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Partner Disclosure and Early CD4 Response among HIV-Infected Adults Initiating Antiretroviral Treatment in Nairobi Kenya

  • T. Tony Trinh ,

    Affiliations Department of Global Health, University of Washington, Seattle, Washington, United States of America, Department of Epidemiology, University of Washington, Seattle, Washington, United States of America, Department of Medicine, University of Washington, Seattle, Washington, United States of America

  • Nelly Yatich,

    Affiliation Coptic Hospital, Nairobi, Kenya

  • Richard Ngomoa,

    Affiliation Coptic Hospital, Nairobi, Kenya

  • Christine J. McGrath,

    Affiliation Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, United States of America

  • Barbra A. Richardson,

    Affiliation Department of Biostatistics, University of Washington, Seattle, Washington, United States of America

  • Samah R. Sakr,

    Affiliation Coptic Hospital, Nairobi, Kenya

  • Agnes Langat,

    Affiliation US Center for Disease Control and Prevention, Nairobi, Kenya

  • Grace C. John-Stewart,

    Affiliations Department of Global Health, University of Washington, Seattle, Washington, United States of America, Department of Epidemiology, University of Washington, Seattle, Washington, United States of America, Department of Medicine, University of Washington, Seattle, Washington, United States of America, Department of Pediatrics University of Washington, Seattle, Washington, United States of America

  • Michael H. Chung

    Affiliations Department of Global Health, University of Washington, Seattle, Washington, United States of America, Department of Epidemiology, University of Washington, Seattle, Washington, United States of America, Department of Medicine, University of Washington, Seattle, Washington, United States of America

Partner Disclosure and Early CD4 Response among HIV-Infected Adults Initiating Antiretroviral Treatment in Nairobi Kenya

  • T. Tony Trinh, 
  • Nelly Yatich, 
  • Richard Ngomoa, 
  • Christine J. McGrath, 
  • Barbra A. Richardson, 
  • Samah R. Sakr, 
  • Agnes Langat, 
  • Grace C. John-Stewart, 
  • Michael H. Chung



Disclosure of HIV serostatus can have significant benefits for people living with HIV/AIDS. However, there is limited data on whether partner disclosure influences ART treatment response.


We conducted a retrospective cohort study of newly diagnosed, ART-naïve HIV-infected adults (>18 years) who enrolled at the Coptic Hope Center in Nairobi, Kenya between January 1st 2009 and July 1st 2011 and initiated ART within 3 months. Analysis was restricted to adults who reported to have either disclosed or not disclosed their HIV status to their partner. Analysis of CD4 response at 6 and 12 months post-ART was stratified by age group.


Among 615 adults newly initiating ART with partner disclosure data and 12 month follow-up, mean age was 38 years and 52% were male; 76% reported that they had disclosed their HIV-status to their partner. Those who disclosed were significantly younger and more likely to be married/cohabitating than non-disclosers. At baseline, median CD4 counts were similar between disclosure groups. Among younger adults (< 38 years) those who disclosed had higher CD4 recovery than those who did not at 6 months post- ART (mean difference = 31, 95% CI 3 to 58 p = 0.03) but not at 12 months (mean difference = 17, 95% CI -19 to 52, p = 0.4). Among older adults (≥ 38years) there was no observed difference in CD4 recovery at 6 or 12 months between disclosure groups.


Among younger adults, disclosure of HIV status to partners may be associated with CD4 recovery following ART.


Disclosure of HIV serostatus can have significant benefits for people living with HIV/AIDS. Disclosure has been associated with reduced anxiety, decreased rates of depression, and an increased sense of acceptance and strengthened relationships [13]. In the era of antiretroviral therapy (ART), disclosure has been linked to increase ART use [4], retention in care [5], and uptake of services such as prevention of mother-to-child transmission [67]. Disclosure to sexual partners has the added benefit of allowing informed choices that lead to risk behavior reduction to prevent HIV transmission [810]. In sub-Saharan Africa where approximately two-thirds of HIV incidence occurs in steady partnerships [11], disclosure remains an important priority in HIV testing and counseling programs.

