Ethical, Social and Legal Implications of DisclosurePrior to beginning work on this discussion, be sure to read the required articles for this week. .You are a consulting psychologist for a local clin

Ethnic differences in HIV-disclosure and sexual risk Jason D.P. Bird a*, David D. Fingerhut a,b and David J. McKirnan a,b aDepartment of Research, Howard Brown Health Center, Chicago, IL, USA; bDepartment of Pscyhology, University of Illinois at Chicago, Chicago, IL, USA (Received 23 March 2010; final version received 7 July2010) Little is known about ethnic differences in HIV-disclosure to sexual partners or the relationship between HIV- disclosure and sexual risk. Differences in HIV-disclosure rates between African-American and White men who have sex with men (MSM) were analyzed using data from the Treatment Advocacy Program. In general, the findings suggest that African-Americans are less likely than Whites to disclose their HIV status to sexual partners.

The findings also suggest that the African-American participants who disclosed to HIV-negative partners were significantly less likely to engage in unprotected anal sex with HIV-negative partners and partners whose HIV status was unknown than those participants who did not disclosure to HIV-negative partners. Although HIV- disclosure appears to be an important factor to consider in HIV-prevention efforts, there are unique factors that influence HIV-disclosure decisions for African-American MSM. Interventions should consider these unique challenges before focusing on HIV-disclosure as a primary tool for reducing the transmission of HIV. Keywords:HIV/AIDS; HIV prevention; African-Americans; men who have sex with men Background/Significance Racial disparities in new HIV infections have become increasingly pronounced, with African-Americans accounting for over 50% of all newly diagnosed HIV/AIDS cases in 2007 (CDC, 2009). Moreover, African-American men who have sex with men (MSM) are a highly vulnerable subgroup with epidemiological data showing they are twice as likely as White MSM to become infected with HIV (CDC, 2009). In response to these rising infection rates, prevention efforts have shifted toward more routine testing and a greater emphasis on prevention inter- ventions with HIV-positive individuals (CDC, 2009; Crepaz & Marks, 2003; Gorbach et al., 2004; Sullivan, 2005). These intervention shifts will inevi- tably fuel the debate regarding the relationship between HIV-disclosure and sexual risk. Given the racial differences in HIV transmission rates, it is possible that HIV-related behavior, such as HIV status disclosure, will show similar disparities and this study seeks to explicitly examine what racial differences in HIV-disclosure to sexual partners might exist.

Debate continues regarding the cause ofracial disparities in the rates ofHIV infection. Research shows that African-American MSM are not more sexually risky and do not have significantly more sexual partners than their White counterparts (Millett, Flores, Peterson, & Bakeman, 2007; Millett, Peterson, Wolitski, & Stall, 2006). Recent data does suggest,however, that riskier sexual networks may be respon- sible for higher infection rates for African-American MSM (Friedman, Cooper, & Osborne, 2009; Kissinger & Malebranche, 2007). In other words, although African-American MSM do not appear to engage in significantly more unprotected sex, the sexual net- works in which they engage contain more infected individuals. Therefore, when unprotected sex occurs, there is a greater likelihood their partner will be HIV- infected, increasing the probability of HIV exposure and infection (Friedman et al., 2009; Kissinger & Malebranche, 2007).

To complicate matters, despite public health messages that have urged people to treat all casual or anonymous sexual partners as though they are potentially infected with HIV, evidence suggests this does not occur in practice (Klitzman et al., 2007; Simoni & Pantalone, 2004). In fact, research suggests that safer sex decisions, such as using a condom, is influenced by the assessments, or assumptions, an individual makes about their partners’ HIV status and the specific risk inherent in the particular encounter (Golden, Brewer, Kurth, Holmes, & Handsfield, 2004; Klitzman et al., 2007; Simoni & Pantalone, 2004). Consequently, a dependence on condom use as the sole avenue for decreasing HIV- infection rates runs the risk of creating a culture of sexual silence that discounts the important role that both direct and indirect communication, such as HIV- disclosure, play on sexual risk decisions (Klitzman et al., 2007).

