Sendo et al.

BMC Public Health 2013, 13:765

http://www.biomedcentral.com/1471-2458/13/765

RESEARCH ARTICLE Open Access

Disclosure experience to partner and its effect on

intention to utilize prevention of mother to child
transmission service among HIV positive pregnant
women attending antenatal care in Addis Ababa,
Ethiopia
Endalew Gemechu Sendo1*, Amsale Cherie1 and Tadese Asfaw Erku2

Abstract
Background: Disclosure of HIV status has become an entry criterion for prevention of mother to child transmission
programs in resource-constrained countries. However, little has been explored about the prevalence of, barriers to,
outcomes and factors associated with HIV status disclosure among HIV positive pregnant women in Ethiopia.
Method: Cross- sectional study was conducted among 107 pregnant women who were attending antenatal care in
public centers from April to June 2011 in Addis Ababa capital city of Ethiopia.
Data was collected using interviewer administered pretested structured questionnaire and entered and was
analyzed using SPSS- 15 version. Results presented in tables.
Result: Seventy three percent of women had disclosed their HIV status to their partner. Discussion about testing
and a smooth relationship with the partner were independently associated with their disclosure. Women who
disclosed to their partners were almost five times more likely to participate in Prevention of Mother to Child
Transmission programs than their counterparts (AOR = 4.74; 95% CI 1.24-18.14).
Conclusions: Although most participants disclosed their HIV sero-positive status, lack of disclosure by some women
might result in a limited ability to participate in PMTCT programs. Thus, assertiveness and improved communication
skills training should be offered to HIV positive pregnant mothers and be reinforced during on-going counseling.
Keywords: HIV status disclosure, PMTCT, Sexual partner

Background (l) about 2.3 million children under 15 years living with
Disclosure of HIV status has become an entry criterion AIDS in the world, and the vast majority of these were
for prevention of mother to child transmission programs in Sub-Saharan Africa.
in resource-constrained countries [1,2]. However, little Mother-to-child transmission of HIV is associated with
has been explored about the prevalence of, barriers to, up to 90% of all infection in children up to six years [4,5].
outcomes and factors associated with HIV status disclos- It is estimated that without any intervention about 35%
ure among HIV positive pregnant women in Ethiopia. of children born to HIV infected mothers will be infected
Disclosure benefits both the individual and the public. with the virus. This percentage has reportedly been re-
To the individual, benefits include less anxiety and [1,3] duced to levels as low as 2% in developed countries with
increased social support. Studies showed that there are the advent of antiretroviral drugs and the implementation
of core PMTCT intervention [6,7].
* Correspondence: [email protected] In addition, a larger proportion of studies from devel-
1
Addis Ababa University, College of Health Science, School of Nursing and oping countries reported that women did not share their
Midwifery, Addis Ababa, Ethiopia, P.O. Box 1176, Ethiopia HIV test results with anyone (10%-78%) as compared to
Full list of author information is available at the end of the article

