Objectives HIV testing and disclosure of results to partners is an important strategy in HIV prevention but is under-researched within heterosexual partnerships. To address this gap, we describe patterns of HIV testing, discrepancies between beliefs and biologically confirmed HIV status of each partner, and characteristics of mutually correct knowledge of HIV status among heterosexual couples in a high-prevalence community.
Methods The study recruited 290 high-risk heterosexual couples in stable relationships from a township in Cape Town, South Africa. Male patrons of shebeens (drinking establishments) were approached to participate with their main partner in an intervention designed to reduce substance use, violence and unsafe sex. All participants were tested for HIV at baseline and asked about their partner's past HIV testing and current status. Using the couple as the unit of analysis, we conducted logistic regression to identify partnership and individual characteristics associated with having mutually correct knowledge of partner's HIV status.
Results Half (52%) of women and 41% of men correctly knew whether their partner had ever been tested for HIV. 38% of women, 28% of men and in 17% of couples, both members reported mutually correct knowledge of their partner's HIV status. Correlates of correct knowledge included married/cohabitating (aOR 2.69, 95% CI 1.35 to 5.40), both partners HIV-negative (aOR 3.32 (1.38 to 8.00)), women's acceptance of traditional gender roles (aOR 1.17 (1.01 to 1.40)) and men's relationship satisfaction (aOR 2.22 (1.01 to 4.44)).
Conclusions Findings highlight the need to improve HIV testing uptake among men and to improve HIV disclosure among women in heterosexual partnerships.
Trial registration number ClinicalTrials.gov registration NCT01121692.
- HIV TESTING
- PARTNER NOTIFICATION
- SEXUAL BEHAVIOUR
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In 2012, an estimated 6.4 million South Africans were HIV-infected, representing 19% of adults 15–49 years of age.1 Although HIV incidence has stabilised in South Africa over the past decade, the country sustains hyper-epidemics within specific regions and populations.2 ,3 The National Institutes of Health proposed the ‘Seek, Test, Treat and Retain’ (STTR) strategy to curtail HIV transmission by expanding HIV testing to seek undiagnosed cases (‘Seek’ and ‘Test’), bringing patients into HIV treatment (‘Treat’), and retaining them in clinical care (‘Retain’).4 With the implementation of widespread HIV testing and counselling (HTC) programmes in South Africa, disclosure of test results to sex partners has been emphasised as a tool for engaging serodiscordant couples in HIV prevention programmes.
Structural determinants and social norms create barriers that dissuade South Africans from HTC and disclosure. Although most pregnant women are tested for HIV in antenatal clinics, men usually do not attend such clinics. Entrenched gender norms surrounding masculinity inhibit men from seeking HTC, disclosing their HIV status and initiating antiretroviral therapy (ART).5–8 Women's experiences of violence,9 traditional gender roles10 ,11 and fear of their partners’ reactions12 deter them from disclosing being tested and the test results. Fear of revealing infidelity discourages both men and women from HTC and disclosure.13
Prior studies that assessed HIV disclosure in South Africa indicate disclosure varies widely by key population, context of recruitment, type of partner14–17 and time of disclosure.17–19 Partnership duration17 and marriage or cohabitation increases the likelihood of serostatus disclosure to sex partners.15 ,16 Although these studies are informative for helping to understand the epidemic, they have limitations. In several studies, participants were recruited from environments amenable to and supportive of informing partners of HIV status (ie, clinics and HIV service organisations) and the studies typically used self-reports from one partner. In light of the heterogeneity of findings, methodological limitations and dearth of heterosexual couple-based studies, further investigation is critical to better understand how to increase couples’ disclosure rates. This research is relevant for scale-up of STTR activities as low rates of HIV disclosure within couples are associated with low rates of HIV treatment initiation and poor adherence to ART.8 ,20–22
To address this gap, we analysed data from a study of 290 high-risk couples in steady partnerships from Khayelitsha (a township with elevated HIV prevalence in Cape Town). We describe patterns of HIV testing, seroprevalence and discrepancies between the biologically confirmed HIV status of each member of the couple and beliefs about the partner's HIV status.
Study staff systematically mapped shebeens (informal drinking venues) throughout Khayelitsha and identified neighbourhoods to serve as the unit of randomisation.23 During 2010–2012, field staff approached men in shebeens purposively sampled because of strict eligibility criteria and limited information on the population sampling frame. After obtaining verbal consent from men interested in the study, gender-matched field staff screened men and their main female partners at or near the shebeen for eligibility. Each partner was screened privately to ensure that men did not coerce their female partners to join the study.
