Barriers to timely disclosure of HIV serostatus: A qualitative study at care and treatment centers in Dar es Salaam, Tanzania.

INTRODUCTION: Disclosure of Human Immunodeficiency Virus (HIV) status is important to prevent the spread of HIV and maintain the health of people living with HIV, their spouses, and the community. Despite the benefits of disclosure, many people living with HIV delay disclosing their status to those close to them thereby increasing the risk for disease transmission. This study aimed to determine the barriers to timely disclosure of HIV serostatus for people living with HIV in Dar es Salaam, Tanzania, and identify what motivated disclosure.
METHODS: A qualitative descriptive study using in-depth individual interviews was conducted with10 participants attending HIV care and treatment centers in Dar es Salaam. The participants were people living with HIV who had delayed disclosing their serostatus for more than one month after diagnosis. Data was analyzed using qualitative content analysis.
RESULTS: Three categories emerged from the analysis: Barriers hindering timely disclosure, motivation for disclosure of serostatus, and consequences of delayed disclosure. Barriers to timely disclosure included denial of one's status, the fear of stigmatization, fear of being separated or divorced, the need to protect loved ones, and lack of adequate knowledge about the disease. Reasons that motivated disclosure included gaining social support, preventing disease transmission and wanting to be at peace.
CONCLUSION: Timely disclosure is hindered by stigma because HIV is negatively perceived by the public. People living with HIV prefer not to disclose to avoid the negative consequences of disclosure, especially because of fear of being discriminated against and losing their social status, which plays a major role in social status in Tanzania. Trust and adequate counseling from health care workers helps prompt disclosure.

Introduction

HIV is a burden for the healthcare systems worldwide and presents a major global public health issue that has taken the lives of more than 35.4 million people to date. Sub-Saharan Africa is the most affected region in Africa with 19.6 million people living with HIV/AIDS (PLWHA), which accounts for two-thirds of the global number of new HIV infections [1].

HIV is a major burden for Tanzania’s health care system with an estimated prevalence of 4.5%. Data for 2017 showed that32,000 people died from an HIV related illness, 1.5 million people were living with HIV, and 65,000 people were newly infected with HIV [2].

HIV/AIDS has social, economic, and health impacts in Tanzania, a low-middle income country where the health care system has limited resources [3]. Prevention of HIV transmission is an important factor in reducing the disease, which can be achieved by disclosure of serostatus, particularly early disclosure.

Disclosure of HIV to a third person is defined as the process of a person revealing their HIV status, whether positive or negative [4].

Disclosure of one’s HIV status to sexual partners is essential in limiting the transmission of HIV infection. It is also important in gaining social support from others and facilitating compliance and adherence to antiretroviral (ARV) medications [5]. However, disclosing HIV serostatus is not easy, as it is a personal and complex matter that is difficult to execute, especially as it is often associated with stigma [6]. Disclosure entails a process of communication about a stigmatized, life-threatening, and highly transmissible infection.

The ambitious 95-95-95 strategy was announced by UNAIDS in 2014, aiming to end the AIDS epidemic by 2030 by achieving 95% diagnosis among all people living with HIV (PLHIV), 95% on antiretroviral therapy (ART) among diagnosis, and 95% virally suppressed (VS) among treated. An intermediate goal of 90-90-90 was set for 2020 [7]. Disclosing serostatus means there is easier access and linkage to care and ARV medication, and therefore viral suppression can be achieved.

Women in Tanzania have a lower rate of disclosure compared with men [8]. This may be because they face stigma and discrimination following disclosure, which may be related to their weak social and economic status within their husband’s family. They also fear violence because of gender inequality as disclosure can possibly endanger or destroy a relationship, leaving the women with an additional financial burden [6,9].

Delay in disclosure prevents PLWHA from reaping the benefits of disclosure and can result in further transmission the disease. In this study, delay in disclosure is defined as the time taken for disclosure of HIV serostatus being longer than one month since diagnosis of the disease. This definition was adopted as several studies found that most people diagnosed with HIV disclosed their status within the first month [6,8,10-12].

It has been reported that PLWHA weigh the risks (e.g. fear of abandonment and discrimination) against the benefits (e.g. need for support) of disclosure before deciding to disclose [4]. An individual’s disclosure decision may also change over time, depending on motivating factors and the individual’s situation and health which may lead to a delayed disclosure. In Ethiopia, a reported reason for delayed disclosure was that patients feared losing their social status and position that they had built for a long time. There was also the fear of discrimination by their relatives or sexual partners [13]. In South Africa, PLWHA delayed disclosure because they lacked skills for disclosure and felt they would not be able to handle negative reactions from the person they disclosed to [14].

In Tanzania, the rate of documented delay in disclosure to partners, family, and others was reported to range from 15–23% after one month of diagnosis [6,8] to partners, family and others.

A study in Dar es Salaam [15] found that there was a delay in disclosure before initiation of ARV therapy because people did not want to be stigmatized early in the disease as symptoms appear at a later stage. PLWHA also feared losing their social status in their social circle, which had been constructed over a long time. Another study conducted in Tanzania found that delay in disclosure among women was related to fear of violence because of gender inequality; disclosure of HIV to a husband could possibly endanger or destroy a relationship [6]. In Morogoro, Tanzania, it was found that a reason for delayed disclosure was that those who were diagnosed were in shock and were struggling with their HIV diagnosis and therefore felt unable to disclose in a timely manner [8].

However, although reasons for this delay have been studied using quantitative methods, there has been little evidence of in depth explorations. More qualitative information is needed to understand why PLWHA choose to delay their disclosure, and to identify reasons and methods used for eventual disclosure. Those who do not disclose in a timely manner forgo the numerous benefits of early disclosure, such as social support, prevention of disease transmission, ARV therapy adherence, viral suppression and early linkage to care. Previous studies from Tanzania highlighted the limited information on reasons why PLWHA delay disclosing their HIV status, and the need to further explore reasons hindering successful and timely disclosure, and to understand the motivation for eventual serostatus disclosure.

