Most HIV infections in sub-Saharan Africa are transmitted by heterosexual sex. The authors analyzed data from the Demographic and Health Surveys in Zambia and Rwanda, and from couples (married, cohabiting, and non-cohabiting) attending a voluntary counseling and testing service. They report that 55 to 93 percent of new, heterosexually acquired HIV infections among adults occurred within serodiscordant marital or cohabiting relationships. The authors calculate that an intervention for discordant couples that reduces transmission from 20 to 7 percent per year could prevent 36 to 60 percent of new HIV infections.

The authors review published studies of HIV discordant couples to examine the factors that allow some individuals to remain uninfected despite repeated exposure to HIV. Factors associated with increased likelihood of transmission include sexually transmitted infections (STIs), particularly genital ulcerative diseases; high HIV viral load; non-use or inconsistent use of condoms; and specific sexual practices, such as a high number of sexual partners and higher frequency of sexual contact. Concurrent sexual partnership may also contribute to risk. Study of long-term discordant couples could help researchers better understand immunity, and these couples could also be valuable as research participants in HIV vaccine and prevention trials. The authors recommend targeted interventions to identify acute infections, diagnose and treat STIs, and promote condom use in non-monogamous couples.

The researchers evaluated the impact of a home-based HIV counseling and testing (HCT) program to identify the HIV status of the partners and family members of index individuals living with HIV. Of 6,300 clients of a clinic in Jinja, Uganda, living with HIV, 811 (13 percent) were in discordant relationships. Scaled-up HCT identified close to half (49 percent) of these couples during the three-month study. Among the serodiscordant couples, 43 percent were in polygamous relationships, and roughly 40 percent were illiterate. The authors conclude that there is an urgent need for “increased access to serodiscordant couples counseling and support services, including polygamous discordant couples.”

Couple-centered HIV voluntary counseling and testing programs have not been widely implemented. Published research on serodiscordant, heterosexual couples in sub-Saharan Africa shows that couple-centered counseling led many infected partners to disclose their HIV status to their partner; decreased partner violence against women who disclosed their HIV status to male partners; and increased condom use. Low client participation is an ongoing challenge. However, promotion of couple-oriented services by the media and home-based visits from trained community health workers appear to be effective. The authors suggest that more programs and research with couple-centered HIV counseling programs could enhance HIV prevention outcomes.

Couples voluntary counseling and testing (CVCT) is an effective strategy to prevent new HIV infections in cohabiting heterosexual couples. However, sustaining efforts to encourage couples testing is a challenge. One promising approach utilizes Influence Network Agents (INAs) from health, religious, non-governmental, and private sectors to invite couples for CVCT. Fourteen percent of couples who received invitations from INAs requested CVCT. Invitations were most successful when delivered in an INA’s home, to both partners, or to someone known to the INA. Obstacles included limited time and money for transportation. Provision of home-based testing might improve uptake.

The Home-Based AIDS Care Project offers home-based antiretroviral therapy care to HIV-positive patients in rural Uganda. Prevention counseling and home-based voluntary counseling and testing to all household members of positive patients are also provided. In individual sessions, participants develop personal sexual behavior plans. Overall there was a 70 percent reduction in reported risky sex (over 85 percent of risky sexual acts occurred within married couples). The authors estimate a 98 percent reduction in the number of seroconversions after six months. The study supports the incorporation of prevention activities into antiretroviral programs.

This study reports on a group-based intervention (adapted from an urban US context) for women living with HIV and their HIV-negative male partners in Zambia. Females attended four group intervention sessions on sexual behavior skills training. Their male partners attended either a single session or a four-session gender concordant intervention. Both men and women reported increased and sustained condom use following the intervention. Women with partners who attended the four-session intervention reported higher rates of condom use, more positive condom attitudes, safer sex intentions, and less alcohol use. The findings highlight the advantage of including both male and female partners to influence the sexual dynamics of a relationship and increase prevention behaviors.

The impact of joint voluntary counseling and testing (VCT) was assessed among 963 cohabiting, heterosexual, HIV-discordant couples. Discordant couples reported a marked increase in condom use after joint VCT, and maintained this reduction for at least a year. Almost one-quarter of discordant couples reported perfect condom use. Most couples reported occasional lapses, but only 10 percent reported unprotected sex at each follow-up visit. However, biological markers indicated significant underreporting of unprotected sex; in half of the instances in which sperm were detected and nearly one-third of pregnancies, couples had reported always using condoms. The authors recommend that biological markers should be used in addition to behavioral changes to assess program efficacy.

The husbands and male cohabiting partners of 684 Rwandan women were recruited to participate in an HIV testing and a male-focused counseling program. All of the women and 256 of the men (37 percent) had previously received standard HIV testing and basic counseling services. Reported condom use increased dramatically for serodiscordant couples participating in the program after 12 months. The effect was especially strong for couples in which the male partner received HIV testing and counseling for the first time. Reported condom use also increased among couples in which both partners had been previously tested and counseled.