At the end of 2008, an estimated 33.4 million people were living with HIV infection worldwide, with 2.7 million people newly infected the same year. Although the incidence of HIV acquisition was approximately 30% lower than at the HIV epidemic peak 14 years ago, it was still very high especially in the sub-Saharan African region, which accounted for 67% of all new infections in 2008.1
Originally, strategies to prevent sexual transmission of HIV have included peer education, condom marketing, interventions targeted at specific risk groups such as truck drivers and sex workers, and education of the general population with an emphasis on 3 general prevention methods: abstinence, marital fidelity, and consistent condom use (“ABCs”). These strategies have been implemented at a large scale but the continued spread of HIV made it clear that they have limits and additional and innovative approaches are necessary. Among these, voluntary counseling and testing of HIV (VCT) services started to be promoted in the 1990s. VCT was developed under the assumption that being aware of one's HIV status is the first step to adopt preventive practices. Indeed, people who are infected with HIV but unaware of their status are not likely to reduce their risk behaviors and protect their sex partners from becoming infected.2 People tested for HIV who do not return for their test results might even increase their risk of transmitting HIV to their partner.3 Also, people infected with HIV unaware of their status are not able to take advantage of antiretroviral therapy, which can keep them healthy and extend their lives, and which may also reduce their risk of transmitting HIV to their partner.4 VCT has thus now become a key intervention for HIV prevention, care, and treatment.5 Over time, the number of HIV testing facilities has grown everywhere and the cost of testing was reduced dramatically—most HIV testing services now being free. Furthermore, opt-out has been progressively implemented and practiced by health professionals. However, in countries with high and medium HIV prevalence and especially in sub-Saharan Africa, suboptimal rates of testing remain common. Within 2 population surveys conducted in 2005-2007 among 17 resource-limited countries and in 2007-2009 among 9 resource-limited countries, respectively, 11% and 33% of women and 10% and 17% of men had been tested for HIV and knew their HIV status.6,7 From these statistics, 2 important observations can be made. First, the coverage of HIV testing remains unacceptably low in the African continent overall, even after >15 years of field experience. Further operational research is thus needed to increase the acceptability and use of HIV testing services. Second, women seem to outnumber men in their access to VCT, which can mostly be explained by the scaling-up of prevention of mother-to-child transmission of HIV programs. Indeed, the number of women counseled and tested for HIV during their pregnancy increased from 5% in 2005 to 26% in 2009.7 Conversely, men remain undertested; HIV testing for men being mostly available in sexually transmitted infection (STI) clinics or more recently within circumcision programs.
Thus, there is an overall need to study factors influencing participation in VCT and to address the issue of HIV testing coverage among men at country level. This is the focus of the ANRS 12127 Prenahtest intervention trial currently ongoing in Cameroon, Dominican Republic, Georgia, and India. This operational research project aims to test the impact of an enhanced prenatal counseling intervention on men's involvement in prenatal HIV testing, namely, on the frequency of partners HIV counseling and testing and of couple counseling. The trial also investigates the effect of this approach on sexual, reproductive, and HIV prevention behaviors within the couple.8 To better understand how the effect of this new counseling intervention operates, we analyzed our baseline data and patterns of HIV testing in each study country. The objective of our present analysis was to identify the factors associated with a previous HIV testing before enrollment in the trial, among participating women and their partners in the Cameroon site.
In Cameroon, HIV prevalence among pregnant women was estimated at 7.6% in 2009. This same year, 1,500,000 people were expected to be tested for HIV, but only 30% were ultimately tested.9 The study was conducted at the Centre-Mère Enfant, Fondation Chantal Biya, a semiprivate reference hospital for mothers and children located in the downtown of Yaoundé. Women attending this structure come from anywhere in the city.
Pregnant women were recruited during antenatal care consultations. Eligibility criteria were as follows: reporting having a stable partner and neither her nor her partner having been tested for HIV during the current pregnancy. Women accepting to participate in the study signed an informed consent form and were randomized to receive either standard posttest HIV counseling or the couple-oriented posttest HIV counseling intervention.
Structured questionnaires were administered to all women before prenatal HIV testing, documenting the woman and her partner's sociodemographic characteristics, couple relationships, and woman's attitudes and practices in terms of family planning and HIV prevention.
