Yanxi Zhu1,a, Zhongfu Liu1,d*
1National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 102206, Beijing, China
a yanxicdc@126.com, d zhongfu_Liu@126.com
*Corresponding Author
Abstract：Objective To investigate the ways of spousal notification and its associated factors among HIV discordant couples.． Methods Face to face questionnaire survey including demographic data，AIDS related knowledge and behavior，and situation of condom use was conducted to investigate relative message on single-positive HIV infected families in Liangshan, Sichuan．AIDS prevention and control data information system was used to collect data on transmission．Results A total of 220 HIV single-positive family couples were surveyed, nd 148 of them were informed of their infection status by the infected person. The results of multivariate stepwise regression analysis showed that male (regression coefficient value was 0.749, t=18.951), junior high school education level or below (regression coefficient value -0.363, t=-5.959), children birth (regression coefficient value was 0.233, t=3.588), and HIV knowledge of infected patients (regression coefficient value was 0.352, t=6.561) were the factors affecting the information of HIV-infected people’s spouses. Conclusions Gender, education level of infected people, knowledge of HIV/AIDS, and parenting are important influencing factors with ways of spousal，HIV discordant couples notification should be strengthened．
Key words: AIDS； Spousal notification；Influencing factor
In recent years, the proportion of HIV transmission through sexual contact in China has gradually increased, becoming the primary mode of HIV transmission [1]. Intrafamilial transmission is one of the significant forms of AIDS spread, and controlling spousal transmission in HIV serodiscordant couples is a crucial step in preventing the epidemic from spreading to the general population [2]. Partner notification refers to the process of informing the fixed and non-fixed sexual partners of infected individuals about exposure risks and providing services such as counseling, testing, and treatment [3]. Partner notification plays a vital role in reducing high-risk behaviors and controlling disease transmission, demonstrating significant effectiveness in early identification of potential HIV infections among the spouses of HIV-positive individuals [4]. It can modify high-risk behaviors, thereby preventing HIV infection and transmission [5], and also alleviate psychological stress and tension in patients [6]. To understand the methods and influencing factors of partner notification among HIV-affected families in Liangshan Prefecture, Sichuan Province, where HIV prevalence is high, this study conducted relevant surveys and research analyses.
- Objects and Methods
1.1 Survey Subjects
The survey subjects were HIV-infected individuals and their spouses from newly reported HIV-affected households since 2017 in four counties of Liangshan Prefecture, Sichuan Province (Butuo, Zhaojue, Yuexi, and Meigu), as recorded in the HIV/AIDS online direct reporting database. In the current HIV/AIDS comprehensive prevention and control information system, individuals without marriage registration certificates issued by the national civil affairs department but cohabiting are also considered spouses. Given the prevalence of de facto marriages in ethnic minority areas of the study site, this survey included spouses who were not officially registered but were in a marital relationship [6].
Inclusion criteria (all must be met):
(1) The most recent medical follow-up management of the infected individual occurred within one year prior to the survey, and the most recent spousal test result of the spouse was within three months prior to the survey;
(2) The survey subject was confirmed HIV-positive, while the spouse was HIV antibody-negative;
(3) Both the infected individual and the spouse were aged 18 or older;
(4) Both parties voluntarily participated and provided informed consent.
1.2 Sampling Method and Sample Size
A convenience sampling method was adopted to identify eligible samples from the HIV/AIDS epidemic database in the surveyed areas based on inclusion criteria. According to the simple random sampling sample size calculation formula N=μ²π(1-π)/δ², a two-sided μ=1.96 was set, with a permissible error δ=0.1*π. The π value was referenced from partial research findings, where the consistent condom use rate during sexual intercourse between infected individuals and their HIV-negative spouses in the past three months, as reported in partner notification surveys, was calculated at 65% [7-11], yielding N=135. To investigate as many samples as possible and ensure the representativeness of the study, the survey scope was further expanded beyond the theoretically calculated sample size.