Materials and methods

Study design and participants

This qualitative descriptive study used individual in-depth interviews and content analysis [16] to explore barriers to timely disclosure of HIV serostatus. The theoretical framework used for this study was the Disclosure Decision Model (DDM): determining how and when individuals will self-disclose [17]. This framework was used to guide discussion related to barriers to timely disclosure and interpretation of the data. The DDM describes the disclosure process and what motivates and influences a person to disclose. It explores how the decision to disclose is based on an evaluation of the possible rewards versus the possible risks of disclosing in any specific social situation.

This study aimed to recruit participants from two care and treatment centers (CTCs) in Dar-es-Salaam: The Mnazi Mmoja Hospital and The Aga Khan Hospital. The Aga Khan Hospital is a private tertiary hospital that mostly receives patients mostly from the urban population in Dar es Salaam. In this hospital, provision of ARV medication is subsidized by the government and is provided free of charge; however, patients must pay for any tests (e.g., cluster of differentiation 4 (CD4) level, viral count) or consultations with the doctor. Physician-initiated testing and counseling is also charged to the patient.

Mnazi Mmoja Hospital is a public/government hospital where all CTC services (medication, tests, and counseling services) are supported by the government and provided free of charge.

Study participants included registered patients at both hospitals who were initiated on treatment, were aged 18 years and above, had a delay in disclosure of more than one month since diagnosis, and provided written informed consent. We excluded patients who were too sick to cooperate and answer questions as well as patients with debilitating mental illness.

Purposeful sampling was used to include participants who were considered most informed about the study topic. Participants from both sexes and different social/economic groups and education levels were included to ensure maximum variation and obtain broad insights and perspectives. Data collection continued until thematic saturation was achieved, which occurred after ten participants had been interviewed. All interviewed participants were from Mnazi Mmoja hospital as no participants from The Aga Khan hospital consented to be part of this study.

Ethical consideration

Scientific review of the proposal was sought from the Aga Khan University Research Committee (AKU-RC) and ethical approval from the Aga Khan University Ethics Review Committee (AKU-ERC).Permission to conduct the study at the hospital was obtained from the Medical Directors of both the Aga Khan Hospital and the Mnazi Mmoja Hospital.

Signed written informed consent for conducting the interview as well as being recorded was sought from the study participants before participation. The consent form was in English and translated into Kiswahili, the national language of Tanzania. The consent form included the standard details of confidentiality and protection of privacy.

Data collection procedure

Participants who had disclosed their status after one month were identified during their monthly drug refill and approached by either the researcher or the CTC nurse. After an introduction about the study, interested patients that were willing to take part were enrolled using a recruitment checklist and then scheduled for an in-depth interview. All interviews were conducted in a counseling room at Mnazi Mmoja Hospital, with the door locked to prevent others entering and to maintain privacy. The in-depth individual interviews were conducted in Kiswahili language using an interview guide that explored participants’ experiences of barriers and reasons for delaying disclosure of HIV serostatus(See supporting information S1 and S2 Files). The interviews took 30–40 minutes on average to complete and were recorded (with participants’ permission) using an audio device which was transcribed verbatim for analysis. Data collection and analysis were undertaken iteratively, and any new, unexpected findings that emerged were incorporated into the process [16]. The interviews were initially conducted by both the main researcher (a final year family medicine resident) and a trained research assistant who was a native Kiswahili speaker with experience in conducting qualitative interviews. After two interviews and following discussion with supervisors, it was decided that the researcher should step back to allow more freedom for the interview discussion as participants were reluctant to talk openly because two people were present in the interview room.

Participants were informed they could decline to participate in this study without prejudice; they were assured that refusing to participate would not influence their access to services when attending regular CTC appointments for check-up and drug refills. Those who participated were given 10,000 TSH (approximately USD 4.3) after the interview as a gesture of appreciation for their time. Field notes on general impressions, contextual matters and non-verbal communication were taken. At the end of each interview, the interviewees were invited to ask questions about the study. All in-depth interviews were anonymized by allocating each participant a number, which was then used for all subsequent analyses and reporting the results.

Data analysis

Data analysis was undertaken out using qualitative content analysis [16]. Interim data analysis occurred concurrently with data collection, with supervisors providing regular feedback to the main researcher. Emerging issues and further data collection needs were identified and incorporated into data collection. All interviews were transcribed and translated into English by a native Kiswahili-speaking nurse who had prior experience in translating and transcribing qualitative research. The transcripts were checked for accuracy against audio recordings to detect any mistakes and changes were made as necessary.

The analysis comprised of repeated readings of the individual interviews to obtain a sense of the whole and to identify meaning units. Next, the identified meaning units were condensed into short, summarized versions (condensed meaning units). Thereafter, codes were formed, which were then grouped to form sub-categories. Finally, from these subcategories and reading back and forth, categories emerged that encompassed the subcategories and reflected the latent content of the text. The whole analysis process was conducted by the main researcher with input from the three supervisors, one of whom was an experienced qualitative researcher. This ensured that data analysis and emerging findings were grounded in the data. An example of the analytic process is shown in Table 1.

Table 1

Example of the analysis process.

Meaning unit	Condensed meaning unit	Codes	Subcategory
“I was so afraid of how he (husband) would receive the information. After all my marriage was still young, just one year, yeah, so I was very afraid that my marriage would end that is why I hesitated to tell him for over a month”	Delayed disclosing because of fear of marriage breaking given that their marriage was 1 year old and was afraid of husband’s reaction	Delay in disclosure because of fear of destroying marriage.Worried about husband’s reaction	Fear of being divorced or losing a partner *

* This subcategory was later included in the category “Barriers hindering timely disclosure”.

Checking for trustworthiness

Four criteria were used to check for trustworthiness: credibility (internal validity), transferability (external validity), dependability (reliability) and, conformability (objectivity) [16,18].

