HIV POSITIVE STATUS DISCLOSURE TO SEXUAL

PARTNERS AMONG WOMEN PLWHA AT HAWASSA

REFERRAL HOSPITAL, SNNPR - ETHIOPIA

BY

TAYE GARI (Bsc)

ADVISOR: DEREJE HABTE (MD, MPH)

A Thesis submitted to the School of Graduate Studies of Addis

Ababa University In Partial Fulfillment of the Requirements for
the Degree of Master in Public Health in School of Public
Health

June 2008
Addis Ababa
ETHIOPIA

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 ADDIS ABABA UNIVERSITY
SCHOOL OF GRADUATE STUDIES

HIV POSITIVE STATUS DISCLOSURE TO SEXUAL PARTNERS

AMONG WOMEN ATTENDING ART CLINIC HAWASSA
REFERRAL HOSPITAL, SNNPR, ETHIOPIA

By: Taye Gari

School of Public Health, Faculty of Medicine, Addis Ababa University

Approved by the Examining Board

______________________________ __________________

Chairman, Department Graduate Committee

_________________________________ ___________________

Advisor

________________________________ ___________________

Examiner

_______________________________ ___________________

Examiner

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 Acknowledgment

Thanks to Almighty God, the Lord of wisdom, knowledge and understanding.

I would like to extend my deepest gratitude and appreciation to my advisor Dr. Dereje

Habte for his unreserved support and constructive comments throughout the preparation of

this thesis.

My appreciation extends to EPHA-CDC project for funding this research.

My gratitude also goes to the library staff of the School of Public Health and AIDS

Resource Center for their support in providing me the necessary references for the success

of this study.

My special appreciation also extends to those who participated in the study, Hawassa

referral Hospital staff, and my friends and to all data collectors.

Last, but not least my sincere thanks go to my lovely wife W/o Aynalem Demissie and my

daughter Ruth Taye who provided me support and enormous encouragement throughout

this work.

Taye Gari, June 2008

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 Table of Content

Page
Acknowledgment.........................................................................................................................I
Table of Content ........................................................................................................................ II
List of Tables ............................................................................................................................III
List of Figures ...........................................................................................................................IV
List of Abbreviations.................................................................................................................V
Abstract .....................................................................................................................................VI
1. Introduction.............................................................................................................................1
2. Literature Review ...................................................................................................................4
3. Objectives .............................................................................................................................13
4. Method and Materials...........................................................................................................14
4.1 Study design and period.................................................................................................14
4.2 Study area: ......................................................................................................................14
4.3 Source and Study population.........................................................................................14
4.4 Sample size determination.............................................................................................15
4.5 Sampling techniques ......................................................................................................15
4.6 Data collection................................................................................................................16
4.6.1 Data collection tools ...................................................................................................16
4.6.2 Data collection method ...............................................................................................16
4.6.3 Recruitment and training of data collectors...............................................................16
4.6.4 Data quality assurance ................................................................................................17
4.7 Data process and Analysis .............................................................................................17
4.8 Variables .........................................................................................................................18
4.9 Ethical Consideration.....................................................................................................19
4.10 Operational Definition .................................................................................................20
4.11 Dissemination of the result..........................................................................................20
5. Result.....................................................................................................................................21
6. Discussion .............................................................................................................................35
7. Conclusion ............................................................................................................................41
8. Recommendations ................................................................................................................42
9. References.............................................................................................................................43
Annex I: Map of SNNPR .........................................................................................................47
Annex II: Questionnaire English version................................................................................48
Annex III Questionnaire Amharic Version.............................................................................57

II

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 List of Tables
Page

Table 1 Socio-demographic characteristics of women PLWHA attending ART clinic,

Hawassa Referral Hospital, SNNPR, April 2008 ...................................................................22
Table 2 HIV/AIDS related knowledge, substance use, sexual behaviour and condom
use of women PLWHA attending ART clinic, Hawassa Referral Hospital, SNNPR,
April 2008 ................................................................................................................................25
Table 3 HIV/AIDS related issues, communication and treatment by HIV positive status
disclosure to regular sexual partners of women PLWHA attending ART clinic, Hawassa
Referral Hospital, SNNPR, April 2008...................................................................................29
Table 4 Barriers to disclose HIV positive status among women with regular and non
regular sexual partners attending ART clinic, Hawassa Referral Hospital, SNNPR, April
2008 ...........................................................................................................................................31
Table 5 Outcome of HIV positive status disclosure among women with regular and non
regular sexual partners attending ART clinic, Hawassa Referral Hospital, SNNPR,
April 2008 .................................................................................................................................32
Table 6 Determinants of HIV positive status disclosure to regular sexual partner of women
PLWHA attending ART clinic Hawassa Referral Hospital, SNNPR, April 2008..............34

III

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 List of Figures Pages

Fig. 1 Number of current sexual partners of women PLWHA attending ART clinic,

Hawassa Referral Hospital, SNNPR, April 2008………………………………………25

Fig. 2 First time HIV positive status disclosures of women PLWHA attending ART clinic,

Hawassa Referral Hospital, SNNPR, April 2008…………………………………………28

IV

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 List of Abbreviations

AIDS – Acquired immunodeficiency syndrome

AOR- Adjusted odds ratio
ART- Anti-retroviral Therapy
ARV- Anti-retroviral
BSS- Behavioral surveillance survey
EDHS- Ethiopian demographic and health survey
F/P-Family planning
HIV- Human immune deficiency virus
HAART- Highly active anti-retroviral therapy
MTCT- Mother to child transmission
OR - Odds Ratio
PLWHA –Peoples living with HIV/AIDS
PMTCT- Prevention of mother to child transmission
SD- Standard deviation
SNNPR- South Nation and Nationalities Peoples Region
SPH – School of Public Health
VCT – Voluntary counseling and testing
WHO- World Health Organization

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 Abstract

Background: Disclosure of HIV status may lead to increased opportunities for social
support, to discuss and implement HIV risk reduction with partners and improved access to
treatment. Thus, status disclosure is major public health goal for HIV prevention &
treatment
Objective: Determine the magnitude and determinants of HIV sero-status disclosure to
sexual partners among women people living with HIV/AIDS at Hawassa Referral Hospital,
SNNPR.
Method: A Cross sectional survey was conducted among 384 HIV positive women who
had sexual partner and age 18 years attending ART clinic from March to April 2008.
Using a structured and pre-tested questionnaire, data were collected through patient
interview consecutively until the required number reached over one month period. Ethical
clearance from concerned bodies and informed consent from participants was obtained.
X2 tests, odds ratios and logistic regression were done to explore associations between
different variables and status disclosure.
Result: Overall 85.7% the women had disclosed their HIV positive status to their sexual
partners. The common barriers reported for non disclosure of HIV status were fear of
abandonment; fear of break-up in relationship and fear of stigma. The negative partner
reaction reported by those women who disclosed to sexual partner in this study was found
to be high (59.3%). Majority (77.9%) had sexual intercourse in the past 6 month. 9.1% of
the women were pregnant since they tested for HIV and condom was inconsistently used
by most of the women. Being married, taking ARV treatment for more than one year and
knowing the HIV status of the sexual partner were predictors of HIV positive status
disclosure.
Conclusion: Even though, the magnitude of HIV positive status disclosure to sexual
partner in this study is encouraging, negative partner reactions following disclosure were
reported by large proportion of women. Follow up counselling, couple counselling and
testing, integrating ART service to reproductive health service particularly F/P should be
emphasized in order to facilitate safe status disclosure and to address the sexual and
reproductive health needs of PLWHA’s.

VI

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 1. Introduction

The estimated number of people living with HIV worldwide in 2007 was 33.2 million, a

reduction of 16% compared with the estimate published in 2006 (39.5 million), and 2.5

million people infected in the year 2007(1, 7).

Sub-Saharan Africa continues to be the region most affected by the AIDS pandemic. More

than two out of three (22.5 million) adults and nearly 90% of children infected with HIV

live in this region and 76% (1.6 million) AIDS deaths in 2007 occurred there, illustrating

the unmet need for antiretroviral treatment in Africa (1). Over and above the personal

suffering that accompanies HIV infection wherever it strikes; HIV in Sub-Saharan Africa

threatens to devastate whole communities, rolling back to decades of progress towards a

healthier and more prosperous future (4).

Through adjustments of the 2005 antenatal care site surveillance and DHS-Plus factors, in

Ethiopia 977,394 Peoples were living with HIV/AIDS. The overall adult HIV prevalence

rate was estimated to be 2.1 % (1.7% males and 2.6% females for 2007). The rural and

urban HIV prevalence was 0.9% and 7.7% respectively (2, 3).

The total number of PLWHA in SNNPR for 2007 was 132,410, of which majority (59%)

were females. The adult HIV prevalence was 1.4% (1.2% for male and 1.7% for female).

The total PLWHA in need of ART for the same year were 34, 254. According to the report

of MOH (2006), the total people involved in VCT in SNNPR were 75,562 (40,867 male

and 34,695 females) with sero positive status prevalence of 9%. The number of health

institutions providing VCT, ART and PMTCT in the region were 217, 36, and 58

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 respectively. Until mid 2006, the number of AIDS cases on ART was reported to be 4259

(52.4 % female, 44.2 % males, and 3.4% children) (2, 3).

The prevention and control of human immuno-deficiency virus (HIV) infection depends on

the success of strategies to prevent new infections and treat currently infected individuals.

HIV testing and counseling serves as both a critical prevention and treatment tool in the

control of the HIV epidemic. Within HIV testing and counseling (VCT) programmes,

emphasis is placed on the importance of HIV status disclosure among HIV infected clients,

particularly to their sexual partners (5).

Disclosure provides many important benefits to the infected individual and to the public.

First, disclosure may motivate sexual partners to seek testing, change behaviour and

ultimately decrease transmission of HIV. In addition, disclosure may facilitate other health

behaviors that may improve the management of HIV. For example, women who disclose

their status to partners may be more likely to participate in programmes for prevention of

HIV transmission from mothers to their infants (6).

