Suzanne Maman, 1,4 Jessie K. Mbwambo, 2 Nora M. Hogan, 2 Ellen Weiss, 3 Gad P. Kilonzo, 2 and Michael D. Sweat 1 INTRODUCTION

Transcription

1 AIDS and Behavior, Vol. 7, No. 4, December 2003 ( C 2003) 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 Suzanne Maman, 1,4 Jessie K. Mbwambo, 2 Nora M. Hogan, 2 Ellen Weiss, 3 Gad P. Kilonzo, 2 and Michael D. Sweat 1 Received July 3, 2002; revised May 7, 2003; accepted May 13, 2003 The rates, barriers, and outcomes of HIV serostatus disclosure to sexual partners are described for 245 female voluntary counseling and testing (VCT) clients in Dar es Salaam, Tanzania. VCT clients were surveyed 3 months after HIV testing to describe their HIV-serostatus disclosure experiences. Sixty-four percent of HIV-positive women and 79.5% of HIV-negative women ( p = 0.028) reported that they had shared HIV test results with their partners. Among women who did not disclose, 52% reported the reason as fear of their partner s reaction. Both 81.9% of HIV-negative women and 48.9% of HIV-positive women reported that their partner reacted supportively to disclosure ( p < 0.001). Less than 5% of women reported any negative reactions following disclosure. VCT should continue to be widely promoted. However, intervention approaches such as development of screening tools and new counseling approaches are important to ensure the safety of women who want to safely disclose HIV serostatus to their sexual partners. KEY WORDS: HIV voluntary counseling and testing; women; HIV-serostatus disclosure. INTRODUCTION The demand for HIV voluntary counseling and testing (VCT) in settings such as Dar es Salaam, Tanzania, has been increasing dramatically (Maman et al., 2001). As the epidemic matures and HIVassociated stigma diminishes, people are increasingly taking steps to learn their infection status in order to relieve anxiety associated with not knowing, attend to 1 Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland. 2 Department of Psychiatry, Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania. 3 Horizons Program/International Center for Research on Women, Washington, D.C. 4 Correspondence should be directed to Suzanne Maman, Johns Hopkins University Bloomberg School of Public Health, Department of International Health, 615 N. Wolfe Street, Room E5033, Baltimore, Maryland ( smaman@jhsph.edu). their health, make reproductive health decisions, and plan for the future (Maman et al., 2001). However, serostatus disclosure to sexual partners remains far from universal. In sub-saharan Africa, reported rates of sersotatus disclosure to sexual partners vary widely. Studies have found that between 16.7% and 86% of HIVinfected individuals share HIV test results with their sexual partners (Antelman et al., 2001; Farquhar et al., 2000; Gaillard et al., 2000; Keogh et al., 1994; Kilewo et al., 2001; Lie and Biswalo, 1996; MacNeil et al., 1999; Nebie et al., 2001; van der Straten et al., 1995). The lowest rates of HIV serostatus disclosure are reported in studies among pregnant women. Research conducted in a variety of settings has shown that there are a number of barriers that HIV-infected individuals face to sharing their HIV test results with friends, family, and, most importantly, sexual partners. These barriers include fear /03/ /0 C 2003 Plenum Publishing Corporation

2 374 Maman et al. of abandonment and loss of economic support, fear of discrimination, fear of violence, fear of upsetting family members, and fear of blame (Antelman et al., 2001; Heyward et al., 1993; Issiaka et al., 2001; Keogh et al., 1994; Kilewo et al., 2001; Ladner et al., 1996; MacNeil et al., 1999; Nebie et al., 2001; Rakwar et al., 1999). There is considerable interest in finding strategies to encourage disclosure because of the public health benefits that may accrue from the disclosure of HIV serostatus to sexual partners, including expanded awareness of risk and behavior change, which may ultimately reduce transmission of HIV. However, the reports of negative outcomes of HIV testing and HIV-serostatus disclosure to partners, particularly physical assault against women, has caused some concern about the widespread promotion of HIV VCT and partner notification (Gielen et al., 2000; Grinstead et al., 2001; Keogh et al., 1994; Kilewo et al., 2001; Matthews et al., 1999). Although there is strong evidence that HIV VCT is an effective and cost-effective HIV prevention strategy (Sweat et al., 2000) and demand for HIV VCT services is increasing, the low HIV-serostatus disclosure rates to sexual partners and the possibility of negative outcomes of disclosure for some clients has raised concerns about HIV VCT. In 1999 we conducted a study among HIV VCT clients in Dar es Salaam, Tanzania, to examine the relationship between HIV and violence against women. The study was conducted among clients of