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FACTORS ASSOCIATED WITH HIV VOLUNTARYDISCLOSURE TO ONE'S STEADY SEXUAL PARTNER INMALI: RESULTS FROM A COMMUNITY-BASED STUDY

MAMADOU CISSÉ, SAMBA DIOP, ALISE ABADIE, EMILIE HENRY, ADELINE BERNIER, LIONELFUGON, BINTOU DEMBELE, JOANNE OTIS and MARIE PREAU

Journal of Biosocial Science / FirstView Article / January 2015, pp 1 - 15DOI: 10.1017/S0021932014000546, Published online: 08 January 2015

Link to this article: http://journals.cambridge.org/abstract_S0021932014000546

How to cite this article:MAMADOU CISSÉ, SAMBA DIOP, ALISE ABADIE, EMILIE HENRY, ADELINE BERNIER, LIONELFUGON, BINTOU DEMBELE, JOANNE OTIS and MARIE PREAU FACTORS ASSOCIATEDWITH HIV VOLUNTARY DISCLOSURE TO ONE'S STEADY SEXUAL PARTNER IN MALI:RESULTS FROM A COMMUNITY-BASED STUDY. Journal of Biosocial Science, Available on CJO2015 doi:10.1017/S0021932014000546

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J. Biosoc. Sci., page 1 of 15, 6 Cambridge University Press, 2014doi:10.1017/S0021932014000546

FACTORS ASSOCIATED WITH HIVVOLUNTARY DISCLOSURE TO ONE’SSTEADY SEXUAL PARTNER IN MALI:

RESULTS FROM A COMMUNITY-BASED STUDY

MAMADOU CISSE*, SAMBA DIOP†, ALISE ABADIE‡, EMILIE HENRY‡,

ADELINE BERNIER‡1, LIONEL FUGON‡, BINTOU DEMBELE*,

JOANNE OTIS§ and MARIE PREAU¶

*ARCAD-SIDA, Bamako, Mali, †Faculte de medecine, USTTB, Bamako, Mali,

‡Coalition Internationale Sida, Pantin, France, §Universite du Quebec a Montreal,

CREcES, Montreal, Canada and ¶GRePS, Universite Lumiere Lyon 2, Lyon, France

Summary. Despite the widespread dissemination of HIV information throughpublic awareness campaigns in Mali, disclosing seropositivity to one’s steady

sexual partner (SSP) remains difficult for people living with HIV (PLHIV). Dis-

closure is a public health concern with serious implications and is also strongly

linked to the quality of life of PLHIV. This study aimed to analyse factors

associated with voluntary HIV disclosure to one’s SSP, using a community-based

cross-sectional study on 300 adult PLHIV in contact with a Malian community-

based organization working in the field of AIDS response. A 125-item question-

naire was administered by trained personnel to study participants between Mayand October 2011. Analysis was restricted to the 219 participants who both

reported having a SSP and answered to the question on disclosure to their

SSP. A weighted multivariate logistic regression was used to determine variables

independently associated with disclosure. In total, 161 participants (73%) re-

ported HIV disclosure to their SSP. Having children (odds ratio [95% con-

fidence interval]: 4.52 [1.84–11.12]), being accompanied to the survey site (3.66

[1.00–13.33]), knowing others who had publicly declared their seropositivity

(3.12 [1.59–6.12]), having higher self-esteem (1.55 [1.09–2.19]) and using meansother than anti-retroviral treatment to treat HIV (0.33 [0.11–1.00]) were inde-

pendently associated with disclosure. This study identified several factors that

should be considered for the design of interventions aimed at facilitating dis-

closure if/when desired in this cultural context.

1

1 Corresponding author. Email: abernier@coalitionplus.org

Introduction

The prevalence of HIV among 15- to 49-year-olds is estimated at 0.9% in Mali

(UNAIDS, 2012). As in most countries in sub-Saharan Africa, HIV transmission

primarily occurs through sexual intercourse. The majority of new infections occur in

steady relationships, the steady sexual partner (SSP) being infected either before the

start of the relationship, or as a result of sexual relations with other partners duringthe relationship (Carpenter et al., 1999; Hugonnet et al., 2002; Malamba et al., 2005;

Guthrie et al., 2007; Eyawo et al., 2010). In this context, one of the main barriers to the

reduction of HIV transmission is the non-disclosure of HIV serostatus to the steady

sexual partner.

