Human Immune Virus positive status disclosure to a sexual partner and associated factors among adult clients in Debre Markos town, 2019

Human Immune Virus’ positive status non-disclosure to a sexual partner is a public health problem where a high prevalence of Human Immune Virus infection is reported on a region with poor partner disclosure status. The aim of this study was to assess Human Immune Virus positive status disclosure to sexual partners and associated factors among adult Human Immune Virus positive clients at Debre Markos town, Amhara Regional State Ethiopia, in, 2019. Facility based cross-sectional study was done among 421 adult Human Immune Virus positive clients in Debre Markos town from September 1-30-2019. Consecutive sampling was used to collect the data. Epidata version 3.1 for data entry and SPSS version 25 for data analysis were used. Hosmer-Lemeshow goodness test of model fitness was checked. Bivariable and multivariable logistic analysis (p<0.05) was performed.

Residence, Duration of Anti-Retroviral Treatment, Adherence status to antiretroviral treatment, provider-initiated Human Immune Virus testing and knowing sexual partner`s Human Immune Virus status have had a statistically significant association with disclosure. It is better to promote provider-initiated Human Immune Virus testing and give special attention to females and rural residents regarding Human Immune Virus status disclosure to sexual partners.

Background
Disclosure of HIV (Human immune virus) positive status is defined as a process of communicating potentially stigmatizing information that had been previously kept hidden in order to increase one's psychological well-being, and in the case of disclosure to sexual partners, to preserve the quality of relationships (1). WHO (World Health Organization) recommends all HIV positive patients should immediately disclose their HIV positive status to prospective sexual partners (2).
Knowing once HIV positive status along with disclosure to sexual partner has a significant implication and plays a vital role in the prevention and control of HIV/AIDS as it allows individuals to access HIV care and treatment services, encourages partners to seek testing, change behavior, and to create awareness and practice of safer sex behavior (3), (4).
Disclosure of HIV positive status allows couples to make informed reproductive health choices by reducing undesirable pregnancies and the risk of maternal to child HIV transmission (3).

International organizations including United Nations Program on HIV/ADIS (UNAIDS), WHO
and center for disease control (CDC) highlight the significance of HIV positive status disclosure for the public health and place stress on disclosure among HIV-infected clients, particularly to their sexual partners (5,6).
HIV positive status non-disclosure to a sexual partner is a public health problem in the prevention and treatment efforts of HIV infection, where higher HIV transmission risk is reported in a high HIV prevalence region with poor partner disclosure status compared with lower HIV transmission risk in low HIV prevalence region with better disclosure status to sexual partner (7).
Disclosure of HIV positive status to sexual partners offer numerous benefits to the infected person as well as to the larger community; However, despite this potential benefits, incidences, and determinants of the disclosure have not been comprehensively reported, particularly in hyper-endemic settings including Ethiopia (1).
In Ethiopia, a lack of disclosing HIV positive status to sexual partners had shown to limit women's ability to participate in the prevention of mother to child HIV transmission programs (8). Similarly, a higher percentage of poor HAART adherence were reported among HIV positive patients who did not disclose their HIV positive status to a sexual partners (9).
The actual threat faced by the person who disclosed HIV positive status such as stigma, discrimination, rejection, divorce, blame, and shame were known to hinder disclosure and reduce the pace of HIV prevention by creating anxiety to the person being infected (10,11).
The issue of HIV positive status disclosure to sexual partner still needs to be addressed to prevent the spread of HIV infection and promotes accessibility to care and treatment programs, attain psycho-social support from partners, reduce stigma, adhere to treatment and promote safer health behaviors.
Identifying factors associated with disclosure is a research priority as a high proportion of people living with HIV/AIDS never disclose in Ethiopia.
Therefore, conducting further studies in an area where no previous assessment was done helps to improve disclosure status by creating strategies and implement an effective intervention on identifing influencing factors. So this study was used to assess the level of HIV positive status disclosure to sexual partners and associated factors among adult Human Immune Virus positive clients at ART clinics in Debre Markos town, Amhara Regional State Ethiopia, in, 2019.

Study Area
Debre Markos is the administrative city of East Gojjam Zone, which is located 300 km away from Addis Ababa, which is the capital city of Ethiopia and 265 km from Bahir-Dar is the capital city of Amhara Regional State. This town has 01 referral hospital, 04 governmental health centers, 07 health posts, 16 private pharmacies, 22 private clinics, 02 diagnostic laboratories, and 12 traditional healer service providers. The study was conducted in those four ART clinics found in this town. These ART clinics are currently providing VCT, PMTCT, antiretroviral treatment, opportunistic infection treatment, TB/HIV Co-infection treatment, and care of HIV exposed infants services. According to Debre Markos town, the administration, the total population of this town projected at 483,127 in 2018. In this town there were 5088 clients who had ART follow-ups and users of ART clinics.

