Issues in Mental Health Nursing, 36:171–181, 2015 Copyright © 2015 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.963209

Risk and Protective Factors for HIV Self-disclosure among Poor African-American Women Living with HIV/AIDS Marcia Polansky Drexel University, School of Public Health, Philadelphia, Pennsylvania, USA

Michelle Teti University of Missouri, School of Health Sciences, Columbia, Missouri, USA

Roshni Chengappa Erika Aaron Drexel University College of Medicine, Division of Infectious Diseases and HIV Medicine, Philadelphia, Pennsylvania, USA

African-American women with HIV are among the fastest growing populations with HIV. The psychosocial factors and beliefs/attitudes associated with disclosure and other un-safe sex practices are not fully understood in this population. A total of 158 HIV-positive women receiving primary care in an HIV clinic in Philadelphia who enrolled in a safe-sex intervention, completed a baseline questionnaire on their sexual activities with male partners and psychosocial factors that were potential protective/risk factors for unsafe sex. Women who were emotionally close and monogamous with their partner were most likely to disclose their HIV status and least likely to worry they had infected their partner. Women who were non-monogamous and who did not have an emotional connection to any of their partners were least likely to self-disclose. Partners were more likely to know each other’s status when the woman felt she had a responsibility to talk about the importance of staying HIV-negative.

INTRODUCTION Heterosexual women are among the fastest growing populations with HIV (McKay & Mutchler, 2011; Raiford, Wingood, & DiClemente, 2007). Of these women, 68% are AfricanAmerican (Department of Health & Human Services, DHHS, 2011). Although many women living with HIV practice safer sex, approximately one-third report unprotected sex with their male partners (Aidala, Lee, Garbers, & Chiasson, 2006; Golden, Wood, Buskin, Fleming, & Harrington, 2007; Wilson et al., ∗

Marcia Polansky and Michelle Teti contributed equally to this article. Address correspondence to Marcia Polansky, Drexel University, School of Public Health, 3215 Market St, Philadelphia, PA 19104, USA. E-mail: [email protected]

2004). HIV/AIDS self-disclosure (self-disclosure) – reporting one’s HIV status to sexual partners – is an important component to decreasing sexual behaviors that risk HIV transmission. Self-disclosure may facilitate open discussions about risk and safe sex in relationships and/or sexual encounters and ultimately lead to safer sex overall (Simoni & Pantalone, 2004). Beyond the benefits associated with safe sex, many HIV-positive women want to disclose their status because they are concerned for their partners’ health (Sowell, Seals, Phillips, & Julious, 2003), and believe it is their responsibility (Duru et al., 2006), or want their partner’s support. Although risk and protective factors for self-disclosure have been extensively studied among various groups of men with HIV (Shacham, Small, Onen, Stamm, & Overton, 2012; Simon Rosser et al., 2008), far less research has addressed factors influencing disclosure among women or low-income AfricanAmerican women in particular, who comprise the majority of women with HIV in the USA (Black & Miles, 2002; Vyavaharkar et al., 2011). Research that does exist indicates that self-disclosure among women with HIV is affected by various complex individual, relational, and social factors. For example, on an individual level, self-disclosure has been positively associated with self-efficacy or confidence to disclose (Sullivan, Voss, & Li, 2010), personal responsibility for protecting others (Simoni et al., 1995), and inversely related to depression (Vyavaharkar et al., 2011). Self-disclosure is also associated with numerous relationship factors. Women with more sexual partners are less likely to disclose their HIV status than women with fewer reported partners (Ciesla, Roberts, & Hewitt, 2004). In addition, romantic intimacy and relationship seriousness affect self-disclosure (Batterham, Rice, & Rotheram-Borus, 2005; O’Brien et al.,

