P1: FLT

Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

Journal of Behavioral Medicine, Vol. 26, No. 4, August 2003 (°

C 2003)

Stress, Social Support, and HIV-Status Disclosure

to Family and Friends Among HIV-Positive
Men and Women
Seth C. Kalichman,1,2 Michael DiMarco,1 James Austin,1
Webster Luke,1 and Kari DiFonzo1
Accepted for publication: February 10, 2003

Patterns of HIV-status disclosure and social support were examined among

331 HIV-positive men and women. Structured interviews assessed HIV-status
disclosure to family and friends, perceived stress of disclosure, social support,
and depression. Results showed patterns of selective disclosure, where most
participants disclosed to some relationship members and not to others. Rates of
disclosure were associated with social support. Friends were disclosed to most
often and perceived as more supportive than family members, and mothers
and sisters were disclosed to more often than fathers and brothers and per-
ceived as more supportive than other family members. Path analyses tested
a model of HIV-status disclosure showing that perceived stress of disclosing
HIV was associated with disclosure, and disclosures were related to social sup-
port. Disclosure and its association to social support and depression varied
for different relationships and these differences have implications for mental
health and coping interventions.
KEY WORDS: social support; HIV-AIDS; psychological adjustment.

Social support is an important aspect of psychological adjustment for

many people living with HIV infection (Green, 1993). Similar to other
chronic illnesses, social support can buffer the stress associated with

1Center for AIDS Intervention Research Medical College of Wisconsin, Milwaukee,

Wisconsin.
2To whom correspondence should be addressed at Department of Psychology, University of
Connecticut, 406 Babbidge Road, Storrs, Connecticut 06269-1020; e-mail: seth.k@uconn.edu.

315

0160-7715/03/0800-0315/0 °
C 2003 Plenum Publishing Corporation
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

316 Kalichman, DiMarco, Austin, Luke, and DiFonzo

living with HIV-AIDS and can promote a sense of emotional well-being.

For people living with HIV-AIDS, receiving social support related to liv-
ing with HIV requires disclosing their HIV-status (Huber, 1996). However,
HIV-status disclosure demands careful consideration because of the poten-
tial for adverse social consequences, including rejection, abandonment, and
even physical assault (Bharat, 1996; Rothenberg and Parskey, 1995). For ex-
ample, Gielen et al. (1998) found that one in five women who disclose their
HIV-status experience negative reactions that ultimately result in loss of
social support. Disclosure of HIV-status is typically a selective process that
occurs over the course of HIV disease progression (Mansergh et al., 1995;
Wolitskiet al., 1998).
Research has shown that disclosure of HIV-status varies depending on
several factors including types of relationships. For example, disclosures of
HIV to sex partners, injection drug using partners (e.g., Marks et al., 1992),
and perhaps, health care providers (Jeffe et al., 2000) are uniquely associated
with protecting others from possible exposure to HIV suggesting that these
disclosures can be focused more on others than on oneself (Schnell et al.,
1992). On the other hand, decisions to disclose HIV-status to family mem-
bers and friends are focused more on oneself perhaps to maintain honesty
in a relationship, relieve the stress of concealing one’s HIV-status, or to ac-
cess social support (Simoni et al., 1995). HIV-serostatus disclosure decisions
therefore depend on the barriers and needs associated with specific types
of relationships. For example, people living with HIV-AIDS demonstrate
a greater inclination to disclose their HIV-status to friends than to their
family. Stempel et al. (1995) illustrated this difference in their finding that
85% of HIV-positive men had told at least one friend that they were HIV
positive whereas 36% had told family members about their HIV infection.
Also demonstrating differences in disclosure between relationship types is
research showing that within families, mothers and sisters are told about
HIV infection more often than fathers and brothers. Table I summarizes the
results of six studies of HIV-status disclosure to friends and families that
represent these patterns of disclosure.
Fear of disrupting relationships, particularly by evoking stigmas that
can result from disclosure of HIV, is a common barrier to disclosure (Simoni
et al., 1995; Stempel et al., 1995). For many persons, disclosure decisions
must balance the need for social support specific to coping with HIV-AIDS
against the potential loss of what could otherwise be generally supportive
relationships. For example, Kimberly and Serovich (1996) did not find an as-
sociation between disclosure of HIV-status and support received from family
members, suggesting that support may be gained, lost, or unchanged with
decisions to disclose or not to disclose. HIV-status disclosure decisions can
therefore be a source of conflict and stress, influencing disclosure decisions
 P1: FLT