Study Design and Period
Facility based cross sectional study design was conducted from September 1-30/7/2019.

Source Population
All adult HIV positive clients who had ART follow up care at Debre Markos town ART clinics during the study period.

Study Population
All adult HIV positive clients on ART follow-up care and who had a sexual partner during their HIV diagnosis and were available during the study period at Debre Markos town ART clinics.

Inclusion Criteria
Age ≥18 years, had a sexual partner during their HIV diagnosis and, being on ART follow up care for at least one-month duration during the data collection period.

Exclusion Criteria
The couple tested HIV positive clients were excluded from the study.

Sample Size Determination and Sampling Techniques
The final required sample size was determined by taking the largest of the two after calculating the sample size for the two objectives separately. For the first objective, For the second objective (for different factors which has an association with HIV status disclosure), the sample size was calculated using Epi 7 software with the assumption of 95% confidence level, 80% power and 1:1 exposed to unexposed ratio [ Table 1]..
Based on this assumption, the required sample size was n2 = 370 and after adding a 10% non-response rate, it was n2 = 407.
Therefor the final required sample for this study was the larger of the two which was sampled size calculated by using the first objective equals n = 421. HIV positive status disclosure to sexual partner: In this study, it is defined as when an HIV positive person told to all his/her sexual partners that he/she is HIV infected(1).
Delayed disclosure: In this study, it is defined as disclosure of HIV positive status to a sexual partner/s after one month of HIV positive diagnosis (13).
Risky sexual practice before disclosure: defined as when an HIV positive individual had unprotected sex (sex without condom) with a sexual partner before disclosed his/her HIV positive status Data Collection Tools and Procedure Data were collected by pre-tested and structured interviewer-administered questionnaire which was adapted from previous related studies conducted in Ethiopia (9,(12)(13)(14). The questionnaire was first, prepared in English, then translated into the local language (Amharic) and back to English to assure its consistency. Finally, the Amharic version was used for the data collection.
Five ART trained, diploma nurses from other work units were recruited and trained about tools, data collection procedure and from them; two were assigned in Debre Markos Referral hospital ART clinic, one in each other ART clinic. And four B.Sc. Nurses from other working units were recruited for supervision in these ART clinics and training of data collectors was provided by the principal investigator for two days before the actual data collection Participants were approached and interviewed while they came to their medical appointments, screened for eligibility, given information about the purpose of the study and requested to participate. Those that agreed to participate after informed consent was obtained were interviewed on exit after they had got their treatment from the health care providers.

Data Quality Assurance
A pretest was done in 21 (5%) of a sample size of Dejene health center, ART clinic one week before the actual data collection and any ambiguity, confusion, difficult words and differences in understanding were revised and corrected based on pretest experience.
Then training of data collectors and supervisors on objectives, questionnaires, and ways of collecting the data was given for two days before the actual data collection time. Before proceeding with the interviewing, client confidentiality was upheld and private counseling space was offered that was free from interruption. The data collectors were supervised by four supervisors; one in each four selected ART clinics. Before entry, data were checked for completeness and coded.

Data Processing and Analysis
Data entry was made using Epidata 3.1 Software. The entered data were exported to the For further explanation, the odds of HIV positive status disclosure to sexual partner were 3 times more likely among males compared to females. Urban residents were nearly 2.6 times to disclose HIV positive status to sexual partners than rural residents. HIV positive status disclosure to sexual partner were 4.5 times higher among participants being on ART ≥39 months when compared to these study participants being on ART <39 months duration. HIV positive status disclosure to sexual partner were 3.2 times more likely among study participant who adhere to ART medication compared to these study participants who did not adhere to ART medication.
Respondents who were tested by the initiation and counseling of health care provider were 2.2 times more likely to disclose HIV positive to sexual partner when compared to those participants whose HIV testing was VCT. Additionally, respondents who knew their partner's HIV status were 2.7 times more likely to disclose HIV positive to sexual partner when compared to these study participants who did not know their partner's HIV status [ Table 3].

