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Optimism, community attachment and serostatus disclosure among HIV-positive men who have sex with men a
a
b
b
Patrick J. Murphy , David Hevey , Siobhán O'Dea , Neans Ní Rathaille & Fiona Mulcahy
b
a
Research Centre for Psychological Health, School of Psychology, Trinity College Dublin, Dublin, Ireland b
The GUIDE Clinic, St. James's Hospital, Dublin, Ireland Published online: 12 Dec 2014.
Click for updates To cite this article: Patrick J. Murphy, David Hevey, Siobhán O'Dea, Neans Ní Rathaille & Fiona Mulcahy (2015) Optimism, community attachment and serostatus disclosure among HIV-positive men who have sex with men, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 27:4, 431-435, DOI: 10.1080/09540121.2014.987105 To link to this article: http://dx.doi.org/10.1080/09540121.2014.987105
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
AIDS Care, 2015 Vol. 27, No. 4, 431–435, http://dx.doi.org/10.1080/09540121.2014.987105
Optimism, community attachment and serostatus disclosure among HIV-positive men who have sex with men Patrick J. Murphya*, David Heveya, Siobhán O’Deab, Neans Ní Rathailleb and Fiona Mulcahyb a
Research Centre for Psychological Health, School of Psychology, Trinity College Dublin, Dublin, Ireland; bThe GUIDE Clinic, St. James’s Hospital, Dublin, Ireland
Downloaded by [Umeå University Library] at 20:46 04 April 2015
(Received 4 June 2014; accepted 10 November 2014) This study investigated the relationship between HIV health optimism (HHO) (the belief that health will remain good after HIV infection due to treatment efficacy), HIV-positive community attachment (HCA), gay community attachment (GCA) and serostatus disclosure to casual sex partners by HIV-positive men who have sex with men (MSM). Cross-sectional questionnaire data were gathered from 97 HIV-positive MSM attending an HIV treatment clinic in Dublin, Ireland. Based on self-reported disclosure to casual partners, participants were classified according to their pattern of disclosure (consistent, inconsistent or non-disclosers). Multinomial logistic regression was used to assess HHO, HCA and GCA as predictors of participants’ pattern of disclosure. Classification as a non-discloser (compared to a consistent discloser) was associated with higher HHO, less HCA and greater GCA. Classification as an inconsistent discloser (compared to a consistent discloser) was associated with higher GCA. The study provided novel quantitative evidence for associations between the constructs of interest. The results suggest that (1) HHO is associated with reduced disclosure, suggesting optimism may preclude individuals reaping the benefits of serostatus disclosure and (2) HCA and GCA represent competing attachments with conflicting effects on disclosure behaviour. Limitations and areas for future research are discussed. Keywords: community attachment; disclosure; health optimism; HIV; men who have sex with men
Disclosure of HIV seropositivity can be challenging, often associated with negative consequences (Block, 2009). However, increased disclosure is associated with benefits including improved treatment adherence and transmission reduction (Gilliam & Straub, 2009; Klitzman et al., 2004). This research examines two factors – community attachment and HIV-related optimism – that may influence disclosure. It focuses on disclosure to sex partners by seropositive men who have sex with men (MSM), as sex between men is the dominant mode of HIV transmission across much of the world (UNAIDS, 2013). Identity theory predicts that as community attachment increases, disclosure of the identity upon which that attachment is predicated also increases (Stryker & Burke, 2000). HIV community attachment (HCA) is associated with increased disclosure (Baumgartner & David, 2009). However, HCA cannot be considered without reference to gay community attachment (GCA), as HIV-positive MSM are more likely to be attached to a gay community than HIVnegative MSM (Zablotska, Holt, & Prestage, 2012). HIV is heavily stigmatised within gay communities, inhibiting disclosure (Smit et al., 2012). Therefore, HCA and GCA may represent conflicting attachments, with conflicting effects on disclosure, but this possibility remains unexplored. Exposure to HIV-related optimism prevalent in both types of community can additionally impact on disclosure. HIV-related optimism is the “favorable feelings about *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
the multiple outcomes from the use of HIV treatments” (Peterson, Miner, Brennan, & Simon Rosser, 2012, p. 92). Prestage et al. (2012) differentiated between HIV health optimism (HHO), the belief that one will remain healthy due to treatment efficacy, and HIV transmission optimism (HTO), the belief that HIV is more difficult to transmit due to treatment efficacy. Few studies have examined the relationship between HIV-related optimism and disclosure of serostatus, and none have differentiated between HHO and HTO. Both forms of optimism may reduce the perceived relevance of HIV infection in sexual contexts; consequently both HHO and HTO may have an inverse relationship with disclosure of serostatus, but investigation is required (Gorbach et al., 2004; Simon Rosser et al., 2008). Based on the previous evidence, the following hypotheses were tested: H1: Greater HCA will be associated with greater levels of disclosure. H2: Greater GCA will be associated with lower levels of disclosure. H3: Greater HHO will be associated with lower levels of disclosure. H4: Greater HTO will be associated with lower levels of disclosure.
