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Combination Approaches: HIV Prevention for Serodiscordant Couples
I. Definition of the Prevention Area
HIV-serodiscordant couples, in which one partner is HIV-positive and the other is HIV-negative, are now recognized as a priority for HIV prevention interventions.
II. Epidemiological Justification for the Prevention Area
Although there is considerable variation across countries, recent studies in sub-Saharan Africa with mature epidemics show that up to two-thirds of infected couples are discordant. These studies seek to assess the extent to which HIV transmission within marriages was spurred by high infection rates in sub-Saharan Africa due to heterosexual transmission. One analysis estimated that 55 to 92 percent of new, heterosexually acquired HIV infections among adults occurred within serodiscordant marital or cohabiting relationships. Additionally, among discordant couples, only the female partner is infected in 30 to 40 percent of cases, dispelling a common misperception that only men, not women, are the HIV-positive partner.
According to a research review, the following factors make it more likely that a person living with HIV will transmit the virus to his or her partner: the presence of other sexually transmitted infections, particularly genital ulcerative diseases; high viral load; failure to use condoms correctly and consistently; 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. The risk of transmission is especially high during early infection, when it is estimated to be 26 times more infectious than during later stages of infection. This makes it especially important to identify HIV infection during the acute stage.
Prevention responses also need to take into account the progress of the epidemic. One hypothesis is that in early epidemics, most discordant couples arise due to HIV infection of one partner from a preexisting relationship, whereas in more mature epidemics, a greater proportion of discordant couples initiate relationships with a new partner who is already infected.
III. Core Programmatic Components
HIV prevention programs among discordant couples are traditionally based on three types of interventions: 1) couples HIV voluntary counseling and testing—via both community-based outreach and in antenatal clinics, 2) group-based workshops with serodiscordant couples, and 3) integrated antiretroviral therapy and HIV prevention programs. These programs often include risk reduction counseling, referrals to treatment, counseling on family planning, and an avenue to further care and support services.
Couples HIV counseling and testing is the cornerstone of many discordant couple interventions; it remains the only way to identify couples in which one partner is HIV-positive and one is HIV-negative. New and innovative methods are being developed to increase uptake of couples counseling and testing as many individuals and couples do not know their status. To increase HIV testing among couples, couples testing programs will likely require integration with broader HIV programs including care, treatment, and support services; mother-to-child-transmission programs; male circumcision; condom promotion; partner reduction; and other behavior change interventions.
Effective prevention programming is necessary for serodiscordant couples, targeted both to the couple and to the individuals. One study showed that the HIV-negative partner increased their number of outside sexual partners after learning the HIV-positive status of their partner. Campbell et al. confirms this result, showing that about 27 percent of seroconverters in serodiscordant couples in the study were infected by an outside partner.
New advances in the biomedical field have demonstrated success in reducing HIV transmission among discordant couples, namely pre-exposure prophylaxis and antiretroviral therapy as prevention. These prevention methods are still under development, and their real-life applicability is currently being reviewed, but they could prove to be valuable prevention methods in the future.
IV. Current Status of Implementation Experience
Programs in developing countries aimed at reducing transmission of HIV in discordant couples are too new to evaluate for effectiveness. To date, interventions have largely been conducted within structured research protocols, so it is still uncertain whether the efficacy of such interventions will work in real-life settings, and whether such interventions can be scaled up to achieve sufficient reach to reduce overall rates of HIV transmission.
Increased Risk of HIV-1 Transmission in Pregnancy: A Prospective Study among African HIV-1-Serodiscordant Couples
Mugo, N. R., Heffron, R., Donnell, D., et al. AIDS (2011), Vol. 25 No. 15, pp. 1887–1895.
