Becker S, Mlay R, Schwandt HM. Comparing couples' and individual voluntary counseling and testing for HIV at antenatal clinics in Tanzania: a randomized trial. AIDS Behav. 2009 Sep 10.
In many sub-Saharan African countries, a large proportion of HIV transmission occurs within married relationships or similar unions.(1) Counseling and testing is particularly important for pregnant couples, but male partner involvement in antenatal clinics (ANCs) is usually low. Studies from Nairobi and Lusaka indicated that only 5%-9% of women came with their partners for voluntary counseling and testing (VCT) in antenatal clinics, despite community outreach.(2, 3)
To evaluate the acceptance and effectiveness of couples' voluntary counseling and testing (CVCT) versus individual counseling and testing (IVCT) within ANCs in Tanzania; to compare uptake of nevirapine for prevention of mother-to-child transmission (PMTCT), sexual risk behavior, marriage dissolution and domestic violence among women receiving either type of counseling
Three ANCs in Dar es Salaam that had not provided VCT previously
Two-arm randomized trial
Pregnant women up to the sixth month of pregnancy presenting for their first ANC visit were enrolled; only women living with a spouse (legal or traditional) or a partner of two years or more were included.
Formative research was carried out to guide the approach to CVCT. Women completed a baseline questionnaire, and were sequentially assigned to either CVCT or IVCT. Women were enrolled from May 2003 to February 2004. Women in the CVCT arm whose partners refused to come to the clinic were offered IVCT; either partner could receive results separately if requested. Sero-positive women were given a prescription for nevirapine for PMTCT. All HIV-positive women in both study arms were asked to return three months post-partum to complete a follow-up questionnaire.
Of 760 women in the IVCT arm, 71% were tested and counseled and received results. In contrast, only 39% of 761 women in the CVCT arm completed testing and obtained results (16% completed VCT with their partner, and 23% opted to switch to IVCT). The number of women in the CVCT arm who never returned was very high (51%). Among women in the CVCT arm, being younger and non-Muslim and not having experienced domestic violence were associated with completing CVCT. Among HIV-positive women returning for follow-up (81/93), mothers who completed CVCT were more likely to have taken nevirapine during delivery, compared to women who completed IVCT (6/11 [55%] vs. 14/70 [20%], respectively); these sample sizes were too small for statistical comparisons.
Loss to follow-up among pregnant women randomized to receiving HIV testing and counseling with their partners was very high, particularly in an area where most women seek antenatal care. The authors suggest that community outreach and promotional activities should be undertaken to improve couple involvement in ANCs. There may be an association between the ability to engage in couples' counseling and not having experienced domestic violence. Women who do have partners who consent to couples' counseling may be more likely to use nevirapine for PMTCT.
This was a good quality study; however, sample sizes were too small for the authors to definitively address their objectives.
As long as 20 years ago, studies showed that couples who receive HIV counseling and testing together are more likely to reduce risky behavior than if each partner receives IVCT.(4) Couples' VCT also could be more cost effective.(5) However, this study indicates that using ANCs as a place to provide couples' counseling can deter women even from returning for routine antenatal care. Unfortunately, sample sizes in this study were small particularly at follow-up, preventing definitive conclusions to be drawn about the relation between domestic violence and couples' counseling and use of nevirapine and safe sex. Before ANCs decide to promote couples' counseling, they should obtain more information about whether this would negatively impact the testing and counseling of pregnant women.
- Becker S, Gray R. Source of new infections in generalized HIV epidemics. Lancet. 2008;372(9646):1299-300.
- Farquhar C, Kiarie JN, Richardson BA, et al. Antenatal couples counseling increases uptake of interventions to prevent HIV-1transmission. J Acquir Immune Defic Syndr. 2004;37(5):1620-6.
- Semrau K, Kuhn L, Vwalika C, et al. Women in couples antenatal HIV counseling and testing are not more likely to report adverse social events. AIDS. 2005;19(6):603-9.
- Allen S, Tice J, Van de Perre P, et al. Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa. BMJ. 1992;304(6842):1605-9.
- Sweat M, Gregorich S, Sangiwa G, et al. Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. Lancet. 2000;356(9224):113-21.