HIV disclosure is defined as the act of telling a third party (e.g. family member,

sexual partner, friend, colleague) that one is seropositive. Disclosure can either be

‘voluntary’ (i.e. the person living with HIV (PLHIV) takes the initiative to disclose) or

‘involuntary’ (e.g. when a third party reveals the seropositivity without the PLHIV’sconsent or when someone deduces one’s seropositivity). Disclosure is a critical issue

for newly diagnosed PLHIV. Disclosing to family, friends or a steady sexual partner

can bring social support to the PLHIV, which may in turn have positive effects on

psychological well-being (Zea et al., 2005). Financial support may also be a reason to

disclose (Miller & Rubin, 2007; Kadowa & Nuwaha, 2009). While it may have been a

strong motivation in Mali, especially for women, the financial burden of HIV care has

eased since the extension of free access to treatment in 2004, with the consequence that

PLHIV can minimize their economic dependence on their family and friends for HIVcare. Within a couple, disclosing entails the possibility to negotiate about safer sex

practices, in particular condom use (Marks et al., 1999; Olley et al., 2004; Loubiere et

al., 2009). Disclosure has also been associated with earlier testing of the sexual partner

and, if necessary, access to care (Nebie et al., 2001; Yameogo et al., 2008). However,

disclosure can be risky for PLHIV in case of negative reactions. Family exclusion of

the PLHIV may follow disclosure and is in some cases associated with emotional and/

or physical violence (Ogden & Nyblade, 2005). The risk of stigmatization and dis-

crimination is still very strong, and can have devastating consequences on the familial,social and economic lives of PLHIV (Mahajan et al., 2008). The anticipation of nega-

tive consequences is the main barrier cited by PLHIV for non-disclosure, as they are

afraid of discrimination and stigmatization, or of a negative reaction of the partner

leading to rejection, abandonment, break-up or violence (Hays et al., 1993; Maman et

al., 2003; Akani & Erhabor, 2006). Disclosure and its positive and/or negative con-

sequences are therefore important determinants of a PLHIV’s quality of life (Chandra

et al., 2003; Preau et al., 2007).

Disclosure is a process that occurs over time as HIV-positive individuals disclose todifferent people in their network, influenced by many factors (e.g. social norms and

context, family dynamics, gender, age group, type of social relationships, income and

educational level, health access and quality) (Hardon et al., 2013). Disclosing to a family

member might be a different challenge than disclosing to one’s spouse or sexual partner,

especially in sub-Saharan Africa. While studies show that the majority of PLHIV dis-

closed to at least one of their relatives, wider variation in terms of disclosure rate to

sexual partners was found, ranging from <20% to >90%, indicating a different and

M. Cisse et al.2

complex underlying mechanism (Obermeyer et al., 2011; Bott & Obermeyer, 2013;

Hardon et al., 2013).

Furthermore, while disclosing seropositivity still remains a very difficult issue forPLHIV in all spheres of their social lives, the Malian legislation requires that PLHIV

reveal their seropositivity to their spouse and sexual partner(s) ‘as soon as possible’ or

‘within six weeks’ after HIV diagnosis (Loi 06-028, 2006), adding even more complexity

to the issue of disclosure for PLHIV in Mali. Despite the importance of this issue, at the

individual level and in terms of public health, very few studies on disclosure, in particular

to one’s sexual partner, have been performed so far in Mali.

In Mali, PLHIV can receive comprehensive care either in public centres or in

community-based organizations (CBO). The CBOs are well known for being criticalstakeholders in PLHIV care in Mali. The biggest CBO in the country, named ARCAD-

SIDA, provides care for more than 50% of the HIV-positive patients in the country. This

organization is renowned for the quality of patient management and the comprehensive

nature of its care, which combines medical attention and psychosocial support, in a spirit

of community mobilization and involvement of PLHIV.

