hiv / aids is increasingly affecting the health and welfare of children and undermining hard - won gains of child survival in highly affected countries .
recent estimates from the joint united nations programs on hiv / aids ( unaids ) suggest that globally about 2.5 million children younger than 15 years of age are infected with hiv : 90% living in sub - saharan africa   and about 64,813 living in ethiopia . without treatment 75% of hiv - infected children
as highly active antiretroviral therapy ( haart ) becomes increasingly available in low resource settings , infected children are living longer .
with increased survival , one of the greatest psychosocial challenges that parents and caregivers of hiv - infected children face is the disclosure of hiv - positive status to their infected children .
one of the most difficult issues that families with hiv - infected children face is when and how to talk about hiv to their children .
hiv - positive status disclosure to infected children and adolescents should take place in a supportive environment with collaboration and cooperation among caregivers and health care providers .
disclosure is contingent on the caregiver 's acknowledgement of the illness , the readiness to disclose , and child 's cognitive skills and emotional maturity .   despite emerging evidence of the benefit of disclosure , when and how to disclose the diagnosis of hiv to children remain a clinical dilemma .
clinicians and other members of multidisciplinary teams should collaborate with caregivers of hiv - infected children to disclose hiv diagnosis to the child in a developmentally appropriate manner .
children react to hiv disclosure in different ways and it is not uncommon for relatives to disagree about disclosing hiv - related information to children .
disclosure has to be individualized taking into consideration the particular child , parent ( s ) , family , household , and community .
hiv diagnosis disclosure entails communication about a potentially life - threatening , stigmatized , and transmissible illness , and many caregivers fear that such communications may create distress for the child .  
the american academy of pediatrics strongly encourages disclosure of hiv - positive status to school - age children .
but in ethiopia , no such recommendations and guidelines are available concerning disclosure of pediatric hiv , and disclosing the diagnosis of hiv or aids to a child is controversial and challenging among health care providers , parents , and caregivers .
thus this study assessed the magnitude of hiv - positive status disclosure and the associated factors among hiv - infected children in northwest ethiopia .
an institution - based cross sectional study design was carried out from march to april , 2012 at the three hospitals of north gondar zone .
north gondar zone is one of the 11 zones in the amhara national regional state .
all hiv - positive children aged 515 years who were on care and support followup at the pediatric art clinics of the three hospitals ( gondar , metema , and dabark ) in north gondar zone .
all caregivers of the children enrolled in the chronic hiv care at pediatric art units of the three hospitals were included . children who came by themselves or with no caregiver or parent
disclosure refers to when the caregiver said that the child knows his / her hiv / aids diagnosis regardless of who told the child .
data were collected by an interview technique using a structured questionnaire which was first prepared in english then translated to the local language amharic .
a clinical nurse working at the pediatric art clinic of each hospital and supervised by a supervisor collected the data .
the prepared questionnaire was pretested and structured accordingly in a logical manner into sociodemographic , clinical characteristics and hiv - positive disclosure parts .
the data were entered in to epi info version 3.5.1 statistical software and analyzed by spss version 20.0 .
variables having p value  0.2 in the bivariate analysis were entered into a multiple logistic regression model to control the confounding effect .
odds ratios with their 95% confidence intervals were calculated to measure associations , and statistical significance was set at p < 0.05 .
efforts were made to assess whether the necessary assumptions for the application of multiple logistic regression were fulfilled . in this regard , the hosmer and lemeshow goodness - of - fit test was considered , and p value > 0.05 is considered as a good fit model .
permission was obtained from the hospitals administration and the art focal persons at each hospital .
after the purpose of the study was explained , verbal consent was obtained from each caregiver .
participants also were informed that participation was on voluntary basis and that they can withdraw at any time if they are not comfortable about the questionnaire .
names or personal identifiers were not included in the written questionnaires to ensure participants ' confidentiality .
a total of 428 caregivers were interviewed . of these , 343 ( 80.1% ) were from gondar university referral hospital .
three hundred thirty - one ( 77.3% ) of the caregivers were females , 368 ( 86% ) were orthodox christians , and the majority ( 89.5% ) were urban residents .
about half ( 51.4% ) of the caregivers had a monthly income of 300999 ethiopian birr per month .
nearly two thirds ( 65.4% ) of the caregivers were biological parents of the children and one third were daily labourers .  
