PROVIDENCE, R.I. -- A study of 203 HIV-positive men and women indicates that almost two-thirds are sexually active and that 40 percent of those having sex do not disclose their HIV status to all sexual partners. Of those who do not disclose, half do not tell their one and only mate, often a spouse or life partner.
Whether or not they inform partners of their HIV status, the study finds that those who are infected and sexually active do not always use condoms. Among individuals who do not inform their partners, 57 percent say they do not use condoms all of the time.
The findings contradict the widespread belief that HIV-positive men and women refrain from sexual activity. Among men and women practicing unprotected sex, viral transmission may be taking place unknown to the partners of HIV-positive individuals.
"The implication is that people may be putting themselves at risk for acquiring HIV without knowing it, and that medical- and health-care personnel may have great difficulty improving the situation," said Michael Stein, M.D., the study's lead author.
For a decade, the U.S. Public Health Service has recommended that HIV-positive individuals tell their sexual partners. Although nondisclosure is condemned morally and legally, human nature, in the form of stigma or shame, may keep some HIV-positive individuals from divulging their status to sexual partners.
"We assume that people in the study know of the risk of transmission to partners, yet we find a high number of people do not routinely use condoms," said Stein, an associate professor of medicine in the Brown University School of Medicine and director of HIV activities at Rhode Island Hospital. "The public health messages about condom use are right. Use of condoms should be happening in all sorts of sexual situations.
"The study suggests that the prevention message goes head-to-head with human nature, which is not to disclose to sexual partners, even if you've had one partner for a long time. From a primary care standpoint, this is a familiar scenario. People who didn't know they were at risk come in here after a spouse has infected them. Could it be the spouse was having unprotected sex? How do we make a dent in that behavior?"
The authors say there are powerful reasons why patients do not tell their partners. The top psychological consequence is rejection, a fear expressed by many of the study's participants. There are also social consequences to disclosure such as missed sexual encounters, or loss of jobs and health-care benefits. Some HIV-infected individuals rationalize that partners need to protect themselves, that protection is the "other's" responsibility.
Medical personnel must discuss disclosure with HIV-positive patients, Stein said.
"We need to talk with patients about who knows their status," he said. "If we find out that sexual partners don't know, then we have to talk with patients about the difficulties in telling those partners. If the patient says they don't know how to tell a partner, we have to bring that individual in, with their partner, to discuss the risks and necessary precautions."
The researchers found that women are more likely than men to divulge their HIV status to sexual partners, even though they are at greater risk for being injured, rejected or isolated by those partners.
Individuals with one sexual partner are 3.2 times more likely to divulge their HIV status than people with multiple partners. Those with strong spousal support are 2.8 times more likely to divulge compared to individuals without such support. Whites or Latinos are 3.1 times more likely than blacks to disclose their HIV status to sexual partners.
The study was based on interviews with 203 patients seeking primary care for HIV at hospitals in Boston or Providence, R.I. Of those patients, 129 reported having sexual partners during the previous six months. In the study, 46 percent of patients were black, 27 percent were white and 23 percent were Latino. The majority - 69 percent - were men.
Overall, 41 percent of study subjects were IV drug users, 39 percent were heterosexually infected and 20 percent were homosexual or bisexual men.
The findings will appear Feb. 9 in the journal Archives of Internal Medicine. The study's other authors include medical personnel affiliated with the Boston Medical Center and the Boston University School of Medicine and Public Health.
Before now, most disclosure studies focused on homosexual and bisexual men. Little was known about factors associated with disclosure in a range of men and women, while data on disclosure among infected women was limited, Stein said.