Many men and women fail to protect themselves against unplanned pregnancy and sexually transmitted infections (STIs), including HIV/AIDS, in part because they find it difficult, if not impossible, to discuss with their partners subjects related to sexuality.
Tools to improve partner communication about such sensitive topics have been used in limited settings and have not been thoroughly evaluated. Furthermore, merely talking about reproductive health does not ensure that couples will take the next, more difficult step of making permanent behavioral changes that protect against reproductive health dangers. Finally, in some cultural settings, increased partner communication about sexuality may disrupt power balances in intimate relationships, leading to marital discord, suspicions of infidelity, and even intimate partner violence.
But efforts by health educators, providers, and program planners to help couples talk about sexuality and share responsibility for their reproductive health decisions can produce potentially life-saving changes in sexual behavior. In fact, helping couples to communicate about sex is in-creasingly viewed as essential to HIV/AIDS prevention strategies.1 And research suggests that facilitating communication between husbands and wives helps these couples agree upon and meet their reproductive goals.
The difficulty that couples often have talking to each other about issues that affect sexual health has been documented in numerous studies. In 36 Demographic and Health Surveys (DHS) conducted since 1995, two-thirds or more of married women in Kenya, Madagascar, and most of the Latin American and Southeast Asian countries studied discussed family planning with their husbands in the year prior to the survey. But fewer than half of married women in 12 countries, mostly in sub-Saharan Africa, did so.2
Lack of communication about reproductive goals or contraceptive use is also suggested by large discrepancies between husbands' and wives' reports of unmet need for contraception in an analysis of data from DHS surveys in Bangladesh, the Dominican Republic, and Zambia. Higher reports by women of unmet need may occur when women want fewer children than men, yet fail to directly communicate that desire to their partners.3
In Uganda, research has shown that, while couples communicated with each other about whether or not to stop childbearing, they did so in indirect and ultimately ineffective ways. (Examples of indirect communication were overheard conversations, suggestive remarks, information gathered from a third party, or nonverbal channels.) This resulted in both men and women overestimating each other's desire for additional children. An analysis of results from 34 focus group discussions and a survey of 1,356 women and their partners, chosen to represent a range of social, demographic, and cultural conditions in Uganda, found that only 19 percent of women believed that their partners wanted no more children, although 30 percent of men said they wanted no more. Conversely, only a quarter of men believed that their partners wanted to stop childbearing, although more than one-third of women said they wished to have no more children. Meanwhile, a substantial number of both men and women admitted that they simply did not know their partners' wishes.4
Communication barriers
Why are such couples unable to communicate effectively about a matter that so profoundly affects their quality of life and sexual health?
"Both the focus group discussions and survey data in Uganda showed that open discussions about reproductive matters were discouraged by the belief that fertility should be left either to God or to male partners, many of whom were opposed to contraception," says Dr. Ann Blanc, co-investigator for the Ugandan study and a demographer with U.S.-based Blancroft Research International. "Male opposition was estimated to account for about 15 percent of unmet need for contraception overall, and led women who used family planning to rely on less-effective traditional methods that might be more easily concealed." Modern method use reported by women who wanted to stop childbearing declined by more than half, from 26 percent to 11 percent, when their partners opposed its use. For all methods combined (including abstinence), partner opposition appeared to reduce contraceptive prevalence by about one-fourth for both men and women.
Also discouraging spousal communication about ways to limit childbearing was the belief that discussing such matters could raise suspicions of infidelity or imply that a man wanted to have children outside of the marriage. "As a woman, when you say that you want to produce few children, the man might think that you are no longer interested in him," said a woman from the rural area of Masaka, Uganda. "Then he has to go outside marriage in order to produce more. And, if the man is enlightened and tells a woman, 'Let us limit the number of children,' the woman might think that the man is no longer interested in her. She'll think, 'He wants me to stop producing so that he can produce from his other women he loves.' "5
In high-fertility settings, points out Dr. Brent Wolff, coinvestigator for the Ugandan study and a senior social scientist at the U.K-based Medical Research Council (MRC) Programme on AIDS in Uganda, "pronatalist norms equate a desire to bear children with fidelity and commitment to a relationship. Thus, attempts to discuss family planning may well raise doubts and jealousy."
