With the increase in pMTCT programs, antenatal clinics may seem an appropriate place to extend VCT services to include spouses as part of couples counseling. By our experience with modest community outreach and education, couple counseling can be successfully incorporated into antenatal VCT services, albeit at a modest rate. Only 10% of women were able to encourage their husband’s participation, and so programs actively encouraging male involvement should anticipate the majority of VCT will be directed to individual women. Nonetheless, the concern that disclosure inherent in couples counseling may increase the likelihood of adverse social outcomes was not supported by the findings reported here. Programs need to identify strategies that empower women to make decisions about HIV testing and pMTCT interventions in the absence of their partners, such as ‘opt-out’ strategies [18
Uptake of HIV testing among couples was high, justifying the effort to solicit male participation. However, couples probably represent a group that is more motivated to come to the clinic specifically seeking counseling and the high uptake within this group may therefore have limited generalizability. Even in this more motivated group, we did not observe a benefit for uptake of NVP. The relatively low uptake of NVP (67.5%) and the failure of improvement with couple counseling is disappointing and suggests that refusal of NVP may be unrelated to partner disclosure. Other antiretroviral drug interventions for pMTCT that require more prolonged regimens may necessitate disclosure to a greater extent and may be more amenable to improvements by couple counseling.
HIV-seroprevalence was higher among women counseled as part of a couple (37.6%) than among women counseled alone (27.4%). Women counseled more than once were significantly more likely to test HIV-positive, suggesting that women who previously tested HIV-positive or suspected HIV infection, were more successful in bringing their partner to VCT. This may also explain the higher rate of positive RPR and dual HIV/RPR infection among the couples-counseled women. As much as 28% of the pregnant women tested may have had biologic false-positive reactions known to occur during pregnancy [20
Granting women the option to test more than once may help them to enlist their husband into couple counseling. A noteworthy number of couples had discordant HIV status (18.0%) providing an important opportunity for prevention counseling. Other studies among discordant couples have found improved communication about sexual matters and increased condom use after couple counselling [1
]. Moreover, prevention counseling has been associated with lower rates of HIV transmission in discordant couples [2
We had hypothesized that couple counseling would reduce adverse social outcomes associated with disclosure of HIV status. Unfortunately, adverse social events were reported in all groups, regardless of disclosure or counseling status. Population-based surveys in Lusaka have described very high rates of reported physical violence against women (26% in the prior 12 months) [15
]. Lower adverse-event rates reported here may be due to differing survey methodology and specific circumstances that are not directly comparable to women participating in community-wide surveys [15
]. Accurate measurement of sensitive social information is a challenge and women may be reluctant to report these events in the relatively non-anonymous setting of a cohort study. Nevertheless, our data suggest that couple counseling is not associated with any increased risk.
Although there was a slight trend towards increased reporting of some adverse social events with disclosure of HIV status, we did not observe a statistically significant increased risk once we adjusted for cohabitation or marital status. Our results may over-estimate adverse consequences of disclosure as these events may have been under-reported among women who did not disclose their HIV status. Although we did not collect pre-test adverse event information and therefore cannot comment on the direct effect of disclosure of HIV status per se, we did observe a trend towards fewer adverse events among the 29 HIV-negative women who did disclose their status to their partner.
Within couples, we did not observe discordance in HIV status to be associated with any changes in the risk of adverse social events. There was a slight trend towards higher levels of divorce or separation among discordant couples, which requires evaluation with more detailed and qualitative data.
As clinical illness becomes apparent (clinical stage III), women were more likely to report being forced from the home, separated or divorced. This may have been due to the spouse or other family member’s perception of illness, fear of increased HIV transmission and/or the inability to care for the woman. As we only examined adverse social events at 6 months after delivery, our inferences about later time points are limited. As disease stage progresses, the consequences of disclosure may differ.
The pMTCT programs in developing areas are often implemented in the context of high background levels of interpersonal violence and poverty and where HIV infection is highly stigmatizing. These social contexts raise many challenges for program implementation. As practiced in our particular setting, couple counseling appeared to be insufficient on its own to reduce adverse outcomes. The quality and extent of the counseling may need to be improved, more community-oriented interventions developed, and activities to assist community mobilization around HIV may be beneficial. Nevertheless, adverse social events were not increased in the couple-counseled group despite the demands of disclosure intrinsic to this counseling strategy. Further research is needed to develop and evaluate community and individual interventions to help ameliorate the complex social issues confronted by men and women living with HIV.