Background: Prevention of mother-to-child HIV transmission (PMTCT) programs usually test pregnant women for HIV without involving their partners. Non-disclosure of maternal HIV status to male partners may deter utilization of PMTCT interventions since partners play a pivotal role in decision-making within the home including access to and utilization of health services. Methods: Mothers attending routine 6-week and 9-month infant immunizations were enrolled at 141 maternal and child health (MCH) clinics across Kenya from June–December 2013. The current analysis was restricted to mothers with known HIV status who had a current partner. Multivariate logistic regression models adjusted for marital status, relationship length and partner attendance at antenatal care (ANC) were used to determine correlates of HIV non- disclosure among HIV-uninfected and HIV-infected mothers, separately, and to evaluate the relationship of non- disclosure with uptake of PMTCT interventions. All analyses accounted for facility-level clustering, Results: Overall, 2522 mothers (86% of total study population) met inclusion criteria, 420 (17%) were HIV-infected. Non-disclosure of HIV results to partners was higher among HIV-infected than HIV-uninfected women (13% versus 3% respectively, p < 0.001). HIV-uninfected mothers were more likely to not disclose their HIV status to male partners if they were unmarried (adjusted odds ratio [aOR] = 3.79, 95% CI: 1.56–9.19, p = 0.004), had low (≤KSH 5000) income (aOR = 1.85, 95% CI: 1.00–3.14, p = 0.050), experienced intimate partner violence (aOR = 3.65, 95% CI: 1.84–7. 21, p < 0.001) and if their partner did not attend ANC (aOR = 4.12, 95% CI: 1.89–8.95, p < 0.001). Among HIV-infected women, non-disclosure to male partners was less likely if women had salaried employment (aOR = 0.42, 95%CI: 0. 18–0.96, p = 0.039) and each increasing year of relationship length was associated with decreased likelihood of non- disclosure (aOR = 0.90, 95% CI: 0.82–0.98, p = 0.015 for each year increase). HIV-infected women who did not disclose their HIV status to partners were less likely to uptake CD4 testing (aOR = 0.32, 95% CI: 0.15–0.69, p = 0.004), to use antiretrovirals (ARVs) during labor (OR = 0.38, 95% CI 0.15–0.97, p = 0.042), or give their infants ARVs (OR = 0. 08, 95% CI 0.02–0.31, p < 0.001). Conclusion: HIV-infected women were less likely to disclose their status to partners than HIV-uninfected women. Non-disclosure was associated with lower use of PMTCT services. Facilitating maternal disclosure to male partners may enhance PMTCT uptake. Keywords: HIV, Male partner, Non-disclosure, Antiretrovirals, PMTCT * Correspondence: email@example.com Kenyatta National Hospital, P.O. Box 2590-00202, Nairobi, Kenya Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kinuthia et al. BMC Public Health (2018) 18:671 Page 2 of 10 Background Methods Worldwide, HIV testing among pregnant women has Study design increased substantially in the last decade . Pregnant The methodology of the parent study has been described women usually receive HIV testing during routine previously . Briefly, we conducted two facility-based antenatal care, which is typically attended without cross-sectional surveys of PMTCT effectiveness from male partners. Following testing, women are expected June to December 2013. The first, PMTCT-MCH survey to disclose their HIV status to their male partners and evaluated the population-level effectiveness of the national encourage them to seek HIV testing . World Health PMTCT program among all women attending randomly Organization (WHO) guidelines recommend couple selected facilities in seven of eight provinces in Kenya. HIV counseling and testing which provides an oppor- ThesecondNyanzaoversample survey purposively tunity to test the woman together with her partner sampled HIV-infected women attending facilities in and enables provider-facilitated disclosure, counseling Nyanza, a former province with the highest HIV preva- on safer sex practices and linkage to care if either lence in Kenya . partner is HIV-infected [3, 4]. However, low male part- ner antenatal clinic (ANC) attendance in sub-Saharan Facility selection Africa limits the utility of