HIV-Status Disclosure

Table I. Summary of Studies Reporting Rates of HIV-Status Disclosure to Family and Friends
Journal of Behavioral Medicine [jobm]

% Participants disclosing to specific relationships

Study Sample Mothers Fathers Sisters Brothers Friends

Hays et al. (1993) 165 gay men in 48 40 98 53 NR

San Francisco
Marks et al. (1992) 101 Hispanic men in 24 8 34 31 58 male friends
Los Angeles infectious 43 female friends
PP893-jobm-467590

disease clinics
Stempel et al. (1995) 93 men in San Francisco 45 30 50 28 NR
hospital cohort
Mansergh et al. (1995) 684 men in Los Angeles 53 43 53 48 86
infectious disease clinics
Simoni et al. (1995) 65 women in Los Angeles 59 31 54 49 78
June 10, 2003

infectious disease clinics

Wolitski et al. (1998) 87 men recruited from 35% reported for all family members 83
community services
19:31

317
Style file version Feb 25, 2000
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

318 Kalichman, DiMarco, Austin, Luke, and DiFonzo

Fig. 1. Generalized model of perceived stress of disclosing HIV-status, disclosure

practices, perceived support, and emotional distress.

and social support. The direct associations between disclosure-related stress,

disclosures, social support, and emotional distress among HIV-positive men
and women have not yet been reported.
This current study describes familial and friendship HIV-status disclo-
sure in a sample of HIV-infected men and women. Whereas most studies
of HIV disclosure have included either men or women living with HIV-
AIDS, we examined HIV-status disclosure for both men and women in
a single study design. In addition to describing patterns of disclosure, we
evaluated the association between HIV-status disclosure and social support
in the context of a conceptual model that suggests the perceived stress of
disclosing HIV in a specific relationship context will predict decisions to
disclose and perceived stress of disclosure and disclosure decisions will in
turn predict perceived social support. In addition, the model relates per-
ceived social support to depressive symptoms as a mental health outcome
(see Fig. 1). Thus, using measures that were keyed to specific relationships,
we investigated the effects of perceived stress of disclosing HIV-status on
disclosures of HIV-AIDS and on perceived social support. In addition, the
effects of disclosure on perceived social support and the influence of social
support on depressive symptoms were tested in the context of the model
applied to multiple relationships. On the basis of previous research, we hy-
pothesized that disclosure of HIV would vary for different relationships,
with greater disclosure occurring to friends, mothers, and sisters than to fa-
thers, brothers, and other family members. Perceived stress of disclosure was
expected to be associated with relationship-specific social support. We also
hypothesized that perceived stress of disclosing HIV in specific relationships
would be related to disclosing HIV, relationship specific social support, and
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

HIV-Status Disclosure 319

depressive symptoms. Gender was included as a factor in all analyses to ex-

plore potential gender differences in disclosure, social support, and mental
health.

METHODS

Participants

Participants were 233 HIV-positive men and 98 HIV-positive women

recruited from community services and infectious disease clinics serving peo-
ple living with HIV-AIDS. The mean age was 37 years and the sample was
72% African American, 23% White, and 5% of other ethnicities. Approx-
imately half of the sample (54%) had completed 12 years of education or
less and 64% of the sample had annual incomes under $10,000. In terms
of sexual orientation, 52% of the sample identified as gay, 11% bisexual,
and 36% heterosexual. Sexual orientation was significantly associated with
gender, with 95% of gay identified and 73% of bisexually identified per-
sons being male and 67% of heterosexuals being female, χ 2 (df = 2, N =
331) = 131.4, p < 0.01. On average, participants were living with HIV for
8.6 years (SD = 10.4) and 36% of the sample had been diagnosed with
AIDS.

Measures

Participants completed two sets of measures as part of an assessment

for a mental health and coping study of people living with HIV-AIDS. The
first assessment consisted of a detailed structured interview of personal re-
lationship history, focusing on decisions to disclose HIV-status to family
members and friends. The second part of the assessment consisted of self-
administered surveys that included instruments to assess demographic char-
acteristics, health status, social support, and mental health. For participants
who demonstrated difficulty reading (<10%), all measures were adminis-
tered in interviews. The specific measures included in study are described
below.

