Mental health training for secondary school teachers in Haiti: a mixed methods, prospective, formative research study of feasibility, acceptability, and effectiveness in knowledge acquisition.

BACKGROUND: Engagement and training of educators in student mental health holds promise for promoting access to care as a task sharing strategy but has not been well-studied in low-income regions. METHODS: We used a prospective and convergent mixed methods design to evaluate a customized school mental health 2½ day training for teachers in rural Haiti (n = 22) as the initial component of formative research developing a school-based intervention to promote student mental health. Training prepared teachers to respond to student mental health needs by providing psychoeducational and practical support to facilitate access to care. We examined level of participation and evaluated feasibility, acceptability, and perceived effectiveness by calculating mean scores on self-report Likert-style items eliciting participant experience. We examined effectiveness of the training on improving mental health knowledge and attitudes by comparing mean scores on an assessment administered pre- and post-training. Finally, we examined self-report written open-ended responses and focus group discussion (FGD) interview data bearing on perceived feasibility, acceptability, and effectiveness to contextualize participant ratings of training and to identify recommendations for enhancing the utility of mental health training locally for educators. RESULTS: Mean scores of knowledge and attitudes significantly improved between the pre-test and post-tests; e.g., knowledge improved from 58% correct at baseline to 68% correct on the second post-test (p = 0.039). Mean ratings of the training were favorable across all categories and FGD data demonstrated widespread participant endorsement of training acceptability and effectiveness; participants recommended extending the duration and number of training sessions. CONCLUSIONS: Findings support feasibility, acceptability, and a limited scope of effectiveness of brief mental health training for secondary school teachers in Haiti. Further development of approaches to engage teachers in promoting school mental health through training is warranted.

Understanding low uptake of contraceptives in resource-limited settings: a mixed-methods study in rural Burundi.

BACKGROUND: Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere. METHODS: We investigated uptake of contraceptives among women of reproductive age in two rural districts of Burundi, using an explanatory sequential, mixed-methods research design. We first assessed availability and utilization rates of modern contraceptives through a facility-based survey in 39 health clinics. Barriers to uptake of contraceptives were then explored through qualitative interviews (N = 10) and focus groups (N = 7). RESULTS: Contraceptives were generally available in the 39 clinics studied, yet uptake of family planning averaged only 2.96%. Greater uptake was positively associated with the number of health professionals engaged and trained in family planning service provision, and with the number of different types of contraceptives available. Four uptake barriers were identified: (1) lack of providers to administer contraception, (2) lack of fit between available and preferred contraceptive methods, (3) a climate of fear surrounding contraceptive use, and (4) provider refusal to offer family planning services. CONCLUSIONS: Where resources are scarce, availability of modern contraceptives alone will likely not ensure uptake. Interventions addressing multiple uptake barriers simultaneously have the greatest chance of success. In rural Burundi, examples are community distribution of contraceptive methods, public information campaigns, improved training for health professionals and community health workers, and strengthening of the health infrastructure.

Maternal depressive symptoms and early childhood cognitive development: a meta-analysis.

BACKGROUND: Previous findings have been mixed regarding the relationship between maternal depressive symptoms and child cognitive development. The objective of this study was to systematically review relevant literature and to perform a meta-analysis. METHOD: Three electronic databases (PubMed, EMBASE, PsycINFO) were searched. Initial screening was conducted independently by two reviewers. Studies selected for detailed review were read in full and included based on a set of criteria. Data from selected studies were abstracted onto a standardized form. Meta-analysis using the inverse variance approach and random-effects models was conducted. RESULTS: The univariate analysis of 14 studies revealed that maternal depressive symptoms are related to lower cognitive scores among children aged ⩽56 months (Cohen's d = -0.25, 95% CI -0.39 to -0.12). The synthesis of studies controlling for confounding variables showed that the mean cognitive score for children 6-8 weeks post-partum whose mothers had high depressive symptoms during the first few weeks postpartum was approximately 4.2 units lower on the Mental Developmental Index (MDI) of the Bayley Scales of Infant and Toddler Development (BSID) compared with children with non-symptomatic mothers (B̂ = -4.17, 95% CI -8.01 to -0.32). CONCLUSIONS: The results indicated that maternal depressive symptoms are related to lower cognitive scores in early infancy, after adjusting for confounding factors. An integrated approach for supporting child cognitive development may include program efforts that promote maternal mental health in addition to family economic wellbeing, responsive caregiving, and child nutrition.

