BackgroundA large proportion of the 2.5 million new adult HIV infections that occurred worldwide in 2007 were in stable couples. Feasible and acceptable strategies to improve HIV prevention in a conjugal context are scarce. In the preparatory phase of the ANRS 12127 Prenahtest multi-site HIV prevention trial, we assessed the acceptability of couple-oriented post-test HIV counseling (COC) and men's involvement within prenatal care services, among pregnant women, male partners and health care workers in Cameroon, Dominican Republic, Georgia and India.MethodsQuantitative and qualitative research methods were used: direct observations of health services; in-depth interviews with women, men and health care workers; monitoring of the COC intervention and exit interviews with COC participants.ResultsIn-depth interviews conducted with 92 key informants across the four sites indicated that men rarely participated in antenatal care (ANC) services, mainly because these are traditionally and programmatically a woman's domain. However men's involvement was reported to be acceptable and needed in order to improve ANC and HIV prevention services. COC was considered by the respondents to be a feasible and acceptable strategy to actively encourage men to participate in prenatal HIV counseling and testing and overall in reproductive health services.ConclusionsOne of the keys to men's involvement within prenatal HIV counseling and testing is the better understanding of couple relationships, attitudes and communication patterns between men and women, in terms of HIV and sexual and reproductive health; this conjugal context should be taken into account in the provision of quality prenatal HIV counseling, which aims at integrated PMTCT and primary prevention of HIV.

Background: Over the last 20 years, community health workers (CHWs) have become a mainstay of human resources for health in many low- and middle-income countries (LMICs). A large body of research chronicles CHWs’ experience of their work. In this study we focus on 2 narratives that stand out in the literature. The first is the idea that social, economic and health system contexts intersect to undermine CHWs’ experience of their work, and that a key factor underpinning this experience is that LMIC health systems tend to view CHWs as just an ‘extra pair of hands’ to be called upon to provide ‘technical fixes.’ In this study we show the dynamic and evolving nature of CHW programmes and CHW identities and the need, therefore, for new understandings. Methods: A qualitative case study was carried out of the Indian CHW program (CHWs are called accredited social health activists: ASHAs). It aimed to answer the research question: How do ASHAs experience being CHWs, and what shapes their experience and performance? In depth interviews were conducted with 32 purposively selected ASHAs and key informants. Analysis was focused on interpreting and on developing analytical accounts of ASHAs’ experiences of being CHWs; it was iterative and occurred throughout the research. Interviews were transcribed verbatim and transcripts were analysed using a framework approach (with Nvivo 11). Results: CHWs resent being treated as just another pair of hands at the beck and call of formal health workers. The experience of being a CHW is evolving, and many are accumulating substantial social capital over time – emerging as influential social actors in the communities they serve. CHWs are covertly and overtly acting to subvert the structural forces that undermine their performance and work experience. Conclusion: CHWs have the potential to be influential actors in the communities they serve and in frontline health services. Health systems and health researchers need to be cognizant of and consciously engage with this emerging global social dynamic around CHWs. Such an approach can help guide the development of optimal strategies to support CHWs to fulfil their role in achieving health and social development goals.

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Since the beginning of the HIV/AIDS epidemic in India, pregnant women attending antenatal clinics (ANC) have been considered as a low HIV risk population. Yet, a substantial proportion of new HIV infections are occurring among stable heterosexual couples. This paper sought to investigate the proportion and profile of women who, within the low-risk population, are potentially at higher risk of HIV infection. HIV risk perception of pregnant women enrolled within the ANRS 12127 Prenahtest trial was described and associated socio-behavioral characteristics, husband's characteristics, and HIV-related characteristics were analyzed using univariate and multivariate logistic regression models. Among 484 women enrolled, baseline data were collected for 479 women and 460 women with completed data were considered for the present analysis (96%). Eighty-nine (19.4%) women perceived themselves at risk of HIV. Women with educational level <11years (Adjusted Odds Ratio, AOR = 2.4 [CI = 1.28-4.53]), who stayed in joint families (AOR = 1.89 [CI = 1.12-3.12]), who had experienced insult or hurt from the partner (AOR = 1.91 [CI = 1.11-3.27]) and whose partner were alcoholic (AOR = 2.19 [CI = 1.31-3.66]) were significantly more likely to perceive themselves at risk of HIV. Women who had heard about sexually transmitted infections were also more likely to report HIV risk perception (AOR = 3.36 [CI = 1.83-6.18]). Substantial proportion of women (one out of five) perceived themselves at risk of HIV and most of these have reported some form of vulnerability in their couple relationship such as intimate partner violence, alcoholic partner, lack of communication, and spaces for communication with partner. Though awareness and knowledge is the first step for prevention, considering the vulnerabilities associated with HIV risk perception, HIV prevention interventions in India should target overall sources of vulnerability to HIV. Targeted risk reduction for women in ANC should be considered for primary HIV prevention among couples.

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