In highly patriarchal societies, where women are often expected to produce children for their husbands and the lineage, the introduction of family planning can produce dramatic and sometimes dangerous imbalances in power relationships between men and women. Based on 36 focus group discussions with married men and women, young and old men and women, and randomly chosen male and female opinion leaders living in rural northern Ghana between 1994 and 1996, researchers concluded that child-spacing is greatly valued, as it is in other parts of sub-Saharan Africa. However, contraceptive use activated tensions in gender relations.6 Such tensions sometimes led to marital discord, physical abuse of wives, and opposition from family members. "If you discuss [family planning] with some men, they will get up and beat you," said a young Ghanaian woman.7 In a study conducted in the diverse settings of Costa Rica, Indonesia, Mexico, and Senegal, the most common reasons married women cited for not negotiating female condom use with their husbands were fear of violence, withdrawal of economic support, or suspicions of infidelity.8
"Usually, women are more likely than men to want to stop talking about reproductive health issues because, if a discussion does not go well, they are more apt to pay the price," says Dr. Wolff. "They not only may face violence and divorce, but they also may lose the opportunity to secretly use contraception."
Differences in race and ethnicity may produce barriers to couple communication about sexual matters. A recent analysis of a national sample of U.S. youth, based on data from some 8,000 adolescents who reported ever having had sexual intercourse, with a total of some 17,000 partners, showed that the less similar adolescents and their partners were to one another, the less likely they were to use condoms and other contraceptive methods. "Persons from different racial and ethnic groups of different social networks may have different expectations about gender roles and communication in relationships, which may affect the likelihood that condom or other contraceptive use will be discussed," researchers concluded.9 Other U.S. studies also suggest that adolescent sexual partners who differ greatly in age may have difficulty communicating about sexual matters, and consequently be less likely to use contraception.10 Thus, counseling for adolescents should include a discussion of relationships where partners differ in age, grade in school, or other characteristics that may affect communication and power dynamics in the relationship.11
Finally, the subject of sex is simply too embarrassing for some couples to discuss. In many settings, women are supposed to know little about sex and may even lack the vocabulary to discuss it. Men with little knowledge of sexual matters may avoid discussing them for fear of exposing their ignorance.
When couples talk
In diverse settings, spousal communication has been consistently associated with greater contraceptive use.12 This association does not necessarily mean that communication directly increases contraceptive use. The reverse may be true: Already having decided to use contraception, couples may then tend to talk more about their sexual health. Nevertheless, in Ghana, women who had discussed contraceptives with their husbands were twice as likely to be current users than those who had not.13 In China, female factory workers and their husbands who together received family planning education emphasizing spousal communication and shared responsibility for contraception were less likely to have a subsequent pregnancy and abortion than couples whose members were educated about spousal communication alone or those who participated only in a standard family planning program.14 In Turkey, repeat abortions were reduced as a result of a program that incorporated family planning counseling for couples into abortion services.15
All India Women's Conference
Many couples find it difficult to discuss subjects related to sexuality.
Research is mixed about whether couples in close relationships (who presumably communicate well) are more likely to use condoms than are those in more casual relationships. Some studies have shown that men are actually more likely to use condoms in casual relationships, mainly as protection against STIs.16 However, an analysis of U.S. data from some 2,000 incarcerated, predominantly Latino adolescents with high numbers of sexual partners showed that youth who communicated with their sexual partners about each others' sexual history were significantly more likely to use condoms than those who did not.17 An analysis of a questionnaire completed by nearly 900 Rwandan women who reported having one steady partner in the past year also found that couple communication was associated with increased condom use, but only when discussion was specific, such as discussing STI risks or condom use.18
Unfortunately, the desire to maintain a relationship often outweighs health concerns; thus, many people — particularly women — will avoid discussing safer sex. Or, they will talk about AIDS only in a general sense not related to their particular sexual relationship.19 Several of 42 project managers and field workers interviewed in Haiti as part of an FHI effort to test behavior change communication tools confirmed that improving women's communication skills was challenging. Commented one: "It's easy to tell a woman to talk to her man, and she's often willing, but she's afraid of losing her mate. But to tell a man to talk to his girlfriend is like telling the boss to go and talk to his employee when he already knows that he is the master."20
Strategies to improve communication
Because discussions between partners about sexuality, contraception, and safe sexual practices are likely to cause anxiety and even outright conflict, some experts argue that attention to interpersonal relations and communication should become part of the overall design of family planning and STI prevention programs.