a freestanding HIV VCT clinic on the grounds of the national referral hospital in Dar es Salaam. The clinic is staffed by four full-time HIV counselors, who counsel and test over 1,000 new clients each month. At the time of this study the clients received HIV pretest counseling and had blood drawn for the HIV test results at their first clinic visit. Clients were then given an appointment to return 2 weeks after this initial visit for their results and a posttest counseling session. Couples who came to the VCT clinic for services together received individual pretest and posttest counseling sessions with a counselor. After receiving their results individually, the two partners were then given the option to meet with the counselor together to share HIV test results with one another. Since the time this study was completed the VCT clinic has adopted an HIV rapid-testing protocol to provide clients with pretest and posttest counseling on the same day. Through a two-phase study we explored violence as a risk factor for HIV infection and as an outcome of HIV testing and disclosure. The goal of the first phase of research was to define violence in this context, describe the HIV testing and serostatus disclosure decision-making process among men, women, and couples, and develop the survey instrument for use in the second phase. In Phase 1 we qualitatively interviewed 15 women, 17 men, and 15 couples who had recently been through the HIV counseling and testing process at the HIV VCT clinic in Dar es Salaam. Based on results from the first phase, we found that women faced greater difficulty than men in making the decision to test and share HIV test results with a partner. Women made reference to the need to seek permission from a partner prior to testing. Women thought about testing for a long period of time prior to coming into the HIV VCT clinic. The most salient barrier to disclosure described by women was fear of partner s reaction and partner s negative attitudes toward HIV testing. Perception of personal risk for HIV is the major factor driving women to overcome barriers to HIV testing. More detailed findings from the first phase of research have been reported elsewhere (Maman et al., 2001). The objectives of the second phase were twofold: First, we measured the prevalence and identified the correlates of violence against women and second we measured the rates and described the outcomes of HIV-serostatus disclosure to partners. Related to the first research objective for this phase, we learned that 37.6% of women had at least one partner in their lifetime who had been physically abusive and 30.2% of women reported at least one physically violent episode with their current partner. To measure violence with their current partner we used a modified version of the Conflict-Tactic Scale (CTS) (Straus et al., 1996). We asked about the frequency of specific behavioral experiences during two different referent periods, in the last 3 months (time since HIV-1 testing) and prior to the last 3 months. To describe lifetime adult violence, we asked informants to tell us how many of their partners had hit, slapped, kicked, pushed, shoved, or otherwise physically hurt them. We also asked women to tell us how many partners had forced them into sexual activity against their will. The odds of reporting at least one physical and sexually violent event ever was significantly higher among HIV-positive women than among HIVnegative women (odds ratio [OR] = 2.63, 95% confidence interval [CI] = ; and OR = 2.39, 95% CI = , respectively). Although caution is warranted in comparing rates of violence across different settings and studies because of different sampling strategies and different measures used to define the scope of the problem, the rates that were described

3 HIV-Serostatus Disclosure to Sexual Partners 375 in the population of women in our study are similar to rates reported in studies from Uganda and Kenya (42% and 41% of women, respectively, reported ever experiencing violence with their current partner) and the United Kingdom (30% of women reported ever experiencing violence in their lifetime) (Heise et al., 1999). The findings on the prevalence and correlates of violence from this study have been reported elsewhere (Maman et al., 2002). METHODS This paper describes the experiences of HIVserostatus disclosure among women from a VCT clinic in Dar es Salaam, Tanzania, the second research objective for Phase 2 of the study. In Phase 2 we enrolled 340 women in the study immediately after pretest counseling before they had learned their HIV infection status. To be enrolled in the study women had to be at least 18 years of age, have a primary sexual partner for at least the past 3 months, and planned on residing in Dar es Salaam for the next 3 months. We systematically enrolled every woman who