*Corresponding author. Email: [email protected] AIDS Care Vol. 23, No. 4, April 2011, 444 448 ISSN 0954-0121 print/ISSN 1360-0451 online #2011 Taylor & Francis DOI: 10.1080/09540121.2010.507757 http://www.informaworld.com Although there is little consensus regarding the connection between HIV-disclosure and sexual risk (Marks & Crepaz, 2001; Simoni & Pantalone, 2004; Sullivan, 2005), there is some research that suggests that HIV-disclosure is associated with decreased sexual risk with HIV-negative partners or partners whose HIV status is unknown (Chen, Gibson, Weide, & McFarland, 2003; Golden et al., 2004; Klitzman et al., 2007; Simoni & Pantalone, 2004). This may be particularly true for HIV-negative men, where data suggest that non-HIV infected MSM are more likely to use a condom with a partner who is known to be HIV-positive (Golden et al., 2004). Likewise, many argue that HIV-disclosure is an important part of sexual negotiation in that it allows all parties to make informed decisions about with whom and how a sexual encounter occurs (Gorbach et al., 2004; Palmer, 2004). Therefore, HIV-disclosure appears to be an important factor to consider and may prove an important avenue through which to alter sexual risk- taking (Klitzman et al., 2007).

Several possible factors may influence rates of HIV-disclosure, including time since diagnosis, age, education, economic status, HIV-related stigma, and race/ethnicity. Research indicates that time since diagnosis is related to the rate ofdisclosure, with the lowest rates occurring for individuals who have had their HIV diagnosis for fewer than three years (Crepaz & Marks, 2003; Klitzman, 1999; Sullivan, 2005). However, as Sullivan (2005) found in a meta- review of17 articles regarding HIV-disclosure pub- lished between 1996 and 2004, age, education, and economic status are generally unrelated to HIV- disclosure.

Researchers have also looked at situational fac- tors to HIV-disclosure such as sexual venue, assumed partner HIV status, and type ofrelationship (i.e., anonymous, casual, or long-term) (Courtenay-Quirk, Wolitski, Parsons, & Gomez, 2006; Gorbach et al., 2004; Klitzman & Bayer, 2003; Klitzman, 1999; Marks & Crepaz, 2001; Simoni & Pantalone, 2004).

Yet, there has been very little research on the role of HIV-related stigma on disclosure, which could be a fundamental barrier to disclosing one’s HIV status (Bird & Voisin, in press). For example, one might choose to not disclose to certain types ofpartners or in certain sexual settings for fear of the potential negative repercussions related to HIV-related stigma.

Whereas research has shown that African-American MSM are less likely to disclose their same-sex sexual behavior than Whites in general (Millett et al., 2006), little is known about whether there are ethnic differences in HIV-disclosure to sexual partners.

Furthermore, there is no research investig- ating the relationship between disclosure and HIVtransmission risk among African-American MSM.

Therefore, this paper describes ethnic differences in HIV-disclosure, sexual risk-taking behavior, and the relationship between HIV-disclosure and sexual risk in a sample ofAfrican-American and White partici- pants.

Methods The data analyzed for this paper were derived from baseline interview data from the Treatment Advocacy Program, a CDC-funded behavioral intervention for 317, ethnically diverse, HIV-positive MSM, con- ducted through Howard Brown Health Center, the University ofIllinois at Chicago, the Chicago De- partment ofPublic Health, and Saint Joseph Hospi- tal. For this analysis, HIV-disclosure was defined as disclosing one’s HIV-positive status to 90% or more oftheir sexual partners, which represents a conserva- tive threshold for identifying patterns of disclosure vs.

non-disclosure. We also used two measures ofsexual behavior, sexual risk, which was defined as any unprotected anal sex regardless ofthe partners’ HIV status, and transmission risk, which was defined as any unprotected anal sex with an HIV-negative partner or a partner whose HIV status was unknown.

Data analyses We conducted two levels ofanalyses in this paper.

First, we examined the sample characteristics for differences across ethnicity. Next, we examined rates ofsexual risk, transmission risk, and HIV-disclosure by ethnicity using a univariate analysis ofvariance (ANOVA). We chose to conduct an ANOVA to control for important factors known or suspected to relate to disclosure. For all ANOVA analyses, we entered age, time since diagnosis, income, and educa- tion as covariates. We also analyzed ethnic differences in HIV-disclosure to sexual partners on three separate levels based on their partners’ known or perceived HIV status, (i.e., HIV-positive, HIV-negative, and HIV-unknown). Finally, we examined the relation- ship between HIV-disclosure and transmission risk.