Community-based participatory research is a form of research aiming at transcending

academic boundaries and evolving towards a model of inter-disciplinary collaborations,

involving academic researchers and community stakeholders in a balanced partnershipensuring mutual benefits. In Africa, this type of research has long been in existence, allow-

ing the gradual emergence of a participatory health democracy (Mosavel et al., 2005).

This form of research is now increasingly used and participates in the global movement

of community mobilization, empowerment and representation. Considering the impor-

tance of community mobilization and empowerment in the issue of disclosure in Mali,

and in the framework of ethical considerations, a community-based study was performed

to explore the factors independently associated with voluntary disclosure of serostatus to

one’s steady sexual partner in a population of PLHIV in contact with the community-based organization ARCAD SIDA.

Methods

This study is a sub-study of PARTAGES, a community-based cross-sectional research

study. Developed and implemented by a mixed (researchers/CBO members) interna-

tional research consortium from seven countries (Canada, Democratic Republic of the

Congo, Ecuador, France, Mali, Morocco and Romania), its objective was to documentthe factors associated with serostatus disclosure by PLHIV in contexts where available

data are rare (Loukid et al., 2014; Lazar et al., 2014).

In Mali, the study was performed between May and October 2011 on 300 PLHIV

who were in contact with ARCAD SIDA. The inclusion criteria were as follows:

HIV positive, 18 years old or over, and aware of seropositivity for more than six

months. Five sites participated in the recruitment of participants: three in Bamako,

one in Koulikoro and one in Kati. The PLHIV were asked during their routine medical

visit at one of these sites if they were willing to participate in the study. After providingwritten informed consent, they were administered a questionnaire by one of ten inter-

viewers, most of whom were members of ARCAD SIDA living with HIV. All were

trained beforehand in interviewing techniques.

HIV disclosure to sexual partner in Mali 3

The questionnaire was designed following individual interviews and focus groups

with PLHIV, health care personnel and social workers. These sessions identified many

challenges faced by PLHIV and field stakeholders. It was considered important toinclude all these challenges in the questionnaire, to be in line with what was identified

by stakeholders and the community. Consequently, the questionnaire contained 125

questions, divided into eight sections (socioeconomic data, history and contact with

HIV, serostatus disclosure and reaction of others to disclosure, self-efficacy, intimate

and social life, sexuality, quality of life and contact with CBOs). The study was

approved by the Faculty of Medicine Ethics Committee of Bamako in 2011.

Explanatory variables

Based on the existing literature and challenges identified by field stakeholders and

PLHIV, the following categories of variables were tested for their association with volun-

tary disclosure to one’s SSP: gender, age, having children, main activity, being accom-

panied to the survey site, number of years since HIV diagnosis, using means other than

highly active anti-retroviral treatment (HAART) to treat HIV and knowing others who

had publicly declared their seropositivity. The last two variables mentioned above are

indicators of beliefs and are fundamental contextual elements, especially in sub-SaharanAfrica.

Additionally, two scales were used in the analysis: a self-esteem scale and a self-

efficacy scale. They were included in the questionnaire because they have been under-

investigated so far, and they are good indicators of individual characteristics. These scales

come from validated scales and have been adapted in the field, with tests on various

persons in different contexts to ensure good understanding of questions as well as

answers. All the items were simplified to a binary choice: agree/yes (1) vs disagree/no

(0). Global scores were constructed as the sum of item scores. The unidimensionalityof each scale was validated with a principal factor analysis of the tetrachoric correlation

matrix, and the internal consistencies were assessed via ordinal alphas (a) (Gadermann

et al., 2012). The results of the factor analyses were satisfactory for each scale, ensuring

the validity of these scales.

Self-esteem, defined as ‘the value which we give to ourselves’ (Martinot, 2001), was

based on the Rosenberg Self-Esteem Scale. Only four of the original scale items were

kept (items 1, 2, 4 and 5). A high score corresponds to a high level of self-esteem

(a ¼ 0.71) (Rosenberg, 1965). The General Self-Efficacy Scale is a ten-item scale adaptedfrom Schwarzer’s scale (questions 1–6, 8–11), assessing perceived efficacy to solve daily

hassles and problems (Schwarzer, 1992). It was asked to focus especially on the problems

related to HIV status. A high score corresponds to a high level of perceived self-efficacy

(a ¼ 0.95).

