Advancing methodology in the study of HIV status disclosure: The importance of considering disclosure target and intent

Alexandra L. Dima, Sarah E. Stutterheim, Ramsey Lyimo, Marijn de Bruin
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Disclosure of HIV status has been the focus of three decades of research, which have revealed its complex relations to many behaviors involved in HIV prevention and treatment, and exposed its central role in managing the HIV epidemic. The causes and consequences of disclosure acts have recently been the subject of several theoretical models. Although it is acknowledged that individual disclosure events are part of a broader process of disclosing one's HIV status to an increasing number of people, this process has received less theoretical attention. In quantitative studies of disclosure, researchers have often implicitly assumed that disclosure is a single unidimensional process appropriately measured via the total number of one's disclosure acts. However, there is also evidence that disclosure may have different causes and consequences depending on the types of actors involved (e.g. family members, friends) and on the presence or absence of the discloser's intention, suggesting that the unidimensionality assumption may not hold. We quantitatively examined the dimensionality of voluntary and involuntary disclosure to different categories of actors, using data collected via structured interviews in the spring of 2010 from 158 people living with HIV in Kilimanjaro, Tanzania. For voluntary disclosure, nonparametric item response analyses identified two multi-category clusters, family and community, and two single-category dimensions, partner and children. Involuntary disclosure consisted of several single- or two-category dimensions. Correlation analyses between the resulting disclosure dimensions and stigma and social support revealed distinct relationships for each disclosure dimension. Our results suggest that treating disclosure as a unidimensional construct is a simplification of disclosure processes that may lead to incorrect conclusions about disclosure correlates. We therefore recommend examining disclosure acts jointly to identify sample-specific dimensions before examining causes and consequences of disclosure. We propose a methodology for investigating disclosure processes, and recommend its adoption in future disclosure studies.