© 2013 Sendo et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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women in developed countries (3%-10%) [8-13]. The preva- unsuitable questions were modified after the pretest had
lence of HIV positive pregnant women in Addis Ababa is been conducted.
7.2% [9]. There are minimal studies regarding disclosure of
HIV status in the study area. Therefore, this present study Data analysis
is undertaken to determine the prevalence of, barriers to, Data was entered, cleaned and analyzed using SPSS version
and effects of HIV positive status disclosure among HIV 15 computer software. Logistic regression model was used
positive pregnant women attending ANC in Public health to examine the association between socio-demographic
Health centers in Addis Ababa, Ethiopia”. characteristics and relationship factors with HIV positive
status disclosure to a partner and also the effect of disclos-
Methods ure on the intention to utilize PMTCT service. First factors
Study design and area related to the dependent variables were analyzed using
An institution- based cross-sectional study was conducted bivariate analyses and those variables found significant
from April to June 2011 among HIV positive pregnant at the bivariate were further entered and analyzed using
women attending ANC public centers in Addis Ababa logistic regression analysis.
capital city of Ethiopia.
Ethical consideration
The study secured ethical clearance from the institu-
Sample size and sampling technique tional review board of Addis Ababa University. All study
A single population proportion formula, [n = (Z α/2)2 participants were adequately informed about the pur-
p (1-p) / d2], was used to estimate the sample size. The pose, method and anticipated benefit and risk of the
following assumptions were made: prevalence of HIV study by the data collectors. Verbal consent was obtained
positive pregnant women in Addis Ababa 7.2%, [3] 95% from each participant and confidentiality of the study
confidence interval, margin of error 5% (d = 0.05) and subjects was maintained.
allowance for non-response 10%. Then the total sample
size calculated was 112. All eight health centers that Results
have a client flow of 4–10 clients per month in the city Socio demographic characteristics
were included in the study. From the selected health A total of eight health centers were included in the study.
centers, all HIV positive pregnant women who gave The study population consisted of 112 HIV positive
their consent to participate were interviewed. pregnant women, of whom 107 of them agreed to be
interviewed, making the respondent rate of 95.5%. The
Data collection remaining five women were not willing to participate in
Structured interviewer questionnaire was developed to the study.
collect information about the dependent variable regarding All 107(100%) participants were married and had one
HIV positive status disclosure to a partner and intension of regular partner. Forty three (42.1%) respondents were in
utilization of PMTCT and characteristics that determine the age group of 25–29 years. Regarding the ethnicity of
disclosure of HIV status namely socio-demographic charac- the respondents, the most numbering 32(29.9%) of the
teristics (age, income, education, religion and occupation), respondents were Amhara. Fifty two (48.6%) mothers had
relationship factors (duration of relationship, fear of part- primary school education. Fifty nine (55.1%) of the re-
ner’s reaction and HIV status of partner), barriers to HIV spondents were house wives and unemployed. Forty-
status disclosure ( fear of abandonment, fear of confidenti- two (39.3%) of the respondents had a monthly income
ality, and fear of accusation of infidelity) and Outcomes of less than 28 Dollars per month. The majority of women
of disclosure (acceptance, understanding, blame and 71(66.4%) were followers of orthodox Christianity. Bivari-
violence). Information about disclosure status was doc- ate analysis showed that there were no statistically sig-
umented by asking if the women had verbally revealed nificant differences between those disclosing their status
her HIV positive status to her sexual partner. compared to those who had not with respect to these
The questionnaire was translated into the Amharic above-mentioned variables (see Table 1).
(national language) by linguistic professionals. Matching
was made on the exact fitness of the two versions. A Disclosure experience of HIV positive pregnant mothers
pretest using the questionnaire was conducted among Seventy eight (73%) of the 107 respondents had disclosed
fifteen percent of the total sample size that was not in- their HIV sero-positive status to their sexual partner.
