Disclosure of HIV seropositivity to sexual partner and psychosocial factors in Ethiopia: Systematic review and meta-analysis

Background : The burden of HIV/AIDS again becomes a public health problem after substantial control of its transmission in Ethiopia. For effective HIV transmission control measures, sero-disclosure to sexual partner is indispensable. Once the infection is established, psychosocial factors would have a great influence on HIV disclosure status to sexual partners which is very important to control viral transmission. This review aimed to estimate the national proportion of HIV disclosure practice to sexual partner and identify associated psychosocial factors. Methods : We searched PubMed, Scopus, African Journals Online, and Google Scholar databases. The Newcastle Ottawa quality assessment scale was used to assess the quality of studies. To ensure the absence or presence of publication bias, we used a funnel plot and performed Egger’s regression test for the subjective and objective assessment, respectively. Variation across studies was assessed using the I 2 statistic. The pooled proportion was estimated by using weighted inverse variance random-effects model meta-analysis. We did subgroup and sensitivity analysis to explore the reason for heterogeneity and the impact of outlier finding on the overall estimation, respectively. Trend analysis was also performed to see the presence of time variation. Results : The proportion of HIV sero-disclosure practice to sexual partners was 76.03 % (95% Confidence Interval (CI): 68.78, 83.27). Being on ART (AOR=6.19; 95% CI: 2.92, 9.49), cohabiting with partner (AOR=4.48; 95% CI: 1.24, 7.72), getting counseling (AOR=3.94; 95% CI: 2.08, 5.80), had discussion prior to HIV testing (AOR= 4.40; 95% CI: 2.11, 6.69), awareness of partner’s HIV status (AOR= 6.08; 95%CI: 3.05, 9.10),smooth relationship with partner (AOR=4.44; 95% CI:1.28, 7.61), and being member of anti-HIV association (AOR=3.70; 95% CI: 2.20, 5.20) facilitates HIV status disclosure.


Conclusions:
In Ethiopia, still more than one-fourth of HIV-infected adults did not disclose their HIV positivity status to sexual partners. Psychosocial factors were the contributing factors of HIV-positive status disclosure. Further work is still needed to increase HIV status disclosure so as to decrease the transmission rate of HIV in Ethiopia.

Background
Sustainable development goal aims to minimize the incidence of Acquired Immunodeficiency Virus Syndrome (AIDS) infection from 2015 baseline data (1). Human Immunodeficiency Virus (HIV) is the global burden disease with major occurrences in sub-Sahara African countries. By 2018, globally, nearly 37.9 million people were living with HIV/AIDS. Of these, 25.7 million were in sub-Sahara African nations (2). In Ethiopia, an estimated 722,248 people were living with HIV by the year 2017 (3).
Universal HIV tests, safe sexual intercourse, one-to-one relationship, and initiation of antiretroviral therapy (ART) help to prevent and control the epidemic transmission of HIV (4)(5)(6). In addition to screening for HIV infection, HIV status disclosure to their sexual partner is also a central strategy to further control the transmission of HIV to the second or third person (7). Partners disclosed their HIV status were more likely to adhere to ART, improve retention in care, and viral-load suppression (8,9). HIV status disclosure is also important to get social and psychological support from their families/partners though negative outcomes sometimes happen following disclosure due to stressful responses towards their status (10).
Psychosocial intervention and all the components therein could influence perception and psychological processes at the individual level. The psychological process influences the disclosure status of HIV infected individuals through direct psychobiological processes or modified behaviors and lifestyles (11). Psychosocial factors are identified as risky behaviors of patients with HIV/AIDS including not disclosing HIV status to sexual partner (12). Thus, the involvement of psychosocial aspects such as being employed, living in the same house with sexual partner, social supports, and counseling could improve selfesteem and confidence, perception to have emotional support, social integration, mental well-being, aspects of the social environment with a positive connotation, and not fearing negative outcomes of disclosure (13). As a result, HIV infected person takes the initiative to disclose their HIV status to their sexual partner. Besides, having ever seen a person who publicly discloses HIV status and getting financial and nutrition aid further avoids the fear of stigma and discrimination, thereby improving HIV disclosure (14)(15)(16). On the other hand, fear of resentment from the parent, fear of stigma, lack of employment, social exclusion, perceive that negative public opinion, fear of losing relationships or getting divorce, unaware of spouse/sexual partner's HIV status were some of the negatively associated factors (17).
It is thought that disclosure as an unremitting social and psychological process of sharing critical health and personal information with others (18). However, regardless of many supportive interventions, only 58.7% of HIV seropositive pregnant women disclose to their sexual partners in South Africa (19). Similarly, 50.9% of Nigerian people who were living with HIV disclose HIV status to their sexual partner (20); 50.5% of seropositive adults in HIV support groups in Kenya (21), and 66% of HIV-positive women attending care and treatment clinics in Tanzania (22) were disclosed their HIV status to their sexual partners.
Studies have shown that HIV status disclosure is important in HIV prevention. Although several individual studies have reported the proportion of HIV status disclosure to sexual partners in Ethiopia, to our knowledge, they could not be used as national representative data. Therefore, this systematic review and meta-analysis aimed to estimate the proportion of HIV disclosure practice to sexual partner and identify associated psychosocial factors in Ethiopia.

