Sexual and Reproductive Life of Women Informed of Their HIV Seropositivity: A Prospective Cohort Study in Burkina Faso

Of the 16,000 new HIV infections that occur every day in the world, 1,600 affect children, chiefly in Africa. Almost all these children acquire HIV infection from their mothers. Treatment of mother alone or mother and child with antiretrovirals and the use of breast-milk substitutes for children born from HIV-infected mothers are the main interventions now available to reduce the number of children infected with HIV throughout the world.

This study was carried out in Bobo-Dioulasso, the second largest city in Burkina Faso, located in the southwestern part of the country. In January 1995, a research program aimed at assessing the acceptance, tolerance, and efficacy of a short regimen of zidovudine and of vaginal disinfection with benzalkonium chloride to reduce mother-to-child transmission of HIV (DITRAME - ANRS 049 clinical trial) was established in three mother-and-child health and family planning (MCH/FP) centers in Bobo-Dioulasso.

In the context of the DITRAME-ANRS 049 research program, voluntary HIV counseling and testing (VCT) services were established for pregnant women. HIV-infected women were advised to disclose their HIV serostatus to their male partners who were also offered VCT, to use condoms to reduce sexual transmission, and to choose an effective contraception method to avoid unwanted pregnancies. This study aimed at assessing how HIV test results were shared with male sexual partners, the level of use of modern contraceptive methods, and the pregnancy incidence among women informed of the risks surrounding sexual and reproductive health during HIV infection.

The first enrollment in the DITRAME-ANRS 049 program was in September 1995 and the last in December 1998. All women were monitored from delivery to weaning with a quarterly medical check-up. At each follow-up visit, each women was offered an individual session of counseling with a social worker who informed her about her HIV seropositivity. At each interview, the social worker collected information on the sharing of HIV test results with the male partner and the subsequent social consequences, the resumption of sexual relations, and the use of condoms and other contraceptives.

Two outcomes were examined: disclosure of the women's positive HIV test result to the male sexual partner and subsequent pregnancy following the HIV diagnosis. A cross-sectional analysis was used to identify factors associated with the disclosure of the HIV test result. The cohort included a total of 314 HIV-positive women living in Bobo-Dioulasso who were informed of their HIV serostatus. Only 54 women (17.6 percent) disclosed their HIV status to their male sexual partners. The median duration of follow-up of those who disclosed their HIV status (13.9 months) was comparable with that of the women who concealed their status (13.5 months).

The only identifiable reason why these women refused to disclose their positive HIV test result to their partner was the fear of domestic violence. Among the 54 women who disclosed their HIV status, only 2 subsequently separated from their partners. There was a significant trend (p = .04) among the women who shared their HIV test with their partners to practice more sexual abstinence and to use a condom during each sexual intercourse.

The 306 women enrolled in the study were observed over a median period of 13.5 months, accounting for 389 person-years of exposure to pregnancy risk. Among these women, 48 had at least one subsequent pregnancy following their positive HIV test result. The longer the exposure to pregnancy risk, the higher the pregnancy incidence rate was, despite information about HIV status and the quarterly counseling about the advantage of reducing pregnancies to preserve maternal health and to reduce the number of children infected with HIV through mother-to-child transmission.

This study revealed that a minority of women who tested seropositive during their pregnancy disclosed their HIV status to their male sexual partners (18 percent), used condoms during each sexual intercourse (8 percent) to avert HIV sexual transmission, and undertook hormonal contraception (32 percent) to avoid a new pregnancy. Thus, incidence of pregnancies subsequent to HIV diagnosis was 12.3 per 100 person-years in this cohort and rose significantly from 4 per 100 person-years in the first year of follow-up, to 18 per 100 person-years in the third year.

In conclusion, the study shows that pregnancy incidence among women informed of their HIV seropositivity in Burkina Faso is not modified by HIV test result sharing with their male sexual partner and the adoption of double contraception. The tendency of couples who share HIV test results to use double contraception methods and low incidence of domestic violence following HIV test result sharing suggest that the best way to develop pregnancy prevention among HIV-infected women is to introduce large-scale VCT services for couples and to strengthen family planning services, which, in general, focus more on couples.

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