Statistical analysis

The sample was weighted using a variable based on the socio-demographic charac-teristics (age group, gender and recruitment site) of PLHIV followed by ARCAD

SIDA, to ensure that the sample was representative of the population followed by the

CBO. To study voluntary disclosure to one’s SSP, the analysis was restricted to the

M. Cisse et al.4

participants who declared having a SSP and who answered the question about dis-

closure to their SSP. Qualitative variables were compared using the w2 test or Fisher’s

exact test, and for quantitative variables the comparisons of the means were performedusing Student’s t-test or non-parametric Kruskall–Wallis or Wilcoxon tests. Potential

explanatory variables were screened for inclusion in the model by testing each one

independently for an association with voluntary disclosure of serostatus to one’s SSP,

using weighted univariate logistic regression. Variables with a significance level of

p a 0.20 in the univariate analysis were included in the multivariate analysis. For the

multivariate analysis, a complete case analysis was performed and the final model was

built using a backward elimination approach based on the log-likelihood ratio test

( p a 0.05). A receiver operating characteristic (ROC) curve was used to assess thelogistic regression model’s ability to accurately distinguish participants who had dis-

closed their seropositivity from the others. The area under the ROC curve (AUC)

provided a measure of discrimination (Hosmer & Lemeshow, 2000). Data management

and statistical analyses were performed using SPSS v20.0 (IBM Corp., 2011).

Results

Among the 300 participants, 219 declared that they had a SSP and answered to thequestion about HIV voluntary disclosure to their SSP. Among them, 161 (73.5%)

declared that they had voluntarily disclosed their serostatus to their steady sexual partner.

A description of the characteristics of these 219 persons is presented in Table 1. Approx-

imately two-thirds of the study sample were female (63%), the mean age was 35.6 years

and a large majority of participants (87%) had children.

In Table 2, the results of the univariate and multivariate analyses are described.

While all the results are presented for the univariate analysis, only the significant ones

for the multivariate analysis are shown ( p a 0.05). Multivariate analysis (Table 2)showed a positive, independent and statistically significant association of the following

factors with HIV voluntary disclosure to a SSP: having children (odds ratio [95%

confidence interval]: 4.52 [1.84–11.12], p ¼ 0.001), being accompanied to the survey

site (3.66 [1.00–13.33], p ¼ 0.05), knowing other PLHIV who had publicly declared

their seropositivity (3.12 [1.59–6.12], p ¼ 0.001) and having higher self-esteem (1.55

[1.09–2.19], p ¼ 0.01). To the contrary, using means other than HAART to treat HIV

was negatively associated with disclosure (0.33 [0.11–1.00], p ¼ 0.05). The area under

the ROC curve of the final multivariate model was 0.75, indicating an acceptabledegree of discrimination, according to Hosmer & Lemeshow (2000).

Discussion

Of the 219 PLHIV included in the analysis, 73% declared that they had voluntarily dis-

closed their serostatus to their SSP. This is higher than in another study performed in

Mali where 59% of the PLHIV interviewed had disclosed their serostatus to their most

recent SSP (Centre d’etude et de recherche sur l’information en population et sante,2012). In other contexts, the percentage of disclosure to one’s SSP varies widely, between

<20% and >90% (Bouillon et al., 2007; Obermeyer et al., 2011; Amoran, 2012; Erku

et al., 2012; Vu et al., 2012; Bott & Obermeyer, 2013). These differences are dependent

HIV disclosure to sexual partner in Mali 5

on study design, but also show the importance of the contextual and individual factors

in the disclosure process.

Eighty-seven per cent of the respondents in the study sample declared that they had

children. Having children was positively associated with disclosure to one’s SSP. Inother studies on seropositive sub-Saharan women, the presence of children in the

household was also shown to be predictive of disclosure (Loubiere et al., 2009; Suzan-

Monti et al., 2011).