Recommended strategies for enhancing couple communication include attempts to enlist the cooperation of men by providing them with family planning, communication, and educational services.21
In the Ugandan research conducted by Drs. Wolff and Blanc, formal education was frequently cited as a primary way to overcome barriers to communication about sexual matters. Both men and women often reported thinking that discussions about stopping childbearing, particularly conversations in which the wife expressed her opinion, occurred among educated urban couples more than among uneducated rural couples.22 A secondary analysis based on this Ugandan data also found that educated women were consistently better able to negotiate sexual matters with their partners, as measured by influence over whether or not to have sex, ease of discussion about sex, and ability of married women to refuse sex with their husbands.23
Another strategy is to directly empower women to discuss sexual health issues. In the Democratic Republic of Congo (formerly Zaire), for example, an empowerment workshop was found to increase discussion and use of condoms among married women and their spouses.24 However, Dr. Wolff notes that discussions "may either help or hurt. Thus, while we need to empower people to discuss sexual health, we must then leave it up to them whether and when to exercise that power."
Based on the Ugandan research, Dr. Blanc also cautions that "because direct communication can generate conflict, it might be best to first promote direct discussions of such sensitive topics by having someone outside of the couple raise them in a public forum."
Improving partner communication is a challenging, often impossible, goal for many programs to achieve. "But what programs can do," Dr. Blanc says, "is recognize the couple dynamic. They should make sure not to treat female clients as if they existed in a vacuum. Instead, female clients should be asked about their sexual relationships, their sexual lives. Ultimately, this kind of information may be just as important to satisfactory reproductive health outcomes as obtaining a medical history."
— Kim Best
References
Family Health International. Dialogue: Expanding the Response to HIV/AIDS, A Resource Guide. Arlington, VA: Family Health International AIDSCAP Project, 1997.
Blanc A. The effect of power in sexual relationships on sexual and reproductive health: an examination of the evidence. Stud Fam Plann 2001;32(3):189-213.
Becker S. Measuring unmet need: wives, husbands or couples? Int Fam Plann Perspect 1999;25(4):172-80.
Wolff B, Blanc AK, Ssekamatte-Ssebuliba J. The role of couple negotiation in unmet need for contraception and the decision to stop childbearing in Uganda. Stud Fam Plann 2000;32(2):124-37.
Wolff.
Bawah AA, Akweongo P, Simmons R, et al. Women's fears and men's anxieties: the impact of family planning on gender relations in Northern Ghana. Stud Fam Plann 1999; 30(1):54-66.
Biddlecom A, Tagoe-Darko E, Adazu K. Factors underlying unmet need for family planning in Kassena-Nankana District, Ghana. Annual Meeting of the Population Association of America, Washington, March 27-29, 1997.
Rivers K, Aggleton P, Elizondo J, et al. Gender relations, sexual communication and the female condom. Crit Public Health 1998; 8(4):273-90.
Ford K, Sohn W, Lepkowski J. Characteristics of adolescents' sexual partners and their association with use of condoms and other contraceptive methods. Fam Plann Perspect 2001;33(3):100-5,132.
Darroch J, Landry D, Oslak S. Age differences between sexual partners. Fam Plann Perspect 1999;31(4):160-67; Abma J, Driscoll A, Moore K. Young women's degree of control over first intercourse: an exploratory analysis. Fam Plann Perspect 1998:30(1):12-18.
