HIV Prevention Knowledge Base
Combination Approaches: HIV Prevention for Serodiscordant Couples
Increased Risk of HIV-1 Transmission in Pregnancy: A Prospective Study among African HIV-1-Serodiscordant Couples
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
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
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.
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
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?
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
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
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.