Youths' strategies for HIV status disclosure in rural Kenya and Uganda: “You can't just trust everyone”

Background: HIV status disclosure is influenced by social values, roles, and rules people take on and adapt, aligned with developmental transitions and cultural expectations. Understanding motivations for disclosure among adolescents and young adults with HIV (AYAH) is important for promoting HIV care engagement. Methods: A cluster-randomized controlled trial in 28 rural communities in Kenya and Uganda tested an intervention to improve viral suppression and health outcomes among AYAH 15-24 years of age. A longitudinal qualitative study embedded within the trial aimed to identify the intervention's mechanisms of action via semi-structured interviews with n = 111 AYAH, providers (n = 45), and selected family members. Analysis for this paper focused on motivations and barriers to disclosure among AYAH, with attention to targets/confidants, contexts, and communication strategies. Results: Social roles and expectations influenced HIV status disclosure motivations among AYAH, including filial piety towards parents, spontaneous reciprocity with friends, and conscientiousness towards school supervisors. Women tended to prefer disclosure before marriage. Younger men tended to prefer disclosure after marriage, but older male youth looking for seroconcordance in a partner were willing to disclose before marriage. Medication bottles or pills often provided a contextual opening for disclosure conversations. Disclosure of antiretroviral therapy (ART) use appeared to present more significant hurdles than disclosure of HIV status alone. Interpretation: may facilitate support for ART adherence. Tailoring disclosure strategies to particular target-confidant types may help youth disclose more easily and validate their social values and chosen ties while supporting successful care engagement.