Table 1. Characteristics of the individuals included in the analysis (n ¼ 219)

Individuals

who did not

disclose their

serostatus to

their partners

(n ¼ 58)

n (%) or

mean (SD)

Individuals

who disclosed

their serostatus

to their partners

(n ¼ 161)

n (%) or

mean (SD)

Total

(n ¼ 219)

n (%) or

mean (SD)

Gender Male 20 (34.5) 62 (38.5) 82 (37.4)

Female 38 (65.5) 99 (61.5) 137 (62.6)

Age (years) 34.2 (7.1) 36.2 (9.6) 35.6 (9.0)

Having children No 14 (24.1) 13 (8.1) 27 (12.3)

Yes 44 (75.9) 147 (91.3) 191 (87.2)

Main occupation Unemployed/

student/

housewife

20 (34.5) 49 (30.4) 69 (31.5)

Informal

employment

29 (50.0) 79 (49.1) 108 (49.3)

Formal

employment

9 (15.5) 33 (20.5) 42 (19.2)

Accompanied to the

survey site

No 55 (94.8) 136 (84.5) 191 (87.2)

Yes 3 (5.2) 25 (15.5) 28 (12.8)

Number of years since

HIV diagnosis

3.6 (2.6) 5.2 (3.7) 4.8 (3.5)

Using means other

than HAART to treat

HIV

No 50 (86.2) 153 (95.0) 203 (92.7)

Yes 8 (13.8) 8 (5.0) 16 (7.3)

Knowing other PLHIV

who had publicly

declared their

seropositivity

No 29 (50.0) 42 (26.1) 71 (32.4)

Yes 29 (50.0) 119 (73.9) 148 (67.6)

Self-esteem scale 3.0 (1.0) 3.3 (0.9) 3.2 (0.9)

Self-efficacy scale 7.8 (3.0) 8.5 (2.3) 8.2 (2.5)

M. Cisse et al.6

The link between parenthood and disclosure may reflect diverse realities, depending

on whether seropositivity was diagnosed before parenthood, during pregnancy or when

children were already present in the household. When seropositivity is discovered

before parenthood, the desire to have a child may encourage disclosure to one’s steady

sexual partner (Desgrees-du-Lou, 2011). Disclosure may highlight the individual’s con-

cern about HIV transmission to the other parent or to future offspring and facilitate

Table 2. Factors associated with voluntary disclosure to one’s steady sexual partner,

univariate and multivariate analyses (n ¼ 219)

Univariate analysis Multivariate analysis

OR [95% CI] p-value aOR [95% CI] p-value

Gender Male 1 0.52 — —

Female 0.81 [0.43–1.52]

Age (years) 1.03 [0.99–1.06] 0.16 — —

Having children No 1 0.002* 1 0.001

Yes 3.74 [1.64–8.52] 4.52 [1.84–11.12]

Main occupation Unemployed/

student/

housewife

1 0.68

Informal

employment

1.12 [0.57–2.19]

Formal

employment

1.49 [0.61–3.65] — —

Accompanied to the

survey site

No 1 0.08 1 0.05

Yes 2.87 [0.88–9.40] 3.66 [1.00–13.33]

Number of years since

HIV diagnosis

1.17 [1.05–1.30] 0.004* — —

Using means other

than HAART to treat

HIV

No 1 0.02* 1 0.05

Yes 0.30 [0.11–0.85] 0.33 [0.11–1.00]

Knowing other PLHIV

who had publicly

declared their

seropositivity

No 1 0.001* 1 0.001

Yes 2.79 [1.49–5.20] 3.12 [1.59–6.12]

Self-esteem scale 1.46 [1.06–2.01] 0.02* 1.55 [1.09–2.19] 0.01

Self-efficacy scale 1.10 [0.99–1.24] 0.08 — —

OR: odds ratio; CI: confidence interval; aOR: adjusted odds ratio.

For multivariate analysis, the model included 217 participants; only the significant results are

presented here (p a 0.05).

*p a 0.05.

HIV disclosure to sexual partner in Mali 7

access to medical and social support specifically tailored to parenthood within the con-

text of seropositivity. Seropositivity may also be discovered during pregnancy thanks

to programmes to prevent vertical transmission. In many countries, women are oftenfirst tested when pre-natal monitoring begins (Desgrees-du-Lou, 2011). Indeed, among

the 137 women in this study sample, 35 (26%) had discovered their seropositivity during

pregnancy. Mothers who disclose their seropositivity to their partner tend to do so just

before giving birth, during early weaning or when sexual relations recommence (Brou

et al., 2007).