For this analysis, the 2 dependant variables were the woman's and the partner's previous HIV testing experience (before the current pregnancy), as reported by women through the baseline questionnaire. Exploratory variables were age, number of years of school education, and income-generating activity of women and partners, marital status, cohabitation with partner and duration of relationship, HIV risk perception, experience of STIs, general couple communication, and couple communication on condom use and/or HIV. For categorical variables, bivariate analyses were done using the chi-square test or Fisher test when appropriate. Factors associated with a previous HIV test among women and their partners were identified using a multivariable logistic regression model. All variables associated with previous HIV testing in univariate analysis with a significance level <0.20 were included in the backward stepwise multivariate analysis using the likelihood ratio test, with consideration for confounding effect and interactions. The final multivariate model contained the variables with a significance level <0.05 in univariate analysis. Data were managed using Epidata 3.1 software and analyzed using the statistical programs SPSS (version 17.0, SPSS Inc., Chicago, IL) and SAS (version 9.1, SAS Institute Inc., Cary, NC).
Ethical and Administrative Aspects
The study was approved by the National Ethics Committee of Cameroon (Authorization No. FWA IRB 00001954). The sponsor did not take any responsibility in the present study report.
Four hundred eighty-four pregnant women with stable partners, attending their first antenatal care consultation, were enrolled in the Prenahtest project at the Cameroon site. Among them, >98% (476 of 484) completed the baseline questionnaire before HIV testing (Table 1). Their median age was 27 years [interquartile range (IQR) 23-31 years) and 44.5% (212 of 476) of them had an income-generating activity. The median age of their male partners was 34 years (IQR 30-42 years) and 91% had an income-generating activity. Secondary educational level was completed for 88% of women (422 of 476) and 93.6% of men (349 of 373). Twenty-eight percent of women (133 of 476) were married and the median duration of relationship with their male partner was 48 months (IQR 24-96). Previous HIV testing was reported by 85.7% of women (408 of 476), 70% (287 of 408) of whom reported having been tested >12 months ago. Among the main reasons for seeking a previous HIV test, women reported a previous pregnancy (41.4%), self-motivation (23.5%), and clinical symptoms (6.7%). Previous partner HIV testing was reported by 70.6% of women. According to women, the main reasons for their partner to have been tested for HIV were self-motivation (19.3%), medically related reasons such as blood donation or medical intervention (21%), and clinical symptoms (8.2%).
Among the women interviewed, 82.4% (392 of 476) reported having ever discussed about condom use with their current partner and 89.1% (424 of 476) reported a history of couple dialogue on HIV. Sixty-two percent of women interviewed (293 of 476) declared perceiving themselves at risk for HIV infection.
Factors Associated With HIV Testing Among Women and Their Partners
In univariate analysis, being ≥20 years old, reporting an income-generating activity, being married, living with the current partner and for >5 years, and being multiparous were significantly associated to a history of HIV testing among female participants (Table 2). The educational level of women and the fact that they had ever used condoms with their current partner were not associated to a previous HIV test.
Reporting a history of HIV testing among male partners was associated with men being ≥30 years old, the couple being in free union, and having ever discussed about HIV. Men's remunerated activity, woman's perception of being at risk for HIV infection, and having a previous STI were not associated factors (Table 3).
In multivariate analysis (Table 4), women with previous HIV testing were more likely to be aged between 25 and 30 years [odds ratio (OR) 5.5, 95% confidence interval (CI): 1.4 to 22.1], to be multiparous (OR 2.7, CI: 1.2 to 6.3), to report feeling at risk for HIV infection (OR 2.1, CI: 1.1 to 3.9), and to have ever discussed about HIV with their partners (OR 2.7, CI: 1.1 to 6.4). Factors associated with a history of HIV testing were for men to have >13 years of school education (OR 5.1, CI: 1.4 to 19.4) and previous couple communication about HIV (OR 2.9, CI: 1.1 to 8.5; Table 5).
In this study, the reported rates of a previous HIV test among participating women and their partners was 85% and 70%, respectively. Although relatively high compared with many other African countries, this coverage is lower than what has been reported in Yaoundé 5 years before.10 Lower coverage of HIV testing among men and women has been reported in urban settings among people with high education,10 and indeed, the educational level of our study population is higher than that of the general population of Cameroon.
The difference in rates of history of HIV testing between women and their partners may be explained by the programmatic accessibility of HIV testing. Women have been increasingly exposed to the opportunity of HIV testing with the gradual scaling-up of prevention of mother-to-child transmission of HIV services in Cameroon since 2002. The provision of HIV testing to the general population has not increased as rapidly as this. Also, as partner HIV testing rates documented within our study were reported by women themselves, they could be underestimated.