Eligibility criteria for men included 18–35 years of age, self-identified as African, lived in Khayelitsha, reported alcohol use in the past 90 days, spent time in a tavern or shebeen at least weekly, and reported unprotected sex with their main partners in the past 90 days. Both members of the couple had to independently report being in the relationship for at least the past 12 months, that they were planning to stay together for at least another 12 months and that they did not intend to try to conceive during the next 12 months. Each member of enrolled couples had separate appointments where they were confidentially tested for HIV and recent drug use, and completed an interviewer-administered baseline questionnaire using computer-assisted personal interview technology programmed in English. Interviewers were fluent in Afrikaans and isiXhosa (indigenous languages of South Africa) and could translate as needed.
Results from two rapid fingerstick tests and one confirmatory test determined HIV serostatus. If either the Unigold or Determine fingerstick test was reactive (positive) or indeterminant, a confirmatory Reveal G3 Rapid HIV-1 Antibody Test I was performed. Participants were classified as HIV-infected if any two of the three tests were positive. Study staff performed standard HTC for all participants and delivered the HIV results at the time of testing and provided them with a list of community services including HIV clinics. The interview asked participants if they were ever tested for HIV and ever told the results were positive. We classified participants as HIV-negative, previously diagnosed with HIV or newly diagnosed with HIV. They were classified as newly diagnosed if they tested HIV-positive at the study visit and reported either they had never been tested or had never been told they were HIV-positive. We classified participants as previously diagnosed if they tested HIV-positive at the study visit and previously told their past HIV test was positive.
The questionnaire asked respondents if they knew whether their partners had ever been tested for HIV, if they knew their partners’ HIV status and to report their partners’ current HIV status. We also examined whether both members of the couple correctly knew their partners’ HIV status, which served as the primary outcome variable. When one member of the couple reported that his or her partner was not infected and the partner was newly diagnosed, the response was treated as ‘correct’.
Potential correlates included partnership features (duration, marital status, children), alcohol and marijuana use, HIV testing and diagnosis history, relationship satisfaction, gender roles and control. In line with the gender-specific definitions of alcohol use put forth by the National Institute for Alcohol Abuse and Alcoholism and Substance Abuse and Mental Health Services Administration (http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking), we classified participants’ drinking patterns as light, binger or heavy defined as follows. Women were classified as (1) light ≤7 drinks per week; (2) binger average of 8–12 drinks per week sporadically and (3) heavy ≥13 drinks per week. Men were classified as (1) light ≤4 drinks per occasion; (2) binger average of 10–24 drinks per week sporadically and (3) heavy ≥25 drinks per week. Marijuana use included self-report during the previous 30 days or testing positive for its metabolites in the urine screen. A subset of 10 questions from the WHO victimisation scale measured aggressive violent behaviours, including verbal/emotional, intimidation and physical violence that was treated as a continuous variable where increasing scores indicate elevated levels.24 Adoption of traditional gender roles was derived from the Power and Attitudes in Relationships scale,25 modified for use in South Africa (αWomen=0.86, αMen=0.86). It elicits dichotomous responses (agree, disagree) to culturally relevant gender norms, such as “Men's opinions are more important than women's in making important decisions in a relationship”. Partnership control was assessed by Sexual Relationship Power scale26 (αWomen=0.84, αMen=0.82) in which participants indicate who has greater influence in the relationship. Relationship quality was assessed with the question: Is your current relationship with your main partner excellent, good, just ok, or not very good? and dichotomised to excellent versus less than excellent. Relationship satisfaction was measured with the question: In general, how satisfied are you now in your relationship with your main partner? The five response choices ranged from extremely unsatisfied to extremely satisfied and the variable was dichotomised to extremely satisfied versus less than extremely satisfied.
Descriptive analyses were stratified by gender for individual characteristics, behaviours and attitudes. We conducted logistic regression analyses treating the partnership as the unit of analysis with mutually correct knowledge of partners’ HIV status as the dependent variable. We used generalised estimating equations to assess whether accounting for the neighbourhood cluster was necessary; the results were comparable with the logistic regression analysis. For simplicity, we report results of the logistic regression. Bivariate analyses identified partnership and participant characteristics associated with both members knowing their partner's HIV status. We assessed marginal correlations among covariates for multivariable model selection and examined the results of a stepwise regression retaining variable on the basis of a p value ≤0.10. Factors associated with correct knowledge in bivariate models, and identified from the stepwise procedure, were included in multivariable models unless highly correlated with another independent variable or the cell sizes were too small to be meaningful.
Staff approached 363 men who had a partner and screened these couples at the same time although separately for potential study eligibility. Of these, 31 couples were ineligible, 32 couples did not attend the baseline study visit and 300 couples enrolled. We excluded 10 couples from analyses because the neighbourhood clusters were not within Khayelitsha,23 leaving 290 couples from 28 neighbourhoods.23 The mean ages were 24 and 26 years for women and men, respectively, most of the sample was unemployed (75%) and few completed high school (27%) (table 1). The majority of men (60%) were heavy drinkers, whereas the majority of women either abstained (42%) or reported light drinking (22%).