The secondary data analysis study explored how pregnancy in serodiscordant couples affected HIV-1 acquisition in women and HIV-1 transmission from women to men. Data from 3,321 African couples in seven countries who were enrolled in the Partners in Prevention HSV/HIV Transmission Study, a study that tested the effect of acyclovir herpes simplex virus type 2 suppressive therapy for the prevention of HIV transmission, was utilized. Multivariate Cox proportional hazard analysis was performed to control for any demographic, clinical, or behavioral factors. During the study period, 151 individuals seroconverted (with 61 infections occurring among women and 90 occurring among men) and there were a total of 823 pregnancies. Couples who became pregnant were younger and more likely to report unprotected sex during pregnancy. About 28 percent of women who HIV-1 seroconverted during the study were pregnant. The incidence of HIV-1 during pregnancy was 7.35 per 100 person-years compared to 3.01 per 100 person-years during nonpregnancy, but was not found to be statistically significant in multivariate analysis. About 21 percent of men who HIV-1 seroconverted during the study period did so while their partner was pregnant. The incidence of female-to-male HIV-1 transmission was 3.46 per 100 person-years during pregnancy compared to 1.58 per 100 person-years when the partner was not pregnant, and was statistically significant after multivariate analysis. In conclusion, there is an increased risk of HIV acquisition among HIV-negative women and increased risk of HIV transmission to men during pregnancy, which calls for more emphasis on risk reduction counseling, family planning, and early initiation of antiretroviral therapy during pregnancy among discordant couples.
Prevention of HIV-1 Infection with Early Antiretroviral Therapy
Cohen, M. S., Chen, Y. Q., McCauley, M., et al. New England Journal of Medicine (2011), Vol. 365 No. 6, pp. 493–505.
This article reports expanded demographic and clinical information from the HIV Prevention Trials Network 052 trial, whose interim findings, released on April 28, revealed a 96 percent reduction in the risk of HIV transmission among participants with a CD4 count between 350 and 550 cells per cubic millimeter (cells/mm³) who received antiretroviral therapy (ART) immediately upon entering the trial. Over half of the participating serodiscordant couples (54 percent, or 954 couples) came from Africa, 531 couples from Asia, and 278 couples from the Americas; 50 percent of the infected partners were men. Enrollees were randomized to receive ART immediately upon testing positive or to delay therapy until their CD4 counts dropped below 250 cells/mm³ or they acquired an AIDS-related illness. Of the total of 39 HIV transmission events, 35 occurred among participants in the delayed arm (with 82 percent occurring among African couples). A total of 61 percent of the 28 “linked” events (in which HIV transmission was directly linked to the infected study partner) occurred among individuals whose partner had a CD4 count greater than 350 cells/mm³, and 64 percent of the HIV transmissions were from female to male partners. Individuals in the immediate treatment arm experienced a 41 percent lower risk of experiencing a clinical event, such as tuberculosis, compared to those in the delayed arm. According to the authors, the most likely mechanism in preventing HIV-1 transmission was sustained suppression of HIV-1 in genital secretions—the result of ART. The authors found that early initiation of ART has clinical benefits for both HIV-1–infected individuals and their uninfected partners, and therefore must be rolled out as a prevention strategy to reduce the spread of HIV-1 infection.
HIV-1 Transmission among HIV-1 Discordant Couples Before and After the Introduction of Antiretroviral Therapy
Reynolds, S., Makumbi, F., Nakigozi, G., et al. AIDS (2011), Vol. 25 No. 4, pp. 473–477.
The observational cohort study examined the relationship between HIV-1 seroconvertion before and after antiretroviral therapy (ART). Discordant couples were indentified through the annual Rakai Community Cohort study and used data from 2004 to 2009 surveys. In 2004, all HIV-positive Rakai residents were offered free ART if their CD4 counts were at or below 250 cells/mL or were at stage IV disease as defined by the World Health Organization. HIV incidence and risk behaviors of the uninfected partners were retrospectively compared with when their partner started ART. During the 2004 to 2009 time period, 250 discordant couples were identified, of whom 32 met the criteria for initiation of ART. In 58 percent of the couples, the male was the HIV-positive index partner. It was found that before the initiation of ART, the transmission rate was 9.2/100 person-years (95 percent confidence interval, 6.59–12.36). There were no HIV-1 transmissions among the couples who started ART. There were no statistically significant differences between the two groups (ART versus non-ART). Consistent condom use with any partner increased from about 14 percent prior to ART compared to about 54 percent after ART and was statistically significant. Viral loads were found to be high. At 6 months, the majority (71.4 percent) had viral loads below 400 copies/mL. The reduced HIV-1 transmission levels among discordant couples most likely were due to the reduced viral loads of the HIV-positive partner.
