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Couple voluntary HIV counselling and testing (CHCT): Recommendations for healthcare workers

Summary
Since April is dedicated as Health Awareness month, AfroAIDSinfo presents an article discussing aspects of voluntary HIV counselling and testing for couples.

Introduction
The Health Systems Trust (HST), a not-for-profit organisation in South Africa, annually compiles a health calendar, in which April is dedicated to Health Awareness (HST, 2014). One of the ways in which health awareness can be increased is through human immunodeficiency virus (HIV) counselling and testing (HCT), since the knowledge of one's HIV status can be empowering and sobering when accompanied by sound advice (Wall, 2012). In this article, AfroAIDSinfo will explore recent research with regards to couples' voluntary HIV counselling and testing (CHCT).

Short history of heterosexual transmission in southern Africa
In the early 1990s, when HIV first made inroads into South Africa, the virus mostly occurred among miners, who were migrant workers on a one-year contract (Whiteside, 2014). The infection quickly spread to landlocked countries, such as Lesotho and Swaziland, and other regions in South Africa when these miners returned to their wives and families (Corno & de Walque, 2012; Whiteside, 2014). With the advent of democracy in SA, it inherited the emerging burden of HIV infection among many other social and political challenges (Whiteside, 2014).

The long periods spent away from home took its toll on the miners and their wives or co-habiting partners, as often both parties engaged in extra-marital sexual relationships during times of separation (Corno & de Walque, 2012). The flourishing commercial sex industry around the mines facilitated the spread of HIV. As a sign of fidelity, miners and their life partners would not use condoms even though the couple sometimes neglected their use with extra-marital sexual partners. In the cultural mind, condoms became associated with unfaithfulness and distrust while HIV-infected women were blamed for bringing the virus into a marriage (Corno & de Walque, 2012; Musheke et al., 2013). Women were placed in this unfortunate position because they were more likely to be tested during visits to antenatal clinics (Matuvo et al., 2013).

Barriers to CHCT and HIV disclosure
The fears of being accused of infidelity, blamed for infecting the family, and the physical, mental, or verbal abuse she might suffer at the hand of her partner, prevented pregnant and non-pregnant women of disclosing their HIV status (Walcott et al., 2013). Disharmony between partners through the lack of love, trust and understanding were other barriers that prevented HIV disclosure. The stigma and discrimination HIV-infected partners might face in the community were also barriers.

Other hurdles preventing HIV disclosure (Walcott et al., 2013) were the need to protect your partner, denial and poverty. Men saw their female partners as weak and not being able to bear the knowledge of an HIV-positive status. Poverty was a major deterrent to HIV disclosure for women because the male partner might withdraw their financial support, while men were willing to disclose only when they knew how they would provide for their family’s basic needs.

CHCT and facilitating HIV disclosure
At antenatal clinics, healthcare workers might teach the female patient how to disclose her HIV status to her partner, ask her to bring her partner to the clinic, or present the test results at the homes of their patients (Walcott et al., 2013). Among the three methods of disclosure, the second method of facilitating HIV disclosure was the preferred method with the least number of disadvantages (Walcott et al., 2013).

Walcott et al. (2013) noted that there were instances where the pregnant woman had been tested, knew her status and was asked to bring her partner to the clinic, where the couple would be tested and their statuses disclosed to each other. This was done to protect the women from abuse, although some were still blamed for the HIV infection. Musheke et al. (2013) found that sometimes men were brought to antenatal clinics under false pretences. They men were either under the impression that the test was compulsory or coerced into taking up CHCT for the health of their unborn child. The coercive methods were not as successful as inviting them to voluntarily visit the clinic to undergo CHCT (Musheke et al., 2013; Wall et al., 2014).

Couples who underwent CHCT preferred disclosing their statuses to each other in the presence of a counsellor as opposed to the counsellor reading the HIV-test results to them (Walcott et al.,2013).

Reported findings of CHCT
Serodiscordant couples
Sometimes the fears of couples were realised (Musheke et al., 2013; Tabana et al., 2013; Walcott et al.,2013). The greatest fear was serodiscordancy, where one partner is HIV positive and the other negative. In cases where the male was HIV positive and the woman negative, the woman’s suspicions of infidelity seemed to be confirmed even though the male partner might have been infected with HIV before they started their relationship. There were instances when the HIV-infected male partner forced the HIV-negative woman to have unsafe sex for intimacy and for reproductive reasons (Tabana et al., 2013). Abuse often resulted when the woman was the HIV-positive partner, not the man. Young couples found it more difficult to handle serodiscordance making the fear of abandonment and the shame that comes with divorce a reality (Tabana et al., 2013; Musheke et al., 2013).

