Increasing HIV serostatus disclosure in low and middle-income countries: A systematic review of intervention evaluations

OBJECTIVE: To review the effectiveness of interventions to increase HIV serostatus disclosure in low and middle-income countries. DESIGN: Systematic review of peer-reviewed articles providing prepost or multiarm evaluations of disclosure interventions, defined broadly as any intervention with the goal of increasing rates of voluntary disclosure of HIV serostatus through self-disclosure or partner notification. METHODS: Articles were included if they reported postintervention evaluation results and were published between 1 January 1990 and 1 August 2014. Searching was conducted through five electronic databases, secondary searching of four journals, and hand searching reference lists of included articles. Systematic methods were used for screening and data abstraction, which was conducted in duplicate. Study quality (rigor) was assessed with eight items. RESULTS: Fourteen articles evaluating 13 interventions met the inclusion criteria, all from sub-Saharan Africa. Most interventions focused on people living with HIV and used cognitive-behavioral group sessions or peer/community health worker support to encourage disclosure to sexual partners, family members, or friends. One focused on maternal disclosure to HIV-uninfected children, whereas two examined voluntary partner notification interventions. Several studies had limitations due to weak designs, small sample sizes, or high attrition. Findings on disclosure were mixed, with most effect sizes being relatively small, and some more rigorous studies showing no effect. Partner notification interventions had the strongest evidence of impact. CONCLUSION: The existing evidence base for interventions to increase disclosure is limited and shows variable results. Further research is needed to determine whether current approaches to increasing disclosure are effective or whether new approaches should be considered.