Factors Associated with HIV Infection in Married or Cohabitating Couples in Kenya: Results from a Nationally Representative Study.
Kaiser, R., Bunnell, R., Hightower, A., et al. PloS One (2011), Vol. 6 No. 3, p. e17842.
The study explored the differences between HIV-negative couples verses HIV discordant couples, and HIV-positive concordant couples verses HIV discordant couples. Data was from the 2007 nationally representative Kenya AIDS Indicator Survey, which collected self-reported data on variables such as demographics, sexual behaviors, male circumcision, and pervious HIV test. Blood samples were also drawn to test for HIV antibodies, herpes simplex virus type 2 (HSV-2), syphilis, and CD4 counts for those who tested HIV positive. A total of 2,748 couples were in the sample and 9.6 percent were affected by HIV (3.8 percent HIV concordant; 5.8 percent HIV discordant). The woman partner was infected with HIV in about half (48.5 percent) of the couples. For HSV-2, both partners were positive in 30.4 percent of the couples and only one partner was positive in 20.7 percent of couples. Of the HIV-positive individuals who were married or cohabitating, less than half (42.8 percent) had a previous HIV test and only 16.4 percent correctly knew their status. A minority (14.9 percent) of HIV-positive individuals who were in a couple both correctly knew their status and disclosed to their partner. Factors associated with HIV discordance compared to HIV-uninfected concordance were younger age in women, increased number of lifetime partners in women, HSV-2 infection is one or both partners, and lack of male circumcision. Factors associated with HIV concordance compared to HIV discordance were HSV-2 infection in both partners and lack of male circumcision. In conclusion, more emphasis should be placed on prevention programs targeted towards married or cohabiting couples since they are a population at high risk of HIV transmission and acquisition.
Viral Linkage in HIV-1 Seroconverters and Their Partners in an HIV-1 Prevention Clinical Trial
Campbell, M. S., Mullins, J. I., Hughes, J. P. et al. PLoS One (2011), Vol. 6 No. 3, p. e16986.
The study linked the HIV-1 strains within HIV discordant couples when the uninfected partner seroconverted to determine if the infection could be epidemiologically connected to the infected partner. The data was from the Partners in Prevention HSV-2/HIV-1 Transmission Study that enrolled HIV serodiscordant couples from several African countries. A total of 3,408 discordant couples were enrolled in the study, and 155 seroconverted to HIV during the course of the trial identified through HIV-1 serology at site. A total of 151 were confirmed by a positive HIV-1 Western bolt test and included in the analysis. The majority (71.5 percent) of transmissions were linked to the infected partner, 26.5 percent were not linked to the infected partner, and 2 percent could not be determined. Seroconverters were most likely female, had a shorter average time to seroconversion than unlinked pairs (6 months versus 12 months after enrollment), and were identified within the first 3 months of the study visit compared to after 3 months. Reporting sexual activity with the infected partner was higher among those who had linked cases. Unlinked cases reported increased sexual activity with outside partners compared to linked cases, and these unlinked cases were more likely male. It was also found that the HIV-positive partner had higher baseline plasma HIV-1 RNA levels in linked cases versus unlinked cases. The results of the study underscore the necessity of HIV prevention interventions targeted toward serodiscordant couples, and messages should be uniquely tailored to gender and HIV-1 status characteristics.
Serodiscordant Couples in Sub-Saharan Africa: What Do Survey Data Tell Us?
Bishop, M., & Foreit, K. USAID/Health Policy Initiative. (2010).
Recent studies show that new HIV infections are from individuals in serodiscordant couples. Data from 10 Demographic Health Surveys and AIDS Indicator Studies were used in the analysis. Each is a population-based survey, which included biological samples to test for HIV-1 antibodies. A total of 1,107 serodiscordant couples were found in the 10 surveys, and half of the countries had less than 100 couples in its sample. It was found that serodiscordant couples shared similar characteristics to the general population. Serodiscordant couples were found in rural and urban areas, there was no male/female difference in who was the HIV-positive individual in the couple, most have never been tested for HIV and did not know their status, many individuals in serodiscordant couples had low comprehensive knowledge on how to prevent HIV transmission, and most did not use condoms. These trends were similar in the general population. Couples HIV testing and counseling needs to be strengthened to identify serodiscordant couples. Then, more targeted programming needs to be implemented to increase services and programs to promote positive health and reduce risk-taking behaviors. Lastly, policy recommendations and program implications are provided.
