Awareness of HIV status and partner disclosure among antenatal clinic attendants: experience from a regional hospital in Ghana

Introduction: A pregnant woman’s knowledge of her human immune deficiency virus (HIV) serostatus and that of her sexual partner and the disclosure of her serostatus to the partner puts her in a better position to make informed choices about her pregnancy, adopt strategies to prevent mother to child transmission (PMTCT) of HIV and reduce sexual transmission of HIV. Some pregnant women however opt out of antenatal HIV testing while others have challenges with partner disclosure. This study sought to assess the pregnant women’s knowledge of their HIV serostatus and that of their partners, and disclosure to partners about their serostatus. Methods: An ethically approved cross-sectional descriptive study was conducted at the antenatal clinic (ANC) of the Kumasi South Hospital, Ghana from the period 8th March to 5th April, 2016. A structured questionnaire was administered to 407 ANC attendants who were randomly selected to participate in the study. Data entry was in Microsoft Excel and analyzed using R Core Team (2014). Results: The study showed that 80.1% (n = 326/407) of the participants knew their HIV serostatus. Of these, 18.1% (n = 59/326) knew prior to the current pregnancy and 81.9% (n = 267/326) were told during the current pregnancy. Among those who knew their HIV serostatus, the majority [83.1%; (n = 271/326)] had disclosed to their partners. Most of the participants [70.76%; (n = 288/407)] had no knowledge of their partners’ status. Conclusion: Every pregnant woman should know their HIV status, disclose it to their sexual partners and know the status of their sexual partners as this will PMTCT, reduce HIV transmission and acquisition among serodiscordant couples.


Introduction
Since the first reported case of acquired immune deficiency syndrome (AIDS) in 1981, the number of people living with human immune deficiency virus (PLWHIV) continues to increase and human immune deficiency virus (HIV) related illnesses are still one of the leading causes of death worldwide [1]. The burden is highest in sub-Saharan Africa where 63% of PLWHIV reside [2].
Central to the control of HIV is the diagnosis and treatment of the infected individuals and prevention of new infections. Voluntary HIV testing and counselling serve these goals. HIV-infected women who know their sero-status are in a better position to make informed choices about their reproductive life, and if pregnant, to access specific interventions, such as antiretroviral treatment, decide on mode of delivery and infant feeding counselling and support, which can significantly reduce the risk of mother-to-child transmission of HIV. Reports indicated that up to one-third of individuals diagnosed with HIV infection continue to have unprotected sex without informing their sexual partners who may be of positive, negative or of unknown sero-status [3]. Partner disclosure may motivate partner testing, encourage changes in sexual and social behaviour and ultimately decrease HIV transmission. It also affords the individual the opportunity for social support, improved access to care including antiretroviral treatment and prevention of mother-to-child transmission (PMTCT) interventions, increased opportunities to discuss and implement HIV risk reduction strategies with partners and to plan for the future. Thus, disclosure of HIV status is an important prevention strategy. National population surveys and epidemiologic studies indicate that the majority of African HIV infected individuals are married or in a stable long-term relationship [4]. Where the HIV status of both partners is known, measures can be taken to prevent infection in the seronegative partner and treat the affected one.
Recently, increased attention to transmission within sero-discordant couples has highlighted the potential role of disclosure as a way to encourage prevention [5]. Advantages of disclosure of HIV status by pregnant women include increased emotional and financial support, freedom to use their HIV drugs in front of sexual partners, and freedom to implement the feeding option they choose for their new-born [6]. However, HIV sero-status disclosure may be associated with some negative outcomes: reduced social support [7], blame for testing without partner's consent [8], separation or divorce [9] and partner violence [10].
In Ghana despite the availability of counselling and testing centers, voluntary testing for HIV is not the norm. Majority of HIV testing are health provider initiated for diagnostic purposes. Despite the scaling up of HIV testing for pregnant women, some still opt out of testing and others after testing, do not disclose their status to their partners as they are more afraid of the consequences rather than the benefits of getting care and support and preventing transmission to their unborn babies.
This research sought to determine the knowledge of HIV sero-status among pregnant women, the rate of sero-status disclosure to their partners whether positive or negative and to assess their knowledge of their partners' HIV status. This will help in planning programs that will improve knowledge, facilitate disclosure and ultimately reduce HIV acquisition and transmission in sero-discordant sexual relationships and reduce MTCT.