HIV-infected persons who disclose their status may find additional support that motivates ART adherence. Those who disclose to their social network avail themselves of emotional and practical support with care appointments and treatment reminders. In steady partnerships, disclosure can provide an open home environment where pill taking need not be concealed. Additionally, knowledge that sustained viral suppression prevents transmission may provide additional motivation to adherence [12].

Despite these benefits, limited evidence exists on whether disclosure is associated with clinical outcomes such as ART treatment response. A small urban-based study reported a trend for higher 2-year post-ART CD4 counts among those who had disclosed [5]. It is well established that immune response is associated with baseline CD4 and age [1314], but there have been no published studies to our knowledge evaluating the association between partner disclosure and immune recovery following ART.

In this study, we performed an age-stratified comparison of CD4 response post-ART among HIV-infected individuals who reported disclosing their HIV status to their steady partner (disclosers) versus those who did not disclose (non-disclosers).


We conducted a retrospective cohort study using data from the Coptic Hope Center for Infectious Disease in Nairobi, Kenya. The Hope Center is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR), administered by the Coptic Orthodox Mission with support from the University of Washington, and has enrolled over 20,000 HIV-infected clients and provided free ART to over 15,000 clients since 2004.

Adults (>18 years) enrolling in care between January 1st 2009 and July 1st 2011 were eligible for analysis. We included adults who were newly diagnosed (first HIV confirmatory test within 3 months), ART-naïve, had a steady partner, and initiated ART within 3 months of enrollment. ART used at the Hope Center was in accordance with WHO guidelines. At enrollment, all clients were interviewed using standardized forms to capture demographic information (age, gender, educational level and employment status).

Partnership and disclosure status were ascertained during pre-ART counseling sessions and recorded on paper forms that were scanned into a database using TeleForm software (Autonomy, Cardiff, Vista, California, USA). Using a standardized questionnaire (S1 File), the client was asked, “how many spouse(s) or steady partner(s) do you have?”. Any client who reported no partner was excluded from analysis. Regarding disclosure, the client was queried “have you revealed your status to your spouse(s) or steady partner(s)”. The answer options were “all” “some” “none” or “has no partner / spouse”. A client was determined to have disclosed to their partner, if they had answered “all” or “some” to the “spouse(s) or steady partner(s)” category of the disclosure question. Partner non-disclosure was determined if the client had answered “none”. Clients with unrecorded answers to the partner or disclosure questions and clients with discordant answers (e.g. > 0 to the partner question, and “has no partner” to the disclosure question) were excluded.

As part of routine care, clients on treatment were evaluated every 3 months. CD4 measurements [BD FACSCalibur, San Jose, California] were taken before ART initiation, 6 and 12 months after initiation within a 60-day time window. The immune recovery analysis included clients with CD4 measurements at both 6 and 12 months post-ART. Clients missing both or either 6 or 12 month post-ART CD4 measurements were excluded.

Chi square tests were used to measure differences between categorical baseline characteristics. A two-sample t-test was used to measure differences between normally distributed continuous baseline variables (i.e., age and time to ART initiation). Wilcoxon-Mann-Whitney test was used to determine differences between CD4 counts at baseline, 6 and 12 months post-ART. CD4 response analysis was stratified by age, categorized as a binary variable using the mean age as the cut off. “Younger adults” comprised those below the mean age. “Older adults” were those including the mean age and older. Multivariable linear regression was used to determine differences in CD4 response from baseline to 6 months and baseline to 12 months, after adjusting for marital status, gender, and baseline CD4. All analyses were performed using Stata/SE 11.2 software (StataCorp). All data was de-identified prior to analysis.


Between January 2009 and July 2011, 3414 adults were enrolled at the Hope Center. Of these, 246 (7%) were previously diagnosed, 286 (8%) were ART-experienced, 1262 (37%) did not initiate ART within 3 months, 702 (21%) did not report a spouse or steady partner, 100 (3%) had incomplete disclosure or partner data, and 203 (6%) were missing 6 or 12-month CD4 measurements. The analysis ultimately included 615 (18%) adult clients who were newly diagnosed, initiated ART within 3 months, and had CD4 count data at 6 and 12 months post-ART.

