Degrees of disclosure: A study of women's covert use of the diaphragm in an HIV prevention trial in sub-Saharan Africa

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2009.08.014 Byline: Nuriye Nalan Sahin-Hodoglugil (a), Ariane van der Straten (b)(c), Helen Cheng (b), Elizabeth T. Montgomery (b)(h), Deborah Kacanek (d), Sibongile Mtetwa (e), Neetha Morar (f), Jane Munyoro (g), Nancy Padian (b) Abstract: In sub-Saharan Africa more women are infected with HIV/AIDS than men and new prevention methods are urgently needed. One major attribute of female-initiated HIV prevention methods is that they can be used covertly, without a male partner's knowledge. Using mixed methods, we explored the predictors and dimensions of covert use of the diaphragm in a randomized controlled trial that tested its effectiveness for HIV prevention. The Methods for Improving Reproductive Health in Africa (MIRA) trial was conducted in Zimbabwe and South Africa, and data collection took place between September 2003 and January 2007. This study is a secondary analysis of quantitative and qualitative data from participants randomized to the intervention group, and their male partners. It includes survey data from 2316 women (mean age=28.3), 14 focus group discussions (FGD) conducted with 104 women, and 7 FGD and 10 in-depth interviews with 37 male partners. The median follow-up for trial participation was 21 months (range: 12-24). At their final visit, approximately 9% of women had never disclosed to their primary partners that they were using the diaphragm (covert use). In multivariate analysis, predictors of covert use included being older, not co-habiting with the partner, having a partner who did not use condoms, and being from South Africa. Qualitative analysis revealed that covert use was not dichotomous, but ranged along a continuum, which we categorized into five levels (i.e. full disclosure; mostly open use; occasional covert use; mostly covert use; and completely covert use). We discuss the critical role of the option of covert use for many women in the context of an HIV prevention trial, as well as gender power dynamics which may influence women's decisions about disclosure. Author Affiliation: (a) Touro University California, COHS Public Health Program, 1310 Johnson Lane, Mare Island, Vallejo, CA 94592, USA (b) RTI International San Francisco Project Office, San Francisco, CA, USA (c) Center for AIDS Prevention Studies, University of California San Francisco, CA, USA (d) Ibis Reproductive Health, Cambridge, USA (e) UZ-UCSF Research Collaborative Programme in Women's Health, Harare, Zimbabwe (f) Medical Research Council, Kwazulu-Natal, South Africa (g) Perinatal HIV Research Unit, Johannesburg, South Africa (h) London School of Hygiene and Tropical Medicine, Infectious Diseases Epidemiology Unit, Department of Epidemiology, London, UK Article Note: (footnote) [star] We would like to thank the women who participated in this study. For H. Cheng, E. Montgomery, N. Padian, N. Sahin-Hodoglugil, and A. van der Straten, a significant part of the work for this paper was conducted while at the University of California San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences. We also thank Norm Constantine, Sylvia Guendelman, Malcolm Potts, and Charis Thompson for their review of the earlier versions of this paper. The MIRA trial was funded through a grant from the Bill and Melinda Gates Foundation (#21082).