Credibility was assured by creating an environment to promote openness and candid discussions with participants because HIV is a sensitive topic. Triangulation was achieved by using both field notes and transcribed data, engagement with the participants by clarifying points and using probing interview questions and checking the transcriptions. The use of direct quotes from participants to support the text description added to the credibility of the findings. Transferability and dependability were achieved by describing the methods in sufficient detail to create an audit trail, and providing clear and detailed descriptions of the selection and characteristics of participants, data collection, and analysis process. Conformability was ensured by triangulation and reflexivity, which was achieved by regular discussions with the supervisors throughout the research and analysis process. Regular debriefing meetings between the interviewer and the main researcher allowed for constant reflection during the data collection process, ensuring the study objectives were met.

Results

Ten participants completed individual interviews. Participants’ ages ranged from 26 to 45 years, and there were six females and four males. Their education ranged from primary school to college/university degree. The time taken from HIV diagnosis to disclosure ranged from 1 month to 8 years. All participants had disclosed to a family member, except for two participants who disclosed to their boss and a friend. All of the participants had one sexual partner and had no prior HIV status knowledge at time of disclosure.

Participants’ demographics on disclosure are presented in Table 2 below.

Table 2

Participants’ demographics and disclosure details.

Participant Identification number	Sex	Age	Marital Status	Economic Status	Level of education	Time to disclose	Disclosed to
1	F	43	Divorced	small business	Primary	1 year	Husband/sister
2	F	34	Married	Unemployed	Secondary school	8 years	Mother/niece
3	F	37	Married	Banker	Degree	1 month	Husband
4	F	37	Married	Petty business	Secondary school	3.5 months	Mother, siblings. and husband
5	F	40	Co-habiting	Social worker	Degree	3 months	Current partner
6	M	42	Married	Unemployed	Diploma in BA	3 months	Wife
7	M	44	Married	Petty business	Primary school	2 months	Friend
8	F	26	Married	Petty business	Secondary school	1 month	Mother
9	M	28	Single	Unemployed	Secondary school	2 months	Uncle
10	M	45	Divorced	Employed	Primary school	4 years	Boss

Categories

Three categories emerged from the data:

Barriers hindering timely disclosure.

Motivation for disclosure of serostatus.

Consequences of delayed disclosure.

Barriers hindering timely disclosure

Once diagnosed and informed of their results, a majority of participants were in denial and experienced an array of emotions including shock, surprise, feelings of loneliness, and sadness. Participants were unable to accept their status, which led them to delay disclosing it to others.

“I was stunned! I did not expect those results. I was not sick, I was not ill, it was just general body malaise…I was just dumbfounded…” P4

“I did not expect that I would get the results like that…But I got the positive results, but I didn’t really accept that situation and that was the reason I did not disclose this to anyone in my family for a long time.” P 1

A majority of them also noted that they were not equipped with adequate knowledge about the disease and did not know how to disclose it to anyone. Many of the participants expressed feeling lonely and isolated as they lacked the skills to disclose.

“We are not very well educated about the matter.” P4

A major barrier to disclosure of HIV status was fear of the stigma associated with and experienced by those with the illness. They feared being outed, pointed at, and belittled by those they disclosed to.

“The issue there is being outed. Most people including myself are afraid of being known, laughed or belittled and finger-pointing." P 2

They also feared being left or divorced, which made them not want to disclose to their sexual partner.

“I was very afraid that my marriage would end that is why I hesitated to tell him for over a month.” P 3

“The real challenge was to the father of my children. How would I begin? I worried a lot about how he would receive the news…” P 8

Participants were selfless. They were hesitant in disclosing their status to those close to them, because they were afraid of how they would react and wanted to protect them from heartache. They were also scared of losing their trust.

“I was so afraid of telling my mother because I knew that if she found out she would feel very bad and would get hypertension from the news.” P 2

There were some undesirable reactions after disclosure experienced by the participants that led to negative outcomes such as loss of support, attempted suicide, being rejected from their partner by being left/divorced, being blamed, financial troubles, and facing discrimination. Discrimination experienced by participants included lack of confidentiality, being belittled, and exclusion from social gatherings. All these factors acted as barriers to trust and to further disclose to others.

“I had my partner before. I disclosed to him and this is the reason that made me not to disclose early, because as soon as I told him he divorced me… There are a lot of challenges, considering I have kids so sometimes I get a lot of financial constraints… My ex-husband does not help me with their upbringing and school fees.” P1

“I told my niece who took it positively but my niece eventually spread the word about my status…My niece told everyone in the family especially ones that didn’t know… Family can really hurt with words and everyone will talk about you and laugh at you constantly.” P2

“My partner blamed me…After that, he stopped communicating with me. You could tell that he was just concerned about the child and had no affection for me and that is when it ended there.” P5

One participant experienced severe discrimination that led to attempted suicide. With no support by his side and facing discrimination, he turned to living on the streets and finally attempting suicide because he had feelings of worthlessness.

“My uncle told his wife… first they stigmatized me. Severely. They regarded me as someone who was going to die. There was no support. The hatred went all the way to his mother as well…it affected me; I ended up leaving home and living on the streets. They do not see my benefit, I feel unworthy. Ever since I have lived in the streets, not even one person has come looking for me. Education wise, I have already given up, I ended up in form four. So, for now no more school for me. I did not do exams because I had school debt. After he found out about my health status he stopped (paying). I attempted suicide. I tried to hang myself, fortunately, God did not want me to die. Somebody saved me. I was tired of feeling worthless, why should I continue suffering? The mind starts running games on you. I have no mother, no father; I really wanted to make up my mind. I left the front porch and went at the back of the house where it was very dark, it was around 8pm. I found a strong shawl, made a noose on my neck, but things did not turn out the way I wanted them to. I shouted, they came, found me and took me to the hospital.” P 9

Motivation for disclosure of serostatus

Participants were asked about what made them eventually disclose after a long period of keeping their status to themselves. Responses varied depending on participants’ situations and circumstances.