Reporting
The protocol's is registration number in the PROSPERO database is CRD42020149092. This review is reported by using the Preferred Reporting Items for Systematic Review and Meta-analysis guideline (23

Inclusion criteria
The articles included in this review were: 1) primary studies that are done through observational approach because no interventional studies were available during the

Quality assessment
The articles were systematically appraised by using the Newcastle Ottawa quality assessment tool (24). We assessed the representativeness of the sample to the target population, adequacy of sample size, acceptability of response rate, reliability and validity of the tool, handling mechanism of confounding factors, outcome assessment mechanism, and appropriateness of statistical test. The third reviewer was involved to solve when discrepancies between two reviewers occur.

Data extraction
Two of the authors independently extracted data using Microsoft Excel (version, 2010).
The first author, year of publication, study setting, study design, study participants, sample size, reported proportion, adjusted odds ratio (AOR), and source of the fund were extracted. Natural logarithm (LN), standard error, and uncertainty interval of proportion and AOR were also calculated by using Microsoft Excel worksheet for further analysis.

Data analysis
Extracted data exported to STATA version 14 for Windows (Stata Corp, 4905 Lake way Drive, College Station, Texas 77845 USA) statistical software for analysis. To ensure the absence of publication bias, we run a funnel plot for subjective and Egger's regression test for objective measurement (25). Variation across the studies was assessed using I 2 statistic when 25%, 50% and 75% representing low, moderate and high heterogeneity, respectively (26). A weighted inverse variance random-effects model meta-analysis was run to estimate the pooled proportion (27). We did subgroup and sensitivity analyses to explore the reason for heterogeneity and the impact of outlier findings on the overall estimation, respectively.

Subgroup analysis
Based on the subgroup analysis, 75.70% of women and 76.16% of men who were infected with HIV disclosed their HIV positive status to their sexual partners ( Figure 4).

Sensitivity analysis
The sensitivity analysis showed that no study leaves have a significant impact on the overall estimation (Table 2).

Trend analysis
Considering the year of publication, the trend graph was generated. The trend line shows HIV status disclosure through time ( Figure 5).

Socio-demographic characteristics
According to a single study report (34), those study participants below the age of 39 years were less likely (AOR=0.014; 95% CI= 0.005, 0.037) to disclose their HIV status to sexual partner than above 39 years old. Another study (35)  As one study has shown, live in urban (AOR = 1.62; 95% CI=1.0, 2.60) (31) was in support of HIV disclosure practice.
One study (36)  The pooled effect from two studies (28,44) showed that being on ART was positively associated with HIV status disclosure (Table 3).

