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Guidance on Couples HIV Testing and Counselling Including Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples: Recommendations for a Public Health Approach. Geneva: World Health Organization; 2012 Apr.

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Guidance on Couples HIV Testing and Counselling Including Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples: Recommendations for a Public Health Approach.

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ANNEX 11Concerns about intimate partner violence (IPV) following CHTC

In many countries, gender disparities and dynamics exist that may lead to power imbalances in relationships between men and women. HIV counsellors need to be aware of these potential gender issues when conducting a couples HIV testing and counselling (CHTC) session, and they must listen to women carefully to ensure that they understand the home situation and the dynamics between the two individuals they are counselling and take these into account when they consider proceeding with CHTC.

Women, however, should not be denied the opportunity to get tested and counselled, and hence have access to effective treatment and prevention, because of counsellors' perceived fears of IPV. The issues should be explored and women (and men) supported to make an appropriate decision on CHTC with the understanding that they may ultimately decide to test alone.

Gender issues have a bearing on vulnerability to HIV, access to treatment and prevention and issues around care and support for communities and families affected by HIV. Gender issues related to HIV include:

  • Economic dependency
  • Property rights and other legal issues
  • Equal access to care, treatment, and support services
  • IPV (including sexual, physical, verbal, emotional abuse)
  • Abandonment
  • Relationship breakup
  • Couple dynamics (e.g., husband speaks for wife, husband makes decisions about couple's sexual behaviour)

IPV and association with HIV

Some studies have found that women who have violence in their families are likely to be more vulnerable to HIV, but a direct causal relationship has not been established. Most countries with generalized HIV epidemics are poor, often with multiple social problems in addition to their burden of HIV-related morbidity and mortality. While problems such as alcoholism, domestic violence, poverty, lack of education and crime exist in parallel with HIV, a direct causal relationship is not clear, and there is no evidence basis for the speculation that disclosing one's HIV-positive status makes IPV more likely. Furthermore, no association between IPV and HIV status was demonstrated in an analysis of data from the most recent Demographic and Health Surveys conducted in Dominican Republic, Haiti, India, Kenya, Liberia, Malawi, Mali, Rwanda, Zambia and Zimbabwe.1

IPV following HTC and disclosure

Some qualitative studies (without comparison groups or before and after data) show possible associations between disclosure of HIV status and IPV. In these descriptive studies, it is important for counsellors to keep in mind, overall very few (less than one out of six) women experience negative partner reactions when disclosing HIV test results.2 The majority of women receive support and understanding from their partners when they disclose their HIV status. Also, less than 5% of couples separate or divorce after disclosure of a positive HIV test result,3, 4, 5 and it should also be recognized that separation is not always a negative outcome for couples. Another study in Khayalitsha, South Africa found no evidence that inviting male partners to ANC and VCT increased the risk of self-reported IPV in either women or men compared to inviting male partners for pregnancy information sessions only.6

More rigorous studies examining stable relationships before and after testing and mutual disclosure are needed to determine if a causal relationship exists that would justify caution or limitations in testing (especially) women for HIV as part of CHTC.

Gender and CHTC

Gender issues can influence the direction and the dynamics of an HIV testing and counselling session and CHTC has some gender-related advantages. One advantage is that both partners learn their status together. When tested individually, gender issues and fear may play a large role in whether a woman will disclose her HIV status to her husband or partner.7, 8 In CHTC, a woman does not need to disclose her status because the counsellor will provide the couple's test results as a unit. The CHTC session also gives the counsellor an opportunity to direct communication, ease tension, and diffuse blame within the couple relationship. Couples counselling offers a safe and supportive environment in which a couple can discuss HIV risk issues and concerns, cope with their HIV test results, and begin to plan for the future of the relationship. Therefore, CHTC is an intervention that can help mediate gender issues related to HIV and prevent negative experiences associated with testing.

Most women will refuse to involve their partner in CHTC if they know their partner is violent. If a couple chooses to go through CHTC, they are ultimately responsible for deciding the course of their relationship (for example, whether the relationship will continue or dissolve) after receiving CHTC services. The counsellor's role is critical in helping the couple cope, be mutually supportive, and adapt to their HIV test results. In rare instances, if a counsellor is concerned that a woman might be at risk for violence, the CHTC site should, at a minimum, offer her individual testing and provide her with information about appropriate crisis support services in the community if they are required. The service provider should also include follow-up monitoring in their programme planning for potentially threatening situations.

If access to testing and counselling is not scaled up – through CHTC or other models – there will be more morbidity and mortality, with disclosure eventually taking place when a partner becomes sick. The poorly defined risk of possible IPV after disclosure must be balanced against the significant benefits to the majority of the community when HIV testing and counselling is widely available and acceptable to individuals and couples.

Harling G, Msisha W, Subramanian SV. No association between HIV and intimate partner violence among women in 10 developing countries PLoS One. 2010. Dec 8 5(12)e14257. [PMC free article: PMC2999537] [PubMed: 21170389]

Maman Suzanne, et al. High Rates and Positive Outcomes of HIV-Serostatus Disclosure to Sexual Partners: Reasons for Cautious Optimism from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania. AIDS and BehaviorVol 7No. 4December2003. [PubMed: 14707534]

Ibid.

Kamenga M, et al. Evidence of marked sexual behavior 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. [PubMed: 2059362]

Nebié Y, 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. 2001;28:367–372. [PubMed: 11707674]

Mohlala B, Boily M-C, Gregson S. The Forgotten Half of the Equation: Randomised controlled trial of a male invitation to attend couple VCT in Khayelitsha, South Africa. AIDS 2011; 25:000-000, 1-7. [PMC free article: PMC3514892] [PubMed: 21610487]

Heyward W, et al. Impact of HIV counselling and testing on child-bearing women in Kinshasa, Zaire. AIDS. 1993;7:1633–1637. [PubMed: 8286073]

Keogh P, et al. The social impact of HIV infection on women in Kigali, Rwanda: a prospective study. Social Science and Medicine. 1994;38:1047–53. [PubMed: 8042052]

Footnotes

1

Harling G, Msisha W, Subramanian SV. No association between HIV and intimate partner violence among women in 10 developing countries PLoS One. 2010. Dec 8 5(12)e14257. [PMC free article: PMC2999537] [PubMed: 21170389]

2

Maman Suzanne, et al. High Rates and Positive Outcomes of HIV-Serostatus Disclosure to Sexual Partners: Reasons for Cautious Optimism from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania. AIDS and BehaviorVol 7No. 4December2003. [PubMed: 14707534]

3

Ibid.

4

Kamenga M, et al. Evidence of marked sexual behavior 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. [PubMed: 2059362]

5

Nebié Y, 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. 2001;28:367–372. [PubMed: 11707674]

6

Mohlala B, Boily M-C, Gregson S. The Forgotten Half of the Equation: Randomised controlled trial of a male invitation to attend couple VCT in Khayelitsha, South Africa. AIDS 2011; 25:000-000, 1-7. [PMC free article: PMC3514892] [PubMed: 21610487]

7

Heyward W, et al. Impact of HIV counselling and testing on child-bearing women in Kinshasa, Zaire. AIDS. 1993;7:1633–1637. [PubMed: 8286073]

8

Keogh P, et al. The social impact of HIV infection on women in Kigali, Rwanda: a prospective study. Social Science and Medicine. 1994;38:1047–53. [PubMed: 8042052]

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