Determinants of Non-Disclosure to Sexual Partner among Human immune virus Infected Adults on Anti-Retroviral Therapy Follow-Up Care at North Shewa Zone public Hospitals in Oromia Region, Ethiopia, 2020.

HIV positive status non-disclosure to sexual partner remains challenging for the prevention and control of Human Immune Virus infection as it results in poor antiretroviral treatment adherence, high risk of transmission and limits women’s ability in the prevention of mother to child transmission. The study tried to identify determinants of non-disclosure to sexual partner/s among Human immune virus infected Adult on Anti-Retroviral Therapy Follow-Up Care at North Shewa zone public Hospitals in Oromia Region, Ethiopia, 2020.


Introduction
Despite progress in our scienti c knowledge towards its prevention, human immune virus infection remains one of the world's most severe community health challenges (1). In the perspective of HIV/ADIS control, "disclosure" is de ned as the process of telling HIV-positive status to a sexual partner(s), family members, or others in their close contact (2). World health organization gives a recommendation that all HIV positive persons should disclose their HIV positive status immediately to a prospective sexual partner (3). HIV positive status disclosure to sexual partners provides a gateway for prevention and treatment efforts, allow couples to make informed reproductive health choices to reducing undesirable pregnancies and the risk of maternal to child transmission (4). In countries such as Ethiopia, where sexual contact is a common means of HIV infection transmission, disclosure has substantial roles in the prevention and management efforts by reducing onward transmission, facilitating greater social support, and improve antiretroviral treatment adherence (5). However, despite these potential bene ts, incidences, and determinants of non-disclosure have not been fully reported, particularly in hyper-endemic settings (2).
Higher HIV infection spread risk is reported in the region with poor partner disclosure status compared to lower spread in the region with better disclosure status to a sexual partner (6). Studies in Ethiopia revealed that non-disclosure to a sexual partner had shown to limit women`s ability to participate in the prevention of mother to child HIV transmission programs(7) and a higher proportion of poor HAART adherence was reported among those who did not disclose to their sexual partner (8). Different levels of HIV positive status non-disclosure status to sexual partner/s ranged from 6.9%-47.4% were reported in Ethiopia (9)(10)(11)(12)(13). Scholars had shown that variables such as age, sex, education, residence, marital status, living with partner/s, having children, antiretroviral therapy duration and adherence status, type HIV testing, knowledge of sexual partner/s, use of alcohol, prior discussion about HIV testing, relationship status, see person publically disclosure HIV status are associated with HIV positive disclosure status of the person (9,11,12,(14)(15)(16)(17)(18)(19)(20)(21).

Study area and design
An institution-based unmatched case-control study was conducted from December 1 up to February 30/2020 among 378 (94 cases and 284 controls) adult Human immune virus-infected Adult on Anti-Retroviral Therapy Follow-Up Care at North Shewa zone public Hospitals in Oromia Region, Ethiopia, 2020. According to a 2007 Central Statics Agency (CSA) report, the zone had a total population of 1431 305 (22). Currently, the zone has four government hospitals that have been provided antiretroviral treatment service for a total of 4025 adult HIV positive patients.

Sample Size Determination
The sample size was computed using Epi-info Stat Calc program by making assumptions of the 95% con dence level, four controls for each case, 80% power, and 4.16 OR of knowing sexual partner's HIV status from a study conducted in Bale Hospital, Oromia region (12), gives a total of 344 samples. By adding a 10% non-respondent rate the total sample size was 378 (94 cases and 284 controls). The sample size was calculated using the double population proportion formula in Epi-info TM version 7.2.0.1.

Sampling Technique and procedures
First proportional allocation of sample size was made to each hospital based on the total number of HIV positive patients on follow-up care. Then data from the cases were collected by consecutive sampling methods whereas data from the controls were collected by using systematic random sampling techniques.

Source Population
All adult Human immune virus-infected Adults on Anti-Retroviral Therapy Follow-Up Care at North Shewa zone public Hospitals in Oromia Region, Ethiopia, 2020.

