Counseling of couples facilitates HIV disclosure.

In settings where many people are infected with HIV, reproductive health professionals face a difficult ethical dilemma. They must protect the confidentiality of their clients, even those who are HIV-positive. Disclosing the HIV status of an infected woman, for example, may lead to violence or abandonment by a partner. Such involuntary disclosure may also discourage both men and women from seeking HIV voluntary counseling and testing (VCT) services, which have been shown in a randomized controlled trial involving some 4,000 participants in Kenya, Tanzania, and Trinidad to be highly effective in reducing sexual risk behavior. (1) But one way to resolve this ethical dilemma is to help HIV-positive clients disclose their status to partners by facilitating communication between them.

Offering VCT to couples is one way to facilitate such communication. About a third of participants in the VCT trial conducted between 1995 and 1998 in Kenya, Tanzania, and Trinidad were couples. Counseling them was more difficult than counseling individuals. But couples who were counseled were more likely to disclose their HIV test results to their sexual partners (91 percent did so) and to reduce high-risk sexual behaviors, counselors and clients in Kenya and Tanzania reported in interviews. (2) That HIV counseling and testing is more effective in reducing sexual risk behavior when both members of a couple participate is supported by research in other countries, including Rwanda and the Democratic Republic of the Congo (formerly Zaire). (3)

"In Tanzania, counselors working with couples said their job was more time-consuming and emotionally challenging," says Dr. Gloria Sangiwa, an FHI expert on HIV/AIDS care and support services and a member of the group that conducted the multicenter VCT study. This was especially true if a couple was HIV-serodiscordant (one individual was infected while the other was not). "Even so, HIV-infected people who were willing to share their results subsequently tried harder to protect their partners from infection," she says. "When both individuals were HIV-negative, couple counseling was still beneficial because it brought people together to make and follow decisions to protect their reproductive health."

In contrast, counselors from the multicenter VCT study reported that it was challenging to facilitate partner notification while working with individuals. Lacking a safe, counselor-mediated environment in which to talk to their sexual partners, these individuals often anticipated difficulties disclosing their HIV status. In Tanzania, only 27 percent of HIV-infected female VCT clients had shared test results with their partners six months after testing. (4) Reported disclosure rates have been even lower in HIV perinatal transmission trials in Tanzania and Burkina Faso. (5)

In a 1999 study based on interviews with 17 individual men, 15 individual women, and 15 couples from Dar es Salaam, Tanzania, women reported that the greatest barriers to HIV testing and test disclosure were decision-making and communication between partners, partners' attitudes towards HIV testing, and the fear of partners' reactions. For some women who chose to disclose their HIV-positive status, negative reactions--particularly abandonment--were a nagging fear that soon became reality. "I used to tell him, `Let's go for testing together,'" said a 29-year-old HIV-positive woman. "But he refused. The day I came for testing I didn't tell him. It took two weeks to tell him. He had derided we get separated but I think it is because of that disease. He wants us to leave each other and me to go away to die." The couple subsequently separated. (6)

In contrast, many of the 28 individuals who had enrolled as couples in the Tanzanian component of the multicenter VCT trial said in interviews that they valued knowing whether they were infected with HIV. The knowledge enabled them to learn to live with their condition or that of their partner. In one HIV-serodiscordant couple, the HIV-positive husband admitted that knowing his condition had "created some chaos" at first, but "after a while we realized that it was better this way, to understand ... in other words, for her to know and me to know in what situation we are in." Most participants felt that counseling had either not harmed or had benefited their relationships. (7) "There were frequent reports of increased harmony and fewer incidences of violence in the relationship, greater mutual understanding, better coping skills, and knowledge of how to live with the results and how to protect each other," says Dr. Sangiwa.

POLICY IMPLICATIONS

Researchers who have studied the effectiveness of VCT services generally recommend that:

* VCT programs recruit couples or partners of individuals who come for HIV testing services. Testing both partners may facilitate disclosure of test results and foster a sense of shared responsibility to reduce the risk of HIV infection.

* Counseling sessions address sexual communication and decision-making, stigmatization of HIV-positive partners, and negative reactions leading to violence. (8)

* Counselors be specifically trained to conduct couple counseling. "in most settings, they should receive one to four weeks of initial counseling training with special emphasis on couple counseling," says Dr. Sangiwa, "and this training should be reinforced every six months. Counselors must also be trained to encourage the disclosure of HIV test results between sexual partners. Most VCT counselors feel they need more skills in this area."

* Provision of additional support and counseling services to couples, particularly serodiscordant couples with an HIV-positive female partner, be encouraged. (9)

* VCT counselors be attentive to youth. "In some settings, about a third of people coming for vet services are younger than 24 years old because youth increasingly want to know their HIV status at the beginning of a relationship," says Dr. Sangiwa. "Given this trend, VCT counselors must be youth-friendly, keeping in mind that dealing with youth is different than dealing with adult married couples."

REFERENCES

(1.) The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. Lancet 2000;356(9224):103-12.

(2.) Grinstead O, van der Straten A, The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Counsellors' perspectives on the experience of providing HIV counseling in Kenya and Tanzania: the Voluntary HIV-1 Counseling and Testing Efficacy Study. AIDS Can 2000;12(5):625-42; Grinstead O, van der Straten A, Sangiwa G, et al. Confidentiality and couple HIV counseling encourage client disclosure of serostatus and risk behavior. Results from the Voluntary HIV Counseling and Testing Efficacy Study. The XII International AIDS Conference, Geneva, Switzerland, June 28-July 3, 1998.

(3.) Kamenga M, Ryder RW, Jingu M, et al. Evidence of marked sexual behaviour change associated with low HIV-1 seroconversion in 149 married couples with discordant HIV-1 serostatus: experience at an HIV counseling center in Zaire. AIDS 1991;5(1):61-67; Allen S, Tice J, Van de Perre P, et al. Effect of serotesting with counseling on condom use and seroconversion among HIV discordant couples in Africa. BMJ 1992;304(6842):1605-9.

(4.) Maman S, Mbwambo J, Hogan N, et al. Women's barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counselling and testing. AIDS Care 2001;13(5):595-603.

(5.) Antelman G, Daaya S, Mbwambo J, et al. Factors related to disclosure of an HIV-positive test result to a sexual partner or any other confidant in Dar es Salaam Tanzania. Conference on Global Strategies for Prevention of HIV Transmission for Mothers to Infants, Montreal, September 1-5, 1999; Kilewo C, Massawe A, Lyamuya E, et al. HIV testing of pregnant women in sub-Saharan Africa: the PETRA experience in Dar es Salaam, Tanzania. Poster Presentation at the XIth International Conference on AIDS and STDs in Africa, Lusaka, Zambia, September 12-16, 1999; Nebie Y, Meda N, Leroy V, et al. Sexual and reproductive life of women informed of their HIV seropositivity: a prospective cohort study in Burkina Faso. J Acquir Immune Defic Syndr Hum Retrovirol 2001;28(4):367-72.

(6.) Maman.

(7.) Sangiwa MG, van der Straten A, Grinstead O, et al. Clients' perspective of the role of voluntary counseling and testing in HIV/AIDS prevention and care in Dar Es Salaam, Tanzania: the Voluntary Counseling and Testing Efficacy Study. AIDS and Behavior 2000;4(1):35-48.

(8.) Van der Straten A, King R, Grinstead O. Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS 1995;9(8):935-44.

(9.) Grinstead O, Gregorich S, Choi K-H, et al. Positive and negative life events after counseling and rating: the Voluntary HIV-1 Counseling and Testing Efficacy Study. AIDS 2001;15(8):1045-52.