Some participants were seeking support in terms of financial aid, emotional support or medical support from those whom they disclosed to. They wanted the person they disclosed to help them if they were to fall sick, and someone to be their spokesperson during their illness. That person would also be a source of emotional support and be able to collect medication on their behalf.

“The main reason of disclosure of my HIV status to my sister is that there is a possibility of me falling sick and I will need her as a companion for support for getting my medications…even when I am sick she will know how and what to tell other relatives.” P1

Participants were in search of peace of mind and freedom from the need for secrecy in taking pills and attending clinic visits. Many expressed the fear of losing the trust of their partners if their status was revealed from other sources.

“I felt like I had to tell him because, firstly, I wanted to be at peace because I was on medication… We live in one house; one room and I am using ARVs in secret. What if he found out accidentally one day and saw the medication?” P3

Despite being scared, participants felt the need to inform their partners out of love for them by encouraging them to go and get tested to protect them from the disease and stop the transmission of the disease.

“I used to get lost in thought, what if he is not infected, and we kept on having sex? That is when I decided that I had to tell him, in case he was not infected, then I might save him…” P3

Other participants waited to disclose their status until their health had deteriorated, and they could no longer keep their condition a secret. When the signs and symptoms started to show, questions would be raised and eventually circumstance meant they had to disclose.

“… I kept it a secret for a long time until when the symptoms showed…during the whole time, I never got ill. Didn’t show symptoms or anything. But in 2010 I started losing weight drastically and it showed. The fevers and malaria became very frequent. I had to disclose then.” P2

Participants noted that counseling from healthcare workers prompted them to disclose and added that receiving proper counseling about their condition and relevant education helped in disclosure and treatment support. Participants tended to disclose to people close to them, who they trusted, such as a family member, partner, or close friend.

“The reason that made me open up to her is that when we came here, we were counseled well and tested.” P2

“I felt at ease telling my siblings because I consider them my confidants” P4

“She (my wife) is my significant other. We have to stand together; you cannot tell anyone else except her. You can tell even your sibling and they would not get it as your partner- it was in me to confide in someone I trust.” P6

After disclosure participants experienced a myriad of reactions from their trusted ones, both positive and negative. Having experienced a positive reaction after disclosure resulted in support, and participants mentioned that compliance to treatment and managing symptoms was easier with that positive support. It also encouraged participants to disclose to others.

“My mom insists on telling me daily that I should be strong and not feel sorry for myself…she follows up my refills and encourages me to take the medication.” P2

“Everyone received the information with a heavy heart truthfully…The most important thing is they encouraged me, telling me examples of how other people were surviving and that it is not the end of my life. They really walked with me in every aspect through it all. They would also remind me to attend the clinic. I was also, very open to them about everything. After I confided in my siblings, they advised that I should also tell my husband so we can use medication together.” P4

“I told my friend after two months… I felt very relieved. I felt free. I told my very close confidant. He was proud of me. He made me stronger by also assuring me about the importance of telling my wife. You see? It was not easy telling my wife. It was easy telling my friend, we grew up together.” P7

Consequences of delayed disclosure

Participants shared some negative consequences that they had experienced because of their lack of timely disclosure. Before disclosing, participants had engaged in regular unprotected sexual intercourse with their regular partner as they could not enforce condom use. This might have led to an increased risk of the transmission of the disease.

“I told him at night in bed. You know being married and all, we must make love without condoms.” P3

It was also noted that there was poor compliance with treatment and adherence to medication before disclosure because of the lack of support from those around them and the need to hide medications. This overall secrecy was hard for participants to maintain, and affected their relationship with their partner and cause distrust.

“… I did not even care about taking medication or disclose to anyone, I had no support.” P10

“I grew restless not sharing my status with him (partner) even when I leave him home alone I always wondered and worried if he could be looking around and scavenging my bags or handbags where I hide my things. So, when I knew he was home I would always come back very fast and just to check what was going on.” P 5

Discussion

All participants revealed that disclosing HIV test results was not an easy decision; rather it was a complex and difficult personal matter that entailed communication about a potential life threatening, stigmatized and transmissible infection. The findings of this study demonstrated that the decision to disclose changed over time, depending on the individual’s situation and circumstances. According to the DDM [17], the first step in disclosure is entering the situation in which a disclosure goal is made salient or accessible; these goals motivate one to disclose. This study suggested that the goals for disclosure were gaining care and support from a confidant during illness, being considerate of others by preventing the transmission of disease, seeking peace of mind and freedom from secrecy, and participants’ health deterioration. These considerations resulted in the disclosure of serostatus. Consistent with previous studies, these findings highlighted that the goals of disclosure included limiting transmission of the disease, gaining emotional and financial support, gaining support in adhering to medication, and being able to use medication freely [5,6].

Adherence to ARVs is important to achieve a suppressed viral load, which interrupts onward HIV transmission to susceptible partners. A previous study conducted in Dar es Salaam revealed that the disclosure of HIV status before initiation of ARV therapy improved patients’ adherence and had a positive influence on CD4+ T-cell counts recovery as well as viral load suppression [15].

It has also been noted that disclosure of serostatus depends on the individual’s state of health, with HIV-infected individuals delaying disclosure until their disease had progressed and it became difficult to conceal their illness from their partners [8,19].

External factors can also influence social goals around disclosure. This study found that participants disclosed their status to others, albeit delayed, if they were prompted and appropriately counseled by CTC nurses. This professional support helped to empower them with knowledge about their condition. This finding was consistent with a study from Ethiopia that demonstrated strong counseling services prompted disclosure [20]. In contrast, participants who were not counseled properly or had inadequate knowledge about their condition tended to delay disclosure. This finding was similar to a study conducted in South Africa that reported disclosure was delayed because of a lack of disclosure skills and support from health care workers to prepare patients for disclosure [14].

