Determinants and Status of HIV Disclosure among Reproductive Age Women on Antiretroviral Therapy at Three Health Facilities in Jimma Town, Ethiopia, 2017

Background: Improving HIV disclosure status is significant for reducing HIV prevalent by promoting safer sexual practices, PMTCT, better treatment retention, partner testing and partners to make informed reproductive health choices. Objective: To explore HIV disclosure and associated factors among reproductive age women in health facilities of Jimma Town. Methods: Conducting a facility based cross-sectional design at three health facilities of Jimma town among women on ART from March 5-April 1, 2017. Finally, 338 women were selected by using systematic random sampling technique and interviewed with interviewer administered questionnaire. Epi data version 3.1 was used to enter data then transferred to SPSS to version 20 for analysis of explanatory variables. Results: Out of 337 women responded to the questionnaire, ever disclosure of women to someone was only 290 (86.1%). Still, 47 (13.9%) of them did not disclose. Having free discussion on safer sex [AOR=6.621, 95% CI (1.719-25.498)], being peer counselor [AOR=3.624, 95% CI (1.049-12.522)], being members anti-HIV association [AOR=3.171; 95% CI (1.183-8.501)] and being on ART [AOR=4.559, 95% CI (1.586-13.103)] were predictors of HIV disclosure. Conclusion: The overall magnitude of HIV disclosure was relatively good but nondisclosure is still high in this study. This will be a great fear on HIV transmission. This will continue as major public health burdens in the districts unless future interventions focuses on the factors that enhance disclosure through peer counselor, free discussion, members of anti-HIV association and on ART.


Introduction
About 38.8 million people were living with HIV, 2.5 million were newly infected, and 1.2 million HIV/AIDS deaths globally. Of this Sub-Saharan Africa account 29 million HIV infected people, 1.9 million new HIV infections, and 0.9 million HIV/ AIDS deaths in 2015, which is extreme region suffering from problem of HIV infection [1]. Women carry a disproportionate global burden of HIV infection. Ten countries, often in southern and eastern Africa including Ethiopia account for nearly 80% of all people living with HIV [2].
In 2015, 768,040 HIV infected people, 39,140 new HIV infections, and 28,650 AIDS deaths [1]. The trends in new HIV infections has inflated from 23 000 in 2010 to 30,000 in 2016 in Ethiopia [3]. There is large prevalence difference among districts (6.6% in Gambella, 5.0% in Addis Ababa, and 0.7% in Southern Nations, Nationalities and Peoples' region). The HIV epidemic in Ethiopia is primarily associated with areas of urban and major transport corridors. Those living within five kilometers of a major road have HIV rates are four-times higher than those who live further away [4].
In Sub-Saharan Africa, the key route of HIV infection in adults through heterosexual sex and in children through vertical transmission. Early marriage, partner violence, and gender inequality as result high divorce rates and significantly raised rates of HIV prevalence associated with divorce and remarriage [4]. The extremely high HIV prevalence in the region due to the lack of appropriate interventions to protect young women [2]. Moreover, male female differences in sexual debut, age discrepancy sex, multiple partners, low condom acceptance and sexually transmitted infections contribute to young women's susceptibility to HIV [5].
HIV/AIDS disclosure is an important because of the multiple benefits for HIV infected individuals, their partners and the community as a whole in HIV/AIDS prevention [6,7]. HIV disclosure among couples is encouraged as it promotes safer sexual behaviours, lowers HIV transmission, decreases stigma and recommends access to testing and treatment, care and support, PMTCT and it can also encourage partners to make informed reproductive health options [8][9][10].
Southwest district of Ethiopia involved different ethnic populations and refugee camp, and adds lots of HIV positive patients attending ART clinic in Jimma town public health facilities. Also, Jimma town is nearby Gambella state which is a small and sparsely populated region that has the highest regional HIV prevalence. Still, the rise of the new HIV infections epidemic in Ethiopia is broadly documented. For that reason, this study pursues to provide new evidence on HIV status disclosure and its influencing factors among women aged 15-49 years at three health facilities in Jimma Town. The study included entire health facilities that provide ART services in the Jimma town as result generalizability of results was stronger and it also added the current frequency of HIV status disclosure. Hence, we explored explanatory variables to determine the most significant factors that influence HIV disclosure status among HIV positive women attending ART services in Jimma town public health institution, Ethiopia.