HIV Status in Discordant Couples in Sub-Saharan Africa: A Systematic Review and Meta-analysis
Eyawo, O., de Walque, D., Ford, N., et al. Lancet (2010), Vol. 10 No. 11, pp. 770–777.
A systematic review of peer-reviewed and unpublished data as well as a meta-analysis on 14 Demographic Health Surveys was performed to determine the gender balance of the index partner in HIV serodiscordant couples. Only African countries were included in the review and analysis. A total of 19 journal articles and 5 conference abstracts were included in the review as well as unpublished data from two cohorts from a study with The AIDS Support Organization. In the analysis, it was found that about half (47 percent) of the index partners were female. When the female was the HIV-positive partner, they were more likely an urban resident, from a country of a higher latitude (i.e., East Africa), older, from a country with more gender equality, and from a country with a lower HIV prevalence compared to others in the model. Program targeting serodiscordant couples should give equal importance to both male and females in the couples.
Cost-Effectiveness of Couple Counseling to Enhance Infant HIV-1 Prevention
John, F. N., Farguhar, C., Kiarie, J. N., et al. International Journal of STDs and AIDS (2008), Vol. 19 No. 6, pp. 406–409.
The Kenyan study examined the acceptance of couple counseling at prevention of mother-to-child transmission (PMTCT) centers and to assess if couple counseling increased uptake of PMTCT services. The cohort study was conducted from 2001 to 2003 in Nairobi, Kenya, within prenatal clinics. Data on HIV prevalence, uptake of couples voluntary counseling and testing (VCT), acceptance to testing, nevirapine use, personnel costs, and costs of supplies were collected from clinics and from the 2,833 women enrolled. It was found that 15 percent of women were HIV-1 positive. Fourteen percent were counseled as couples, and women who received couple counseling were more likely to receive nevirapine compared to those were counseled individually. Couples VCT had a higher number of women accepting HIV testing compared to the standard option. Couples VCT also resulted in more infections averted and disability-adjusted life years (DALYs) saved compared to the standard option (91 versus 88 infections averted; 2,861 versus 27,772 DALYs saved). Couples VCT was cost-effective, especially in areas of higher HIV prevalence. Increasing men’s involvement in prenatal care is essential to augment HIV testing and improve PMTCT service uptake among women.
HIV-1 Prevention for HIV-1 Serodiscordant Couples
Curran, K., Baeten, J. M., Coates, T. J., et al. Current HIV/AIDS Reports (2012), Vol. 9 No. 2, pp. 160–170.
The review explores the various HIV prevention options within serodiscordant couples. Half to two-thirds of HIV-1– infected adults are in a couple with an uninfected partner; therefore, prevention interventions need to be targeted toward these relationships. The primary service is offering couples HIV testing and counseling (CHTC). Studies have shown that serodiscordant couples who participated in CHTC report increased condom use, uptake of family planning, and uptake of prevention to mother-to-child transmission (PMTCT) services. Antiretroviral therapy for the prevention of HIV is another method to reduce transmission to the uninfected partner, though efficacy is still being explored. Pre-exposure prophylaxis is a prevention option for the HIV-uninfected partner in a serodiscordant couple. The paper also details positive evidence on PMTCT, behavior change interventions, and male circumcision and its challenges. A combination of prevention interventions is necessary.
Outside Sexual Partnerships and Risk of HIV Acquisition for HIV Uninfected Partners in African HIV Serodiscordant Partnerships
Ndase, P., Celum, C., Thomas, K., et al. Journal of Acquired Immune Deficiency Syndromes (2012), Vol. 59 No. 1, pp. 65–71.