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P.J. Murphy et al.
Method Design Cross-sectional data were gathered from a convenience sample of HIV-positive MSM attending the largest HIV clinic in Dublin, Ireland, between February and June 2013. Ethical approval was obtained from the relevant IRBs.
Results Sample
Eligibility criteria were: a minimum age of 18 years, HIV seropositivity, self-identification as MSM and at least one casual sex encounter in the 6 months prior to participation. Patients at the clinic were approached by the first author, the study was explained and an information sheet presented. Those wishing to participate provided consent, and questionnaires were completed in the clinic. A debriefing sheet was provided, and psychological supports were available if required.
Of the 299 patients approached, 151 were ineligible, 42 declined participation and 5 recent diagnoses were not included to avoid distress. Of the 101 who agreed to participate, 4 withdrew, leaving 97 participants. The median number of partners disclosed to was 1.0 (IQR = 0.0–2.0), the median number not disclosed to was 2.0 (IQR = 1.0–4.0), and the median number of total partners was 3.5 (IQR = 2.0–6.0). Twenty-two (22.7%) were classified as consistent disclosers, 40 (41.2%) as inconsistent disclosers and 33 (34.0%) as non-disclosers. There were no significant differences in sample characteristics across disclosure classifications (Table 1).
Measures
Descriptive statistics
Characteristics assessed were age, place of birth, number of years living in Ireland, urban versus rural residence, education level, employment status, relationship status, time since diagnosis, medication status and viral load. Participants specified the number of casual partners disclosed to in the last 6 months, and the number not disclosed to. Participants were classified as non-disclosers (never disclosed), inconsistent disclosers (sometimes disclosed) or consistent disclosers (always disclosed; Parsons et al., 2005). GCA was measured using 3 items adapted from Fergus, Lewis, Darbes, and Kral (2009), measuring the amount of time spent with gay men and at organisations that support gay men, and the proportion of friends who are gay men. Internal consistency for the current sample was good (α = .73). HCA was measured with an equivalent set of 3 items, specific to HIV; internal consistency was also good (α = .71). HHO was measured using Prestage et al.’s (2012) 3-item scale. Internal consistency was acceptable (α = .66) and the mean inter-item correlation fell within the recommended ranges (r = .41; Briggs & Cheek, 1986). HTO was measured using Prestage et al.’s (2012) 4-item scale. However, internal consistency for the current sample was poor (α = .55), and the mean inter-item correlation (r = .25) was lower than recommended (Briggs & Cheek, 1986). Consequently, descriptive statistics for HTO are reported, but it was not included in further analyses.
Table 2 shows descriptive statistics for each measure. GCA was more strongly endorsed than HCA, indicating a greater degree of community attachment with other MSM rather than other HIV-positive people. HHO scores were similar to those previously reported for HIV-positive MSM, while those on the HTO scale were markedly lower (Prestage et al., 2012).
Participants
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(IQRs) are reported. Multinomial logistic regression (MLR) assessed predictors of disclosure pattern. An alpha level of .05 (two-tailed) was used.