Through disclosure of her status, a woman may receive support from her family or others

in her social network and may be able to access available support services. By adequately

addressing the emotional, social, and practical sequelae of her positive status, she may be

more willing to adopt and maintain health behaviour such as cessation of breastfeeding or

adherence to treatment regimens (5, 6).

However, disclosure of HIV status may have potential risk for the infected women. These

risks include loss of economic support, blame, discrimination, disruption of family

relationship and so on. These risks may lead women not to disclose their sero-status, which

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 in turn leads to missed opportunities for prevention of new infections to their partners and

infants (5, 8).

In a setting where women’s access to resources independent of their partner is uncommon,

disclosure is a question of survival and thus the negative outcome of HIV positive status

disclosure is a serious concern. The absence of social security and health insurance in most

African countries also make women dependent on their partner and family for their health

care, therefore women may choose not to disclose their HIV status in order to benefit from

family support (5).

There are reports that indicate HIV infected pregnant women are not fully participating in

the PMTCT program. According to the Ethiopian DHS of 2005, to date only about 2% of

HIV positive pregnant women needing PMTCT have benefited from the services (31).

One of the reasons for low participation is that, non-disclosure of HIV test result to sexual

partners. The uptake and adherence to PMTCT is difficult for women whose partners are

unaware of their status (6).

Therefore, this study assessed the magnitude and determinant of HIV positive status

disclosure among women and may give recent valuable data that can be used to compare

with results of similar research in Ethiopia and other countries. Furthermore the finding

will be an input to the HIV prevention endeavor in devising evidence based intervention

regarding sero-status disclosure.

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 2. Literature Review

2.1 Rates of HIV sero-status disclosure.

Meta analysis conducted by WHO on HIV status disclosure showed that, for developed

countries the disclosure rate to sexual partners ranged from 42% to 100%, depending in

large part on the type of sexual partner to whom the person disclosed. Among the studies,

that reported disclosure rates to current and/or steady sexual partners the average rate of

disclosure was 79%. For developing countries, the rate of HIV status disclosure to sexual

partners ranged from 16.7% to 86%. Among the studies, that reported disclosure rates to

current and/or steady partners the average rate of disclosure was 49%, considerably less

than the average rate reported from studies conducted in the developed world (79%) (5).

A study done in southern USA showed that, majority of the women had disclosed to some

sex partners, close family and friends, and health care professionals. However, for 3.8% of

the women disclosure of HIV infection is a difficult issue (8).

A study conducted in New York City, among 230 HIV positive women from out patient

clinic, 82% of the women disclosed their HIV positive status to sexual partner(9)

Even though, status disclosure is higher in developed countries, in some studies it was

found to be low. For instance, a study conducted on 2 sites; Boston City Hospital HIV

Diagnostic unit and Rhode Island Hospital HIV clinic showed, 60% of individuals had

disclosed their HIV status to all sexual partners and 40% had not disclosed (10).

A study carried out among hospital cases on French Antilles and French Guiana indicated

that, one third of PLWHA had kept their HIV status secret. Disclosure within a steady

partnership was less likely among non-French individuals (11). A research carried out on

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 disclosure among HIV positive Black Africans men and women living in UK showed that,

majority of the participants had disclosed to one person (12).

Three month after voluntary counseling and testing, 64% of HIV positive women and

79.5% of HIV negative women reported that they had shared HIV test result with their

partners in Dar es Salaam, Tanzania (13).

A study done in Nairobi, Kenya among HIV positive pregnant women attending antenatal

clinic, 65% of the women had informed partners their HIV status and 27% brought their

partners for HIV testing (14).

Relatively high (84.9%) disclosure rate two weeks after testing was reported from study

conducted on the pregnant women screened for HIV in Kigali, Rwanda (15).

The local study conducted in Gore and Mettu Towns, and St. Paul Hospital, Addis Ababa,

Ethiopia, showed HIV positive status disclosure rate of 69% and 92% respectively (16, 40)

2.2 Determinants of HIV positive sero-status disclosure to sexual partner

A WHO cross country review of women sero positive status disclosure found that

HIV positive sero-status disclosure may be affected by many factors. These factors

include, socio-economic status, age, duration of relation with the partner, level of

education, culture, discussion on HIV and its test among the partners before the test,

number of partners and so on. In addition, variation in rates of HIV status disclosure to

sexual partners among different ethnic groups was also identified. This suggests that there

may be important cultural factors that influence the patterns of self-disclosure to sexual

partners. It is also indicated that, as the length of time since diagnosis increases the rate of

disclosure also increase (5).

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 A study conducted in Paris, France on HIV positive patients in ambulatory HIV clinic,

42.5% of the participants disclosed immediately, 21% waited one month, 24% waited more

than one year to disclose. Women disclosed immediately after learning status more often

than men (17)

The numbers of sexual partners affect status disclosure. Women who have fewer sexual

partners are more likely to disclose their HIV sero positive status than those with multiple

partners. From the Boston City Hospital HIV Diagnostic Evaluation Unit, and Rhode

Island Hospital HIV Clinic study, of those individuals with 1 partner, 21% had not

disclosed their sero-status; 58% of those with 2 or more partners had not informed all their

partners (10).

HIV sero-positive status disclosure depends on modes of transmission of the disease. From

one study in Taiwan, the rate of status disclosure was 36% in men having sex with men,

34% in heterosexuals, and 21% in injection drug users. Men having sex with men were

more likely than heterosexual men or male injection drug users to disclose their HIV status

directly to friends immediately after learning of their HIV diagnosis (18)

Partner involvement in the pre-test counseling can determine the HIV sero-status

disclosure. A study done to evaluate the influence of partner participation in the mother

class to the PMTCT services in Cambodia, showed the acceptance rate to the pre-test

counseling as well as disclosure of their results to their partners is higher among those with

their partner involvement (19).

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 2.3 Barriers to HIV sero-status disclosure

HIV related stigma and discrimination remains an enormous barrier to effectively fighting

HIV/AIDS epidemic in Africa. Fear of discrimination often prevents people from being

tested, seeking treatment for AIDS or from admitting their HIV status publicly; which in

turn can have implications for health care and further HIV transmission (4).

Measures to reduce MTCT of HIV, especially the administration of antiretroviral drugs,

and avoidance of breast-feeding, make it virtually impossible for HIV positive women to

keep their HIV infection a secret from their families and people in the wider community. It

is therefore essential to the safety and acceptability of MTCT interventions that effective

steps to be taken to combat rejection of PLWHA. Where women fear discrimination, and

violence, they will be reluctant or unable to take advantage of opportunities offered to

protect their infants from infection (6, 8).

Particularly in developing countries, fear of abandonment in women was closely tied to

fear of loss of economic support from a partner. In these settings where resources are

extremely scarce and women's access to resources independent of their partner is

uncommon, fear of losing instrumental support from a partner is a major consideration

when deciding whether to share results or not. The absence of social security and health

insurance in most African countries also make women dependent on their partner and

family for their health care, therefore women may choose not to disclose their HIV status

in order to benefit from family support (5, 8, 13, 16, 33).

In addition, the decision to disclose HIV status involves a cognitive appraisal of negative

consequences that is based on an individual’s knowledge of HIV, attitudes toward

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 HIV/AIDS or HIV-related behavior and perceived social attitudes towards people with

HIV(8).

Fear of rejection and change in relationship were the main barriers reported by the

participants to disclose HIV positive status in Paris, France (17).

Similarly study conducted in China showed, willingness to disclose was negatively

associated with misconceptions about HIV transmission and stigma. Stigma mediated the

relationship between misconceptions and willingness to disclose among women but not

men. The mediation effect of stigma suggests that stigmatization reduction would be an

important component of HIV prevention approaches. Gender inequality needs to be

addressed in stigmatization reduction efforts (20).

A study done on African-American women in New Orleans, USA, showed 44 % of the

participants had not disclosed to sexual partner; due to fear of losing economic support

from sexual partners (21).

Researches conducted in Zaire, Burkina Faso, Kenya, Thailand, Tanzania, and Rwanda

found that the reason for not sharing the HIV status to sexual partner were fear of being

accused as the source of infection, fear of accusations of infidelity or being considered

unfaithful, fear of separation/divorce, fear of shaming their family, fear of being rejected or

abandoned, and fear of blame (14, 22, 23).

A study conducted in "Khayelitsha MTCT Pilot Project”, South Africa; revealed that

women who had not disclosed raised the issue of fear of rejection, discrimination, verbal

abuse and concerns about public ignorance of the disease (31).

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 In Ethiopia, according to the 2005 EDHS and BSS reports, the proportion of respondents

with an accepting attitude towards PLWHA is low. This indicates the existence of

extensive HIV related stigma in the country, which can affect status disclosure (24, 25).

2.4 Outcomes of HIV sero-status disclosure to sexual partners

Most studies, both in developing and developed countries reported that positive outcomes

were common following disclosure. Positive outcomes reported by women include

increased support, acceptance (neutral), and kindness (5).

A study conducted on women receiving care at a clinic in London, UK, 57% of HIV

positive women disclosed their status to their parents and reported that their parents were

supportive (26).

Similarly 76% of HIV positive women in Baltimore, USA, reported acceptance, support,

and understanding after disclosure (27).

More than two third of the women in Rwanda and Tanzania reported that their relationship

continued after HIV positive status disclosing to their partners (28).

Disclosure was associated with less anxiety, fewer symptoms of depression, and increased

social support. The negative outcomes of disclosure reported by the respondents include

blame, abandonment, anger, violence, stigma, and depression. An important finding from

both developed and developing country studies is that disclosure was not associated with

the break-up of long-term relationships. Even if the fear of most women to disclose is

break-up of relations, disclosure was not associated with abandonment (5, 16).