clinic-based couple testing The PMTCT-MCH survey used probability proportion- approaches as a strategy to facilitate disclosure . ate to size sampling to randomly sample 120 facilities Approaches to promote male partner involvement from among the 540 medium and large facilities across such as reorganizing ANC clinic operations to offer Kenya. The Nyanza Oversample survey included all large male testing during evenings or weekends, fast tracking facilities in the former Nyanza province (n = 30). Nine pregnant women who are accompanied by their male facilities in the former Nyanza were included in both partners and written invitations to male partners to at- surveys, thus a total of 141 facilities were sampled be- tend ANC have not consistently resulted in marked in- tween both surveys. Facilities located in the North Eastern crease in number of men attending ANC clinics [6–8]. province were excluded due to security concerns and lo- Alternative strategies include home-based testing which gistic feasibility. have been shown to reach more male partners and re- sults in increased couple HIV testing and facilitated Study population mutual disclosure [9, 10]. All mothers bringing their infants for 6-week or 9-month A systematic review in 2014 reported rates of disclos- infant immunizations were eligible to participate. The ure of HIV status among pregnant and postpartum National PMTCT-MCH survey recruited all eligible women in sub-Saharan African vary widely, ranging mother-infant pairs attending selected facilities during a from 30.2 to 93.3% . HIV-uninfected women have fixed 5-day recruitment period, regardless of maternal few or no concerns about disclosing their HIV status to HIV status. The Nyanza Oversample survey recruited all their partners . In contrast, HIV-infected women eligible HIV-positive mothers and their infants attending may delay disclosure or choose not to disclose due to selected facilities in Nyanza during a fixed 10-day recruit- fears of accusations of infidelity, abandonment, discrim- ment period. Mothers were included in the current ana- ination, and violence [12, 13]. Previous studies from lysis if they had data available on HIV status and reported Kenya found maternal disclosure of HIV status to male a current male partner. partners was associated with use of antiretroviral drugs for PMTCT , higher rates of facility delivery , and adherence to infant feeding guidance thereby Data collection reducing risk of vertical HIV infection and increasing Study staff administered the survey using Open Data Kit infant HIV free survival . However, correlates of on tablet computers. The survey instrument was adapted non-disclosure are not well defined. As PMTCT Op- from previous surveys designed to measure PMTCT tion B+ scales up with regimens that require life-long effectiveness [19–21], and field tested prior to imple- antiretroviral treatment (ART) adherence, the need mentation. The questionnaire included uptake of ANC, for HIV-infected pregnant and breastfeeding women maternal HIV testing, non-disclosure of status, partner to disclose their status to their male partners be- HIV status, intimate partner violence (IPV), and use of comes more critical in order to maintain adherence ARVs among HIV-infected women as well as maternal to ART. In a national survey evaluating effectiveness and paternal demographics and reproductive and family of PMTCT programs in Kenya, we assessed preva- planning history. Among HIV exposed infants, ARVs lence and correlates of maternal non-disclosure of and HIV testing were assessed. IPV was defined by a HIV status to male partners and impact on utilization score ≥ 10.5 on the Hurt Insult Threaten Scream (HITS) of PMTCT services. scale . Kinuthia et al. BMC Public Health (2018) 18:671 Page 3 of 10 Statistical analyses Utilization of maternal health services Statistical models were analyzed separately for Frequency of having the recommended ≥4 ANC was HIV-infected and uninfected women to describe the 59% among HIV-infected mothers and 49% among study population and examine the correlates of HIV-uninfected mothers. Approximately 1 in 3 male non-disclosure in these two unique groups. All analyses partners were reported to