Disclosure Experience Interview

HIV-Status Disclosure

The HIV-status disclosure interview probed participants’ experiences

disclosing their HIV status to family members, friends, and other persons in
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

320 Kalichman, DiMarco, Austin, Luke, and DiFonzo

their life. The interview first elicited whether participants had living mothers,
fathers, stepparents, sisters, brothers, extended family members, and friends
with whom participants had relationships. Initials were recorded for each
member of the participant’s social network elicited during the first segment
of the interview. Then, person-by-person, participants were asked whether
they had disclosed their HIV-status to that person and how supportive they
felt the person was (see next section for support measure). Interviewers
probed a second time for persons not identified in the initial elicitation pro-
cess. Percentages of persons to whom participants had disclosed were calcu-
lated using the total number of persons identified within each relationship
category as the denominator. For example, a participant who reported hav-
ing four sisters and disclosed their HIV-status to three of the four sisters was
defined as having disclosed to 75% of his or her sisters. This procedure was
followed for each relationship category except parents, where mother and fa-
ther disclosures were coded dichotomously—disclosed to or not disclosed to.

Relationship-Specific Support

For each relationship elicited in the disclosure interview, we obtained

social support ratings in response to the question “how much would you say
that you can rely on this person to help you out and be there for you in a
time of need?” Interviewers used this item to avoid assessing perceived sup-
port specific to dealing with HIV-related issues. Responses were recorded
on a 3-point scale using the following anchors and numeric values, 0 = not
at all, 1 = a little, 2 = very much. Higher support ratings for each individual
member of participants’ social networks indicated greater support. We sub-
sequently summed support ratings within relationship categories and within
other groupings of relationship members, such as persons disclosed to versus
not disclosed to, within or across given relationship categories. We therefore
obtained independent social support scores yoked to relationship categories
and for persons to whom participants had and had not disclosed their HIV
status.

Mental Health Survey

Demographic Characteristics and Health Status

Participants were asked their age, years of education completed, income

level, and self-identified gender, ethnicity, and sexual orientation. Partici-
pants were also asked what month and year they tested HIV seropositive
and whether they had been diagnosed with an AIDS case defining condition.
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

HIV-Status Disclosure 321

Perceived Stress of HIV Disclosure

Two items of perceived stress for disclosing HIV status were used; dis-
tress for disclosing to family members (i.e., “Telling a family member that you
have HIV”), and disclosure to friends (i.e., “Telling a friend that you have
HIV”). For both items, responses were recorded on 6-point scales ranging
from 1 (no stress) to 6 (extreme stress).

Beck Depression Inventory (BDI)

The BDI consists of 21 items that reflect cognitive, affective, behavioral,

and somatic symptoms of depression and are responded to along four lev-
els of severity over the previous 7 days, with each item scored 0–3. In this
study we used the cognitive-depression subscale of the BDI to avoid inflated
estimates of depression that can result from overlapping symptoms of de-
pression and HIV-AIDS disease progression (Kalichman et al., 2000). Beck
and Steer (1993) suggested omitting 8 items that primarily represent somatic
concerns and vegetative symptoms when using the BDI to assess depression
in medical populations. The suggested clinical cutoff for moderate depres-
sion on the cognitive-depression subscale is 10. The cognitive-depression
scale was reliable in the current sample (α = 0.89).

Social Support Questionnaire

This measure consists of 15 items assessing perceived social support

(Brock et al., 1996). Items included availability of support and validation
of support, such as “There are several people that I trust to help me solve
problems”; “I feel a strong emotional bond with at least one other person”;
and “It would be difficult to find someone who would lend me their car for a
few hours” (reverse-scored). These items are responded to on 4-point scales
ranging from 1 (definitely true) to 4 (definitely false) (α = 0.89).

Statistical Analyses

Disclosure in specific relationships was assessed within an interview

and rates of disclosure were calculated for each relationship type. Partici-
pants who indicated that a relationship type was not applicable (e.g., par-
ent is deceased, did not have a brother or sister, etc.) were excluded from
the analyses involving those specific relationships. We conducted a series of
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