Socio-economic and partner relationship factors associated with antenatal depressive morbidity among pregnant women in Dar es Salaam, Tanzania.

Depression during pregnancy may negatively influence social functioning, birth outcomes and postnatal mental health. A cross-sectional analysis of the baseline survey of a prospective study was undertaken with an objective of determining the prevalence and socio-demographic factors associated with depressive morbidity during pregnancy in a Tanzanian peri-urban setting. Seven hundred and eighty seven second to third trimester pregnant women were recruited at booking for antenatal care at two primary health care clinics. Prenatal structured interviews assessed socio-economic, quality of partner relationships and selected physical health measures. Depressive symptoms were measured at recruitment and three and eight months postpartum using the Kiswahili version of the Hopkins Symptom Checklist. Completed antenatal measures available for 76.2% participants, showed a 39.5% prevalence of depression. Having a previous depressive episode (OR 4.35, P<0.01), low (OR 2.18, P<0.01) or moderate (OR 1.86, P=0.04) satisfaction with ability to access basic needs, conflicts with the current partner (OR 1.89, P<0.01), or booking earlier for antenatal care (OR 1.87, P=0.02) were independent predictors of antenatal depression in the logistic regression model; together explaining 21% of variance in depression scores. Attenuation of strength of multivariate associations suggests confounding between the independent risk factors and socio-demographic and economic measures. In conclusion, clinically significant depressive symptoms are common in mid and late trimester antenatal clinic attendees. Interventions for early recognition of depression should target women with a history of previous depressive episodes or low satisfaction with ability to access basic needs, conflict in partner relationships and relatively earlier booking for antenatal care. Findings support a recommendation that antenatal services consider integrating screening for depression in routine antenatal care.

Understanding women's experiences of distress during pregnancy in Dar es Salaam, Tanzania.

Several studies show depression is common during pregnancy. However, there is limited information in Tanzania on the magnitude of perceived distress during pregnancy and meanings ascribed to such distress. A descriptive survey collected data using unstructured interviews from 12 traditional practitioners and 10 peri-urban women with previous pregnancy related mental health concerns identified using a depression vignette. The objectives were to describe the sources and characteristics of distress during pregnancy, and idioms of distress that could inform cultural adaptation of depression screening tools. Narrative analysis showed an emergent category of "problematic pregnancies" framed women's recollections of prolonged periods of sadness. This experience was qualified using various idioms of distress that were differentially emphasized depending on informant's perceived causes of health concern. The idiom kusononeka was consistently used to describe extreme sadness across causal categories and clustered with at least two typical features of major depression. This suggested existence of a construct with similarities to biomedical criteria for depression. "Thinking too much" emerged as a distinctive expression associated with prolonged sadness. Distinctive expressions of social functioning impairments were identified that can inform depression severity assessments. In conclusion, contextual inquiry into experiences of psychological distress showed distinct local idioms that clustered in patterns similar to symptoms of biomedical depressive episodes. Further studies to assess the utility of local idioms of distress and distress related functional impairment in depression assessment tools are warranted.

Economic risk factors for HIV infection among women in rural Haiti: implications for HIV prevention policies and programs in resource-poor settings.

AIMS: The goals of this study were to (1) estimate the prevalence of HIV infection among women accessing services at a women's health center in rural Haiti and (2) to identify economic risk factors for HIV infection in this population. METHODS: Women who accessed healthcare services at this center between June 1999 and December 2002 were recruited to participate. The analysis was based on data from a case-control study of sexually transmitted diseases (STDs) in rural Haiti. HIV prevalence in the study population was 4%. RESULTS: In multivariate analyses, partner occupation was associated with HIV infection in women, with mechanic (OR 9.0, 95% CI 1.8-45) and market vendor (OR 4.2, 95% CI 1.6-11) reflecting the strongest partner occupational risk factors. Partner's occupation as a farmer reduced the risk of infection in women by 60% (95% CI 0.14-1.1). Factors indicating low socioeconomic status (SES), such as food insecurity (OR 2.0, 95% CI 0.75-5.6) and using charcoal for cooking (OR 1.7, 95% CI 0.72-3.8) suggested an association with HIV infection. CONCLUSIONS: Given pervasive gender inequality in Haiti, women's economic security often relies on their partners' income earning activities. Our findings show that although factors reflecting poverty are associated with HIV-positive status, stronger associations are observed for women whose partners indicated a more secure occupation (e.g., mechanic or market vendor). Policies and programs that expand access to education and economic opportunities for women and girls may have long-term implications for HIV prevention in Haiti and other resource-poor settings.