cluded in the study. Out of the 107 participants 42 (39.3%) of them had HIV
The pretest as well as the study was done by trained data positive partners. However, 25(23.4%) of them had HIV
collectors (experienced nurse counselors who were working negative partners (discordant), 35(32.7%) had sex part-
in the respective PMTCT centres) and any ambiguous and ners whose HIV status was not known, and only 5(4.7%)
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Table 1 Socio demographic characteristics of respondents Table 2 Sero-positive HIV status disclosure experience
by disclosure status (n = 107) among HIV Positive pregnant women
Variables Frequency Percent (%) Variable Number %
Age: Disclosure of HIV status to sexual partner (n = 107)
15 – 19 6 5.6 Yes 78 72.9
20 – 24 26 24.3 No 29 27.1
25 – 29 43 42.1 Duration of time for disclosure since diagnose (n =
78)
30 – 34 23 21.5
< 1 month 51 65.4
35 – 39 35 5.7
1–2 months 10 12.8
Religion:
3–4 months 11 14.1
Orthodox 71 66.4
>4 months 6 7.7
Muslim 33 23.5
Disclosure of HIV Status to others (n = 107)
Protestant 3 2.8
Yes 43 40.2
Educational level:
No 64 59.8
Illiterate (cannot read & write) 20 18.7
Disclosure of HIV status to family members (n = 43)
Can Read and write 9 8.4
Father 6 12.8
Primary (1–8) 52 48.6
Mother 24 51.1
Secondary (9–12) 21 19.6
Sister(s) 8 17.0
Diploma and above 5 4.7
Brother(s) 2 4.3
Marital status:
Others 3 6.4
Married 107 100
Reasons for disclosure of HIV status to sexual partner (n = 78)
Single, divorced/widowed 0 0
Ethical responsibility 5 6.4
Occupation:
Concern for partner’s health 52 66.7
Employed 16 15.0
Encouragement from counselors 14 17.9
House wife 59 55.1
Positive social support 1 1.3
Others 22 20.5
Discussion about VCT before HIV test (n = 78)
Household income per month:
Yes 49 45.8
Less than 28 Dollars 42 58.3
No 29 27.1
28 – 56 Dollars 9 12.5
Above 56 Dollars 21 29.2
partners, relationship before test, and prior discussion
about VCT test. Among the 78 respondents who had
disclosed, 52(48.6%) of them learnt their HIV positive
of the participants did not know their partner’s HIV status during ANC. Of eighty (74.8%) respondents who
status. reported smooth relationship with their partners, 69(64.5%)
The reasons cited for disclosure were multiple and had disclosed their HIV status while out of 20 (18.7%) who
included concern for their partner’s health 52(66.7%), had disagreement with their partners, 9(8.4%) had disclosed
encouragement from their counselors 14(17.9%), and their HIV status to their partner. Out of 107 study partici-
ethical responsibility 5(6.4%). pants 42(39.3%) had HIV positive partners, and 25(23.4)
In addition, 24(51.1%), 8(17.0%), 6(12.8%), 2(4.3%) and HIV negative partners (discordant). Thirty-six (33.6%) out
3(6.4%) of the respondents disclosed their HIV seroposi- of forty-two study participants whose partner’s HIV status
tive status to their mother, sisters, father, brothers & was known disclosed their HIV status to their partner
others respectively. Regarding time of disclosure the and 22(20.6) out of twenty –five of the discordant disclosed
majority 51(65.4%) of the respondents disclosed their their HIV status to their partner. Fifty one (47.7%) study
status within the first month after diagnosis (see Table 2). participants had discussion about HIV testing prior to
seeking VCT services but 56(52.3%) of the respondents
Factors associated with disclosure of HIV status to did not. Those who had discussion with their partner to
sexual partner undertake the HIV test 49(45.8%) had disclosed their
Factors influencing disclosure of HIV positive status to HIV positive status in comparison to those had no prior
sexual partner include duration of relationship with their discussion about HIV test with their partners 29(27.1%).
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Table 3 Factors influencing disclosure of HIV positive status to sexual partner among HIV Positive pregnant women
Variables Disclosed (N = 78) Not disclosed (N = 22) COR (95% CI) AOR (95% CI)
Duration of relationship with partners:
0-2 yrs 12(15.4) 6(5.6) 0.69(5.05,103.0) 12.28 (2.53, 59.52)
>2 yrs 66(84.6) 23(21.5) 1.00 1.00
Relationship before test:
Smooth relationship 69(64.5) 11(10.3) 7.6(4.51 – 34.87) 6.76 (2.14,21.31)
With disagreement 9(8.4) 11(10.3) 1.00 1.00
Time of HIV Status learnt
During ANC 52(48.6) 22(20.6) 0.6(1.1-2.7) 0.2 (0.5-2.1)
Before ANC 26(24.3) 7(6.5) 1.00 1.00
Discussion about VCT before HIV test:
Yes 49(64.5) 2(1.9) 22.8(5.0 – 103.0) 12.28 (2.53, 59.52)
No 29(8.4) 27(25.2) 1.00 1.00
Partner’s HIV status
Positive 36 (33.6%) 22(20.6) 2.6 (0.62, 1.43) 0.79 (0.44, 1.45)
Negative 25(23.4) 40(37.4)
COR Crude odds ratio, AOR Adjusted odds ration.