If seropositivity is discovered when there are already children in the household, the

desire to have children tested may be a driver for disclosure to one’s partner. In this

sample, among participants having children, 17% had at least one seropositive childrenand 12% had lost one or more children to HIV/AIDS. Previous HIV transmission to

a child may increase a mother’s vigilance towards other children of the household.

Although HIV infection may threaten the strength of the couple relationship by com-

plicating the issue of sexuality and reproduction (Desgrees-du-Lou, 2011), the fact that

children are already present is often perceived as providing stability and a guarantee

for the future. Then, the presence of children may limit the fear of being abandoned

or rejected when the PLHIV contemplates disclosure.

A positive link between being accompanied to the survey site and voluntary dis-closure to the SSP was found. On the day of the survey, 13% of the PLHIV in the

study sample were accompanied to the health care site. The survey questionnaire was

administered without the presence of the accompanying person(s). The PLHIV may be

accompanied to the health care site by a close family member or friend, by one of the

steady partner’s family members or relatives, or by the steady partner him/herself. In

this sample, women were more often accompanied than men ( p ¼ 0.06). This may be

explained by the fact that in Malian society, women are more often economically and/

or socially dependent on their family or on their partner. In Mali, women are moreoften accompanied by one of their steady partner’s family members or relatives rather

than by their male spouse or steady partner. Previous studies have highlighted this low

level of involvement by male spouses/partners in health care programmes, including

HIV care programmes (Antelman et al., 2001; Orne-Gliemann et al., 2011). If accom-

paniment was not chosen or agreed upon, especially for women, it was certainly difficult

for PLHIV to hide their status, because the nature and function of the health care estab-

lishment providing HIV services are easily identifiable on site. In this case, PLHIV may

have decided to disclose their seropositivity to their sexual partner to prevent the latterfrom discovering it by him/herself, either upon arrival at the health care unit or from

the person who accompanied the PLHIV.

If accompanied by the partner, it may be part of a disclosure strategy involving the

help of the health care team. In this kind of situation, the seropositive person may re-

peat the HIV test at the same time as the partner, and then pretend to discover his/her

seropositivity for the first time when the results are made known to the couple (Henry

et al., 2010). Strategies involving medical personnel in the announcement of seroposi-

tivity to a partner have been identified in other studies (Collignon et al., 1994; Ky-Zerboet al., 2013). The PLHIV’s primary concern is to ensure that their partner takes the HIV

test. If the partner is found to be seropositive, the PLHIV can protect him/herself from

the possible accusation that it was he/she who first brought the infection to the couple.

M. Cisse et al.8

In Burkina Faso, for example, this kind of accusation is primarily directed towards

women (Egrot, 2004). The desire of PLHIV for their partners to be tested has been

identified as one of the main reasons to disclose (Kadowa & Nuwaha, 2009). Indeed,in Abidjan, male partners informed about their female partner’s seropositivity were

more likely to go for testing than those unaware (Brou et al., 2007). Being accompanied

to the health care centre may also be the consequence of a poor state of health, which

makes it more difficult for PLHIV to keep their seropositivity secret from their partner

(Bouillon et al., 2007).

This study has highlighted that knowing other PLHIV, either personally or through

the media, who had publicly declared their serostatus, was positively associated with

disclosure to a steady sexual partner. Public declaration of seropositivity by PLHIVchanges the social environment and may reduce stigmatization by demystifying the

negative social perceptions associated with HIV infection (Paxton, 2002). In Mali, public

declarations by PLHIV are quite frequent. HIV has been visible in the media since the

beginning of the epidemic. Despite the scepticism of a minority of the audience regarding

their veracity, public declarations give the epidemic a face and increase people’s aware-

ness of the daily lives of those living with the disease. For the PLHIV’s partner and close

circle of family and friends, it therefore becomes easier to ‘hear’ announcements of

seropositivity, which in turn may facilitate the PLHIV’s decision to disclose.Public declarations of seropositivity may also provide the occasion for a PLHIV

whose infection is still secret to ‘test’ what his/her partner’s perceptions and opinions

are about the issue (Orne-Gliemann et al., 2011). This may even entail discussion about

the subject with the possible realization that the partner is not as adverse to the subject

as previously thought (Galliard et al., 2000). The anticipation of support from one’s

partner has been shown to be associated with the act of disclosing (Amoran, 2012).