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2003). Among a national cohort of women with HIV across the USA, Wilson et al. (2007) found that sexual partnerships more recently initiated were less likely to involve consistent condom use and mutual HIV disclosure than more established partnerships. Finally, fears of violence, actual violence (Gielen et al., 2000), and feeling safe enough to disclose (Sullivan et al., 2010) also influence women’s decisions to self-disclose HIV status. Social support has been found to increase self-disclosure (Reilly & Woo, 2004; Reilly, Woodruff, Smith, Clapp, & Cade, 2010), although contexts exist in which social support can facilitate non-disclosure as well. For example, in a social network in which the social norms allow for risky sexual behavior (Latkin, Forman, Knowlton, & Sherman, 2003) or if safe sex is not discussed by social network members (Kennedy, 2010), the network can potentially increase risky sexual behavior, including non-disclosure in high-risk populations. Qualitative research has unearthed additional social reasons for non-self-disclosure, including HIV-related stigma and shame (Black & Miles, 2002). The majority of existing research does not focus on low-income African-American women with HIV who face unique challenges and opportunities with disclosure and other HIV-risk practices. For instance, they contend daily with a myriad of racial/ethnic, socioeconomic, gender, and health-based inequalities. These limit their power in relationships and may compromise their ability to discuss their HIV status or their sexual practices with their partners (Harvey, Bird, Galavotti, Duncan, & Greenberg, 2002; Harvey & Bird, 2004). The growing number of women living with HIV, the escalating HIV crisis for low-income AfricanAmerican women, and evidence of ongoing risk behavior among women with HIV, underscores the importance of understanding risk and protective factors for disclosure among AfricanAmerican women with HIV. Specifically, this study investigates risk and protective factors for disclosure of HIV to male sex partners and self-perceived risky sexual behavior among poor African-American women with HIV who received their primary care in an urban US HIV clinic in the northeast. Factors studied included romantic-sexual relationships, social support, HIV-related self-efficacy, and sexual responsibility. METHOD Design and Study Population The present study is a cross-sectional study using baseline data from a randomized controlled trial of an intervention to promote safe sex for women with HIV (Protect and Respect (P&R); Teti et al., 2007). This intervention study was part of an initiative of the Health Resources and Service Administration ‘Prevention with Positives’ (PwP), which sought to develop interventions for HIV-positive individuals for preventing the transmission of HIV. The study population of the randomized controlled trial was comprised of HIV-positive, low-income, uninsured, African-American women who received their HIV care from an academic hospital-based HIV clinic in Philadel-

phia, PA. All women who received treatment in the HIV clinic were offered the opportunity to participate in this study. The pre-intervention data of the evaluation was used for the present study. A total of 184 of the women (40%) receiving care in the clinic enrolled in the intervention between April 2004 and July 2006. The majority (158 of the 184) of the women who participated in P&R were African-American. The sample used for this study was a sub-group of African-American women. The mean age of the women was 39.9 years; 46.5% of the women did not graduate from high school, and 73.2% of the women reported an annual income of $10,000 or less.

Data Collection and Study Variables The questionnaires used were developed by the Center for AIDS Prevention Studies (CAPS) at UCSF, which was the evaluation center for PwP. The evaluation team developed a questionnaire which comprehensively covered potential risk and protective factors for HIV prevention and sexual behavior. The questionnaire was designed to be understandable for those with low socioeconomic status and low literacy. The questionnaires were administered using an Audio Computer-assisted Self-interview system (ACASI). The ACASI simultaneously audio-plays and displays on the computer screen the pre-recorded questions and responses. As the questionnaire is ‘computer administered’ personal information can be obtained discreetly and confidentially and provides more accurate personal data than person administered questionnaires (Schroder, Carey, & Vanable, 2003). The questionnaire included in-depth questions on sexual-romantic behavior in relation to living with HIV (Table 1). The questions on attitudes and beliefs were rated on a Likert scale. Self-disclosure of HIV status was a primary outcome of interest in the present study. Self-disclosure to all partners, to primary partners, and non-primary partners separately, were analyzed. Primary partners were partners described as those whom you ‘see a lot, and to whom you have felt a special emotional commitment.’ An additional disclosure variable, ‘knowing each other’s status’ (‘both knowing’) was created. Previous research has found that most self-disclosure occurs as part of a (simultaneous) mutual disclosing (Latka et al., 2006). ‘Both knowing’ could be determined using an additional question regarding whether the participant’s partner knew her HIV status. If someone other than the participant disclosed her status, this would not be picked up. Another outcome studied was: ‘I am worried that I could have infected someone else with HIV in the last six months.’ The statement was rated on a 7-point Likert scale with ratings anchored by strongly disagree and strongly agree. These responses were dichotomized for statistical analysis as 1 and 2 (strongly disagree and disagree) vs 3+ (neutral to strongly agree). The structures of romantic relationships among low-income women with HIV are varied and can be complex. Some women have traditional relationships defined by monogamy and

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TABLE 1 Ethical responsibility, stigma/shame, self-efficacy, knowledge questions All Statements It is my role as a person living with HIV to discuss with HIV-negative people how important it is to stay uninfected The responsibility for not getting infected with HIV should be placed on HIV-negative people more than on HIV-positive people Most people are afraid to be around a person with HIV I feel ashamed that I have HIV Using condoms correctly is an effective way to prevent HIV transmission I am confident that I could use a condom successfully It is not possible to re-infect someone who is already HIV-positive Make unpleasant thoughts go away Take your mind off unpleasant thoughts Stop yourself from being upset by unpleasant thoughts Get friends to help you with the things you need Get emotional support from friends and family Make new friends Break an upsetting problem down into smaller parts Sort out what can be changed and what cannot be changed Make a plan of action and follow it when confronted with a problem