The baseline HIV prevalence was 20%. Women (26%) were more than twice as likely as men (13%) to be HIV-infected (OR=2.34, 95% CI 1.52 to 3.59). Among HIV-infected participants, 40% were newly diagnosed (table 1). Significantly more men (63%) were newly diagnosed than women (28%) (OR=2.36, 95% CI 1.52 to 3.59). Only 8% of women as compared to 32% of men reported they had never had HTC. More than half of women reported past pregnancy (62%); nearly all previously pregnant women (97%) had been tested (likely a result of universal opt-out HTC in South African public antenatal clinics). For the majority of couples, neither member was HIV-infected (69%, table 1). Serodiscordant partnerships and HIV-infected seroconcordant couples comprised 21% and 9% of partnerships, respectively. In half (52%) of the partnerships, both members reported that they did not know their partners’ HIV status, 31% misreported it and in 17% of the couples, each member correctly reported their partners’ status.
Correct knowledge of HIV testing and serostatus within partnerships
Nearly half of the women (49%) believed their partner had been tested for HIV, and among these women, most of their partners had been tested (78%) (table 2). Among the women (35%) who did not believe their partner had been tested, 60% of male partners reported past HIV tests. Only 14 women reported that their partner was HIV-positive, and of these, 6 were correct. Of the 108 (38%) women who reported their partner was not infected, 95% were correct; 58% of women reported not knowing their partner's status. In sum, 38% of women correctly reported their partners’ HIV status; the majority comprised uninfected partners.
Of the 111 (38%) men who believed their partner had previously tested, nearly all were correct (96%). Men under-reported their partner's testing history: 43% of men believed their partner had never been tested, yet 88% of the women had been tested. Twenty-nine per cent of men believed their partner was HIV-negative, and most were correct (83% and 4% newly diagnosed). Nevertheless, the majority of men (66%) did not know their partner's HIV status. Similar to the women's pattern, 28% of men knew the correct status of their partner, and the majority of these women were uninfected (table 2).
Correlates of correct knowledge of HIV serostatus within partnerships
Married or cohabitating couples (42%) were twice as likely as unmarried couples (24%) to know each other's serostatus (OR=2.22, 95% CI 1.16 to 4.22) (table 3). Similarly, couples who had children together were more than twice as likely to accurately report their partners’ HIV serostatus (OR=2.60, 95% CI 1.30 to 5.19). If both members of the couple were HIV-negative, they were three times as likely to report each other's status correctly (OR=3.06, 95% CI 1.31 to 7.11).
Individual attitudes and behaviours associated with each member of the couple knowing their partners’ HIV status differed by gender (table 3). Among women, most variables were not associated with mutually correct knowledge of HIV status including risk behaviours, previous HIV diagnosis and the time since diagnosis, assessments of gender-based violence and partner control (table 3). However, women's higher acceptance of traditional gender roles increased the likelihood of correct HIV status knowledge in the partnership (OR=1.18, 95% CI 1.03 to 1.36 per unit increase in scale score). In contrast, men who reported ever being tested for HIV (OR=13.9, 95% CI 3.30 to 58.8) or who were previously diagnosed (OR=3.01, 95% CI 0.96 to 9.42, p=0.06) were more likely to be in partnerships where there was mutually correct knowledge of HIV status. Mutually correct knowledge of partner HIV status was twice as likely in partnerships where men were extremely satisfied (OR=2.07, 95% CI 1.09 to 3.94).
The variables associated with mutually correct knowledge of HIV status for both members of the couple identified in bivariate analysis and retained in the multivariable model persisted to be correlated with correct knowledge (table 4). Having children was excluded from the model because of its high correlation with marital status. The cell sizes were too small to keep HIV testing and HIV diagnoses in the model.
Using baseline data from a study of 290 high-risk couples from Khayelitsha, this analysis investigated couples’ beliefs about their partners’ HIV testing and serostatus. Instead of using self-reported measures of HIV disclosure from one member of a couple as is often published, we conducted an analysis at the level of the partnership. Using self-reported data about participants’ HIV testing experience, biological HIV test results and beliefs of partners’ HIV testing and serostatus, we demonstrate that correct knowledge of HIV statuses within high-risk partnerships (17%) was alarmingly low.
