In a study conducted in Abidjan, Côte d'Ivoire, the proportion of women who had discussed STIs with their partner increased substantially after the women underwent prenatal HIV testing and counseling, regardless of the woman's serostatus.1 The proportion of HIV-negative women who reported having discussed STIs with their partner increased from 65% at prenatal testing to 97% at an 18-month postpartum visit; among HIV-infected women, the proportion increased from 28% to 65%. Moreover, after testing and counseling, most women suggested that their partner obtain an HIV test and that he use condoms with other partners.
Although HIV prevention messages have focused primarily on the reduction of such risky sexual behaviors as intercourse with occasional partners or sex workers, these behaviors do not constitute the full measure of risk. In Africa, most new infections occur within couples, as a result of either infidelity or the prior infection of one partner. In resource-limited countries where HIV testing is uncommon, prenatal counseling and testing can increase couples' awareness of HIV and provide an entry point to related services. To aid in the development of transmission prevention strategies, the authors of the current study examined communication between partners about STIs before and after prenatal testing, and examined levels of consistent condom use among HIV-infected and HIV-negative women.
As part of a broader mother-to-child transmission prevention program conducted in 2001–2005, prenatal HIV counseling and testing was offered to all pregnant women attending seven prenatal clinics in two districts of Abidjan. Women who tested positive were enrolled in the transmission prevention program and followed for two years after delivery; women who were HIV-negative also were followed for two years after delivery, at biannual reproductive health visits. All of the women were encouraged to advise their partner to be tested.
The study initially included 875 women, of whom 355 HIV-negative and 347 HIV-infected women attended their 18-month postpartum visit and were included in the analyses. At the prenatal HIV testing and counseling visit, all women were asked about their demographic characteristics and their sexual behaviors in the two years before their current pregnancy; those with regular partners were asked about their partner's age and education, their union type (polygamous or monogamous) and whether they had discussed STIs with their partner during the past two years. Women were queried about their sexual activities at each postpartum follow-up visit, and at the 18-month visit they reported whether their partner had undergone HIV testing and whether they had discussed STIs with their partner since the prenatal HIV test. In addition, to create an indicator of communication on sexual risk within couples, the researchers measured the proportions of women who had disclosed their HIV status to their partner, who had suggested at least once that their partner get tested for HIV and who had advised their partner to use condoms if he had sex with other women. If a woman had discussed all three issues with her partner, their communication was considered complete; if they had discussed only one or two of these issues, their communication was considered partial; if none of these matters had been discussed, communication was classified as nonexistent.
Compared with HIV-negative women, infected women were older, had older partners and were more often in polygamous unions. Prior to testing, a higher proportion of HIV-negative women than HIV-infected women had discussed STIs with their partner in the past two years (65% vs. 28%). By the 18-month postpartum follow-up, the proportion had increased by more than 30 percentage points in both groups—97% of HIV-negative women and 65% of infected women had discussed STIs with their partner since HIV testing. Moreover, HIV-negative women reported high levels of communication with their partner at the 18-month follow-up visit: Ninety-seven percent had disclosed their HIV status to their partner, an identical proportion had suggested their partner get tested and 94% had suggested their partner use condoms in extramarital relations. Among HIV-infected women, 43% had disclosed their HIV status to their partner, 72% had suggested their partner get tested and 58% had suggested he use condoms with outside partners. Eighty-one percent of HIV-infected women who disclosed their status reported that their partner had been understanding; only 4% said that he had responded to the news with anger or rejection.
Seventy-eight percent of HIV-infected women and 94% of HIV-negative women had resumed sexual activity by the 18-month follow-up; levels of condom use among sexually active respondents did not differ by HIV status. Among infected women, only 27% of those whose partner had not been tested had used condoms consistently since their last follow-up visit, compared with 39% of those whose partner was HIV-negative and 50% of those whose partner was HIV-positive. Consistent condom use among women with complete or partial communication on sexual risk issues was twice that of women who had not discussed sexual risk (37–38% vs. 19%). Among HIV-positive women, higher levels of partner education were associated with consistent condom use.
Although the researchers are encouraged by the increase in communication about STIs following prenatal HIV testing and by the level of condom use among study participants (which was greater than that typically observed in Côte d'Ivoire), they note that the level of condom use "remains insufficient to ensure a good prevention of HIV transmission." They conclude that prenatal counseling and testing may "help HIV-infected individuals learn their HIV status, disclose their status to their partner and encourage partner testing," and that it "is an efficient tool for sensitizing women and their partners to HIV prevention." However, HIV prevention within relationships "remains difficult and needs to be specifically addressed."—L. Melhado
1. Desgrées-du-Loû A et al., From prenatal HIV testing of the mother to prevention of sexual HIV transmission within the couple, Social Science & Medicine, 2009, 69(6):892–899.