Sexual behavior of HIV discordant couples after HIV counseling and testing

Sustained effect of couples' HIV counselling and testing on risk reduction among Zambian HIV serodiscordant couples

Background

We present temporal trends in self-reported and biological markers of unprotected sex and sex with concurrent partners in discordant couples receiving couples' voluntary HIV counselling and testing (CVCT).

Methods

Heterosexual Zambian HIV-serodiscordant couples were enrolled into longitudinal follow-up in an open cohort (1994–2012). Multivariable Anderson-Gill models explored predictors of self-report and biological indicators of unprotected sex within (including sperm on a vaginal swab, incident pregnancy or incident linked HIV infection) and outside (including self-report, STI and unlinked HIV infection) the union. Measures of secular trends in baseline measures were also examined.

Results

At enrolment of 3049 couples, men were 35 years old on average, women were 29 years, and couples had been together for an average of 7 years. M+F− couples reported an average of 16.6 unprotected sex acts in the 3 months prior to enrolment (pre-CVCT), dropping to 5.3 in the >0–3 month interval, and 2.0 in >6 month intervals (p-trend <0.001). Corresponding values for M−F+ couples were 22.4 unprotected sex acts in the 3 months prior enrolment, dropping to 5.2 in the >0–3 month interval, and 3.1 in >6 month intervals (p-trend <0.001). Significant reductions in self-report and biological markers of outside partners were also noted. Predictors of unprotected sex between study partners after CVCT included prevalent pregnancy (adjusted HR, aHR=1.6–1.9); HIV+ men being circumcised (aHR=1.2); and HIV− women reporting sex with outside partners (aHR=1.3), alcohol (aHR=1.2), injectable (aHR=1.4) or oral (aHR=1.4) contraception use. Fertility intentions were also predictive of unprotected sex (aHR=1.2–1.4). Secular trends indicated steady declines in reported outside partners and STIs.

Conclusion

Reductions in self-reported unprotected sex after CVCT were substantial and sustained. Reinforced risk-reduction counselling in pregnant couples, couples desiring children and couples with HIV− women having outside partners or using alcohol or injectable or oral contraception are indicated.

What Level of Risk Compensation Would Offset the Preventive Effect of Early Antiretroviral Therapy? Simulations From the TEMPRANO Trial

Whether risk compensation could offset the preventive effect of early initiation of antiretroviral therapy (ART) on human immunodeficiency virus (HIV) transmission remains unknown. Using virological and behavioral data collected 12 months after inclusion in the TEMPRANO randomized trial of early ART (Abidjan, Côte d'Ivoire, 2009-2012), we estimated the risk of HIV transmission and compared it between the intervention (early ART; n = 490) and control (deferred ART; n = 467) groups. We then simulated increases in various sexual risk behaviors in the intervention group and estimated the resulting preventive effect. On the basis of reported values of sexual behaviors, we estimated that early ART had an 89% (95% confidence interval: 81, 95) preventive effect on the cumulative risk of HIV transmission over a 1-month period. This preventive effect remained significant for a wide range of parameter combinations and was offset (i.e., nonsignificant) only for dramatic increases in different sexual behaviors simulated simultaneously. For example, when considering a 2-fold increase in serodiscordance and the frequency of sexual intercourse together with a 33% decrease in condom use, the resulting preventive effect was 47% (95% confidence interval: -3, 74). An important reduction of HIV transmission may thus be expected from the scale-up of early ART, even in the context of behavioral change.

'People say that we are already dead much as we can still walk': a qualitative investigation of community and couples' understanding of HIV serodiscordance in rural Uganda

Background

Stable, co-habiting HIV serodiscordant couples are a key population in terms of heterosexual transmission in sub-Saharan Africa. Despite the wide availability of antiretroviral treatment and HIV educational programs, heterosexual transmission continues to drive the HIV epidemic in Africa. To investigate some of the factors involved in transmission or maintenance of serodiscordant status, we designed a study to examine participants’ understanding of HIV serodiscordance and the implications this posed for their HIV prevention practices.

Methods

In-depth interviews were conducted with 28 serodiscordant couples enrolled in a treatment-as-prevention study in Jinja, Uganda. Participants were asked questions regarding sexual behaviour, beliefs in treatment and prevention, participants’ and communities’ understanding and context around HIV serodiscordance. Qualitative framework analysis capturing several main themes was carried out by a team of four members, and was cross-checked for consistency.

Results

It was found that most couples had difficulty explaining the phenomenon of serodiscordance and tended to be confused regarding prevention. Many individuals still held beliefs in pseudoscientific explanations for HIV susceptibility such as blood type and blood “strength”. The participants’ trust of treatment and medical services were well established. However, the communities’ views of both serodiscordance and treatment were more pessimistic and wrought with mistrust. Stigmatization of serodiscordance and HIV-positive status were reported frequently.

