Men’s serostatus disclosure to parents: Associations among social support, ethnicity, and disease status in men living with HIV

Abstract

Background. Directly disclosing a positive HIV serostatus to family members can affect psychological and disease status. Perceptions that one is in a supportive family environment may moderate these effects; however, ethnic differences may exist in the support processes of families coping with HIV. Methods. We examined the role of serostatus disclosure to parents, HIV-specific family support, and ethnicity (Latino versus non-Hispanic White) in explaining disease status (HIV Viral Load, CD4+ cell count) in a sample of men living with HIV (MLWH). Men (n = 120) reported whether they had disclosed their serostatus to their mothers and fathers, rated their perceptions of HIV-specific social support received from family members, and provided morning peripheral venous blood samples to assess immune function. We also collected psychosocial and urinary neuroendocrine indicators of stress/distress as possible mediator variables. Results. A three-way interaction emerged between serostatus disclosure to mothers, HIV-specific family support, and ethnicity in explaining both viral load and CD4+ cell count. Non-Hispanic White men who had disclosed to mothers and were receiving high family support had a lower viral load and higher CD4+ cell count, but Latino men who had disclosed to mothers and were receiving low family support had a higher viral load. These associations were not accounted for by men’s medication adherence, psychological distress, or neuroendocrine hormones. Disclosure to fathers was not related to disease status. Conclusions. The effects of serostatus disclosure on disease status may depend, in part, on ethnic differences in the interpersonal processes of men’s close family relationships.

Introduction

Compared to non-Hispanic White men, Latino men are two to three times more likely to be infected with HIV and in some cases show faster rates of disease progression (Hall et al., 2007, Harawa et al., 2004). This health disparity cannot be fully explained by differences in sociodemographic factors or health behaviors, including sexual behaviors, and drug use (Harawa et al., 2004). Ethnic differences in interpersonal processes, such as disclosing one’s positive serostatus to family members and the perception of HIV-specific support received from family members, may help to explain these health disparities in HIV disease progression. The current study examines HIV-specific social support from family members and ethnicity as moderators of the associations between serostatus disclosure to parents and immune function in a sample of Latino and non-Hispanic White MLWH.

Serostatus disclosure is a form of self-disclosure, as it involves revealing personal information about the self (Yep, 2000, Zea et al., 2004). Individuals may disclose as a way of expressing trust and gaining intimacy in their personal relationships (Jourard, 1971). However, disclosing a positive serostatus can be a source of interpersonal stress, and individuals weigh the costs and benefits of the disclosure act prior to disclosing (Serovich, 2001). For both Hispanic (Latino) and non-Hispanic White (White) people living with HIV (PLWH), serostatus disclosure is less likely to occur when negative reactions are expected and more likely to occur when positive outcomes (e.g., social support) are expected (Mason et al., 1995, Zea et al., 2007, Zea et al., 2003).

MLWH often disclose to friends more often than family members and to mothers more often than fathers (Kalichman et al., 2003). Disclosure is more likely to occur to individuals who already know of the male discloser’s sexual orientation (Marks et al., 1992). While some men prefer not to disclose to parents to protect their own privacy or their relationship with their parents, others will disclose to their parents out of a sense of obligation (Derlega et al., 2004, Mason et al., 1995). However, given that family members, particularly parents, are important sources of support for PLWH despite support from friends (Bor et al., 1993), it is important to examine patterns of serostatus disclosure to parents.

Men’s serostatus disclosure to family members has been associated with both psychological and disease outcomes. Associations between serostatus disclosure and psychological outcomes appear to be largely dependent on the social context in which the disclosure occurs. Some research suggests that social support that is received as a result of serostatus disclosure accounts for the associations between serostatus disclosure and well-being (Zea et al., 2005). However, other research suggests that improvements in individuals’ social networks as a result of disclosing may buffer the stress of living with HIV (Cohen and Wills, 1985, Kalichman et al., 2003). Serostatus disclosures that yield positive or helpful reactions tend to be associated with lower levels of psychological distress whereas disclosures that yield negative or undermining reactions tend to be associated with increased levels of distress (Derlega et al., 2003, Ingram et al., 1999). Importantly, within families, mothers tend to provide more social support than fathers and other family members following disclosure (Kalichman et al., 2003).