have attended antenatal care accounted for facility-level clustering. We determined among both HIV-infected and uninfected mothers correlates of non-disclosure of HIV status and impact (Table 1). Delivering at health facility for their most re- of non-disclosure on utilization of PMTCT services cent birth was common among HIV-infected mothers using logistic regression models. Multivariate logistic (84%) and HIV-uninfected mothers (78%). regression was conducted for covariates statistically as- sociated (p < 0.05) with non-disclosure in univariate Correlates of HIV non-disclosure among HIV-uninfected analysis. We decided a priori to adjust all multivariate mothers models for marital status, relationship length and male In univariate analyses, HIV-uninfected mothers were more partner attendance at ANC based on previous literature likely not to disclose if they were unmarried, had an in- which identified relationship stability and partner en- come ≤KSH 5000/month, and experienced IPV from their gagement in care as predictors of disclosure . male partner or if their male partner did not attend ANC; STATA version 11 (STATA Corp, College Station, delivery within a health facility was associated with de- Texas, USA) was used to analyze data. creased likelihood of non-disclosure (Table 2). All poten- tial predictors significantly associated with non-disclosure among HIV-uninfected mothers in univariate models Results remained significant in multivariate models after adjust- Overall, 2522 mothers (86% of total study population) ment for marital status, relationship length and male part- had known HIV status, reported having a current part- ner ANC attendance. ner and were included in the final analysis. Of these In multivariate analyses, the likelihood of non-disclosure mothers, 420 (17%) were HIV-infected and 2102 (83%) was 4-fold higher among unmarried mothers compared to were HIV-uninfected. The mean age was 28.4 years HIV-uninfected mothers who were married or cohabiting (standard deviation [SD] 5.5) for HIV-infected mothers (adjusted odds ratio (aOR = 3.79, 95% CI: 1.56–9.19, p = and 25.8 years (SD 5.5) for HIV uninfected mothers. 0.004). HIV-uninfected mothers who experienced IPV Ninety-seven percent of both HIV-infected and were nearly 4 times as likely to not disclose as mothers HIV-uninfected mothers were married or cohabiting who did not experience IPV (aOR = 3.65, 95% CI: 1.84– with their current parent; the mean relationship dur- 7.21, p < 0.001). Having a partner who did not attend ation was 6.8 years (SD 5.2) and 5.3 years (SD 4.7) for ANC was associated with a 4-fold higher likelihood of HIV-infected and HIV-uninfected mothers, respect- non-disclosure compared to having a partner who ively. Among HIV-infected women, frequency of having attended ANC among HIV-uninfected mothers (aOR = no formal education was 8 and 9% had salaried employ- 4.12, 95% CI: 1.89–8.95, p < 0.001). HIV-uninfected ment; 7% of HIV-uninfected women had no formal mothers who delivered in healthcare facilities were less education and 11% had salaried employment (Table 1). likely to not disclose their HIV status (aOR = 0.47, 95% CI: Male partners of HIV-infected women had a mean age of 0.26–0.82, p =0.009). 35.0 years (SD 7.7) and male partners of HIV-uninfected women had a mean age 31.2 years (SD 6.8). Few male partners of HIV-infected women (5%) and HIV-uninfected Correlates of HIV non-disclosure among HIV-infected women (3%) had no education and frequency of un- mothers employment among male partners was 13 and 12% for In univariate analyses, HIV-infected mothers were more HIV-infected and HIV-uninfected mothers, respect- likely not to disclose their HIV status to their partners ively. Among mothers with male partners who had if they were unemployed or if their male partner did been tested for HIV, 71% of HIV-infected mothers and not attend ANC (Table 3). HIV-infected mothers were 1% of HIV-uninfected mothers had HIV-infected less likely to not disclose if they were in longer relation- partners. ships and had employed partners in univariate analyses Overall, 125 of the 2522 (5%) mothers included in the (Table 3). After adjustment for marital status, relationship analysis reported