A study conducted on HIV positive mothers attending an outpatient clinic in Cape Town,

South Africa, 27% of women reported at least one problem with disclosure, 13%

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 experienced violence from partners following disclosure, 9% reported that their partner left

them, and 3% said they were forced to move away from their home (29). From the study in

Tanzania 14.6% of partners reacted violently following disclosure (28)

Study done on HIV Voluntary Testing and Counselling Efficacy Trials in Tanzania,

Kenya, and Trinidad, 27% reported a break-up of a sexual relationship, 5% reported a

break-up in the marriage and 4.5% reported physical abuse by a sexual partner (30).

2.5 Disclosure to partners compared to family members and friends

Studies indicated that, many participants have specific criteria for deciding to whom to

disclose. These criteria were, based on one of three factors: their relation to the person

(health care provider, sexual partner or family member), the quality of their relationship

(accepting versus rejecting) and the perceived ability of the other person to keep the

information confidential. For many of the women, health care providers, or at least those

health care providers rendering direct care, represented a group that ‘needed to know’ (8).

Self-disclosure of HIV infection examined among 105 African-American men and 264

European-American men in Los Angeles showed that the African-Americans were less

likely to disclose their sero-status to intimate lovers, close friends, and family members or

to discuss HIV-related worries with others (13).

A study done in Baltimore, Miami, Newark, USA, 89% of individuals had disclosed their

HIV status to at least one other person 6 to 24 months after being tested; 28% reported that

they had first disclosed to a sexual partner, 31% had first disclosed to a relative and 29%

reported they had first disclosed to neither a sexual partner nor a relative (32)

10

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 A study conducted in Taiwan indicated, 72.4% had disclosed their HIV status to at least

one person, including 62% to an immediate family member and 21% to friends.

Heterosexual men and male injection drug users often disclosed to their immediate

families a few days after obtaining an HIV diagnosis. Perceived consequences after

disclosure included: increased substantial support from family, assistance with medical and

healthcare, encouragement of living positively with HIV, being rejected, treated as

contagion, and condemnation. In general most of the people disclose their HIV status to

their intimate family member or friend than their sexual partners (18).

2.6 Behaviour change related to HIV status disclosure

Many researches found that condom use is more common among those women who

disclosed their status than those did not (5, 16).

The finding from Boston City Hospital HIV Diagnostic Evaluation Unit and Rhode Island

Hospital HIV Clinic study showed, non-disclosers were less likely to regularly use

condoms than disclosers are; as a result, sexual partners of HIV-infected persons continue

to be at risk for HIV transmission (10).

A study conducted in South Africa found that, participants who had not disclosed to their

sex partners were significantly more likely to have multiple partners, HIV negative

partners, partners of unknown HIV status, and unprotected intercourse with non-

concordant sex partners (33).

It was also indicated that sexual risk behavior is higher among HIV infected peoples on

preventive therapy than those on HAART. This may be due to repeated counseling of

patients on risk behavior during care provision. Study conducted in Mombassa, Kenya

11

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 showed in both the HAART group and the preventive therapy (PT) group, around 40

percent of PLWHA did not know their regular partner’s HIV status and about 20 percent

did not disclose their own status to their regular partners. Lack of knowledge of partner’s

sero-status and low levels of disclosure of one’s own HIV status, coupled with inconsistent

condom use, sets the stage for HIV transmission to sero-discordant partners, especially

within regular partner relationships. Transmission of resistant viral strains and re-infection

with new strains are serious public health risks. Unprotected sex also carries the risk of

unwanted pregnancy and the subsequent risk of HIV transmission to the child (34).

12

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 3. Objectives

3.1 General objective

Determine the magnitude and determinants of HIV sero-positive status disclosure to sexual

partners among women PLWHA at Hawassa Referral Hospital, SNNPR.

3.2. Specific Objectives

• Assess the magnitude of HIV positive status disclosure to sexual partners

• Identify barriers to HIV positive status disclosure to sexual partners

• Determine the outcome of HIV positive status disclosure to sexual partners

• Assess the determinants of HIV positive status disclosure to sexual partners

13

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 4. Method and Materials

4.1 Study design and period

Cross sectional study was conducted from March to April 2008.

4.2 Study area:

The study was conducted in Hawassa Referral Hospital, Hawassa town, which is the

capital city of South Nations and Nationality Peoples Region (SNNPR) and is located

270km south of Addis Ababa.

Hawassa city has a total population of 200,000 (35). There are different levels of both

government and private health institutions offering health services in the city.

Hawassa Referral Hospital is the only Referral Hospital in the City as well in the region. It

was established in 2004/05GC and currently provides comprehensive health services

(prevention, curative and teaching) including ART and PMTCT. The ART clinic was

established in June 2006GC. At the end of February 2008, 1110 cases were on ART and

731 cases were on pre-ART follow up in the clinic. Of those on ART (1110), the total

numbers of pediatric age groups were 56. The service is rendered by one physician, five

nurses, one laboratory technician, one pharmacy technician and one data clerk; who were

trained on VCT and ART.

4.3 Source and Study population

All PLWHA attending the ART clinic in the Hospital were source population. And women

who had sexual partner and attending ART clinic at Hawassa Referral Hospital were the

study subjects.

14

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 Inclusion: Study subjects were women who had sexual partners and at least 18 years old;

able to give informed consent, and not seriously ill.

Exclusion: exclusion criteria were women whose age is less than 18 years old, absence of

sexual partner, unable to hear, mentally disabled or unconscious.

4.4 Sample size determination

The sample size required for this study was determined using the formula for estimating

single population proportion. The prevalence of HIV status disclosure from the previous

study for developing countries on average was 49% (6).

Using 5% level of significance and 5% margin of error (precision) the sample size was:

Z 1−α P()Τϕ
1− P /Φ3 15.406 Τφ 1 0 0 1 212.64 466.77 Τµ (
2

n= 2

d2

Where,

n= minimum sample size

Z= 1.96 (95% confidence interval)

p=anticipated population proportion or prevalence

d= margin of error

1.96 × .49()Τϕ
1 − .49 /Φ3 15.328 Τφ 1 0 0 1 204.24 282.93 Τµ ()
n= 2
= 384
.05

A total of 384 women were used for this study.

4.5 Sampling techniques

Study subjects were selected using convenience sampling method. Patients came to ART

clinic and contact the data clerk. At this point women who had sexual partners were

identified by asking the respondents themselves. Based on the inclusion criteria all eligible

15

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 PLWHA women who came for follow up and treatments from March to April 2008, over

one month period, were interviewed consecutively until reaching the required sample size.

4.6 Data collection

4.6.1 Data collection tools

The questionnaire format was taken from the previous study done in Addis Ababa (40);

modified and additional questions were also added from other sources (16). Questions

were first prepared in English and then translated into Amharic and then back to English.

4.6.2 Data collection method

The information was collected from the 384 patients on follow up and ART. After the aim

of the study was clearly explained, informed consent obtained from the respondents and

interviewer administered questionnaire was used to collect the data.

4.6.3 Recruitment and training of data collectors

Recruitment- Three data collectors were selected; all of them were female nurses who

were working in the ART clinic and one supervisor, who was in charge of the ART clinic

coordination.

Training- Training was given for the data collectors and the supervisor by the investigator

for two days, using lecture and role play method of training. The objective of the study,

method of interview, how to keep confidentiality, and way of handling and approaching

study subjects was given due attention during training. A manual on HIV status disclosure

to sexual partner (benefits, potential risks, and barriers) was given to each interviewer and

supervisor.

16

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 4.6.4 Data quality assurance

Questionnaire were formulated from previous studies and translated from English to

Amharic and back to English to assure consistency. Then, questionnaire was pre-tested

after which the relevant changes were made with the input from pre-testing.

Pre-testing

Before the actual data collection pre-test was carried out on 15 subjects, who were not

included in the proper study but were client of ART clinic, to check whether the data

collectors understood the questions in similar way and collect the intended information as

well evaluate the completeness and the consistency of the questionnaires. Then after, minor

modifications were made.

The collected data were checked for completeness, accuracy, clarity and consistency by the

supervisor and principal investigator. Daily strict follow up and checking of the data

collected was done in order to manage any problem encountered. Timely feed back was

given for the data collectors and the supervisor through meeting that was held before the

next day data collection began

4.7 Data process and Analysis

Data was entered, edited, and coded in to EPI info version 2002 computer software, and

finally 10% of the data entered was cross checked. Minor discrepancies related to error in

data entry were found and rechecked from the original hard copy questionnaire and then

corrected.

Data was analyzed using SPSS version 12.1 and EPI info version 2002 software. Tables

were generated using cross tabulation comparing status disclosure with other variables.

Logistic regression analyses were done to identify the relation ship between sero-status

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 disclosure and the independent variables. Frequency, Odds Ratio with 95% CI and P-value

were used to present the finding.

4.8 Variables

4.8.1 Independent Variables

• Socio-demographic variables such as age, occupation, marital status, religion,

ethnicity, educational level, monthly income

• Type of partnership

• Membership to PLWHA association

• Discussion between couples on HIV related issues

• Duration of relation with partner

• Duration since tested and duration since ARV treatment started

• Knowledge of partner HIV status

• Condom use

4.8.2 Dependent Variable

HIV positive status disclosure

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 4.9 Ethical Consideration

Ethical clearance for the proposal was obtained from the Research and publication

Committee, Faculty of Medicine, Addis Ababa University. Written letter of permission

was obtained from, school of pubic health Addis Ababa University and Hawassa Referral

Hospital Medical Director.

The aims, purpose, benefit and method of the study was clearly explained to the

participant. All of the study participants were informed that, their response will be kept

secret; and only health workers who were currently working in the ART clinic collected

the data. Finally, they were interviewed after informed consent was obtained. The

interview was conducted in a way that it would not violate their privacy and confidentiality

of information. Thus, name and address of the interviewees was not recorded in the

questionnaire.

The respondents were informed that they have the right to be involved or not to be

involved in the study, and that non-involvement otherwise will not affect the clinical care

they receive.