Results Sample characteristics African-American MSM represented 32% (N 101) and White MSM represented 47% (N 150) ofthe sample of317 HIV-positive participants in the Treatment Advocacy Program (TAP) study. There were no statistically significant differences between the African-American and White participants in ageAIDS Care445 and number ofsexual partners; however, the sample differed on education (earned at least a Bachelor’s degree: [AA vs. White] 19.8% vs. 44.7%,pB0.001), income (annual incomeB$10,000: [AA vs. White] 50% vs. 17.4%,pB0.001), and years since HIV diagnosis ([AA vs. White] 9.5 vs. 7.6,pB0.05).

Sexual risk/Transmission risk Controlling for age, income, education, and time since an HIV diagnosis, we found that African- American participants were significantly less likely than White participants to engage in sexual riskF(1, 238) 4.95,pB0.05. However, we found no differ- ences in HIV-transmission risk by ethnicity; in other words, the African-American and White participants engaged in behavior likely to transmit HIV at similar rates.

Disclosure We analyzed HIV-disclosure for three levels of sexual partners’ serostatus: HIV-positive, HIV-negative and unknown HIV status. For each ANOVA conducted, we entered age, income, education, and time since HIV diagnosis, as covariates. On the whole, African- American participants were significantly less likely to disclose their HIV status to partners compared to White participants as demonstrated in Figure 1.

Specifically, African-American participants were less likely to disclose their status to HIV-positive partners, F(1, 213) 12.51,pB0.001, HIV-negative partners, F(1, 209) 14.88,pB0.001, and partners whose HIV status was unknown,F(1, 212) 5.46,pB0.05.

Disclosure and transmission risk When we analyzed a subsample ofparticipants, again controlling for age, income, education and time since HIV diagnosis, we found that African-American participants who disclosed to 90% or more oftheir HIV-negative sexual partners had significantly lesstransmission risk than the White participants who disclosed to 90% oftheir HIV-negative partners, F(1, 107) 4.87,pB0.05. More importantly, those African-American participants who disclosed to 90% or more oftheir HIV-negative partners reported significantly less transmission risk than those Afri- can-American participants who did not disclose at the 90% level,F(1, 89) 5.57,pB0.05. However, this pattern was not replicated with 90% disclosure to those sexual partners whose HIV status was un- known.

Conclusion/Discussion Overall, HIV-disclosure and sexual risk-taking among the African-American and White participants in this study followed unique patterns. Although the African-American participants were less likely than the White participants to report engaging in sexual risk activities (i.e., unprotected anal sex with a sexual partner), there were no significant differences between the two cohorts in HIV-transmission risk behavior (i.e., unprotected anal sex with a known HIV- negative partner or a partner whose HIV status was unknown). In general, African-American participants were significantly less likely to disclose to their sexual partners regardless oftheir partners’ HIV status. Yet, those African-American participants who did disclose at the 90% level to their HIV-negative sexual partners were significantly less likely to engage in transmission risk than those African-American or White partici- pants who did not disclose to their HIV-negative sexual partners at the 90% level. Therefore, disclo- sure to HIV-negative partners appears to have an important protective relationship to decreasing trans- mission risk.

Ifthe hypothesis is that African-American MSM are engaged in more risky sexual networks (with a greater probability ofencountering an HIV-infected partner), then the fact that the participants reported engaging in less overall sexual risk is unlikely to significantly decrease their exposure to HIV. The fact that there were no significant differences between the African-American and White participants intrans- mission riskbehavior suggests that decreasing overall risk may not be sufficient in decreasing the rate of HIV infection; to significantly impact the transmis- sion ofHIV, it is essential thattransmission riskbe reduced. In this sample, disclosure to HIV-negative partners appears to be one effective tool in accom- plishing this important goal. However, the fact that the African-American participants were significantly less likely to disclose to their HIV-negative partners or those partners whose HIV status was unknown Figure 1. Disclosure to at least 90% ofsexual partners by sero-status.

Note: *pB0.05; **pB0.01.

446J.D.P. Birdet al. complicates the usefulness of disclosure as a preven- tion tool.

Therefore, to effectively leverage HIV-disclosure in prevention interventions, the challenges must be fully understood and addressed. Previous predictors ofdisclosure did not seem to apply to this subset of men. For example, the African-American MSM were more likely to have been diagnosed with HIV for a longer period oftime than the White MSM, a factor that has generally been associated with increased HIV-disclosure. This suggests that disclosure patterns for African-American MSM may be influenced by unique factors that are different than those identified in the general literature. One hypothesis is that African-American MSM experience more HIV- related stigma than White MSM and that this HIV- related stigma serves as a primary and fundamental barrier to disclosure. Goffman (1963) describes stig- ma as an intensely discrediting attribute, general knowledge ofwhich can interfere with an individual’s ability to successfully function within their commu- nity and society. HIV infection, which is often interpreted as a reflection of an individual’s poor moral and deviant character and a signifier of disease and death, can stimulate intense stigmatization. This stigmatization extends into the gay community, where the potential negative consequences ofdisclo- sure can result in social isolation and rejection from friends, community, and sexual networks (Courtenay- Quirk et al., 2006). Ifthis hypothesis is accurate, then it illuminates a fundamental obstacle that must be addressed to understand individuals’ motivations to disclose or not to disclose their HIV status.