Sexually active

n

Mean

SD

n

Mean

SD

152

6.03

1.60

92

6.15

1.44

153

3.66

2.30

93

3.51

2.25

154 154 154

5.11 4.49 6.40

1.84 2.24 1.11

94 94 94

5.15 4.60 6.60

1.81 2.21 .81

153 150 153 153 152 152 152 152 152 152 152

6.50 2.83 4.82 4.74 4.57 4.92 5.26 5.11 4.71 5.12 5.21

1.08 2.18 1.75 1.90 1.84 1.99 1.88 1.92 1.71 1.64 1.66

94 92 94 94 94 94 94 94 94 94 94

6.60 2.52 4.59 4.59 4.40 4.85 5.20 4.96 4.49 4.89 5.14

.94 2.01 1.74 1.83 1.81 2.01 1.92 1.92 1.70 1.69 1.69

Primary partner is one you have ‘seen a lot, and to whom you have felt a special emotional commitment.’

emotional closeness, while other women have multiple partners. The level of closeness and commitment often differs for different partners. Disclosure and safe sex may differ depending on the overall structure of the women’s romantic relationship, as well as her emotional connection with the particular partner. Therefore, it is informative to categorize romantic-sexual relationships more finely than has been done previously and to determine self-disclosure and safe sex for these subgroups. We formed the categories of romantic-sexual relationship structure by cross-classifying women by the importance-commitment given to her partner(s) and whether she had one, or more than one partner. Emotional importance/commitment was classified into three levels: (a) married; (b) committed but not married; (c) primary, ‘seen a lot, and to whom you have felt a special emotional commitment.’ For women with multiple partners, the mix of primary and non-primaries was also taken into account in the classification. Table 2 gives the number of women in each of the romantic-sexual relationship categories. Most sexually active women belonged to one of four main categories: (1) monogamous and committed to partner (n = 14); (2) one primary partner (n = 40); (3) multiple partners, at least one primary (n = 28); and (4) all non-primary partner(s) (n = 18). There was only a very small number of married women (n = 6). Also, as can be seen in Table 2, the women with multiple partners and at least one primary partner were divided equally between those having one primary and those having more than

one primary. In almost all cases, if a woman had more than one primary partner, all her partners were primary (12 out of the 14 women). Also, if a woman had no primary partners, generally she had multiple partners (13 out of 18). The two categories created for the non-sexually active respondents were ‘e,’ single and not sexually active (n = 39) and ‘f,’ living together or married but not sexually active (n = 13). The knowledge/belief/psychological questions were used as potential predictors of self-perceived risky behavior and selfdisclosure. The questions used consisted of eight questions regarding various domains of self-efficacy, including self-efficacy questions related to confidence in using condoms. There were also questions regarding stigma/shame, ethics/responsibility in not transmitting HIV, and perceived risk of infecting one’s sexpartner (Table 1). The statements were rated on a 7-point Likert scale with ratings anchored by strongly disagree and strongly agree.

Statistical Analysis The χ 2 -test for independence and the non-parametric Mann–Whitney test were used to test for associations among disclosure variables and relationship status. The χ 2 -test for trend was used to test for associations for self-disclosure (dichotomous) with stigma, HIV-related self-efficacy variables, and ethical responsibility/role variables (ordinal). Spearman

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TABLE 2 Relationship categories for sexually active women n Married Monogamous Non-monogamous In a committed relationship Monogamous Non-monogamous Primary relationship(s) Monogamous Non-monogamous One primary partner and non-primary partners More than one primary partners All partners are primary More than one primary and non-primary partner(s) No primary relationships One sex partner More than one sex partner Total