Methods
This cross-sectional descriptive study was conducted at the antenatal clinic (ANC) of the Kumasi South Hospital, Ghana from the period 8 th March 2016 to 5 th April, 2016. The principal objective was to assess the knowledge of antenatal clinic attendants at the Kumasi South Hospital of their HIV status and partner disclosure of the status and its impact.
The Kumasi South Hospital is a government facility located in the Ashanti Region of Ghana. This hospital was chosen for the study because it has a very large HIV clinic and has an effective PMTCT program. It runs a daily antenatal clinic that sees about 150 clients per day. The patients are given HIV education, counselled and offered HIV testing at the booking visit. Clients are encouraged to disclose their HIV status after they have been tested.
The study population was antenatal attendants at the Kumasi South Hospital from 8 th March to 5 th April, 2016. Antenatal clinic attendants below the age of 18 years were excluded from the study. After sample size calculation, 407 women were recruited into the study.
Recruitment into the study was done at the antenatal clinic by a random sampling technique. A data collection tool (questionnaire) designed for the purpose of the study was pre-tested and used to collect the data. The purpose of the study was fully explained to the participants and an informed consent form was signed if a woman agreed to be enrolled into the study. Participants who could not sign were made to thumbprint. The participants were then interviewed using the questionnaires with both closed and open ended questions that addressed the principal and specific objectives.
Ethical approval for the study was obtained from the hospital ethical committee. Confidentiality was maintained throughout the study. Respondents did not receive any incentives to participate in this study. No participant was forced or coerced to answer questions they did not wish to answer. Information extracted include patient demographics, awareness of HIV status, prevention of mother to child transmission, disclosure of HIV status to partner and knowledge of partner's HIV status.
In computing the sociodemographic characteristics of the study participants, frequencies and percentages were used whilst chi square test was used to assess the relationship between disclosure of HIV status and other variables. The results are presented in the form of tables and figures.

Demographic Characteristics
The demographic characteristics of the study participants are depicted in Table 1.

PMTCT
From Table 2, 334 out of 407 respondents had HIV test. Table 3 shows PMTCT of seropositive patients. It shows that 2.4% (n = 8/334) of the participants had tested positive for HIV during this or a previous pregnancy with 97.6% (n = 326/334) testing negative. The HIV diagnosis was made in 62.5% (n = 5/8) of participants prior to this pregnancy and in 37.5% (n = 3/8) during the current pregnancy. Of the HIV positive participants, 42.9% (n = 3/7) were on TDF/3TC/EFV, 14.2% (n = 1/7) were on TDF/3TC/NVP and 42.9% (n = 3/7) on ZDV/3TC/NVP. Table 3 also shows that 42.8% (n = 3/7) have been on ART for up to a year, 28.6% (n = 2/7) have been on ART for 1-5 years and 28.6% (n = 2/7) had been on ART for 6-10 years. With respect to previous PMTCT, 50% (n = 4/8) had PMTCT in the previous pregnancy.  Table 4 shows that out of the participants who knew their HIV status, 83.1% (n = 271/326) had disclosed their status to their partners with 16.9% (n = 55/326) not disclosing their status. 60.00% (n = 33/55) of those who had not disclosed did not deem it necessary to disclose as they were HIV negative. 29.08% (n = 16/55) had not disclosed because they had not been asked by their partners, 3.64% (n = 2/55) were afraid of being divorced if they disclosed and the same number had not disclosed because their partners were violent. All the participants had disclosed voluntarily. 8.49% (n = 23/271) of the participants who had disclosed reported being happy, 0.37% (n = 1) of them reported the partner accepted the results and 91.14% (n = 247/271) reported no positive impact. None of the participants who had disclosed experienced a negative impact of disclosure.         Of the participants who had tested during pregnancy, 97% had disclosed their HIV status compared to 94.6% of the participants who had tested prior to the pregnancy disclosing their HIV status.