Analysis Data were analysed with SPSS 21. As data were nonnormally distributed, medians and interquartile ranges
Multivariate analysis MLR assessed predictors (HHO, GCA, HCA, age and total number of partners) of disclosure classification (Table 3). Due to missing data the sample was 84 participants, sufficient to meet the minimum recommended ratio of participants to predictors (Hosmer, Lemeshow, & Sturdivant, 2013). The model explained a significant amount of variability [χ2(10, 84) = 30.02, p < .05]. Pearson and deviance statistics were both nonsignificant, indicating the model was a good fit to the data. Pseudo-R2 values were relatively high (Cox and Snell: .30; Nagelkerke: .34), and the model resulted in a 51.2% accuracy classification (a 44.6% improvement over the proportional by-chance accuracy rate of 35.4%). Only GCA and total number of partners contributed significantly to the likelihood of being classified as an inconsistent discloser rather than a consistent discloser. As GCA increased, and as the total number of partners increased, the likelihood that a participant would be classified as an inconsistent discloser increased. All predictors contributed significantly to the likelihood of being classified as a non-discloser rather than a consistent discloser. As HHO, GCA, age and the total
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Table 1. Characteristics of the sample, broken down by pattern of disclosure. Non-disclosers (N = 33)
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N (%) Age Place of birth Ireland Europe Other Years living in Irelanda Urban or rural residence Urban Rural Education completed Primary Secondary Third level Employment status Full-time employment Full-time education Part-time employment Other Relationship status Single In a relationship Years since diagnosis Medication status On ART No medication Viral load Detectable Undetectable
Inconsistent disclosers (N = 40)
Median (IQR)
N (%)
41.0 (32.0–45.0) 19 (57.6) 9 (27.3) 5 (15.2)
Median (IQR)
Consistent disclosers (N = 22) N (%)
34.0 (29.0–42.0) 30 (75.0) 6 (15.0) 4 (10.0)
6.5 (2.5–12.8)
32.0 (29.5–41.5) 16 (72.7) 2 (9.1) 4 (18.2)
8.0 (3.0–16.5)
3.0 (1.8–7.0)
25 (75.8) 8 (24.2)
36 (90.0) 4 (10.0)
16 (72.7) 6 (27.3)
1 (3.0) 5 (15.2) 27 (81.8)
2 (5.0) 8 (20.0) 30 (75.0)
0 (0.0) 6 (27.3) 16 (72.7)
24 1 5 3
22 3 7 8
12 2 1 7
(72.7) (3.0) (15.2) (9.1)
23 (69.7) 10 (30.3)
(55.0) (7.5) (17.5) (20.0)
28 (70.0) 12 (30.0) 4.0 (1.7–8.5)
Median (IQR)
(54.5) (9.1) (4.5) (31.8)
15 (68.2) 7 (31.8) 5.0 (2.4–7.6)
4.3 (2.1–7.9)
25 (75.8) 8 (24.2)
35 (87.5) 5 (12.5)
16 (72.7) 6 (27.3)
10 (30.3) 23 (69.7)
13 (32.5) 27 (67.5)
7 (31.8) 15 (68.2)
a
Participants born outside of Ireland only. Note: Differences between groups were tested for all variables. No significant differences were found.
number of partners increased, the likelihood that a participant would be classified as a non-discloser increased. As HCA increased, the likelihood of classification as a non-discloser decreased. Table 2. Descriptive statistics for the study variables. Range Measure/item HIV Health Optimism (HHO) HIV Transmission Optimism (HTO) Gay Community Attachment (GCA) HIV Community Attachment (HCA) IQR, Interquartile range.
Median
IQR
Potential
Observed
6.0
5.0–7.0
0–9
1–9
4.0
2.0–5.0
0–12
0–8
6.0
5.0–7.0
3–12
3–9
5.0
3.0–6.0
3–12
3–7
Discussion As hypothesised (H3), HHO differentiated between consistent disclosers and non-disclosers, with participants reporting greater HHO being more likely to be classified as non-disclosers. This result supports the proposed inverse relationship between HHO and disclosure (Gorbach et al., 2004). Also as hypothesised (H1), participants reporting lower HCA were more likely to be classified as non-disclosers. This finding aligns with studies that linked HCA with greater serostatus disclosure (Baumgartner & David, 2009). Neither HHO nor HCA differentiated between consistent and inconsistent disclosers. Disclosure is the result of a combination of individual differences and situational cues (Omarzu, 2000), and situational cues may result in inconsistent disclosure of HIV, for example, perceived serodiscordance greatly decreases the likelihood of disclosure occurring (Klitzman et al., 2007). The second hypothesis (H2) was supported. GCA differentiated between both consistent disclosers and
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Table 3.
Multinomial logistic regression predicting disclosure pattern.