1.3 Survey Method
A self-designed questionnaire was employed based on research needs, and face-to-face interviews were conducted with the surveyed subjects. The questionnaire primarily included the following contents: general demographic characteristics of HIV-infected individuals and their spouses; HIV infection status; awareness of prevention and treatment knowledge; condom use; antiretroviral therapy status; as well as the method of partner notification, timing of notification, changes in marital relationships post-notification, and changes in the frequency of sexual intercourse between spouses after notification.
1.4 Statistical Analysis
After all questionnaires were reviewed and verified as qualified, a database was established using Epidata 3.1, and statistical analysis was performed using SPSS19. The distribution was described through frequency, composition ratio, and rate. Univariate analysis and multivariate stepwise regression analysis were conducted on factors influencing HIV disclosure between spouses in affected families, with a two-sided significance level of 0.05 as the statistical criterion.
2 Results
2.1 Basic Information of Survey Subjects: A total of 284 AIDS-affected families meeting the inclusion criteria were sampled, with 220 families (440 individuals) effectively completing the entire questionnaire, yielding a valid response rate of 86.1%, which were subsequently included in statistical analysis. Comparison with demographic data from the AIDS Comprehensive Prevention and Treatment Information System database showed no statistically significant differences in ethnicity, age, or gender composition between the 220 analyzed families and the initially recruited 284 families. Among the 220 families, the HIV-positive individuals were predominantly male (148, 67.3%), aged 18–51 years (mean: 26.5 years), with education levels primarily at junior high school or below (196/220, 89.1%). Ethnicities were mainly Yi (131/220, 59.5%) and Han (74/220, 33.6%). Occupations were primarily migrant workers (91/220, 41.4%) and farmers (86/220, 39.1%). Annual household income was mostly below 6,000 CNY (162/220, 73.6%). Marital status (including de facto marriages) was predominantly first marriage (176/220, 80.0%), with remarriages or higher accounting for 44/220 (20%). Couples’ cohabitation duration was mainly 1–3 years (80/220, 36.4%), and most families had children (192/220, 87.3%).
2.2 HIV/AIDS Knowledge Awareness Among Spouses: Per the “National Eight-Item” standard, the average awareness rate among 440 respondents from 220 families was 57.7% (254/440). Specifically, HIV-positive individuals exhibited 62.2% awareness (137/220), while HIV-negative spouses showed 53.2% (117/220). Notably, the lowest correct response rate among HIV-positive individuals was for “Can eating with an HIV-infected person transmit AIDS?” (98/220, 44.5%), whereas the highest was for “Can receiving HIV-contaminated blood transmit AIDS?” (162/220, 73.6%). Among HIV-negative spouses, the lowest accuracy was for “Can an HIV-infected person be identified by appearance?” (108/220, 49.1%), and the highest was for the blood transmission question (137/220, 62.2%).
2.3 Spousal Disclosure Status: Among the 220 HIV-affected families, 192 index cases disclosed their status to their spouses, yielding a spousal disclosure rate of 87.3%. Regarding disclosure agents, 77.1% (148/192) of cases were disclosed by the infected individuals themselves, 14.1% (27/192) by local HIV prevention workers, and 8.8% (17/192) through indirect disclosure via relatives or others. In terms of disclosure timing, 63.5% (122/192) disclosed within one month of diagnosis, 20.4% (19/192) within 1-3 months, 17.2% (16/192) within 3-6 months, and 4.3% (4/192) within 6-12 months post-diagnosis. Concerning marital relationship changes, 55.7% (107/192) reported no significant change after disclosure, while 44.3% (85/192) experienced deterioration. As for changes in sexual behavior frequency post-disclosure, 50.5% (97/192) showed no significant alteration, whereas 49.5% (95/192) exhibited marked reduction or complete cessation of sexual activity.
