Disclosure to sexual partner and condom use among HIV positive clients attending ART clinic at a tertiary health facility in South West Nigeria

Introduction Condom use and disclosure of HIV status increase the safety of sexual activity. Its extent will determine the need for appropriate interventions. The objective of this study was to identify determinants of condom use and disclosure to sexual partners among individuals receiving Antiretroviral Therapy at a tertiary health facility in South West Nigeria. Methods A cross-sectional study of 578 clients enrolled in the ART program of Federal Medical Centre Owo, Ondo State Nigeria, was conducted. Results The mean age of respondents was 38.6+9.6 years, more than half (66.6%) were females and 7% were currently married. Three-quarter were sexually active out of which 324(75.9%) used condom consistently and correctly and 323(75.6%) disclosed their status to their sexual partner. Use of condom was by 81% of those with tertiary education (p=0.002), and 84.5% of singles utilized condom (p<0.001). Determinant of condom use wwere, male (OR: 2; CI: 1.1- 3.3; p=0.013), secondary and tertiary education (OR: 3.69; CI: 1.48 - 9.19; p=0.005) and (OR: 4.79; CI: 1.84 - 12.44; p=0.001) respectively. Determinant of disclosure was being married (OR: 11.8; CI- 5.5-25.7; p<0.001). No significant association exist between disclosure and condom use. Conclusion Most of the people living with HIV accessing ART were sexually active. A good proportion of them used condom consistently and correctly. Disclosure did not have significant effect on condom use. More health education intervention to increase disclosure rate and safe sexual behaviour among HIV positive clients is needed.


Introduction
Human immunodeficiency virus infection (HIV) and acquired immunodeficiency syndrome (AIDS) epidemic has become a serious developmental and health problem in many countries around the world [1]. Globally, an estimated 35.3 (32.2-38.8) million people were living with HIV in 2012 [2]. HIV/AIDS is ravaging sub-Saharan Africa, with greater than 60% of all HIV infections in the world occurring in this Region [3]. AIDS continues to be the leading cause of death in Africa, the prevalence in Nigeria is 4.6% and studies have shown that condoms are highly effective in preventing transmission when used correctly and consistently [4,5]. HIV and AIDS is to a large extent a crisis of sexual behaviour, as unsafe sex is responsible for majority of HIV infection in the sub-Saharan Africa [5].
HIV counselling and testing programmes emphasis is placed on the importance of HIV status disclosure among HIV-infected clients, particularly to their sexual partners. Disclosure may motivate sexual partners to seek testing, change behaviour and ultimately decrease transmission of HIV. In addition, other health behaviours that may improve the outcome of care of HIV positive clients are facilitated [6].
Morbidity and mortality rates among HIV infected patients have decreased as a result of the introduction of antiretroviral therapy (ART), more people with HIV live longer and healthier lives [7].
Condom use by sero-concordant couples may be necessary not only to prevent pregnancy and STIs but also HIV drug-resistant and super-infection [8]. Therefore, the non-use of condom by seroconcordant couples encourages the spread of resistant strains of the virus and occurrence of super-infection, and the non-disclosure of status usually has a psychosocial effects on clients [9].
To further reduce the transmission of HIV/AIDS infection and for positive clients to live a healthier and more productive lives, news on disclosure and condom use should be spread widely. Increasing the level of disclosure of HIV status and decreasing risky sexual activities will not be effective if its extent is not known. This study aimed at assessing the magnitude of disclosure to sexual partners and condom use among HIV positive client and the effect of disclosure on condom use among clients attending ART clinic, FMC

The Study Area
The study was conducted in Federal Medical Centre, Owo. It is located in the Owo Local Government Area of Ondo state in South West Nigeria, at the intersection of roads from Akure, kabba and Benin City. The hospital provides healthcare services at the primary, secondary and tertiary levels to the people within its catchment areas which are Ondo, Kogi, Edo, Ekiti and Osun States and its surrounding states. It also receives patients from almost all the states of the Federation because it is situated a stone throw from the highway that links Abuja to Lagos. It is also an approved training centre by both the West African Postgraduate College and the National Postgraduate College to train Resident Doctors in some specialist area of Medicine. Presently the centre has 21 clinical and 7 non-clinical departments [10]. It is a 250 bed tertiary health centre with average monthly attendance, by all age groups, at the outpatient department put at about 4,980 and the bed occupancy of not less than 70% at every point in time. The staff strength of the hospital is above 1000 [10].