Disclosure pattern Inconsistent disclosers
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Non-disclosers
Variable
b
SE
Wald
Intercept HHO GCA HCA Age # Partners Intercept HHO GCA HCA Age # Partners
−6.93 .34 .59* −.51 .09 .34* −9.15 .54* .62* −.84* .18* .32*
2.96 .21 .29 .33 .05 .15 3.12 .23 .31 .35 .05 .16
5.48 2.73 4.04 2.43 3.77 5.02 8.57 5.58 4.05 5.75 9.06 4.25
Odds ratio
OR 95%, CI
1.41 1.82 .60 1.10 1.41
.94, 1.02, .32, .99, 1.04,
2.12 3.24 1.14 1.22 1.89
1.72 1.85 .43 1.17 1.38
1.09, 1.02, .22, 1.06, 1.02,
2.71 3.38 .86 1.29 1.88
*p < .05, two-tailed. Note: Reference category is consistent disclosers. HHO, HIV health optimism; GCA, gay community attachment; HCA, HIV community attachment; # Partners, number of partners in past 6 months.
inconsistent disclosers, and consistent disclosers and non-disclosers, with participants reporting greater GCA being more likely to be classified as inconsistent disclosers and non-disclosers. This result supports research suggesting GCA, through increased stigma awareness, inhibits disclosure (Smit et al., 2012).
Future research and limitations HIV-related optimism may be formed through exposure to discourses circulating in communities to which individuals are attached (Prestage et al., 2012). However, HIV-related optimism may have reciprocal effects on community attachment, for example by lessening the need to affiliate with an HIV-positive community in order to garner social support (Baumgartner & David, 2009). Research should investigate how these variables interact in producing disclosure behaviour, as well as investigating other variables that influence how HHO, HCA and GCA produce disclosure outcomes. Replication of the results is warranted, both to accumulate evidence for the relationship between the examined constructs and to develop measures with strong psychometric properties. In particular, future studies should use other measures of HTO to better understand its relationship with disclosure. Previous research suggests that HIV-related optimism and community attachment predict disclosure behaviour (Baumgartner & David, 2009), but the cross-sectional design precluded causal determinations and longitudinal studies are recommended. Generalisability of the results is limited by participant self-selection, and recruitment of a relatively small number of participants from a single site.
Conclusion This study provides novel evidence for the association between disclosure and HHO, and for the association between disclosure and HIV-positive and GCA. Acknowledgement The authors would like to thank all the staff and patients at the GUIDE Clinic at St. James’s Hospital, Dublin, and the Society for the Study of Sexually Transmitted Diseases in Ireland.
Disclosure statement No potential conflict of interest was reported by the authors.
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AIDS Care of HIV disclosure among HIV-positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle. Sexually Transmitted Infections, 80, 512–517. doi:10.1136/sti.2004.010918 Hosmer, Jr., D. W., Lemeshow, S., & Sturdivant, R. X. (2013). Applied logistic regression. Hoboken, NJ: Wiley. Klitzman, R., Exner, T., Correale, J., Kirshenbaum, S. B., Remien, R., Ehrhardt, A. A., … Charlebois, E. (2007). It’s not just what you say: Relationships of HIV dislosure and risk reduction among MSM in the post-HAART era. AIDS Care, 19(6), 749–756. doi:10.1080/09540120600983971 Klitzman, R. L., Kirshenbaum, S. B., Dodge, B., Remien, R. H., Ehrhardt, A. A., Johnson, M. O., … The Nimh Healthy Living Trial Group. (2004). Intricacies and interrelationships between HIV disclosure and HAART: A qualitative study. AIDS Care, 16, 628–640. doi:10.1080/ 09540120410001716423 Omarzu, J. (2000). A disclosure decision model: Determining how and when individuals will self-disclose. Personality and Social Psychology Review, 4, 174–185. doi:10.1207/ S15327957PSPR0402_05 Parsons, J. T., Schrimshaw, E. W., Bimbi, D. S., Wolitski, R. J., Gómez, C. A., & Halkitis, P. N. (2005). Consistent, inconsistent, and non-disclosure to casual sexual partners among HIV-seropositive gay and bisexual men. AIDS, 19 (Suppl. 1), S87–S97. doi:10.1097/01.aids.0000167355. 87041.63 Peterson, J. L., Miner, M. H., Brennan, D. J., & Simon Rosser, B. R. (2012). HIV treatment optimism and sexual risk