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 4.10 Operational Definition

• Sexual partner: -is a person with whom one engages in sex acts.

• Regular partner -means spouse(s) or live-in sexual partners or regular boy friend

• Non-regular partner- Sexual partners that one is not married to and never lived

with that partner

• Cohabiting partners -partners who are not married but living together

• Outcome of disclosure: Considered as positive outcome, if the partner reaction

following disclosure is acceptance and increased support; but considered as

negative if the reaction is abandonment, anger, and blame.

• HIV sero-positive status disclosure to sex partner - refers to the act of informing

the HIV sero-positive status of an infected person to sex partner by the person

herself.

• Chat/ khat: is a substance which is used by some one for stimulant purpose.

4.11 Dissemination of the result

The study result will be disseminated to SPH, Medical Faculty of Addis Ababa University,

EPHA, SNNPR Health Bureau and Referral Hospital. Attempts will be made to publish the

finding in peer-reviewed journal and present in scientific conference.

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 5. Result

5.1. Socio-Demographic Characteristics

Majority 348 (90.6%) of respondents were from urban area. The dominant ethnic groups

were Wolayta and Amhara, 116 (30.2%) and 109 (28.4%) respectively. More than half

(54.4%) of the women were Orthodox Christians. The age range of the study participant

was from 18 to 57 years and 293 (76.3%) of them were less than 35 years old with mean

(SD) of 29.5 (7.1) years (Table 1).

One hundred and twenty (31.3%) have attended primary school, (39.6%) were house

wives, 247 (64.3%) were married and 215 (56%) had an average monthly income of less

than or equal to 250 Ethiopian birr. The average monthly income of the respondent’s

sexual partner was above 250 Ethiopian birr for half 201 (52.3%) of them (Table 1).

Two hundred seventy (70.6%) of them were not members of PLWHA association and two

hundred fifty seven (66.9%) of the women were taking ARV drugs and 127 (33.1%) were

on pretreatment follow up.

The duration of diagnosis for the study subjects ranged from 1month to 84month. One

hundred fifty seven (43.3%) of the study participants had known their HIV status for less

than one year but the rest 206 (56.7%) of the women knew their positivity and lived with

HIV for more than one year.

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 Table 1 Socio-demographic characteristics of women PLWHA attending ART clinic, Hawassa Referral
Hospital, SNNPR, April 2008.

Variables (n=384) Number %

Address
Urban 348 90.6
Rural 36 9.4
Age(in years)
18-24 102 26.6
25-34 191 49.7
35 91 23.7
Religion
Orthodox 209 54.4
Protestant 122 31.8
Muslim 40 10.4
Other 13 3.4
Educational level
Do not read and write 86 22.4
Read and write 36 9.4
Primary 120 31.3
Secondary 102 26.5
Certificate and above 40 10.4
Occupation
Government employee 51 13.3
House wife 152 39.6
Merchant 63 16.4
Daily laborer 47 12.2
Student 31 8.1
Farmer 21 5.5
Others 19 4.9
Ethnicity
Wolayta 116 30.2
Amhara 109 28.4
Sidamo 61 15.9
Oromo 41 10.7
Gurage 27 7
Others(Kambata, Hadya, Gamu) 30 7.8
Current marital status
Currently married 247 64.3
Cohabiting 71 18.5
Never married 25 6.5
Others(Divorced, Widowed) 41 10.7
Monthly own income (in ETH. Birr)
No income 30 7.8
250 215 56
251-500 48 12.5
501 91 23.7
Membership to any PLWHA Association
Yes 113 29.4
No 271 70.6

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 5.2 HIV/AIDS related knowledge, substance use, sexual behaviour and condom use of

study subjects

Three hunderad and sixty five (95.1%) of the respondents knew that they can transmit HIV

to their sexual partner but 16(4.2%) did not. 349(90.9%) of the respondents did know how

to protect their sexual partner from being infected with HIV. Of those who knew way of

prevention, 348(99.7%) reported condom use can prevent transmission of HIV to sexual

partner. Of the 348 women who did know condom use in HIV prevention, 12(3.4%) did

not know the place or person where they can get condom. 364(94.8%) of the respondents

never had alcohol in the last 30 days. Twenty (5.2%) and seventy (4.4%) of the study

subjects had alcohol and chat respectively once or more in the last 30 days prior to the

study (Table 2).

359 (93.5%) of the women had at least one sexual partner and 25 (6.5%) women did not have

sexual partner during the survey. Of all (384) women 346 (90.1%) of the women reported to

have regular sexual partner and the rest 38(9.9%) have non regular partners. 299(77.9%)

had sexual intercourse in the past 6 month. Thirty five (9.1%) of all women were pregnant

since they tested for HIV, of these 25(71.4%) gave birth, 10 (28.6%) were pregnant during

the study period. The pregnancies were not intentional in 9(25.7 %.) and also 5(20%) of

those women who gave birth did not have access to PMTCT services for last delivery

(Table 2).

The number of current sexual partners of the respondents were two for 12(3.1%) and three

and above for 7(1.8%) of the women (fig 1).

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 Concerning condom use, only 30.6% of regular and 60.5% of non regular sexual partners

used condom always since they knew their HIV positive sero status. Where as condom use

by the women the last time they had sexual intercourse with their partner was 67.9% for

regular and 91.9% for non regular partner.

The common reason for non use of condom as it was reported by the participants were;

partners objection (34.9% of regular and 60% of non regular), in order not to be suspected

by sexual partner (37.2% of regular and 40% of non regular), and being HIV positive

sexual Partner(19.8% of regular and 40% of non regular partners).

1.8%
3.1%

One

Two

Three & above

95.1%

Fig: 1 Number of current sexual partners of women PLWHA attending

ART clinic, Hawassa Referral Hospital, April 2008

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 Table 2 HIV/AIDS related knowledge, substance use, sexual behaviour and condom
use of women PLWHA attending ART clinic, Hawassa Referral Hospital, SNNPR,
April 2008

Characteristics Number %
Knowledge on transmission of HIV to sexual
partner (n=384)
Yes 365 95.1
No 3 0.8
Do not Know 16 4.2
Knowledge of protecting partner from HIV
(n=384)
Yes 349 90.9
No 35 9.1
Knowledge on condom use to prevent HIV
transmission to sexual partner (n=349)
Yes 348 99.7
No 1 0.3
Knowledge of source of condom(n=348)
Yes 336 96.6
No 12 3.4
Alcohol use in the past 30 days (n=384)
Never 364 94.8
Yes, once per month 7 1.8
Yes, once per week 12 3.1
Yes, daily 1 0.3
Chat use in the past 30 days (n=384)
Yes 17 4.4
Never 367 95.6
Pregnancy after HIV test (n=384)
Yes 35 9.1
No 349 90.9
Gave birth after positive HIV status (n=35)
Yes 25 71.4
No 10 28.6
Pregnancy intention (n=35)
Wanted 26 74.3
Unwanted 9 25.7
Access to PMTCT for last delivery (n=26)
Yes 21 80.7
No 5 19.3

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 5.3 Rate of HIV Positive Status Disclosure

5.3.1 Rates of HIV positive status disclosure among all study participants

Three hundred and fifty four (92.2%) of the respondents disclosed their HIV positive status

to anyone and 329(85.7%) disclosed to their sexual partner. However, for 55(14.3%) of the

women disclosure of HIV infection is a difficult issue to sexual partner. The rate of HIV

positive status disclosure varies by the type of sexual partners of the women. It was 71.1%

and 87.3% for non regular and regular sexual partner respectively.

The rate of disclosure to any one (92.2%) was achieved over a period of time. Two

hundred sixty two (68.2%) of the participants disclosed within one month, (15%) between

1month and 6month, 5.2% after 6month of diagnosis and the rest 3.1% did not remember.

As shown in figure 2, the first individual to whom the respondents disclosed their HIV

result was mainly to sexual partners 267(75.4%). More than half 219(57%) of them next

disclosed their HIV positive status to family members.

The main reasons for disclosure of HIV result to sexual partner in 347(98%) of the study

participants were felt responsibility, concern for not to risk others health, seeking social

support and in 89.5% of the participants to teach others about the disease.

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 300
75.4%

250

200
Frequency

150

100
http://www.pdf4free.com

50
9.6% 8.8%
2% 3.4% 0.80%
0
Community
Relatives

Friends
Sibling
Parent
Partner

Members
Other

Preferred individuals

Fig. 2 First time HIV positive status disclosures of women PLWHA attending ART
clinic, Hawassa Referral Hospital, SNNPR, April 2008
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27
 5.3.2 HIV positive status disclosure among women having Regular sexual partners

Of the 346 women having regular sexual partners 87.3% disclosed their positive status to

their partners. The relation of respondents with their regular partner was 2years for

64(19.3%) and >2year for 267(80.7%) with mean (SD) 7.7(6.2) years.

Majority (70%) of the study participants reported that they did not discuss on HIV and

VCT issues with their partner prior to HIV test and the rest 30% discuss. Two hundred and

twenty one (63.9%) of the women did asked about the HIV status of most recent regular

partner and 203 (58.7%) of them knew the HIV status of their partners. Of those who knew

their recent regular partner’s HIV status, 187(92.1%) of the sexual partners were HIV

positive and 16(7.9%) were HIV negative. Condom use was higher among those who

disclosed their results (p<0.05). But discussion on HIV and VCT issues prior to the test

among the partners did not found to have association with status disclosure. The social

relation ship of the respondents with the partner prior to the HIV test was smooth in

302(87.3%) and the rest with disagreement as shown in table 3.

