Objective To find out why pregnant women who receive HIV-1 positive test results and are offered short course antiretroviral prophylaxis to prevent transmission of HIV from mother to child do not participate in necessary follow up visits before starting prophylaxis.

Many HIV-1-seropositive women in Africa who are offered antiretroviral prophylaxis to prevent mother-to-child transmission (MTCT) of HIV do not begin interventions. Research on barriers to participation has not addressed the possible effects of women's sociocultural and economic circumstances. We examined these factors at an MTCT prevention programme in Abidjan, Cote d'Ivoire. We interviewed two groups of women after they had received HIV-positive test results and had been invited by the programme staff to return for monthly follow-up visits before beginning short-course zidovudine prophylaxis. Participants (n = 30) completed follow-up visits and prophylaxis. Non-participants (n = 27) refused or discontinued follow-up visits and did not begin zidovudine. Fewer non-participants had been born in Cote d'Ivoire (67% vs. 97%) or were Ivorian nationals (48% vs. 77%); they had lived in the country for less time (21 vs. 26 median years). They were less likely to be French-literate (37% vs. 77%), and more of them reported having had Koranic education only (18% vs. 0). They more often reported miscarriages, stillbirths, or infant deaths (69% vs. 33%), and had partners with low-ranked jobs (63% vs. 30%). Our findings suggest that the non-participants were more marginal socioculturally and economically in Ivorian society than participants. Greater attention to mitigating the effects of broader structural factors on women's participation in interventions may increase the effectiveness of MTCT prevention in Africa.

A cross-sectional study was carried out at a programme to prevent mother-to-child transmission of HIV (MTCT) at a public antenatal clinic in Abidjan, Côte d'Ivoire. The objectives were to obtain information from women concerning their reactions to HIV test results received through the programme, their experiences with faithfulness to partners as a means of primary HIV prevention for themselves and their infants, their relationships with partners, their own and their partners' experiences with HIV testing, and their knowledge of their partners' HIV serostatus. The participants were a purposive sample of 87 women who had received HIV-1-positive test results and 30 women who had received HIV-1-negative test results through the clinic's programme. Eighty-five per cent of the HIV-positive women were surprised by their test result; 52% of those who tested HIV-negative anticipated that result. Nearly two-thirds of those who were surprised to be HIV-positive and a similar proportion of those who expected to be HIV-negative explained their reactions by referring to faithfulness to their partners. Only five of the 117 women interviewed expressed a belief that their partners were faithful to them; and only two, and none of those who received an HIV-positive test result, reported using condoms with partners. No more than one-fourth of either the HIV-positive or the HIV-negative groups of women had been previously tested for HIV; less than one-fourth of the women in each group reported having partners who had been tested for HIV, or knew their partners' serostatus. Relationship characteristics of some HIV-positive women may have increased their vulnerability to HIV infection. Although being faithful to partners can be effective for the primary prevention of HIV infection, the manner in which it was practiced by many of the women in our study may have further increased their risk of infection. Organisations that choose to fund HIV prevention programmes that promote faithfulness to partners, and the programmes that stress faithfulness, must ensure that women are informed about the conditions that can influence the effectiveness of faithfulness as a protective action. However, women need more than information. Prevention programmes, whether concerned primarily with prevention of MTCT or with HIV prevention more broadly, must promote and elicit cooperation from women's sexual partners to support women's efforts to be tested for HIV, to be tested for HIV themselves, to disclose their test results, to reciprocate women's faithfulness and, if HIV serodiscordant or unwilling to be faithful, to use condoms. These steps may increase the likelihood that women will be able to protect themselves and their infants from HIV infection by being faithful to their partners.

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