HIV This Week

Lesch A, Swartz L, Kagee A, Moodley K, Kafaar Z, Myer L, Cotton M. Paediatric HIV/AIDS disclosure: towards a developmental and process-oriented approach. AIDS Care 2007;19:811-6.

As antiretroviral therapy becomes more widely available in low-resource settings and children with HIV live for longer periods, disclosure of HIV diagnosis to infected children is becoming increasingly important. This article reviews the current literature on HIV-related disclosure in light of theories of cognitive development, and argues for the adoption of a process-oriented approach to discussing HIV with infected children. Disclosure presents unique challenges to healthcare workers and caregivers of children with HIV that include controlling the flow of information about the child's HIV status to him/her and deciding on what is in his/her best interest. Health care workers' and caregivers' views regarding disclosure to children may often be contradictory, with healthcare workers likely to support disclosing the diagnosis of HIV to children and caregivers more reluctant to discuss the disease with them. There is a clear need for practical interventions to support paediatric HIV disclosure which provide children with age-appropriate information about the disease.

Editors’ note: Decisions about when and how to disclose HIV status to a child need to consider the evolving capacity of children to understand about HIV infection and their socio-psychological readiness for learning their status. Understandably, caregivers may want to delay disclosure even when a child could take the information on board. Discussions between caregivers and healthcare workers are important to coming to agreement on tailoring the timing, manner, and content of disclosure to the child’s situation. The goals are mutual: supporting the child’s positive adaptation to the news and his or her engagement to stay healthy.

Klitzman R, Exner T, Correale J, Kirshenbaum SB, Remien R, Ehrhardt AA, Lightfoot M, Catz SL, Weinhardt LS, Johnson MO, Morin SF, Rotheram-Borus MJ, Kelly JA, Charlebois E. It's not just what you say: relationships of HIV disclosure and risk reduction among MSM in the post-HAART era. AIDS Care 2007;19:749-56.

In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviours and partner variables. Klitzman et al interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviours. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had >1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for <5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study – the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART - indicates that almost one fifth reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.

Editors’ note: Disclosure is difficult for many people, not the least those who have learned their status more recently and who only have casual partners. This study of men who have sex with men reveals that being on treatment and viral load are not influencing decisions to disclose or not whereas other factors such as relationship type clearly are. Lack of disclosure combined with unprotected anal sex fuel ongoing transmission among men who have sex with men. Qualitative action oriented research to help people create solutions that work for them is needed.