met the eligibility criteria and who consented to participate in the research study. We conducted structured survey interviews 3 months after enrollment with 245 of the women that we enrolled in the study. To recruit women back to the clinic for the follow-up interview, we asked each woman we enrolled on a voluntary basis for personal contact information that would enable us to re-contact her 3 months after testing and remind her of her appointment. Project tracers sent generic reminders through the mail 2 weeks prior to the scheduled interview, telephoned women who missed their interview 1 week after it was scheduled, and physically traced all women who missed the interview 2 weeks after it was scheduled. The survey interviews were conducted in a private room at the VCT clinic and lasted approximately 1 hr. They were conducted in Kiswahili, the national language of Tanzania, by a trained survey interviewer. RESULTS Sample Characteristics Table I presents the demographic characteristics of the 245 women who participated in this study. On average, women who were interviewed were 32 years old and had 9.23 years of education; 29.8% were HIV infected, 48.3% were married, and the average duration of relationships was 7.5 years. Eighty-seven percent of women who came to the clinic were tested as an individual and 13% were tested as part of a couple. We were able to follow and interview 245 of the 340 women that we enrolled at baseline (72%). The major reasons for loss to follow-up included change of residence outside of Dar es Salaam (n = 69), refusal (n = 12), death (n = 8), and unknown (n = 6). The only factor that was statistically different between women who were followed and those lost to follow-up was the baseline report of violence with their current partner prior to the past 1 year. Among women who were followed, 47.6% reported violence with their current partner prior to the past year as compared to 61.8% of women lost to follow-up (p = 0.068). There were no differences in rates of recent partner violence (within the past 1 year) among women who were followed and those who were lost to follow-up. Rates of HIV-Serostatus Disclosure to Partners and Other Social Network Members Seven-percent of HIV-negative women and 16.7% of HIV-positive women ( p = 0.032) reported that they had not shared their test results with anyone. When we examined HIV-serostatus disclosure rates to sexual partners among women who came to the clinic as individuals, 79.5% of HIV-negative women and 64% of HIV-positive women (p = 0.028) had disclosed their HIV test results to their partner 3 months after HIV testing. Among women who came to be tested as part of a couple, we found that 100% of both HIV-positive and HIV-negative women shared their serostatus with their partner. When asked about HIV-serostatus disclosure to other social network members, 31% of women reported that they disclosed their HIV test results to a sister, 26% told a female friend, 22% told their mother, and 12% told their brother. Whereas HIV serostatus disclosure rates were higher among HIV-negative women than among HIV-positive women, the patterns of disclosure, such as whom they told and in what order they told these individuals, were similar for the two groups. Sixty-five percent of women said that the first person they told was their primary partner, followed by a female confidant, either a sister or a female friend. Forty-four percent of women identified at least one person to whom they did not want to disclose HIV test results. Thirty percent of these women said that this person was a relative, 27% said it was their parents,

4 376 Maman et al. Table I. Demographic Characteristics of Women in the Sample HIV HIV+ (n = 172; 70.2%) (n = 73; 29.8%) Overall (n = 245) Characteristic (%) (%) (%) p value Age (years) Education (years) Religion Catholic Protestant Muslim Other Marital status Married (mono/polygamous) Not married/living with partner Not married/not living with partner Employment status Employed Not employed Socioeconomic status Low Medium High Duration of relationship (years) Couple/individual testing Tested as individual Tested as couple % said it was a partner, 7% said it was a neighbor, and 6% said it was a friend. Among women who did not disclose HIV test results to sexual partners, 52% reported that their reason for nondisclosure was fear of their partner s reaction. The partner reactions that women feared most were abandonment and loss of economic support. Among the women who identified specific people other than their sexual partner to whom they did not wish to disclose results, their reasons for nondisclosure included concerns that this person would inform others of their HIV serostatus (31%), fear of worrying others (26%), and fear of negative outcomes including blame and discrimination (20%). Predictors of Disclosure