The Relational Context of Non-disclosure in HIV Positive Women Presenting author: Shani Harris Peterson, PhD Contributing authors: Ralph DiClemente, PhD Gina Wingood, ScD, MPH Delia Lang, PhD Emory University Rollins School of Public Health Center for AIDS Research Department of Behavioral Science and Health Education

Why disclose? Limit transmission of HIV. (CDC, 2006) Increase protective sexual behaviors. (Wenger, et al., 1994 in Ciccarone, et al., 2003) Permit informed sexual decision making. (Chapman, 2006; O’Brien et al., 2003) Increased social/emotional support. (Petrak, et al., 2001)

Disclosure Risks For women, risks include: Emotional distress. Rupture of relationships. Decreased sexual satisfaction. Violence from partners. (VanDevarter, 1999; Kitterman, 2003)

Patterns of disclosure in women Majority of women disclose to their sexual partners 86.8% disclosed to current sexual partner (Simoni, et. al, 2000) 78% reported to all past sexual partners (Stein, et. al, 1998) Rates of disclosure consistent across relationship type Exclusive or non-exclusive Seroconcordant or serodiscordant (Ciccarone, 2003)

Non-disclosure Internal Motivation Consequences Fear partner abandonment/rejection (Derlega, et. al, 2004) Believe partner can’t handle it Too stressful Need time to deal with own emotions first (Stein, et. al, 1998) Consequences Emotional distress Limited confidence in disclosing around sex (Kalichmann, 1999)

Relational correlates of non-disclosure Low spousal support High friend support Multiple sexual partners (Stein, et. al, 1998; Niccolai, 1999)

Romantic relationships and disclosure Women in monogamous relationships 3.2x more likely to disclose. (Stein, et. al, 1998) Some avoid exclusive relationships to circumvent pressure to disclose. (Maticka & Tyndale, 2002)

PURPOSE To determine whether relationship characteristics predict non-disclosure of serostatus in women living with HIV.

METHOD WiLLOW study (HIV intervention program) Sample 320 women Average age 34 (eligible range 18-50) 80% African-American

METHOD Eligibility Requirements Between 18 and 50 years Seeking medical care for HIV/AIDS on site Sexually active in past 6 months Provided written informed consent Recruited from 7 large clinics/health depts in Georgia and Alabama, U.S.

METHOD: Main Outcomes Disclosure Disclosure History Have you told your main sexual partner that you are HIV+? Disclosure History Divided number of sex partners disclosed to by total number of sex partners since diagnosis

METHOD: Relationship and Individual Characteristics Relationship faith ( =.93) Length of relationship (months) Partner communication ( =.86) Partner condom response ( =.95 )

METHOD: Relationship and Individual Characteristics Individual Attitudes/Behavior Condom attitudes ( =.95) Consistent condom use past 30 days (yes or no) STI history (# of STIs) Multiple sexual partners (yes or no)

RESULTS: Non-disclosure

RESULTS: Between group means

Bivariate Associations: Non-disclosure to main sex partner NO YES M M p-value Relationship Characteristics Faith 6.2 8.4 .00 Length 34 56.8 .07 Partner Communication 4.1 3.2 .02 Sexual Characteristics Partner condom response .22 .07 .01 Condom Attitudes 2.9 3.1 .07 STI History 1.6 2.1 .99 Other sex partners .17 .09 .17 Consistent Cndm Use .50 .69 .17

Correlations: Low Disclosure History P-corr p-value Relationship Characteristics Faith .224 .000 Length .202 .001 Partner Communication -.146 .009 Sexual Characteristics Partner condom response -.161 Condom Attitudes .159 .005 STI History -.164 .007 Other sex partners -.227 Consistent Cndm Use -.016 .820

Multivariate Associations: Low disclosure history PREDICTORS ß t Sig. F r2 Model .000 6.453 .18 Relationship Variables 1. Rel. Faith .187 2.651 .009 2. Rel. Length .081 1.116 .266 3. Partner comm. -.029 .412 .681 4. Partner cndm rspn -.094 -1.310 .192 Individual Variables 5. Condom Attitudes .120 1.717 .088 6. STI History -.094 -1.354 .178 7. Other sex partners -.260 -3.676 .000 Note. N=179

What this tells us… Disclosure may be promoted by exclusive relationships. Women who do not disclose have: shorter, less committed relationships, more sexual partners, and hold less faith in their main sexual relationships.

What this tells us… Non/low-disclosers use condoms as frequently and consistently as women high disclosers. Despite condom use, women who do not disclose may be at greater risk of experiencing emotional consequences of non-disclosure (depression, etc).

What this tells us… An Alternative Skill Set Some women may seek out sexual relationships that enable them to avoid disclosure. (Maticka & Tyndale, 2002) Low disclosers report greater refusal/negotiation skills and more positive responses from partners regarding condom use.

Future directions: Practice Assess relationship stability/faith. Provide access to couples counseling. Provide access to individual counseling to address disclosure fears/avoidance. Assess/encourage emotional support outside of intimate relationships.

Future directions: Research Investigate the impact of relationship faith/security on the overall health and well-being of women living with HIV. Determine how disclosure effects romantic relationships and identify successful strategies for managing the disclosure stress.

Future directions: Research Identify alternative, protective factors that may promote the overall health of women in the absence of secure romantic relationships. For additional info contact: shpeter@emory.edu

Acknowledgements The Fellowship in Research and Science Teaching (FIRST) Program, NIH Institutional Research and Academic Career Development grant, #K12 GM00680-05. Michael D. Harris, PhD, University of North Carolina, Chapel Hill, for use of his original artwork entitled “Four Women.” Jerris Raiford, PhD, Center for AIDS Research, Rollins School of Pubic Health, Emory University. For additional info contact: shpeter@emory.edu

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Bivariate Associations: Non-disclosure to main sex partner Low relationship faith*** Shorter relationships* Fewer threats of violence at request for condom use*** Greater communication about sex preferences/refusal skills** Negative attitudes towards condoms* *p<.10, **p<.05, ***p<.01

Bivariate Associations: Low disclosure history Low faith in relationship with main sex partner*** Shorter length of relationship* More partner communication about sex prefs/refusal skills* More positive partner response to condom use request* Higher lifetime incidence of sexually transmitted infections* More likely to have multiple sexual partners*** *p<.10, **p<.05, ***p<.01