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Research Letters

Vulnerability of women in an African setting: lessons for mother-to-child HIV transmission prevention programmes

Gaillard, Philippea,b; Melis, Reinhildeb; Mwanyumba, Fabianc; Claeys, Patriciaa; Muigai, Estherc; Mandaliya, Kishorchandrac; Bwayo, Jobd; Temmerman, Marleena

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After discussing advantages and risks, only a third of the 290 HIV-infected women included in an intervention study to reduce mother-to-child transmission of HIV in Mombasa, Kenya, informed their partners of their results. Despite careful counselling, 10% subsequently experienced violence or disruption of their relationship. To increase the uptake of interventions to reduce perinatal HIV transmission safely, we recommend the involvement of partners in HIV testing. In addition, the counselling of women has to address methods and skills to deal with violence.

Antiretroviral drug therapy or formula feeding to prevent the mother-to-child transmission (MTCT) of HIV are perceptible interventions, implying that a woman is HIV infected and requiring their partner's agreement and support. In the African context, little is known about the consequences of disclosing HIV status to a partner, but violence has been described [1,2]. We followed HIV-infected women tested in the context of an intervention study to reduce MTCT in Coast Provincial General Hospital, Mombasa, Kenya, to measure the impact of bringing the news to the partner.

The women recruited were part of a perinatal intervention study using chlorhexidine vaginal lavage during labour and delivery [3]. The day after delivery women received information about the study and pre-test HIV counselling. Consent to participate and undergo HIV testing was asked individually. Women were asked to come back 6 weeks after delivery for a follow-up visit when they received their HIV results with individual post-test counselling. No pressure was put on HIV-infected women to share the result with their partner, but the risks and benefits of sharing the test results with their partner were discussed. Three months after delivery, a questionnaire on the consequences of announcing HIV seropositivity was administered in the format of an interview. A project counsellor traced HIV-infected women who did not show up during one of the planned follow-up visits.

The recruitment took place between April 1997 and April 1999 (Fig. 1). The follow-up for HIV-infected women at 6 and 14 weeks was 79.6 and 47.4%, respectively, and 331 HIV-infected women were interviewed at an average of 64 days after receiving their HIV result. The mean age of the women included was 24 years (range 18–40), 35.5% had reached the secondary level of education, 87.8% were Christian and 12.2% Muslim, and 87.1% reported to be in a stable relationship.

Fig. 1.
Fig. 1.:
Recruitment.

Among 290 women in a stable relationship, 90 (31.0%) informed their partner. Women under the age of 22 years (33rd percentile) were more likely to inform their partner (43.5 versus 27.0%, P = 0.007). Of the partners informed, 73.3% were understanding and supportive, 8.9% did not believe the results, and 8.9% did not make any comment. In three cases, the woman was chased away by her partner, and in three cases she reported violence. Therefore, six (6.6%) of the 90 HIV-infected women expecting a supportive attitude experienced violence. Of the 39 women not in a stable relationship, eight (20.5%) informed somebody else of their HIV status. The majority (94.1%) of the 191 women who did not disclose their seropositivity to their partner were scared of his reaction. Over 72% of these women reported that they will never inform him.

Of 305 HIV-infected women who answered the question, 254 (83.3%) found it useful to know their HIV status: 64.6% because they will be more careful with health-related issues, treat early infections or eat a balanced diet; 14.6% will give better care to their baby; 10.6% will use family planning; and 7.1% because of advice on how to live with HIV. On the contrary, 51 (16.7%) HIV-infected women did not see any advantage in knowing their HIV status, mainly because they were now worried about being sick or dying (68.6%), and because AIDS could not be cured anyway (35.3%).

Only a third of women in a stable relationship shared their HIV seropositivity with their partner. This finding is consistent with other African studies [1,4]. Younger women were found to share their HIV results more often with their partner. They might feel in a safer relationship, or older women may have already experienced difficulties when involving their partner in sensitive issues. Two-thirds of the women were carrying the burden of knowing that they were HIV infected alone. The most common reason for not informing the partner was the fear of his reaction, as was also reported in other American [5] and African [1,4,6,7] studies.

The majority of women who had chosen to inform their partner after weighing the risks and benefits with a counsellor got a positive reaction from the partner. Nevertheless, six women (6.6%) experienced violence, with three cases of disruption of the relationship. The baseline level of violence in couples was not known, but we suppose that precisely those women who chose to disclose their seropositivity had confidence in the relationship and did not feel threatened. Violence against women disclosing their seropositivity to their partner or abandonment have already been described in studies in the USA [5] and in Africa [1], especially when women were urged by a counsellor to notify their partner. In a study in Rwanda [8], 25% of HIV-infected women said their marriage deteriorated after disclosure.

We also found that the majority of HIV-infected women found it useful to know their HIV serostatus. The main reason was that they planned to be more careful about their health and diet to avoid rapid progression to AIDS. This could be overestimated, as they might have repeated the advantages for testing presented during the pre-test counselling to please the counsellors. However, 16% of the women also reported finding testing useless and were depressed, mainly because AIDS has no cure.

As other authors have recommended, we suggest that counselling should explicitly address the stigmatization of HIV-positive women and negative reactions leading to violence [9,10]. It should make it clear that partners’ reactions are not always predictable. We also recommend couple-counselling and partner involvement in MTCT prevention programmes, as only testing women can increase their susceptibility to violence despite careful counselling. Men are often not in favour of having their wives tested, fearing the indirect disclosure of their own infection [11]. However, involvement of the partner might be inevitable, especially in interventions that are perceptible by the household members. In some African pilot projects, the uptake of interventions to reduce MTCT has been hampered by, among other things, women's fear of being tested [12,13]. The partner's attitude has been described as one of the obstacles to the adoption of formula feeding by HIV-infected mothers [14]. Promoting infant health as the responsibility of both the mother and the father should be part of messages to encourage future fathers to be tested for HIV jointly with their wives.

Philippe Gaillarda,b

Reinhilde Melisb

Fabian Mwanyumbac

Patricia Claeysa

Esther Muigaic

Kishorchandra Mandaliyac

Job Bwayod

Marleen Temmermana

Acknowledgements

The authors are indebted to the mothers and infants who participated in this study. They would like to thank Esther Getambu, Chief Administrator for Coast Provincial General Hospital, Mombasa, Kenya, for facilitating the implementation of the study in the hospital. The authors would also like to thank Chris Verhofsetede, AIDS Reference Laboratory, University of Ghent, Belgium and Varsha Chohan, Coast Provincial General Hospital, Mombasa, Kenya for the biological tests, and the counsellors, midwives and clinical officers for their daily work on the study.

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© 2002 Lippincott Williams & Wilkins, Inc.