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 Table 3 HIV/AIDS related issues, communication and treatment by HIV positive
status disclosure to regular sexual partners of women PLWHA attending ART clinic,
Hawassa Referral Hospital, SNNPR, April 2008

Characteristics Status Disclosure to regular sexual

partner X2(P-value)
Yes No
Number (%) Number (%)
Own monthly income(Eth. Birr)
250 192(63.6) 18(40.9) 7.348(0.007)
>250 110(36.4) 26(59.1)
Duration of relation with
partner
2year 22(51.2) 42(14.6) 29.795(0.000)
>2year 21(48.8) 246(85.4)
Knowledge of Partner status
Yes 200(66.2) 3(6.8) 53.473(0.000)
No 102(33.8) 41(93.2)
Duration of HIV test
11month 112(37) 24(54.5)
12month 172(57) 19(43.2) 5.249(0.072)
Do not remember 18(6) 1(2.3)
Relationship before test
Smooth relation 32(72.7) 270(89.4) 8.179(0.004)
With disagreement 12(27.3) 32(10.6)
Duration of ARV started
1 year 20(45.5) 111(36.8)
>1 year 2(4.5) 100(33.1) 1.041(0.000)
Not started 22(50) 91(30.1)
Discussion before test
Yes 55(18.2) 7(15.9)
No 212(70.2) 32(72.7) 0.150(0.928)
Do not remember 35(11.6) 5(11.4)
Condom use
Yes 174(57.6) 5(11.4) 60.447(0.000)
No 51(16.9) 34(77.3)

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 5.3.3 HIV positive status disclosure among women having non regular sexual

partners

Thirty eight or 9.9 percent of the total (384) study participants had non regular sexual

partners. Of the 38 women having non regular sexual partner majority (65.8%) of them

discusses on HIV/AIDS issues and VCT with their partner before tested for HIV.

The duration of relation with the recent partner was 5month for 23(67.6%) and 6month

for11 (32.4%) of the respondents with mean and standard deviation of 5 and 3.6 months

respectively. Despite, 27(71.1%) of the women disclosed their HIV positive status to these

sexual partners, only 10(26.3%) of them knew the HIV status of the most recent regular

partner.

5.4 Barriers to HIV sero-status disclosure

The most common barriers to disclose the test results as reported by the women were fear

of stigma and rejection 49(89.1%), client skill and psychological factors such as difficulty

of accepting the test result and didn't know how to tell the person about the diagnosis

26(47.3%), fear of abandonment 25(45.5%), fear of confidentiality 21(38.2%) and fear of

accusation of infidelity 2(3.6%) (Table 4).

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 Table 4 Barriers to disclose HIV positive status among women with regular and non
regular sexual partners attending ART clinic, Hawassa Referral Hospital, SNNPR,
April 2008 (n=55)

Women having Women having Total

regular sexual non regular sexual (n=55)
Barriers to status disclosure partner (n=44) partners (n=11)
Number (%) Number (%) Number (%)
1. Fear of stigma and rejection 38(86.4) 11(100) 49(89.1)
2. Fear of abandonment 17(38.6) 8(72.7) 25(45.5)
3. Fear of confidentiality 13(29.5) 8(72.7) 21(38.2)
4. Client skill and
psychological factor 18(40.9) 8(72.7) 26(47.3)
5. Fear of accusation of
infidelity 0(0) 2(18.2) 2(3.6)

5.4 Outcomes of HIV sero-status disclosure to sexual partners

Following disclosure of the HIV test result to their partners, the reaction was positive in

123(40.7%) of regular partner and 9(33.3%) of non regular partner. But the negative

reaction after status disclosure was 179(59.3%) for regular partners and 18 (66.7%) for non

regular partners.

Positive outcome following HIV positive sero status disclosure to sexual partner as

reported by the respondents were receiving kindness 132(40.1%), neutral 85(25.8%), and

increased support 104(31%).

The negative outcome commonly encountered following sero status disclosure were

abandonment 81(24.6%), anger 181(55%), blame 187(56.8%), stigma 91(27.7%), violence

52(15.8%) and break up in the relationship 47(14.3%)(Table5)

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 Table 5 Outcome of HIV positive status disclosure among women with regular and
non regular sexual partners attending ART clinic, Hawassa Referral Hospital,
SNNPR, April 2008

Women having Women having

regular sexual non regular
partner (n=302) sexual partners Total
(n=27) (n=329)
Outcomes Number (%) Number (%) Number (%)
Positive outcome 123(40.7% 9(33.3) 132(40.1)
1. Receiving kindness 102(33.8) 7(25.9) 109(33.1)
2. Neutral 77(25.5) 8(29.6) 85(25.8)
3. Increased support 96(31.8) 8(29.6) 104(31.6)
4. Decide to be tested 123(40.7)4 13(48.1) 136(41.3)

Negative outcome 179(59.3%) 18(66.7) 197(59.9)

1. Abandonment 70(23.2) 11(40.7) 81(24.6)
2. Anger 164(54.3) 17(63) 181(55)
3. Blame 169(56) 18(66.7) 187(56.8)
4. Stigma and discrimination 79(26.2) 12(44.4) 91(27.7)
5. Violence 45(14.9) 7(25.9) 52(15.8)
6. Breakup in relationship 44(14.6) 3(11.1) 47(14.3)

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 5.6 Predictors of HIV positive status disclosure to sexual partners

Logistic regression for HIV positive status disclosure to regular sexual partner and other

variables were done and as shown in table six women who were cohabiting in marital

status were less likely to disclose HIV positive status to sexual partner [AOR=0.158(0.04-

0.598) ].

Positive statistical association found between status disclosure to regular sexual partner

and Knowledge of partner HIV status [AOR =0.016(0.003-0.08)]. Participants who did not

know the HIV status of their sexual partners were less likely to disclose their HIV positive

status (Table 6).

Women who had been on ARV treatment for more than one year were significantly more

likely to disclose the HIV positive status to their regular partner [AOR=8.62(1.347-55.22)].

Illiterate( do not read and write) in educational status, house wife in occupation and

smooth social relationship before HIV test were significantly more likely to disclose their

HIV positive status, which was not observed after adjustment.

Participant with a monthly income of less than or equal to 250 Ethiopian Birr and those in

relation with their partner for more than two years were more likely to disclose their status

in bivariate analysis but this did not remain significant when controlled for other variables.

No statistically significant association was observed in the other socio-demographic

variables in relation to positive status disclosure to sexual partner (Table 6)

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 Table 6 Determinants of HIV positive status disclosure to regular sexual partner,
of women PLWHA attending ART clinic Hawassa Referral Hospital, SNNPR,
April 2008

Variable (n=346) HIV status Crude OR AOR (95%CI)**

disclosure (95%CI)
Yes No
Marital status
Married 233 14 1.00 1.00
Cohabiting 27 19 0.09(0.04-0.20)* 0.158(0.04-0.598) *
Others 42 11 0.23(0.09-0.59)* 0.880(0.224-3.453)
Occupation
Gov’t employee 39 11 1.00 1.00
House wife 141 9 4.42(1.56-12.63)* 0.922(0.151-5.636)
Merchant 54 8 1.90(0.63-5.80) 1.036(0.204-5.270)
Other s 68 16 1.20(0.46-3.08) 0.360(0.059-2.210)
Educational status
Do not read and write 77 4 3.42(1.12-11.66)* 1.254(0.264- 5.950)
Literate 225 40 1.00 1.00
Own monthly income( Birr)
250 192 18 2.52(1.27-5.05)* 3.989(0.903-17.62.)
>250 110 26 1.00 1.00
Duration of relation with
partner
2year 42 22 0.16(0.08-0.34)* 0.598(0.187-1.918)
>2year 246 21 1.00 1.00
Knowledge of Partner status
Yes 200 3 1.00 1.00
No 102 41 0.04(0.01-0.13)* 0.016(0.003-0.08)*
Duration of HIV test
11month 112 24 0.52(0.26-1.03) 1.594(0.527-4.823)
12month 172 19 1.00 1.00
Relationship before test
Smooth relation 270 32 1.00 1.00
With disagreement 32 12 0.32(0.14-0.72)* 0.391(0.109-1.395)
Duration since ARV started
1 year 111 20 1.34(0.66-2.75) 1.243(0.432-3.582)
>1 year 100 2 12.09(2.64-76.59)* 8.62(1.347-55.22)*
Not started 91 22 1.00 1.00
* Statistically significant
** Adjusted for other variables

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 6. Discussion

Overall 85.7% the participants reported that they had shared their HIV positive test result

with their partners. The meta-analysis studies by WHO for developing countries found

disclosure rate range 16.7% to 86%. From the studies conducted in Mettu and Gore towns

and Addis Ababa, St. Paul Hospital (MPH thesis 2007 unpublished) found disclosure rate

of 69% and 92% respectively (16, 40).

The rate of HIV positive status disclosure in this study was relatively higher than many

studies. This could be explained by first, more than 90% of the participants were from

urban area where access to HIV/AIDS information and services are abundant; the other

explanation could be the relatively longer duration of diagnosis of the participants, which

ranged 1month to 84months.

For 14.3% of the women in this study disclosure of HIV infection is a difficult issue. Like

many other studies both in developing and developed countries including local studies (5,

17), the main reasons for non disclosure reported in this study were fear of abandonment,

stigma and client psychological factor. Fear of abandonment can be explained by, in

settings where resources are extremely scarce and women's access to resources

independent of their partner is uncommon, fear of losing instrumental support from a

partner is a major consideration when deciding whether to share results or not. The absence

of social security and health insurance also make women dependent on their partner and

family for their health care, therefore women may choose not to disclose HIV status in

order to benefit from family support.

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 Fear of discrimination can also be related with fear of social discrimination leading to

social isolation and lack of support and fear of socioeconomic discrimination which may

lead to problems with jobs, housing, and other practical socioeconomic considerations(5 ).

In our study only 30.6% of the women used condom always since they learned their HIV

positive status and 67.9% of the respondents did used condom during most recent sexual

intercourse with their regular partner. From St. Paul Hospital, Addis Ababa study 65.2%

and 73.4% used condom always and during most recent sexual intercourse respectively

(40). Condom use in this study was relatively low; this could be explained by first, the

women might feel powerless to negotiate safer sex practices with their partner. Second,

the miss-understanding that once both the partners were HIV positive importance of

condom use will be ignored or due to lack of knowledge on re-infection, or unavailability

of condom or none disclosure of the status. So that those couples with none or inconsistent

condom use were at risk of HIV transmission of resistant viral strains and re-infection with

new strains, which are serious public health risks.