Although research notes that men and women with higher rates of serostatus disclosure to family members report higher levels of medication adherence (Stirratt et al., 2006), little research has examined the links between serostatus disclosure and disease outcomes, including immune and virologic status. Research on sexual orientation disclosure, however, suggests that MLWH who conceal their sexual orientation experience faster disease progression (Cole et al., 1996) and that higher levels of sexual orientation disclosure coupled with high levels of satisfaction with support is associated with better immune function in MLWH (Ullrich et al., 2003). Moreover, compared to MLWH who wrote about neutral topics, MLWH who were emotionally expressive in writing about traumatic events experienced gains in CD4+ cell counts over time (Petrie et al., 2004). Thus, it is plausible to assume that disclosing one’s serostatus to family members has the potential to contribute to better disease status in MLWH and that men’s social environment may promote or detract from these health benefits.

In our previous research in ethnic minority women who disclosed their serostatus to family members, we found that HIV-specific social support from family members modified the associations between disclosure to mothers and women’s perceived stress, distress, and 24-h urinary free cortisol. Specifically, women who had disclosed to mothers and were receiving adequate levels of HIV-specific social support from their family experienced less perceived stress, fewer depressive symptoms, and lower levels of 24-h urinary free cortisol (Fekete et al., in press). Disclosure to mothers in a less supportive family was not associated with less stress, depression or cortisol. Taken together, these studies suggest that the social context in which the process of disclosure occurs may play an important role in how disclosure is ultimately associated with disease status in MLWH.

Another limitation of research on serostatus disclosure in MLWH is a lack of research considering the role of ethnic differences in the disclosure process. Compared to non-Hispanic white men, Latinos living with HIV are more selective in who they disclosure to, and thus disclose their serostatus less frequently to social network members (Mason et al., 1995, Zea et al., 2004). This may be due, in part, to ethnic differences in cultural values.

Compared to White culture, Latino culture is more collectivist in nature and promotes close, nurturing, and supportive familial relationships (Marín and Marín, 1991, Yep, 1992). Latinos tend to rely strongly on their families as a source of support during times of stress (Keefe et al., 1979, Raymond et al., 1980) and tend to have fewer social connections with individuals who are not part of their family unit (Keefe et al., 1979, Vernon and Roberts, 1985). One might expect Latino MLWH to receive more support from family members than non-Hispanic White MLWH after disclosing an HIV positive serostatus.

However, Latino culture traditionally views homosexuality negatively (Marks et al., 1992), and the disclosure of sexual orientation is strongly associated with serostatus disclosure (Zea et al., 2004). In addition, Latino cultures also encourage a sense of simpatía, or attempts to promote harmony within interpersonal relationships and a desire to protect families from shame or embarrassment (Triandis et al., 1984). This suggests that although Latino MLWH may have closer family ties than non-Hispanic White MLWH, they may experience more discord in their social relationships as a function of revealing their positive serostatus to close family members.

Research suggests psychosocial stressors are consistently associated with immune function through both biological and psychological mechanisms associated with stress appraisals. Adrenal hormones, including cortisol and norepinephrine, and psychosocial factors such as depressive symptoms and perceived stress have been proposed as mediators of the stressor-immune function relationship (Antoni, 2003, McEwen, 1998). Recently, reductions in cortisol and depressed mood following a cognitive behavioral stress management intervention (CBSM) were associated with sustained increases in immune function in MLWH (Antoni et al., 2005). It is possible that associations between psychosocial variables such as serostatus disclosure, support, and ethnicity and men’s disease status may be mediated by neuroendocrine hormone regulation and psychological distress (Cole et al., 2001).

The overarching goal of our study was to examine the extent to which associations between serostatus disclosure to parents and disease status (i.e., viral load and CD4+ cell count) are modified by HIV-specific family support and ethnicity in MLWH. Because we were specifically interested in examining ethnic differences in interpersonal processes within the familial relationships of MLWH, we chose to focus on serostatus disclosure to parents. Further, because prior research has noted that disclosure in general is not consistently associated with psychological health outcomes in PLWH, but disclosure to specific social network members is associated with psychological health outcomes (Kalichman et al., 2003), we chose to examine disclosure to each parent separately.

We hypothesized that the associations between serostatus disclosure to parents and disease status in MLWH would be modified by the amount of HIV-specific family support men perceived receiving. Specifically, we hypothesized that men who had disclosed to either their mothers or fathers and were receiving high levels of HIV-specific family support would have a better disease status, but men who had disclosed to either parent and were receiving low levels of HIV-specific family support would have poorer disease status. We also examined whether these associations would vary based on men’s ethnicity. Because Latino culture promotes a more closely knit familial social environment than White culture, we hypothesized that the combination of serostatus disclosure and greater social support buffering would be more strongly associated with better disease status in Latino men than in non-Hispanic White men. We examined these associations while controlling for potential behavioral confounders such as Highly Active Antiretroviral Therapy (HAART) medication status. Finally, we explored whether the effects of these interpersonal processes on disease status were explained via stress/distress using psychosocial and neuroendocrine indicators.