosure.
However, a considerable 74 studies used qualitative methods, including in-depth interviews and focus-group discussions, and some 11 studies combined questionnaires with qualitative methods, often to explore the relational context of disclosure and how individuals coped with their HIV status. Table 2 summarizes the of studies on levels and patterns of disclosure in general as well as disclosure to specific of people, such as sexual partners, family members, and friends. Overall, a striking finding of this review was that the majority of people disclosed their HIV status to someone.
The levels of reported disclosure to anyone, as shown in Table 2ranged mostly from about two thirds to about three fourths of respondents, with a few lower rates in sub-Saharan Africa. Three studies explicitly refered to involuntary disclosure, but the rest were concerned with voluntary disclosure exist, suggesting that most people willingly disclosed their HIV status.
For multiple studies on a country or population, the table presents the range of disclosure rates minimum and maximum reported in the studies. The frequencies summarized in Table 2 indicate that gender differences in levels and patterns of disclosure exist.
Women as mothers and sisters were more frequently mentioned than were men as recipients of disclosure.
Only a few studies have investigated gender differences in HIV-positive disclosure rates to partners, and the findings have been mixed. Other differences in disclosure frequency had to do with HIV status and to whom status was disclosed. Studies that included information on HIV status almost always reported that disclosure was lower when HIV status was positive. Disclosure to relatives was higher than was disclosure to friends. Partner disclosure varied greatly, but it was generally lower with casual partners than it was with steady partners.
Some studies explored sociodemographic factors that influence disclosure, principally residence and ethnicity. For example, research in South Africa found higher disclosure rates in urban settings than in rural settings. Socioeconomic factors and access to resources also appear to play an important role. In the South African study mentioned earlier, urban communities with higher disclosure rates had more institutional sources of support, including nongovernmental organizations and hospitals. Research from Nigeria and among migrants from Africa in Sweden revealed that more educated respondents disclosed more often than did their less educated counterparts.
Conversely, low-wage employment and economic vulnerability reduced disclosure by Tanzanian women, 91 Dominican male sex workers, and Canadian female sex workers. This finding is consistent with the frequencies in Table 2which tended to be higher in higher-income countries the United States and Europewhereas levels in developing countries of Africa, Asia, and the Caribbean showed much greater variation. We found that different processes have been subsumed under the concept of disclosure, underscoring the need for researchers to clarify more consistently how disclosure is measured. Quantitative studies have shown large differences in disclosure frequencies depending on what information was given and by whom, whether HIV status was positive or negative, and whether that status was disclosed to 1 or more persons, to anyone, to sexual partners, to friends, or to Casual encounters Switzerland.
Qualitative studies, on the other hand, have raised questions about the multiple dimensions and meanings of disclosure. Disclosure is not always voluntary, an issue raised primarily though not exclusively in studies conducted outside Europe and the United States. Varga et al. Research has found large variations in the amount of information that people reveal.
For example, only about half of respondents in a study from India disclosed the exact nature of their illness to those around them; others preferred partial disclosure or referred to a less stigmatizing illness, such as fever, heart problems, or general illness.
Rather than being a one-time event, as it is sometimes assumed to be, disclosure is often a gradual process of disclosing to an increasing of others in one's networks over time. For example, a study among homosexual and bisexual men in the United Kingdom found that immediately after diagnosis, respondents were more likely to opt for nondisclosure, but later they used disclosure as a mechanism for coping with the disease.
Some qualitative studies explored differences among those who disclose and those who do not, such as the criteria motivating decisions, the process of communication, and coping styles. Most of these studies were conducted in the United States, tended to emphasize the psychological aspects of disclosure, and focused on individual factors and processes, but some considered the social context of disclosure in Africa, 77and others analyzed the connections between the choices made by individuals and the ethical debates and social policies around HIV disclosure.
Much has been written about the stigma associated with disclosure of HIV-positive status. Fear of stigma is thought to discourage disclosure, and disclosure has often been considered a proxy measure for stigma, because people living with HIV are more likely to disclose in low-stigma contexts, where they expect fewer negative consequences.
Women are thought to face special barriers related to fears of stigma, as documented in numerous sources. However, it has been difficult to document the causal link between HIV disclosure and adverse events, in part because baseline rates of negative experiences such as violence are often unknown, and because HIV-positive individuals who eventually face negative reactions often come Casual encounters Switzerland disadvantaged groups that are already at high risk for violence.
Reactions of support are more likely where HIV-positive individuals are not seen as responsible for getting HIV, whereas those seen as having been infected because of their own behavior may face negative reactions. In addition, low disclosure and high support may indicate that individuals are careful not to disclose their HIV status if they expect negative reactions. Studies have also examined the behavioral outcomes of disclosure, including its possible effect on safer sex.
Disclosure of HIV-positive status to partners has been associated with safer sexual practices in the United States, 1721, France, 60 and Cameroon. Indeed, not all studies have found an association between disclosure and safer behaviors. In addition, because safer sex requires explicit discussions beyond simply disclosing HIV status, 35 the effect of disclosure needs to be considered in relation to other behaviors and attitudes. The influence of health services on disclosure has not been systematically examined, but we can piece together information on 3 interrelated questions: first, whether staff at health facilities contribute to reducing stigma and discrimination, thus normalizing HIV; second, whether they encourage disclosure by HIV-positive persons and promote testing and referral of partners and family members; and third, whether they are prepared to counsel and support those who are tested, to facilitate voluntary disclosure and support.
The extent to which health facilities promote disclosure depends in part on whether they provide a supportive context for the difficult experience of being HIV positive. Evidence suggests that health facilities sometimes fall short in this regard. Discrimination against HIV-positive individuals was reported to occur when health workers treat them differently, use excessive precautions, or withhold appropriate care.
Another indication of how disclosure is linked to health services comes from studies that examined its connection with adherence to antiretroviral therapy.
Initiatives to provide antiretroviral therapy sometimes require that patients disclose to a supportive individual in their network, on the basis of a large body of evidence indicating that disclosure facilitates initiation of and adherence to antiretroviral therapy, whereas worries about disclosure contribute to secrecy and missed medications.
In addition, health workers sometimes communicate test to individuals other than HIV-positive patients, as documented in numerous settings. Involuntary disclosure by health workers has been attributed in part to circumstances at health facilities, which often lack private spaces and where it is difficult to manage patient files without compromising confidentiality. More importantly, however, the issue of involuntary disclosure by health workers highlights the difficulty of balancing medical confidentiality with the need to facilitate disclosure to those around an HIV-positive person.
Health workers are supposed to encourage testing of partners and family members and to promote disclosure to mobilize support for treatment and prevention, but these objectives are often incompatible with guaranteeing absolute patient confidentiality. The difficulty of promoting partner disclosure is manifested in the low rates of partner referral. Some studies suggest that HIV-positive health workers find disclosure difficult because they worry that they may be stigmatized or that a positive diagnosis will mean they have failed as a role model.
These fears may hamper their own ability to be tested, to disclose, and to promote testing, as documented among health workers in Kenya and Malawi. Despite these difficulties, some studies have shown that health workers can help people cope with disclosure and its aftermath.
In Sweden, contact with counselors increased the probability of disclosure by immigrant African families, filling a gap in their disrupted social network.Casual encounters Switzerland
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