2.4 Analysis of Influencing Factors for Spousal Disclosure: Among the 220 HIV-affected families, 148 families had the disclosure made by the infected individuals themselves to their spouses. To understand the influencing factors of spousal disclosure by the infected individuals, a chi-square test was employed for cross-analysis to examine the differences in 11 variables—gender, age, education level, ethnicity, occupation, household income, marital status, duration of cohabitation, child-rearing, the infected individuals’ awareness of HIV, and the spouses’ awareness of HIV—based on whether the infected individuals disclosed their status to their spouses post-infection.
The results are presented in Table 1.
| Table 1: Cross (Chi-square) analysis results of notifications by the infected individuals’ spouses | ||||||||||||
| Influencing factors | name | Whether the infected person informs his or her spouse(%) | amount to | χ² | p | |||||||
| No（n=72） | Yes（n=148） | |||||||||||
| sex | woman | 57(79.17) | 15(10.14) | 72(32.73) | 104.838 | 0.000** | ||||||
| man | 15(20.83) | 133(89.86) | 148(67.27) | |||||||||
| age | 18-25 | 7(9.72) | 27(18.24) | 34(15.45) | 5.260 | 0.154 | ||||||
| 25- | 32(44.44) | 65(43.92) | 97(44.09) | |||||||||
| 35- | 22(30.56) | 45(30.41) | 67(30.45) | |||||||||
| 45- | 11(15.28) | 11(7.43) | 22(10.00) | |||||||||
| Educational level | Junior high school (and below) | 50(69.44) | 146(98.65) | 196(89.09) | 42.505 | 0.000** | ||||||
| Junior high school level or above | 22(30.56) | 2(1.35) | 24(10.91) | |||||||||
| nation | Other | 3(4.17) | 12(8.11) | 15(6.82) | 10.612 | 0.005** | ||||||
| Yi ethnic group | 54(75.00) | 77(52.03) | 131(59.55) | |||||||||
| Han ethnic group | 15(20.83) | 59(39.86) | 74(33.64) | |||||||||
| occupation | Farmer | 24(33.33) | 62(41.89) | 86(39.09) | 15.823 | 0.001** | ||||||
| Migrant work | 25(34.72) | 66(44.59) | 91(41.36) | |||||||||
| Unemployed | 11(15.28) | 16(10.81) | 27(12.27) | |||||||||
| Engaging in business | 12(16.67) | 4(2.70) | 16(7.27) | |||||||||
| Household income | 6,000 yuan and above | 26(36.11) | 32(21.62) | 58(26.36) | 5.238 | 0.022* | ||||||
| Less than 6,000 yuan | 46(63.89) | 116(78.38) | 162(73.64) | |||||||||
| Marital status | Remarriage and above | 21(29.17) | 25(16.89) | 46(20.91) | 4.413 | 0.036* | ||||||
| First marriage | 51(70.83) | 123(83.11) | 174(79.09) | |||||||||
| Years of cohabitation | ≤1 year | 20(27.78) | 43(29.05) | 63(28.64) | 4.925 | 0.085 | ||||||
| 1-3 year | 20(27.78) | 60(40.54) | 80(36.36) | |||||||||
| ＞3year | 32(44.44) | 45(30.41) | 77(35.00) | |||||||||
| Raising children | No | 5(6.94) | 23(15.54) | 28(12.73) | 3.222 | 0.073 | ||||||
| Yes | 67(93.06) | 125(84.46) | 192(87.27) | |||||||||
| Awareness of HIV/AIDS among infected individuals | Unaware | 20(27.78) | 63(42.57) | 83(37.73) | 4.510 | 0.034* | ||||||
| Aware | 52(72.22) | 85(57.43) | 137(62.27) | |||||||||
| Spouse’s awareness of HIV/AIDS status | Unaware | 34(47.22) | 73(49.32) | 107(48.64) | 0.086 | 0.770 | ||||||
| Aware | 38(52.78) | 75(50.68) | 113(51.36) | |||||||||
| * p<0.05 ** p<0.01 | ||||||||||||
The chi-square test (cross-analysis) revealed that whether HIV-infected individuals in families disclosed their infection status to their spouses showed no statistically significant differences (p>0.05) in terms of age, duration of cohabitation, child-rearing, or the spouse’s awareness of HIV status. However, statistically significant differences were observed for the following seven factors: gender (χ²=104.838, P<0.001), education level (χ²=42.505, P<0.001), ethnicity (χ²=10.612, P=0.005), occupation (χ²=15.823, P=0.001), household income (χ²=5.238, P=0.022), marital status (χ²=4.413, P=0.036), and the infected individual’s awareness of HIV status (χ²=4.510, P=0.034).