322 Kalichman, DiMarco, Austin, Luke, and DiFonzo

descriptive analyses to examine rates of disclosure within specific relation-

ship categories. For comparisons involving disclosure to mothers and fathers,
we used contingency table chi-square tests. For the other four relationship
types (sisters, brothers, extended family, and friends), we used a 2 (gender) ×
4 (relationship type) multivariate analysis of variance (MANOVA) to test for
differences in percentages of disclosure to persons in relationship categories.
Significant differences were followed by planned comparisons for both the
within-subjects and between-subjects effects. We also conducted tests for
whether rates of HIV-status disclosure were artifacts of family size and social
network density. These analyses were conducted by comparing persons with
below and above the median number of total family members (Median = 5)
and below and above the median number of friends (Median = 4).
Social support in relation to HIV-status disclosure was examined for
the six relationship types (mothers, fathers, sisters, brothers, extended fam-
ily, and friends) using a 2 (gender) × 6 (relationship-type) MANOVA on
social support scores. We also conducted analyses comparing perceived so-
cial support received from persons disclosed to and not disclosed to. These
pairwise comparisons included participants with experience disclosing and
not disclosing to persons in each relationship category. The number of par-
ticipants included in each of these comparisons therefore varied depending
on an individual’s relationships. We also compared ratings of perceived sup-
port received from various relationship members, controlling for whether
participants had disclosed. In these analyses, we compared perceived sup-
port received from each relationship (mothers, fathers, sisters, etc.) within-
subjects, only including those relationship members to whom participants
had disclosed their HIV status. We were therefore able to directly compare
perceived support from specified persons in relationships that were aware
of the participants’ HIV-status.
In a second approach to investigating perceived social support from spe-
cific relationship members, path analyses were used to test a model predicting
the associations among perceived stress of HIV disclosure, HIV disclosure
practices, perceived social support, and depressive symptoms (Arbuckle and
Wothke, 1999). We first tested a generalized model of these associations, us-
ing unspecified measures of each construct (total disclosure distress, total
disclosures, and general social support) followed by a series of models using
measures that were specified to participants’ relationships types. Standard-
ized regression weights are reported, with significance levels indicated in
the results. For each of the models tested we also report the Comparative
Fit Index (CFI) with values that range between 0 and 1; values closer to 1
indicate a better fit. For all analyses, we report findings that are statistically
significant at p < .05. However, because of the large number of comparisons
and associated increased rates of statistical error, we only interpret findings
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

HIV-Status Disclosure 323

at the p < .01 significance level. Degrees of freedom vary depending on

complete data for each respective analysis.

RESULTS

Across study participants, 74% (N = 270) of people living with HIV-

AIDS had disclosed their HIV status to all of their family members and 88%
(N = 305) had disclosed to all of their friends. In contrast, 21% (N = 47) had
not disclosed their HIV status to any family members and 5% (N = 14) had
not disclosed to any friends. Seventy-nine percent (N = 191) of participants
had disclosed their HIV status to their mothers and 65% (N = 117) had told
their fathers that they were HIV positive. For persons who reported having
both living parents, it was significantly more likely for participants to have
disclosed their HIV status to their mothers than to fathers, X2 (df = 1, N =
154) = 58.5, p < 0.01; specifically 20% (N = 24) of participants who had
disclosed to their mothers had not disclosed to their fathers. However, men
and women differed in their disclosure to mothers; women were more likely
to disclose to their mothers (85%), X2 (df = 1, N = 243) = 6.3, p < 0.01, than
were men (75%). On average, participants disclosed to 86% (SD = 28.9)
of their friends, 78% (SD = 37.3) of their sisters, 68% (SD = 42.9) of their
brothers, and 69% (SD = 41.9) of their extended family members.
We conducted a 2 (gender) × 4 (relationship-type) MANOVA, treat-
ing relationship type as a within-subjects factor for participants who had
at least one sister, brother, extended family member, and friend for whom
they reported disclosure data. Results showed differences within-subjects
for disclosure in different types of relationships, Wilks’ lambda = 0.86, F(1,
122) = 9.5, p < 0.01. Planned comparisons showed that friends and sisters
were significantly more likely to be disclosed to than any other relationship
type, with no difference between disclosing to brothers and extended family
members (see Table II). The differences between genders and the Gender ×
Relationship Type interactions were not significant.

Table II. Mean (SD) Percentages of Persons in Relationship Types Disclosed to by

HIV-Positive Men and Women
Sisters Brothers Extended family Friends
M SD M SD M SD M SD

Men 76 40 65 44 66 44 89 25
Women 80 36 72 42 75 36 86 31
Total 77 39 67 44 69 41 88 26
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

324 Kalichman, DiMarco, Austin, Luke, and DiFonzo

To examine whether disclosure rates were a function of family size and

social network density, we divided participants into groups with relatively
fewer (below the median) and greater (at and above the median) numbers
of family members (Median = 5) and friends (Median = 4). Results showed
that disclosure to family was related to family size, F(1, 329) = 4.7, p < 0.05;
persons with smaller families disclosed to relatively more family members
(M = 81%, SD = 27) than did persons with large families (M = 74%, SD =
30). Although the result of this comparison was statistically significant, the
relative difference was small. Disclosure to friends was not, however, related
to the number of friends participants had; disclosure rates were nearly the
same for persons with relatively fewer (M = 88%, SD = 29) and greater
number of friends (M = 89%, SD = 23). We therefore conclude that rates
of disclosure were not a meaningful function of family size or social network
densities.