A prospective study was conducted to measure the sexual behaviors of HIV-negative individuals in serodiscordant couples. Data was from the Partners in Prevention HSV/HIV Transmission study that was carried out from 2004 to 2008 in seven African countries. The HIV-negative partners completed an interviewer-administered questionnaire on sexual behavior at enrollment and every quarter. Blood samples were also collected to genetically link the HIV subtypes of the HIV-positive partner to the newly infected partner. A total of 3,381 serodiscordant couples were enrolled in the study. Over the two years of follow-up, the number of outside partners among the uninfected individuals in the couple increased from 3.1 percent to 13.9 percent. Those who reported sex with their HIV-positive partner in the month prior to the questionnaire were less likely to have an outside partner. Uninfected partners reported less sexual activity with their infected partner during the two-year follow-up period (73.2 percent to 93.5 percent). There was also an increase of the uninfected partner reporting no sexual activity with the infected partner and an increase of sexual activity with an outside partner during the follow-up period. Condom use was more common among outside partners than with the HIV-positive partner. Of those who HIV seroconverted during the study and reported to have an outside partner, most (86 percent) had an HIV subtype that was distinct from their HIV-positive partner, which indicates that they did not acquire HIV from their primary relationship. Risk-reduction measures adopted by the HIV-negative partner should be taken into account when counseling serodiscordant couples.
What’s Love Got to Do With It? Explaining Adherence to Oral Antiretroviral Pre-Exposure Prophylaxis for HIV-Serodiscordant Couples
Ware, N. C., Wyatt, M. A., Haberer, J. E., et al. Journal of Acquired Immune Deficiency Syndromes (2012), Vol. 59 No. 5, pp. 463–468.
A qualitative study was conducted to identify influences on adherence to pre-exposure prophylaxis (PrEP) from both the HIV-negative partner and -positive partner in serodiscordant couples. Participants who were enrolled in the Partners PrEP study and were from the Kabwohe Clinical Research Centre in rural Uganda were sampled for this study. Forty-five PrEP participants and fifteen of their partners were interviewed. Mean duration of the partnership was 9.8 years, and 80 percent of the couples had children. It was found that there was a dilemma between wanting to continue the relationship but fearing infection, loss of health, and early death when learning of their discordant status. PrEP offered many a means for hope and opportunity in being able to maintain the relationship while staying uninfected. In other couples, tension and anger still persisted after PrEP use, and adherence suffered. The results of the qualitative study suggest that the strength of the relationship has a direct effect on adherence. Participants also preferred to use PrEP over condoms as an HIV prevention method. It is important to understand why couples want to stay together in supporting PrEP adherence.
Optimal Uses of Antiretrovirals for Prevention in HIV-1 Serodiscordant Heterosexual Couples in South Africa: A Modeling Study
Hallett, T. B., Baeten, J. M., Heffron, R., et al. PLoS Medicine (2011), Vol. 8 No. 11, p. e1001123.
The paper describes a modeling study that tested various scenarios on the effectiveness of early initiation of pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for prevention within HIV serodiscordant couples. The model used data from three sites in South Africa that participated in the Partners in Prevention HSV/HIV Transmission Study as well as results from the specific clinical trials on PrEP and ART for prevention. Three analyses were performed: 1) four different PrEP implementation strategies, 2) starting PrEP then discontinuing use when the infected partner begins ART compared to early ART but no PrEP, and 3) various models were tested to determine the optimal combination of PrEP and ART, and cost and efficiency were reviewed as well. It was found that PrEP use at all times, whether or not the infected partner was taking ART, was the most effective out of the four scenarios in reducing transmission. For the second analysis, it was found that both scenarios increased costs and reduced infections. For the third analysis, when PrEP and ART were available, it would be most effective for higher-risk couples to offer PrEP to the uninfected partner before the infected partner started ART. For lower-risk couples, early initiation of ART would be the most cost-effective. In conclusion, PrEP and ART could be reliable combination prevention strategies to reduce transmission and acquisition for serodiscordant couples.
Knowledge and Attitudes about Male Circumcision for HIV-1 Prevention among Heterosexual HIV-1 Serodiscordant Partnerships in Kampala, Uganda
Mugwanya, K. K., Baeten, J. M., Nakku-Joloba, E., et al. AIDS Behavior (2010), Vol. 14 No. 5, pp. 1190–1197.