Discussion
Disclosure of HIV positive status to a sexual partner is among varies HIV prevention strategy to prevent the spread of infection. It is the base for accessing care and treatment programs, attains psycho-social support and reduces stigma, adheres to treatment and promotes safer health behavior particularly for couples.
In this study the magnitude of HIV positive status disclosure to sexual partner was 73.4 % (95%, CI: 69-78). This finding is lower than a study done in Zimbabwe 93% (15). It is higher than the finding of studies conducted in China, 51% and in South-Western Uganda 75% (16,17). This discrepancy might be due to difference in population characteristic.
The finding of this study is lower than studies done in Ethiopia at Woldia Hospital ART clinic which was 76.6%, in Hawassa University Referral Hospital ART clinic 85.7% and at Kemissie Health center ART clinic 93.1%, (14,18,19). This discrepancy might be due to difference in methods used to assess HIV positive disclosure status where in the current study it was assessed from chart reviewed whereas in these studies, it was assessed through self-reporting questions.
The study found that male sex, urban residence, having children, knowing partner's HIV status, tested by health care provider initiated and counseling, Good ART adherence and longer ART follow up care were independent predictors of HIV positive status disclosure to sexual partner.
The odds of disclosing HIV positive status to sexual partner were three times more likely among male participants than female participants. This finding is similar to studies done in South Africa and in Tanzania (20,21). This might be due to male partner dominancy which hindered females to disclose due to fear of partner's negative reaction.
Urban residents were 2.6 times more likely to disclose to sexual partner than rural residents. This finding is supported by study done at in South-Western Uganda (17). The possible justification for this is urban dwellers might get adequate HIV related information than rural residents.
The odds of disclosing HIV positive status to sexual partner among study participants who were on ART follow up care for ≥39 month's duration were 4.5 times more likely than study participants being on ART for < 39 months duration. This finding is supported by a study done at Michelle Referral Hospital in Ethiopia (13), in France and in Nigeria (22,23).
The possible explanation for this might be the result of a continuous counseling at each contact with health professionals and helping patients to develop healthy behaviors including disclosure to sexual partner.
When we goes to ART medication adherence, HIV positive status disclosure to sexual partner was 3.2 times more likely among respondents who had good ART medication adherence than poor ART medication adherence status. This finding is similar to a study done in Togo (24). This might be respondents may receive information continually and encouragement for caregivers to create favorable psychological conditions to disclose their HIV sero-positive status to their sexual partners.
In another way, HIV positive status disclosure to sexual partner were 2.2 times more likely among study participants whose HIV testing type was provider initiated than client initiated testing. This is similar with a study done at Woldia hospital ART clinic in Ethiopia (18). This might be due to getting more information regarding to the benefit of disclosure to a sexual partner.
Lastly but not least, Knowing partner HIV status was positively associated with status disclosure. Respondents who knew their sexual partner's HIV status were about 2.7 times more likely to disclose their HIV status to their partner as compared to those who did not know their partner's HIV status. This is also in line with other studies conducted in Bale Zone Hospital, Woldia hospital, Kemissie health center in Ethiopia (12,14,18)

and in Ogun
State in Nigeria and in Togo regional hospital (24, 25). Because of aware of sexual partner's HIV positive status may encourage partners to disclosure for the purpose of preventing HIV transmission and to support each other.

Limitation Of The Study
The reported nature of the data collection approach could be affected by social desirability bias which is an important issue with regards to the sensitive topic such as HIV positive status disclosure

Conclusion
In this study, HIV positive status disclosure to sexual partners was low. The study also found significant association between male sex, urban resident, Knowing the partners HIV status, longer ART follow up care (≥ 39 months), Good ART adherence status, and heath care provider initiated HIV testing with HIV positive status disclosure to a sexual partner.

For Health care providers
It is better to promote ongoing ART adherence counseling services and provider initiated HIV testingthrough extensive health education particularly, for females and rural residents. Furthermore, health education programs should be focused on promoting mutual partner HIV testing to increase the awareness of partner's HIV status.

For Government and None Governmental Organization
It is better to focus on promoting HIV disclosure status for planning of future interventions among women and rural residents and to encourage provider initiated HIV testing widely

For Researchers
This study did not address health service provider and related factors. Therefore, it is better to carry out further study to address these variables.

Consent to publication
Not applicable.

Availability of data and materials
The data can be accessed from the corresponding author through the following address mengistubinayew7@gmail.com. The data might be accessed if and only if for research purpose.

Competing interests
The authors declare that they have no competing interests.

Funding
Not applicable Authors' contributions MB was participated in the title selection, design, and statistical analysis, and interpretation of results. MT and HZ were involved in this thesis research by giving suggestions, comments, supports, encourages, and contribution from the beginning of the research proposal throughout the thesis work. AF was involved in manuscript drafting, critical interpretation, and critical revision in addition to he was participating during in tittle selection. All authors read and have given approval for this manuscript to be published.

Acknowledgments
First of all, we would like to thank Debre Markos University for giving me the chance to develop this research work.
Second, we would like to thank all the data collectors for their faithfulness to collect the data. Variables significantly associated HIV disclosure to a sexual partner Sample Size Urban residence % in exposed group P1=58.01% 370 % in non-exposed group P2=42.95% Receiving disclosure counseling service % in exposed group P1=91.66% 64 % in non-exposed group P2=58.97% Knowledge of sexual partner`s HIV status % in exposed group P1=64.05% 66 % in non-exposed group P2=27.69% Maximum sample size =370 Then by adding 10% non-response rate for n =370, it becomes, n2 = 407. Since the sample size is larger for the first objective, we take the final sample size to be = 421.