One response to HIV-related stigma may be that some participants choose to avoid sexual risk instead ofdisclosing, thereby avoiding the stigma and nega- tive social consequences that might be associated with HIV-disclosure. However, this strategy is not effective ifnot practiced consistently. Furthermore, the data presented here suggest that decreased transmission risk is not related to non-disclosure; therefore, it does not appear that using condoms represents an alter- native strategy to HIV-disclosure.

It is also important to note that, although dis- closure to HIV-negative partners was associated with less transmission risk, disclosure to sexual partners whose HIV status was unknown did not appear to have any significant impact on transmission risk. The data available in this study are not sufficient for explaining why these patterns exist. One possible hypothesis is that an individual may be willing to engage in sexual risk with a partner whose HIV status is unknown once they have disclosed because there is a sense that they have fulfilled their responsibility and that their partner is making an informed decisionabout engaging in risk. However, the fact that they do not know their partner’s HIV status suggests that the communication occurring around HIV is unequal.

This could be problematic ifthe participant is choos- ing to use non-direct strategies to disclose (i.e., hinting about their status or leaving HIV-specific magazines or medications in plain sight), which could potentially lead to a misunderstanding or inaccurate understand- ing about his HIV status. Ultimately, it does not appear that non-mutual HIV-disclosure was sufficient for decreasing transmission risk in this sample.

Overall, the data show that in addition to a conti- nuing need for culturally tailored HIV-prevention interventions that target sexual risk-taking behavior, focusing on issues of HIV-disclosure may be an important avenue for decreasing transmission risk.

However, the data also suggest that interventions specifically targeting disclosure must take into ac- count ethnic differences in disclosure patterns, the unique population-level barriers to disclosure, and the primary goals for targeting disclosure. For ex- ample, focusing on disclosure with African-American MSM may be one avenue for decreasing transmission risk, at least with known HIV-negative partners.

However, it must also be acknowledged that there are unique barriers to HIV-disclosure for African- American MSM that must be explored and under- stood ifthere is an expectation that HIV-disclosure should occur. Focusing on disclosure without regard to these unique challenges could be counterproduc- tive, exacerbating the barriers to disclosure rather than diminishing them.

While these findings highlight important points for future intervention, there were limitations to this study. First, the disclosure data are partner-based rather than incident or episode-based, which could have resulted in underreporting in non-disclosure.

For example, ifan individual did not disclose with one sexual partner until the third sexual encounter, this partner may be classified as someone to whom they disclosed, even though non-disclosure also occurred. Second, we did not collect demographic information about the participants’ sexual partners, such as age or race. Therefore, we are unable to examine whether partner-level characteristics influ- enced disclosure decisions such as concordant race.

Finally, data from the Treatment Advocacy Program cannot fully evaluate the reasons why these risk and disclosure patterns are different between African-American and White participants; however, they highlight the need for greater quantitative and qualitative research regarding these group differences.

It is important to examine issues ofHIV-disclosure and the relationship between disclosure and risk through future studies to more clearly define theAIDS Care447 particular patterns ofsexual risk and HIV-disclosure for African-American MSM. Additionally, a parti- cular focus on the role of HIV-related stigma would increase our understanding ofthe challenges and barriers associated with disclosure. This type of information will be essential to accurately assess the impact ofinterpersonal communication in HIV interventions, safer sex negotiation, and HIV-disclo- sure among groups at high risk for HIV infection.

Acknowledgements This study was funded by the Centers for Disease Control and Prevention ofthe Department ofHealth and Human Services and conducted through Howard Brown Health Center in collaboration with the University ofIllinois Chicago, the Chicago Department ofPublic Health, and the medical clinic ofSlotten, Klein, and French.

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Journal of the Association of Nurses in AIDS Care, 16(6), 33 47. doi:10.1016/j.jana.2005.09.005 448J.D.P. Birdet al. Copyright of AIDS Care is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.