Safer disclosure of HIV serostatus for women living with HIV who experience or fear violence

A nurse speaks with a pregnant woman who has taken an HIV test, at an antenatal clinic, Kenya

Safer disclosure of HIV serostatus for women living with HIV who experience or fear violence

Key Findings

Despite significant attention to the intersections between HIV and violence as well as international policy consensus on the need to facilitate safer disclosure of HIV serostatus for women who experience or fear violence, the systematic review identified only two studies evaluating such interventions globally. Both studies were from sub-Saharan Africa and employed strong randomized designs. However, neither provided clear evidence for the effectiveness of a safer disclosure intervention as they were not designed to isolate the contribution of the safer disclosure components from the broader multiple component interventions. The evidence base for interventions to facilitate safer disclosure is thus quite limited, and further studies are needed.

 

For all women, the SHARE study in Uganda reported positive outcomes for disclosure and violence at the second follow-up. Unpublished data among HIV-positive women showed non-significant but positive trends in disclosure. However, these analyses could not distinguish women who had received the enhanced counselling intervention from those who had not or newly diagnosed women from those who had known their HIV-positive status for a long time, both of which would likely attenuate an effect toward the null. In the SAHAPS study in South Africa, unpublished data showed that women who were exposed to the enhanced counselling intervention were no more likely to disclose to their partner or report violence after HIV diagnosis than women who received standard of care HIV testing services. Additional analyses suggested that women who were already at higher risk of IPV – particularly HIV-positive women – chose not to disclose despite, or perhaps because of, the safer disclosure intervention, while women who disclosed were those who already knew it was safe to do so.

 

Evidence included in this review

The systematic review authors identified two studies that ultimately met the inclusion criteria, one cluster randomized controlled trial with 35 months of follow-up, and one individual randomized controlled trial with 9 months of follow-up.

 

Quality assessment

Both studies received generally high marks on the Cochrane risk of bias tool, although due to the nature of the interventions, neither study was able to blind participants or study staff to intervention allocation. Both studies examined the impact of the intervention on disclosure and violence; both measured violence using an adapted version of the conflict tactics scale.

 

Clinical Implications

The findings suggest that while IPV continues to be a significant barrier to disclosure for women who fear violence, it has not been adequately addressed in current approaches related to provision of HIV testing, treatment and care services in healthcare settings. There are several options to be considered in such a scenario. One option is that in the absence of specific interventions to respond to violence or promote safety, women who are at risk of violence may be better off being supported in a decision not to disclose their status. Another consideration is to promote safety for women who do want to disclose or who may experience inadvertent disclosure of their status and to do so in line with WHO guidelines. These guidelines recommend training of healthcare providers, especially in HIV testing settings, to identify women who are at risk of IPV and offer a response that includes first-line psychological support including safety planning, addressing immediate needs for physical and mental health and providing referrals to appropriate services that address violence.

 

Further research

Further research is needed to identify which interventions can best achieve the objective of supporting women living with HIV who experience or fear violence to safely disclose their HIV serostatus – or not to disclose at all, as appropriate – in order to inform programme and policy decisions.

 

 

References

Kennedy CE, Haberlen S, Amin A, Baggaley R, Narasimhan M. Safer disclosure of HIV serostatus for women living with HIV who experience or fear violence: a systematic review. J Int AIDS Soc. 2015;18(6 Suppl 5):20292. doi:10.7448/IAS.18.6.20292

Abstract

Introduction: Supporting individuals as they disclose their HIV serostatus may lead to a variety of individual and public health benefits. However, many women living with HIV are hesitant to disclose their HIV status due to fear of negative outcomes such as violence, abandonment, relationship dissolution and stigma.

Methods: We conducted a systematic review of studies evaluating interventions to facilitate safer disclosure of HIV status for women living with HIV who experience or fear violence. Articles, conference abstracts and programme reports were included if they reported post-intervention evaluation results and were published before 1 April 2015. Searching was conducted through electronic databases for peer-reviewed articles and conference abstracts, reviewing websites of relevant organizations for grey

literature, hand searching reference lists of included studies and contacting experts. Systematic methods were used for screening and data abstraction, which was conducted in duplicate. Study quality (rigor) was assessed with the Cochrane risk of bias tool.

Results: Two interventions met the inclusion criteria: the Safe Homes and Respect for Everyone cluster-randomized trial of combination HIV and intimate partner violence (IPV) services in Rakai, Uganda, and the South Africa HIV/AIDS Antenatal Post-Test Support study individual randomized trial of an enhanced counselling intervention for pregnant women undergoing HIV testing and counselling. Both programmes integrated screening for IPV into HIV testing services and trained counsellors to facilitate discussions about disclosure based on a woman’s risk of violence. However, both were implemented as part of

multiple-component interventions, making it impossible to isolate the impact of the safer disclosure components.

Conclusions: The existing evidence base for interventions to facilitate safe HIV serostatus disclosure for women who experience or fear violence is limited. Development and implementation of new approaches and rigorous evaluation of safe disclosure outcomes is needed to guide programme planners and policy makers.