non-disclosure of HIV status to their length and male partner ANC attendance, all potential partners. The proportion of HIV-infected women who did predictors significantly associated with non-disclosure not disclose their status was significantly higher 13% (53/ among HIV-infected mothers in univariate models 420) compared to 3% (72/2102) among HIV-uninfected remained significant in multivariate models. No associ- women (p <0.001). ation was detected between non-disclosure and IPV, Kinuthia et al. BMC Public Health (2018) 18:671 Page 4 of 10 Table 1 Characteristics of mothers with current male partners and known HIV status (n = 2522) Characteristic N (%), Mean (SD) HIV-infected (n = 420) HIV-uninfected (n = 2102) Maternal characteristics Age (years) 28.4 (5.5) 25.8 (5.5) Unmarried/not cohabiting 11 (3%) 64 (3%) Duration of relationship (years) 6.8 (5.2) 5.3 (4.7) Education None 32 (7.6%) 141 (6.7%) Primary 243 (58%) 988 (47%) Secondary 111 (26%) 669 (32%) > Secondary 34 (8%) 304 (14%) Employment Salaried 38 (9%) 221 (11%) Self employed 138 (33%) 564 (27%) Housewife 173 (41%) 956 (46%) Unemployed 68 (16%) 335 (16%) Income/month KSH ≤ 5000 118 (48%) 837 (62%) KSH > 5000 128 (52%) 507 (38%) IPV (from current male partner) 60 (14%) 111 (5%) Current male partner characteristics Partner age 35.0 (7.7) 31.2 (6.8) Partner education None 19 (5%) 63 (3%) Primary 150 (39%) 697 (34%) Secondary 175 (45%) 859 (42%) > Secondary 44 (11%) 405 (20%) Partner employment Unemployed 54 (13%) 240 (12%) Self employed 199 (48%) 943 (45%) Salaried 162 (39%) 900 (43%) Partner tested for HIV 322 (77%) 1471 (70%) Partner HIV status HIV infected 228 (71%) 7 (1%) HIV uninfected 88 (27%) 1433 (97%) Unknown 6 (2%) 31 (2%) Obstetric history Number of living children 2.9 (1.4) 2.3 (1.5) Attended any ANC 414 (99%) 2080 (99%) ≥4 ANC visits 240 (59%) 988 (49%) Partner did not attend ANC 270 (66%) 1288 (62%) Health facility delivery 352 (84%) 1640 (78%) HIV status disclosure Did not disclose HIV status to current male partner 53 (13%) 72 (3%) SD standard deviation, IPV intimate partner violence, ANC antenatal care Missing data not shown, all models adjusted for clinic-level clustering IPV defined as having a score ≥ 10.5 on HITS scale Among male partners who were tested for HIV During the most recent pregnancy income or delivering in a health facility among HIV-infected a decreased likelihood of non-disclosure of HIV status to mothers. male partners (aOR = 0.90 per increase in year, 95%CI: In multivariate models among HIV-infected women, each 0.82–0.98, p = 0.015). Having salaried employed was associ- increasing year of relationship duration was associated with ated with increased likelihood of non-disclosure compared Kinuthia et al. BMC Public Health (2018) 18:671 Page 5 of 10 Table 2 Correlates of HIV status non-disclosure among HIV-uninfected mothers with current male partners (n = 2102) Univariate Multivariate Characteristic OR (95% CI) p-value aOR (95% CI) p-value Maternal characteristics Age (years) 0.98 (0.93–1.03) 0.502 Unmarried/not cohabiting 5.90 (2.69–12.94) < 0.001* 3.79 (1.56–9.19) 0.004 Duration of relationship (years) 0.99 (0.94–1.04) 0.613 Education None ref Primary 1.67 (0.56–4.95) 0.350 Secondary 0.79 (0.25–2.46) 0.677 > Secondary 0.81 (0.23–2.86) 0.738 Employment Salaried ref Self employed 3.09 (0.93–10.31) 0.066 Housewife 2.35 (0.74–7.50) 0.146 Unemployed 3.64 (0.96–13.81) 0.057 KSH ≤ 5000 income/month 2.25 (1.23–4.12) 0.009* 1.85 (1.00–3.41) 0.050 IPV (from current male partner) 3.48 (1.83–6.62) < 0.001* 3.65 (1.84–7.21) < 0.001 Current male partner characteristics Partner age (years) 0.99 (0.94–1.04) 0.634 Partner education None Ref Primary 2.89 (0.38–21.99) 0.304 Secondary 1.71 (0.21–13.72) 0.613 > Secondary 1.25 (0.14–10.77) 0.838 Partner employment Unemployed Ref Self employed 1.55 (0.65–3.71) 0.321 Salaried 0.80 (0.30–2.10) 0.641 Partner tested for HIV 1.25 (0.67–2.31) 0.476 Partner HIV status HIV-uninfected Ref HIV-infected – Unknown 4.23 (0.92–19.50) 0.064 Obstetric history Number of living children 1.08 (0.94–1.23) 0.266 ≥4 ANC visits 0.63 (0.40–0.99) 0.047 Partner did not attend ANC 4.17 (1.92–9.05) < 0.001 4.12 (1.89–8.95) < 0.001 Health facility delivery 