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.”