Eighty nine (83.2%) respondents lived with their part- The feeling of respondents following disclosure was
ners for more than two years. reported as worried 12(15.4%), felt free 44(56.4%), felt
Strong association was found between prior communi- lighter 19(24.4%), and felt abandoned 3(3.8%) (Table 4).
cation about HIV testing with a partner and HIV-sero-
status disclosure. Women who reported prior discussion The effects of HIV status disclosure on intension to utilize
about HIV testing were twelve times more likely to dis- PMTCT service
close their HIV status to partners than their counter- Measures cited by respondents to prevent mother to child
parts (AOR 12.28, 95% CI 2.53-59.52). transmission of HIV includes starting ART 43(40.2%),
Women who reported to have smooth relationship with and bringing new born for ART prophylaxis 71(66.4)
the partner before the HIV test were six times more likely (AOR1.45 95% CI 0.44-5.12, 4.74 95% CI 1.24 – 18.14,
to disclose their HIV status to partners than those who respectively) (Table 5).
reported living with their partners with disagreement
(AOR 6.76, 95% CI 2.14-21.31) (Table 3). Discussion
This study aimed to determine prevalence of, barriers to
and independent predictors of disclosure of HIV positive
Outcomes of HIV status disclosure status to a sexual partner among the pregnant women
Positive outcomes reported by women in this study in- attending ANC in selected Health Centers in Addis
cluded increased support and less anxiety and increased Ababa, Ethiopia.
intention to utilize PMTCT programs. Out of seventy- Seventy eight (73%) of the 107 respondents had disclosed
eight study participants, most 42(53.8%) reported that their HIV sero-positive status to their sexual partner. This
their partners reacted supportively to the disclosure of is higher than a study from Tanzania (16.7%), Burkina
their HIV status, and only 15.4% reported any negative Faso (31.6%) and Kenya (65%) [13-15]. The higher rate
reaction from their partners. More than 44(56.4) study of disclosure in this study may be related to advances in
participants reported that they felt free following disclosure PMTCT and antiretroviral treatment programs. These
to their sexual partner. Although disclosure has a number advances have led to decreased HIV associated stigma
of benefits, it is not without problems. in the community, recognition among who test positive
Negative outcomes from their partners included annoyed of the benefits of disclosure and increased expertise of
2(2.6%), yelled at me 10(12.8%), worried about his HIV sta- counselors who work with these clients. However, 27.1%
tus 7(9.0%), blamed me to infect him 2(2.6%), talked about of the people interviewed in this study didn’t disclose
divorcing me 1(1.3%), don’t know 1(1.3) and no response their status to their partner. Counseling of HIV positive
7(9.0%). pregnant women who did not disclose their HIV status
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Table 4 Outcomes of HIV status disclosure among HIV 8 months after VCT. But in relation to time of disclosure,
Positive pregnant women in this study about two-third of the women (65.4%) who
Variable Number (%) ever disclosed to a partner their HIV positive status did so
Partner’s reaction to HIV status disclosure with in less than one month of knowing their HIV status.
(n = 78) 42(53.0) However, 12.8% of the disclosures were delayed by 1-2
months, 14.1% by 3–4 months, and 7.7% by more than
“Supportive” 7(9.0)
four months respectively. These study participants might
“Annoyed” 2(2.6)
have at least one sexual contact with their partner before
“Yelled at me” 10(12.8) disclosure. This raises the possibility of transmission risk if
“Worried about his own HIV status” 7(9.0) condoms were not used and may limit the beneficial as-
“Blamed me to infect him” 2(2.6) pect of disclosure making negotiating safer sex difficult
“Talked about divorcing me” 1(1.3) and perhaps putting the partner at risk of infection.
Inconsistent with other studies [13-15] the proportion
“Don‘t know” 7(9.0)
of disclosure to partners (73%) was found to be far greater
No response
than disclosure to family members (40.2%). One possible
Feeling of respondents after disclosure of HIV positive status: (n = 78) explanation for the low disclosure rate to family members
“Worried” 12(15.4) is the difference in the concern about the health condition
“Felt free” 44(56.4) of one’s partner. In this study, it was found that concern
“Felt lighter” 19(24.4) for partner’s health was the major reason cited for disclos-
ing to sexual partners. This result is also similar to other
“Felt abandoned” 3(3.8)
studies [13].
Despite the high rate of HIV status disclosure, a sig-
during ANC would help them to disclose their status. nificant proportion (14.0%) had sex partners whose HIV
Service providers at PMTCT clinics should ensure that status was not known and some (4.7%) of the partici-
all efforts are made to counsel HIV positive pregnant pants did not know their partner’s HIV status. The si-
women about disclosure of their status to their sexual part- lence of the partners could be either acknowledging that
ner from the beginning in every PMTCT interventions. she is already infected with the HIV or the result of the
Our estimate of delayed disclosure is somehow lower emotional rejection of the partner. These findings re-
than those reported in another studies. In a PMTCT study mind us that individuals with unknown or negative HIV
conducted in Tanzania, only 22% of women disclosed to status should be educated about the need for consistent
someone within 18 months period following diagnosis. use of condoms with their sexual partners.
Other study conducted in Burkina Faso [14] among 79 In this study, prior discussion with one’s partner to
HIV Positive pregnant women at ANC 31.6% had shared undertake HIV test and having smooth relationship with
their status with their partner at all average duration of one’s partner is significantly associated with disclosure.