Logistic regression analysis was conducted to identify factors associated with HIV serostatus disclosure to sexual partners. The dependent outcome in the analysis was disclosure/nondisclosure of HIV test results to the primary sexual partner. A primary partner was defined as a sexual partner that they have been with for 3 months or longer. The average duration of relationships was 7.5 years. Independent variables included women s HIV status, age, educational status, marital status, duration of relationship, and communication with their partner about HIV testing prior to coming to the clinic to be tested. There was a very strong association between prior communication about HIV testing with a partner and HIV-serostatus disclosure. The odds of disclosing HIV serostatus to a sexual partner was 22 times greater among women who had discussed testing with their partner prior to coming in to be tested than among women who had not discussed testing with their partner prior to coming in for HIV testing (95% CI = ). Age was also associated with disclosure. The odds of disclosing serostatus to a primary

5 HIV-Serostatus Disclosure to Sexual Partners 377 sexual partner was 1.67 times greater (95% CI = ) among older women (30 55 years) than among younger women (18 29 years). Given our sample size, it was not possible to conduct separate logistic regression analyses for both HIV-positive and HIV-negative women to identify predictors of HIV-serostatus disclosure. Partners Reactions to HIV-Serostatus Disclosure Whereas the major barrier to disclosing HIV serostatus to sexual partners was fear of their partner s reaction, the majority of HIV-negative women (81.9%) and nearly half of HIV-positive women (48.9%) who shared HIV test results with their partner reported that their partner was supportive and understanding (p < 0.001) (see Figure 1). A total of 12 women reported one or more negative responses by a partner after disclosing. This included being blamed for the results (8 HIV-positive women, 2 HIVnegative women), being physically assaulted (2 HIVpositive women, 1 HIV-negative woman), and being forced to leave the house or being abandoned (2 HIVpositive women and 1 HIV-negative woman). Small yet similar proportions of HIV-positive and HIVnegative women reported that their partner said he would come for testing when they shared their HIV test results with him (16.3% and 16.7%, respectively, p = 0.956). DISCUSSION Rates of HIV-Serostatus Disclosure We found that 79.5% of HIV-negative women and 64% of HIV-positive women who received HIV VCT services as an individual as compared to those who received services as part of a couple reported that they shared HIV test results with their partner 3 months after HIV testing. These rates of HIV serostatus disclosure to sexual partners are higher than we initially anticipated. Results from an earlier study on the efficacy of HIV counseling and testing that was conducted at the same clinic from 1995 to 1998 showed that 6 months after HIV testing 27% of HIV-positive women who enrolled as individuals reported that they had shared their HIV test results with their partners (Grinstead et al., 2001). This represents more than a twofold increase in reported rates of HIV serostatus disclosure over time among women tested as individuals. Higher rates of disclosure among women in our study than the women in the mid-1990s may reflect the increased openness in public discussions related to HIV/AIDS, which we feel has lead to greater demand for HIV VCT services, increased communication about HIV/AIDS between couples, and increased willingness to share HIV test results with partners among those individuals who seek HIV VCT in Tanzania. There has also been a greater emphasis on sharing results with sexual partners within counseling sessions at the VCT study clinic and it is likely that this has contributed to higher rates of disclosure among VCT clients. However, the rates of HIV serostatus disclosure to sexual partners that we found among women at the VCT clinic differ sharply from rates reported among women enrolled in HIV perinatal transmission trials that were being conducted during the same time period and at the same hospital in Dar es Salaam, Tanzania. Kilewo et al. (2001) found that only 16.7% of women enrolled in the PETRA study shared results with their partner, and Antelman (Antelman et al., 2001) reported that 22% of HIV-infected pregnant women in their trial shared HIV test results with their partners 2 months after diagnosis. There are important differences in the populations of women who are tested in HIV VCT clinics and within HIV perinatal transmission trials that may explain this discrepancy in HIV-serostatus disclosure rates. From our study we learned that women who came to the VCT clinic to test for HIV thought about HIV testing for a long