Multivitamin supplementation in HIV-positive pregnant women: impact on depression and quality of life in a resource-poor setting.

OBJECTIVES: The primary objective of this study was to examine the effect of vitamin supplementation on health-related quality of life and the risk of elevated depressive symptoms comparable to major depressive disorder (MDD) in HIV-positive pregnant women in Dar es Salaam, Tanzania. METHODS: From April 1995 to July 1997, 1078 HIV-positive pregnant women were enrolled in a randomized controlled trial. We examined the effects of vitamin supplementation on quality of life and the risk of elevated depressive symptoms, assessed longitudinally every 6-12 months. RESULTS: A substantial prevalence of elevated depressive symptoms (42%) was observed in HIV-positive pregnant women. Multivitamin supplementation (B-complex, C and E) demonstrated a protective effect on depression [relative risk (RR)=0.78; P=0.005] and quality of life [RR=0.72 for social functioning (P=0.001) and vitality (P=0.0001); RR=0.70 for role-physical (P=0.002)]; however, vitamin A showed no effect on these outcomes. CONCLUSIONS: Multivitamin supplementation (B-complex, C and E) resulted in a reduction in risk of elevated depressive symptoms comparable to MDD and improvement in quality of life in HIV-positive pregnant women in Tanzania.

Late presentation for HIV care in central Haiti: factors limiting access to care.

OBJECTIVE: Many patients with HIV infection present for care late in the course of their disease, a factor which is associated with poor prognosis. Our objective was to identify factors associated with late presentation for HIV care among patients in central Haiti. METHODS/DESIGN: Thirty-one HIV-positive adults, approximately 10% of the HIV-infected population followed at a central Haiti hospital, participated in this research study. A two-part research tool that included a structured questionnaire and an ethnographic life history interview was used to collect quantitative as well as qualitative data about demographic factors related to presentation for HIV care. RESULTS: Sixty-five percent of the patients in this study presented late for HIV care, as defined by CD4 cell count below 350 cells/mm3. Factors associated with late presentation included male sex, older age, patient belief that symptoms are not caused by a medical condition, greater distance from the medical clinic, lack of prior access to effective medical care, previous requirement to pay for medical care, and prior negative experience at local hospitals. Harsh poverty was a striking theme among all patients interviewed. CONCLUSIONS: Delays in presentation for HIV care in rural Haiti are linked to demographic, socioeconomic and structural factors, many of which are rooted in poverty. These data suggest that a multifaceted approach is needed to overcome barriers to early presentation for care. This approach might include poverty alleviation strategies; provision of effective, reliable and free medical care; patient outreach through community health workers and collaboration with traditional healers.

Latent tuberculosis infection: risks to health care students at a hospital in Lima, Peru.

SETTING: University hospital and university campus in Lima, Peru. OBJECTIVE: To demonstrate the risk of latent tuberculosis infection (LTBI) in the hospital relative to the community. DESIGN: Prospective cohort study of university students measuring prevalence, boosting, and conversion of tuberculin skin tests (TSTs) among health care students (HCS) and non-health care students (NHCS). RESULTS: Among the HCS relative to NHCS, prevalence of initial positive TST was 20.9% vs. 12.2% (P < 0.001), and conversion rate was 1.1% vs. 0% (P = 0.423) at the 10 mm cut-off and 11.8% vs. 0% at the 6 mm cut-off (P = 0.00005). Multivariate analysis showed that the HCS group had a higher risk of baseline positive TST compared with the NHCS group after controlling for confounding factors (OR 1.7, 95% CI 1.1-2.6). CONCLUSION: HCS are at greater risk than NHCS for having positive baseline TSTs and for TST conversion at the 6 mm cut-off. We conclude that the hospital we studied in Lima, Peru, poses a greater risk than the surrounding community for tuberculosis infection, and greater attention to hospital infection control measures is warranted. A higher rate of skin test boosting among the HCS cohort suggests the possibility of transient, non-progressive LTBI, which merits further study.

Limitations in knowledge of HIV transmission among HIV-positive patients accessing case management services in a resource-poor setting.