This is an important issue as it demonstrates that when the PLWHA do not receive adequate support and counseling after learning about their status they are less likely to disclose. The support and counseling they receive from health care providers empowers them to accept their serostatus, disclose this status to those they trust, and access benefits from early disclosure. Strengthening counseling services provided by health care providers by equipping them with adequate knowledge and counseling training can help timely disclosure among PLWHA.

The second stage of the DDM involves decisions about whether disclosure is an appropriate strategy to exercise, and with whom. The desire to avoid or delay disclosure of HIV status is influenced by the relationship with the target person. In this study, it was shown that participants would disclose this sensitive information to confidants that they relied on, trusted, and were close to. This finding was consistent with other studies from the US [10,21] that noted participants selected targets they trusted and were close to.

The next stage of disclosure is assessing the subjective utility of disclosure versus the subjective risk from disclosure. Subjective utility refers to the perceived value of the desired outcome to the individual who is disclosing, which was a similar finding in this study and previous studies [22]. Participants sought positive outcomes such as the need to be accepted by confidants and treated with respect as well as wanting to receive support after their disclosure.

The subjective risk from disclosure in this study was the perceived anticipated possible risks and negative outcomes encountered after disclosure, which formed the barriers to disclosure.

The biggest barrier faced by participants in this study was fear of stigmatization. They were worried about and fearful of social rejection and stigmatization by their confidants and families following disclosure, which would lead to loss of social support. Stigmatization was perceived in many forms, including social stigma, being laughed at or labeled, being left/divorced or being discriminated against. There also was a component of fear about being stigmatized early in the disease because the medication masked the physical effects of HIV progression.

The majority of participants in this study found out their status during their routine antenatal care when pregnant and others when they fell sick. Tanzania incorporates HIV testing and counselling in antenatal and reproductive and child health services and recommends engagement with, testing of, and counselling partners at health facilities [23]. For all participants it was the testing for the first time and so did not have prior knowledge on their status or when and where from they contracted the disease. On disclosure it lead to disagreements, loss of trust, strain in the relationship between partners and in some cases a breakdown of the relationship.

Similarly, several previous studies demonstrated that there were risks in disclosure, such as fear of stigma and abuse, fear of conflict, and fear of breach of confidentiality (i.e. betrayal) [8,15,24-26]. Other studies showed that delayed disclosure was attributable to fear of early stigmatization before the symptoms appeared because of the effectiveness of ARVs in concealing symptoms [13,27].

A striking finding was that the majority of the participants faced stigmatization (e.g. being laughed at, being discriminated), experienced infidelity, and one participant had attempted suicide.

This fear of stigmatization and the finger-pointing associated with HIV meant that all participants were hesitant in disclosing their serostatus. This highlighted that stigma was a major barrier to the disclosure process. PLWHA are faced with discrimination and loss of the social status that they worked hard to build within their society throughout their lifetime.

In a country such as Tanzania, social relationships are highly valued. The use of relationships to obtain benefits and achieve desired ends has been termed “social capital.” The components of social capital are trust, cooperation, reciprocity, and sociability [28]. Stigma is feared because it leads to social isolation, thereby undermining relationships that are essential for survival. Avoiding HIV-related stigma therefore can be understood as an effort to conserve social capital.

Other studies in Tanzania have also demonstrated this aspect. After disclosure, individuals face stigma, discrimination, fear of their partner’s reaction, and fear of a fall in social status, facing oppression, and divorce [8,9].Women are particularly vulnerable in this regard because of their weak social and economic status within their husband’s families.

Another major finding from this study was that disclosure occurred after participants’ acceptance of their own status. Participants had to mentally come to terms with their serostatus before they could disclose it to anyone. Their medication adherence also improved after acceptance. Similar findings were reported in other studies where disclosure took place after an individual’s serostatus acceptance [8,21,29].

Health care workers play a prominent part in counseling PLWHA, which integrates acceptance of serostatus and equipping them with knowledge about their disease. This prompts self-acceptance leading to eventual disclosure.

A limitation of this study was that it became a single-center study despite initially (at the proposal stage) intending to include two hospitals (The Aga Khan Hospital and Mnazi Mmoja Hospital). However, individuals approached at The Aga Khan Hospital were reluctant to participate, stating reasons such as not having time, not wanting to be seen, and being wary of confidentiality.

There were several possible explanations for these responses. The Aga Khan Hospital caters to a higher social class of patients and this status of clientele may have an increased level of stigmatization around them. It was also thought that counseling provided by the hospital CTC might not have been adequate regarding the stigma of HIV, which could have made patients less receptive to discussing their experiences with HIV and the disclosure process.

A previous systematic review that discussed the role of social class on stigma reported that although it is recurrently implicated in HIV-related stigmatization, social class does not receive much notice in literature and is a neglected area of research [30]. This suggests that more studies are needed to specifically address stigma, particularly in private hospitals that cater for patients from higher social classes.

Another limitation of this study was the sampling method, which might have introduced selection and recall bias, especially for those who had a long period since they disclosed.

Conclusion

Although it has been 30 years since HIV was first discovered in Tanzania, PLWHA still feel negative after effects of the stigma associated with the disease.

Timely disclosure is essential in minimizing the risk and preventing further transmission of HIV via sexual transmission to partners, as well as to improve ARV therapy adherence to support viral suppression. These factors would help achieve two parameters of the 95-95-95 target set by UNAIDS; namely, easier access and linkage to medications and subsequent viral suppression by 2030.

Timely disclosure is hindered by stigma. Stigma was the greatest barrier to disclosure identified in this study. HIV is negatively perceived by the public and PLWHA prefer not to disclose to avoid negative aspects such as being outed, risking a breach in confidentiality, being labeled, discriminated against, and loss of social status, which has a prominent role in Tanzania. Given that HIV is a highly stigmatized epidemic with multiple layers (gender, social class, sexual orientation, race, hyper sexuality), further qualitative studies are needed to help understand the role of stigma in social class among PLWHA in Tanzania and how to identify strategies to reduce stigma.

