"Do Ask, Do Tell" - UCSF study analyzes disclosure by HIV-positive persons to sexual partners

By Wallace Ravven

A troubling 13 percent of HIV-infected individuals failed to disclose their positive status to their HIV-negative or HIV-unknown sexual partners before engaging in unprotected anal or vaginal intercourse, according to UCSF and RAND Health researchers.

“While the vast majority of HIV-positive individuals either abstain, disclose or attempt to minimize risk, the worrisome number of HIV-positive people, both gay and straight, who ‘don’t tell’ and who ‘aren’t asked’ while engaging in risky behavior, does call for new approaches. The most effective mechanisms are likely to be through promoting community norms that robustly say ‘do ask, do tell’,” said the study’s lead author, Daniel H. Ciccarone, MD, MPH, assistant professor of family and community medicine at the UCSF Urban Health Study.

The study, published in the June issue of the American Journal of Public Health, looks at a national sample consisting of 606 gay and bisexual men, 287 heterosexual men and 504 heterosexual women, all HIV-positive. Participants were asked about their disclosure practices over the prior six-month period with exclusive and non-exclusive sexual partners, together with questions about their sexual activities and the serostatus of their sexual partners.

Among those who had engaged in sex without disclosure, gay and bisexual men were much more likely to be involved in a non-exclusive partnership as opposed to an exclusive partnership. This was not true for heterosexual men and women.

“For gay and bisexual men, the type of relationship matters. Those who have a single sexual partner whom they consider to be their primary relationship partner are very likely to have disclosed their HIV status to that person. Most of the sex without disclosure occurs in non-exclusive partnerships,” said study co-author, David E. Kanouse, PhD, a senior behavioral scientist at RAND Health.

Of HIV-positive gay and bisexual men who had sex without disclosure in a non-exclusive partnership, 42 percent reported engaging only in oral sex or receptive anal sex-activities that pose a lower risk for HIV transmission to their partners.

“Our results suggest that many HIV-infected gay and bisexual men tailor their sexual activity to reduce the risk that they will transmit HIV to casual partners to whom they do not disclose. Public health messages have urged all gay men to ‘act as if every partner is HIV-positive.’ Such messages may have had the unintended consequence of making disclosure seem optional and non-disclosure acceptable in some encounters,” said Kanouse.

“Additional study is needed to explore the circumstances in which gay and bisexual men may not feel the need to disclose and to assess the very real risk for miscommunication in those circumstances,” he added.
The study does not identify individual reasons for non-disclosure, but notes that significant disincentives to disclosure exist at the socio-cultural level.

“Barriers to disclosure of HIV status such as stigma and fears of rejection, discrimination and violence persist and efforts to address the problem of non-disclosure are likely to fail unless they speak to these very personal concerns,” said Ciccarone.
Co-authors are Rebecca L. Collins, PhD, senior behavioral scientist; Angela Miu, MS; and Sally C. Morton, PhD, senior statistician, all with RAND Health, Santa Monica, CA; James L. Chen, MPH, from the California Epidemiological Investigation Service in Los Angeles; and Ron Stall, PhD, MPH, chief of the Behavioral Interventions Research Branch at the Division of HIV/AIDS Prevention at the Centers for Disease Control.

This study was funded by grants from the National Institute for Child Health and Human Development and the Agency for Healthcare Research and Quality.