HIV has increasingly become an infection of poverty. Adequate HIV transmission knowledge among HIV-positive patients is necessary to reduce the risk of secondary infection and protect those who are uninfected from transmission. This study was conducted among individuals enrolled in a program that serves impoverished HIV patients in the Boston area. Although the mean HIV transmission knowledge score was 80% for this group, a significant proportion of patients demonstrated limitations in knowledge of HIV transmission. Highly vulnerable patients, such as those who reported not accessing HIV medications, a history of sexual abuse, or problems getting clothing, had lower levels of HIV knowledge. This paper hopes to alert providers that their most vulnerable patients may be at an increased risk of re-infection or transmission due to limited HIV knowledge. Programs that serve HIV-positive patients coping with poverty and other serious problems need to ensure adequate knowledge of HIV transmission to reduce the overall burden of HIV in resource-poor settings.

Identification of chlamydia and gonorrhoea among women in rural Haiti: maximising access to treatment in a resource poor setting.

OBJECTIVE: To develop a risk assessment algorithm that will increase the identification and treatment of women with cervical infection in rural Haiti. METHODS: Study participants were randomly selected from new patients who accessed services at a women's health clinic in rural Haiti between June 1999 and December 2002. This case-control study included women who tested positive for chlamydia and/or gonorrhoea based on the Gen-Probe PACE 2 laboratory test as cases. Controls were women who tested negative for both of these infections. RESULTS: Women from this area of rural Haiti had a limited level of education and lived in impoverished housing conditions. The sensitivity estimates of Haitian Ministry of Health and WHO algorithms for detecting chlamydia and/or gonorrhoea were generally low (ranging from 16.1% to 68.1%) in this population. Risk scores based on logistic regression models of local risk factors for chlamydia and gonorrhoea were developed and sensitivity estimates were higher for algorithms based on these risk scores (up to 98.8%); however, specificity was compromised. CONCLUSIONS: A risk assessment algorithm to identify women with chlamydia and/or gonorrhoea is more sensitive and less specific than the syndromic management approach advocated by WHO and adapted by the Haitian Ministry of Health. Using a risk assessment tool with high sensitivity based on local risk factors of cervical infection will maximise access to care, improve outcomes, and decrease morbidity in women who have cervical infection in rural Haiti.

Drug resistance profiles of Mycobacterium tuberculosis isolates: five years' experience and insight into treatment strategies for MDR-TB in Lima, Peru.

SETTING: Lima, Peru. OBJECTIVE: To describe drug resistance profiles of TB isolates from patients at risk for multidrug-resistant tuberculosis (MDR-TB), and to consider the implications of these findings for treatment. DESIGN: Descriptive study of drug susceptibility testing (DST) results for TB isolates from 1680 patients referred for suspicion of MDR-TB between 1996 and 2001. RESULTS: Of 1680 isolates tested, 1144 (68%) were resistant to at least one anti-tuberculosis drug and 926 (55%) were MDR-TB strains. Of 926 MDR isolates, 50 (5%) were resistant to INH and RMP alone, while 367 (40%) were resistant to at least five first-line drugs. We identified 146 unique drug resistance profiles, the most common of which accounted for 11% of drug-resistant isolates. The annual prevalence of isolates with resistance to at least five first-line drugs rose significantly during the study period, from 29% to 37% (P = 0.00086). CONCLUSIONS: This is a group of patients with TB disease among whom the prevalence of a broad spectrum of often highly drug-resistant strains appears to be increasing over time. A single standardized retreatment regimen may be inadequate to cure most patients. Capacity for drug sensitivity testing is essential for development of multiple standardized retreatment or individualized treatment regimens and epidemiological surveillance for planning.

Factors associated with forced sex among women accessing health services in rural Haiti: implications for the prevention of HIV infection and other sexually transmitted diseases.

