Care and support for people living with HIV/AIDS

Report on the global HIV/AIDS epidemic – June 2000– even when mutual – is protective only when both partners have entered the relationshipwithout HIV infection.Condoms are commonly used in some areas for family planning purposes, but inmost populations, despite vigorous promotion campaigns, the use of condoms withspouses is very low. Low condom rates in marriage are common even when eitheror both partners also have unprotected sex outside marriage. In a large national surveyin Zambia, married men who reported extramarital partners were no more likelyto use condoms with their wives than men who said they were faithful. Since justone-third of men with extramarital partners had used a condom the last time theyhad casual sex, many married women are put at risk for HIV by their husbands’behaviour.In the light of these prevention challenges, it is hardly surprising that the scale of HIVtransmission within marriage and other stable relationships is considerable. Studiesconfirm that this is the case, especially in areas where infection rates are high.Just as voluntary HIV testing and counselling can be a first step in helping HIV-positivewomen reduce their chances of having an infected baby (see page 81), it canserve the same purpose for couples in which one partner might be infected and theother one vulnerable to sexual transmission of the virus. Studies of the preventiveeffectiveness of voluntary counselling and testing have yielded conflicting findings indifferent populations and places. Encouragingly, however, there is increasing evidencethat this measure can successfully prevent the onwards transmission of thevirus in heterosexual partnerships, especially when the two partners choose to comeas a couple for counselling and testing.While HIV testing can be useful for people who are already married and even oncea woman is pregnant, as described below, some argue that “premarital” counsellingand testing would be even more helpful, given the high risk in some placesof entering marriage when already infected and the general failure of condom promotioncampaigns to encourage open discussion and use of condoms for HIVprevention within stable relationships. In a number of countries, including twodeveloping countries with striking successes in prevention – Thailand andUganda – an increasing number of people are choosing to be tested for HIVbefore getting married. At Uganda’s AIDS Information Centre, the proportion ofthose getting tested because they are considering marriage or a new relationshiphas risen steadily over time, from 6% in 1992 to 33% in 1997. Two-thirds of thesemen and women came with their prospective partners, and the vast majoritytested negative. Indeed, people taking these “precautionary” tests were far lesslikely to be infected with HIV than people tested for other reasons. In 1997, just6% of premarital tests were positive, compared with a quarter of those tested forother reasons.Voluntary counselling and testing will never appeal to all individuals or couples,whether heterosexual or homosexual, and it will never successfully prevent onwardstransmission in all those who are tested. However, it is an important option to include80