Short Communication: Communication Between Pregnant Women and Male Partners About HIV Testing in the United States

Abstract

Male partner uptake of HIV testing during antenatal care is poor despite women's reported desire for partner testing. This qualitative study of HIV-negative pregnant women and their partners in a high HIV prevalence city in the United States assessed communication between partners about HIV testing. Facilitators and barriers of partner testing were identified. Women are the driving force behind couples' communication; however, male partner uptake is underutilized. A common barrier to male partner uptake is the concept of “negative by proxy,” as well as male partner lack of follow-up for testing and nondisclosure of results. Future research is needed to assess specific barriers to male partner HIV testing as an approach to preventing perinatal HIV transmission.

Elimination of perinatal human immunodeficiency virus (HIV) transmission is a critical goal of HIV public health interventions. HIV seroconversion during pregnancy significantly increases the risk of perinatal transmission, and prevention of transmission requires early knowledge of HIV status to employ necessary antenatal, intrapartum, and postpartum interventions.^1–3 Routine maternal HIV testing is recommended in pregnancy; however, a critical yet underutilized HIV prevention strategy is testing and knowledge of partner HIV status.⁴

International data demonstrate that male partner uptake of HIV testing is low.^5–7 However, some interventions, including couples-based HIV counseling, home testing, and male partner participation in antenatal care, can improve rates of male partner HIV testing.^8–12 In the United States, limited data suggest a majority of pregnant women do not know their partner's HIV status but desire this information as well as availability of partner HIV testing at the site of prenatal care.^13,14 Yet, our own group has demonstrated that even when free partner HIV testing is available, male participation is low, suggesting that barriers to testing beyond financial, logistical, and educational exist.^14,15

Partner communication regarding HIV testing influences testing behavior and is a poorly described but important aspect of male partner testing uptake.¹⁶ For example, international data suggest that male partners engaged in couples-based communication about HIV were more likely to participate in male-partner HIV testing.¹⁷ Thus, to understand how communication between partners regarding HIV testing influences partner HIV testing in the prenatal period in a U.S.-based cohort, we performed a qualitative study of HIV-negative pregnant women and their partners to assess couple's interpersonal communication about HIV testing.

Eligible participants were English-speaking patients and their partners (≥18 years) receiving publicly funded prenatal care at a single tertiary care center in Chicago, Illinois. This analysis was a secondary objective of an evaluation of a quality improvement program initiated at an obstetrics practice in which free HIV counseling and testing was offered to male partners of pregnant patients.¹⁵ In-depth individual interviews using semistructured guides were conducted to investigate interpersonal communication about HIV and HIV testing. Participating couples underwent separate individual interviews with trained research assistants. Individuals were eligible for inclusion regardless of their decision regarding partner HIV testing. Women were eligible to participate regardless of their partner's participation. Transcripts were analyzed using the constant comparative method to determine themes, and interviews were conducted until all investigators agreed that saturation of themes was reached. Analysis was completed by two trained investigators through an interactive iterative process of inductive analysis involving frequent team discussion. All study activities were approved by the Northwestern University Institutional Review Board and all participants provided written informed consent.

Participants included 29 pregnant women and 22 male partners. The majority (62%) of pregnant individuals were in a relationship, whereas 7% were married and 28% identified as single. A majority (72%) of pregnant participants identified as non-Hispanic black and 24% as Hispanic. Analysis demonstrated themes within couples' decision-making and actions regarding HIV communication. We identified facilitators and barriers to two aspects of testing communication: (1) communication before undergoing HIV testing (“pretest communication”) [regarding the desire or lack thereof for either partner to undergo HIV testing] and (2) communication after undergoing or discussing HIV testing (“post-test communication”) [regarding whether testing occurred and the outcome of testing]. Exemplary quotations for each subtheme are provided in Table 1.

Table 1.

Patterns of Testing Communication Regarding HIV Testing

Pretest communication
Theme	Subtheme	Exemplary quotations
Facilitators	Female-initiated	“Just letting him know that, you know, I have received an STD from one of my kids' dads so ever since then, anybody that I meet you have to go to the doctor, so I took him with me.”
	Initiation of sexual intercourse	“We had our first conversation [about HIV/STD testing] a month after we went together. I guess the reason was because we were about to become sexually active with each other, and I guess I just wanted to make sure it was okay.”
	Presentation of symptoms	“It came about because I tested positive for chlamydia and I needed to let him know. Yeah. Because we had unprotected sex and so I felt that he should know and so it was kind of awkward and I, you know, well, you need to get tested and you need to get treated because I am too. So that's kinda how it went. And then when I followed up I let him know how it went and that it was all gone and you know just making sure that he kept up with it too.”
	“Nothing to hide” attitude	“… I don't know what she would have thought if I was like no, you know what I mean? Like why would I wanna go do that? Maybe she would have thought I was being a little irresponsible, like and then it would have been questions later like why didn't you wanna [take an HIV test]…”
Barriers	Trust in partner without desire for confirmation	“I just don't think [HIV testing is] necessary. It hasn't been, when's the last time he's been tested? I don't know actually. I don't know. I just don't, I trust him. We're in a monogamous relationship.”
	Perceived low risk status	“He's like, you know we've never talked about this. He's like, we've been together for so many years. You know we have, you know, how many kids already? He's all like, I'm like I don't know. It was just never a topic that was brought up, ya know?”