The goals of the current study were to: (1) estimate the prevalence of forced sex among women accessing services at a women's health clinic in rural Haiti; and (2) examine factors associated with forced sex in this population. Based on data from a case-control study of risk factors for sexually transmitted diseases (STDs), a cross-sectional analysis to examine factors associated with forced sex was performed. A number of factors related to gender inequality/socioeconomic vulnerability placed women in rural Haiti at higher risk of forced sex. The strongest factors associated with forced sex in multivariate analyses were: age, length of time in a relationship, occupation of the woman's partner, STD-related symptoms, and factors demonstrating economic vulnerability. The findings suggest that prevention efforts must go beyond provision of information and education to the pursuit of broader initiatives at both local and national levels. At the community level, policy-makers should consider advancing economic opportunities for women who are vulnerable to forced sex. Improving access to community-based income-generating activities may begin to address this problem. However, the viability of these local projects depends largely upon Haiti's 'macro-economic' situation. In order to ensure the success of local initiatives, external humanitarian and development assistance to Haiti should be supported. By broadening the definition of "prevention" interventions, we may begin to address the systemic problems that contribute to the occurrence of forced sex and the increasing incidence of HIV infection throughout the world, such as gender inequality and economic vulnerability. Taking into account factors influencing risk at the local level as well as the macro-level will potentially improve our capacity to reduce the risk of forced sex and the spread of STDs, including HIV infection, for millions of women living in poverty worldwide.

Psychiatric issues in the management of patients with multidrug-resistant tuberculosis.

INTRODUCTION: Psychiatric issues present a challenge in the treatment of patients with multidrug-resistant tuberculosis (MDR-TB). Both baseline psychiatric disorders and development of psychiatric complications related to anti-tuberculosis drugs and psychosocial factors require aggressive management. SETTING: A community-based non-governmental health organization in Lima, Peru. OBJECTIVE: To review the literature for psychiatric complications associated with anti-tuberculosis medications, to describe the incidence and prevalence of depression, anxiety and psychosis among individuals receiving MDR-TB therapy, and to detail the management approach used in this cohort. METHODS: A retrospective case series was performed among the first 75 patients to receive individualized MDR-TB therapy in Lima, Peru, between 1996 and 1999. RESULTS: Baseline depression and baseline anxiety were observed in respectively 52.2% and 8.7% of this cohort. Most individuals with baseline depression experienced improvement of depressive symptoms during the course of TB therapy. The incidence of depression, anxiety and psychosis during MDR-TB treatment was 13.3%, 12.0% and 12.0%, respectively. While the majority of individuals with depression, anxiety and psychosis required psychiatric pharmacotherapy, cycloserine was successfully continued in all but one case. CONCLUSION: Psychiatric comorbidities are not a contra-indication to MDR-TB therapy. Management of psychiatric complications is possible without compromising anti-tuberculosis treatment.

Identifying early treatment failure on category I therapy for pulmonary tuberculosis in Lima Ciudad, Peru.

SETTING: Ambulatory, public tuberculosis treatment facilities, central Lima, Peru. OBJECTIVE: To identify risk factors for failure on directly observed Category I therapy. DESIGN: Case-control study. All failures of Category I (2HREZ/4H2R2) therapy in 2000 (2.9% of smear-positive TB patients) were included as cases; two controls per case were matched on health center and approximate time of treatment initiation. RESULTS: The study included 38 cases and 76 controls, all new smear-positive, pulmonary TB patients treated with Category I therapy in central Lima in 2000. Neither treatment irregularity nor incidence of adverse events predicted failure in the study group. Mean baseline body mass index was lower in cases than in controls (P = 0.06). Cases gained less weight during therapy (P = 0.01). Smear positivity at 2 months of therapy was strongly associated with failure (OR 11.7; 95%CI 2.4-57.5). No controls had positive smears at or after 3 months of therapy (OR [corrected] 144.9; 95%CI 8.4-2500). Nearly 75% of cases with isolates tested for susceptibility to first-line drugs had multidrug-resistant TB (MDR-TB). CONCLUSION: A large proportion of failures on Category I therapy can be identified early. As three-quarters of patients with susceptibility results have MDR-TB, early referral for culture and drug susceptibility testing is critical for prompt initiation of appropriate therapy and improved outcomes.

Prevalence and risk factors of STDs in rural Haiti: implications for policy and programming in resource-poor settings.

The goals of the current study are to: (1) estimate the prevalence of sexually transmitted diseases (STDs) among women accessing services at a women's health clinic in rural Haiti; and (2) identify risk factors for STDs in this setting. The design is a case control study, comparing risk factors for women who demonstrated positive laboratory results for chlamydia and/or gonorrhoea to women who tested negative for both of these pathogens. The strongest risk factors for chlamydia and/or gonorrhoea were largely economic variables, with work as a domestic servant increasing the risk by four-fold. Working as a market vendor reduced a woman's risk of having an STD by approximately 45%. Given that economic factors are strongly associated with STD risk in this context, one potential mechanism for reducing the risk of STDs, including HIV, would involve increasing economic opportunities for women in rural Haiti.