6 6 0 14 14 0 40 28 14 14 12 2 18 5 13 106

correlations were used to determine the associations among these psychosocial variables. Logistic regression was used to identify the subset of psychosocial factors that in combination were most predictive of disclosure. Psychosocial variables, which were significant univariately at the 0.05 level by either the Mann–Whitney test or the χ 2 -test were included in the logistic regression. The ‘no emotional connection’ relationship group was not included in the multivariate analysis. All the women in this group did not disclose to all their partners, so the fact that they were in this group completely predicted self-disclosure status for these women. Only women who had been sexually active in the past 6 months were asked about disclosure and so only these women could be included in the analyses with disclosure as the outcome variable. Dichotomized ‘worrying that she had infected someone in the past 6 months’, was analyzed using the univariate tests and logistic regression in the same manner as was done for the disclosure outcome variables. All the women were asked this question, including the abstinent women. RESULTS Self-disclosure to Partners and Romantic-Sexual Relationships Disclosure to all Partners Self-disclosure to all partners was greatest for women who had only one partner. The disclosure rate was 79% for the monogamous committed women and 74% for the monogamous with a primary partner. Women who had more than one partner with one or more of their partners being a primary partner had

FIGURE 1. Percentage of women who disclosed to all their partner(s) by romantic relationship status.

the next highest disclosure rate to all their partners of 43% (p = 0.02 and p = 0.05 for this group vs the former groups with one partner, respectively). The women with all non-primary partners had the lowest disclosure rate, as none of these women disclosed to all their partners. The disclosure rate for this group of women was significantly less than the disclosure rate for the first three groups of women who felt close to at least one partner (p < 0.01). None of the other psychosocial variables studied (Table 2) were associated with self-disclosure to all partners. Disclosure to Primaries vs Non-primaries Most women with more than one primary partner had all primary partners. Of the 14 women with more than one primary partner, 12 had all primary partners while only two women had also a non-primary partner(s). Only 43% of the women with multiple primaries disclosed to all their primaries. Their disclosure rate was statistically significantly lower than the disclosure rates for (a) the committed-monogamous group; (b) women with one primary partner with whom they were monogamous but not committed to; and (c) the non-monogamous with only one primary partner (43% vs 79%, 74% and 71%, p = 0.03 Fisher’s exact test with the latter three categories combined). For women with both primary partners and non-primary partners (n = 16), the disclosure rates for their primary vs nonprimary partners can also be compared (Figure 1). Their disclosure rate to their primary partners was 75%, which is similar to the disclosure rate for monogamous women to their sole partner. However, their disclosure rate to their non-primary partner was only 25%, which trended to significance when compared with the disclosure rate to their primary partners(s) (p = 0.13 McNemar’s test). Predictors of Sex Partners Knowing Each Other’s HIV Status Sex partners knowing each other’s HIV status was highly associated with the romantic-sexual relationship type. Among women who had one sex partner, approximately 70% knew her partner’s status and vice versa. Only 25% of women with multiple sex partners and at least one being a primary partner knew all her partners HIV-status’ and they all knew hers. None

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TABLE 3 Univariate and multivariate analyses for predictors of both knowing∗ Proportion of partners who know each others’ HIV status

Variable-statement Romantic relationship status over past 6 months Single/multiple sex partners – at least one a primary Single/monogamous with a primary sex partner Emotionally committed – monogamous with sex partner It is my role as a person living with HIV to discuss with HIV-negative people how important it is to stay uninfected. (Groupings: strongly disagree to agree vs strongly agree) Using condoms correctly is an effective way to prevent HIV transmission. (Groupings: strongly disagree to agree vs strongly agree) Take your mind off unpleasant thoughts (Groupings: strongly disagree to neutral vs agree to strongly agree)

Those in less agreement with statement†

Those in more agreement with statement

p value (univariate)

OR (adjusted) (95% CI)

p value (adjusted)

NA

21.4

Ref

NA

68.4

8.00 (2.31–27.70)

< 0.001

NA

71.4

< 0.001

6.81 (1.38–33.57)

0.02

36.4%

66.7%

0.01

1.57 (1.04–2.37)

0.03

33.34%

60.7%

0.05

NS

0.12

61.4%

41.7%

0.05

0.68 (0.48–0.96)

0.03



n = 78 for multiple logistic regression. This column is not used for relationship status since this variable was not dichotomized. Agreement with statement categorized for the univariate analysis using the cut-point giving closest to 50% split.



of the 18 women who reported not being emotionally close to any of their sex partner(s), reported knowing all her partner(s) HIV-status’ and he/they all knew hers (p < 0.01 for overall comparison of groups) (Table 3). Women who believed that the HIV-positive person’s role is to talk with others about staying negative more often knew their partners’ status and he/they hers, than did those who did not share this belief (adjusted OR (CI: = 1.04–2.37, p = 0.03, Table 3). Being able to take (one’s) mind off upsetting problems was negatively associated with knowing each other’s HIV status (adjusted OR (CI) 0.68 (0.48–0.96, p = 0.03). Believing that condoms are effective for preventing HIV was significantly associated with knowing each other’s HIV status in the univariate analysis but not in the multivariate analysis. Of those who agreed strongly that condoms are effective, 60.7% knew each other’s HIV status vs 33.3% for those not agreeing strongly (p = 0.05, χ 2 -test for trend for ungrouped Likert ratings). None of the other psychosocial factors studied (Table 2) were associated with knowing each other’s HIV status.