0.43 (0.26–0.71) 0.001* 0.47 (0.26–0.82) 0.009 SD standard deviation, IPV intimate partner violence, ANC antenatal care, OR odds ratio, aOR adjusted odds ratio Missing data not shown; all models adjusted for clinic-level clustering Multivariate models adjusted for marital status, duration of relationship and partner ANC attendance IPV defined as having a score ≥ 10.5 on HITS scale Among male partners who were tested for HIV During the most recent pregnancy to being unemployed among HIV-infected mothers likely to not disclose than women whose partners were (aOR = 9.19, 95% CI: 1.06–79.41, p = 0.044). Compared unemployed (aOR = 0.42, 95% CI 0.18–0.96, p = 0.039). to HIV-infected mothers whose partners attended ANC, those with partners who did not attend were Non-disclosure of HIV status and utilization of PMTCT nearly 3 times more likely to not disclose (aOR = 2.62, services among HIV-infected mothers 95% CI 1.28–5.35, p = 0.009). HIV-infected mother Among HIV-infected mothers, those who did not dis- whose partners had salaried employment were less close their HIV status to male partners were less likely Kinuthia et al. BMC Public Health (2018) 18:671 Page 6 of 10 Table 3 Correlates of HIV status non-disclosure among HIV-infected mothers with current male partners (n = 420) Univariate Multivariate Characteristic OR (95% CI) p-value aOR (95% CI) p-value Maternal characteristics Age (years) 0.95 (0.89–1.02) 0.137 Unmarried/not cohabiting 1.56 (0.33–7.41) 0.572 Duration of relationship (years) 0.91 (0.84–0.98) 0.017* 0.90 (0.82–0.98) 0.015* Education None ref Primary 1.31 (0.40–4.30) 0.653 Secondary 1.63 (0.46–5.78) 0.447 > Secondary 1.67 (1.41–6.74) 0.470 Employment Salaried ref ref Self employed 4.18 (0.49–35.51) 0.188 4.11 (0.47–35.77) 0.198 Housewife 5.67 (0.71–45.23) 0.100 5.07 (0.65–39.52) 0.120 Unemployed 10.47 (1.20–91.31) 0.034* 9.19 (1.06–79.41) 0.044 KSH ≤ 5000 income/month 0.61 (0.26–1.47) 0.269 IPV (from current male partner) 1.08 (0.49–2.38) 0.853 Current male partner characteristics Partner age (years) 0.97 (0.92–1.02) 0.209 Partner education None ref Primary 0.29 (0.08–1.03) 0.056 Secondary 0.40 (0.11–1.45) 0.163 > Secondary 0.44 (0.10–2.03) 0.290 Partner employment Unemployed ref ref Self employed 0.59 (0.28–1.25) 0.165 0.61 (0.30–1.24) 0.169 Salaried 0.43 (0.20–0.93) 0.033* 0.42 (0.18–0.96) 0.039 Partner tested for HIV 0.69 (0.26–1.81) 0.445 Partner HIV status HIV-uninfected ref HIV-infected 0.46 (0.17–1.24) 0.124 Unknown – Obstetric history Number of living children 0.89 (0.69–1.16) 0.405 ≥4 ANC visits 0.65 (0.37–1.15) 0.139 Partner did not attend ANC 2.65 (1.29–5.43) 0.009* 2.62 (1.28–5.35) 0.009* Health facility delivery 1.10 (0.48–2.54) 0.823 HIV-related characteristics CD4 testing uptake 0.29 (0.14–0.59) 0.001* 0.32 (0.15–0.69) 0.004 CD4 results received 0.49 (0.22–1.10) 0.084 Currently on HAART for own health 0.39 (0.21–0.74) 0.005* 0.51 (0.25–1.04) 0.063 Maternal ARV use During pregnancy 0.42 (0.16–1.10) 0.078 During labour 0.25 (0.11–0.53) < 0.001* 0.38 (0.15–0.97) 0.042 During breastfeeding 0.30 (0.15–0.62) < 0.001* 0.50 (0.22–1.14) 0.096 Infant received PCR testing 0.56 (0.31–1.01) 0.053* 0.60 (0.32–1.09) 0.093 Infant ARV use 0.08 (0.03–0.22) < 0.001* 0.08 (0.02–0.31) < 0.001 SD standard deviation, IPV intimate partner violence, ANC antenatal care, OR odds ratio, aOR adjusted odds ratio Missing data not shown; all models adjusted for clinic-level clustering Multivariate models adjusted for marital status, relationship length, and partner ANC attendance IPV defined as having a score ≥ 10.5 on HITS scale Among male partners who were tested for HIV During the most recent pregnancy *highlights factors were significantly different in univariate analysis Kinuthia et al. BMC Public Health (2018) 18:671 Page 7 of 10 to not uptake CD4 testing (aOR = 0.32, 95% CI: 0.15– encouragement or more kindness from their male part- 0.69, p = 0.004), less likely to use ARVs during birth ners following disclosure of status, but this is uncom- (aOR 0.38, 95% CI 0.15–0.97, p = 0.042) and less likely monly reported . Several studies have noted that to give their infants ARVs (aOR = 0.08, 95% CI: 0.02– disclosure remains extremely difficult for HIV-infected 