Ford.
Blanc.
Salway S. How attitudes towards family planning and discussion between wives and husbands affect contraceptive use in Ghana. Int Fam Plann Perspect 1994;20(2):44-47.
Wang C, Vittinghoff E, Lu S, et al. Reducing pregnancy and induced abortion rates in China: family planning with husband participation. Am J Public Health 1998;88(4):646-48.
Pile J, Bumin Ç, Çiloglu A, et al. Involving Men as Partners in Reproductive Health: Lessons Learned from Turkey. AVSC Working Paper, No. 12. New York: AVSC, 1999.
Ku L, Sonenstein F, Pleck J. The dynamics of young men's condom use during and across relationships. Fam Plann Perspect 1994;26(6):246-51; Forste R, Morgan K. How relationships of U.S. men affect contraceptive use and efforts to prevent sexually transmitted diseases. Fam Plann Perspect 1998;30(2):56-62; Landry D, Camelo T. Young unmarried men and women discuss men's role in contraceptive practice. Fam Plann Perspect 1994; 26(5):222-27.
Rickman RL, Lodico M, DiClemente RJ. Sexual communication is associated with condom use by sexually active incarcerated adolescents. J Adolesc Health 1994;15(5):383-88.
Van der Straten A, King R, Grinstead O. Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS 1995;9(8):935-44.
Bowen SP, Michal-Johnson P. The crisis of communicating in relationships: confronting the threat of AIDS. AIDS Public Policy J 1989;4(1):10-19; Cline R, Johnson S, Freeman K. Talk among sexual partners about AIDS: interpersonal communication for risk reduction or risk enhancement? Health Commun 1992;4(1):39-56.
Mahler H. Descriptive Analysis of AIDSCAP/Haiti BCC Projects. Arlington, VA: Family Health International AIDSCAP Project, 1996.
Bawah AA, Akweongo P, Simmons R, et al. Women's fears and men's anxieties: the impact of family planning on gender relations in Northern Ghana. Stud Fam Plann 1999;30(1):54-66; Bankole A, Singh S. Couples' fertility and contraceptive decision-making in developing countries: hearing the man's voice. Int Fam Plann Perspect 1998:24(1):15-24.
Wolff.
Wolff B, Blanc AK, Gage AJ. Who decides? Women's status and negotiation of sex in Uganda. Culture, Health & Sexuality 2000; 2(3):303-22.
Schoepf BG. AIDS action-research with women in Kinshasa, Zaire. Soc Sci Med 1993;37(11):1401-13.
Efforts to help sexual partners talk to each other about reproductive health matters are limited. Few have been evaluated.
However, FHI has developed and is evaluating a tool to help men and women communicate openly with each other about sex and other issues affecting their sexual health. Called Dialogue, this communication tool to facilitate group discussions was first presented in 1996 by FHI's AIDS Control and Prevention Project (AIDSCAP) Women's Initiative at a satellite meeting of the Eleventh International Conference on AIDS. Since that time, various initiatives using the Dialogue process have been conducted in Asia, Africa, and Latin America and the Caribbean.
Elizabeth Gilbert/The David and Lucile Packard Foundation
People gather at an outdoor market in India.
In 1997, for example, the Indian Institute of Health Management Research (IIHMR), with financial assistance from FHI, tested Dialogue among some 400 married men and women (about 200 each) from one rural and one urban area of Jaipur district, India. Two-thirds of the men were truck drivers, who are considered at high risk for HIV infection due to a tendency to have multiple sexual partners.1 Similarly, two-thirds of the husbands of women respondents were truck drivers. Researchers trained to guide and record the Dialogue process conducted 60 focus group discussions, 12 of which involved men and women talking to each other. Main discussion points included: the roles and responsibilities of men in the family, gender equity, virtues of a good man and a good woman, knowledge of symptoms, causes and prevention of sexually transmitted infections (STIs) and HIV/AIDS, use of condoms, promiscuous sexual behavior of men, and safer sexual practices.