Concordant positive couples
Concordant positive (where both partners are HIV positive) partners did not have to deal with the risk of seroconversion of the non-infected partner although they too had to balance safe sex with the innate desire to have children (Tabana et al., 2013; Musheke et al., 2013). These couples reported stronger, more deeply committed relationships (Musheke et al., 2013; Tabana et al., 2013; Walcott et al., 2013). The realisation that they were facing HIV infection together helped them find ways to cope and put the past behind them. Although the couples experienced distrust, bitterness, and lack of intimacy at first, they were able to overcome these issues. The women in these concordant-positive couples were more likely to find support through new social relationships than the men (Musheke et al., 2013; Tabana et al., 2013; Walcott et al., 2013). A positive finding was that these couples encouraged each other to adhere to their antiretroviral medication.

Concordant negative couples
As with concordant-positive couples, concordant-negative couples (where both partners tested HIV negative) reported that their relationship deepened and their commitment to each other was renewed. These couples put the past behind them and became committed to staying HIV negative (Musheke et al., 2013; Walcot et al., 2013).

What the healthcare worker can do
Based on the experiences of these couples, healthcare workers can encourage uptake of CHCT and increase awareness in the community by:

  • respecting the male partner's right to not go for CHCT (Musheke et al., 2013) and using non-coercive means by either visiting the home and conducting CHCT there (Walcott et al., 2013) or hand-delivering an invitation to the couple (Wall et al., 2012).
  • being sensitive to the couple’s past experiences and the fragility of their relationship (Musheke et al., 2013).
  • changing the image of condom use in marriage to increase its usage (Musheke et al., 2013).
  • explaining the importance of participation in support groups, especially male participation (Musheke et al., 2013).
  • visiting all the homes in a community, not just certain homes, to offer and perform CHCT, but discussing family health and HIV-prevention first before offering CHCT (Walcott et al., 2013).

Conclusion
These findings provide some guidelines for healthcare workers to increase uptake of CHCT and facilitate disclosure of HIV status in an empathetic environment. All the participants in the studies discussed above (Musheke et al., 2013; Tabana et al., 2013; Walcott et al., 2013) favoured the idea of home-based CHCT as long as the healthcare workers visited everyone in the community.

References

  • Corno, L. and de Walque, D. (2012) 'Mines, migration and HIV/AIDS in Southern Africa' Journal of African Economies 21, 465-498.
  • Darbes, L. A., van Rooyen, H., Hosegood, V., Ngubane, T., Johnson, M. O., Fritz, K. and McGarth, N. (2014) 'Uthando Lwethu ('our love'): A protocol for a couples-based intervention to increase testing for HIV: A randomized controlled trial in rural KwaZulu-Natal, South Africa' Trials 15, 64.
  • Health Systems Trust (2013) 'Health Calendar 2014' [Online] Accessed on 05 March 2014.
  • Matovu, J. K. B., Denison, J., Wanyenze, R. K., Ssekasanvu, J., Makumbi, F., Ovuga, E., McGarth, N. and Serwada, D. (2013) 'Trends in HIV counseling and testing uptake among married individuals in Rakai, Uganda' 13, 618.
  • Musheke, M., Bond, V. and Merten, S. (2013) 'Couple experiences of provider-initiated couple HIV testing in an antenatal clinic in Lusaka, Zambia: Lessons for policy and practice' BMC Health Services Research 13, 97.
  • Tabana, H., Doherty, T., Rubenson, B., Jackson, D., Ekström, A. M. and Thorson, A. (2013) “'Testing together challenges the relationship': Consequences of HIV testing as a couple in a high HIV prevalence setting in rural South Africa” PLoS ONE 8, e66390.
  • Walcott, M. M., Hatcher, A. M., Kwena, Z. and Turan, J. M. (2013) 'Facilitating HIV status disclosure for pregnant women and partners in rural Kenya: A qualitative study' BMC Public Health 13, 1115.
  • Wall, K. M., Kilembe, W., Nizam, A., Vwalika, C., Kautzman, M., Chomba, E. et al. (2012) 'Promotion of couples' voluntary HIV counselling and testing in Lusaka, Zambia by influence network leaders and agents' BMJ Open 2, e001171.
  • Whiteside, A. (2014) 'South Africa's key health challenges' Annals of the American Academy of Political and Social Science 652, 166-185.

Author: Waldo Adams (BSc Hons Biochemistry)
Reviewed by: Hendra van Zyl (MPH), Jean Fourie (MPhil) and Michelle Moorhouse (MBBCh, DA)

Contact: afroaidsinfo@mrc.ac.za
Date: April 2014

Preferred citation
Adams, W. (2014) Couple voluntary HIV counselling and testing (CHCT): Recommendations for healthcare workers , AfroAIDSinfo. Issue 14 no. 4, Health Profession (Open access).

Last updated: 2 April, 2014