1. www.aids2014.org HIV Serostatus Disclosure to Sex Partners and associated factors among high-risk MSM and Transgender Women in Lima, Peru Rostislav Castillo 1,3 ; Kelika A. Konda 2 ; Segundo R. Leon 3 ; Alfonso Silva-Santisteban 3 ; Ximena Salazar 3 ; Thomas J. Coates 2 ; Carlos F. Cáceres 3 1. School of Medicine, Stanford University, Stanford, CA, 2. School of Medicine, University of California, Los Angeles, CA, 3. Universidad Peruana Cayetano Heredia, Lima, Peru

2. www.aids2014.org Introduction HIV serostatus disclosure can inform risk perception and sexual behavior. HIV serostatus disclosure may be an important HIV prevention strategy, especially as newer biomedical interventions such as PrEP are rolled out. We explored disclosure among MSM and Transgender Women in Peru

3. www.aids2014.org Study procedures & Methods We ethnographically recruited 718 participants to assess the effectiveness of an 18-month community-level, HIV prevention intervention. MSM and Transgender Women were enrolled if they reported being primarily attracted to men, were 18 years or older, and planned to be in their community for the duration of the study.

4. www.aids2014.org Measures & Data analysis Participants were asked about HIV status disclosure and sexual risk behaviors at baseline, 9- and 18- months – Detailed behavioral data were collected on the last 3 sex partners – At baseline HIV status was based on self-report, participants then received HIV testing as part of the study We defined disclosure as having told a sex partner about ones’ HIV status GEE models were used to explore disclosure – At baseline, to the last 3 sex partners, looking at the partnership level – Longitudinally, over the study’s follow-up visits, at the individual level among all participants

5. www.aids2014.org Disclosure at baseline Participants disclosed to 39% of their 1116 reported sex partners Disclosure was lower among participants reporting an HIV positive status –HIV positives disclosed to 27% of their sex partners vs. 45% among HIV negatives

6. www.aids2014.org Disclosure among self-reported HIV positives at baseline 33/41 (80%) shared their result with someone – Primarily family (66%) or friends (37%) The 8 who did not share their results – 6 (60%) wanted to keep their result private – 4 (50%) did not have anyone with whom to share the result

7. www.aids2014.org Disclosing to a partner at baseline * p-value <0.05, ** p-value <0.01 VariablesCrude PR (95%CI)Adjusted PR (95%CI) Individual characteristics Age (by 5 year increase)1.09 (1.03 - 1.15)**1.02 (0.98 - 1.06) Post-secondary education1.37 (1.17-1.60)**1.05 (0.95 - 1.17) HIV NegativeRef Positive self-reported HIV status 0.59 (0.39 - 0.90)**0.68 (0.49 - 0.97)* Unknown HIV status 0.70 (0.59 - 0.82)**0.85 (0.76 - 0.95)** Partnership characteristics Insertive anal sex, last 6 months NeverRef Always with a condom1.06 (0.82 - 1.37)1.05 (0.87 - 1.25) 1+ acts without a condom1.39 (1.16 - 1.67)**1.05 (0.90 - 1.22) Length of relationship <8 weeksRef 9 weeks to 6 months1.20 (0.99 - 1.45)1.04 (0.89 - 1.21) 7 months to 2 years 1.49 (0.23 - 1.81)**0.99 (0.85 - 1.16) +2 years 1.68 (1.39 - 2.03)**1.03 (0.87 - 1.21) Type of partner StableRef Casual 0.62 (0.54 - 0.71)**0.94 (0.83 - 1.05) Client 0.46 (0.32 - 0.66)**0.72 (0.50 - 1.04) Partner disclosed their HIV status 5.96 (4.84 - 7.34)**5.20 (4.13 - 6.56)**

8. www.aids2014.org Disclosing to a partner at baseline The participant being HIV positive (aPR 0.68) or of unknown HIV status (aPR 0.85) were associated with less disclosure The most influential factor was if the sex partner had disclosed to the participant (aPR 5.20) – After adjustment for this variable, only participants’ HIV status remained significantly associated with disclosure We also stratified by if the partner had shared their HIV status with the participant – Results remained very similar between strata, being HIV positive or of unknown status were associated with less disclosure in both strata

9. www.aids2014.org Time from HIV test to disclosure Among the non-HIV positive participants, many disclosed based on old or no testing information – 72% disclosed <1 year from their last HIV test – 12% disclosed 1 - 5 years after their last HIV test – 5% disclosed 6+ after their last HIV test – 11% disclosed without having a previous HIV test

10. www.aids2014.org Disclosure during follow-up Overall, disclosure did not increase during follow- up – 51% disclosed at baseline, 49% at 9 months, and 42% at 18 months Among HIV positives, disclosure did increase during follow-up – 15% disclosed at baseline and 26% disclosed at 9 and 18 months – Many HIV positive participants (71%) had been previously unaware of their HIV status