Reasons for seeking an HIV test before this pregnancy differed between women and their male partners. The main reason for women to be tested was a previous pregnancy, whereas the main reason for male partners to be tested was a medically related condition. Women are now systematically offered HIV testing during pregnancy, but as most antenatal clinics are not so much male-friendly, men rarely use the opportunity of HIV testing during prenatal care of their female partners. These gender differences in reasons for seeking HIV testing may also reflect different perceptions between women and men regarding medically related conditions. Pregnancy remains perceived as a health issue of the female partner but not of the couple. Male partners are more concerned about other medically related conditions like clinical events, medical intervention, and blood donation.
Overall, these results highlight a clear lack of linkage between antenatal screening and male partner HIV testing. First, the absence of a couple approach to HIV testing and HIV prevention within the family may be explained by the poor content of HIV counseling received by women and the weakness of couple communication skills. At the time of the survey, HIV testing was proposed after a generic educational session where women were informed of many aspects of HIV infection and HIV testing, without any mention of how to address such topics with the male partner. As partner consent is often required by women before undergoing HIV testing,11 this could lead to a low uptake of individual and couple testing. Investing in the strengthening of HIV counseling, especially the posttest counseling session, with elements aiming to empower women and improve their communication skills concerning HIV, could facilitate a couple approach of HIV testing. Second, as a gateway to partner HIV testing, we may also need to reinforce the benefits of HIV-related medical assistance such as access to effective antiretroviral treatment, which have been reported elsewhere as an issue that could influence the decision to seek and accept HIV testing.11,12
In this study, independent variables associated to a history of HIV testing among women were as follows: aged between 25 and 30 years, being multiparous, feeling at risk for HIV infection, and having ever discussed about HIV with the male partner. Increasing uptake of HIV testing with age may be explained by the awareness of a high accumulation of risk for infection with age, by a higher number of opportunities to be offered HIV testing, and by the fact that older women are more likely to take autonomous decisions. In our study, women aged between 25 and 30 years were more likely to have been previously tested for HIV than women aged ≥30 years, and this is very likely to be related to the fact that the proportion of married women in this last group was significantly more important; thus, requiring male partner consent under these circumstances could have been a constraint to HIV testing. Self-perceived risk for HIV infection was associated to HIV testing in our study. Such an association has been reported in Ethiopia13 and in Burkina Faso.11 Other studies also reported this association, although they added that self-perception of being at risk for HIV infection influenced the willingness to be tested but was not an indicator of the acceptation of the test result.14,15 In our study, having previously discussed about HIV with the male partner was associated with the decision for women to be tested, whereas frequently discussing with the partner “about the day” was not. This suggests that HIV is a very specific topic of discussion within couples that requires specific skills. Interventions aiming at strengthening communication skills regarding HIV and sexual risks need to be promoted within health services, especially antenatal services.
Previous HIV testing among men was associated with a higher educational level (>13 years of education) and previous discussion about HIV with their female partners. It is difficult to provide a rationale explanation concerning the level of education of male partners. Although this was not a confounding factor, it is possible to imagine that men with a high level of education are overall more prone to discuss with their female partners. Therefore, during these discussions, topics such as HIV and recent benefits implemented in health facilities could influence more their decision to undergo HIV testing.
In our study in Yaoundé, discussion about HIV within couples was one of the main factors associated with a history of HIV testing among participating women and men. This key finding needs to be addressed in all its components (HIV knowledge, communication skills about HIV topic, etc) during HIV counseling sessions to improve the involvement of the male partner within antenatal testing and to improve couple HIV testing and couple HIV prevention. The innovative approach for prevention developed during this trial, called couple-oriented counseling (COC), could be an answer in addition to the increasing offer of opt-out HIV testing to pregnant women by health professionals. If the results of the trial confirm COC as an incentive for male partner involvement in antenatal HIV testing, COC could help address the very low couple HIV testing rate reported in Cameroon and the difficult question of HIV prevention within families.
The authors thank the Centre Mère-Enfant and the Prenahtest team in Yaoundé for their time and energy dedicated to this project. They also acknowledge the entire Prenahtest team involved in the study: Marija Miric and Eddy Perez-Then from CENISMI (Santo Domingo, Dominican Republic); Maia Butsashvili, Maia Kajaia, George Kamkamidze, and Marina Topuridze from Maternal Child Care Union (Tbilisi, Georgia); Shrinivas Darak, Mukta Gadgil, Maitreyi Kulkarni, Sanjeevani Kulkarni, and Vinay Kulkarni from Prayas Health Group (Pune, India); Annabel Desgrées du Loû from UMR 196 CEPED (Paris, France); and Eric Balestre and François Dabis from INSERM U897, Institut de Santé Publique, d'Epidémiologie et de Développement, Université Bordeaux 2 (Bordeaux, France).
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Keywords:Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.
factors associated; previous HIV testing; Cameroon