HIV Prevention for Serodiscordant Couples
Putting It Into Practice
Summaries of Key Interventions on HIV Serodiscordant Couples
Identification and review of relevant interventions is currently in process. The section below highlights some key interventions by type. Note that this is not an exhaustive list, and in particular, does not necessarily capture all of the discordant programs being implemented at the field level. These will be updated as information becomes available.
Couple-centred Testing and Counselling for HIV Serodiscordant Heterosexual Couples in sub-Saharan Africa
Reproductive Health Matters (2008), Vol. 16 No. 32, pp. 151-161
Desgrees-du-Lou, A. & Gliemann, J.
Seizing the opportunity for HIV prevention within the context of serodiscordant, stable relationships, couple-centered HIV voluntary counseling and testing (VCT) can facilitate HIV status disclosure, communication, and ongoing HIV prevention behavior. Couple-centered approaches have not been widely implemented, however; most counseling interventions for discordant couples occur at the individual level (e.g., within antenatal programs, STI care). This paper reviews published research on couple-centered VCT programs among serodiscordant, heterosexual couples in sub-Saharan African. All published couple-centered counseling interventions have demonstrated the following: increased disclosure of HIV status to one’s partner; decreased partner violence among women who disclosed their HIV status to their male partners; and increased condom use. Gender issues were also raised: in one multi-site study, serodiscordant couples in which the woman was HIV-positive were more likely to report an end to the marriage (though this trend was found in settings both with and without couple-based VCT). An ongoing challenge to couple-centered VCT is a lack of participation due to of low acceptability of the program among potential clients, but promotion of couple-oriented services with media and home-based visits by trained community health workers seemed to be effective. The authors highlight the need for more programs and research with couple-centered HIV counseling programs in order to enhance HIV prevention outcomes.
Sexual Behaviour of HIV Discordant Couples after HIV Counseling and Testing
AIDS (2003), Vol. 17, pp. 733-740
Allen, S., et al.
The impact of joint voluntary counseling and testing (VCT) was assessed with 963 cohabiting heterosexual HIV discordant couples. HIV 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.
Promotion of Couples’ Voluntary Counselling and Testing for HIV through Influential Networks in two African Capital Cities
BMC Public Health (2007), Vol. 7, pp. 349
Allen, S., et al.
While couples voluntary counseling and testing (CVCT) is an effective strategy to prevent new HIV infections in cohabiting heterosexual couples, implementing sustainable strategies to encourage couples testing remains challenging. A promising approach utilizes Influence Network Agents (INAs) from health, religious, non-governmental, and private sectors to invite couples for CVCT. In four months, 61 INAs distributed 9,900 invitations which resulted in 1,411 (14.3 percent) couples requesting CVCT. Invitations were most likely to be successful when delivered in an INA’s home, to both partners, or to someone known to the INA. Obstacles of limited time and money for transportation must be addressed in order to increase CVCT uptake. Uptake of invitations might also increase if INAs could provide home-based testing or be accompanied by someone trained to do so.
Evolution of Couples’ Voluntary Counseling and Testing for HIV in Lusaka, Zambia
JAIDS (2008), Vol. 47 No. 1, pp. 108-115
Chomba, E., et al.
Couples’ voluntary counseling and testing (CVCT) can be an effective strategy for reducing risk of HIV transmission in cohabitating couples. Developing promotional strategies to reach couples and encourage them to test together remains challenging. In order to facilitate access to CVCT services, community workers are recruited from among previously tested couples to perform outreach. After training, community workers conduct promotional activities door-to-door near the clinic. The program provides transport, childcare and lunch, addressing common access barriers. Door-to-door efforts by community workers resulted in substantial increases in CVCT attendance. Attendance dropped once community outreach ended, despite continued mass media advertisements. While effective, the peer model was labor and cost intensive. The study demonstrated that couples will access joint VCT if financial and logistical obstacles are overcome.