Methods
A facility based cross-sectional study was conducted in three health facilities of Jimma town which provides ART services (Jimma university specialized hospital, Shenen gibe general hospital and Jimma health center). Jimma town is found in South West Oromia and it is far-away 365 km from capital city of Ethiopia. The main reason to consider these all ART services of health facilities, most people living with HIV/AIDS in Jimma and Gambella districts are attending in these three health facilities of Jimma town. Moreover, a stronger generalizability of results and current frequency of HIV disclosure was also another reason. Currently, Jimma health facilities has given service to 5159 ART users. Of this reproductive age women were 2288. This study was carried out from March 5 to April 1, 2017.

Sample size and sampling techniques
A single population proportion formula was used to determine the sample size with the assumption of 63.8% proportion of disclosure, 95% confidence interval, 5% margin of error and 10% of contingency. Total sample size of the study was 338. Sampled respondents from each health institutions was proportional to clients flow enrolled in the health facilities in one month by using prior three month average of client flow. Systematic sampling procedure was used to recruit every kth respondents according to registration of patient flow at each health facilities as sampling frame. Fortunately, the sampling interval was 7 for three health facilities of Jimma town. The first interview client was taken by lottery method then every seventh of patient was selected until required sample size was reached.

Instrumentation
and data collection procedures A structured questionnaire was adapted from previous literatures and translated in to two local languages (Afan Oromo and Amharic) then back to English language to check internal consistency and amendment of meaning. Four ART nurses who were presently working in the corresponding health facilities were collected the data by face to face interview technique in order to maximize confidentiality and to get full response. A pre-test was carried out among 5% of ART clients in Agaro health center outside of Jimma town but within comparable set up. Amendments were conducted after pretest result analysis. Data quality was controlled by training data collectors and supervisor, using pretest and local language speakers. The principal investigator and supervisors conducted supervision. The consistency and completeness of data were checked on each day.

Ethical consideration
Ethical clearance was gotten from institutional review board of Jimma University College of public health and medical sciences. A permission letter was gotten from respective facilities by Jimma town Health department office. The purpose, benefits, risk, confidentiality of the study were explained for each client before interview and informed consent was gotten from each respondent.

Data analysis
Data entry and cleaning was conducted by using EpiData Version 3.1 statistical software and then transferred to SPSS software package version 22 for analyses. Frequency tables, graphs and descriptive summaries were used to describe the study variables and determine the magnitude of HIV disclosure. In bivariate analysis, explanatory variables with pvalue of <0.25 were included for multivariable analysis to control confounding factors. P-value of <0.05 with 95% CI was used to reveal as statistical significance.

Socio-demographic characteristics of respondents
Out of 338 HIV positive women the response rate was 337(99.7). Majority 174 (51.6) of respondents were found between the age of 15-24 years. The mean and standard deviation of age were 31 (SD ± 7.5). Majority (49%) of the respondents were married. About (41.8%) of respondent religion were Orthodox followed by Muslim (40.7%) religion. Most (49.3%) of the respondents were Oromo ethnics. About (40.7%) of respondents had attended primary education. Most (30.3%) of the respondents were Daily worker. Majority 287 (85.2) of the respondents were urban area (Table 1).

Medical care characteristics of respondents
The great majority, 289(85.8%) of the respondents had post diagnosis counseling at ART clinic. Most 245(72.7) of the participants got disclosure counseling from peer counselors. Most 226(67.1%) of the participants were member of Anti-HIV/AIDS association. Majority 119(35.3%) of the study participants had stage III of WHO clinical stage at baseline. Out of the total respondents, 261(77.4%) of the respondents were on antiretroviral therapy (ART) ( Table 3).

Magnitude of HIV disclosure
Out of the 337 participants 290(86.1%) of them disclosed their HIV positive status to someone and 184(83%) disclosed to their current sexual partner. Though, 47(13.9%) of them didn't disclose. The main reasons of respondents for not disclosing HIV status were fear of stigma and discrimination (57.4%), lack of trust on people (32%) and others (10.6%).