Study Instrument
The study was carried out in the ART clinic of FMC, Owo. A descriptive cross sectional design was used. In all, 578 consenting adults on HAART who attended the clinic over 3 months were recruited. Appropriate sample size was calculated using the Leslie Kish formula. Data was analysed with SPSS version 21.0.
Association between categorical variables were explored with Chi square test and determinants of disclosure to sexual partners and condom use were identified using logistic regression analysis at 5 % level of significance.
Data quality was maintained through careful design of study tool.
We used semi-structured interviewer administered questionnaire.

Ethical Consideration
Ethical clearance was obtained from Health Research Ethics Committee of FMC Owo. Informed consent was obtained from respondents after the objective of the study was explained to them.
Each respondent was given information on the benefit of the study and that she/he could participate voluntarily and had the right to withdraw at any time without any negative effect.

Results
The mean age of respondents was 38.6±9.6 years. Out of the 578 respondents 193(33.4%) were males and about half were married 339 (58.6%); 175(30.3%) of the respondents had tertiary education. The socio-demographic characteristic of the participants are as shown in Table 1.  Other association between socio-demographic characteristics and disclosure of HIV status to sexual partner is as shown in Table 3.
Significantly, the odds of male respondents to have used condom is two times compared to female (OR: 2 (CI-1.1-3.3) p=0.013).
Consistent and correct Condom use rate was higher in respondents who had formal education especially tertiary and secondary education (OR: 3.69 (CI-1.48 -9.19)) and (OR: 4.79(CI-1.84 -12.44)) respectively than those without formal education. The number of current sexual partner(s) did not significantly affect condom use. Table 4 shows the predictors of condom use among respondents.  higher prevalence of condom use among males [11,12]. One of the reasons for this may be due to the stigma of promiscuity attached to females suggesting the use of condom [13]. Inability of females to guarantee condom use if their partners did not wish to use it has Page number not for citation purposes 4 been reported to be a reason for low condom use among females [12]. This study did not ascertain whether or not female condoms were readily available.

Discussion
Condom use was significantly higher in singles than the married respondents. This is commendable since consistent and correct use of condom has been widely recommended as a public health strategy against sexually transmitted infections, including heterosexual transmission of HIV infection [14]. This finding is in contrast to the study done in Osun State, Nigeria which shows a higher prevalence among married respondents [15]. Desire for children could have prevented the married from using condom [16,17]. The belief that witchcraft plays a role in HIV transmission has been shown to be related to less positive attitudes about condoms, less belief in condom effectiveness for HIV prevention, and lower intention to use condom among men [18]. Condom use in this study was higher in respondents who had formal education especially tertiary and secondary. Their awareness and knowledge about condom could have contributed to this as reported in another Nigerian study [11].
Disclosure of HIV status to sexual partner was reported by 75% of the respondents. In this study, the odds of married couples disclosing their status was about 12 times compared to singles as seen in most other studies reported in the developing countries [19,20]. Though a study done in Abeokuta shows that low level of disclosure of HIV status may raise the possibility of not practising safer sex [21]. Women who disclosed their status to their partners are more likely to participate in the prevention of Mother to child transmission, hence fulfilling one of the goals of HIV/AIDS prevention as outlined by the Centre for Disease Control and Prevention (CDC) [22,23]. Also studies have shown that disclosure improves adherence to ART treatment [24]. The effect of disclosure of HIV status on condom use in this study was not statistically

Competing interests
The authors declare no competing interest.

Authors' contributions
Ayodeji Matthew Adebayo conceived the study, Olayinka Stephen Ilesanmi was involved in relevant literatures review. All Authors contributed to the discussions section and review of the manuscript.

Acknowledgments
The authors would like to acknowledge Drs D. T. Falana, I. F.
Amenkhienan, and S. O. Olaniyan for their involvement in data collection.