almost half ( 49.3% ) of children were males and the mean age of children was 9.96  3.0 sd years .
the median age at diagnosis of hiv was 6.0 years ( iqr = 5 years ) .
three hundred four ( 71% ) of the children attended their primary school and nearly two third of them were living with their biological parents ( table 1 ) .
nearly two third ( 61.9% ) of the caregivers were hiv - positive of whom 92.5% were on art and 86.4% had disclosed their hiv - positive status to someone else .   majority ( 81.3% ) of the children had a who clinical stage i disease .
majority , that is , 344 ( 80.4% ) children , had history of opportunistic infections ( ois ) and 42.5% were hospitalized .
three hundred forty - eight ( 81.3% ) children were on art at the date of interview ( table 2 ) .
of the 428 children , 169 ( 39.5% , 95% ci : 34.8 , 43.7 ) of the children living with hiv / aids were disclosed their hiv - positive status . the mean age at disclosure was 10.7 years ( 2.3 years ) .
sixty - nine ( 40.8% ) children were disclosed by their biological parents while 38.5% of children were disclosed by health care providers .
the prominent reasons for disclosure as mentioned by caregivers were  child thought to be matured  ( 44.4% ) and repeated questionings of  what happened to me  ( 27.2% ) by the child ( figure 1 ) .
participants mentioned reasons for not disclosing the child about his / her hiv - positive status .
more than half still believe that the child is too young ( 57.1% ) and another one fifth fear the negative emotional and health consequence ( 20.1% ) of disclosure ( figure 2 ) .
two hundred twenty - one ( 81.1% ) of the caregivers believed that disclosing the hiv - positive status to the child is advantageous and three quarters ( 76.8% ) had the intension to disclose in the near future .
as clearly depicted on the multivariate logistic regression , caregiver 's relation with the child , age of the child and loss of a family member were independently and significantly associated with disclosure of hiv - positive status to hiv - infected children .
however , factors related to the caregiver such as sex , religion , hiv - positive status , and educational status , as well as sex of the child , history of ois , and art status of children were not significantly associated with disclosure of hiv - positive status to hiv - infected children .   accordingly
, nonbiological parents were 4.14 ( aor = 4.14 , 95% ci : 1.22 , 14.04 ) times more likely to disclose hiv - positive status to hiv - infected children as compared to biological ones . age of the child was one of the factors significantly associated with disclosure of hiv - positive status in which children older than 10 years of age were 8.54 ( aor = 8.54 , 95% ci : 4.5 , 15.53 ) times more likely to be disclosed as compared their counterparts .
those children who lost any of their family members were two ( aor = 2.04 , 95% ci : 1.16 , 3.6 ) times more likely to be disclosed their hiv - positive status as compared to their counterparts ( table 3 ) .
in ethiopia , due to the recent improvements in access to antiretroviral therapy , dramatic decline of mortality and morbidity of hiv - infected children has been observed . as children survived for longer periods of time , disclosure issues emerge related to pubertal development and sexuality , fear of transmission , and the need to promote adherence to complex and often toxic regimens .
promotion of trust , improved adherence , open family communication , and better long - term health and emotional well - being in children are some of the advantages .   in this study , 39.5% of hiv - positive children
this finding is similar to studies conducted in usa which reported a disclosure rate of 3543% [ 1113 ] .
but it is very low as compared to studies done in high - income countries in which the disclosure rate ranges from 57 to 100% [ 10 , 14 , 15 ] .
the lower prevalence of disclosure in our study might be due to fear of stigma and discrimination by the family members .
since the majority of hiv - infected children acquired the virus from their mothers , disclosure of a child 's hiv - positive diagnosis often leads to disclosure of other family secrets that leads to stigma and discrimination .
caregiver 's perceived lack of emotional preparedness of children and [ 16 , 17 ] and the absence of recommendations and guidelines for disclosure of hiv - positive children in ethiopia might have also contributed for the lower rate of disclosure .
this finding was somewhat higher as compared to studies conducted in poland ( 16.2% ) , thailand ( 30.1% ) , ghana ( 21% ) , and nigeria ( 13.5% ) .
it is also higher as compared to a study conducted in addis ababa , ethiopia ( 17.4% ) .