Demographics
The study showed that majority of the participants (72.98%) were between 20-30 years of age. This represents the peak reproductive age for most women. The age of pregnant women is known to influence disclosure of their HIV serostatus. Some studies found that younger women under the age of 24 years were more likely to disclose their status than older women [11,12]. This study, however, showed a high disclosure rate across all age categories: 83.04% for those aged 25 years and below, 81.10% for those aged between 26-30 years, 87.27% for those aged between 31-35 years and 81.82% of those aged above 35 years.
The study showed that majority of study participants (92%) had some formal education (basic to tertiary level). The urban settings where this study was conducted could possibly account for this. Being educated may have positive implications for HIV status disclosure as some studies have reported that women with higher level of education were more likely to disclose their HIV test results to their partners than woman who were illiterates [13,14].
The majority of the participants were married (57%) or co-habiting (28.25%). Pregnant women from these stable family environments may have challenges with disclosure due the fear of violence, rejection, accusations of infidelity, abandonment, and loss of economic support from a partner [15]. In resource poor countries where women are not economically independent of their partners, the fear of losing this important source of support is a real cause for worry for these women. On the other hand, supportive husbands or partners may offer the best support for seropositive pregnant women to facilitate a successful PMTCT.
The majority of the participants (57.74%) either had no child or had one child, with 36.85% having 2 or 3 children. This may have positive implication to the successful uptake of PMTCT as the mothers will be eager to have healthy children knowing the importance of having children in our society. This study showed that 80.88% of the participants had some sort of livelihood (trading, professional careers and farming) but whether the income generated was enough to make them financially independent and responsible is difficult to determine. Being financially dependent may mean women would have challenges with disclosure due to fear of loss of economic support.

Awareness of HIV status
There was a high level of awareness of HIV status (80.1%) among study participants. This could be attributable to the scale up of the PMTCT programs in hospitals across the country. Pregnant women are given an opt-out option of HIV testing and women are told of their HIV serostatus. Among respondents who knew their HIV status, 18.1% knew it prior to their current pregnancy whilst 81.9% knew it during the current pregnancy. This compares to a Tanzanian serostatus disclosure study which showed 80.8% of pregnant women learnt of their HIV status during their current pregnancy [16]. Knowledge of one's preconception HIV status is one of the important preventive strategies for an effective PMTCT program. The HIV infected woman can be started on ART for her own health and for preventing transmission to her unborn child and sexual partner. Additionally, she will be able to make an informed decision before embarking on a pregnancy.
The study showed a high acceptance of the HIV testing offered at the ANC as the majority of the participants (82.1%) had tested for HIV infection during the current pregnancy. This number could have been higher as at the time of the study, there was a problem of non-availability of test kits at the clinic.
This study showed that 2.4% of the participants had tested positive for HIV during this or a previous pregnancy. In the 2014 HIV status report by Ghana AIDS Commission (GAC), out of 601,726 pregnant women who tested for HIV, 12,583 representing 2.1% were found to be HIV positive. 87.5% of the HIV positive participants were on ART. This falls short of the National AIDS Commission Programme recommendation that all HIV positive pregnant women be treated with ART. Even though knowledge of HIV status and acceptability was high, the level of HIV education received from the ANC by the participants was low (38.3%). This could be due the fact that some of the participants may arrive at the clinic after the health talk is given usually before consultation starts at the clinic.
In this study, reasons given for non-disclosure includes HIV negative status (60.00%), partners not asking (29.08%), fear of divorce (3.64%) and fear of violence from partners (3.64%). Several studies have reported similar reasons for non-disclosure of HIV status to partners [14,12,11,17,20]. Our series shows that 60.00% of participants did not disclose their status because they were seronegative and so did not deem it important to disclose. This is in contrast with studies done in Tanzania where 85% of HIV negative women disclosed their status to their partners [19]. HIV negative women in this study assume that because they are not infected, their partners are also not infected thus their reason for non-disclosure. This demonstrates a lack of understanding of serodiscordancy and is rather disturbing as these patients stand the risk of acquisition of HIV infection from infected partners if they are in a serodiscordant relationship. Acute seroconversion in pregnancy is associated with a high risk of HIV transmission to the unborn baby due to high viraemia therefore putting the unborn baby at a very high risk of contracting HIV infection.

Impact of HIV Disclosure
All HIV status disclosures were done voluntarily. None of the participants experienced a negative impact of HIV status disclosure. Negative outcomes reported include 4% domestic dispute without violence following HIV disclosure [14], and separation, physical assault, blame, anger disbelief and fear [13]. Positive outcomes of serostatus disclosure have also been reported: encouraging attitudes, partners' become understanding, acceptance and kindness [20] whilst some studies have reported indifference of some partners to serostatus disclosure [14,20,21].
Partner's support after serostatus disclosure have the following advantages: they offer the best environment for seropositive pregnant women to undergo a successful PMTCT program, the women are more likely to accept antiretroviral treatment or prophylaxis [11,22,23] given at birth in a health facility and adhere to recommended HIV related care [24].

