The social and gender context of HIV disclosure in sub-Saharan Africa: a review of policies and practices.

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.