The paper examined serodiscordant couple’s knowledge, attitudes, and understanding of male circumcision, as they are a high-risk group for HIV transmission and acquisition. Couples were recruited at a research clinic in Kampala, Uganda, for this cross-sectional study. A standardized gender-specific questionnaire was administered to each partner separately, medical records were reviewed to know their HIV serostatus, and an examination was performed to determine if the male was circumcised. The final sample size in the study was 318 couples. The majority of men were not circumcised (67.2 percent). Both men and women had a high knowledge of the protective ability of male circumcision. The majority had heard a health information message stating the benefits of male circumcision to HIV-negative men. Over 90 percent of participants had a favorable attitude about male circumcision as an HIV prevention strategy. About half (53 percent) of uninfected males expressed interest in undergoing male circumcision, while the majority (88 percent) of their female partners wished that they undergo the procedure. Uninfected males were more interested in undergoing male circumcision if they had discussed the procedure with their female partners and were knowledgeable on the positive benefits of male circumcision, compared to those who did not discuss it with their partners and were not knowledgeable. The main motivators to get circumcised were to prevent sexually transmitted infections/HIV infection and hygiene benefits. Barriers included cost of the procedure, being absent from work, fear of complications, fear of pain, and religious sentiments. The findings will aid in developing messages to promote male circumcision in Uganda.
Behavioural Interventions for HIV Positive Prevention in Developing Countries: A Systematic Review and Meta-analysis
Kennedy, C.E., Medley, A.M., Sweat, M.D., O’Reilly, K.R. Bulletin of the World Health Organization (2010), Vol. 88 No. 8, pp. 615–623.
The review explores the efficacy of prevention programs for people infected with HIV in the developing world setting. The review also seeks to explore if interventions targeting both HIV-positive and -negative individuals have varying effectiveness. Eighteen articles met the criteria for inclusion. Most (15 studies) were conducted in Sub-Saharan Africa, were in clinical settings (14 studies), and were with heterosexual populations (12 studies). Nine studies targeted both HIV-positive and HIV-negative individuals and stratified the results by target population. These nine studies were within HIV counseling and testing interventions. Ten studies evaluated behavioral interventions targeted to HIV-positive individuals. Five studies were with serodiscordant couples. When comparing behavioral interventions targeting HIV-negative and -positive individuals, it was found that condom use statistically increased among positive individuals but was not statistically significant among negative individuals. Interventions targeting serodiscordant couples increased condom use significantly. There was also a modest positive affect on reducing multiple sexual partners in behavioral interventions targeted to HIV-positive adults as well as an increase in disclosing one’s HIV-positive status. These results demonstrate the positive affect on behavioral outcomes from prevention interventions; therefore, prevention interventions should be expanded among HIV-positive individuals and serodiscordant couples.
Successful Increase in Contraceptive Uptake among Kenyan HIV-1-Serodiscordant Couples Enrolled in an HIV-1 Prevention Trial
Ngure, K., Heffron, R., Mugo, N., et al. AIDS (2009), Vol. 23 No. Suppl. 1, pp. S89–S95.
The paper describes a successful intervention to increase uptake of family planning services among HIV-1–serodiscordant couples in Kenya. Study participants were from the Thika, Kenya, site within the Partners in Prevention HSV/HIV Transmission Study, and compared with three other Kenyan sites that did not have the supplemental family planning intervention. At the Thika study site, 213 serodiscordant couples were enrolled, and the majority (74.7 percent) of infected partners were female. Most women had one living child and were married to their study partner. A total of 1,216 couples were enrolled in the other three Kenyan sites and were similar to the Thika participants. It was found that noncondom contraceptive use increased among Thika female participants, both in infected and uninfected women. The injectable was the preferred contraceptive choice of women followed by the pill, surgical procedures, implants, and intrauterine devices. Noncondom contraceptive use did not statistically change in the other three sites. Reported condom use was high throughout the study at all sites. The incidence of pregnancy also reduced among study participants from the Thika study site and increased at the other sites. The increased utilization of contraceptives in this cohort indicates an unmet need that can be satisfied with successful comprehensive family planning interventions.