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behaviors among HIV positive African American men who have sex with men. AIDS Education and Prevention, 24(2), 91–101. doi:10.1521/aeap.2012.24.2.91 Prestage, G., Down, I. A., Bradley, J., McCann, P. D., Brown, G., Jin, F., & Hurley, M. (2012). Is optimism enough? Gay men’s beliefs about HIV and their perspectives on risk and pleasure. Sexually Transmitted Diseases, 39, 167–172. doi:10.1097/OLQ.0b013e31823e67a9 Simon Rosser, B. R., Horvath, K. J., Hatfield, L. A., Peterson, J. L., Jacoby, S., & Stately, A. (2008). Predictors of HIV disclosure to secondary partners and sexual risk behavior among a high-risk sample of HIV-positive MSM: Results from six epicenters in the US. AIDS Care, 20, 925–930. doi:10.1080/09540120701767265 Smit, P. J., Brady, M., Carter, M., Fernandes, R., Lamore, L., Meulbroek, M., … Thompson, M. (2012). HIV-related stigma within communities of gay men: A literature review. AIDS Care, 24, 405–412. Stryker, S., & Burke, P. J. (2000). The past, present, and future of an identity theory. Social Psychology Quarterly, 63, 284–297. doi:10.2307/2695840 UNAIDS. (2013). Global report: UNAIDS report on the global AIDS epidemic 2013. Retrieved from http://www.unaids. org/en/media/unaids/contentassets/documents/epidemiology/ 2013/gr2013/UNAIDS_Global_Report_2013_en.pdf Zablotska, I. B., Holt, M., & Prestage, G. (2012). Changes in gay men’s participation in gay community life: Implications for HIV surveillance and research. AIDS and Behavior, 16, 669–675. doi:10.1007/s10461-011-9919-9
AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Optimism, community attachment and serostatus disclosure among HIV-positive men who have sex with men a
a
b
b
Patrick J. Murphy , David Hevey , Siobhán O'Dea , Neans Ní Rathaille & Fiona Mulcahy
b
a
Research Centre for Psychological Health, School of Psychology, Trinity College Dublin, Dublin, Ireland b
The GUIDE Clinic, St. James's Hospital, Dublin, Ireland Published online: 12 Dec 2014.
Click for updates To cite this article: Patrick J. Murphy, David Hevey, Siobhán O'Dea, Neans Ní Rathaille & Fiona Mulcahy (2015) Optimism, community attachment and serostatus disclosure among HIV-positive men who have sex with men, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 27:4, 431-435, DOI: 10.1080/09540121.2014.987105 To link to this article: http://dx.doi.org/10.1080/09540121.2014.987105
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
AIDS Care, 2015 Vol. 27, No. 4, 431–435, http://dx.doi.org/10.1080/09540121.2014.987105
Optimism, community attachment and serostatus disclosure among HIV-positive men who have sex with men Patrick J. Murphya*, David Heveya, Siobhán O’Deab, Neans Ní Rathailleb and Fiona Mulcahyb a
Research Centre for Psychological Health, School of Psychology, Trinity College Dublin, Dublin, Ireland; bThe GUIDE Clinic, St. James’s Hospital, Dublin, Ireland
Downloaded by [Umeå University Library] at 20:46 04 April 2015
(Received 4 June 2014; accepted 10 November 2014) This study investigated the relationship between HIV health optimism (HHO) (the belief that health will remain good after HIV infection due to treatment efficacy), HIV-positive community attachment (HCA), gay community attachment (GCA) and serostatus disclosure to casual sex partners by HIV-positive men who have sex with men (MSM). Cross-sectional questionnaire data were gathered from 97 HIV-positive MSM attending an HIV treatment clinic in Dublin, Ireland. Based on self-reported disclosure to casual partners, participants were classified according to their pattern of disclosure (consistent, inconsistent or non-disclosers). Multinomial logistic regression was used to assess HHO, HCA and GCA as predictors of participants’ pattern of disclosure. Classification as a non-discloser (compared to a consistent discloser) was associated with higher HHO, less HCA and greater GCA. Classification as an inconsistent discloser (compared to a consistent discloser) was associated with higher GCA. The study provided novel quantitative evidence for associations between the constructs of interest. The results suggest that (1) HHO is associated with reduced disclosure, suggesting optimism may preclude individuals reaping the benefits of serostatus disclosure and (2) HCA and GCA represent competing attachments with conflicting effects on disclosure behaviour. Limitations and areas for future research are discussed. Keywords: community attachment; disclosure; health optimism; HIV; men who have sex with men