Among the analysis cohort, mean age was 38.3 years [95% Confidence Interval (CI) 37.6–39.0) and 52% were male. A large majority were married/cohabitating (90%), had a secondary education or higher (73%), and were employed (78%) (Table 1). Disclosure was reported in 76% of the cohort. Disclosers were significantly younger (37.8 versus 40.0 years, p <0.02) and more likely to be married/cohabitating (93% versus 80%, p<0.001) than non-disclosers. There was no difference in baseline median CD4 count between disclosers (125 cells/μL) and non-disclosers (109 cells/ μL; p = 0.15).

Table 1. Characteristics of adults with steady partners (n = 615) initiating ART, but disclosure status at enrollment.

Among younger adults (< 38 years), disclosers had a higher CD4 recovery at 6 months post-ART than non-disclosers after adjusting for gender, baseline CD4 count (mean difference = 31, 95% CI 3 to 58 p = 0.03) but not at 12 months (mean difference = 17, 95% CI -19 to 52, p = 0.4) (Table 2). Among older adults (≥ 38 years) there was no observed difference in CD4 recovery at 6 or 12 months between disclosure groups.

Table 2. Average difference in CD4 response* between disclosers versus non-disclosers following ART initiation stratified by age.


In our retrospective cohort of new enrollees initiating ART we found a majority (76%) had disclosed their HIV serostatus to their partners. At baseline, disclosers were younger and more likely to be married or cohabitating with their partners compared to non-disclosers. Among younger adults, disclosers had a significantly higher average CD4 response compared to non-disclosers at 6 months after ART initiation.

The prevalence of partner disclosure (76%) in our study is similar to that observed in other studies in sub-Saharan Africa. Studies from a variety of sites in South Africa found the prevalence of disclosure was approximately 80% [1516]. Not surprisingly, disclosure was more common among married partners in our study. HIV-positive individuals have reported a greater sense of responsibility to disclose to partners with whom there was a shared emotional relationship [17]. Similar to our study, many other studies have observed a lower prevalence of disclosure among older clients. Observational studies in both resource rich and limited settings have shown that HIV-infected older adults are less likely to disclose to partners, friends and family due in part to an increased sense of stigma [15,1722].

It is also well established that older age is associated with lower CD4 response following ART. Thus, it is not surprising that among older adults in our study, we found no differences in CD4 response between disclosure groups at 6 or 12 months post ART. Viard and colleagues showed that older age was associated with both a lower absolute CD4 cell gain and a longer time to maximum response independent of baseline CD4 count and other factors effecting CD4 response [14]. Given the blunted CD4 response among older adults, any association between disclosure and CD4 response in this group would likely have required a much larger sample size and longer follow up period than our study was designed for.

However, among younger adults, we found that disclosers had a significantly higher CD4 response at 6 months of ART, than non-disclosers. Difference in early treatment response is likely associated with a difference in ART-adherence patterns. In a cross-sectional study in rural Zambia, partner disclosure and knowledge of partner status was associated with improved adherence [23]. Similarly, in a US-based cross-sectional study assessing ART adherence tracked by bottle cap devices, and self-reported disclosure, there was higher adherence among those with HIV disclosure [24]. Conversely, non-disclosure limits the potential for support persons to assist with treatment reminders and limits the ability to take ART openly. One study noted disclosure-related reasons for missing ART doses as “I didn’t want others to notice me taking medication” and “I was with people who didn’t know I was HIV positive” [24]. As it is well known that suboptimal adherence predisposes to suboptimal treatment response [25], our finding provides important complementary evidence regarding the clinical benefits of disclosure especially for those starting ART.

At 12 months post-ART, CD4 counts did not differ significantly between disclosure groups. One potential reason for this is that our ascertainment of disclosure status was only at baseline. Studies have shown that disclosure is a dynamic process that occurs over time. In a large cohort in Tanzania, prevalence of disclosure was 22% within 2 months to 40% nearly 4 years after diagnosis [26]. It is likely that a proportion of non-disclosers in our study disclosed after enrollment, thus attenuating any CD4 differences over time.