0.31, p < 0.001) compared to mothers who disclosed. women and highlights the need to strengthen support ser- There were trends towards an association between vices for these women in order to maximize opportunities non-disclosure and decreased likelihood of using for HIV prevention [12, 35]. HAART (aOR = 0.51, 95% CI 0.25–1.04, p = 0.063), using Consistent with previous studies, we found that ARVs during breastfeeding (aOR = 0.50, 95% CI: 0.22– shorter duration of relationship and employment status 1.14, p = 0.096) and receipt of infant PCR testing (aOR = were associated with non-disclosure of HIV-positive 0.60, 95% CI: 0.32–1.09, p = 0.093), though our statisti- status, though our estimates for the association between cally power was limited to detect associations. employment and non-disclosure should be interpreted with caution due to imprecise estimations [34, 36]. Discussion Concerns about abandonment or breakdown of relation- Even though most mothers (approximately 95%) reported ship have been cited as barriers to disclosure . disclosing their HIV status to their male partners in this HIV-infected women in a relationship for a short duration survey of 141 MCH clinics in Kenya, HIV-infected may perceive that the partnership as weak and possibly mothers less frequently reported disclosure than not able to withstand the strain that would result from HIV-uninfected mothers. The non-disclosure rate of 13% HIV disclosure. Women who are unemployed and those among HIV-infected mothers that we observed, although dependent on male partners for financial support may markedly higher than among HIV-uninfected mothers in potentially opt not to disclose for fear that partners may the same clinics, is lower than in previous studies in discontinue support, particularly during pregnancy when Kenya and sub-Saharan Africa [13, 15, 24]. Two recent it is more difficult for the women to find employment to studies in Kenya from 2013 and 2014 reported that 51 and support themselves. Strategies to empower these women 69%, respectively, of pregnant HIV-infected mothers did are therefore an important complement in HIV preven- not disclose their status [15, 24]. The lower levels of tion efforts. non-disclosure noted in our study may be due to sus- Consistent with other studies we found that women tained campaigns promoting HIV testing following launch who were unmarried were more likely not to disclose of the elimination of mother-to-child transmission of HIV [34, 36, 37]. This association was seen in (EMTCT) and Keeping Mothers Alive Campaign in No- HIV-uninfected but not HIV-infected women. Unmar- vember 2012, wider knowledge about routinized HIV test- ried women may have felt reassured by their HIV nega- ing in pregnancy and increased availability and use of tive status and did not feel need to disclose status. ART in recent years [25–27]. It is possible that there has However, in view of the high HIV discordance rates in been some decrease in stigma regarding HIV because of Kenya, non-disclosure results in missed opportunity to these developments that have encouraged pregnant encourage male partner testing as a strategy to identify HIV-infected women to disclose their status. However, couples in HIV discordant relationship and promote despite these efforts, 1 in 8 HIV-infected mothers did not adoption of primary HIV prevention interventions disclose their status and non-disclosure was associated among HIV-uninfected women . with decreased uptake of PMTCT services. In our study, We found that partner ANC non-attendance was as- we found that non-disclosure of HIV status to male part- sociated with non-disclosure among both HIV-infected ners persists as a gap to maximizing improved health out- and HIV-uninfected mothers. Partner ANC attendance comes for mothers, their male partners and infants. provides an opportunity to counsel and educate men In sub-Saharan Africa, most HIV infections are acquired about HIV and PMTCT, offer couple HIV testing and through heterosexual partnerships . Women who test facilitate disclosure of HIV test results. However, male HIV-positive may therefore experience anxiety when con- ANC attendance remains low in sub-Saharan African sidering disclosure