Social Support and HIV-Status Disclosure

Results of within-subjects comparisons limited to participants reporting

relationship categories for perceived social support from specific relation-
ships showed significant differences, Wilks’ lambda = 0.79, F(1, 53) = 4.7,
p < 0.01. Planned within-subjects comparisons among persons who had
disclosed their HIV-status to specific relationship members were conducted
across all possible pairs of relationship types. Note that N’s vary depending
on whether participants reported both relationships for any given compari-
son. Results shown in Table III indicated that friends who were told about
the participant’s HIV status were significantly more supportive than all other
persons who were disclosed to, including mothers and sisters (see first row
of Table III for means for comparisons of friend ratings to all other re-
lationships). In addition, extended family members were viewed as more
supportive than all immediate family members except mothers (see second
row of Table III for comparisons between extended family and all other
family relationships). In contrast, fathers and brothers who were aware of
the participant’s HIV-status were perceived as significantly less supportive
than all other relationship categories, but not different from each other in
perceived social support.
Comparisons between (a) persons who had not completely disclosed
to family members and friends and (b) participants who had disclosed to
all persons in a specific relationship type showed that greater support was
perceived from all immediate family members (i.e., mothers, fathers, sis-
ters, brothers) among those who completely disclosed compared to persons
who had not completely disclosed. In contrast, there were no differences in
 P1: FLT

HIV-Status Disclosure

Table III. Mean Support Ratings and Within-Subjects Comparisons for Immediate Family, Extended Family, and Friends Who Knew the
Journal of Behavioral Medicine [jobm]

Participant’s HIV-Positive Status

Mothers Fathers Sisters Brothers Extend family

Friends 1.72 (1.95) 1.45 (1.94) 1.69 (1.92) 1.59 (1.91) 1.85 (1.94)
[N = 162, p = .01] [N = 99, p = .01] [N = 184, p = .01] [N = 169, p = .01] [N = 150, p = .01]
Extended 1.75 (1.82) 1.41 (1.83) 1.62 (1.83) 1.52 (1.85)
family [N = 113, n.s.] [N = 64, p = .01] [N = 132, p = .01] [N = 119, p = .01]
Brother 1.79 (1.62) 1.52 (1.54) 1.73 (1.55)
PP893-jobm-467590

[N = 129, p = .01] [N = 91, n.s.] [N = 150, p = .01]

Sister 1.73 (1.67) 1.51 (1.71)
[N = 140, n.s.] [N = 91, p = .01]
Father 1.71 (1.45)
[N = 94, p = .01]
June 10, 2003

Note. Means outside parentheses represent support ratings for relationships represented along horizontal (top) axis and means inside parentheses
represent support ratings for relationship along vertical (left side) axis.For each within-subject paired comparison, Ns vary because of differences
19:31

in relationship and disclosure patterns, and are shown with respective means and significance test results.
325
Style file version Feb 25, 2000
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

326 Kalichman, DiMarco, Austin, Luke, and DiFonzo

Table IV. Differences in Social Support Between Persons Who Disclosed to and Had Not
Disclosed to Family and Friends

Persons who had disclosed to Persons who disclosed to some

all members of relationship or no relationship members
Relationship M SD N M SD N t p<

Mother 1.7 0.6 191 1.4 0.8 48 2.5 0.01

Father 1.4 0.8 116 0.9 0.9 56 3.2 0.01
Sisters 1.6 0.6 216 1.4 0.7 45 2.2 0.05
Brothers 1.5 0.6 196 1.1 0.8 64 4.3 0.01
Other family 1.8 0.4 180 1.7 0.4 41 0.8 ns
members
Friends 1.9 0.2 280 1.8 0.3 13 1.0 ns

Note. Each comparison is limited to participants indicating relationships within each category.

perceived support received from extended family and friends among per-
sons who completely disclosed their HIV status compared to persons who
selectively disclosed (see Table IV).