Moreover, as theories of social identity suggest (Tajfel & Tuner, 1986), PLHIV who

publicly declare their seropositivity may be considered role models by other PLHIV,who feel more confident about following their example. The former are often actors

involved within CBOs, and their public declaration increases the visibility of such

organizations. In turn, this increased visibility may encourage PLHIV to visit these

organizations and meet other PLHIV, some of whom have already publicly disclosed

their seropositivity.

A positive association between disclosure to a steady sexual partner and self-esteem

was observed. Self-esteem manifests itself by a positive or negative orientation towards

oneself, starting from an evaluation of one’s own worth (Terra et al., 2013). The feelingof self-esteem daily impacts on physical and psychological well-being (Martinot, 2001)

and influences social performance (Terra et al., 2013). Accordingly, self-esteem may be

considered as an indicator of psychosocial well-being. In this study, a higher level of

self-esteem was associated with disclosure. Disclosure to a steady sexual partner may

strengthen a PLHIV’s self-esteem, especially when the partner reacts positively to the

news. In this way, the study by Parsons et al. showed that one of the ‘positive rewards’

for disclosing was ‘the reaffirmation of one’s sense of self’ (Parsons et al., 2004). In a

study on homosexual and bisexual men, Holt et al. also showed that disclosure helpedto facilitate the self-acceptance of one’s condition (Holt et al., 1998).

Having high self-esteem may also facilitate the process of coming to terms with

one’s seropositivity and disclosing it, in particular to one’s sexual partner. An interest-

ing fact is that in our study, self-esteem is significant and not self-efficacy. Self-esteem is

HIV disclosure to sexual partner in Mali 9

the emotional component of the self, whereas self-efficacy refers to beliefs about the

efficacy of one’s behaviours (Martinot, 1995, 2001). Thus, self-efficacy is a more accurate

and selective measure than self-esteem. In the case of serostatus disclosure to one’s sexualpartner, self-efficacy only concerns the behaviour of revealing one’s serostatus, while

self-esteem refers to the global emotional effort of taking the decision to disclose to

one’s sexual partner. In relation to the disclosure to one’s sexual partner, it seems plau-

sible that the global emotional effort of taking the decision to disclose is more strongly

associated with disclosure than the belief in the efficacy of one’s behaviour of disclosing.

A negative association between using means other than HAART to treat HIV and

voluntary disclosure to one’s SSP was identified. A small number of respondents (7%)

declared that they used traditional and alternative means to treat their HIV infection,including the use of plants (in particular leaf decoctions, tree bark or tree roots) or

making offerings. Most of these people were on HAART (91%). This is similar to find-

ings in other contexts (Owen-Smith et al., 2012). The belief that HIV can be cured thanks

to alternative treatments, often described as being used to ‘complement’ HAART, reflects

mystical and inaccurate perceptions. If a PLHIV is convinced that he/she can be cured,

disclosure to his/her sexual partner may seem less necessary. Accordingly, in a study per-

formed in Cameroon on seropositive women, a significant link was found between the

belief that HAART cures HIV and non-disclosure of seropositivity to a primary partner(Loubiere et al., 2009). A study in Uganda also showed that ‘not seeing any reason to

disclose to sexual partners’ – which could potentially reflect a poor understanding of the

different ways of HIV transmission – was associated with keeping serostatus confiden-

tial from one’s partner (Kadowa & Nuwaha, 2009). Nevertheless, the small number of

people in this study sample using alternative treatments suggests these results should be

interpreted with caution.

Study limitations

First, the sample used in this study was a convenience sample, drawn from sero-

positive persons in contact with a Malian CBO working in the fight against HIV/

AIDS. The beneficiaries of this organization’s services are supported medically, psy-

chologically and socially. In particular, they are encouraged and supported in their

decision to disclose their serostatus. Therefore, PLHIV in this sample might have dis-

closed more than those who are not in contact with CBOs (Ncama, 2007). This sample

then cannot be considered as representative of all the PLHIV in Mali. Second, the studybeing cross-sectional, the dynamics of the disclosure process could not be captured. Third,

thanks to a standardized questionnaire, disclosure was explored in the five countries

participating in the PARTAGES study. The different socio-cultural contexts in these

countries may limit the relevance of the concept of ‘steady sexual partner’. In Mali,

polygamy is authorized by law, and men may therefore legally have up to four wives.

