* Any views expressed in this opinion piece are those of the author and not of Thomson Reuters Foundation.
An aura of silence hovers over the room as a few men and 17 women sit on benches patiently waiting to be registered at the antenatal clinic in Mukongoro Health centre, Uganda.
The nurse comes in and announces that all women who have come with their husbands should sit on the front bench. The women who are without their partners should go home until these men come back with them for HIV counselling and testing.
A plea by one of the mothers to be tested because she had a fever fell on deaf ears. The women without husbands or male partners present stood up and left the antenatal clinic quietly.
Among the pregnant women who leaves is Sarah*, 36, of Achumia village in Mukongoro subcounty, Kumi District. Her husband Robert* did not accompany her to the health facility for HIV counseling and testing.
When Sarah returned home and told her husband what had happened, he reacted angrily, accusing her of sleeping around with men.
“He undressed me, eventually pushing his fingers into my vagina, ostensibly to check whether I had slept with another man. In the process, he inflicted severe injuries and I started bleeding profusely. I rushed back to the health facility for urgent treatment,” Sarah said.
Fortunately, the injuries did not affect Sarah's fetus and she was given medication to treat the injuries and stop bacterial infection.
Testing for HIV in antenatal facilities
In Uganda, HIV testing at antenatal health facilities is routinely offered to pregnant women, although usually many do not agree to it unless they have consent from their husbands or partners.
Women are often fearful of men’s reactions, if they discover they are living with HIV. One woman at the clinic said: “My husband is the one to allow me to test. If I do without his consent, he can easily beat me or send me away from his home.”
In 2006, a policy for couple HIV counseling and testing was introduced in Uganda, urging pregnant women and their spouses to be HIV tested together during antenatal care.
Most antenatal clinics in Uganda therefore request that pregnant women attend with their husbands, to try and persuade both to have HIV counselling and testing. If the woman tests positive it also helps to get both partners involved in treatment to prevent transmission of HIV to their baby.
However, the situation is complex and men often refuse to accompany their wives for testing for a number of reasons, including stigma and the need for men to seem strong and not seek treatment, particularly in an antenatal care setting which is perceived as a woman's domain. Another main driver is wishing to avoid marital conflict, particularly if one partner is diagnosed with HIV while the other is not.
Dr Charles Okadi, district health officer in Soroti, said: “There is low male partner involvement in antenatal care and couple voluntary counselling and testing in elimination of mother-to-child transmission programmes in Soroti district. This is deemed to be one of the major factors responsible for women’s failure to embrace services offered in programmes such as HIV testing, using safe infant feeding options, delivery under skilled care and adherence to drugs given to her including antiretrovirals.”
The important role of men
Reaching out to men, to help them understand why they should support their wives and participate in testing is crucial. Agnes Auca, coordinator for elimination of mother to child transmission of HIV at The Aids Support Organisation, said: “Men are expected to play important roles of supporting and escorting HIV-positive pregnant women to the antenatal clinics for proper check-up, treatment of opportunistic infections and later safe delivery from skilled medical birth attendants.”
Clearly HIV service providers require male involvement for testing because they see this as good for the success of treating mothers with HIV, and for the good of men`s own health.
Fortunately for Sarah, her husband eventually agreed to accompany her to the antenatal clinic. But her experience shows the dilemma placed on many women by the government's policy, and those who can't persuade their partners to accompany them are left in a very difficult position.
Some women are forced into ‘hiring’ other men to accompany them. For example, motorbike taxi drivers, commonly known as boda boda riders, who take them to the clinics or male relatives who pose as their husbands so that the women can be tested.
Albert*, a boda boda rider from Soroti, who was once ‘hired’ by one pregnant woman, said: “Since I already know my HIV status, I am no longer scared, and after all, the woman hiring me will pay me for my services as I will miss my work in order to accompany her.”
Policy is more hindrance than help
Although it's good to encourage men to be responsible partners, and pregnancy should not be viewed as a woman’s affair alone, Uganda's policy provokes some important questions that need answering. Does the current healthcare approach allow women an opportunity to exercise their right in decision making on whether they should take a test or not? Is the woman’s consent sought about whether she is comfortable with being tested with her partner?
If there is any doubt about the answer to these questions it may be high time the effectiveness of the current practice is reviewed.
*Name changed to protect identity
James Odong lives in Uganda and is a member of Key Correspondents, a citizen journalism network reporting for action on HIV. The network is supported by the International HIV/AIDS Alliance