due to fears of accusations of bringing . Low ANC attendance could possibly be due to HIV infection into the family through extramarital part- historical view of reproductive health as analogous to nerships or promiscuity . While it may be acceptable women’s health and therefore almost exclusively the for a man to have more than one partner in some African responsibility of the women . Increasing male par- communities, it is a taboo for women to do so and likely ticipation requires re-organization of services to be to provoke negative consequences [29–31]. Women who more welcoming for men and education campaigns to test HIV-positive fear that disclosure could result in aban- change beliefs and attitudes of men as well as address- donment, loss of economic security, discrimination and ing institutional barriers such as long wait times at the violence [13, 32–34]. Some HIV-infected women report clinics [38, 39]. Kinuthia et al. BMC Public Health (2018) 18:671 Page 8 of 10 HIV-uninfected mothers who reported frequent IPV and thus our estimates are not representative of small fa- were more likely not to disclose. Surprisingly, this associ- cilities. Oversampling women in Nyanza province allowed ation was not seen among HIV- infected women. A recent for an adequate number of HIV-infected women to assess meta-analysis evaluating risk factors of IPV among preg- correlates of non-disclosure among HIV-infected women. nant women in Africa reported a positive association be- Limitations of the study included, recall bias in ascertain- tween HIV infection and IPV . A study in Kenya ment of non-disclosure status, and reliance on self-report reported that after disclosure of HIV test results, the odds for HIV disclosure status, introducing the risk of social de- of HIV-positive pregnant women reporting domestic vio- sirability bias. The study was not originally designed to lence were 4.8 times those of HIV-negative women . primarily assess non-disclosure limiting the depth of our Additionally, a strong relationship has been reported exploration of correlates. Finally, women were selected between history of violence and current violence in preg- based on attendance at infant immunizations at participat- nancy highlighting the need for routine screening for IPV ing health facilities, and thus this sample does not include during antenatal care. Similar to other studies, we did not the subset of potentially most at-risk women who do not find association between education level and disclosure attend MCH clinic. [34, 37, 42]. Also, we did not find association between non-disclosure and partner education level, in contrast to Conclusion a South African study which found that women with part- In conclusion, we found low rates of non-disclosure of ners who had tertiary education were more likely to dis- maternal HIV status among all mothers, but higher among close . those who were HIV-infected. Non-disclosure among Consistent with previous studies, we found that HIV-infected women was associated with reduced use HIV-infected women who had not disclosed their results PMTCT services. Promoting male partner antenatal clinic were less likely to use PMTCT services . These find- attendance may be useful to enhance disclosure and ings explain our previous finding of higher rates of MTCT optimize PMTCT intervention adherence. There is need among women who have not disclosed status to their male for novel strategies to facilitate use of PMTCT interven- partners . Optimal utilization of PMTCT interventions tion by women reluctant to disclose their status. can reduce the risk of vertical HIV transmission to below Abbreviations 5%, the target for EMTCT . However, women who ANC: Antenatal care; ART: Antiretroviral treatment; EMTCT: Elimination of have not disclosed their status may have serious challenges mother-to-child transmission of HIV; IPV: Intimate partner violence; with both uptake and adherence to maternal and or infant MCH: Maternal and child health; PMTCT: Prevention of mother-to-child HIV transmission; WHO: World Health Organization ARVs or exclusive breastfeeding, compromising efforts towards EMTCT [15, 46–48]. Our findings highlight the Acknowledgements need for innovative