Disclosure-Associated Stress, Disclosure, Social Support,

and Depressive Symptoms

To test the hypothesis that perceived stress of disclosing HIV is asso-

ciated with patterns of disclosure and social support, we conducted path
analyses for a generalized model followed by separate analyses specified
for familial relationships and friendships. Correlations among variables in-
cluded in the path models are shown in Table V. Using the general conceptual
framework presented in Fig. 1, we tested the influence of perceived stress
of disclosing HIV-status on disclosure and perceived support. The model
simultaneously tested whether disclosure affected perceived support as well
as the effects of perceived support on depressive symptoms. Results shown
in Table VI indicate that all paths tested in a generalized model were statis-
tically significant, predicting general social support scores (Social Support
Questionnaire) from rates of HIV-status disclosure across all relationships
and general perceived stress of disclosing HIV status (average rating for fam-
ily and friend disclosure-related stress items). The CFI suggests that the data
provide an excellent fit of the generalized model. We therefore proceeded to
test the model within each of the specified relationships-using relationship-
specific measures of disclosure stress, disclosure, and social support. All of
the specified relationship models indicated an excellent fit as indexed by the
CFI. Unlike the generalized model, however, perceived stress of disclosing
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

HIV-Status Disclosure 327

Table V. Correlations Among Perceived Disclosure Stress, Disclosure, Perceived Support, and
Depressive Symptoms for Generalized Measures and Within Specific Relationships

Stress Depression Disclosure

Generalized Model
Support 0.18∗∗ 0.02 0.07
Disclosure −0.19∗∗ −0.09
Depression 0.39∗∗
Disclosure to Mother
Support −0.09 −0.06 0.20∗∗
Disclosure −0.21∗∗ −0.11
Depression 0.33∗∗
Disclosure to Father
Support −0.10 −0.18∗∗ 0.30∗∗
Disclosure −0.19∗∗ −0.14
Depression 0.33∗∗
Disclosure to Sister
Support −0.12∗ −0.10 0.22∗∗
Disclosure −0.23∗∗ −0.05
Depression 0.33∗∗
Disclosure to Brother
Support −0.16∗∗ −0.17 0.25∗∗
Disclosure −0.22∗∗ 0.12∗
Depression 0.33∗∗
Disclosure to Extended Family
Support −0.11 −0.15∗ 0.11
Disclosure −0.23∗∗ 0.01
Depression 0.33∗∗
Disclosure to Friends
Support −0.16∗∗ 0.03 0.16∗∗
Disclosure −0.03 −0.01
Depression 0.38∗∗
∗p < .05. ∗∗ p < .01.

HIV status was not associated with perceived social support from persons
in any given specific relationship. In addition, disclosure to immediate fam-
ily members was related to perceived support from these persons, but the
path between disclosure and support was not significant for extended family
and friends. Finally, only for fathers, brothers, and extended family mem-
bers were there significant associations between perceived social support
and depressive symptoms.

DISCUSSION

This study is among the first to investigate the association of HIV-status

disclosure and social support in specified familial and friendship relation-
ships. However, results from this research must be interpreted in light of
 P1: FLT

328
Journal of Behavioral Medicine [jobm]

Table VI. Results of Path Analyses Testing the Effects of Perceived Disclosure Stress on Rates of Disclosure and Social Support, Effects of
Disclosure on Social Support, and Effects of Social Support on Depression Symptoms

Relationship Stress → Disclosure Stress→ Support Disclosure→ Support Support→ Depression CFI

Generalized model −0.19a −0.32a 0.14a −0.42a 0.99

PP893-jobm-467590

Mother −0.21a −0.05 0.18a −0.08 0.98

Father −0.22a −0.10 0.25a −0.22a 0.97
Sisters −0.23a −0.10 0.23a −0.10 0.98
Brothers −0.22a −0.10 0.25a −0.17a 0.98
Extended family −0.23a −0.12 0.09 −0.18a 0.98
Friends −0.16a −0.01 0.12 0.03 0.98
June 10, 2003

Note. Standardized regression coefficients significant, p < 0.01.

19:31

Kalichman, DiMarco, Austin, Luke, and DiFonzo

Style file version Feb 25, 2000
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