There are additional limitations to our study. This was a single-site study in an urban setting in Kenya using retrospective data. We did not have data on adherence and thus could not analyze its potential role as a mediator between disclosure and CD4 response. We did not control for active co-morbid diseases that could have affected CD4 measurements independent of ART. We restricted our disclosure definition to steady partners and excluded disclosure to friends, family, or other social support persons. There is growing evidence that disclosure to a partner/spouse is a distinct process separate from disclosure to friends and family [27] and that those who choose to disclose between family and friends may differ from those who choose to disclose to partners exclusively [18]. Any association between clinical outcome and disclosure may be more linked to disclosure recipients identified as social supporters independent of their identities as partners. Additionally, we restricted analysis to retained clients in order to ascertain CD4 data. This excluded those with significant difficulties engaging in care who may be the most affected by stigma and most reluctant to disclose.


In conclusion, our study is the first to analyze the association between early CD4 response and partner disclosure among ART-naïve patients initiating treatment. Our results suggest that partner disclosure may be associated with early CD4 recovery following ART initiation among younger adults. More research is needed to better understand the dynamics of disclosure and the impact/role of disclosure on clinical outcomes in HIV-infected patients initiating ART.

Supporting Information

S1 File. Hope Clinic Counselor Screening Form.


Author Contributions

  1. Conceptualization: TTT MHC NY.
  2. Data curation: TTT BAR.
  3. Formal analysis: TTT RN BAR.
  4. Investigation: TTT RN.
  5. Methodology: TTT NY RN.
  6. Project administration: SRS.
  7. Resources: SRS.
  8. Supervision: GCJ MHC.
  9. Validation: TTT BAR.
  10. Writing – original draft: TTT NY.
  11. Writing – review & editing: TTT CJM GCJ MHC AL.