Psychosocial Predictors Worrying that the woman had ‘infected someone in the past 6 months’, was also significantly associated with relationship type (p = 0.03, χ 2 -test for independence). Women who were single/abstinent and women who were sexually active/committed/monogamous were least likely to report worrying that they had infected someone in the past 6 months; 21.6% (8 of 37) of the single/abstinent and 21.4% (3 of 14) of the sexually active/committed/monogamous worried they had infected someone in the past 6 months. Those who were monogamous with a primary sex partner and those who were abstinent and committed or married had an intermediate rate of worry (41.0%, 16 out of 39 and 46.2%, 6 out of 13, respectively). Those who had multiple sex partners and who had at least one primary had the highest rate of worrying they had infected someone; 57% (16 out of 28) worried they had infected someone in the past 6 months. None of the other risk/protective factors studied were associated with worrying they had infected someone.

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DISCUSSION We found that self-disclosure of HIV status was positively associated with closeness and commitment among low-income urban African-American women with HIV in this study. Women in monogamous/committed relationships self-disclosed their HIV status to their partners 79% of the time. Women with a primary partner, a partner defined as someone she ‘saw a lot and has a special emotional commitment to,’ and women who were monogamous had a similar rate of self-disclosure (74%). Women who had primary partner(s) and additional non-primary partners, were much less likely to disclose to all their partners (43%). None of the 13 women with multiple non-primary partners disclosed their HIV status to all of their partner(s). Three women with one non-primary partner also did not disclose to their partners. This result suggests that emotional closeness may foster self-disclosure. Most women with more than one primary partner had all primaries (12 out of the 14). The disclosure rate to all their primaries for the women with multiple primaries was significantly lower than the disclosure rates to primary(s) for those with only one primary. As the women were asked about sexual-romantic activity in a 6-month timeframe, we do not know whether the primary partners were sequential partners with whom they had short duration relationships, or whether they were simultaneous relationships. A non-exclusive emotional commitment may indicate less of an emotional commitment, which might in turn provide less of an emotional impetus for disclosing. Multiple short-term relationships in a limited time period may be due to emotional commitment issues building up in the relationships, leading to break-ups. The women who had multiple partners and who were not emotionally committed to any of them may be women who have difficulty in forming emotional attachments. An inability to form emotional attachments can be due to an underlying mental health disorder, such as attachment disorders and post-traumatic stress disorder (PTSD). Attachment disorders occur at a much higher rate among those with HIV than in the general population (Riggs, Vosvick, & Stallings, 2007). Attachment disorders are caused by a child not developing a secure emotional attachment to the mother or other primary caregiver during the first few years of life (Bowlby, 1969, 1973, 1988). Child abuse and neglect interfere with the emotional bond between mother and child and cause attachment disorders. The feelings of insecurity towards the mother can lead to general fears of abandonment and to keeping an emotional distance from romantic-sexual partners later in life and lack of satisfaction in romantic relationships (Ben-Ari & Lavee, 2005; Creasey, 2002). Attachment disorders have also been found to be associated with high-risk sexual behavior among those with HIV (Ciesla et al., 2004) and in the general population (Ahrens, Ciechanowski, & Katon, 2012; Kershaw et al., 2007). There were a significant number of women with multiple partners in this study and this high-risk behavior is associated with attachment disorders (Ciesla et al., 2004).