HIV-Status Disclosure 329

its methodological limitations. Our study relied entirely on self-report to

assess rates of HIV-status disclosure to family and friends. Given the social
demands placed on people living with HIV to disclose their HIV status, our
findings may overestimate rates of disclosure. We also used a cross-sectional
study design to examine associations of disclosure, social support, and emo-
tional distress. It is therefore not possible to draw causal inferences and we
cannot determine whether other unmeasured factors may account for our
results. In addition, our sample was one of convenience and cannot be consid-
ered representative of people living with HIV-AIDS. Finally, our measures
of perceived stress of disclosing HIV status and social support from parents
and other relationship categories with only one relationship member relied
on single items and may therefore have limited reliability. Although multi-
item assessments for each construct and each familial relation and friend
would create a considerable respondent burden, greater confidence in re-
sults would be achieved by multiple items in assessing complex constructs.
Having noted these potential limitations, we believe that our study findings
have important implications for future research and practice.
Our findings show that the majority of people living with HIV-AIDS
disclosed their HIV status to family members and friends and that HIV sta-
tus was disclosed to friends significantly more often than family members.
Extending past research, we found that mothers and sisters are more likely
to know of a person’s HIV infection status than their fathers and brothers.
Across relationships, however, there was a close association between dis-
closure of HIV status and perceived social support. Participants who had
fully disclosed to immediate family members, specifically parents and sib-
lings, reported more social support from those relationships. However, the
link between disclosure and social support differed for extended family and
friends. Thus, we found that extended family members and friends were
similar in terms of associations between disclosure and social support. One
explanation for this finding is that friends and extended family elicited in the
interviews, unlike parents and siblings, were persons selected by participants
to be included in their social sphere. Therefore, it makes sense that friends
and extended family members who were identified in the interviews were
persons that participants had shared their HIV status with and were viewed
as supportive. In essence, we appear to have observed a facet of persons
being able to choose their friends and extended family members but not
their immediate family and that such choices may reflect perceived social
support.
Within a generalized model of HIV-status disclosure and social support
depicted in Fig. 1, our findings showed that perceived stress associated with
disclosing HIV status was related to both disclosure and social support. In ad-
dition, rates of disclosure across relationships were related to social support
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

330 Kalichman, DiMarco, Austin, Luke, and DiFonzo

and lower levels of general social support were associated with depressive
symptoms. These associations were predicted on the basis of previous re-
search. However, analyses that focused on specified family relationships and
friendships did not universally support the generalized disclosure—social
support model. First, in contrast to the generalized model, perceived stress
of disclosing HIV status did not predict social support derived from any of
the specified relationships. Therefore, the degree to which individuals feel
that disclosure to family or friends is stressful is not related to the social
support they garnish from these relationships. Second, disclosing HIV sta-
tus was not associated with social support in extended family relationships
and friendships. This finding is likely explained by the near ceiling effects of
disclosing HIV status to extended family and friends who were identified in
the interviews. As noted earlier, participants would be unlikely to identify
extended family or friends from whom they conceal their HIV status and do
not feel supported. Finally, the well-documented association between social
support and depressive symptoms, which occurred in the generalized model,
and for fathers, brothers, and extended family members, was not significant
for mothers, sisters, and friends—the most supportive persons participants
identified. These findings indicate that social support varies with HIV-status
disclosure and that social support is most closely tied to depressive symptoms
in relationship with persons for whom disclosure is least likely.
Our results suggest that people living with HIV-AIDS who have dis-
closed their HIV status to family and friends enjoy greater social support
from those relationships and that social support may buffer emotional dis-
tress in people living with HIV-AIDS. Consistent with past research (e.g.,
Hays et al., 1993; Simoni et al., 1995; Stempel et al., 1995), fathers and broth-
ers were least likely to be disclosed to and were considerably less supportive
than other family and friends. Thus, within the context of the family, indi-
viduals may benefit from interventions that assist them in managing rela-
tionships with fathers and brothers. Interventions focused on public educa-
tion, family counseling, and efforts to reduce AIDS stigmas and prejudices
against people living with HIV-AIDS will help remove barriers to disclosing
HIV and may therefore improve the mental health and quality of life for
many families affected by AIDS (Sowell et al., 1997). Efforts to improve
HIV-status-disclosure decision-making skills and communication skills for
effective disclosure may also benefit people living with HIV-AIDS. Skills for
effective disclosure decisions may include identifying safe situations for dis-
closure, assuring a safety net in case disclosure is met with rejection or other
adverse outcomes, and building communication skills focused on disclosing
HIV status to various relationship categories. Disclosing one’s HIV status
is not always in one’s best interest and can lead to rejection, abandonment,
and other sources of lost social support. Interventions are therefore needed
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

HIV-Status Disclosure 331

to assist people living with HIV-AIDS in reducing disclosure-related stress,

making effective disclosure decisions, and maximizing the potential positive
outcomes that can occur with HIV-status disclosure.

ACKNOWLEDGMENTS

The authors thank the staff of AIDS Survival Project of Atlanta for their
assistance with data collection. Supported by National Institute of Mental
Health (NIMH) Grants R01-MH57624 and R01-MH63666 supported this
research.

