From prenatal HIV testing of the mother to prevention of sexual HIV transmission within the couple.

The first step in preventing mother-to-child HIV transmission (PMTCT) programmes is offering HIV counselling and testing to pregnant women. In developing countries where HIV testing remains rare, it represents a unique opportunity for many women to learn their HIV status. This prenatal HIV testing is not only the entry point to prevention of mother-to-child HIV transmission, but also an occasion for women to sensitize their male partner to sexual risks. Here we explore if these women, HIV-tested as mothers, apply the prevention recommendations they also receive as women. In the Ditrame Plus PMTCT program in Abidjan, Côte d'Ivoire, two cohorts of women (475 HIV-infected women and 400 HIV-negative women) were followed up two years after the pregnancy when they were offered prenatal HIV testing. In each cohort, we compared the proportion of women who communicated with their regular partner on sexual risks, prior to and after prenatal HIV testing. We analysed socio-demographic factors related to this communication. We measured two potential conjugal outcomes of women HIV testing: the level of condom use at sex resumption after delivery and the risk of union break-up. Prenatal HIV testing increased conjugal communication regarding sexual risks, whatever the woman's serostatus. This communication was less frequent for women in a polygamous union or not residing with their partner. Around 30% of women systematically used condoms at sex resumption. Among HIV infected ones, conjugal talk on sexual risks was related to improved condom use. After HIV testing, more HIV-infected women separated from their partners than HIV-uninfected women, despite very few negative reactions from the notified partners. In conclusion, offering prenatal HIV counselling and testing is an efficient tool for sensitizing women and their partners to HIV prevention. But sexual prevention in a conjugal context remains difficult and need to be specifically addressed.

Beneficial effects of offering prenatal HIV counselling and testing on developing a HIV preventive attitude among couples. Abidjan, 2002-2005.

Prenatal HIV counselling and testing is mainly an entry-point to the prevention of mother-to-child transmission of HIV, but it may also play an important role in triggering the development of spousal communication about HIV and sexual risks and thus the adoption of a preventive attitude. In Abidjan, Côte d'Ivoire, we investigated couple communication on STIs and HIV, male partner HIV-testing and condom use at sex resumption after delivery among three groups of pregnant women who were offered prenatal counselling and HIV testing: HIV-infected women, uninfected women, and women who refused HIV-testing. The proportion of women who discussed STIs with their regular partner greatly increased after prenatal HIV counselling and testing in all three groups, irrespective of the women's serostatus and even in the case of test refusal. Spousal communication was related to more frequent male partner HIV-testing and condom use. Prenatal HIV counselling and testing proposal appears to be an efficient tool to sensitize women and their partner to safer sexual practices.

When do HIV-infected women disclose their HIV status to their male partner and why? A study in a PMTCT programme, Abidjan.

BACKGROUND: In Africa, women tested for HIV during antenatal care are counselled to share with their partner their HIV test result and to encourage partners to undertake HIV testing. We investigate, among women tested for HIV within a prevention of mother-to-child transmission of HIV (PMTCT) programme, the key moments for disclosure of their own HIV status to their partner and the impact on partner HIV testing. METHODS AND FINDINGS: Within the Ditrame Plus PMTCT project in Abidjan, 546 HIV-positive and 393 HIV-negative women were tested during pregnancy and followed-up for two years after delivery. Circumstances, frequency, and determinants of disclosure to the male partner were estimated according to HIV status. The determinants of partner HIV testing were identified according to women's HIV status. During the two-year follow-up, disclosure to the partner was reported by 96.7% of the HIV-negative women, compared to 46.2% of HIV-positive women (chi(2) = 265.2, degrees of freedom [df] = 1, p < 0.001). Among HIV-infected women, privileged circumstances for disclosure were just before delivery, during early weaning (at 4 mo to prevent HIV postnatal transmission), or upon resumption of sexual activity. Formula feeding by HIV-infected women increased the probability of disclosure (adjusted odds ratio 1.54, 95% confidence interval 1.04-2.27, Wald test = 4.649, df = 1, p = 0.031), whereas household factors such as having a co-spouse or living with family reduced the probability of disclosure. The proportion of male partners tested for HIV was 23.1% among HIV-positive women and 14.8% among HIV-negative women (chi(2) = 10.04, df = 1, p = 0.002). Partners of HIV-positive women who were informed of their wife's HIV status were more likely to undertake HIV testing than those not informed (37.7% versus 10.5%, chi(2) = 56.36, df = 1, p < 0.001). CONCLUSIONS: In PMTCT programmes, specific psychosocial counselling and support should be provided to women during the key moments of disclosure of HIV status to their partners (end of pregnancy, weaning, and resumption of sexual activity). This support could contribute to improving women's adherence to the advice given to prevent postnatal and sexual HIV transmission.

[Refusal of prenatal HIV-testing: a case study in Abidjan (Côte d'Ivoire)]. / Le refus du dépistage VIH prénatal: étude de cas à Abidjan (Côte d'Ivoire).

One of the main obstacles to HIV prevention in Africa remains the insufficient number of HIV tests performed. The low percentage of individuals aware of their serostatus is due in part to the insufficient availability of HIV testing, but also to individuals' refusal to have the HIV test. Because affordable treatment is now available, it is possible to implement on a much greater scale programs of prevention of mother-to-child HIV transmission, accompanied by the expansion of prenatal HIV testing. It is therefore important to understand the reasons women refuse these tests. Here we analyse the women who refused the offer of prenatal HIV testing in the DITRAME Plus research program, intended to prevent mother-to-child transmission in Abidjan from 2001 through 2005. Three groups of women were followed for two years after they were offered HIV counselling and testing during an antenatal consultation: 347 HIV-infected women, 393 seronegative women, and 62 women who refused HIV testing. Nine months after delivery, HIV testing was again offered to the latter group. We collected quantitative data on social and demographic characteristics, sexual behavior, and communication with their male partners about STIs, HIV, and HIV testing, before and after the pregnancy. In-depth interviews were conducted with 15 women who refused HIV-testing. We sought to determine if their sociodemographic and behavioural profile was closer to that of HIV-positive or seronegative women, to assess the effects of prenatal counselling and the offer of testing on their attitudes about HIV risk, and to measure the percentage of women who accepted testing when the offer was repeated 9 months postpartum. Women who refused HIV-testing had a sociodemographic profile similar to that of the women who accepted testing and were seronegative. They did not have more at-risk behaviours. These women offered several reasons for their refusal, including avoidance of the anguish of a positive test result and the desire to ask their husbands first. Among the women who initially refused prenatal testing, only 23% had discussed STI/HIV issues with their male partner; after the testing offer, more than 90% suggested that their partner have an HIV test. Finally, 20% accepted the postpartum test offer, and those whose male partner had an HIV test were four times more likely than the others to accept (RR = 4.05 [1.55-10.58]). This study shows that prenatal counselling and the offer of HIV testing have beneficial effects on HIV prevention within the couple, even for women who refuse testing. It also points out that the decision to accept testing may take time and that repeating the offer is worthwhile. Finally, our results confirm the importance of the role of the regular partner in the acceptance of HIV testing, and reinforce the relevance of a couple-centred approach to voluntary counselling and testing.