A Group-based Intervention to Increase Condom Use among HIV Serodiscordant Couples in India, Thailand, and Uganda
McGrath, J. W., Celentano, D. D., Chard, S. E., et al. AIDS Care (2007), Vol. 19 No. 3, pp. 418–424.
The paper describes a study among serodiscordant couples where the HIV-positive individual has to disclose their status to their partner, they have to decide together to participant in the intervention, and to test whether there are any changes in condom use among study participants. The study was conducted in one site each in India, Thailand, and Uganda. Forty-three couples were enrolled in the study, and forty couples completed all study requirements. The intervention consisted of four sessions that covered HIV, risk reduction strategies, and skill training on how to improve couple communications. Participants were interviewed at baseline and at one and three months after the intervention. All participants stated that they were satisfied with the intervention and that it helped them communicate with their partner about sex. High communication skills were also reported at the one- and three-month follow-up visits. Participants appreciated the HIV information that they received, appreciated the correct information and skills on how to use a condom, and reported to be less shy about discussing HIV topics after the intervention. The ability to refuse sex if their partner did not want to use a condom increased significantly from baseline to the three-month follow-up visit. Sexual activity also increased in the India cohort based on the resumption of sex or the increased comfort level in discussing sex. Reported condom use at all sites reached 100 percent after the intervention. The study demonstrates how an intervention targeting serodiscordant couples can be replicated in multiple settings with unique epidemics.
Willingness of Kenyan HIV-1 Serodiscordant Couples to Use Antiretroviral Based HIV-1 Prevention Strategies
Heffron, R., Ngure, K., Mugo, N., et al. Journal of Acquired Immune Deficiency Syndromes (May 2012), e-publication ahead of print.
According to the authors of this cross-sectional study, nearly 40 percent of HIV-positive Kenyans in stable serodiscordant relationships (where the partner is HIV-negative) expressed reservations about initiating early antiretroviral therapy (ART) for the purpose of treatment as prevention, particularly about the potential side effects. The HIV-negative partners expressed a high willingness (nearly 90 percent) to use pre-exposure prophylaxis (PrEP) over the long term. The authors also report that control of the method was a factor in participants’ decision making since, when given a hypothetical choice, HIV-negative partners chose PrEP and HIV-positive partners chose ART if it was medically necessary. The larger PrEP study found that HIV-positive partners indicated a higher level of willingness to initiate ART when they were experiencing lower CD4 counts or symptomatic diseases, or had had personal experience with ART use. Based on these results, the authors suggest that serodiscordant couples follow a dual HIV prevention strategy, with the HIV-negative partner using PrEP until the HIV-positive partner is willing and able to initiate ART. The authors also stress the importance of understanding couples’ concerns and preferences about using ART for HIV prevention, before developing treatment as prevention strategies.
HIV Testing and Counseling Leads to Immediate Consistent Condom Use among South African Stable HIV-Discordant Couples
Rosenberg, N.E., Pettifor, A.E., De Bruyn, G., et al. Journal of Acquired Immune Deficiency Syndromes (October 2012), e-publication ahead of print.
This study explored condom use and number of unprotected sexual acts among long-term HIV serodiscordant couples after HIV testing and counseling and one-month follow-up visits. Participants were from the Partners in Prevention HSV/HIV Transmission Study, a randomized, placebo-controlled trial to assess the impact of twice-daily acyclovir use on HIV-1 disease progression in HIV-1/HSV-2 co-infected persons. The 508 HIV-positive participants and their partners were followed for two years. Couples received risk reduction counseling and were provided with free condoms each month, and the HIV-negative partner was tested for HIV quarterly. Interviewer-administered questionnaires collected demographic and behavioral data at baseline and monthly visits. The study compared the sexual behavior of newly and previously tested persons at baseline as well as at months one, six, and twelve. It was found at baseline that for those who recently tested for HIV (less than seven days earlier), odds of reporting unprotected sex were greater than for those who had most recently been tested more than 30 days before; the odds became comparable at the one month mark and remained constant at the sixth and twelfth months. The odds of unprotected sex were lower at month one, six, and twelve compared to baseline. The authors conclude that HIV counseling and testing results in a reduction of sexual risk among HIV serodiscordant couples.