Interviews with the approximately 400 men and women prior to the Dialogue sessions showed that spousal communication about sexual matters barely existed. Discussions were largely limited to husbands expressing their desire for or satisfaction with sex. About 60 percent of respondents reported discussing STIs with their spouses, but most women had simply suggested that their husbands be careful to avoid infection. Nearly half of the 128 truck drivers and a quarter of the 81 men from other professions admitted having sex with multiple partners. This practice put their wives at risk of STI/HIV infection. But only 18 percent of the men reported regularly using condoms while having extramarital sex, and only 12 percent reported doing so while having sex with their wives.
In contrast, interviews conducted after the Dialogue sessions with a selected group of couples representing about one-fourth of the total participants showed marked changes in both men's and women's attitudes towards sex, sexuality, and sexual health. Some 70 percent of the 92 respondents reported being more comfortable sharing such issues with spouses during Dialogue discussions. More importantly, condom use doubled for men having extramarital sex (from 18 percent to 36 percent) and for men having sex with their wives (from 12 percent to 23 percent).2
"It is more difficult to open a discussion on sex and related matters in the presence of near and dear ones," says Dr. R.S. Goyal, principal coordinator for the project and a professor at IIHMR. "People find it difficult to talk about such issues. But once the ice is broken, dialogue is more intense and effective. In this case, dialogue helped to create an enabling environment for a free and open discussion of sex and related issues, and its most important achievement was as much as a 100 percent increase in the use of condoms."
Evaluation of this communication tool will continue in India. In a study in Rajasthan, Dialogue will be used among 400 of 1,600 adolescents likely to be at risk for pregnancy and sexually transmitted infections. To determine the intervention's impact, researchers will evaluate whether adolescents' knowledge about reproductive and sexual matters has improved, an environment for the free and open discussion of sex and related issues has been created, and whether practices that protect reproductive and sexual health have been adopted.
A Dialogue Between the Sexes: Men, Women and AIDS Prevention describes the Dialogue process and is available here.
— Kim Best
References
Rao A, Nag M, Mishra K, et al. Sexual behavior patterns of truck drivers and their helpers in relation to female sex workers. Indian J Soc Work 1994;55(4):603-17.
Goyal RS, Kumar CS, Nigam S. Promoting sexual health through dialogue between men and women within social networks. Unpublished paper. Indian Institute of Health Management Research, 1998.
Traditional Method Use, Communication Sometimes Linked
Modern methods of contraception prevent pregnancy more effectively than traditional methods, such as the rhythm method or withdrawal. Yet, some women prefer traditional methods because they feel that their effective use requires a commitment by their partners to regulate fertility and demonstrates marital cooperation and communication.
In a study involving 26 married Mexican women ages 15 to 50 living either in the United States or in Mexico, 11 women who used the rhythm method or withdrawal explained that they liked doing so because the physical restraint required of their husbands confirmed a shared commitment to a nonreproductive sexual relationship.1
Those who used the rhythm method, which requires couples to avoid sexual intercourse for one to two weeks each month, felt that its use built more egalitarian relationships. They were more likely than users of withdrawal to discuss sexual matters with their husbands and to value the quality of sex more than its frequency.
"Rhythm, which teaches men and women to force their bodies to wait for sex but then values pleasure over self-control during actual intercourse, is a traditional way of expressing modern ideas about sexuality and marriage," researchers concluded.
Withdrawal, while allowing men to enjoy sex at any time, often left women sexually unsatisfied, and the four women in the study who preferred withdrawal reported that the method was their husband's choice. Nevertheless, women using either withdrawal or the rhythm method appreciated the fact that their husbands were endeavoring to protect them, and commonly and affectionately used the phrase el me cuida (he takes care of me) to refer to these techniques.
Notably, some women preferring traditional methods of contraception did so because they viewed their fertility as a precious resource that they shared with their husbands and feared that it might be endangered by use of a more modern method. And, some women who were socially and economically dependent on their husbands felt that independently controlling their fertility with use of a modern method could compromise the quality and intimacy of their marriage. This was a risk that they were not willing to take.