Sexual Practices of HIV Discordant and Concordant Couples in Rwanda: Effects of a Testing and Counselling Programme for Men
International Journal of STD & AIDS (2001), Vol. 12 No. 3, pp. 181-188
Roth, D., et al.
The husbands and male cohabiting partners of 684 Rwandan women were recruited to participate in an HIV testing and male-focused counselling program. All of the women and 256 of the men (37%) had previously received standard HIV testing and basic counseling services, while 428 men were receiving testing and counseling for the first time. The rate of 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. Increase in condom use was also observed in couples where both partners had been tested and counseled previously. These findings suggest that male- and couple-focused HIV counseling and testing programs may provide an additional impetus for HIV prevention behavior change among heterosexual couples.
Efficacy of Voluntary HIV-1 Counselling and Testing in Individuals and Couples in Kenya, Tanzania, and Trinidad: A Randomised Trial
The Lancet (2000), Vol. 356, pp. 103-12
Coates, T. J. & The Voluntary HIV-1 Counseling and Testing Efficacy Study Group.
Voluntary counseling and testing (VCT) in developing countries has been advocated as an important prevention strategy, and there is an increasing emphasis on couples’ VCT (CVCT). This study examined the impact of VCT on individuals and couples in Kenya, Tanzania, and Trinidad. Couples receiving VCT reduced unprotected intercourse with their sex partners enrolled in the study significantly more than couples receiving only health information. However, no differences were found in unprotected intercourse with sex partners not enrolled in the study. Couples in which one or both partners were diagnosed with HIV were more likely to reduce unprotected intercourse than couples in which both partners were uninfected. The study shows CVCT can promote behavior change among couples.
Antenatal Couple Counseling Increases Uptake of Interventions to Prevent HIV-1 Transmission
Journal of Acquired Immune Deficiency Syndromes (2004), Vol. 37 No. 5, pp. 1620-1626
Farquhar, C., Kiarie, J., & Richardson, B.
This study highlighted the benefits of antenatal couple counseling and voluntary testing and counseling (VCT) to prevent HIV infections. Women attending an antenatal clinic in Nairobi were encouraged to invite their partners to the clinic for VCT and were offered individual or couple post-test counseling. Among 2,104 women accepting testing, 308 (15 percent) had partners participate in VCT, of whom 116 (38 percent) were couple counseled. Partner participation in VCT was associated with increased uptake of interventions to prevent sexual and mother-to-child HIV transmission. The HIV-positive women (10 percent of 314 HIV-positive women) who came with their partners for VCT were three times more likely to return for Nevirapine and to report administering the drug to their infants at delivery. HIV-positive women receiving couple counseling were five times more likely to avoid breast feeding compared with those who were counseled individually. Couples who received partner notification of HIV-positive test results were more likely to use condoms. The association between partner participation and uptake of these interventions was strongest when partners agreed to be counseled as a couple. One of the challenges emerging from the study is identifying strategies to increase partner participation.
The Efficacy of a Relationship-based HIV/STD Prevention Program for Heterosexual Couples
AJPH (2003), Vol. 93 No. 6, pp. 963-969
El Bassel, N., et al.
This study of 217 heterosexual couples in the United States demonstrated the efficacy of a relationship-based HIV/STI prevention program for couples at risk for infection. The six-session intervention was based on the AIDS Risk Reduction Model and emphasized relationship dynamics. Couples were randomly assigned to one of three groups: 1) six-session intervention delivered to couples together; 2) six-session intervention delivered to the woman alone; and 3) a control group in which a one-session intervention was delivered to the women alone. The study found the couple and individual women’s interventions were equally effective in reducing the proportion of unprotected sexual acts and increasing the proportion of protected sexual acts.
Group-based Workshops with Serodiscordant Couples
Influence of Partner Participation on Sexual Risk Behavior Reduction among HIV-positive Zambian Women
Journal of Urban Health (2005), Vol. 82 No. 3, pp. iv92-iv100
Jones, D., et al.