Psychosocial-related factors
Having open discussion on safer sex with partner (44) Table 3.  In the other view, lack of governmental insurance for once infected with HIV infection for different incentives such as provide government employment, favors in housing, education opportunities, and other benefits for the partner may responsible for decrement or low disclosure rate in Ethiopia.
Based on this review, being on ART were more likely to disclose HIV status to sexual partner. This finding is supported by evidence in Uganda (16). The possible explanation might be ART initiation by itself pass a step in convincing the patient to live with HIV as a healthy individual. Moreover, through the process of taking ART, knowledge, and attitude about HIV prevention and treatment mechanism has increased and they disclose their status to sexual partner easily as a result.
HIV infection affects the physical, psychological, social, and spiritual aspects of HIVinfected people and their parents (53). These lead to psychosocial issues that support disclosure experiences through stabilizing psychological well-being because thinking to disclose once own HIV-positive status has raise psychosocial conflict and psychosocial problems, like HIV-related stigma, anxiety, depression, insomnia, suicidal thoughts, and substance use disorder. Thus, cohabiting with a partner, had a smooth relationship with the partner, getting counseling, had discussion prior to HIV testing with a partner, knowing partner's HIV status, and being a member of ant-HIV association were considered psychosocial related-factors of HIV-positive status disclosure practice. All these variables would help in enhancing problem-solving skills, lifestyle changes, helping the patient to identify choices, evaluate the value and consequences of choices, linking the patient to spiritual and psychological support, and providing a solution-focused counseling approach, support the wellness of the entire family, encourage peer contact and support, discourage use of drugs and alcohols, and increase their meaning in life.
In this meta-analysis we found that individuals cohabiting with a partner were more likely to disclose HIV status to sexual partners. Living together usually involves sexual activities and concerns about the risk of HIV transmission. It also increases a sense of well-being and helps to develop empathy between couples. Moreover, this might be due to the relationship is more trusting and feel get social support intrinsically (54).
Relationship quality with a partner might act as either a risk or a resilience factor in the HIV status disclosure process (55). Similarly, this review found those who had smooth relationships with partner were more likely to disclose HIV status to sexual partner. This might be due to the fact that the probability of sharing a secret is high among those in good relationship with the partner. Fear of stigma, violence, and separation would be less if the relationship is smooth and thus HIV partner disclosure could be high. This evidence is supported by a study conducted in China, where disclosing HIV status to partners was significantly related to a better quality of relationships with partners and open and effective family communication (56).
Counseling is important to determine the presence of risky behavior, facilitate the expression of their concerns and worries, make the patient understand the risks of nondisclosure, bring change in behavior, and prevent and reduce psychological morbidity (57). Besides, receiving counseling about HIV test to have psychological preparation, relieve stress and anxiety, and forecast the benefit of disclosure. Deal with painful emotional issues, express thoughts, emotions, and behaviors, feel good about themselves, learn to function comfortably, act, change, adapt and/or achieve specified desired results (58). Besides, it improves ability to accept HIV positive results, increased knowledge about the HIV disease process, medication, and reduce fear to expose their HIV status.
Having received alternative information from health professionals assists them to develop self-confidence and self-esteem. Even, they could prepare themselves how they solve the challenges following disclosure to the sexual partner. Therefore, those who received counseling could develop positive behavior towards their HIV infection and disclose their status to a partner. Similarly, this review revealed that HIV-infected people had got counseling were more likely to disclosed HIV status to sexual partners. A study from Uganda also found the same attributes (16).
Anti-HIV association is a group of people who share common beliefs and value that supports HIV disclosure practice. The current meta-analysis revealed that those HIVpositive people being part of anti-HIV association were more likely to disclose HIV positive status to sexual partner. Being part of HIV-related association helps to reduce negative myths and misinformation about HIV. It allows getting emotional, aid, structural, and functional support (59). It encourages better relationships between people and building a stronger sense of self and community. Being an anti-HIV association member allows being members of a peer support system that help to mutually give and receive help from one

Strength And Limitation
To the best of our knowledge, this is the first review done to pool the national experiences and identified comprehensive determinants.
As to the limitation, though all the studies are done in Ethiopia, followed similar study design, similar measurement tool, and subgroup analysis is done, statistical heterogeneity value found to be high. In some instances, I-square is not the absolute measure of heterogeneity; this heterogeneity might be due to the command we used ("Metan" command was applied). Due to the nature of the cross-sectional study, the associated factors might not have a cause-effect relationship as it does in interventional or follow-up study.

Conclusions
In Ethiopia, still more than one-fourth of HIV-infected adults did not disclose their HIV positivity status to sexual partners. Being on ART, cohabiting with a partner, had a smooth relationship with a partner, getting counseling, had a discussion prior to HIV testing, knowing partner's HIV status, being a member of an ant-HIV association, and being on ART were supporting factors of HIV-positive status disclosure. Behavioral change to disclose once seropositivity to sexual partner is highly needed to further decrease the transmission rate of HIV in Ethiopia which would be the focus on health and education sectors in the country.

Declarations
Ethical approval and consent to participate: Not applicable Consent to publication: Not applicable Availability of data and materials: All the required data are included in the manuscript.    Subgroup analysis based on the study participant included in the original study