Partners in HIV prevention

Sub-Saharan African women make up nearly 60 percent of all adults living with HIV in the world today. Methods are available for these women to prevent HIV transmission to their offspring, but getting such options used has been difficult.

Now, a new study from the University of Washington and Fred Hutchinson shows that involving male partners in HIV/AIDS counseling during a woman's pregnancy increases the adoption of specific strategies to prevent mother-to-child and partner transmission of the disease.

The study was conducted by Dr. Carey Farquhar, co-director of the International AIDS Research and Training Program and a UW assistant professor of medicine and epidemiology. Co-investigators included UW's Dr. Grace John-Stewart, a Public Health Sciences Division-affiliated investigator, and Dr. James Kiarie at the University of Nairobi. They collaborated with Dr. Barbra Richardson, a PHS biostatistician, along with colleagues in Nairobi, Kenya, where the work took place. The study was published in the Dec. 15 edition of the Journal of Acquired Immune Deficiency Syndromes.

"This is the first study to try to bring partners into a traditionally woman-oriented setting, invite them to participate, and then see if, by facilitating communication between the woman and her partner, we could then encourage her to take up interventions to prevent HIV transmission to her infant," Farquhar said. "That's the big problem. We can provide women with interventions, but if they haven't told anyone, how will they be able to implement them? Partner support is an important first step."

UNAIDS estimates that 800,000 babies are born HIV-positive in Africa every year. In the absence of any intervention, the risk of mother-to-child HIV transmission is around 15 percent to 30 percent, if the mother does not breastfeed the child. A single dose of the antiviral drug nevirapine given at the onset of labor, and a few drops administered to the newborn in the first 72 hours, halves the risk of mother-to-child HIV transmission during childbirth and the early breast-feeding period. Transmission rates can rise as high as 30 percent to 45 percent with prolonged breast-feeding.

Despite increasing understanding and availability of interventions to protect babies and partners from HIV transmission, many African women choose not to receive their HIV test results. Even for those who know they are HIV-infected, many do not use any interventions to prevent mother-to-child or partner transmission.

Getting couples to counsel

The researchers found that couple counseling may be critical to changing those behaviors. In the current study, 88 percent of the HIV-infected women who were couple counseled accepted and used nevirapine. They were also five times more likely to avoid breast-feeding, and four times more likely to use condoms, even after adjusting for differences between women who were counseled as a couple and those who were not.

Despite these successes, the number of couples willing to be tested for HIV and counseled together was small. "Given the opportunity, only about 7 percent overall were couple counseled," said Richardson, who is also a UW research associate professor of biostatistics. "That's a pretty low yield. The trick is how to get these women to bring their partners in."

To understand the obstacles, says Farquhar, you have to understand Kenyan culture. "Childbearing is seen as the woman's role, so only women go to these very busy antenatal clinics," she said. "There are no appointments. Women just show up and wait to be seen, sometimes for hours and hours. This deters men with jobs from attending."

The researchers helped overcome some of these issues by providing letters of invitation to partners to excuse them from work and by holding clinics on weekends to avoid workdays.

Concern over relationships and social standing is a harder stumbling block. For an African woman, using infant formula instead of breast-feeding or taking a daily regimen of pills is tantamount to publicly announcing her HIV-positive status. The social stigmatism — and sometimes, abandonment or domestic violence — that accompanies such disclosure is often more feared than AIDS itself.

"In general, people are reluctant to get tested or bottle-feed because they don't want other people to know. HIV is still perceived in Africa as a disease that kills people and that there's no cure for, that you get because you've done something 'bad,' like had multiple partners, been promiscuous or had sex with commercial sex workers. For all of those reasons, it's still very stigmatized," Farquhar said.

In Kenya, an estimated 1.4 million people are infected with HIV/AIDS. In the capital city of Nairobi, one person in 10 has HIV/AIDS. About 10 percent of those reported HIV/AIDS cases are in children 5 years old and under, mostly due to mother-to-child transmission, according to the Nairobi Ministry of Health.

Equal assess to treatment

Farquhar believes access to treatment for HIV/AIDS is key to improving communication, acceptance and support. Of the 25 million Africans living with HIV, close to 4 million have advanced to the stage where anti-retroviral drugs are necessary to forestall or reverse the onset of full-blown AIDS. Even as treatment slowly expands today, less than 4 percent of all Africans who need it get it.

"Having treatment there will make a big difference because HIV won't just be a death sentence," she said. "Who wants to say, 'I'm going to die in the next five years'? Anti-retrovirals have changed the outlook of HIV-positive patients and how they're perceived by others because now they can continue to work and lead normal lives."

"Treatment may help increase couple counseling, too. There's something that can be done if one's partner is infected — not just to keep that person healthy, but to prevent transmission to the uninfected partner, too."

Farquhar and colleagues are conducting focus groups and doing other formative research in Nairobi to better understand attitudes toward partner notification and couple-counseling. They hope to entice more men to come to clinics and are trying to determine ways to make the sites more "man-friendly."

"My hope is that men will become more involved in the mother-child transmission prevention effort. It's really hard for women to do this on their own," she said. "If couple counseling could be offered, even a small decrease in HIV-infected infants could make it a success."

Co-authors included Dr. Ruth Nduati, Dr. Dorothy Mbori-Ngacha, Marjory Kabura and Francis John at the University of Nairobi. Many of the Kenyan researchers were scholars in the NIH-funded International AIDS Research and Training Program, trained at the UW's School of Public Health and Community Medicine and have collaborated on numerous studies with the center and UW. The Elizabeth Glaser Pediatric AIDS Foundation funded the study.