Post-traumatic stress disorder (PTSD) may also be the underlying cause of the high-risk behavior found among HIV-positive women who are not emotionally committed in their romantic relationships. PTSD causes both relationship difficulties (Lassri & Shahar, 2012) and high-risk behavior (Cavanaugh, Hansen, & Sullivan, 2010; Machtinger, Wilson, Haberer, & Weiss, 2012). PTSD has been found to occur at a much higher rate among women with HIV than in the general population (Machtinger et al., 2012). A high rate of childhood abuse has been found among women with HIV. Childhood abuse is associated with unsafe sex both among women (Sikkema, Hansen, Meade, Kochman, & Fox, 2009; Simoni & Ng, 2000) and among men (Welles et al., 2009). Furthermore, childhood abuse can result in PTSD lasting into adulthood. PTSD may be a mediator between childhood abuse and unsafe sex (Machtinger et al., 2012). There are other psychosocial factors, such as fear of violence, lack of power in relationships, depression, and poverty, which have been found to be risk factors for unsafe sex in other populations, which we did not study. These factors may also be risk factors for unsafe sex for women living with HIV. The rate of both knowing and self-disclosing HIV status was similar for women who were monogamous and emotionally committed to their partner. This finding suggests that for monogamous-emotionally committed partners, there is mutual disclosure of HIV status. Mutual disclosure of personal information is part of the intimacy of an emotionally committed relationship (Eustace & Ilagan, 2010). Disclosure of having HIV may be a highly personal disclosure occurring as part of the intimacy of the relationship. A previous study of women with HIV found that self-disclosure of HIV occurs more often when the woman and her partner jointly disclose their HIV status (Latka et al., 2006). A qualitative study explored the context of women’s self-disclosure of HIV to their partners (Sowell et al., 2003). The word ‘trust’ was specifically used by 30 women to describe their feeling that led to self-disclosure. Others selfdisclosed because of close feelings. For example, a woman was quoted as saying: ‘cause me and him live together and I don’t want to keep it from him.’ Another woman said: ‘I decided who was most important, and who I love, and who love me.’ Selfdisclosure has also been found to be positively associated with emotionally close relationships among gay men (Laurenceau, Barrett, & Pietromonaco, 1998; Sullivan, 2005). Mutual disclosure of personal information is an integral part of a healthy intimate relationship (Moss & Schwebel, 1993). The sharing of personal feelings helps strengthen the emotional bond as well as naturally occurring when there are close feelings (Laurenceau et al., 1998; Sullivan, 2005). Thus, disclosure of HIV status may be made possible because of emotional closeness and commitment to the relationship. In turn, mutual-disclosing has the potential to further strengthen the relationship. Disclosure of HIV can also provide positive benefits to the person disclosing. Some partners provide emotional and

RISK AND PROTECTIVE FACTORS FOR HIV SELF-DISCLOSURE

tangible support in living with HIV when the HIV-positive person discloses their HIV status (Zea, Reisen, Poppen, Bianchi, & Echeverry, 2005). However, there are also risks in disclosing HIV status. Some partners end the relationship or become angry or violent when they find out that their partner is HIV-positive (Klitzman et al., 2004; Parsons et al., 2004; Simoni et al., 1995). Disclosure has however, been found to be related to better psychological outcomes (Vance, 2006; Zea et al., 2005) and utilization of medical services among those with HIV (Stirratt et al., 2006; Wohl et al., 2011). For non-monogamous women, the woman disclosing her HIV status was often not part of mutual disclosing. The rate of the partners not disclosing was approximately double the rate of the woman not disclosing. However, some of these partners may have HIV. They may be unaware of the danger of re-infection with HIV or acquiring other sexually transmitted infections, and have unprotected sex (DiClemente et al., 2005; Stoner et al., 2003). The results of this study suggest why some women disclose their HIV status and know the HIV status of their casual partners. The finding that, ‘It is my role as a person living with HIV to discuss with HIV-negative people how important it is to stay uninfected’ was associated with disclosure to all partners after controlling for relationship status. A feeling of personal responsibility can lead to self-disclosure to nonprimary partners, as it does not depend on intimacy between partners. Other studies have also found an association between disclosure and men’s (Serovich & Mosack, 2003) and women’s (Simoni et al., 1995) feelings of responsibility to talk about HIV. An inverse relationship was found for women who could put upsetting thoughts out of their mind and both partners knowing each other’s HIV statuses. A positive association between these factors might be expected based on self-efficacy theory. Selfefficacy for dealing with upsetting feelings is a main domain of self-efficacy. However, it could be that these women also put out of their mind the risk of re-infection to themselves or their partner’s risk of contracting HIV if they had unprotected sex. Gore-Felton & Koopman (2002) describe the women’s denial of the risk of infection as an ‘active avoiding of thinking about the connection between their behavior and risk.’ This ‘avoidant coping’ is a coping style that can develop when the person is overwhelmed with life and/or has PTSD (not uncommon among those with HIV). Vosvick et al. (2002) discusses the use of avoidant coping among those with HIV. He discusses mental disengagement (e.g., ‘I’ve been turning to work or other activities to take my mind off things’) and behavioral disengagement (e.g., ‘I’ve been giving up trying to deal with it’) and denial (e.g., ‘I’ve been saying to myself: ‘this isn’t real’). The real drawback of avoidant coping is that this style ‘reduce[s] immediate stress at a high cost to later quality of life’ (Carver, Scheier, & Weintraub, 1989). Of note is that, while both knowing was associated with ‘being able to put upsetting thoughts out of my head,’ self-disclosure was not. A man who does not