— Kim Best
Reference
Hirsch JS, Nathanson CA. Some traditional methods are more modern than others: rhythm, withdrawal and the changing meanings of sexual intimacy in Mexican companionate marriage. Culture, Health & Sexuality 2001;3(4):413-28.
In settings where many people are infected with HIV, reproductive health professionals face a difficult ethical dilemma. They must protect the confidentiality of their clients, even those who are HIV-positive. Disclosing the HIV status of an infected woman, for example, may lead to violence or abandonment by a partner. Such involuntary disclosure may also discourage both men and women from seeking HIV voluntary counseling and testing (VCT) services, which have been shown in a randomized controlled trial involving some 4,000 participants in Kenya, Tanzania, and Trinidad to be highly effective in reducing sexual risk behavior.1 But one way to resolve this ethical dilemma is to help HIV-positive clients disclose their status to partners by facilitating communication between them.
Nash Herndon/FHI
Offering HIV voluntary counseling and testing services to couples may facilitate disclosure of HIV status between couples. Here, a couple in the Dominican Republic talks in a seaside park.
Offering VCT to couples is one way to facilitate such communication. About a third of participants in the VCT trial conducted between 1995 and 1998 in Kenya, Tanzania, and Trinidad were couples. Counseling them was more difficult than counseling individuals. But couples who were counseled were more likely to disclose their HIV test results to their sexual partners (91 percent did so) and to reduce high-risk sexual behaviors, counselors and clients in Kenya and Tanzania reported in interviews.2 That HIV counseling and testing is more effective in reducing sexual risk behavior when both members of a couple participate is supported by research in other countries, including Rwanda and the Democratic Republic of the Congo (formerly Zaire).3
"In Tanzania, counselors working with couples said their job was more time- consuming and emotionally challenging," says Dr. Gloria Sangiwa, an FHI expert on HIV/AIDS care and support services and a member of the group that conducted the multicenter VCT study. This was especially true if a couple was HIV-serodiscordant (one individual was infected while the other was not). "Even so, HIV-infected people who were willing to share their results subsequently tried harder to protect their partners from infection," she says. "When both individuals were HIV-negative, couple counseling was still beneficial because it brought people together to make and follow decisions to protect their reproductive health."
In contrast, counselors from the multicenter VCT study reported that it was challenging to facilitate partner notification while working with individuals. Lacking a safe, counselor-mediated environment in which to talk to their sexual partners, these individuals often anticipated difficulties disclosing their HIV status. In Tanzania, only 27 percent of HIV-infected female VCT clients had shared test results with their partners six months after testing.4 Reported disclosure rates have been even lower in HIV perinatal transmission trials in Tanzania and Burkina Faso.5
"HIV-infected people who were willing to share their results subsequently tried harder to protect their partners from infection."
In a 1999 study based on interviews with 17 individual men, 15 individual women, and 15 couples from Dar es Salaam, Tanzania, women reported that the greatest barriers to HIV testing and test disclosure were decision-making and communication between partners, partners' attitudes towards HIV testing, and the fear of partners' reactions. For some women who chose to disclose their HIV-positive status, negative reactions — particularly abandonment — were a nagging fear that soon became reality. "I used to tell him, 'Let's go for testing together,' " said a 29-year-old HIV-positive woman. "But he refused. The day I came for testing I didn't tell him. It took two weeks to tell him. He had decided we get separated but I think it is because of that disease. He wants us to leave each other and me to go away to die." The couple subsequently separated.6
In contrast, many of the 28 individuals who had enrolled as couples in the Tanzanian component of the multicenter VCT trial said in interviews that they valued knowing whether they were infected with HIV. The knowledge enabled them to learn to live with their condition or that of their partner. In one HIV-serodiscordant couple, the HIV-positive husband admitted that knowing his condition had "created some chaos" at first, but "after a while we realized that it was better this way, to understand ... in other words, for her to know and me to know in what situation we are in." Most participants felt that counseling had either not harmed or had benefited their relationships.7 "There were frequent reports of increased harmony and fewer incidences of violence in the relationship, greater mutual understanding, better coping skills, and knowledge of how to live with the results and how to protect each other," says Dr. Sangiwa.