the possible justification can be difference in time period and there might be also increased awareness on the benefit of disclosure by caregivers . additionally , this study assessed disclosure status among children 515 years of age , but the study conducted in addis ababa includes all pediatric age groups .  
age was identified as a factor for disclosure in this study and in another study conducted in ethiopia .
this could be due to the caregivers ' belief that at early age , the child is lacking the emotional and cognitive maturity needed to understand the disease and its implications [ 12 , 13 , 21 , 22 ] . in this study ,
the mean age at disclosure was 10.7 years which was high as compared to studies done in new york ( 7 years ) and nigeria ( 8.7 years ) but somewhat comparable with a study conducted in ghana ( 11.72 years ) [ 7 , 17 , 20 ] .
reasons cited by the caregivers were consistent with that of studies in resource - limited countries ; namely , child is too young , fear of emotional and health consequences , fear of stigma and discrimination , and fear that the child would not keep diagnosis to themselves .
caregivers believed their children were too young to know their status .   in our study ,
the factors that were independently and significantly associated with disclosure were the age of the child , nonbiological parent relation with the child , and loss of family member .
consistent with previous studies done in ghana and london , children were more likely to be disclosed if they were orphaned [ 11 , 23 ] .
the results of our study supported previous studies done in nigeria , thailand , london , and massachusetts [ 11 , 19 , 20 , 23 ] that showed older age of infected children as a determinant factor for hiv - positive status disclosure .
children older than 10 years were more likely to be disclosed than those younger than 10 years .
the child 's theory of cognitive understanding of illness is also in favour of this finding .
accordingly , the age from 9 to 10 years and older is considered to be the best time for hiv - infected children to know about their sickness as at this age children can understand about the complex causes of illness and its consequences .   in this study , nonbiological caregivers were more likely to disclose the child 's hiv - positive status than biological caregivers .
this finding is in agreement with studies done in philadelphia and thailand [ 19 , 21 ] where most children who knew their diagnosis were living with caregivers who were not related to them , whereas the majority of children who did not know the diagnosis were living with biological parents .
as argued by these studies biological parents might not be willing to confront the fact of their own responsibilities in passing the infection onto their children .  
the sample size is relatively larger than other studies done in sub - saharan africa , and generalization can be made to children on chronic hiv / aids care in ethiopia . but as a cross - sectional study , the associations observed may not be causal . because of lack of data on adherence to treatment , we could not include it in the analysis . furthermore , the study did not explore the benefits of disclosure on adherence and clinical improvement in hiv / aids .
the rate of disclosure of hiv - positive status to hiv - infected children is low in this study .
non biological parent caregivers , children older than 10 years of age , and loss of family member were independently and significantly associated with disclosure of hiv - positive status to hiv - infected children .
hence , it is important to target young children living with their biological parents and those having young parents .
guideline for disclosure of children with hiv / aids has to be established in ethiopian context .
we recommend further studies to be undertaken to explore the benefits of disclosure of hiv - positive status to hiv - infected children .
 
 introduction . 
 clinical reports have indicated positive outcomes associated with disclosure of hiv - positive status in children . 
 this study assessed the level and associated factors of hiv - positive status disclosure to hiv - infected children in northwest ethiopia . 
 methods . 
 institution - based cross - sectional study was conducted among hiv - positive children from march to april 2012 . 
 data were collected using a structured questionnaire by face - to - face interview technique . 
 bivariate and multivariate analyses were performed . 
 results . of the 428 children , 169 ( 39.5% ) were disclosed their hiv - positive status . 
 the mean age of hiv - positive status disclosure was at 10.7 ( 2.3 ) years . having a nonbiological parent ( aor = 4.14 , 95% ci : 1.22 , 14.04 ) , child 's age older than 10 years ( aor = 8.54 , 95% ci : 4.5 , 15.53 ) , and death of a family member ( aor = 2.04 , 95% ci : 1.16 , 3.6 ) were significantly and independently associated with disclosure of hiv - positive status to infected children . conclusions . 
 the rate of disclosure of hiv - positive status to infected children still remains low in north gondar . 
 hence , it is important to target children living with their biological parents and having young parents and children younger than 10 years . 
 the guideline for disclosure of children with hiv / aids should be established in an ethiopian context . 
1. Introduction 
2. Methods 
3. Results
4. Discussion 
5. Conclusions