period of time, often talked to their partner about their decision to test, and often had a high perception of personal risk for HIV that motivated them to seek HIV VCT services (Maman et al., 2001). In contrast, women who are offered HIV testing within the context of antenatal care may not have had time to psychologically prepare themselves for HIV testing and may not have had a chance to talk to their partner before deciding to test for HIV, and so the barriers to disclosure that they face may be more formidable. Another possible explanation for the lower disclosure rates among pregnant women may be related to the high value placed on fertility in places such as Tanzania. Some women may fear interfering with their pregnancy by disclosing HIV test results to a partner. We found lower rates of disclosure among young women in our sample, which may support the idea that younger women who still want to have children may be less likely to share HIV test results with a partner than older women.

6 378 Maman et al. Fig. 1. Partner s reaction to serostatus disclosure. Barriers to HIV-Serostatus Disclosure The major barrier to disclosing HIV serostatus to sexual partners reported among the women we studied was fear of negative reactions. Based on the qualitative interviews that we conducted with women in the first phase, we found that the reaction that women feared most was abandonment and loss of economic support. When describing their decision-making process for HIV-serostatus disclosure, the women described tension with their partner surrounding their decision to seek HIV testing. Women either fought hard to defend their decision to test or made the decision to test on their own without the consent of the partner. If they opted to test without the consent or knowledge of their partner, then the barriers to sharing their results with their partner were substantial (Maman et al., 2001). Heyward et al. (1993), Keogh et al. (1994), and Antelman et al. (1999) also found that many of the participants they interviewed did not disclose HIV serostatus to partners because they feared negative consequences. Outcomes of HIV-Serostatus Disclosure Over 80% of HIV-negative women and almost half of HIV-positive women reported that their partner reacted supportively to the disclosure of serostatus. Less than 5% of HIV-positive women and a smaller proportion of HIV-negative women reported any negative outcomes. Although concern is certainly warranted for all women who experience any negative outcomes as a result of disclosure, it is important not to lose sight of the fact that for the majority of women HIV testing and disclosure is a positive experience. Due to the small number of women we enrolled who sought VCT services as part of a couple (n = 32), we were unable to examine and compare statistically the outcomes of disclosure among women who were counseled and tested as an individual with those who were counseled and tested as part of a couple. Investigators in the HIV VCT Efficacy Study found that the outcomes of disclosure among couples as compared to individuals varied by serodiscordancy status. Participants in seroconcordant negative couples were most likely to report the strengthening

7 HIV-Serostatus Disclosure to Sexual Partners 379 of relationships. Investigators also found that participants in serodiscordant female-positive couples were most likely to report the break-up of a sexual relationship, highlighting women s vulnerability in such couples (Grinstead et al., 2001). We found a discrepancy between the anticipated and the actual outcomes of HIV serostatus disclosure to sexual partners. Whereas the majority of women who did not disclose to partners cited fear of partner s reaction as the major reason, the majority of HIV-negative women and a large proportion of HIVpositive women who did disclose experienced supportive reactions from their partners. This discrepancy could mean one of two things. First, it is possible that only women who were reasonably confident that their partner would react supportively chose to share HIV test results. It could also mean that women perceived that the risk of a negative outcome is more likely than it is in actuality. The perceived risk of violence may be understandable given the high background rates of partner violence reported by women in the study. Concerns about HIV-serostatus disclosurerelated violence has lead some people to question the usefulness of strategies that promote HIV VCT and partner notification. Studies from the United States and a small number of studies from sub-saharan Africa indicate that there are a limited number of women who share HIV test results with their sexual partners and experience negative outcomes. In a review of the literature on HIV serostatus disclosure-related violence in the United States, Koenig and Moore (2000) found that the rates ranged between 0.5% and 4%. Among the HIV-positive women we interviewed, 4.1% reported that their partner physically assaulted them when they disclosed their HIV status. We found that the difference in the rate of violence with a current partner prior to the past 1 year approached significance among women who were lost to follow-up as compared to women we interviewed 3 months after enrollment. It is therefore possible that the negative outcomes reported by women in our follow-up sample were an underestimate of the actual rate. However, there was no significant difference in the rate of recent physical violence with a current partner (in the past 1 year), which we feel may be a more accurate predictor of disclosure-related violence than violence that occurred in the partnership prior to the past 1 year. Therefore, although the potential for underreporting violence is a reality for any study, we do not feel that our loss to follow-up may have led to a further underreporting of violence to any significant degree. Higher rates of disclosure-related violence have been reported in other studies among pregnant women from sub-saharan Africa. Kilewo et al. (2001) found that 14.6% of women in Tanzania reported violence and Matthews et al. (1999) found that 13% of women from South Africa reported HIV-serostatus disclosure-related violence. Pregnant women who are tested for HIV in the context of their antenatal care have not psychologically prepared themselves and many have not involved their partner in the decision to test, which may in part explain the higher rates of negative outcomes in this population. It is also possible that the pregnancy status may make women more vulnerable to violence from their sexual partner (Gazmararian et al., 1996; Heise et al., 1999). Due to the cross-sectional nature of the data from all studies that report HIV-serostatus disclosurerelated violence, it is difficult to determine whether the violence experienced by women following disclosure represents an increase over the baseline rates that women in these studies may have faced. Disclosure of HIV test results may represent another trigger for physical assault in an already violent and troubled relationship. Furthermore, as Gielen et al. (2000) suggested, examining the specific case of violence following disclosure is too narrow a lens through which to understand the role of violence in the lives of women after HIV-positive diagnosis (Gielen et al., 2000). The abuse associated with sharing test results may occur not out of immediate anger in reaction to the disclosure, but rather some time later in the context of an ongoing or new cycle of violence. It is worth noting that some HIV-negative women also experience negative outcomes as a result of HIVserostatus disclosure to their sexual partners. We found that two HIV-negative women reported being physically assaulted and one HIV-negative woman reported being forced to leave the house or abandoned as a result of disclosure. From the in-depth interviews we conducted with men and women in the first phase of data collection, we learned that the act of testing itself might be a threat to the relationship. Men and women explained that telling a partner one would like to be tested for HIV or that one has already been received VCT services may communicate mistrust about their own sexual behavior or their partner s sexual behavior. Therefore, among the HIV-negative women who reported negative outcomes, the partners of these women were most likely reacting negatively

8 380 Maman et al. to the fact that the women had been tested without their knowledge or consent. Implications for Interventions Based our findings, we feel there is a range of different program and policy approaches that need to be taken in order to increase HIV-serostatus disclosure rates and support women through the HIV-serostatus disclosure process. First, there is a need to involve women s male partners earlier in the HIV counseling and testing process. We found that all HIV-positive and HIV-negative women who received HIV VCT as part of a couple shared results with their partner. High rates of disclosure among couples was also found in the VCT Efficacy Study (Grinstead et al., 2001). Involving male partners in the process of HIV counseling and testing may bypass many of the barriers associated with disclosure and may also facilitate sustained behavior change among couples due to the fact that men generally have control over the sexual decision making within couples. The most effective way to promote more HIV VCT among couples remains an open question. However, social marketing to promote VCT for couples may be one strategy to increase service utilization by couples. New HIV counseling approaches to support women through the testing and HIV-serostatus disclosure process