Among HIV-1-infected women presenting for routine antenatal care in this cohort, partner participation in VCT was associated with increased uptake of interventions to prevent vertical and sexual HIV-1 transmission. Women whose partners came to the antenatal clinic for counseling were more likely to receive nevirapine during follow-up, avoid breast-feeding their infant, and report condom use. The association between partner participation and uptake of these interventions was strongest when partners who came to the clinic agreed to be counseled as a couple. These data show that partner participation in VCT can improve acceptance and utilization of preventive strategies and suggest that couple counseling in the antenatal setting may have additional benefits to individual VCT.
We hypothesize that partner participation in the antenatal VCT program and couple counseling influenced intervention uptake by promoting dialogue between women and partners about methods to prevent mother-to-child and sexual HIV-1 transmission. This may not have been the case when women simply notified partners that they were HIV-1 seropositive in the absence of partner VCT. In the partner notification scenario, women relay test results but do not necessarily provide additional information regarding specific interventions to prevent HIV-1 transmission. Conversely, men coming for individual or couple VCT were informed of the pros and cons of antiretrovirals, alternative infant feeding, and condom use. When a couple presents for posttest counseling together, the counselor tailors discussions to meet the couple's needs and facilitates interactions that are difficult to initiate. The benefits of couple counseling are supported by the stepwise increase that we observed in intervention uptake from partner notification of a positive test result, to partner participation in individual counseling, and finally to couple counseling.
In addition to increasing intervention uptake, offering couple counseling and encouraging women to bring partners for VCT appears to have increased partner notification rates in this cohort. Among HIV-1-infected women in the cohort, 64% informed their partners of HIV-1–positive results vs. <40% in other African studies.7,11,12
The fact that women were encouraged to discuss VCT before testing and were able to provide partners with a reason for HIV-1 testing and a site for free VCT may account for higher notification rates. It is also possible that the clinic's emphasis on including partners in the counseling process made women more aware of the important role the partner can play in preventing HIV/AIDS transmission. Correlates of partner notification included being unemployed and less sexually experienced (fewer lifetime sexual partners, older age at first sex, no prior condom use). These findings have not been reported in all studies of HIV-1 status disclosure during pregnancy7,11
; however, they are consistent with reports from 2 earlier perinatal studies conducted in East Africa.9,12
One interpretation is that women who work outside the home or have more sexual experience believe that they are more likely to be blamed for infidelity and do not disclose as a result of this fear.
Another interesting finding in this study was that among HIV-1-seronegative women, partner participation was associated with lower rather than higher condom use posttest. Partner testing may have provided these men and women with the assurance that they were in a concordant HIV-seronegative relationship. We observed that >95% of the partners of seronegative women who came for testing were also HIV uninfected. However, these HIV-1-seronegative men were not different from HIV-1–seropositive men when comparing the number of lifetime sexual partners (P = 0.7), suggesting that they are at similar risk for acquiring and transmitting HIV-1. Lower condom use in this setting may place women at risk for acute HIV-1 infection, especially in relationships that are not monogamous, a potentially more common scenario during late pregnancy and the early postpartum period. We conclude that after establishing that both members are seronegative, it is important to consistently promote condoms, even if this is difficult because it suggests infidelity within the relationship. Continued emphasis on condom use and monogamy in concordant HIV-seronegative relationships is essential to protect against future transmission.
Many mother-to-child HIV-1 transmission prevention programs are already receiving support from governmental and nongovernmental organizations in sub-Saharan Africa. Thus, the idea of working within antenatal clinics to promote VCT has great potential. By offering couple counseling within the antenatal setting, couple VCT may be integrated into existing HIV/AIDS prevention programs and fulfill an important counseling service for both men and women. To effectively implement such a program, it will be necessary to explore ways to increase partner participation. In our study, relatively high rates (64%) of reported partner notification were not matched by high rates of VCT acceptance by partners (15%). Fifteen percent of women who underwent testing had partners who came for VCT and fewer than half of these women received posttest counseling as a couple. A lack of community awareness about the importance of partner VCT and cultural beliefs that men should not participate in antenatal activities may explain low partner involvement. National and local VCT campaigns promoting couple counseling can be used to address barriers to testing male partners and increase awareness in the general public.18
Poor uptake of VCT and couple counseling may also have been due to women not informing partners of VCT availability or to conflicts between clinic hours and men's work schedules. Although we used some strategies to overcome these barriers, such as providing letters of invitation to partners to excuse them from work and holding clinics on weekends to avoid workdays, more efforts to enhance male participation are required as these met with limited success. One option would be to offer a separate clinic distinct from the antenatal screening site to make men feel more comfortable; however, this would not facilitate couple counseling. Qualitative research to explore ways to increase uptake of couple counseling will be important to increase use of this counseling model in antenatal programs.
A final consideration is that this study was a prospective cohort study and not a randomized clinical trial. Women whose partners came to clinic were a select group who differed from those whose partners did not come. These underlying differences, rather than partner participation or couple counseling, may have resulted in effects on uptake of interventions. Specifically, we found that women with partners who came to clinic were more likely to be living together and older at sexual debut than women who did not have partners who came to clinic. However, after adjusting for these cofactors in our multivariate model, all associations retained statistical significance, suggesting that partner participation and couple counseling have independent effects on intervention uptake. Nevertheless, the possibility exists that a difference between the 2 groups went unrecognized and may have contributed to the effects we observed. For example, the quality of the relationship may have independently led to improved uptake of interventions rather than couple counseling itself. A randomized comparison of couple counseling vs. conventional models of testing is necessary to better determine the benefits and risk of this approach.
To our knowledge, this study was the first to evaluate couple counseling in a prevention of mother-to-child HIV-1 transmission program. While we found it challenging to achieve high rates of partner participation, we observed that significant benefits were associated with partner involvement. These findings support using couple counseling as a strategy to reduce risk of perinatal HIV-1 transmission and emphasize the need for feasible, affordable approaches to encourage men to participate in VCT and couple counseling.