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disclose his HIV status to his partner even though she disclosed it to him would be expected to raise her concerns as to what other information he might not be sharing and she might decide not to engage in sexual activity. A woman who could ‘put upsetting thoughts out of her head’ might proceed with sexual relations and not think about the possible dangers to which she is exposing herself. Most aspects of self-efficacy studied were not found to be associated with risky behavior. This may because the self-efficacy questions were not specific enough (Table 1). For example, the question on self-efficacy for social support from friends did not distinguish between friends that were also sex partners and friends where there was no sexual relationship. If the woman depended on the sex partner for social support, she might be less likely to self-disclose so as not to risk jeopardizing the relationship. The attitude of a non-sexual friend toward safe sex would also be a factor. If the friend was supportive of safe sex, this would be expected to support her in practicing safe sex but if the friend did not practice safe sex, this could encourage unsafe sex. Research on self-efficacy as a construct has also suggested that it may be more meaningful to define self-efficacy in terms of carrying out a specific task or activity, rather than in terms of broader self-efficacy abilities (Semple, Patterson, & Grant, 2000). The question related to a specific activity of using a condom, ‘believing condoms are effective in preventing HIV transmission,’ was associated with knowing each other’s HIV status in our study. Although this question about condoms asked about condom effectiveness unrelated to the skill of the person using it, the responses to this question were statistically correlated with the responses to the self-efficacy question for condoms (whether the respondent felt that she knew how to use condoms). This association suggests that the respondents may have interpreted the question in terms of their own self-efficacy in using a condom, and that confidence about using a condom and their efficacy may support women’s self-disclosure. The question of risking infecting someone in the past 6 months was associated only with romantic-sexual relationship status. This question was asked of sexually inactive women as well as sexually active women. The rate of risking infecting someone was greater than the rate of non-disclosure. This suggests that either un-safe sex was practiced though the woman had disclosed or that she did not feel self-efficacious in her safe-sex practice, such as in using a condom. The women with the lowest rate of risking infecting her partner were those who were sexually active/monogamous/fully committed and those who were single/abstinent. The highest rate of risking infecting someone, was those with multiple partners. Approximately half of the women who had multiple partners worried they had infected someone in the past 6 months. Although the rate of HIV disclosure was the same for those who were monogamous/committed and those who were monogamous with a primary, the latter more often worried they had infected someone. This suggests that the women with the

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lesser commitment, although they disclosed, had unprotected sex. Approximately 40% of abstinent/monogamous/committed women worried that they had infected their partner, even though transmission is unlikely. One explanation could be the ‘past 6 months’ timeframe of the question. Women might have been sexually active with their partner prior to 6 months ago or may misunderstand how HIV is transmitted and the HIV window period. This finding underscores the importance of addressing HIV transmission and safe sex with all women with HIV. Methodological Weaknesses The respondents were asked to reveal behaviors and beliefs that are not considered socially acceptable, which may result in some non-disclosure. This source of bias was minimized by the use of ACASI, so that the women could provide this sensitive information anonymously and without anyone present. This study has determined that there are a number of different patterns of sexual behavior among low-income women with HIV. The likelihood of HIV disclosure and risky sexual behavior was found to differ among sub-groups. To more completely identify the factors that predict disclosure by the type of partner (primary or non-primary) in the context of the overall structure of the women romantic-sex life necessitates a larger study. Another issue in classifying women’s relationships is that we could not distinguish short-term monogamous relationships from simultaneous relationships, since questions were asked for a timeframe of 6 months, rather than for each partner. The woman might have had sequential short-term relationships in the interval or she may have had simultaneous partners. A sub-group of women at high risk of transmitting HIV, were the women who had all non-primary partner(s). This sub-group included 18 women. Due to the relatively small number, we could not study the relationship between attitudes and beliefs and self-disclosure and high-risk behavior for this group of women. Larger studies of HIV-positive women who have multiple casual partners are needed. Additionally, each person interprets subjective statements in his/her own unique way. Emotional closeness might mean a very intense emotional bond for one woman, while for another woman, a strong liking. There was a sub-group of women who reported having multiple primary partners. These women apparently have more than one man with whom they are very close and spend a lot of time with. They do not appear to have one person who has unique importance to them. However, the self-disclosure rate of these women was lower than the disclosure rates for women with one primary. This lower disclosure rate raises the question whether they were not as close to their multiple primaries as were the women with just one primary. However, there were only 12 women in our study with multiple primary partners and there were no follow-up questions for these women. Also more in-depth data obtained using semi-structured interviews would be needed to fully capture the emotional quality of intimate relationships.