Study Population
All adult Human immune virus-infected Adult on Anti-Retroviral Therapy Follow-Up Care at and had a sexual partner during their HIV diagnosis at North Shewa zone public Hospitals in Oromia Region, Ethiopia, 2020

Inclusion and Exclusion Criteria
This study includes HIV positive patients age ≥18 years, had a sexual partner during HIV diagnosis and, had at least one month of ART follow up care. It excludes couple tested HIV positive patients.

Operational De nition
Sexual partner: In this study, it is de ned as someone's husband/wife if married and girl or boyfriend if single.
Current sexual partner: In this study, it is de ned as a person's sexual partner during an HIV diagnosis.
Lifetime sexual partner: is de ned as the total number of sexual partner a person had in his/her lifetime Delayed disclosure: it is de ned as disclosure of HIV positive status to sexual partner/s after one month of HIV positive diagnosis.
Risky sexual practice: Sex without a condom with a sexual partner before disclosure of HIV positive status.

Data Collection Tools
The data collection tool was developed from reviewing a similar study conducted previously in Ethiopia (8, 11, and 12). The tool was prepared in English rst and translated into Afaan Oromo and Amharic then back to the English language.

Data Collection technique and Procedure
After screened for eligibility, taken written informed consent, and given information about the purpose of the study data was gathered from the medical record and the patients by interviewing while they come for their medical appointments.

Data Collectors and supervisors
Eight BSc degree nurses, two assigned in each ART clinic from other work units were recruited and trained about tools and ways of the data collection procedure. Similarly, two MSc Nurses from other working units were recruited for supervision.

Data Quality Control
A pretest was conducted on 5% of the sample size at Sheno primary Hospital one week before the actual data collection. Then training of data collectors and supervisors on objectives, questionnaires, and ways of collecting the data was given for one day before the actual data collection time. To keep study participants' con dentiality private room free from interruption for interviewing was prepared. Before entry, data were checked for completeness.

Data Processing and Analysis
The data were checked for completeness and entered into Epi Data Version 3.1 and exported into SPSS version 25 for analysis. Descriptive statistics such as frequency and percentage has been presented using graphs and tables. A binary logistic regression model was used to identify the potential predictor variables for HIV positive status non-disclosure. Those independent variables which had a p-value of less than 0.25 during binary logistic regression analysis were entered into multivariable logistic regression analysis. Then Adjusted Odds Ratio (AOR) with 95% CI and p-value < 0.05 were used to identify factors signi cantly associated with HIV positive status non-disclosure to sexual partner/s.

Ethical Approval Statement
Ethical clearance was obtained from the Ethical Review Committee of Salale University. Permission letter also was obtained from Oromia Health Bureau and the respective hospitals. Written informed consent was taken from each study participant and explained the importance and purpose of the study. Any potential identi ers were eliminated to ascertain con dentiality.

Socio-demographic characteristics
Of a total of 378 sampled respondents, 369 were interviewed (92 cases and 277 controls) with an overall response rate of 97.5%. Among the study participants, 39.3% (36 cases and 109 controls) belonged to the age group of 31-40 years. The majority of the respondents were 53.4% (61 cases and 136 controls) were females. Those who were unable to read and write accounted for 39.3% (100 controls and 45 cases).

Social related factors
The majority of the respondents 86.4% (238 controls and 81 cases) were not a member of Anti-HIV/ADIS club whereas most of the respondents 77.0% (203 controls and 81 cases) have not ever seen public HIV status disclosed (Table 4).
Justi cation for non-disclosure Fear of divorcing 45(12.2%) and fear of stigma 24(6.5%) were the most common reason for nondisclosed their HIV status to sexual partner/s (Figure 1).
Determinants of Non-disclosure to sexual partners A binary logistic regression model was performed to detect determinants of non-disclosure to a sexual partner. Thus variables in binary logistic regression analysis with p-value < 0.25 were entered into the multivariable logistic regression analysis model. Variables that showed associations with non-disclosure were sex, antiretroviral treatment duration, WHO clinical stage one, number of lifetimes sexual partner/s, see public disclosure. Regarding HIV positive status non-disclosure, males were 75% less likely as compared to females (AOR: 0.25, 95%: CI=0.13-0.47). HIV positive patients having less than 36 months of antiretroviral follow-up care were 2.13 times more likely to not disclosed than those patients having 36 months and above antiretroviral follow-up care (AOR:2.13,95%:CI=1.14-4.01). The odds of non-disclosure were 3 times more likely among HIV positive patients who had WHO clinical stage one as compared to their counterparts (AOR:3.00, 95%: CI=1.26-7.12). Likewise, HIV positive patients who had more than twolifetime sexual partners during their diagnosis were 59% less likely to not disclosed as compared to their counterparts (AOR:0.46,95%:CI=0.22-0.95). In addition, the odds of non-disclosure were 3.12 times more likely among HIV positive patients who had seen a person publically disclosed HIV status(AOR:3.12,95%:CI=1.47-6.65)( Table 5).