Seeking and testing women for HIV has clearly achieved success, as 93% of women reported receiving HTC at least once. Almost all women who reported a previous pregnancy knew their HIV status likely due to the universally accessible opt-out HIV testing and counselling for pregnant women attending public antenatal services. Nevertheless, many women did not disclose their HIV serostatus to their partners—only 7 of the 55 women (13%) previously diagnosed with HIV were in partnerships with mutually correct knowledge of their partners’ serostatus. Contrary to other studies suggesting that fear of retribution from their partners inhibits disclosure,10 ,12 ,27 women's self-reports in this study about violence and control in their relationships were not associated with correct knowledge of HIV status in the partnerships. Contrarily, adoption of traditional oppressive gender norms for women increased the likelihood of correct knowledge. Increased endorsement of these norms was also inversely associated with women's opinion about the quality of (OR=0.68, 95% CI 0.60 to 0.77) and their satisfaction with the relationship (OR=0.89, 95% CI 0.80 to 0.99); this correlation may be a marker of underlying currents of men's dominance in the relationship.28 ,29
Among HIV-positive men at the baseline visit, 63% were newly diagnosed. With the promotion of the STTR paradigm, clearly HIV testing remains woefully inadequate for men. Nonetheless, although men do not seek HIV testing nearly as often as women, in this population when men had received HTC or were previously diagnosed with HIV, both members of the couple were more likely to know their partner's HIV status.14 ,30 This promising finding suggests that if STTR measures increase the uptake of testing among men more disclosure will take place and couples may engage in fewer sexual risk behaviours. Even if STTR strategies improve among men, the low rates of HIV status disclosure among women remains a threat to public health in the region. In addition to increasing testing among men, research is needed to develop and evaluate strategies for helping couples overcome communication barriers with their partners and to address other relationship dynamics that dissuade disclosure, particularly among women.
Furthermore, as the multivariable analysis suggests, men's experiences and investment in the relationship seem to drive whether both members of the couple know their partners’ HIV status. The likelihood of correct HIV knowledge with women's acceptance of traditional gender roles also aligns with the interpretation that men dominate when and if disclosure occurs. Men's control of circumstances surrounding disclosure of HIV may be part of a broader social norm where men also control women's access to HIV care and ART adherence, which may impede the success of STTR efforts.
The study and analysis has limitations. The study restricted eligibility for men to Africans in Khayelitsha, who frequented shebeens, many of whom drank alcohol in excess and were in stable heterosexual relationships for at least 12 months. Accordingly, these findings may not be generalisable to other populations and settings. The sample size is too small for extensive multivariable analysis. Some participants may have guessed (correctly or incorrectly) the status of their partner. In addition, males had to report unprotected sex with their partner to be eligible. There may be some stigma attached to admitting unprotected sex with a discordant partner, which could have led to intentional misreporting. Social desirability bias may have led to an underestimate of partner victimisation as they are low in this study in relation to estimates from other studies of partner victimisation in South Africa,28 ,29 explaining in part the lack of an association with the outcome. Couples willing to enrol in an intervention trial may have been reluctant to report victimisation; alternatively, couples who were living in severely abusive relationships may have been unwilling to participate in the study alongside their abusive partner.
Our study brings methodological strengths to address gaps in past examinations of HIV disclosure in couples residing in a South African community with elevated HIV incidence and prevalence. We determined whether couples knew the biologically confirmed HIV serostatus of their partners. Few participants correctly reported their partner's HIV status, and even fewer partnerships (17%) had mutually correct knowledge of partners’ HIV status. Further, 21% of the partnerships were serodiscordant, representing a substantial risk of HIV acquisition to the other member of the couple. These findings underscore that the STTR effort in South Africa must extend its reach to men and include components that can help both members of the couple overcome communication barriers and other relationship dynamics to disclose their HIV test results to each other and take appropriate measures to prevent onward transmission.
‘Seek, Test, Treat, and Retain’ (STTR) is a strategy for curbing HIV transmission by finding undiagnosed HIV-infected persons and maintaining their clinical care used in South Africa.
In this longitudinal study of 290 stable couples in Cape Town, the prevalence of biologically confirmed HIV was 26% and 13% among women and men, respectively, and 63% men and 28% of women were newly diagnosed at enrolment.
38% of women, 28% of men and in 17% of couples, both members mutually reported the correct HIV status of their main partners. In almost half of the partnerships (52%), both partners did not know their partner's status.
To reduce onward transmission of HIV in South Africa, STTR programmes must be expanded to reach more men and to facilitate disclosure of HIV status for both genders.
Handling editor Jackie A Cassell
Contributors IAD conducted the analysis and drafted and finalised manuscript with much input from BM. AMM contributed to the analysis. TLK assessed psychometrics and prepared the dataset. WAZ, CP and NE contributed study design and monitored implementation and contributed to the manuscript. WMW was the principal investigator who conceived and oversaw all aspects of the study and granted final approval for this work.
Funding This research was supported by the National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism Grant R01 AA018076 (PI: Wechsberg).
Competing interests None declared.
Ethics approval The Institutional Review Boards at RTI International and at Stellenbosch University's Faculty of Health Sciences granted ethical approval for the study.
Provenance and peer review Not commissioned; externally peer reviewed.