REFERENCES

Arbuckle, J. L., and Worthke, W. (1999). Amos 4. 0 User’s Guide, SmallWaters Corporation,
Chicago.
Beck, A. T., and Steer, R. A. (1983). BDI: Beck Depression Inventory manual, Psychological
Corporation, New York.
Bharat, S. (1996). Disclosure in the family. Int. Conf. AIDS 11: 44.
Brock, D., Sarason, I., Sarason, B., and Pierce, G. (1996). Simultaneous assessment of perceived
global and relationship-specific support. J. Soc. Pers. Relat. 13: 143–152.
Gielen, A. C., O’Campo, P., Faden, R. R., and Eke, A. (1997). Women’s disclosure of HIV
status: Experiences of mistreatment and violence in an urban setting. Women & Health 25:
19–31.
Green, G. (1993). Social support and HIV. AIDS Care 5: 87–104.
Hays, R. B., McKusick, L., Pollack, L., and Hilliard, R. (1993). Disclosing HIV seropositivity to
significant others. AIDS 7: 425–431.
Huber, C. H. (1996). Facilitating disclosure of HIV-positive status to family members. Fam. J.:
Counsel. Ther. Couples Fam. 4: 53–55.
Jeffe, D. B., Khan, S. R., Meredith, K. L., Schlesinger, M., Fraser, V., and Mundy, L. M. (2000).
Disclosure of HIV status to medical providers: Differences by gender, race, and immune
function. Public Health Rep. 115: 38–45.
Kalichman, S. C., Rompa, D., and Cage, M. (2000). Distinguishing between overlapping somatic
symptoms of depression and HIV disease in people living with HIV-AIDS. J. Nerv. Ment.
Dis. 188: 662–670.
Kimberly, J. A., and Serovich, J. M. (1996). Perceived social support among people living with
HIV/AIDS. Am. J. Fam. Ther. 24: 41–53.
Mansergh, G., Marks, G., Simoni, J. J. (1995). Self-disclosure of HIV infection among men who
vary in time since seropositive diagnosis and symptomatic status. AIDS 9: 639–644.
Marks, G., Bundek, N., Richardson, J., Ruiz, M., Malonado, N., and Mason, H. (1992). Self-
Disclosure of HIV Infection: preliminary results from a sample of Hispanic men. Health
Psychol. 11: 300–306.
Rothenberg, K. H., and Paskey, S. (1995). The risk of domestic violence and women with HIV
infection: Implications for partner notification, public policy, and the law. Am. J. Public
Health 85: 1569–1576.
Schnell, D., Higgins, D., Wilson, R., Goldbaum, G., Cohn, D., and Wolitski, R. (1992). Men’s
disclosure of HIV test results to male primary sex partners. Am. J. Pub. Health 82: 1675–
1676.
Serovich, J. M., Kimberly, J. A., Greene, K. (1998). Perceived family member reaction to
women’s disclosure of HIV-positive information. Fam. Stud. 47: 15–22.
P1: FLT
Journal of Behavioral Medicine [jobm] PP893-jobm-467590 June 10, 2003 19:31 Style file version Feb 25, 2000

332 Kalichman, DiMarco, Austin, Luke, and DiFonzo

Simoni, J., Mason, H., Marks, G., Ruiz, M., Reed, D., and Richardson, J. (1995). Women’s self-
disclosure of HIV infection: Rates, reasons, and reactions. J. Consult. Clin. Psychol. 63:
474–478.
Smith, M. Y., and Rapkin, B. D. (1996). Social support and barriers to family involvement in
caregiving for person with AIDS: Implications for patient education. Patient Educ. Counsel.
27: 85–94.
Sowell, R. L., Lowenstein, A., Moneyham, L., Demi, A., Yuko, M., and Seal, B. F. (1997).
Resources, stigma, and patterns of disclosure in rural women with HIV infection. Public
Health Nurs. 14: 302–312.
Stempel, R. R., Moulton, J. M., and Moss, A. R., (1995). Self-disclosure of HIV-1 antibody test
results: The San Francisco general hospital cohort. AIDS Educ. Prev. 7: 116–123.
Wolitski, R. J., Rietmeijer, C. A. M., Goldbaum, G. M., Wilson, R. M. (1998). HIV serostatus
disclosure among gay and bisexual men in four American cities: General patterns and
relation to sexual practices. AIDS Care 10: 599–610.
Copyright of Journal of Behavioral Medicine is the property of Springer Science & Business Media B.V. and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.