Table 5 Effects of HIV status disclosure on intension to utilize PMTCT service

Variable Disclosed (n = 78) Didn’t disclose (n = 29) COR (95% CI) AOR (95% CI)
Start ART after disclosure of the test?
Yes 43(40.2) 9(8.4) 2.7(1.10-6.75) 1.45(0.44-5.12)
No 35(32.7) 20(18.7) 1.00 1.00
Timing of new-born visit for ART prophylaxis:
Within one day after delivery 68(63.5) 15(14.0) 6.3(3.1-12.7) 1.9(0.6-4.9)
Two days or more after delivery 10(9.3) 14(13.1) 1.00 1.00
Do you bring the new born for ART prophylaxis if you deliver at home?
Yes 71(66.4) 16(15.0) 8.24(2.84 – 23.95) 4.74(1.24 – 18.14)
No 3(2.8) 6(5.6) 1.00 1.00
Do not know 4(3.7) 7(6.5)
After knowing your HIV serostatus, have you started practicing safer sex?
Yes 54[50.4] 4[3.7] 14.06(0.42, 0.92) 0.71(0.40, 1.27)
No 24[22.1] 25[23.4] 1.00 1.00
COR Crude odds ratio, AOR Adjusted odds ratio.
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This might help the study participants to anticipate their common for participants who had disclosed their status
partner’s reaction and is quite important in women’s to their main partners. These findings are similar with
negotiation and decision making around disclosure. many other studies [16,21,22].
This finding agrees with many other studies that showed Disclosure was also associated with less anxiety and
people who reported to have good relationship and dis- increased social support [23,24]. Similarly, more than
cussion prior to HIV testing are more likely to disclose half of the women in this study (56.4%) reported that
their HIV status [16-18]. they felt free following disclosing of their HIV status to
The majority of women in this study reported that their main partners.
their partners reacted supportively to disclosing of their The findings of this study should be interpreted in the
HIV status. Negative out comes reported by women in- light of its limitations. The result of this study depended
cluded annoyed at me, yelled at me, worried about his on self-report of a sensitive topic disclosure of HIV status.
HIV status, blamed me to infect him & talked about di- As a result there may be influence of social desirability.
vorcing me. The reasons cited for non-disclosure were However, measures were taken to reduce this bias by
fear of divorce & violence, fear of abandonment, fear of granting confidentiality, maintaining privacy and explaining
confidentiality, and fear of accusation of infidelity. This the purpose of the study to participants. In addition, the
finding is in agreement with other studies [18]. Women high response rate is one of the strength of this study. The
who experienced fear of negative consequences of dis- findings of this study may mainly be applied to similar
closure were less likely to disclose their HIV positive population in urban/periurban areas in Ethiopia.
status [19]. This could be explained that attitudinal out-
come beliefs such as these are extremely important in Conclusions
predicting behavior [20]. This study revealed that HIV positive status disclosure
In this study, women who disclosed their status to among pregnant women is high. Although most partici-
their partner were found to be more likely to participate pants disclosed their HIV sero-positive status, lack of
in Prevention of Mother to Child Transmission (PMTCT) disclosure by some women resulted in a limited ability
programs. HIV positive pregnant women that reported to participate in PMTCT programs. Thus, assertiveness
disclosure to their partner in this study were found to and improved communication skills training should be
bring their new born for ART prophylaxis if delivered at offered to HIV positive pregnant mothers and be reinforced
home four times compared to those who did not disclose. during on-going counseling.
We found a very strong statistical association between
having disclosed one’s HIV status to partner and engaging Competing interests
in safe sex practice. Participants who had disclosed to sex The authors declare that they have no competing interests.
partners were 14 times more likely to practice safe sex
Authors’ contributions
than those participants who did not disclose their HIV EG and AC participated from the inception of the research idea to proposal
sero-status. This could be explained that disclosure fa- development, data collection, analysis and preparation & revision of the
cilitates other behaviors that may improve utilization of manuscript and TA participated in the preparation of the manuscript for
publication. All authors read and approved the final version of the manuscript.
PMTCT programs and HIV/AIDS prevention. In the case
of PMTCT, women who have knowledge about modes Acknowledgments
of MTCT of HIV infection may be more likely to par- We are very grateful to Addis Ababa University for the approval of the ethical
ticipate in prevention of mother- to- child Transmission clearance and for their technical support. We would like also appreciate ALKAN
UNIVERSITY COLLEGE and NUFU/ GEMESO Research Project on HIV/AIDS for
(PMTCT) programs. financial support. We would like to thank all patients who participated in this
In addition, women who disclose their status are in a study for their commitment in responding to our interviews.
better position in terms of reproduction choices as well
Author details
as psychosocial support. This study showed that women 1
Addis Ababa University, College of Health Science, School of Nursing and
who disclosed their results need to take ART medication Midwifery, Addis Ababa, Ethiopia, P.O. Box 1176, Ethiopia. 2Nursing
themselves and give it to their new-born, breast feed ex- Department, Debre Markos University, Health Science College, Debre Markos,
P.O.Box 269, Ethiopia.
clusively for 6 months and deliver in the health institu-
tions to reduce the risk of mother to child transmission Received: 6 January 2013 Accepted: 8 August 2013
of HIV Infection. This is in line with other studies [7]. Published: 17 August 2013
Pregnant women who disclosed to their partners re-
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