In an HIV-endemic setting, a large proportion of women (41%) and men (32%) with recent (partner) pregnancy did not know their partner’s HIV serostatus. Just 4% of 2344 women and 13% of 255 men who met age and pregnancy criteria knew that they were in a serodiscordant relationship prior to pregnancy. HIV prevalence for adults aged 15–49 years in KwaZulu-Natal is estimated at 28%  and the prevalence of serodiscordant couples is likely between 20 and 30% [3, 4]. Thus, our data are unlikely to reflect low prevalence of serodiscordant couples, rather they indicate the low prevalence of HIV serostatus disclosure and/or knowledge of personal HIV status. HIV prevention strategies targeting HIV-serodiscordant couples, such as early ART or PrEP, may have limited impact in South Africa without innovative solutions to increase testing and mutual disclosure between sexual partners.
Disclosure is a complex process affected by fear of stigma and discrimination [23–25], level of engagement with HIV care [26, 27], concepts of masculinity , communication within the relationship , and pregnancy itself [23, 28, 30]. Although mutual disclosure can facilitate informed decision-making and safer sex practices [26, 27], non-disclosure to sexual partners is common in South Africa [24, 26, 27, 31]. Moreover, knowledge of HIV serostatus – a first step towards serostatus disclosure – remains inadequate, especially among men [22, 32]. In our sample, 29% of HIV-positive men and 47% of HIV-positive women reporting HIV-negative partners were unaware of their own status prior to the referent pregnancy. Evidence suggests that stigma and negative attitudes towards HIV counseling and testing (HCT), as well as the physical spaces in which this is offered, continue to influence poor uptake [33–35].
To address this problem, current national [36, 37] and international  guidelines advocate couples-based HIV counseling and testing (CHCT). This has been associated with increased disclosure to sexual partners, enhanced adherence to interventions to reduce perinatal HIV transmission, and reductions in sexual risk behavior . Yet little published data exists on CHCT in South Africa [24, 30, 39]. In a Western Cape study to promote CHCT in an ANC setting, 35% of men whose pregnant partners were given invitations for them to attend completed HCT, versus 11% of men whose partners received pregnancy education alone . A behavioral intervention for pregnant women and their partners in Mpumalanga (Partnersplus) resulted in a small increase in male HIV testing and disclosure . Anecdotal evidence suggests that some South African men and women use CHCT as a means of disclosure [34, 39]; however, access to and uptake of CHCT services nationally is undetermined.
Further research into CHCT is of great importance in South Africa. However, limited recruitment for couples-based interventions may forecast challenges to more widespread implementation of CHCT in South Africa: 40% of screened pregnant women could not recruit partners to the Partnersplus project , (D. Jones, personal communication, May 2013) and the Project Accept team screened more than three times the number of index individuals in order to interview 20 couples . In our study, among 248 enrolled women, only one recruited her male partner. A ‘couple-oriented’ approach to HCT , which includes counseling on strategies for disclosure and to encourage partner HCT, may therefore be an important alternative in this context. This approach has demonstrated success in a recent multisite study (including one site in sub-Saharan Africa) but awaits further exploration in South Africa .
Although HIV prevention interventions for pregnant couples target perinatal rather than periconception transmission, their relative successes demonstrate that the desire for a healthy child can act as a powerful lever for HIV prevention. Incorporating messages on testing and mutual disclosure into PMTCT education may reduce periconception HIV transmission by moving the HIV prevention time frame ‘for a healthy baby’ up to pre-conception.
Our data suggest a high level of periconception HIV risk behavior among known HIV-positive individuals: of participants who met age and pregnancy criteria, 38% of men and 11% of women knew they were HIV-positive prior to pregnancy with an at-risk partner (pooled results for those reporting HIV-negative or unknown serostatus partners). While we do not dispute the right of these individuals to have children, many of these pregnancies were likely unintended [44–47]. There is a clear need for safer conception programs for those who choose to conceive and improved access to contraception for those who do not want to conceive .
These screening data represent a large sample of women and men in an HIV-endemic area with recent pregnancy. Limitations to interpretation include social desirability bias: men and women who knew their HIV status prior to pregnancy may have been reluctant to report this given counseling messages that persons living with HIV should not have sex without condoms; individuals may also have been reluctant to report partner serostatus. In addition, serodiscordance status is based on the report from just one partner. While most women were pregnant at time of screening, men were asked to reflect on a partner pregnancy in the past three years, thus recall bias may have affected responses. Additionally, since limited partner recruitment required us to enroll men from ARV clinic, male and female participants likely had very different experiences of HIV, with men more likely than women to be HIV-infected, and if so, to be engaged with treatment and support. Our screening tool stopped when any inclusion criterion was not met, thus the data are incomplete for the full sample of screened individuals.