Discussion
There is a wide range of discrepancies and inconsistencies in the reported rates of HIV disclosure from different studies done worldwide. Non-disclosure to sexual partners is a barrier to make informed reproductive health choices and increases the risk of HIV transmission from mother to child. In this study fear of divorcing was the major reason for non-disclosure to sexual partners which accounts12.2%. The study result revealed that the odd of non-disclosure were 75% times less likely to occur among males as compared to females. This idea is agreed with the study nding in South Africa and in Tanzania (15,23). This might be due to that males are not more vulnerable to negative outcomes of disclosure such as blame and physical violence from family or society. It also showed that HIV-positive Patients who had less than 36 months on antiretroviral treatment follow-up care were 2.13 times more likely to not disclosed to sexual partners as compared to their counterparts (AOR:2.13, 95% CI:1.14-4.01). This nding is consistent with a study nding in Ethiopia Michelle Referral Hospital (11), in France, and in Nigeria (21,24).
Similarly, the nding of the study revealed that HIV positive patients who had not ever seen a person publically disclosed HIV status was 3.12 times more likely to not disclosed as compared to those who had ever seen a person publically disclosed HIV positive status (AOR:3.12, 95% CI: 1.47-6.65). This nding correlated with the study conducted in Woldia Hospital, Ethiopia (9). The possible explanation for this might be experiencing public disclosure will reduce the fear of disclosure. Inanition, baseline WHO clinical staging of the disease and numbers of lifetime sexual partners have shown an association in this study which had not shown an association in studies previously conducted. The odd of non-disclosure was 54% times less likely to occur among patients who had lifetime sexual partners more than one as compared to those who had a one-lifetime sexual partner. This could be due to the fact that the person will fear the blames from each of the partners. And also the odds of non-disclosure were 3 times more likely to occur to those who had baseline WHO clinical-stage one as compared to those who had baseline WHO clinical stage four (AOR: 3.00, 95% CI: 1.26-7.12). This could be due to the fact that clinical-stage one patient could not be experiencing physical symptoms as compared with clinical-stage four. Due to this reason, they may not be disclosed to sexual partners.

Conclusions
In this study variables such as sex, baseline WHO clinical staging one, Number of lifetime sexual partners, Duration on ART follow-up care and see a person publically disclosed HIV status were found independent determinant factors of non-disclosure to sexual partners. This study recommends that health care providers working in the area of HIV/ADIS should give deep and continuous disclosure counseling service for those in WHO clinical staging one and those having multiple sexual partners, and short antiretroviral follow up care. Furthermore, it better to promote public HIV disclosure to reduce fear and anxiety.

Declarations Ethics Approval and Consent to Participate
First, the ethical clearance letter was obtained from the Ethical Review Committee of the Salale University, College of health science. A permission letter was obtained from each health facility administrative body and given to the respective ART unit. The Data collection was made after written consent was taken from each study participant. The privacy and con dentiality of the respondents were ensured by excluding the name on the questionnaire and interviewed them in a private space that is free from interruption and cannot be observed or heard by other people within the facility environment.

Consent to Publication
Not applicable.
Data availability: Data cannot available at present time. However, it will be accessed from the crossponding author on reasonable request.

Competing interests
Authors of this paper state that they have any competing interests.

Funding:
Salale University had funded this research work. But, has no role in the decision to publish.

Authors' contributions
All the authors have equally participated in this paperwork starting from the beginning to the nal work in conceptualization, design, and statistical analysis, interpretation of results, critical interpretation, critical revision, and manuscript preparation. All authors have read and approved this manuscript to be published.