According to the World Health Organization, nearly three-quarters of the world's 40 million human immunodeficiency virus (HIV)-infected people are living in Sub-Saharan Africa. Sixty-five per cent of the 4.3 million infected in 2006 caught the virus in this part of the world where women are particularly at risk. Figures for the Ivory Coast show for example that twice as many women than men are likely to be HIV-infected. In contrast to what is observed in other regions of the world, most people in Sub-Saharan Africa who are living with HIV are women. Doctors first attempt to persuade pregnant women to agree to undergo tests as, without treatment, they run the risk of transmitting the virus to their child during pregnancy or after the birth. Faced with this situation, many years ago many African countries set up mother-to-child HIV transmission prevention programmes. Such schemes consist of provision of medical, and sometimes psychosocial, follow-up of HIV-positive pregnant women, so that appropriate medical treatments can be administered to prevent infection of the baby. Unfortunately, many women are still reluctant to undergo HIV tests because they are afraid of being rejected by their partner if found to be HIV-positive. In the Ivory Coast, nearly 40% of pregnant women thus refuse to have tests. Men are considered to be an obstacle to acceptance of testing and are therefore scarcely involved in prevention programmes.
A series of papers published by an IRD team, working jointly with INSERM and supported by the ANRS, has indicated ways of bringing the male partners more fully into the process of prenatal screening and HIV prevention. The team offered pregnant women in the Ivory Coast an AIDS test plus psychosocial counselling during the following two years. More than 900 women agreed to undergo the test and take part in the study, representing 546 HIV-positives and 393 HIV-negatives. In parallel, 62 women who had refused the testing nevertheless agreed to be followed-up over the same period.
This long-term monitoring and counselling showed that counselling and prenatal testing for HIV improved the impact of prevention campaigns, even where women had refused to be tested. Furthermore, in order better to help HIV-infected women make the difficult step of disclosing their HIV status to their spouse, the IRD team identified the moments these women chose as the best time to tell him. For two-thirds of them disclosure was made just before delivery, during early weaning for those who breast-feed their child, or several months after delivery on resumption of sexual activity. These results showed that psychosocial support provided for HIV-positive women during these three key moments helped them to handle their infection better in the context of their conjugal life while making prenatal testing more acceptable.
The study showed that AIDS screening provision is beneficial, whatever decision the women take. Among those who refused the test, 8 out of 10 discussed the matter with their partner and suggested that he underwent the test. When the male partner did so, his decision strongly influenced the fact that the woman in her turn agreed to testing. Indeed 20% of the women who had initially refused changed their mind at the end of the monitoring period.
In the light of the results, which illustrate a change in attitudes in African societies, future prevention programmes will certainly have to target more strongly the involvement of male partners. Whereas 20 years ago, most marriages celebrated in Africa still set the seal to the joining together of the lands of two families, with no possibilities for opposition by the two spouses, the continent is seeing an increasing number of couples whose union is chosen by mutual consent, hence marked by strong matrimonial bonds which allow the couple to face up to the discovery that one of them is HIV-positive. However, such couples are coexisting with others who are more traditional, for whom sexuality and, even more so, testing for AIDS remain taboo subjects.
Grégory Fléchet - DIC