Gender, age, education level, ethnicity, occupation, household income, marital status, cohabitation duration, child-rearing status, HIV awareness of the infected individual, and HIV awareness of the spouse were assigned as independent variables, while post-infection spousal disclosure by the infected individual was designated as the dependent variable. A stepwise regression analysis (using the stepwise method) was conducted. Through automatic model identification, four variables remained in the final model: gender, education level, HIV knowledge awareness, and child-rearing status. The R-squared value was 0.716, and the model passed the F-test (F=89.479, p=0.000<0.05). See Tables 2 and 3.
Table 2 Variable Assignment in Regression Analysis
| Variable | Assignment |
| Y | Whether condoms were consistently used after infection: 1=Yes, 0=No |
| X1 | Gender: 1=Male, 0=Female |
| X3 | Education level: 1=Junior high school or below, 0=Above junior high school |
| X4 | Ethnicity: 1=Han Chinese, 0=Yi and other ethnic minorities |
| X5 | Occupation: 1=farming, 0=working, business and others |
| X6 | Household income: 1=6000 yuan and above, 0=less than 6000 yuan |
| X7 | Marital status: 1=First marriage, 0=Remarriage, third marriage and others |
| X8 | Duration of cohabitation: 1=≤1 year, 0=more than 1 year |
| X9 | Raising children: 1=Yes, 0=No |
| X10 | AIDS awareness rate: 1=unaware, 0=aware |
| X11 | Spouse’s awareness rate of HIV/AIDS: 1=unaware, 0=aware |
Table 3: Stepwise regression analysis of spouse notification by infected individuals themselves
| variable | β | P | Beta | t | R2 |
| Gender (male vs female) | 0.749 | 0.000** | 0.749 | 18.951 | 0.575 |
| Educational attainment (junior high school and below vs. above junior high school) | -0.363 | 0.000** | -0.241 | -5.959 | |
| Raising children (No vs. Yes) | 0.233 | 0.000** | 0.165 | 3.588 | |
| Awareness of HIV status among infected individuals (aware vs. unaware) | 0.352 | 0.000** | 0.309 | 6.561 | |
| constant | 1.058 | 0.002** | – | 3.121 |
The stepwise regression analysis reveals the following findings: The regression coefficient for gender is 0.749 (t=18.951, p=0.000<0.01), indicating a statistically significant positive influence on whether the infection status is disclosed to the spouse. The regression coefficient for education level is -0.363 (t=-5.959, p=0.000<0.01), demonstrating a statistically significant negative impact on consistent condom use post-infection. The regression coefficient for HIV/AIDS awareness among infected individuals is 0.352 (t=6.561, p=0.000<0.01), showing a statistically significant positive effect on consistent condom use post-infection. The regression coefficient for child-rearing status is 0.233 (t=3.588, p=0.000<0.01), reflecting a statistically significant positive correlation with consistent condom use post-infection.