Unprotected sex also carries the risk of unwanted pregnancy and the subsequent risk of

HIV transmission to the child. This study showed considerable proportion of women get

pregnant since they learned their HIV positive status, of which one fourth of the

pregnancies were not intentional. This is an important reminder that emphasis should be

given to involve partners and educating clients on the use of Condom in the prevention of

unwanted pregnancy, re-infection, and transmission to partners as well as to child.

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 In our study of all the participants who disclosed their sero-status to their partner, 40.7%

reported positive outcomes such as being supportive or neutral in response to the

disclosure. This finding is by far lower than other studies (5, 26, 27, 38).

From a study in Gore and Mettu towns and Addis Ababa, St. Paul Hospital found 75.9 %

and 90% of HIV positive women who disclosed their result reported positive partner’s

reaction (16, 40).

Most of the findings from both developed and developing country studies showed that

disclosure was not associated with the break-up of long-term relationships. Even if the fear

of most women to disclose is break-up of relations, disclosure was not associated with

abandonment (5, 26, 27, 39).

Negative partner reaction following HIV status disclosure to sexual partner was reported

by considerable proportion of woman (59.3%) in this study. Even though blaming and

anger were the commonest reactions; abandonment, violation, stigma and break-up in

relationship was also common reactions reported by study participants which was again by

far higher than other studies.

The study conducted in Gore and Mettu towns reported 24.1% negative outcomes

following status disclosure (13). Only 6.4% negative partner reaction following status

disclosure was reported from the study conducted in Addis Ababa, St. Paul Hospital (40).

Despite, most marriages survived disclosure in our study; significant number of the women

14.6% reported that disclosure ended up break in marriage and 11.1% break in sexual

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 relation. This finding is nearly similar with studies conducted in Cape Town, South Africa

and Dar Es Salaam, Tanzania 14.6% and 13% of violence following disclosure

respectively ( 36,37). Beside to this study conducted in Tanzania, Kenya, and Trinidad,

27% of the women reported a break-up of a sexual relationship, 5% reported a break-up in

the marriage and 4.5% reported physical abuse by a sexual partner (30)

This implies with rapid scale up of VCT and PMTCT services in the region larger absolute

numbers of women would be at risk of experiencing abuse and even violence. So that,

mechanisms should be devised for identifying and supporting those women who are likely

to experience negative outcomes while scaling up VCT services. Researchers reported that

male involvement must be a key element in addressing and eliminating potential negative

consequences of sero-status disclosure. Men dominate decision-making in many

relationships, and while many women would accept testing, they can return for the result,

in many cases, only after discussion with their partner. It was suggested that women should

be enabled to negotiate disclosure of their partner’s sero-status along with disclosure of

their own and that they are left at a serious disadvantage disclosing their own sero-status

without knowing their partner’s (3).

So that counselors should assist PLWHA’s to determine whether fears of negative

outcomes are grounded in reality or whether they can be overcome. This finding suggests

the need for encouraging disclosure when it is safe and feasible for the woman.

Additionally, whenever possible women should be encouraged to bring their partners with

them to voluntary counselling and testing clinics and the couples should be counselled

together to facilitate disclosure in a safe environment.

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 Only 30% and 58.7% of the respondents reported that they used to discuss on HIV and

VCT issues prior to the study and knew their partners HIV status respectively.

The St. Paul Hospital study reported 95.8% discuss on HIV/VCT issues and 79.8% knew

partner status (40).

Similar to other findings (40), in this study women who were married in marital status

were more likely to disclose HIV positive status to sexual partner. This could be due to

intimacy, strength of their relationship, strong confidence and might have chance to raise

issues related to HIV and test.

Knowledge of partner HIV status was found to be predictor of HIV positive status

disclosure to regular sexual partner. However, more than 40% of the women did not know

the HIV status of their partners.

Consistent with other studies women who had been on ARV treatment for more than one

year was significantly more likely to disclose the HIV positive status to their regular

partner. This could be explained by repeated counselling given for the patients in the ART

clinic during follow up and treatment.

Unlike other studies (5, 17) no statistical association was observed between sex partners

who hold prior discussions about HIV/VCT issues, age, own income, duration of test,

education and HIV status disclosure.

There are reports that HIV status disclosure to sexual partner is affected by multiple factors

such as age, duration of relationship with sexual partner, education, socioeconomic status,

level of education, culture, ethnic group, discussion on HIV and VCT prior to test, number

of partner and partner involvement in the test (5, 17,40).

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 Strength of the Study

• Pre-tested and modified questionnaire used for data collection.

• Female nurses working in the ART clinic were used to collect the data from all

respondents so that confidentiality reassured.

• The principal investigator and supervisor were supervising the daily data collection

activity.

Limitation

• Convenient sampling was used that may incur selection bias.

• Qualitative methods were not used which could have enabled us to find out

additional relevant information.

• Social desirability bias due to sensitive and personal questions related to sexuality.

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 7. Conclusion

• The study showed that married by marital status, those who knew partner status and

took ARV drug for more than one year were predictors of HIV positive status

disclosure to sexual partners.

• Despite, the rate of HIV positive status disclosure to sexual partner in this study is

encouraging; still considerable proportion of women living with HIV/AIDS did not

share their HIV positive result with sexual partners.

• The main reasons for disclosure of HIV result by the study participants were felt

responsibility, concern for not to risk others health and seeking social support.

• The major barrier reported for not disclosing HIV positive result to sexual partners

was fear of negative partner reaction such as abandonment, stigma and rejection.

• Negative outcome following HIV positive status disclosure to sexual partner was

reported by a relatively large proportion of women.

• Significant proportion of women PLWHA did not use condom always. The

common reasons reported for non use of condom were; partners objection, in order

to avoid partner suspicion and having HIV positive sexual Partner.

• Majority of the women were sexually active and considerable proportion of women

conceived (got pregnant) after learning their HIV positive status.

• Discussion on HIV and VCT issues among partners prior to the test was uncommon

and many women still did not know their partner HIV status.

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 8. Recommendations

1. Emphasis should be given to behaviour rehearsal techniques in HIV testing and

counselling programmes because it can assist women develop the skills they need to

disclose results to sexual partners.

2. Special attention should be given to the efforts to promote couple counselling and

testing that may help women to overcome the barriers to disclose their positive status and

also facilitate positive outcomes and minimize negative outcomes.

3. Follow up counseling in VCT centers need to be strengthened to identify couples who

either failed to disclose or faced negative outcome after disclosure and mechanisms should

also be devised for supporting those women who were experiencing negative outcomes.

4. ART clinics should be linked with Reproductive Health services to address the sexual

and reproductive health needs of PLWHA’s with emphasis on Family Planning.

5. Further research is needed specially a qualitative study to explore the context before and

following disclosure is vital as input for future Behavior Change Communication (BCC)

and counseling programs.

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 9. References

1. UN AIDS/WHO. AIDS epidemic update; December 2007.

2. Federal MOH/National HIV/AIDS Prevention and Control Office. Single point
HIV prevalence estimate; June 2007
3. Federal MOH/National HIV/AIDS Prevention and Control Office. AIDS in
Ethiopia 6th ed.; 2006
4. HIV/AIDS in Africa; 2006. htt://www.avert.org/africa.htm.
5. WHO document. Gender Dimension of HIV status disclosure to sexual partners,
Rates, Barriers, and outcomes for women, Geneva, Switzerland; 2003
6. WHO, Counseling and HIV/AIDS, US AIDS, best practical collections,
Geneva;1997
7. UN AIDS/WHO. AIDS epidemic update; December 2006.
8. Seals B. F. Phillips K. D. and Julious C. Disclosure of HIV infection: how do
women decide to tell? Health Education Research Theory and Practice Vol.18 no.1
2003; Pages 32–44.
9. Simoni J et al. HIV disclosure among women of African descent: associations with
coping, social support, and psychological adaptation. AIDS and Behaviour, 2000;
4:147-158
10. Michael D, Kenneth A. Sexual ethics, disclosure of HIV-positive status to partner;
Arch Intern Med, 1998;158:253-25
11. Bouillon et al. Factors correlated with disclosure of HIV infection in the French
Antilles and French Guiana: AIDS. 21 Supp 1: S89-S94,2007
12. Hetherton J. Brook G. Disclosure of HIV among black African men and women
attending a London HIV clinic. AIDS Care, Volume 19, March 2007 , p385 – 391

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 13. Suzanne M, et.al. High Rates and Positive Outcomes of HIV sero- status disclosure
to Sexual partners: Reasons for Cautious Optimism from a voluntary Counseling
and testing Clinic in Dar es Salaam, Tanzania. AIDS and behavior, Volume7,
number 4, 2000, p 373-382
14. Farquhar C et al. Prevalence and correlates of partner notification regarding HIV-1
in an antenatal setting in Nairobi, Kenya. International Conference on AIDS; 2000.
2000;381.
15. Ladner J et al. A cohort study of factors associated with failure to return for HIV
post-test counselling in pregnant women: Kigali, Rwanda, 1992-1993. AIDS, 1996;
10:69-75
16. Kebede D,Wassie L, Yismaw D. Determinants and outcomes of disclosing HIV-
sero positive status to sexual partners among women in Mettu and Gore towns,
Illubabor Zone southwest Ethiopia; Ethiop. J. Health Dev. 2005; 19(2):126-131
17. Levy A et al. Disclosure of HIV sero positivity. Journal of Clinical Psychology,
1999; 55:1041-9.
18. Lee S, Wang Ko. Differences in HIV disclosure by modes of transmission in
Taiwanese families. AIDS Care, Volume 19, July 2007 , p791 – 798
19. Kakimoto K, Leng Chou T, Sedtha C. Influence of the involvement of partners in
the mother class with voluntary confidential counseling and testing acceptance for
Prevention of Mother to Child Transmission of HIV Programme (PMTCT
Programme) in Cambodia. AIDS Care, Volume 19, March 2007, pages 381 – 384
20. Yang H., Stanton B, Fang X. Lin D, and Naar-King S, HIV-related knowledge,
stigma, and willingness to disclose: A mediation analysis, AIDS Care. October
2006; 18(7): 717–724.
21. Armistead L et al. African-American women and self-disclosure of HIV infection:
Rates, predictors, and relationship to depressive symptomatology. AIDS and
Behaviour, 1999; 3:195-204.
22. Keogh P et al. The social impact of HIV infection on women in Kigali, Rwanda: a
prospective study. Social Science and Medicine, 1994; 38:1047-53.