strategies to facilitate utilization of The authors thank all the study participants for their contributions and the available PMTCT interventions by women hesitant to dis- staff at all participating institutions for their support. close their status. Funding We found that of the HIV-infected women who had This publication was made possible by support from the U.S. President’s not disclosed their status, approximately 20% reported Emergency Plan for AIDS Relief (PEPFAR) through cooperative agreement HIV-uninfected partners who were at risk of HIV acqui- [#U2GPS002047] from the U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV/AIDS (DGHA). CM was supported by the sition. A modeling study among adults in Zambia and University of Washington STD/AIDS Research Training Fellowship (NIH NRSA Rwanda estimated that between 55·1% and 92·7% of new T32AI007140) and NIH research career development award (K12HD052023: heterosexually acquired HIV infections occurred within Building Interdisciplinary Research Careers in Women’s Health Program – BIRCWH). Support for G.J.S. includes a NIH K24 grant (HD054314) and the serodiscordant marital or cohabiting relationships . University of Washington (UW) Global Center for Integrated Health of Non-disclosure of status limits utilization of HIV pre- Women Adolescents and Children (Global WACh). Lastly, support by the NIH ventive interventions such as condoms and pre-exposure funded program, UW Center for AIDS Research (CFAR) (P30 AI027757). prophylaxis [49, 50]. Availability of data and materials The study had several strengths and limitations. The The datasets used and/or analyzed during the current study are available study enrolled women from across Kenya, except for the from the corresponding author on reasonable request. former North Eastern Province, where access was lim- CDC disclaimer ited due to security concerns. However, the region is The findings and conclusions in this paper are those of the author(s) and do sparsely populated limiting the impact of excluding this not necessarily represent the official position of funding agencies. region. We enrolled both HIV-infected and uninfected women allowing for assessment of association of HIV Authors’ contributions CM, BS, JK and GJS designed the study. JK performed data analysis. JK, BS, CM, status with non-disclosure. The relatively large sample BO, AL, AK, LN and JP implemented the study. JK drafted the manuscript. JK, BS, size ensured that we had adequate power to assess cor- CM, BO, AL, AK, LN, JP and GJS revised the manuscript. All authors read and relates of non-disclosure. Small clinics were excluded approved the final manuscript. Kinuthia et al. BMC Public Health (2018) 18:671 Page 9 of 10 Ethics approval and consent to participate 14. Spangler SA, et al. HIV-positive status disclosure and use of essential PMTCT Ethical approvals for the study were obtained from the Human Subject and maternal health Services in Rural Kenya. J Acquir Immune Defic Syndr Division, University of Washington, Kenya Medical Research Institute Ethical (1999). 2014;67(Suppl 4):S235–42. Review Committee and the US Centers for Disease Control and Prevention’s 15. Onono M, et al. HIV serostatus and disclosure: implications for infant feeding Office of the Associate Director of Science before initiating study procedures. practice in rural South Nyanza, Kenya. BMC Public Health. 2014;14(1):390. Authorization was also obtained from the regional and local administrators 16. Aluisio A, et al. Male antenatal attendance and HIV testing are associated of the health facilities where study was conducted. Written consent was with decreased infant HIV infection and increased HIV-free survival. J Acquir obtained from all mothers who participated in the study. Immune Defic Syndr. 2011;56(1):76–82. 17. McGrath CJ, et al. Non-disclosure to male partners and incomplete PMTCT regimens associated with higher risk of mother-to-child HIV transmission: a Competing interests national survey in Kenya. AIDS Care. 2017:1–9. The authors declare that they have no competing interests. 18. 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Published: May 30, 2018
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