3 Conclusions and Discussion
Notification of spouses of infected individuals, testing, condom promotion, and early antiretroviral therapy for serodiscordant couples are important components of household-based interventions to prevent HIV transmission between spouses [5], with spousal notification being the crucial first step [6]. This study found that the spousal notification rate among HIV serodiscordant couples in the surveyed population was 87.3%, with 77.1% of notifications made by the infected individuals themselves. Compared to domestic studies on HIV spousal notification rates [7-10], Liangshan Prefecture has achieved relatively higher notification rates among HIV serodiscordant couples in recent years.
This study demonstrates that gender, educational level of the infected individuals, their awareness of HIV/AIDS knowledge, and child-rearing status are significant influencing factors for spousal disclosure, which aligns with findings from both domestic and international studies [6, 7, 9, 10]. Regarding gender, research indicates that due to traditional cultural influences, men generally hold higher economic and familial statuses than women, who often find themselves in disadvantaged positions. Consequently, women are more inclined to conceal their infection status to avoid domestic violence and the social and economic pressures associated with child-rearing, resulting in lower spousal disclosure rates among female HIV-positive individuals compared to males [2, 12, 13].
Concerning educational attainment and HIV/AIDS-related knowledge, studies worldwide have shown that spousal disclosure rates increase with higher educational levels among the infected [6, 8, 10]. Those with greater education are more likely to accurately understand HIV/AIDS-related information, alleviating disease-related panic. They also possess better communication and interpersonal skills, which help mitigate internal pressures, enabling them to disclose their status more openly and proactively seek external support to gain greater societal understanding and assistance [8, 10].
In terms of child-rearing, individuals without children are more inclined to disclose their status to their spouses. This may be linked to their future reproductive needs and awareness of HIV/AIDS knowledge—specifically, understanding that protecting their partners from infection is crucial for effectively reducing mother-to-child transmission risks. Thus, they choose spousal disclosure to better access prevention of mother-to-child transmission (PMTCT) services [15].
This study indicates that the educational level of local survey respondents is generally low, suggesting that when conducting spousal notification and health education campaigns in Liangshan Prefecture, it is essential to fully consider the audience’s comprehension level, explore educational approaches that are easily understood by local residents, and enhance audience acceptance [11]. In spousal notification initiatives, efforts should be made to strengthen men’s awareness and responsibility in preventing HIV transmission between spouses, while simultaneously improving women’s self-protection awareness and capabilities [14], thereby increasing the willingness of female patients to disclose their status. Additionally, special attention should be given to HIV-infected pregnant women experiencing their first pregnancy, with intensified efforts in spousal notification, condom use, and mother-to-child transmission prevention, as well as exploring and formulating effective measures to promote their utilization of these services [15].
This study found that among surveyed individuals who had disclosed their status to spouses, 14.1% were informed by HIV/AIDS prevention workers, while 8.8% were indirectly informed by the infected individuals through relatives or others. Regarding disclosure by workers, the newly enacted “Yunnan Province HIV/AIDS Prevention and Control Regulations” in December 2020 stipulates that “infected individuals and patients should promptly disclose their HIV status to their spouses or sexual partners; if they fail to do so, medical and health institutions have the right to inform,” providing policy justification for mandatory disclosure by workers [16]. Provinces such as Zhejiang, Henan, Gansu, and Guangxi have also implemented clear spousal disclosure policies for infected individuals [7]. While protecting the privacy of infected individuals and avoiding family discord, it is worth considering how to develop localized disclosure guidelines and policies in regions lacking mandatory disclosure policies.
In summary, spousal notification of HIV status is not influenced by unilateral factors, but rather by a combination of individual, social environmental, and prevention service intervention factors. This study is a cross-sectional investigation and has certain limitations in interpreting the causal relationship between spousal notification behaviors and influencing factors. The study participants were drawn from HIV high-prevalence areas in Liangshan Prefecture, specifically serodiscordant couples, and thus the findings may not fully represent characteristics of other regions. Future research could further explore the influencing factors of spousal notification within the context of ethnic minority cultures, social backgrounds, and notification policies, thereby providing a robust scientific basis for developing interventions to promote spousal disclosure.
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