Disclosure of HIV seropositivity can be challenging, often associated with negative consequences (Block, 2009). However, increased disclosure is associated with benefits including improved treatment adherence and transmission reduction (Gilliam & Straub, 2009; Klitzman et al., 2004). This research examines two factors – community attachment and HIV-related optimism – that may influence disclosure. It focuses on disclosure to sex partners by seropositive men who have sex with men (MSM), as sex between men is the dominant mode of HIV transmission across much of the world (UNAIDS, 2013). Identity theory predicts that as community attachment increases, disclosure of the identity upon which that attachment is predicated also increases (Stryker & Burke, 2000). HIV community attachment (HCA) is associated with increased disclosure (Baumgartner & David, 2009). However, HCA cannot be considered without reference to gay community attachment (GCA), as HIV-positive MSM are more likely to be attached to a gay community than HIVnegative MSM (Zablotska, Holt, & Prestage, 2012). HIV is heavily stigmatised within gay communities, inhibiting disclosure (Smit et al., 2012). Therefore, HCA and GCA may represent conflicting attachments, with conflicting effects on disclosure, but this possibility remains unexplored. Exposure to HIV-related optimism prevalent in both types of community can additionally impact on disclosure. HIV-related optimism is the “favorable feelings about *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
the multiple outcomes from the use of HIV treatments” (Peterson, Miner, Brennan, & Simon Rosser, 2012, p. 92). Prestage et al. (2012) differentiated between HIV health optimism (HHO), the belief that one will remain healthy due to treatment efficacy, and HIV transmission optimism (HTO), the belief that HIV is more difficult to transmit due to treatment efficacy. Few studies have examined the relationship between HIV-related optimism and disclosure of serostatus, and none have differentiated between HHO and HTO. Both forms of optimism may reduce the perceived relevance of HIV infection in sexual contexts; consequently both HHO and HTO may have an inverse relationship with disclosure of serostatus, but investigation is required (Gorbach et al., 2004; Simon Rosser et al., 2008). Based on the previous evidence, the following hypotheses were tested: H1: Greater HCA will be associated with greater levels of disclosure. H2: Greater GCA will be associated with lower levels of disclosure. H3: Greater HHO will be associated with lower levels of disclosure. H4: Greater HTO will be associated with lower levels of disclosure.
432
P.J. Murphy et al.
Method Design Cross-sectional data were gathered from a convenience sample of HIV-positive MSM attending the largest HIV clinic in Dublin, Ireland, between February and June 2013. Ethical approval was obtained from the relevant IRBs.
Results Sample
Eligibility criteria were: a minimum age of 18 years, HIV seropositivity, self-identification as MSM and at least one casual sex encounter in the 6 months prior to participation. Patients at the clinic were approached by the first author, the study was explained and an information sheet presented. Those wishing to participate provided consent, and questionnaires were completed in the clinic. A debriefing sheet was provided, and psychological supports were available if required.
Of the 299 patients approached, 151 were ineligible, 42 declined participation and 5 recent diagnoses were not included to avoid distress. Of the 101 who agreed to participate, 4 withdrew, leaving 97 participants. The median number of partners disclosed to was 1.0 (IQR = 0.0–2.0), the median number not disclosed to was 2.0 (IQR = 1.0–4.0), and the median number of total partners was 3.5 (IQR = 2.0–6.0). Twenty-two (22.7%) were classified as consistent disclosers, 40 (41.2%) as inconsistent disclosers and 33 (34.0%) as non-disclosers. There were no significant differences in sample characteristics across disclosure classifications (Table 1).