Given that adequate, efficient, and supportive counseling leads to self-acceptance, empowerment of PLWHA, and timely disclosure, more efforts need to be directed to ensuring quality counseling services at CTCs. This can be achieved by auditing and assessing the counseling provided by health care workers. Additional support should also be provided in terms of training for health care workers.

Interview guide: English.

(DOCX)

Click here for additional data file.

Interview guide: Kiswahili.

(DOCX)

Click here for additional data file.

19 Jan 2021

PONE-D-20-37341

Barriers to timely disclosure of HIV serostatus: A qualitative study at care and treatment centers in Dar es Salaam, Tanzania.

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We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

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2. Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

3.We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Additional Editor Comments:

The reviewers provided positive recommendations and some critical issues to be addressed especially those related to the writing style of the paper.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This qualitative study is an exploration of the barriers and motivation for disclosure of HIV status to other by people living with HIV in Tanzania. This topic has the potential to strengthen HIV prevention programs and to inform programs that can facilitate effective HIV disclosure to others. Nonetheless, the paper needs more work to be suitable for publication. Below are areas that authors need to address to strengthen the paper.

Introduction

1. Line 59-61: Authors need to make it clear that disclosure of HIV status is one of the strategies that can help to prevent the transmission of HIV. The way it has been written, it is like disclosure of HIV status is the only way that can help to prevent the transmission of HIV.

2. The sentence covered by lines 65-67 needs citation.

3. It is important to describe the operational definition of HIV disclosure in this study as this can help to guide the interpretation of the findings.

4. The justification for conducting this study is not convincing or correct. Authors identify lack of studies that have assessed barriers to timely disclosure. However, contrary to the authors’ claim there are several studies in Tanzania that have been conducted related to barriers to disclosure of HIV status to others or sexual partners some of them include the following (Damian et al., 2019; Hallberg et al., 2019; Maluka, 2014). Thus, authors need to be clear with the reasons for conducting this study. Why is it important to conduct this study? What will it add to the existing literature regarding disclosure of HIV status to others/sexual partners in Tanzania?

Materials and methods

5. Where did data collection take place in the research site? How were participants approached to take part in the interview? How long did each interview take to be completed? How many people were involved in the data analysis process?

6. Given that no interview took place at Aga Khan Hospital, it is not necessary for the authors to include information about this facility in this article.

7. What type of questions were included in the interview guide. It would be important if authors can include the interview guide as supplementary material to their submission

Results

8. The findings in the three categories seem to be limited. For example, the last category ‘Consequences of delayed disclosure’ is too brief and lacks sufficient detail to be a standalone category. As a qualitative study, the findings of the study should have some depth to enable the readers to understand participants’ perspectives. The findings are also missing some important information that might be relevant to the study aim for example, what prompted participants to disclose their HIV status to the people they disclosed to? How did the significant others/family members reacted to the disclosure? How was the disclosure done?

Discussion

9. Authors have discussed some findings which are not presented in the findings section. For example, line 316-318, the authors have indicated that a majority of the participants experienced some sort of stigmatization (getting laughed at, discrimination); infidelity and one participant attempted suicide. This information is not described in the findings section.

10. The limitations of the study need more work. Aga Khan Hospital is not part of the research site in this study as none of the participants was recruited from this research site. Researchers should highlight the limitations of the research methodology used in this study.

11. The implications of findings for practice, research and policy are also not clearly explained in this section.

12. Lines 352 to 256, authors have discussed social class in relation to stigma. However, social class has not been presented in the findings of the study. Authors need to discuss or make research recommendations based on the findings of the study.

General comment

13. All sections of the paper need editing.

Reviewer #2: Congratulations on an interesting study, the findings of which should be of interest to others working in Africa.

The methods you have used and have described in your paper are sound and appropriate.

The results, whilst not new, are important as they highlight the need for consistent high quality counselling of PLWHA in order to disclose early and interrupt onward transmission to sexual partners.

The points you raise in your discussion are clear and reference other appropriate and relevant research. I suggest you consider including in the discussion some thoughts about the importance of adherence to ARVs and attaining a suppressed viral load in interrupting onward HIV transmission to susceptible partners - i.e. undetectable viral load = unable to transmit. From a population perspective, I think this is a vital point that is a consequence of the point you raise about people who are provided appropriate counselling and support, that they are more likely to disclose earlier and also more likely to adhere to treatment.

My main concern with this paper is the style in which it is written. The writing style, in my opinion, is not of an academic standard that would be acceptable to peer reviewed journals and needs to be tightened up considerably. There is a consistent use of 'non academic language' throughout the paper and whilst the content is sound, the presentation is not. e.g. 'What stood out for the most part' - this phrase is fine when speaking but does not read well in an academic paper. Another example, using words such a 'spread' in reference to HIV is not ideal, it would be preferable to use the word 'transmission'. I would encourage you to look closely at the expressions you have used and re-write the paper using acceptable academic phrasing (e.g. analysis was done - would read better as -analysis was undertaken). The grammar also needs some significant work.

There are some font issues - e.g. see lines 99 & 100

Also, line 297 - write vs as a word, i.e. versus

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Fatch Welcome Kalembo

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

13 May 2021

1. Line 59-61: Authors need to make it clear that disclosure of HIV status is one of the strategies that can help to prevent the transmission of HIV. The way it has been written, it is like disclosure of HIV status is the only way that can help to prevent the transmission of HIV

Response: Agreed and changed (Line 57-59)

2. The sentence covered by lines 65-67 needs citation.

Response: Agreed and added reference (Line 67)

3. It is important to describe the operational definition of HIV disclosure in this study as this can help to guide the interpretation of the findings

Response: Agreed and added in introduction (Line 60-61)

4. The justification for conducting this study is not convincing or correct. Authors identify lack of studies that have assessed barriers to timely disclosure. However, contrary to the authors’ claim there are several studies in Tanzania that have been conducted related to barriers to disclosure of HIV status to others or sexual partners some of them include the following (Damian et al., 2019; Hallberg et al., 2019; Maluka, 2014). Thus, authors need to be clear with the reasons for conducting this study. Why is it important to conduct this study? What will it add to the existing literature regarding disclosure of HIV status to others/sexual partners in Tanzania?