Policy implications
"After a while we realized that it was better this way, to understand ... in other words, for her to know and me to know in what situation we are in."
Researchers who have studied the effectiveness of VCT services generally recommend that:
VCT programs recruit couples or partners of individuals who come for HIV testing services. Testing both partners may facilitate disclosure of test results and foster a sense of shared responsibility to reduce the risk of HIV infection.
Counseling sessions address sexual communication and decision-making, stigmatization of HIV-positive partners, and negative reactions leading to violence.8
Counselors be specifically trained to conduct couple counseling. "In most settings, they should
receive one to four weeks of initial counseling training with special emphasis on couple counseling," says Dr. Sangiwa, "and this training should be reinforced every six months. Counselors must also be trained to encourage the disclosure of HIV test results between sexual partners. Most VCT counselors feel they need more skills in this area."
Provision of additional support and counseling services to couples, particularly serodiscordant couples with an HIV-positive female partner, be encouraged.9
VCT counselors be attentive to youth. "In some settings, about a third of people coming for VCT services are younger than 24 years old because youth increasingly want to know their HIV status at the beginning of a relationship," says Dr. Sangiwa. "Given this trend, VCT counselors must be youth-friendly, keeping in mind that dealing with youth is different than dealing with adult married couples."
— Kim Best
References
The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. Lancet 2000;356(9224):103-12.
Grinstead O, van der Straten A, The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Counsellors' perspectives on the experience of providing HIV counseling in Kenya and Tanzania: the Voluntary HIV-1 Counseling and Testing Efficacy Study. AIDS Care 2000;12(5):625-42; Grinstead O, van der Straten A, Sangiwa G, et al. Confidentiality and couple HIV counseling encourage client disclosure of serostatus and risk behavior. Results from the Voluntary HIV Counseling and Testing Efficacy Study. The XIIth International AIDS Conference, Geneva, Switzerland, June 28-July 3, 1998.
Kamenga M, Ryder RW, Jingu M, et al. Evidence of marked sexual behaviour 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; Allen S, Tice J, Van de Perre P, et al. Effect of serotesting with counseling on condom use and seroconversion among HIV discordant couples in Africa. BMJ 1992;304(6842):1605-9.
Maman S, Mbwambo J, Hogan N, et al. Women's barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counselling and testing. AIDS Care 2001;13(5):595-603.
Antelman G, Daaya S, Mbwambo J, et al. Factors related to disclosure of an HIV-positive test result to a sexual partner or any other confidant in Dar es Salaam, Tanzania. Conference on Global Strategies for Prevention of HIV Transmission for Mothers to Infants, Montreal, September 1-5, 1999; Kilewo C, Massawe A, Lyamuya E, et al. HIV testing of pregnant women in sub-Saharan Africa: the PETRA experience in Dar es Salaam, Tanzania. Poster Presentation at the XIth International Conference on AIDS and STDs in Africa, Lusaka, Zambia, September 12-16, 1999; Nebie Y, Meda N, Leroy V, 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 Hum Retrovirol 2001;28(4):367-72.
Maman.
Sangiwa MG, van der Straten A, Grinstead O, et al. Clients' perspective of the role of voluntary counseling and testing in HIV/AIDS prevention and care in Dar Es Salaam, Tanzania: the Voluntary Counseling and Testing Efficacy Study. AIDS and Behavior 2000;4(1):35-48.
Van der Straten A, King R, Grinstead O. Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. AIDS 1995;9(8):935-44.
Grinstead O, Gregorich S, Choi K-H, et al. Positive and negative life events after counseling and testing: the Voluntary HIV-1 Counseling and Testing Efficacy Study. AIDS 2001;15(8):1045-52.