Measures
Descriptive statistics
Characteristics assessed were age, place of birth, number of years living in Ireland, urban versus rural residence, education level, employment status, relationship status, time since diagnosis, medication status and viral load. Participants specified the number of casual partners disclosed to in the last 6 months, and the number not disclosed to. Participants were classified as non-disclosers (never disclosed), inconsistent disclosers (sometimes disclosed) or consistent disclosers (always disclosed; Parsons et al., 2005). GCA was measured using 3 items adapted from Fergus, Lewis, Darbes, and Kral (2009), measuring the amount of time spent with gay men and at organisations that support gay men, and the proportion of friends who are gay men. Internal consistency for the current sample was good (α = .73). HCA was measured with an equivalent set of 3 items, specific to HIV; internal consistency was also good (α = .71). HHO was measured using Prestage et al.’s (2012) 3-item scale. Internal consistency was acceptable (α = .66) and the mean inter-item correlation fell within the recommended ranges (r = .41; Briggs & Cheek, 1986). HTO was measured using Prestage et al.’s (2012) 4-item scale. However, internal consistency for the current sample was poor (α = .55), and the mean inter-item correlation (r = .25) was lower than recommended (Briggs & Cheek, 1986). Consequently, descriptive statistics for HTO are reported, but it was not included in further analyses.
Table 2 shows descriptive statistics for each measure. GCA was more strongly endorsed than HCA, indicating a greater degree of community attachment with other MSM rather than other HIV-positive people. HHO scores were similar to those previously reported for HIV-positive MSM, while those on the HTO scale were markedly lower (Prestage et al., 2012).
Participants
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(IQRs) are reported. Multinomial logistic regression (MLR) assessed predictors of disclosure pattern. An alpha level of .05 (two-tailed) was used.
Analysis Data were analysed with SPSS 21. As data were nonnormally distributed, medians and interquartile ranges
Multivariate analysis MLR assessed predictors (HHO, GCA, HCA, age and total number of partners) of disclosure classification (Table 3). Due to missing data the sample was 84 participants, sufficient to meet the minimum recommended ratio of participants to predictors (Hosmer, Lemeshow, & Sturdivant, 2013). The model explained a significant amount of variability [χ2(10, 84) = 30.02, p < .05]. Pearson and deviance statistics were both nonsignificant, indicating the model was a good fit to the data. Pseudo-R2 values were relatively high (Cox and Snell: .30; Nagelkerke: .34), and the model resulted in a 51.2% accuracy classification (a 44.6% improvement over the proportional by-chance accuracy rate of 35.4%). Only GCA and total number of partners contributed significantly to the likelihood of being classified as an inconsistent discloser rather than a consistent discloser. As GCA increased, and as the total number of partners increased, the likelihood that a participant would be classified as an inconsistent discloser increased. All predictors contributed significantly to the likelihood of being classified as a non-discloser rather than a consistent discloser. As HHO, GCA, age and the total
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Table 1. Characteristics of the sample, broken down by pattern of disclosure. Non-disclosers (N = 33)
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N (%) Age Place of birth Ireland Europe Other Years living in Irelanda Urban or rural residence Urban Rural Education completed Primary Secondary Third level Employment status Full-time employment Full-time education Part-time employment Other Relationship status Single In a relationship Years since diagnosis Medication status On ART No medication Viral load Detectable Undetectable
Inconsistent disclosers (N = 40)
Median (IQR)
N (%)
41.0 (32.0–45.0) 19 (57.6) 9 (27.3) 5 (15.2)
Median (IQR)
Consistent disclosers (N = 22) N (%)
34.0 (29.0–42.0) 30 (75.0) 6 (15.0) 4 (10.0)
6.5 (2.5–12.8)
32.0 (29.5–41.5) 16 (72.7) 2 (9.1) 4 (18.2)
8.0 (3.0–16.5)
3.0 (1.8–7.0)
25 (75.8) 8 (24.2)
36 (90.0) 4 (10.0)
16 (72.7) 6 (27.3)
1 (3.0) 5 (15.2) 27 (81.8)
2 (5.0) 8 (20.0) 30 (75.0)
0 (0.0) 6 (27.3) 16 (72.7)
24 1 5 3
22 3 7 8
12 2 1 7
(72.7) (3.0) (15.2) (9.1)
23 (69.7) 10 (30.3)
(55.0) (7.5) (17.5) (20.0)
28 (70.0) 12 (30.0) 4.0 (1.7–8.5)
Median (IQR)
(54.5) (9.1) (4.5) (31.8)
15 (68.2) 7 (31.8) 5.0 (2.4–7.6)
4.3 (2.1–7.9)
25 (75.8) 8 (24.2)
35 (87.5) 5 (12.5)
16 (72.7) 6 (27.3)
10 (30.3) 23 (69.7)
13 (32.5) 27 (67.5)
7 (31.8) 15 (68.2)
a
Participants born outside of Ireland only. Note: Differences between groups were tested for all variables. No significant differences were found.
number of partners increased, the likelihood that a participant would be classified as a non-discloser increased. As HCA increased, the likelihood of classification as a non-discloser decreased. Table 2. Descriptive statistics for the study variables. Range Measure/item HIV Health Optimism (HHO) HIV Transmission Optimism (HTO) Gay Community Attachment (GCA) HIV Community Attachment (HCA) IQR, Interquartile range.
