aInstitut de Santé Publique Epidémiologie Développement (ISPED), Université Victor Segalen Bordeaux 2, Bordeaux, France
bInstitut de Recherche pour le Développement (IRD), UMR CEPED, Paris, France.
Received 4 June, 2007
Revised 22 September, 2008
Accepted 30 September, 2008
Correspondence to Joanna Orne-Gliemann, PhD, ISPED - Université Victor Segalen Bordeaux 2, 146 rue Leo Saignat, 33076 Bordeaux, France. Tel: +33 557 57 45 17; e-mail: Joanna.Orne-Gliemann@isped.u-bordeaux2.fr
In 2007, 420 000 children under 15 years of age were infected with HIV, mainly through mother-to-child transmission of HIV (MTCT) . Prenatal HIV counselling and testing, maternal and infant antiretroviral prophylaxis and alternatives to prolonged and mixed breastfeeding can reduce the risk of MTCT by half . However, prevention of MTCT (PMTCT) services are still largely insufficient and inadequate in most low-income countries. In 2007, 20% of pregnant women in sub-Saharan Africa received an HIV test and 33% of HIV-infected women were offered PMTCT prophylaxis . PMTCT implementation faces organizational constraints and the deteriorating quality of existing health services. The low coverage of prenatal HIV counselling and testing is also explained by personal and social perceptions of HIV infection, and particularly by the poor place given to men within PMTCT programmes.
In sub-Saharan Africa studies, pregnant women have reported the need to first consult their partner [4–6], and for him to approve their decision  before undertaking HIV testing. More recently in Uganda, partner's consent was still the main reason for opting out from HIV testing . The preexisting level of communication within the couple around sexual and reproductive health issues influences the acceptability of prenatal HIV counselling and testing : in urban Tanzania, women were less likely to collect their test results if they had never discussed reproductive health matters with their partner . Men seem to influence the perceptions (grounded or not) of women who evaluate their personal and social risks before using prenatal HIV testing services. Yet, the place of men in the promotion and implementation of PMTCT has been very small to date.
First, the structural and conceptual basis of PMTCT programmes has not contributed to a family approach to prenatal HIV counselling and testing. PMTCT, integrated within mother and child health services, which are rarely male-friendly , has excluded de-facto men. Health workers are still often reluctant to encourage male attendance in prenatal care , and in certain settings, men have been forbidden in prenatal wards . Also, in most countries in the world, dominant social norms present pregnancy and maternity care as women's domain and accompanying male partners can be stigmatised . In addition, sex-specific vulnerabilities such as violence against women may prevent women from considering/desiring the involvement of their partner within prenatal HIV counselling and testing. In 2004, a review estimated that between 3.5 and 14.6% of pregnant women reported negative consequences of HIV status disclosure . Moreover, PMTCT programmes have erected women as educators: women bring home the prevention messages heard during HIV counselling. But in Tanzania, according to traditional masculinity codes, men are the vectors of health information within the family  and thus, may have been reluctant to engage within PMTCT if asked by women. More generally, over the past decades, reproductive health programmes have aimed at ensuring that women have control over their own body  and that their reproductive and sexual choices are free from male domination. The numerous limitations of women-centred PMTCT have rapidly appeared. To manage their HIV test results and consequently to adopt adequate infant feeding practices and safe sex behaviours, women need fathers and partners to be involved within PMTCT.
Men's involvement in prenatal HIV counselling and testing requires the integration of PMTCT within a global approach to HIV prevention, involving couples or families or both. However as yet, few men are counselled and tested for HIV, individually or as couples. In Côte d'Ivoire, if the majority of HIV-negative women encouraged their partner to be tested, only a quarter of these men used HIV testing services . In Zambia, partners tested for HIV represented less than 1% of women tested . In spite of repeated recommendations within the international community , few published studies have explored the interest of a couple's approach to HIV counselling and testing, and PMTCT in general. The available data are edifying. In Zambia and Kenya, where pregnant women were offered individual or couple HIV counselling, couple HIV counselling improved the uptake of HIV testing, antiretroviral prophylaxis and alternatives to prolonged and mixed breastfeeding, and no increased risk of adverse social events was reported compared with individual counselling [5,20]. Community-based promotional strategies have recently been recommended to increase the uptake of couple HIV counselling and testing in Zambian urban clinics [21,22]. An ongoing multicentric international intervention trial [The French National Agency for AIDS Research (ANRS) 12127 prenahtest] is evaluating the feasibility and impact of couple-oriented posttest HIV counselling as a simple public health intervention to improve men's involvement within prenatal HIV counselling and testing [23,24].
Interventions that focus on women only as if they were single and living alone, and do not take into account their couple relationship, are likely to be counterproductive by placing women in an impossible situation. Couple approaches to PMTCT and general HIV/AIDS prevention and care need to be further documented and implemented.
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