Factors associated with disclosure
The association of factors with HIV disclosure was measured by bivariable and multivariable analysis. After controlling the effect of possible confounding variables, open discussion on safe sex, disclosure counselor, on ART and member of anti-HIV association were strong predictor of HIV disclosure. Women who had open discussion about safe sex were more likely to disclose their HIV status compared to their counterparts (AOR=6.621; 95% CI: 1.719-25.498). Woman with HIV who are working in ART clinic as counselor were more likely to disclose their HIV status when compared to those were ART nurse (AOR=3.624; 95% CI: 1.049-12.522). Women on ART were more likely to disclose their HIV statuses when compared to those were not on ART (AOR=4.559; 95% CI: 1.586-13.103). Women with member of Anti-HIV association were more likely to disclose their HIV status when compared to those who did not have members of Anti-HIV association (AOR=3.171; 95% CI: 1.183-8.501) ( Table 4).

Discussion
The current study displays that disclosure of HIV status was greater prevalence (86.1%) compared to those who didn't disclose (13.9%) among reproductive age women on ART in health facilities of Jimma town, Ethiopia. This result is consistent with the findings from Ethiopia (Southern region) [11]. However, the current finding was lower when compared to studies conducted in different part of Ethiopia [12][13][14], Tanzania [15] and Zimbabwe [16]. The possible explanation for this difference might be due to the socio-demographic difference; plus this study includes all health facilities of ART clinics and uses only reproductive age women as study population. In this study, the main reasons of respondents for not disclosing HIV status were fear of stigma and discrimination, and lack of trust on people. This finding is also supported by other studies [15,16].
Participants with members of Anti-HIV association increased the likelihood of disclosure as compared to those who had none. This result is consistent with findings from Ethiopia [12,14]. This might be because these women are expected to have more freedom to reflect their thoughts with followers, and inspire for those psychologically and spiritually to accept HIV disclosure. Women under ART were more likely to disclose their HIV positive sero status as compared to those with not on ART. The finding is consistent with the findings from Uganda and Ethiopia [17,18].
The reason behind this might be due to sharing experience from HIV positive women counselors who are working in chronic HIV/AIDS care unit and interactions of each other during ART follow up; plus initiation of ART after the presence of medical AIDS signs as they couldn't mask their status from the society or it enables to disclose their status. Being trained peer counselor increased the likelihood of HIV disclosure status as compared to ART nurses. This might know HIV status of peer counselor gives strength to disclose their own HIV status. Having free discussion about safer sex increased the likelihood of HIV disclosure status as compared to those who had none. The reason might be because individual's concerned and committed for health of their sexual partners hence they disclose their HIV status. The strength of this study including all health facilities of Jimma town that provide ART services for southwest district, generalizability of results may be stronger to women attending health facilities at Jimma town and it also explored certain important explanatory variables HIV disclosure.

Conclusion
This study result showed that the magnitude of disclosure by HIV positive women of reproductive age was higher compared to those who didn't disclose. However, significant number of respondents did not disclose. It is an alarming message for low-income countries; particularly to Ethiopia among the most suffered SSA countries from the HIV epidemic. This will be a great concern on HIV transmission from women to partners, babies and HIV consequences after unintended pregnancy. This will remain to present as major community health burdens unless future interventions targeting on disclosure of HIV status.

Recommendations
Based on the findings of the study it can be concluded that HIV disclosure had significant association with open discussion on safer sex, member of Anti-HIV association, peer counselor and under ART. For that reason, we would like to recommend that the Jimma town's Health department office in collaboration with peer counselors and anti-HIV associations should focus on increasing the coverage of HIV treatment and encouraging tailored counseling of disclosure in the HIV/AIDS chronic care unit.

Competent interests
The authors declare no competing interests.

Authors' contribution
GK designed the study, participated in data collection, analysis, and interpretation and prepared the manuscript. TB, MS and ZT approved the design, participated in data collection,, analysis, interpretation and critical review of the manuscript. All authors read and approved the final manuscript.