Median
IQR
Potential
Observed
6.0
5.0–7.0
0–9
1–9
4.0
2.0–5.0
0–12
0–8
6.0
5.0–7.0
3–12
3–9
5.0
3.0–6.0
3–12
3–7
Discussion As hypothesised (H3), HHO differentiated between consistent disclosers and non-disclosers, with participants reporting greater HHO being more likely to be classified as non-disclosers. This result supports the proposed inverse relationship between HHO and disclosure (Gorbach et al., 2004). Also as hypothesised (H1), participants reporting lower HCA were more likely to be classified as non-disclosers. This finding aligns with studies that linked HCA with greater serostatus disclosure (Baumgartner & David, 2009). Neither HHO nor HCA differentiated between consistent and inconsistent disclosers. Disclosure is the result of a combination of individual differences and situational cues (Omarzu, 2000), and situational cues may result in inconsistent disclosure of HIV, for example, perceived serodiscordance greatly decreases the likelihood of disclosure occurring (Klitzman et al., 2007). The second hypothesis (H2) was supported. GCA differentiated between both consistent disclosers and
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Table 3.
Multinomial logistic regression predicting disclosure pattern.
Disclosure pattern Inconsistent disclosers
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Non-disclosers
Variable
b
SE
Wald
Intercept HHO GCA HCA Age # Partners Intercept HHO GCA HCA Age # Partners
−6.93 .34 .59* −.51 .09 .34* −9.15 .54* .62* −.84* .18* .32*
2.96 .21 .29 .33 .05 .15 3.12 .23 .31 .35 .05 .16
5.48 2.73 4.04 2.43 3.77 5.02 8.57 5.58 4.05 5.75 9.06 4.25
Odds ratio
OR 95%, CI
1.41 1.82 .60 1.10 1.41
.94, 1.02, .32, .99, 1.04,
2.12 3.24 1.14 1.22 1.89
1.72 1.85 .43 1.17 1.38
1.09, 1.02, .22, 1.06, 1.02,
2.71 3.38 .86 1.29 1.88
*p < .05, two-tailed. Note: Reference category is consistent disclosers. HHO, HIV health optimism; GCA, gay community attachment; HCA, HIV community attachment; # Partners, number of partners in past 6 months.
inconsistent disclosers, and consistent disclosers and non-disclosers, with participants reporting greater GCA being more likely to be classified as inconsistent disclosers and non-disclosers. This result supports research suggesting GCA, through increased stigma awareness, inhibits disclosure (Smit et al., 2012).
Future research and limitations HIV-related optimism may be formed through exposure to discourses circulating in communities to which individuals are attached (Prestage et al., 2012). However, HIV-related optimism may have reciprocal effects on community attachment, for example by lessening the need to affiliate with an HIV-positive community in order to garner social support (Baumgartner & David, 2009). Research should investigate how these variables interact in producing disclosure behaviour, as well as investigating other variables that influence how HHO, HCA and GCA produce disclosure outcomes. Replication of the results is warranted, both to accumulate evidence for the relationship between the examined constructs and to develop measures with strong psychometric properties. In particular, future studies should use other measures of HTO to better understand its relationship with disclosure. Previous research suggests that HIV-related optimism and community attachment predict disclosure behaviour (Baumgartner & David, 2009), but the cross-sectional design precluded causal determinations and longitudinal studies are recommended. Generalisability of the results is limited by participant self-selection, and recruitment of a relatively small number of participants from a single site.
Conclusion This study provides novel evidence for the association between disclosure and HHO, and for the association between disclosure and HIV-positive and GCA. Acknowledgement The authors would like to thank all the staff and patients at the GUIDE Clinic at St. James’s Hospital, Dublin, and the Society for the Study of Sexually Transmitted Diseases in Ireland.
Disclosure statement No potential conflict of interest was reported by the authors.
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