Conclusions

The results indicate that despite years of treatment and prevention methods being available, stigmatization and mistrust persist in the communities of HIV-affected individuals and may directly contribute to new cases and seroconversion. We suggest that to optimize the effects of HIV treatment and prevention, clear education and support of such methods are sorely needed in sub-Saharan African communities.

Implementation and Operational Research: Evolution of Couples' Voluntary Counseling and Testing for HIV in Rwanda: From Research to Public Health Practice

BACKGROUND

Couples' voluntary HIV counseling and testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda.

METHODS

From 1988 to 1994 in Rwanda, pregnant and postpartum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and sexually transmitted infection rates, particularly among HIV-discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were reintroduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the prevention of mother-to-child transmission program expanded to >400 clinics. In 2009, the GoR adopted joint posttest counseling procedures, and in 2010 a quarterly follow-up program for discordant couples was established in government clinics with training and technical assistance. An estimated 80%-90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections.

CONCLUSIONS

Rwanda is the first African country to have established CVCT as standard of care in antenatal care. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators, and budgets. Governments, bilateral, and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections.

Promoting Partner Testing and Couples Testing through Secondary Distribution of HIV Self-Tests: A Randomized Clinical Trial

BACKGROUND

Achieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.

METHODS AND FINDINGS

We conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18-39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.

CONCLUSIONS

Provision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02386215.

Pathways That Affect Wives' HIV Risk Among Serodiscordant Couples in India: Results From the Positive Jeevan Saathi Study

This study examined factors that mitigate or heighten HIV risk among HIV-negative wives in serodiscordant relationships in Gujarat, India. Grounded theory was used to analyze 46 interviews (23 couples) where husbands were HIV-positive and wives were HIV-negative. A conceptual framework emerged from analysis from which we identified five pathways and four key behaviors: (a) safer sex, (b) no sex, (c) coercive sex, and (d) unprotected sex. Most couples either practiced safe sex or abstained from sex. Factors such as wives' assertiveness, a wife's fear of acquiring HIV, mutual understanding, positive sex communication, and a husband's desire to protect wife influenced safe sex/sexual abstinence. Factors such as desire for children, a husband's alcohol use, and intimate partner violence influenced coercive and unprotected sex. Counseling topics on sex communication, verbal and non-verbal safer sex strategies, as well as addressing intimate partner violence and alcohol use may be important in preventing risk to HIV-negative wives.

Why do marital partners of people living with HIV not test for HIV? A qualitative study in Lusaka, Zambia

BACKGROUND

Knowledge of HIV status is crucial for HIV prevention and management in marital relationships. Yet some marital partners of people living with HIV decline HIV testing despite knowing the HIV-positive status of their partners. To date, little research has explored the reasons for this.

METHODS

An exploratory qualitative study was undertaken in Lusaka, Zambia, between March 2010 and September 2011, nested within a larger ethnographic study. In-depth interviews were held with individuals who knew the HIV-positive status of their marital partners but never sought HIV testing (n = 30) and HIV service providers of a public sector clinic (n = 10). A focus group discussion was also conducted with eight (8) lay HIV counsellors. Data was transcribed, coded and managed using ATLAS.ti and analysed using latent content analysis.

RESULTS

The overarching barrier to uptake of HIV testing was study participants' perception of their physical health, reinforced by uptake of herbal remedies and conventional non-HIV medication to mitigate perceived HIV-related symptoms. They indicated willingness to test for HIV if they noticed a decline in physical health and other alternative forms of care became ineffective. Also, some study participants viewed themselves as already infected with HIV on account of the HIV-positive status of their marital partners, with some opting for faith healing to get 'cured'. Other barriers were the perceived psychological burden of living with HIV, modulated by lay belief that knowledge of HIV-positive status led to rapid physical deterioration of health. Perceived inability to sustain uptake of life-long treatment - influenced by a negative attitude towards treatment - further undermined uptake of HIV testing. Self-stigma, which manifested itself through fear of blame and a need to maintain moral credibility in marital relationships, also undermined uptake of HIV testing.

CONCLUSIONS

Improving uptake of HIV testing requires a multi-pronged approach that addresses self-stigma, lay risk perceptions, negative treatment and health beliefs and the perceived psychological burden of living with HIV. Strengthening couple HIV testing services, including addressing conflict and addressing gendered power relationships are also warranted to facilitate joint knowledge, acceptance and management of HIV status in marital relationships.