Men and women can also have several partners outside marriage. This study only focused

on the ‘main’ steady sexual partner identified spontaneously by the PLHIV. Finally, the

existence of a law requiring PLHIV to disclose to their SSP may have introduced aselection and/or a desirability bias. Nevertheless, this bias should be very limited since

the law has never been enforced in Mali. Most PLHIV did not even know of its existence.

Moreover, the fact that the study was conducted by NGO members who had been trained

M. Cisse et al.10

on the study protocol and ethical issues as well as the pre-existing confidence relationship

between respondents was rather a guarantee of good-quality answers.

Perspectives

This study highlights the link between disclosure of one’s seropositivity to a steady

sexual partner and multi-level factors. At the individual level, the familial context plays

a role in the disclosure process. Parenthood was significantly associated with disclosure

to a steady sexual partner. Accordingly, the offer of care during pregnancy could en-

courage testing and disclosure in the couple. It could also reduce the risk of transmis-

sion to both the child and the partner. Innovative approaches focusing on the coupleand the nuclear family should be developed on the field. A few interventions have been

recently developed in this way. The study by Orne-Gliemann et al. showed the feasibility

and the relevance of implementing pre-natal HIV counselling for couples (Orne-

Gliemann et al., 2011). This study also highlighted the link between being accompanied

to the health care site and disclosure to a steady sexual partner. Including, with the

PLHIV’s consent, the circle of family and friends in issues regarding medical care is

important as their emotional and economic support plays a major role in the disclosure

process.Other individual characteristics of PLHIV, in particular self-esteem, are also deter-

mining elements for disclosure. Certain activities organized by CBOs help to build self-

esteem, strengthening the PLHIV’s capacity in terms of self-acceptance, trust in others

and communication of seropositivity, especially to a partner. Such activities should be

expanded. In this way, the Gundo So programme (Otis et al., 2012), culturally adapted

to the Malian context from a Canadian programme (Otis et al., 2010), focused on

increasing self-awareness and developing personal competences in women living with

HIV to support them in their decision whether to disclose their seropositivity or not.The PLHIV’s beliefs about infection and treatments may also be associated with

disclosure to a steady sexual partner. Consequently, medical personnel and community-

based actors should work together in order to increase PLHIV’s understanding of infec-

tion and treatment mechanisms. If traditional healers are involved, it may be possible to

convince them to help in the process of providing correct and comprehensive informa-

tion regarding these aspects, to prevent denial of seropositivity or treatment adherence

problems.

Finally, the social environment is also associated with disclosure. Social models,particularly through public declarations of HIV infection, seem to be an important factor

facilitating disclosure to a steady sexual partner. Consequently, this study validates the

benefit of CBOs’ activities at the community level focusing on the issue of disclosure,

like support groups.

Conclusion

In conclusion, this study identified several factors associated with disclosure toone’s SSP in Mali. Interventions aiming at facilitating disclosure to partners should be

personalized and take into account individual characteristics, as well as familial and

social environment. Empowerment interventions should be developed in the field to

HIV disclosure to sexual partner in Mali 11

improve personal skills as well as knowledge regarding the disease, routes of infection

and treatment options. Finally, global interventions aiming at reducing stigmatization

and discrimination, like public declarations of seropositivity, should be continued, soas to ensure positive reaction of the social environment of PLHIV if/when willing to

disclose.

Acknowledgments

This study was funded by the French Agency of AIDS Research (ANRS) and Sidaction.

These organizations were not involved in the study design, implementation, analysis or

writing of the article. This study was made possible thanks to the organization ‘CoalitionInternationale Sida’. The authors thank all the PLHIV who agreed to participate in this

study, and the partners of the other countries involved in PARTAGES for their con-

tribution to its success at the local and international level. Finally, the authors would

like to thank Jude Sweeney for reviewing the English in this manuscript.

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