11. www.aids2014.org Disclosure during follow-up * p-value <0.05, ** p-value <0.01 Variables Crude OR (95% CI)Adjusted OR (95% CI) Age (by 5 year increase) 1.04 (0.96 - 1.13)0.97 (0.89 - 1.06) Post-secondary education 1.51 (1.19 - 1.91)**1.50 (1.16 - 1.93)** HIV Prevalence and Incidence HIV Negative Ref HIV Positive at Baseline 0.52 (0.38 - 0.70)**0.55 (0.40 - 0.77)** HIV Incident during follow-up 0.54 (0.31 - 0.93)*0.71 (0.40 - 1.27) Had condomless anal sex, last 6 months 1.35 (1.12 - 1.69)**1.20 (0.95 - 1.52) Had a stable partner 1.61 (1.26 - 2.06)**1.45 (1.09 - 1.92)* Been with a partner 2+ years 1.77 (1.42 - 2.20)**1.67 (1.32 - 2.11)** A partner disclosed their HIV status 2.17 (1.72 - 2.73)**1.86 (1.44 - 2.39)** Transactional sex 0.81 (0.65 - 0.99)*0.83 (0.66 - 1.05) Lacked basic needs Never Ref Rarely 0.85 (0.61 - 1.20)0.89 (0.60 - 1.32) Sometimes 0.76 (0.54 - 1.07)0.81 (0.54 - 1.22) Often 0.46 (0.29 - 0.71)**0.58 (0.35 - 0.94)*

12. www.aids2014.org Disclosure during follow-up Disclosure during the study was positively associated with at least one sex partner disclosing to the participant (aOR 1.86) HIV positivity at baseline was negatively associated with disclosure during the study (aOR 0.55) – Incident HIV (n=26) was also negatively associated with disclosure, although this was not significant

13. www.aids2014.org Discussion MSM and TW disclosed to less than half of their sex partners Being HIV positive or of unknown serostatus were associated with less disclosure Disclosed HIV status information was often out-of-date – Context: criminalization “knowingly” spreading HIV infection, stigma and discrimination, challenging logistics for HIV testing, fear of or negative experiences with health care personnel – Fear of partner’s reactions (violence and dissolution of the relationship) – We also do not know the content of quality of these disclosures A partner’s disclosure was very important for disclosure – Communication about HIV and serostatus within partnerships should be promoted, potentially along with or in the context of couples voluntary counseling and testing – We are conducting qualitative individual and couple interviews to explore CVCT for this setting

14. www.aids2014.org Thank you! We would like to thank the study participants as well as the field and laboratory staff. Funding: Peru Fulbright Commission, National Institutes of Health NIMH R01 MH078752 (PI Coates), Research reported was supported by NIH Research Training Grant # R25TW009343 funded by the Fogarty International Center, Office of Behavioral and Social Sciences Research, Office of Research on Women’s Health, Office of AIDS Research, National Institute of Mental Health, and National Institute on Drug Abuse, as well as the University of California Global Health Institute. – The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the University of California Global Health Institute.

15. www.aids2014.org References 1. Silva-Santisteban A, Raymond HF, Salazar X, et al. Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru: results from a sero-epidemiologic study using respondent driven sampling. AIDS and Behavior. 2012;16(4):872-81. 2. Beyrer C, Baral SD, Walker D, et al. The expanding epidemics of HIV type 1 among men who have sex with men in low- and middle-income countries: diversity and consistency. Epidemiologic reviews. 2010;32(1):137-51. 3. Nagaraj S, Segura ER, Peinado J, et al. A cross-sectional study of knowledge of sex partner serostatus among high-risk Peruvian men who have sex with men and transgender women: implications for HIV prevention. BMC public health. 2013;13(1):1-7. 4 Gorbach PM, Galea J, Amani B, et al. Don’t ask, don’t tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practicing high risk behaviour in Los Angeles and Seattle. Sexually Transmitted Infections. 2004;80(6):512-7. 5. Carballo-Diéguez A, Miner M, Dolezal C, et al. Sexual negotiation, HIV-status disclosure, and sexual risk behavior among Latino men who use the internet to seek sex with other men. Archives of sexual behavior. 2006;35(4):473-81. 6. Simoni JM, Pantalone DW. Secrets and safety in the age of AIDS: does HIV disclosure lead to safer sex? Topics in HIV Medicine. 2004;12:109-18. 7. Zea MC, Reisen CA, Poppen PJ, et al. Disclosure of HIV status and psychological well-being among Latino gay and bisexual men. AIDS and Behavior. 2005;9(1):15-26. 8. Padian NS, McCoy SI, Karim SSA, et al. HIV prevention transformed: the new prevention research agenda. The Lancet. 2011;378(9787):269-78. 9. Holt M, Rawstorne P, Worth H, et al. Predictors of HIV disclosure among untested, HIV-negative and HIV-positive Australian men who had anal intercourse with their most recent casual male sex partner. AIDS and Behavior. 2011;15(6):1128-39. 10. Maman S, Mbwambo JK, Hogan NM, et al. High rates and positive outcomes of HIV-serostatus disclosure to sexual partners: reasons for cautious optimism from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. AIDS and Behavior. 2003;7(4):373-82. 11. Obermeyer CM, Osborn M. The utilization of testing and counseling for HIV: a review of the social and behavioral evidence. American journal of public health. 2007;97(10):1762.

16. www.aids2014.org Disclosure at baseline Among participants with a previous HIV test, 57% disclosed to at least 1 sex partner – They disclosed to 42% of their 1116 reported sex partners Disclosure was lower among participants reporting an HIV positive status at baseline – 42% of HIV positive vs. 61% of HIV negatives disclosed