Peripheral neuropathy associated with treatment for multidrug-resistant tuberculosis.

OBJECTIVE: To review the incidence and management of peripheral neuropathy in patients receiving therapy for MDR-TB. METHODS: A case series with retrospective chart review of 75 patients who initiated individualized therapy for multidrug-resistant tuberculosis (MDR-TB) in Lima, Peru, between 1 August 1996 and 31 January 1999. RESULTS: All patients had confirmed MDR-TB and were receiving individualized therapy, comprised of an average of six drugs. Ten (13%) of these patients presented with symptoms of peripheral neuropathy, confirmed by electromyography. All symptoms were reported in the lower extremities, and all were sensory in nature. Median time to presentation from initiation of MDR-TB therapy was 9.1 months. No significant risk factors associated with development of peripheral neuropathy were identified. Management strategies depended on the severity of symptoms and included the treatment of contributing co-morbidities, medications for neuropathic pain, and adjustment of doses of possible offending agents. All patients responded to management; three patients were left with mild residual symptoms. Patients whose neuropathy resolved had symptoms for a median of 7 months. CONCLUSIONS: Peripheral neuropathy was encountered in 13% of our cohort of MDR-TB patients. The diagnosis of peripheral neuropathy can be based on clinical presentation alone, and effective management of this side-effect is possible without sacrificing MDR-TB treatment efficacy.

Validity of the Hopkins Symptom Checklist-25 amongst HIV-positive pregnant women in Tanzania.

OBJECTIVE: To validate the Hopkins Symptom Checklist-25 (HSCL-25) for use as a depression screen amongst human immuno-deficiency virus (HIV) positive pregnant women. METHOD: Amongst 903 (mean age 24.8 years) HIV-positive pregnant women, a two-phased design included measures for health-related quality of life, perceived social support, and the HSCL-25 screen for depressive (HSCL-15 subscale) and anxiety symptoms. The Structured Clinical Interview for DSM-IV (SCID) was independently administered on a stratified random subsample. RESULTS: Internal consistency of the HSCL-25 (alpha 0.93) and HSCL-15 (alpha 0.9) was adequate, with expected findings demonstrated in discriminant validity analysis. A depression-anxiety construct explained nearly 40% of the variance. Eight individual HSCL-25 items demonstrated an area under the curve (AUC) greater than 0.6 for DSM-IV major depression and the HSCL-25 and HSCL-revised had an optimal depression cut-off score of 1.06 and 1.03 for the HSCL-15. CONCLUSION: The HSCL-25 demonstrated utility as a screen for depression; its inability to gauge severity of symptoms in this cultural context is discussed.

Predictors of HIV-1 serostatus disclosure: a prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania.

OBJECTIVES: To examine the socio-demographic and behavioral factors predictive of women's disclosure of an HIV-positive test result in Dar es Salaam, Tanzania. DESIGN: From April 1995 to May 2000, 1078 HIV-positive pregnant women participated in an ongoing randomized trial on micronutrients and HIV-1 vertical transmission and progression. Disclosure to a partner or to a female relative was assessed 2 months after post-test counseling and at 6 monthly follow-up visits. Socio-demographic, health, behavioral and psychological factors were measured at baseline and during follow-up. METHODS: Predictors of time to disclosure of HIV serostatus were determined using Cox proportional hazards regression models. RESULTS: Prevalence of disclosure to a partner ranged from 22% within 2 months to 40% after nearly 4 years. Women were less likely to disclose to their partners if they were cohabiting, had low wage employment, had previously disclosed to a female relative, or reported ever-use of a modern contraceptive method. Women reporting fewer than six lifetime sexual partners or knowing someone with HIV/AIDS were more likely to disclose to their partners. Disclosure to a female relative was predicted by knowing more than two individuals with HIV/AIDS, full economic dependency on their partner, high levels of social support, and prior attendance at a support group meeting. CONCLUSIONS: A substantial proportion of HIV-infected pregnant women never disclosed their result to a partner or a close female relative. Lack of disclosure may have limited their ability to engage in preventive behaviors or to obtain the necessary emotional support for coping with their serostatus or illness.