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Double Disclosure Bind: Complexities of Communicating an HIV Diagnosis in the Context of Unintended Pregnancy in Durban, South Africa

Double Disclosure Bind: Complexities of Communicating an HIV Diagnosis in the Context of Unintended Pregnancy in Durban, South Africa

Disclosure of HIV status to sexual partners and significant others has been recognized as essential to the modification of sexual behavior and the management of HIV (12). In addition, communicating HIV diagnosis to significant others is viewed as an important step in securing support, which has been shown to positively influence the overall health, quality of life, and treatment adherence of HIV-positive individuals (35). Rooted in the historical voluntary counseling and HIV testing (VCT) context, the prevailing disclosure model is based on a medical model of prevention which assumes that some form of verbal negotiation between partners, including communication about past risks, takes place before embarking on a sexual relationship (68). However, disclosure of HIV status is mediated by a host of factors, including an individual’s psychological state, her/his communication skills, the individual’s relationship with the intended disclosure recipient, and the fear of being stigmatized by others (915).

Effective interventions for the prevention of mother-to-child transmission (PMTCT) are an ongoing priority in South Africa, where the national antenatal HIV prevalence is 29.5% (16). In this context, HIV disclosure is generally recommended by PMTCT health providers and counselors as a means to support safer sexual behaviors to reduce the probability of HIV transmission to sexual partner(s), as a way to access social support to promote antiretroviral treatment adherence, and as a method to garner partner and/or family support for exclusive breastfeeding. Recent data indicate that nondisclosure of HIV status is strongly associated with nonoptimal PMTCT outcomes and increased risk of mother-to-child HIV transmission (1718).

The current HIV-disclosure counseling paradigm, however, is not consistent with the reality of many women’s lives in South Africa, as it largely assumes that women are in stable monogamous relationships, have access to birth control, plan their pregnancies, and have reliable access to food and shelter. In fact, many women are likely to discover their HIV status before their sexual partners as a result of antenatal clinic attendance (1920), and are therefore burdened with the responsibility of disclosing their HIV-positive status and/or pregnancy to partners who might respond negatively. The 1998 South African Demographic Health Survey, in which 11,735 women were interviewed in all the country’s provinces, found that 61% of all first pregnancies and 46% of all second pregnancies were unintended* (21). A study among 242 antenatal attendees in the KwaZulu-Natal province found that 84% of all pregnancies were unintended (22). Prior research has shown that pregnant women, as a general population, are especially vulnerable to experiencing violence (2324), and HIV-positive women, in particular, are more likely to report lifetime violence than HIV-negative women (25). Following disclosure, HIV-positive women have also been found to experience breakdown or dissolution of a relationship (326), economic abandonment, rejection, and isolation (3142729). Prevailing assumptions that an HIV-positive pregnant woman will prioritize her own, her partner’s, and her infant’s health once made aware of her status do not allow for the possibility that this may be subordinated to more immediate and basic needs.

We conducted a qualitative study to investigate HIV-disclosure dynamics among HIV-positive pregnant women accessing PMTCT services in an urban area with high HIV prevalence. This study will inform a broader theoretical position that well-informed counseling and support is required for HIV-positive pregnant women in a clinical context, in order to achieve better maternal mental-health and, by extension, child-health outcomes.

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