Post-test communication
Theme	Subtheme	Exemplary quotations
Facilitators	Couples testing	“Most of our tests that we went to is always that moment, like I think it may be 30 minutes they would tell us and then we get the piece of paper and then we go home feeling good.”
	Personal need for confirmation of partners negative status	“I wasn't gonna believe the paper unless I saw the paper myself so (laughs)…I don't think I showed him my results but (laughs) I've seen his…Not to say I didn't trust him. It's just that I'd rather trust my own eyes…I wanted to make sure he went.”
Barriers	No follow-up	“Basically I think he needs to get [tested] […] it's been almost a year and you still have not even tried to go to the doctor with me. Like I totally will pay for an Uber just to go with you, and you don't even want to go.”
	Partner nondisclosure of test results	“He said that he didn't have anything and he got tested and he was perfectly healthy but every time I would force him to, I would try to go to the doctor's appointments, he would just say that he went but never did [tell me]. Yeah. Then he says that they're over the phone. Yeah. Lie.”
	Negative by proxy assumption	“That I don't know. I don't know when he went to the doctor that they actually tested him for it. Because I got tested, so I feel like, you know, I know it can linger in your body and it can take a while to show up but when I get tested, I feel like okay, well if it was something hopefully it would have popped up.”

Facilitators of pretest communication included female-initiated conversations, desire to initiate sexual activity with a new partner, presentation of symptoms in either partner, or having a “nothing to hide” attitude (i.e., desire for open attitude about sexual health). In contrast, barriers to pretest communication included perceived low risk status and assumption of the male partner's negative status without desire for confirmation.

Facilitators of post-test communication (resulting in female knowledge of male test results after prior communication) included the couple undergoing testing together and the female partner expressing a personal need for confirmation of the partner's negative status. Barriers to post-test communication included partner lack of follow-up after prior communication regarding testing, partner nondisclosure of test results, or the couples' assumption that the female's negative prenatal HIV test was assurance of the male partner's negative status (i.e., assumption that male partners are negative by proxy after negative HIV testing in pregnant partner), which was a belief demonstrated by both male and female partners. Female initiation of discussion was an overarching facilitator of successfully communicating about HIV testing within the couple.

In this population of low-income pregnant women and their partners residing in a high-prevalence HIV region, women were commonly the driving force behind couples' communication about HIV testing. However, even when communication regarding testing was initiated, barriers such as male lack of test completion or failure to disclose results impeded knowledge of partners' HIV serostatus.

Our findings are similar to work conducted in the international setting. Discussion between partners about testing and positive relationship dynamics are facilitators to male involvement in HIV testing.^18,19 Barriers to male partner involvement include disagreement with HIV counseling and testing education, negative relationship dynamics, and communication patterns in which couples did not fully express themselves, or where communication was lacking.¹⁸ Furthermore, the assumption that the pregnant partner's negative test was proof of male partner HIV-negative status has also been documented as a significant barrier to testing.¹⁶ The “negative by proxy” concept is an inaccurate but common assumption. As in our analysis, in which a common attitude was that male testing was felt to be unnecessary when the woman was engaged in prenatal care, a frequent barrier in other contexts was the perception that antenatal care was for women alone.¹⁸ Finally, although not reported as a concern in our interviews, intimate partner violence is common, particularly during pregnancy, and the fear of intimate partner violence is a significant barrier for women in communicating about HIV testing.^16,20

Recommended strategies to improve communication regarding antenatal HIV testing include counseling programs that facilitate discussion of sexual risk between couples, and woman-initiated conversation about HIV testing with a plan to involve partners early in antenatal HIV testing.¹⁸ In addition, education and communication programs must emphasize that a women's HIV status is not a proxy for partner HIV serostatus.¹⁸ Our findings support these recommendations and provide new insight into extending beyond male partner involvement to additionally including male partner testing. These interventions should receive further research in a U.S.-based population, where male uptake of HIV testing antenatally remains poor.

Elimination of perinatal HIV requires knowledge of partner HIV serostatus. Improving uptake of partner testing may be enhanced by understanding how partners communicate about HIV and HIV testing. Future steps include understanding how health care providers and health systems can play a role in increasing involvement of partners in antenatal care through initiatives that encourage and facilitate partner communication strategies.

Authors' Contributions

Study concept and design by L.M.Y. and E.S.M.; L.M.Y. and E.S.M. also obtained the grants that supported this project. J.J. and K.L. performed data collection and data analysis. C.M.D. performed literature review and drafting of article. All authors approved of the final article.

Disclaimer

Comments and views of the authors do not necessarily represent views of the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by unrestricted grants from the Friends of Prentice Women's Health Grants Initiative (FY 2017). In addition, L.M.Y. and E.S.M. were supported by K12 HD050121 at the time of the study.