  1. 1. WHO. Gender Dimensions of HIV status disclosure to sexual partners: Rates, Barriers and Outcomes. 2004. A review paper
  2. 2. Kalichman SC, Dimarco M, Austin J, Luke W, Difonzo K. Stress, social support, and HIV-status disclosure to family and friends among HIV positive men and women, Journal of Behavioral Medicine 2003; 26, 315–332. pmid:12921006
  3. 3. Pryzbyla SM, Golin CE, Widman L Grodensky CA, Earp JA, Suchindran C. Serostatus disclosure to sexual partners among people living with HIV: examining the roles of partner characteristics and stigma. AIDS Care 2013; 25(5): 566–572 pmid:23020136
  4. 4. Waddell EN, Messeri PA. Social support, disclosure and use of anti-retroviral therapy. AIDS and Behavior; 2006; 10(3) 263–272 pmid:16496089
  5. 5. Halperin J, Pathmananathan I, Riche LE. Disclosure of HIV status to social networks is strongly associated with increased retention among an urban cohort in New Orleans, AIDS Patient Care STDS 2013; 27(7) 375–377 pmid:23789731
  6. 6. Sendo EG, Cherie A, Erku TA. Disclosure experience to partner and its effect on intention to utilize prevention of mother to child transmission service among HIV pregnant women attending antenatal care in Addis Ababa, Ethiopia, BMC Public Health. 2013 Aug 17;13(1):76 pmid:23957627
  7. 7. Farquhar C, Kiarie JN, Richardson BA, Kabura MN, John FN, Nduati RW, et al. Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission. J Acquir Immune Defic Syndr. 2004;37(5):1620–1626 pmid:15577420
  8. 8. Bachanas P, Medley A, Pals S, Kidder D, Antelman G, Benech I, et al. Disclosure, Knowledge of partner status, and condom use among HIV-positive patients attending clinical care in Tanzania, Kenya, and Namibia; J Acquir Immune Defic Syndr. 2013 27(7): 425–435 pmid:23829332
  9. 9. Crepaz N, Marks G. Serostatus disclosure, sexual communication and safer sex in HIV-positive men. AIDS Care 2003; 15(3) 379–387 pmid:12745398
  10. 10. Brooks RA, Kaplan RL, Lieber E, Landovitz RJ, Lee SJ, Leibowitz AA. Motivators, concerns, barriers to adopt preexposure prophylaxis for HIV prevention among gay and bisexual men in HIV-serodiscordant male relationships. AIDS care 2011; 23(9) 1136–1145 pmid:21476147
  11. 11. Chemaitelly H, Awad SF, Shelton JD, Abu-Raddad LJ. Sources of HIV incidence among stable couples in sub-saharan Africa. Journal of the International AIDS Society 2014, 17:18765 pmid:24560339
  12. 12. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011 Aug 11;365(6):493–505 pmid:21767103
  13. 13. Corbeau P Reynes J. Immune reconstitution under antiretroviral therapy: the new challenge in HIV-1 infection Blood 2011; 117 (21) 5582–5590 pmid:21403129
  14. 14. Viard JP, Mocroft A, Chiesi A, Kirk O, Rege B, Panos G, et al. Influence of Age on CD4 Cell Recovery in Human Immunodeficiency Virus—Infected Patients Receiving Highly Active Antiretroviral Therapy: Evidence from the EuroSIDA Study. J Infect Dis. 2001; 183 (8): 1290–1294. pmid:11262215
  15. 15. Vu L, Andrinopoulos K, Mathews C, Chopra M, Kendall C, Eisele TP. Disclosure of HIV status to sex partners among HIV-infected men and women in Cape Town, South Africa. AIDS Behav. 2012 Jan;16(1):132–138 pmid:21197600
  16. 16. Skogmar S, Shakely D, Lans M, Danell J, Andersson R, Tshandu N, et al. Effect of antiretroviral treatment and counselling on disclosure of HIV-serostatus in Johannesburg, South Africa. AIDS Care. 2006;18(7):725–730. pmid:16971281
  17. 17. Larkins S, Reback CJ, Shoptaw S, Veniegas R. Methamphetamine-dependent gay men's disclosure of their HIV status to sexual partners AIDS Care. 2005 May;17(4):521–532 pmid:16036238
  18. 18. Shacham E, Small E, Onen N, Stamm K, Overton ET. Serostatus disclosure among adults with HIV in the era of HIV therapy. AIDS Patient Care STDS. 2012 Jan;26(1):29–35. pmid:22107039
  19. 19. 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. Bull World Health Organ. 2004 Apr;82(4):299–307 pmid:15259260
  20. 20. Centers for Disease Control and Prevention. HIV-related knowledge and stigma—United States, 2000 MMWR; 49:1062–1064. pmid:11186610
  21. 21. Tsai AC, Bangsberg DR, Kegeles SM, Katz IT, Haberer JE, Muzoora C, et al. Internalized stigma, social distance, and disclosure of HIV seropositivity in rural Uganda. Ann Behav Med. 2013 Dec;46(3):285–294 pmid:23690283
  22. 22. Emlet CA. A comparison of HIV stigma and disclosure patterns between older and younger adults living with HIV/AIDS. AIDS Patient Care STDs. 2006;20:350–358. pmid:16706709
  23. 23. Birbeck GL Chomba E, Kvalsund M, Bradbury R, Mang'ombe C, Malama K, et al. Antiretroviral adherence in rural Zambia: the first year of treatment availability. Am J Trop Med Hyg. 2009 Apr;80(4):669–74. pmid:19346397
  24. 24. Stirratt MJ, Remien RH, Smith A, Copeland OQ, Dolezal C, Krieger D. The role of HIV serostatus disclosure in antiretroviral medication adherence. AIDS Behav. 2006;10(5):483 pmid:16721505
  25. 25. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available: Accessed May 3, 2014
  26. 26. Antelman G, Smith Fawzi MC, Kaaya S, Mbwambo J, Msamanga GI, Hunter DJ, et al. Predictors of HIV-1 serostatus disclosure: prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania AIDS, 2001;15 (14):1865–1874 pmid:11579250
  27. 27. Dima AL, Stutterheim SE, Lyimo R, de Bruin M. Advancing methodology in the study of HIV status disclosure: The importance of considering disclosure target and intent. Soc Sci Med. 2014;108:166–174. pmid:24641881