Response: Modified the wording on justification.

There are studies that have shown the prevalence in the delay in disclosure, and some managed to get reasons but they were not explored in depth to get a deeper meaning qualitatively especially in Tanzania.

This study deals with the barriers to and facilitators of motivation for the timely disclosure. It explores the reasons why PLWHA have a delay in disclosing and what helped them eventually overcome it.

Knowing the barriers that prevent timely disclosure will help counsellors address them to promote early disclosure to reap the benefits of timely disclosure such as ARV adherence, viral suppression and prevention of the spread of HIV.

The study by Hallberg et al and Damian et al were quantitative studies that focused on factors that affected disclosure, they did not study reason/barriers for timely disclosure. Study by Maluka too did not study timely disclosure (Line 98-117)

5. Where did data collection take place in the research site?

How were participants approached to take part in the interview?

How long did each interview take to be completed?

How many people were involved in the data analysis process?

Response: Modified and added the information (Line 155-157

Line 152-153

Line 159-161

Line 190-192)

6. Given that no interview took place at Aga Khan Hospital, it is not necessary for the authors to include information about this facility in this article.

Response: I think it is important to include Aga Khan hospital. Lack of participants explains the social class theory that we mentioned in the discussion section. (Line 459 -473)

7. What type of questions were included in the interview guide. It would be important if authors can include the interview guide as supplementary material to their submission

Response: Uploading the interview guide as supporting information – S1 and S2 (Line 159)

8. The findings in the three categories seem to be limited. For example, the last category ‘Consequences of delayed disclosure’ is too brief and lacks sufficient detail to be a standalone category.

Response: Added details in the third category (Line 348 -364)

As a qualitative study, the findings of the study should have some depth to enable the readers to understand participants’ perspectives. The findings are also missing some important information that might be relevant to the study aim for example, what prompted participants to disclose their HIV status to the people they disclosed to?

Response: This was addressed in the sub-category motivation for disclose of serostatus where we discussed that participants would disclose to those they were close to and had established trust with them (Line 323 -330)

How did the significant others/family members reacted to the disclosure

Response: Included as negative and positive reactions/outcomes in the results section.

Positive reactions were added under the subcategory motivations to disclose. This is because positive reactions encouraged further disclosure.

Negative reactions were placed under the subcategory Barriers hindering timely disclosure as these reactions prevented further disclosure

(Line 331 -346, Line 256 - 288)

How was the disclosure done?

Response: Not part of my objectives

9. Authors have discussed some findings which are not presented in the findings section. For example, line 316-318, the authors have indicated that a majority of the participants experienced some sort of stigmatization (getting laughed at, discrimination); infidelity and one participant attempted suicide. This information is not described in the findings section.

Response: This is included in the findings under the subcategory barriers to disclose. Experiencing a negative outcome hindered and prevented further disclosure (Line 256-288)

10.The limitations of the study need more work. Aga Khan Hospital is not part of the research site in this study as none of the participants was recruited from this research site. Researchers should highlight the limitations of the research methodology used in this study.

Response: Our limitation was based on the fact that we got no participants from Aga khan. Which was why we discussed social class and perceived stigma – see comment 12 below.

However I have added other limitations after discussion section

(Line 459-475)

11. The implications of findings for practice, research and policy are also not clearly explained in this section.

Response: Discussed in the conclusion

Implication of finding: strengthen the counselling services of HCW by training to promote timely disclosure.

Areas of research: stigma surrounding HIV, relationship of social class and HIV

( Line 493-497, Line 485-491)

12. Lines 352 to 256, authors have discussed social class in relation to stigma. However, social class has not been presented in the findings of the study. Authors need to discuss or make research recommendations based on the findings of the study

Response: Social class was brought up when we tried to understand why we were not able to recruit any participant from the Aga Khan hospital which caters for relatively higher class of patients.

Our recommendation was to have other studies that see if there is a relation with HIV stigma and social class. Evidence show that social class in HIV does not receive much notice in literature and is a neglected area in research (see discussion)

(Line 464-473)

13. All sections of the paper need editing

Response: Thank you for your comments and review

14. Congratulations on an interesting study, the findings of which should be of interest to others working in Africa.

The methods you have used and have described in your paper are sound and appropriate.

The results, whilst not new, are important as they highlight the need for consistent high quality counselling of PLWHA in order to disclose early and interrupt onward transmission to sexual partners.

The points you raise in your discussion are clear and reference other appropriate and relevant research. I suggest you consider including in the discussion some thoughts about the importance of adherence to ARVs and attaining a suppressed viral load in interrupting onward HIV transmission to susceptible partners - i.e. undetectable viral load = unable to transmit.

From a population perspective, I think this is a vital point that is a consequence of the point you raise about people who are provided appropriate counselling and support,that they are more likely to disclose earlier and also more likely to adhere to treatment.

My main concern with this paper is the style in which it is written. The writing style, in my opinion, is not of an academic standard that would be acceptable to peer reviewed journals and needs to be tightened up considerably. There is a consistent use of 'non academic language' throughout the paper and whilst the content is sound, the presentation is not. e.g. 'What stood out for the most part' - this phrase is fine when speaking but does not read well in an academic paper. Another example, using words such a 'spread' in reference to HIV is not ideal, it would be preferable to use the word 'transmission'. I would encourage you to look closely at the expressions you have used and re-write the paper using acceptable academic phrasing (e.g. analysis was done - would read better as -analysis was undertaken). The grammar also needs some significant work.