Sexual Life and Fertility Desire in Long-Term HIV Serodiscordant Couples in Addis Ababa, Ethiopia: A Grounded Theory Study
Hailemariam, T.G., Kassie, G.M., Sisay, M.M. BMC Public Health (2012), Vol. 12 No. 900.
A qualitative study was conducted in Addis Ababa, Ethiopia, to better understand HIV serodiscordant couples’ view of fertility and sexual relations in long-term relationships. Participants were selected from among those receiving services for antiretroviral therapy and prevention of mother-to-child transmission at three public hospitals. Thirty-six informants were recruited from two groups—individuals in serodiscordant relationships and health professionals who care for them. The study found the core category of the “struggle to maintain (the) relationship.” After couples learned that one partner was HIV positive, they either separated or strove to maintain the relationship. Those who wanted to maintain the relationship experienced a period of transition to become comfortable with their new status. Challenges arose when one partner wanted a child or more children and the other did not, or when both wanted a child but feared transmitting the virus to the uninfected partner. Participants also noted: a change in their desire to have sex; sacrificing of self-interest for the benefit of their family; nondisclosure or selective disclosure of their status to family and friends; and increasing focus of attention on existing children. The authors conclude that in order for HIV serodiscordant couples to maintain their relationship they have to develop a variety of strategies.
HIV Prevention for Serodiscordant Couples: Technical Brief
Spino, A., Clark, M., & Stash, S. 2010. AIDSTAR-One.
The technical brief provides an overview of the research on HIV prevention for serodiscordant couples including an introduction on the epidemiological significance in targeting this population and key prevention interventions. There are three broad categories of prevention interventions among discordant couples: couples HIV counseling and testing, group-based interventions, and a supportive environment. Several successful programs are highlighted through the document. The challenges and barriers to implementing prevention programs for serodiscordant couples are listed, and their solutions are discussed. These include how to involve the partners in the intervention, gender imbalances, increasing knowledge about what it means to be discordant, and guaranteeing that the quality of interventions is high. Clear messages are outlined such as stating that HIV discordance is common, couples can remain discordant for a long time, discordance does not necessarily mean the partner is unfaithful, no one is immune to HIV, the HIV-negative partner is at high risk of HIV, and effective risk reduction options do exist. Four common questions that are pertinent to implementation are asked and answered in the brief. Additional resources are provided.
Guidance on Oral Pre-Exposure Prophylaxis (PrEP) for Serodiscordant Couples, Men and Transgender Women Who Have Sex with Men at High Risk of HIV: Recommendations for Use in the Context of Demonstration Projects
World Health Organization (2012).
PrEP clinical trials have been successful in two populations--men and transgender women who have sex with men (MSM-TG) and serodiscordant heterosexual couples. However, translating these results to real world settings is less known. WHO recommends that countries implement demonstration projects that will offer advice on key safety, effectiveness, adherence, and sustainability questions surrounding PrEP interventions. The guidance provides an overview of the research conducted to date and recommendations on PrEP for serodiscordant couples, MSM-TG, and other groups. The guidance lists nine key points to guide demonstration projects including assuring the HIV-negative status of participants, monitoring the safely of participants, supporting high levels of adherence, and developing transition mechanism for those who want/need to discontinue treatment. It is planned that WHO will review and revise its guidance in 2015.
Debate Three: Discordant Couples and HIV Transmission
The World Bank and the U.S. Agency for International Development. 2010.
The co-sponsored World Bank and U.S. Agency for International Development debate was centered around the statement: “Intracouple HIV transmission between couples in long term stable partnerships drive a majority of HIV transmission and should receive the majority of HIV prevention funding.” Two experts argued for and two argued against the statement. The summary report can be found at the site as well as additional materials including the program, supplemental information, flyer for the debate, and links to various pages on the AIDSTAR-One Prevention Knowledge Base. Viewers can also watch the debate in four parts through the website.
Related AIDSTAR-One Publications
- Technical Brief | HIV Prevention for Serodiscordant Couples: A systematic review of core programmatic components (PDF, 297 KB)
- Spotlight on Prevention: The Astonishing Neglect of an HIV Prevention Strategy
- Related Practice (G3P): Couples HIV Counseling and Testing, Rwanda and Zambia