CONCLUSION We have found that disclosure rates differ among HIVpositive women, depending on the overall structure of the women’s romantic-sexual relationships and her emotional closeness to the particular sex-partner. Different approaches may be needed to promote safe sex depending on the structure of the women’s romantic-sex life. For women who report being monogamous/committed, strengthening their relationship would be expected to help promote self-disclosure and safe sex. Relationship satisfaction has been found to be associated with safer sex among men who have sex with men (MSM) (Davidovich, De Wit, & Strobbe, 2006; Witte, El-Bassel, Gilbert, Wu, & Chang, 2007). Empirical studies of ‘relationship based’ interventions for women in relationships with men have shown promise in decreasing high-risk behavior. One such intervention (El-Bassel et al., 2003) was assessed using a randomized controlled trial (RCT) and was found to have a positive effect. The intervention emphasized intimacy, closeness, monogamy, and trust, and also educated participants about how to prevent gender roles and expectations to become a barrier to safer sex. Addressing underlying attachment issues may also augment the effectiveness of interventions, as attachment style has been found to be associated with relationship quality and closeness (Ben-Ari & Lavee, 2005; Creasey, 2002). Relationship-based interventions may also be useful for the non-monogamous women with one primary partner. As these women have one partner they view as ‘primary,’ they may be interested in strengthening their relationship or making their relationship monogamous, which would lead to less risk with this partner and prevent transmission to other partners (Previti & Amato, 2004). There also may be some women whose characteristic relationship structure is one primary partner and additional non-primary partners who would also benefit from relationship interventions. Among MSM, relationship satisfaction and commitment has been found to be associated with safer sex in men who have ‘steady’ partners with and without monogamy (Davidovich et al., 2006). Similarly, having sexual agreements and communication with their primary partner regarding reducing risk in relation to sex with casual partners has been found to be associated with safer sex (Horvath, Oakes, & Rosser, 2008). Progress has been made in developing interventions to increase safe sex for committed non-monogamous men (Wilton et al., 2009). Interventions such as these may also be options for African-American low-income women with HIV. Most interventions for safe sex for heterosexual men and MSM address the ethical responsibility of a person with HIV not to infect others with HIV. We found that women who believed it was the HIV-positive person’s responsibility to talk to HIV-negative people about not getting infected were more likely to be in a relationship in which she and her partner knew each other’s HIV status. This supports that promoting sexual responsibility is also an important component of an intervention for safe sex for HIV-positive heterosexual women. Our other

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finding that the denial of the risks of infection was associated with unprotected sex suggests that denial of risk of infection would also need to be addressed by the intervention. Support groups may be important for promoting safe sex among low-income African-American women with HIV. A significant proportion of these women have multiple partners and there may not be a strong enough emotional commitment to a partner for a relationship-based intervention to be effective. Also, there were women who were not currently sexually active but who could become sexually active. A support group is a natural setting for developing skills for safe sex for women who do not have an emotional commitment to a partner and those who are not currently sexually active. Support groups could also be useful for women who are in relationships with power imbalance. The support group could provide support for women to assert themselves with their partners in practicing safe sex (Kalichman, DiMarco, Austin, Luke, & DiFonzo, 2003; Teti et al., 2007). Social support has been found to be associated with self-disclosure (Kalichman et al., 2003) and safe sex (Kennedy, 2010). The support group could provide social support for women who do not have social support from the people in their lives. The P&R group intervention, in which the women in this study participated, was a group-based intervention with social support among group members, as its foundation was found to be effective in fostering safe-sex (Teti et al., 2007). The supportive environment of the group enabled the woman to discuss the sensitive issues arising in being in intimate relationships while living with HIV. The group facilitator collaborated with the women in developing an understanding of the importance of practicing safe sex, as well as helping the women develop the skills needed to practice safe sex. The facilitator also facilitated the group process so that the group was supportive, accepting, and respectful. The group members served as a social network with the shared belief of the importance of safe sex and who reinforced each other’s motivation to practice safe sex. The women in the group also provided emotional support when a woman’s partner withdrew his affection or became angry when she tried to adhere to safe sex. A high percentage of women with multiple partners worried they had infected someone in the past 6 months. The opportunity to obtain relief from worrying about infecting others might provide motivation for these women to participate in an intervention. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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African-American women with HIV are among the fastest growing populations with HIV. The psychosocial factors and beliefs/attitudes associated with dis...
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