Knowledge of Partner's HIV Status
The majority of the study participants (70.76%) did not know their partners' HIV status. This compares with a Tanzanian study by which showed that only 23% of study participants knew their partners' HIV status [16]. This lack of knowledge of partners' status has implications for HIV acquisition and transmission among partners who may happen to be in serodiscordant relationships. The reasons given for not knowing partners' HIV status includes; the participants not asking their partners (81.9%) or partners not testing (18.1%). Despite high disclosure rates among the pregnant women, their knowledge of their partners' HIV status was very low. This may be due to the fact that majority of the participants were HIV negative and they disclosed their status without enquiring of their partners' status. This could be happening due to lack of knowledge and understanding of serodiscordancy which means that the HIV education done at the Antenatal clinic has to properly address this issue.

Serodiscordancy
The level of serodiscordancy in the study participants could not be well established as most of the participants were not aware of their partners' HIV status. Consistent condom use is one of the key methods of prevention of HIV transmission. Participants in an assumed seroconcordant relationship who fail to use condoms may acquire HIV infection if the partner turns out to be seropositive. In a serodiscordant relationship, condom use is a key HIV preventive strategy. The study showed that participants' use of condoms was low with 1.48% almost always using condom, 15.48% using condoms occasionally and 83.04% never using condoms. These findings support the finding that the prevalence of consistent condom use remains low in Ghana and in sub-Saharan Africa: 1.8% to 40% [25,26,27,28].
Early testing of new born babies is important to the success of PMTCT programs. This allows for early detection of HIV infection allowing for early initiation of ART and improved survival of the infant. In this study only 27.05% of the participants with children had ever tested them for HIV infection. All the children tested were HIV seronegative. The low percentage of children tested could be explained by the high number of seronegative mothers whose children are not tested because they are not HIV exposed.
The study did not show a statistically significance relationship between disclosure of participants' HIV status and knowledge of HIV status (p-value: 0.51), however having had HIV education, participants' testing for HIV in current pregnancy, knowing partner's HIV status and having had children tested for HIV had a statistically significant relationship with disclosure of their HIV status (p-values 0.3, 0.4, 0.00 and 0.21 respectively).

Conclusion
The study showed a relatively high level of disclosure of HIV test results by pregnant women to their sexual partners without them using the opportunity to enquire of partners' HIV status thus resulting in low level of knowledge of partners' HIV serostatus. Participants had very little knowledge of serodiscordancy. This has implications for the implementation of the use of PrEP as a preventive strategy in Ghana.
Male involvement in PMTCT has been primarily focussed on the HIV-infected women however it is also important to test partners of HIV-uninfected pregnant women in order to achieve the virtual elimination of MTCT of HIV. Male involvement has the potential to prevent seroconversion in the negative partner and improve uptake of HIV-prevention interventions among HIV-discordant couples, including treatment as prevention, PrEP, which would prevent horizontal acquisition or vertical transmission of HIV infection.

Limitations
The study was based on interview information, with disclosure being assessed based on self-reporting by clients. Over estimation or underestimation of the prevalence of disclosure cannot be ruled out as information obtained could not be verified. The findings could also have been biased as clients might have reported what they felt was expected.

Abbreviations
AIDS -Acquired immune deficiency syndrome ANC -Antenatal clinic ART -Antiretroviral therapy ARVs -Antiretrovirals FTC -Emtricitabine GPRTU -Ghana private road transport union HLA -Human leucocyte antigen HIV -Human immunodeficiency virus IDU -Injection drug use MTCT -Mother-to-child transmission NVP -Nevirapine PCR -Polymerase chain reaction PMTCT -Prevention of mother-to-child transmission PrEP -Pre-exposure prophylaxis PROTOA -Progressive transport owners' association TDF -Tenofovir UNAIDS -United Nations programme on HIV and AIDS UNESCO -United Nations educational, scientific and cultural organization VCT-Voluntary counselling and testing WHO -World health organization ZDV -Zidovudine