There are some font issues - e.g. see lines 99 & 100

Also, line 297 - write vs as a word, i.e. versus

Response: We have included the importance of ARV in the discussion

We also have edited the grammatical and vocabulary errors throughout the paper using academic language and tracked the changes

Corrected the font

(Line 381 -385)

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

1 Jun 2021

PONE-D-20-37341R1

Barriers to timely disclosure of HIV serostatus: A qualitative study at care and treatment centers in Dar es Salaam, Tanzania.

PLOS ONE

Dear Dr. Matillya,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 16 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed issues identified in the previous review. However, The paper needs thorough editing to make it suitable for publication as there are many typos and grammar errors that are obscuring the clarity of the paper.

In the conclusion section, page 34 line 489-490 reads, “This paves the way to achieve two parameters of the 90-90-90 target set by UNAIDS; namely, easier access and linkage to medications and subsequent viral suppression.” Authors need to be aware that the 90-90-90 target set by UNAIDS finished in 2020. UNAIDS set another target, the 95:95:95 target to end the AIDS epidemic by 2030.

Reviewer #2: Thank you for addressing my previous comments.

One thing that surprises me is that none of the participants in your study questioned where they had acquired the HIV infection from - for example - none suspected they had acquired it from their sexual partner and therefore questioned that partner's fidelity. This is a common occurrence in other countries, especially from women who suspect their husband/partner has had sex with another (infected) person. Perhaps you could add a sentence or two about why the participants in your study didn't suspect their partner's of infecting them - did all participants have more than one sexual partner? You would also need to comment about whether or not your participants had had a previous negative HIV test and could therefore estimate the period of time in which they became infected. e.g addressing whether Tanzania routinely test antenatal women for HIV?

Otherwise, Congratulations on an interesting paper.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Fatch Kalembo

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

30 Jun 2021

Reviewer: The authors have addressed issues identified in the previous review. However, The paper needs thorough editing to make it suitable for publication as there are many typos and grammar errors that are obscuring the clarity of the paper.

Response: Have resubmitted it to English editors to make it ready for publication

Reviewer: In the conclusion section, page 34 line 489-490 reads, “This paves the way to achieve two parameters of the 90-90-90 target set by UNAIDS; namely, easier access and linkage to medications and subsequent viral suppression.” Authors need to be aware that the 90-90-90 target set by UNAIDS finished in 2020. UNAIDS set another target, the 95:95:95 target to end the AIDS epidemic by 2030

Response: Thank you for pointing that out. We have rectified it both in the introduction and conclusion.

Reviewer #2: Thank you for addressing my previous comments.

One thing that surprises me is that none of the participants in your study questioned where they had acquired the HIV infection from - for example - none suspected they had acquired it from their sexual partner and therefore questioned that partner's fidelity. This is a common occurrence in other countries, especially from women who suspect their husband/partner has had sex with another (infected) person. Perhaps you could add a sentence or two about why the participants in your study didn't suspect their partner's of infecting them –

Response: Thank you so much for insightful feedback and comments about our manuscript. This study main aim was to explore the barriers contributing to delayed disclosure and the reasons that made participants overcome it and finally disclose. Since it was not the focus of our study, we did not ask if they questioned where they had acquired the infection from and we do not have data for such.

However, the data shows that, after disclosing to partners they were blamed to have been the ones who brought the disease into the relationship. This led to a strain and in some cases a break in the relationship. This is mentioned in the barriers of disclosure under the negative outcomes experienced.

Reviewer: did all participants have more than one sexual partner?

Response: From the interviews we did, the participants all had one partner at time of disclosure.

Mentioned that in the results section

Reviewer: You would also need to comment about whether or not your participants had had a previous negative HIV test and could therefore estimate the period of time in which they became infected. e.g addressing whether Tanzania routinely test antenatal women for HIV?

Otherwise, Congratulations on an interesting paper.

Response: All participants that were interviewed had not tested prior and so did not have a negative test before that. We have added a couple of lines in the discussion section about the introduction of HIV testing in routine antenatal and RCH services in Tanzania

We appreciate the feedback that has helped improve the quality of our manuscript.

Submitted filename: Response to reviwers.docx

Click here for additional data file.

15 Jul 2021

PONE-D-20-37341R2

Barriers to timely disclosure of HIV serostatus: A qualitative study at care and treatment centers in Dar es Salaam, Tanzania.

PLOS ONE

Dear Dr. Matillya,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Thank you for addressing the previous comments. Please kindly address a few minor comments in relation to proof reading and final editing the paper.

Please submit your revised manuscript by Aug 29 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: No

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Reviewer #1: The authors have addressed the comments I made in my previous review. Nonetheless, there are still several areas in the manuscript where there is no spacing between words or between words and references e.g. lines 52, 57, 51, 89, 172. Line 85 has a different font size from the rest of the manuscript.

Reviewer #2: (No Response)

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Reviewer #1: Yes: Fatch W Kalembo

Reviewer #2: No

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7 Aug 2021

Reviewer #1: The authors have addressed the comments I made in my previous review. Nonetheless, there are still several areas in the manuscript where there is no spacing between words or between words and references e.g. lines 52, 57, 51, 89, 172. Line 85 has a different font size from the rest of the manuscript.

Response: Thank you for your observation.

We have rectified all the spacing issues and fonts.

Submitted filename: Response to reviwers.docx

Click here for additional data file.

10 Aug 2021

Barriers to timely disclosure of HIV serostatus: A qualitative study at care and treatment centers in Dar es Salaam, Tanzania.

PONE-D-20-37341R3

Dear Dr. Matillya,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

12 Aug 2021

PONE-D-20-37341R3

Barriers to timely disclosure of HIV serostatus: A qualitative study at care and treatment centers in Dar es Salaam, Tanzania

Dear Dr. Matillya:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Joel Msafiri Francis

Academic Editor

PLOS ONE