Johannesburg — In theory, it should go something like this: pregnant woman tests HIV-positive as part of prevention of mother-to-child HIV transmission (PMTCT) services at her antenatal clinic, and tells dad-to-be; dad tests for HIV and they support each other, start treatment if need be, and prevent HIV transmission to baby or dad.
It seldom turns out that way. In a small, qualitative study of about 60 women in two clinics in the Durban area, Tamaryn Crankshaw, a PMTCT programme manager at McCord hospital in Durban, South Africa found that while two-thirds of the women did tell their partners they were HIV positive, only half of them reported that their partner had been tested for HIV as a result.
"There were some positive outcomes but mostly there was a lot of blame, recrimination, and silences,"Crankshaw told News. "HIV was never raised again within the context of the relationship, and in a lot of cases it was actively discouraged."
As in previous studies, the women also reported being physically, verbally and emotionally abused after disclosing their HIV-positive status.
Surprisingly, the women's disclosure sometimes prompted men to disclose that they were also HIV-positive, or to consider their partner's HIV-positive diagnosis as a proxy for their own HIV status.
In two cases, women reported that their disclosure had prompted unprotected sex as their partners, who purported to be HIV-negative, intentionally exposed themselves to HIV infection to show their commitment to the relationship and to starting a family, said Crankshaw, who presented her findings at the recent 1st International HIV Social Sciences and Humanities Conference in Durban.
"In South Africa, HIV disclosure is a very prominent component of HIV prevention and treatment because it's assumed to mediate sexual risk behaviour, and is widely regarded as important to... supporting [adherence to] antiretrovirals," she told News.
"In the PMTCT setting, HIV disclosure receives particular emphasis because of [HIV] prevention aims however... very little attention has been paid to the success of these strategies, and whether they do reduce risks or change behaviour."
What's love got to do with it?
About 30 percent of women choose to keep silent about their HIV-positive diagnosis. New research shows how a lack of trust between partners in some communities may be interfering with the expected HIV prevention benefits of HIV disclosure. This may merit a new take on HIV counselling and testing for couples.
For most women, multiple concurrent partnerships are a relationship reality. There is also mutual suspicion, a very low expectation of permanency, and their own emotional baggage, like being unwilling to trust. This may affect a partner's willingness to disclose his HIV status, Crankshaw said.
"The thing is, we also have our ups and downs," said one 29-year-old mum. "I am not sure about our future... so I don't see the need to tell him something so confidential [like my HIV-positive status]."
Multiple concurrent partnerships, in which men and women have more than one sexual partner at the same time, are thought to be one of the main drivers of HIV in southern Africa.
Data from a larger sample of 656 men and women in rural KwaZulu-Natal, analysed by researcher Deborah Mindry of the University of California, Los Angeles, reinforced many of Crankshaw's observations about relationships.
We forget to look at the fact that what drove prior risky behaviour will continue to drive future risky behaviour. Disclosure is not going to change that
Mindry found that awareness of the HIV risks associated with multiple concurrent partnerships and fear of contracting HIV led many men to monitor their partner's behaviour in order to assess their own HIV risk. This included, for example, asking a girlfriend's family to confirm her whereabouts over a weekend, or sending male friends to ask their girlfriends out as a test of the woman's fidelity.
"Sometimes men... end up controlling a person... this is what I feel when it comes to using condoms," said one HIV-positive new mum, who spoke to Crankshaw about the guilt she felt after not being able to negotiate safe sex with her partner. "I felt I was not in control of the situation but... I was counselled here and I knew everything."
Crankshaw said the reality that disclosure by HIV-positive mums did not always spark partner testing or risk reduction should lead to a rethink of PMTCT programme design:
"We forget to look at the fact that what drove prior risky behaviour will continue to drive future risky behaviour. Disclosure is not going to change that," she told News. "We have to stop accessing only the pregnant woman because she's the easy one to access, because she's already in care."
What's best for baby
Crankshaw suggested that couples counselling might help share the burden of behaviour change between new mums and dads. Couples counselling has gained popularity in recent years, but it is still not easy to get couples, especially with complicated relationship dynamics, to test together in large numbers.
Mindry found that many couples were grappling with major issues and were reluctant to address HIV, but many were better able to talk about HIV and risky behaviours within discussions about existing or future children.
Crankshaw said Mindry's findings are part of a growing body of research showing that voluntary HIV testing and counselling - and subsequent behaviour change - may be more palatable to couples when presented in the context of reproductive services. As a result, McCord Hospital will begin offering reproductive services to people living with HIV.
"People have very serious issues in their relationships already, and HIV just adds another dimension," she told News. "We have to start addressing these lived realities, and see how we might address broader issues in their lives and... how this can help us address HIV."
[This report does not necessarily reflect the views of the United Nations]