are also needed. Although we found that the rates of negative outcomes of disclosure reported by women were low, the major barrier to disclosure was fear of negative outcomes. Women need support from a counselor to weigh the potential benefits and drawbacks of HIV-sersotatus disclosure and develop detailed disclosure plans to support them through the process. Counselors can help women try to clarify the real versus perceived risk of violence associated with HIV-serostatus disclosure. Among those women for whom violence is a real risk, counselors may counsel these women against disclosure or may counsel women to defer disclosure until a time when their safety can be assured. There are different counseling strategies that counselors may use to support women who wish to disclose and who are not at risk for serious negative outcomes. A mediated form of disclosure in which either the counselor mediates the disclosure between couples in the clinic or the client identifies a trusted family member or friend to mediate the disclosure process in the home offers a potentially effective and culturally sensitive approach to supporting women. Disclosing results in the context of a third party guiding the process may be considerably easier than a woman trying to do it on her own. Other counseling techniques to support women who want to safely share results with their partners include behavioral rehearsal techniques such as role plays and scenarios that are designed to develop the self-efficacy and interpersonal communication skills required for disclosure. These techniques not only may help clients overcome the communication challenges they may face when disclosing to their sexual partners, but also serve as an opportunity to carefully develop a personal disclosure plan with the counselor. Repeated opportunity for counseling on disclosure is another strategy that may be used in HIV VCT programs to try to increase rates of HIV serostatus disclosure to sexual partners. DeRosa and Marks (1998) found that rates of disclosure among clients in the United States increased with the number of times that a health official at the HIV clinic where they received care discussed the issue of disclosure. At a minimum, raising the issue of disclosure during both the HIV pretest and the posttest counseling session is necessary in order to address the barriers and plan for disclosure to sexual partners. Multiple opportunities for discussion of disclosure are also important from the counselors perspective in order to assess whether clients have the social support they need to cope with the diagnosis. Finally, the development of support groups for infected women provides another avenue for ongoing support that may help clients address the barriers that they face to HIV-serostatus disclosure. In many sub-saharan African countries HIV rapid-testing protocols have become the standard for VCT service delivery. The implications of our findings do not change in the face of rapid-testing protocols. Similar strategies to enhance counseling including the use of role-play scenarios and development of detailed disclosure plans can be integrated into the counseling and testing protocols for those clinics that provide pre- and posttest counseling on the same day for clients. A potential drawback to rapid-testing protocols is that without the 2-week waiting period between pretest counseling and collection of HIV test results, clients do not have the opportunity to speak with their partners about their testing experience if they have not already done so. We learned from our research that clients who did speak to their partner about HIV testing prior to collection of test results were significantly more likely to share HIV test results with that partner. One of the benefits of rapid testing is the speed with which clients can receive

9 HIV-Serostatus Disclosure to Sexual Partners 381 results and consequently the decrease in the number of clients who do not return for HIV test results. This emphasis on quick turnaround of results in settings that use rapid-testing protocols needs to be carefully balanced with ensuring that clients receive adequate counseling to support them through the process of HIV-serostatus disclosure. As the rates of HIV infection in sub-saharan Africa continue to soar, there is urgent need to identify strategies to prevent new infections and to improve the quality of life for individuals who are already infected. The disclosure of HIV serostatus has the potential to serve both of these purposes. Through expanded awareness of risk that comes from increased disclosure, individuals may change behaviors that prevent new HIV infections. Disclosure may also increase social support and improve the medical management of infection among HIV-infected individuals. 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