Deepak AsudaniI,1; John CorserII; Ruchita S. PatelIII
IResident Physician, Department of Medicine and HIV Medicine, New York Medical College/Metropolitan Hospital Center, 1918 First Avenue, Mail Box 245, New York, NY 10029, USA
IIChief, Division of HIV Medicine, New York Medical College/Metropolitan Hospital Center, New York, NY, USA
IIIResident Physician, Department of Internal Medicine, New York Medical College/Metropolitan Hospital Center, New York, NY, USA
Editor Medley et al. (1) observed that the negative outcomes of HIV serostatus disclosure were far less than anticipated and infrequently led to divorce or separation. While it is true that this may have been because of the reasons they cited that only those women who have confidence in their relationships choose to disclose or that the risk of a negative outcome was exaggerated the serostatus of the male partner is an important aspect that was not discussed. Male partners who knew of their own seropositivity, and did not disclose their serostatus, would probably have been the most receptive to their partner's disclosure. Even those male partners who considered themselves to be at a high risk of acquiring HIV infection, or later tested positive, might have been receptive and supportive. This is particularly important in settings where the prevalence of HIV infection is high. Treatment of the HIV-positive mother, and prevention of mother-to-child transmission (MTCT) of HIV infection is viewed as a joint responsibility.
Awareness of HIV transmission and social configuration has immense importance in determining HIV serostatus disclosure (2). Perhaps the most important determinant of a woman's willingness to disclose her serostatus is her awareness of HIV transmission and HIV prevalence in the community. As observed by Medley et al. in their analysis of 17 studies from peer-reviewed journals, the negative outcomes were fewer than initially feared. On the contrary, it is heartening to observe that in long run, disclosure turned out to offer positive outcomes in most instances. Certainly, disclosure of HIV serostatus has helped partner participation in the treatment and has had positive implications in the prevention of MTCT. However, a woman may find herself vulnerable to family disputes, social embarrassment, violence and exile. Although the negative outcomes were fewer than expected, they were substantial and should not be overlooked.
It is important to analyse the four-pronged approach to prevent HIV infection in mothers and their infants, as advocated by WHO. Reduction of HIV transmission to potential mothers is essential. However, such an approach should not be restricted only to "sexual partners". Partners sharing needles are also at risk of acquiring HIV and later contributing to MTCT. Reduction of unwanted pregnancies among HIV-infected women and girls warrants education and, if necessary, the provision of safe termination of pregnancies. Use of antiretroviral agents should be maximized, in view of the effectiveness in the prevention of MTCT.
The reluctance of patients to disclose their serostatus is common in view of anticipated negative outcomes. This initial reluctance is expected but can be overcome by emphasizing the long-term benefit of preventing MTCT. In our practice, we have often observed that repeated counselling allows most patients to decide in favour of disclosing their serostatus. As health-care professionals, we think that it is important to reinforce, educate and facilitate this disclosure.
Overall, we appreciate the input given of Medley et al. and their valuable analysis of both the importance of disclosing HIV serostatus and the repercussions. We agree that, in most instances, the difficulty lies in breaking the ice and taking the initiative.
Conflicts of interest: none declared.
1. Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother- to-child transmission programmes. Bulletin of World Health Organization 2004;82:299-307.
2. Sigxaxhe T, Matthews C. Determinants of disclosure by HIV positive women at Khayelitsha mother-to-child transmission pilot project. In: XIII International AIDS Conference, 9-14 July 2000, Durban, South Africa; 2000. p. 209.
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