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 23. Bennetts A et al. Determinants of depression and HIV-related worry among HIV-
positive women who have recently given birth, Bangkok, Thailand. Social Science
and Medicine, 1999; 49:737-749.
24. CSA. Ethiopian Demographic and Health Survey (EDHS); 2005 report.
25. CSA. Ethiopian Behavioral Surveillance Survey (EBSS); 2005 reports.
26. Beevor A, Catalan J. Women's experience of HIV testing: the views of HIV
positive and HIV negative women. AIDS Care, 1993; 5:177-186.
27. Gielen AC, O'Campo P, Faden RR, Eke A. Women’s disclosure of HIV status:
experiences of mistreatment and violence in an urban setting. Women’s Health,
1997; 25:19-31.
28. Kilewo C et al. HIV counselling and testing of pregnant women in Sub-Saharan
Africa. Journal of Acquired Immune Deficiency Syndromes, 2001; 28:458-462.
29. Matthews C et al. Disclosure of HIV status and its consequences. South African
Medical Journal,1999; 89:1238
30. Grinstead OA et al. Positive and negative life events after counselling and testing:
The Voluntary HIV-1 Counselling and Testing Efficacy Study Group. Aids, 2001;
15:1045-1052
31. Sigxaxhe T, Mathews C. Determinants of disclosure by HIV positive women at,
“Khayelitsha mother to child transmission pilot project” South African setting, Int.
Conf AIDS. 2000 Jul 9-14
32. Kilmarx P, Hamers F, Peterman T. Experiences and perspectives of HIV-infected
sexually transmitted disease clinic patients after post-test counselling. Sexually
Transmitted Diseases, 1998; 25:28-37.
33. Leickness S, Anna S, Allanise C, Nomvo H., Ayanda M., and Seth C. Risk

behaviors among HIV Positive men and women HIV status disclosure to Sex
Partners and sexual in Cape Town, South Africa; 2006
34. Sarna A et al. “Does being treated with HAART affect the sexual risk behavior of

people living with HIV/AIDS? Mombassa, Kenya. 2005

35. Zeleke K, Sarkaem A. History of Awassa from 1952-1999EC; Aug. 2007.

36. Kilewo C et al. HIV counselling and testing of pregnant women in Sub-Saharan
Africa. Journal of Acquired Immune Deficiency Syndromes, 2001; 28:458-462

45

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 37. Matthews C et al. Disclosure of HIV status and its consequences. South African
Medical Journal, 1999; 89:1238.
38. Niccolai L et al. Disclosure of HIV status to sexual partners: predictors and
temporal patterns. Sexually Transmitted Diseases, 1999; 26:281-285.
39. Allen S et al. Effect of sero-testing with counselling on condom use and sero-
conversion among HIV discordant couples in Africa. BMJ, 1992; 304:1605-9.
40. Lemma F. HIV Sero-positive Status Disclosure to Sex Partners and Sexual Risk
Behaviors of PLWHA’s in Addis Ababa, MPH Thesis; October 2007(unpublished)

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 Annex I: Map of

SNNPR

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 Annex II: Questionnaire English version

Information sheet

AAU, MF, School of Public Health QUESTIONNAIRE of cross-sectional survey of

HIV status disclosure to sexual partners

Introduction

I am__________________________ ,working as a data collector in this study that assess HIV

status disclosure rate, barriers and outcome at Awassa referral hospital in the ART clinic. The study

is run by AAU, School of Public Health, in collaboration with Awassa referral hospital.

Please remember that all your answers are confidential. On this questionnaire your name will

not be written and will not be linked to your name. This information will remain only with

the research team.

The answer you give will be used to plan the ways to address women who have difficulty of

disclosing and help them in order to increase their full participation in the PMTCT and ART

program. Please do the best you can to answer all the questions. You do not have to answer, if you

do not wish to answer a question, even you may end this interview any time you want.

Your refusal to participate in this study does not affect the quality of service given to you by the

ART clinic. The time it will take for this interview is only 15-20 minutes.

Do you agree to participate in this study?

Yes__________ No____________

Identification Number_____________ Date of interview____________

Time started_______________ Time ended____________________

Interviewer Signature_____________

Supervisor Name________________________ Sign.__________

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 QUESTIONNAIRES

Section I: Socio- demographic characteristics

S.no. Questions Coding Categories Skip
Pattern
101 Address Zone_____________
Woreda __________
1. Urban
2.Rural
102 Age in years( enter number) ----------years
103 Ethnic group 1.Sidamo 2.Wolayta 3.Gurage 4.Amhara
5.other specify
104 Religion 1. Orthodox 2.Protestant 3.Muslim
4. other specify______________
105 What is your highest educational 1. Illiterate 2.Read and write 3. Primary
level? 4. Secondary 5. Technical and vocation/
Diploma and above
106 Occupation 1. Government employee 2. Farmer
3. House wife 4. Merchant 5.Student
6.Non governmental 7. Daily laborer
8. Other (specify)______________
107 Your own monthly income(birr) 1. < 200 2. 200-250 3. 251-500
4. 501-999 5. 1000 and above
6. Other (specify)______________
107 Your sexual partner monthly 1. < 200 2. 200-250 3. 251-500
income(birr) 4. 501-999 5. 1000 and above
6. Other (specify)______________
108 What is your current marital status? 1.Currently married
2. Cohabiting
3. Never married
4.Divorced
5.Widowed
6.Other (specify)______________

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 Part II. General Information (from both respondents with regular and non regular sexual
partners)
QID Questions Response Options Skip Pattern
201 Are you a member of any PLWHA 1. Yes 2. No
associations?
202 Did you gate pregnant after you knew 1. Yes 2. No If no. Q206
your HIV positive status?
203 Did you give birth after you tested for 1. Yes 2. No
HIV? If yes, how many? _______
Record the date of delivery of the
last child? ________________
204 Did all the pregnancies are intentional? 1. Yes 2. No
205 Did you have access for PMTCT 1. Yes 2. No
service for the last delivery?
206 How long since you have known your _________month
HIV status? __________year
Do not remember
207 Have you disclosed your HIV status to 1. Yes
anyone? 2. No If No Q212
208 If you disclosed your HIV test 1.Immediately
result, when did you disclosed? 2.________month
3. ________year
4. Do not remember
209 To who have you disclosed your status 1 Partner / spouse
first? 2 Parent.
3 Sibling
4 Other Relatives
5 Friends
6 Neighbors/community members
7 Friends / Room mates
8 Others (specify)__________
210 To who, have you disclosed your status 1 Partner / spouse
next? 2 Parent.
(Circle all that apply to you) 3 Sibling
4 Other Relatives
5 Friends
6 Neighbors/community members
7 Friends / Room mates
8 Others (specify)__________
211 Reasons for Disclosure of Sero-positive status to others
Factor 1: Responsibility Yes No
1 I felt obligated to tell this person. 1 2
2 Didn't want to risk any more health 1 2
problems for me or the other person
Factor 2: Instruction Yes No
1 My goal was to teach others about 1 2
the disease
2 Other, specify____________

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 212 Are you taking antiretroviral treatment? 1. Yes If No Q214
2. No
213 How long since you are started on ________ months
treatment? _________ year
Other, Specify______________

214 As far as you know can a person get a 1. Yes

disease or infection through sexual 2. No
intercourse?

215 Do you think you can transmit HIV to 1. Yes

your sexual partners? 2. No

216 Do you know how to protect your sex 1. Yes If No Q219

partners from being infecting them with 2. No
HIV?
217 If yes to the above question, how? ____________________ If answer is not
condom Q219
218 Do you know any places or people 1. Yes
where you can obtain condoms? 2. No
219 How often have you had an alcoholic 1 Never
drink in the last 30 days (one month)? 2 Once
3 2-3 times
4 Once or twice a week
5 3-4 times a week
6 Nearly every day
7 Daily
220 Have you used any of the following 1 Alcohol
drugs for the last 6 months? 2 Chat
(Circle all that apply to you) 3 Cocaine
4 Marijuana
5 Others (specify)____________

Part III. Sexual Behaviors, HIV Sero-status Disclosure and Barriers

I will now ask you some questions about your sexual history. Some of these questions may be
sensitive. Please remember that all your answers are confidential and will not be linked to
your name. This information will remain only with the research team.