This study reports on a group-based intervention (adapted from an urban US context) for HIV-positive women and their HIV-negative male partners in Zambia. Females attended four group intervention sessions and received sexual behavior skills training. Their male partners attended either a single session or a four-session gender concordant intervention. Both men and women 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, safe sex intentions and less alcohol use. The findings highlight the opportunity of interventions to include both partners to influence the sexual dynamics of a relationship.
A Group-based Intervention to Increase Condom Use Among HIV Serodiscordant Couples in India, Thailand, and Uganda
AIDS Care (2007), Vol. 19 No. 3, pp. 418-424
McGrath, J. W., Celentano, D. D. & Chard, S. E.
A group-based intervention with serodiscordant couples was conducted in India, Thailand and Uganda. The intervention consisted of four sessions: the first two sessions were single sex groups, and the last two sessions included both partners. The intervention focused on communication, problem solving and negotiation skills. Participants were enthusiastic about the intervention, citing information about HIV serodiscordancy and the opportunity to meet couples ‘like us’ as important features. At follow-up, 90 percent of participants reported using some of the skills learned. Condom use with sexual contacts reached 100 percent at the first follow-up visit, although the authors noted that social acceptability bias might be a factor in the reported high use of condoms.
Project Eban: A Giant Step Forward (Editorial).
JAIDS (2008), Vol. 49 No. 1, pp. S1-S2
Williams, D., Allen, S. & Padian, N.
The theory-based Eban Project is an Afrocentric intervention comprised of four couple sessions and four group sessions, addressing individual, interpersonal and community level factors that contribute to HIV/STI transmission risk. Study participants were 535 HIV serodiscordant heterosexual African American couples. Interesting features of the intervention development highlighted in this editorial may be relevant for other programs developing interventions for underserved and stigmatized populations. These include: implementing an intervention with a hard-to-reach and transitory population often with multiple co-morbidities; integrating African American cultural context into the intervention; and working with couples in a committed partnership of 6 months or more. The study plans to test the effects of the intervention on STI incidence and condom use (findings pending).
Integrated Antiretroviral Therapy and HIV Prevention Programs
Changes in Sexual Behavior and Risk of HIV Transmission After Antiretroviral Therapy and Prevention Interventions in Rural Uganda
AIDS (2006), Vol. 20 No. 1, pp. 85-92
Bunnell, R., et al.
The Home-Based AIDS Care Project offers home-based antiretroviral therapy care to HIV positive patients. It offers prevention counseling and home-based voluntary counseling and testing to all household members of positive patients. In individual sessions, participants develop personal sexual behavior plans. Overall there was a 70 percent reduction in risky sex (over 85 percent of risky sexual acts occurred within married couples) and an estimated 98 percent reduction in the number of seroconversions after six months. The study supports arguments for incorporating prevention into antiretroviral programs.
Undiagnosed HIV Infection and Couple HIV Discordance Among Household Members of HIV-infected People Receiving Anti-retroviral Therapy in Uganda
J Acquir Immune Defic Syndrome (2006), Vol. 43 No. 1, pp. 91-95
Were, M., et al.
The Home-Based AIDS Care Project offers home-based antiretroviral therapy (ART) care to HIV-positive patients. It also offers prevention counseling and home-based VCT to all household members of HIV-positive patients. Couples were encouraged to receive results together, and where HIV discordance was identified, partners were offered enhanced couple counseling that included making personalized couple risk reduction plans. Of the household members of people taking home-based ART, 99 percent accepted VCT and almost all were tested in their homes. Many persons with HIV believe their partners are already infected and therefore do not avoid high risk practices; however, the study found that of patients’ spouses tested for HIV, 43 percent were HIV-negative. The study demonstrated that delivering VCT to household members of people initiating ART is well accepted by household members and can result in the detection of a large number of previously undiagnosed HIV infections and HIV discordant relationships.
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