QID Questions Response Options Skip Pattern

301 How many sexual partners did you have 1. None
during the last 6 months? 2. One
3. Two
4. Three and above
302 Have you had sexual intercourse in the 1. Yes
last 6 months? 2. No

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 REGULAR PARTNERS
Now, I would like to ask you some questions about your regular partner (s)
By regular partner we mean spouse(s) or live-in sexual partners or regular boy friend.
303 Do you have a regular sex partner? 1.Yes
2.No If No Q321
304 How long since you have relation with _________month
this sexual partner? _________year
Do not remember

305 Your social relation with your 1.smooth relation

partner before test result of HIV is 2.with disagreement
3. Other specify_________
306 Did you discuss on HIV/AIDS 1. Yes 2.No
issues and VCT with your partner
before you tested for HIV?
307 Did you ask your most recent regular 1. Yes
partner about his/her HIV status? 2. No
308 Do you know the HIV status of your 1. Yes
Most recent regular partner? 2. No If No Q310
309 What is his/her HIV sero-status? 1. HIV positive
2. HIV negative
310 Have you disclosed your HIV sero- 1. Yes
status to this partner? 2. No If No Q312

311 What was the reaction from this Response Next 316
partner?

Positive outcome 1. Yes 2. No

1 Receiving kindness 1 2
2 Acceptance 1 2
3 Increased support 1 2
4 Decide to be tested for HIV 1 2
5 Specify other________________-

Negative outcome 1. Yes 2. No

1 Abandonment 1 2
2 Anger 1 2
3 Blame 1 2
4 Stigma 1 2
5 Violence 1 2
6 Break up in the relationship 1 2
312 Why did you not disclose your HIV Response
sero-status to this partner?
Factor I: Fear of abandonment Yes No
1 We weren't very close to one 1 2
another

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 2 All the financial and material 1 2
resources are under the control of
partner.
Factor II: Fear of stigma and Yes No
rejection
1 Concerned how this person would 1 2
feel about me after knowing.
2 Concerned this person wouldn't 1 2
understand
3 I worried person would no longer 1 2
like me after knowing.
Factor III: Fear of confidentiality Yes No
1 My diagnosis is my own private 1 2
information
2 I have a right to privacy 1 2
3 Specify if any______________
Factor V :Fear of accusation of Yes No
infidelity
1 I worried that my partner would 1 2
accuse me, of being unfaithfulness.
Factor VI: Client skill and Yes No
psychology
I had difficulty of accepting my 1 2
HIV status.
I didn't know how to tell the person 1 2
about my diagnosis.
I don't have to tell anyone if I don't 1 2
want to
313 Do you think it is your duty to disclose 1. Yes
your HIV sero-positive status to this 2. No If no. Q315
partner?
314 Do you think you are efficient enough 1. Yes Next 316
to tell to this partner? 2. No
215 Whom do you think is the right person 1. Father 4. brother
to disclose your HIV positive sero- 2. Mother 5. Friends
status 3. Sister 6. Religious leader 7. Health
worker
8. Other, specify________________
316 Have you had sexual intercourse with 1. Yes 2. No If no. Q 321
your regular sexual partner since you
knew that you are living with HIV?
317 Did you use condom during this time? 1. Yes, always
2. Yes, most of the time
3. Yes, some times
4.No

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 318 Did you use a condom the last time 1. Yes If no and Don’t
you had sexual intercourse with this 2. No Remember
partner? 3.Don’t remember Q320
319 Who suggested condom use in the 1. I 2. He Next Q 321
last night sexual intercourse? 3. Both of us
320 If you did not put on a condom to Yes No
your clients, what was the reason? 1. He is living with HIV 1 2
2. It reduce my sexual pleasure 1 2
3.In order to not suspect me 1 2
4. Due to lack of knowledge about
condom 1 2
5. Not available 1 2
6. Partner objected 1 2
7. Other specify ------------------------
-----------------------------

NON- REGULAR PARTNERS

Now I would like to ask you some questions about your non-regular partners Sexual partners that
you are not married to and never lived with and include commercial sex workers
321 Do you have a non-regular sex partner? 1. Yes
2. No If No Q236
322 How long since you have relation with _________month
this sexual partner? _________year
Do not remember
323 Your social relation with your partner 1.smooth relation
before test result of HIV is 2.with disagreement
3. Other specify__________

324 Did you discuss on HIV/AIDS issues 1. Yes

and VCT with your partner before you 2. No
tested for HIV?
325 Did you ask your most recent regular 1. Yes
partner about his/her HIV status? 2. No

326 Do you know the HIV status of your 1. Yes

Most recent regular partner? 2. No If No Q328

327 What is his/her HIV sero-status? 1. HIV positive

2. HIV negative
328 Have you disclosed your HIV sero-status 1. Yes
to this partner? 2. No If No Q330

329 What was the reaction from this partner? Response Next 334

Positive outcome 1. Yes 2. No

1 Receiving kindness 1 2
2 Acceptance 1 2

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 3 Increased support 1 2
4 Decide to be tested for HIV 1 2
5 Specify other________________-
Negative outcome 1. Yes 2. No
1 Abandonment 1 2
2 Anger 1 2
3 Blame 1 2
4 Stigma 1 2
5 Violence 1 2
6 Break up in the relationship 1 2
330 Why did you not disclose your HIV sero-
status to this partner?
Factor I: Fear of abandonment Yes No
1 We weren't very close to one another 1 2
2 All the financial and material 1 2
resources are under the control of
partner.
Factor II: Fear of stigma and Yes No
rejection
1 Concerned how this person would feel 1 2
about me after knowing.
2 Concerned this person wouldn't 1 2
understand
3 I worried person would no longer like 1 2
me after knowing.
Factor III: Fear of confidentiality Yes No
1 My diagnosis is my own private 1 2
information
2 I have a right to privacy 1 2
3 Specify if any______________
Factor V :Fear of accusation of Yes No
infidelity
1 I worried that my partner would 1 2
accuse me, of being unfaithfulness.
Factor VI: Client skill and Yes No
psychology
I had difficulty of accepting my HIV 1 2
status.
I didn't know how to tell the person 1 2
about my diagnosis.
I don't have to tell anyone if I don't 1 2
want to
331 Do you think it is your duty to disclose 1.Yes
your HIV sero-positive status to this 2. No If no. Q333
partner?

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 332 Do you think you are efficient enough to 1. Yes Next 334
tell to this partner? 2. No
333 Whom do you think is the right person to 1. Father 4. brother
disclose your HIV positive sero-status 2. Mother 5. Friends
3. Sister 6. Religious leader
7. Health worker
8. Other, specify________________

334 Have you had sexual intercourse with 1. Yes 2. No

your regular sexual partner since you
knew that you are living with HIV?
335 Did you use condom during this time? 1. Yes, always If no. Q 338
2. Yes, most of the time
3. Yes, some times
4.No
336 Did you use a condom the last time 1. Yes If no and Don’t
you had sexual intercourse with this 2. No Remember
partner? 3.Don’t remember Q338
337 Who suggested condom use in the last 1. I 2. He
night sexual intercourse? 3. Both of us
338 If you did not put on a condom to your Yes No
clients, what was the reason? 1. He is living with HIV 1 2
2. It reduce my sexual
pleasure 1 2
3.In order to not suspect me 1 2
4. Due to lack of knowledge about
condom 1 2
5. Not available 1 2
6. Partner objected 1 2
7. Other specify ----------------------
-------------------------------

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 Annex III Questionnaires Amharic Version
SÖÃp

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¾T>cÖ<ƒ ULi KT>Ÿ}K<ƒ ¾Ö?“ ›ÑMÓKA„‹ °pÉ ÁÓ³M::
1. ¾U`S^ ¨<Ö? †¨< ¾SÓKê ‹Ó` ÁKv†¨< c?„‹” KS`ǃ
2. u›? ›` +“ Ÿ“ƒ ¨Å ê”e ›?‹ ›Ã y= S}LKõ” KSŸLŸM uT>ÁÓ²<
–aÓ^V‹ LÃ ¾c?„‹” S<K< }dƒö KTdÅÓ
v¡ ” G<K<”U SÖÃp KSSKe ¾}‰KAƒ” G<K< uTÉ[Ó ÁÓ²<”::
nK SÖÃl” KSSKe vÃðMÑ<U J’ Ts[Ø u=ðMÑ< S<K< Swƒ ›KAƒ::
unK SÖÃl KSd}õ ðnÅ— vKSJ• U¡”Áƒ ¾T>Å[ÓKAƒ ¾¡K=’>Ÿ< ›ÑMÓKAƒ Ø^ƒ ›Ãk”eU::

nK SÖÃl ¾T>ð˨< 15-20 Åmn w‰ ’¨<::

›G<” KSd}õ ðnÅ— SJ•” ÃÓKèM˜::

eTTKG< ›MeTTU

________ _____________
__________ __________
¾nK p ›É^Ñ>¨< ò __________
¾c<ø`zò` eU ________________________
ò __________
I. TQu^©“ ›=¢•T>Á© :- ( /vÊ x ¨<” ÃS<K< )

QID

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 υ
101 ________ µ ”________ ¨[Ç ________
(1. Ÿ}T 2. ÑÖ` )
102
________ ( )
103 wN?[cw 1. c=ÇT 2. ¨LÃ 3. Ñ<^Ñ@ 4. ›T^
5.K?L ÃÖke ___________________
104 1. 3. pò
2. 4. 5.
6. K?L ÃÖke __________________
105 1.
2.
3. 1— Å[Í (1-6)
4. 2— Å[Í (7-10)
5.
6.
106 1. W^}—
2. Ñu_
3.
4. (’ÒÈ
5.
6.
7.
6.K?L ÃÖke___________________
107 ¾ÓKA ¾¨` Ñu= SÖ” (uw`) 1. < 200 2. 200-250
3. 251-500 4. 501 –999
5. 1000 “ Ÿ²=Á uLÃ
6. K?L ÃÖke___________
108 ¾vKu?„/ ¾Õ ¾¨` Ñu= SÖ” (uw`) 1. < 200 2. 200-250
3. 251-500 4. 501 –999
5. 1000 “ Ÿ²=Á uLÃ
6. K?L ÃÖke___________________
109 1.
2. ¹
3.
4.
5.
6.K?L Öke________________

II. . ›ÖnLà Ÿ “ - ∏ L†¨< }d ò ‹ :-

( / vÊ x ¨<” ÃS<K< )
QID
υ
201 1.
2.
202 Ÿ›?‹ ›Ã y= zÃ[e Ò` S•` ŸËS\ ¨Ç=I ›`Ó²¨< 1.
Á¨<nK< 2. 206
203 Ÿ›?‹ ›Ã y= zÃ[e Ò` S•` ŸËS\ ¨Ç=I MÏ ¨MŪM 1.

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