The Use of Technology to Advance HIV Prevention for Couples

The majority of HIV prevention studies and programs have targeted individuals or operated at the community level. This has also been the standard approach when incorporating technology (e.g., web-based, smartphones) to help improve HIV prevention efforts. The tides have turned for both approaches: greater attention is now focusing on couple-based HIV prevention and using technology to help improve these efforts for maximizing reach and potential impact. To assess the extent that technology has been used to help advance HIV prevention with couples, a literature review was conducted using four databases and included studies that collected data from 2000 to early 2015. Results from this review suggest that technology has primarily been used to help advance HIV prevention with couples as a tool for (1) recruitment and data collection and (2) intervention development. Challenges and limitations of conducting research (e.g., validity of dyadic data) along with future directions for how technology (e.g., mHealth, wearable sensors) can be used to advance HIV prevention with couples are then discussed. Given the growing and near ubiquitous use of the Internet and smartphones, further efforts in the realm of mHealth (e.g., applications or "apps") and eHealth are needed to develop novel couple-focused HIV-preventive interventions.

Development of a prospective cohort of HIV Exposed Sero-Negative (HESN) individuals in Jos Nigeria

BACKGROUND

HIV/AIDS continues to be a global health problem. With currently no cure, it is critical to get an effective vaccine to add to the arsenal of prevention and treatment tools. HIV Exposed Sero-Negative (HESN) individuals were enrolled and followed for 2 years.

METHODS

A prospective observational cohort study to enroll HESN volunteers and their partners was developed with a 2-year follow up. This was a vaccine preparedness study and designed as a Phase IIb trial. We provided counseling, lab testing and conducted medical examinations for all enrollees.

RESULTS

A total of 534 HESN were enrolled with 48 % (256) females and 52 % (278) males, a mean age of 37 ± 9 years. Three female HESN enrollees seroconverted giving this cohort a HIV incidence rate [95 % coefficient interval (CI)] of 3.2 (2.3-4.2) per 100,000 person-months of observation. Baseline analysis showed that female HESN are 24 % more likely to have their spouse consistently use condoms (RR 1.24; p = 0.04); 16 % more likely to have HIV+ partners with detectable viral load (RR 1.16, p = 0.03) and 28 % more likely that their HIV+ partners has a CD4 count less than 350cells/μl (RR 1.28, p = 0.03) when compared to male HESN.

CONCLUSIONS

Our findings suggest that female HESN are more at risk of HIV acquisition due the low CD4 counts and detectable viral load among their HIV+ spouses. Moreover, we provide additional information on incidence and risk factors among naturally exposed persons, which might impact biomedical prevention research and immune responses to HIV vaccines.

Factors that lead to changes in sexual behaviours after a negative HIV test: protocol for a prospective cohort study in Kinshasa

BACKGROUND

Considering the high percentage of couples in which one or both members are HIV negative, the frequency of transmission among non-regular partners and the probabilities of non-disclosure, attention should be paid to people getting a negative HIV test at the Voluntary Counseling and Testing (VCT). Research has shown that a negative HIV test may be followed by a change in sexual behaviours. In Sub-Saharan Africa, where most HIV infections occur, there are few studies that have analysed the factors associated with changes in sexual risk behaviours after a negative HIV test at the VCT clinic. The aim of this project is to evaluate the specific factors associated with changes in sexual behaviours, three months after a negative result in an HIV test, and to analyse the effect of counseling and testing on HIV-related knowledge of participants in an outpatient centre of Kinshasa (Democratic Republic of Congo).

METHODS AND DESIGN

Prospective cohort study from December 2014 until March 2016. People 15-60 year old that received VCT at Monkole Hospital (Kinshasa) were followed three months after they got a negative HIV test. In a face-to-face interview, participants replied to a baseline and a follow-up research questionnaire on HIV-related knowledge, attitudes and behaviours. At follow-up respondents were also offered a new HIV test and additional HIV counseling. Four hundred and fifteen participants completed the baseline questionnaire and 363 (87 %) came back for their 3-month follow up.

DISCUSSION

This is the first longitudinal study in the DRC that evaluates the factors associated with changes in sexual behaviours after a negative HIV test at the VCT. Participants attending the VCT services within a clinical setting are a good study population as they can be good transmitters of preventive information for other people with no access to health facilities.

Hormonal Contraception, Pregnancy, Breastfeeding, and Risk of HIV Disease Progression Among Zambian Women

Background:

Some studies suggest that hormonal contraception, pregnancy, and/or breastfeeding may influence rates of HIV disease progression.

Methods:

From 1994 to 2012, HIV discordant couples recruited at couples' voluntary HIV counseling and testing centers in Lusaka were followed 3-monthly. Multivariate survival analyses explored associations between time-varying contraception, pregnancy, and breastfeeding and 2 outcomes among HIV-positive women: (1) time to death and (2) time to antiretroviral treatment (ART) initiation.

Results:

Among 1656 female seropositive, male seronegative couples followed for 3359 person-years (PY), 224 women died [6.7/100 PY; 95% confidence interval (CI): 5.8 to 7.6]. After 2003, 290 women initiated ART (14.5/100 PY; 95% CI: 12.9 to 16.2). In a multivariate model of time to death, hormonal implant [adjusted hazard ratio (aHR) = 0.30; 95% CI: 0.10 to 0.98] and injectable (aHR = 0.59; 95% CI: 0.36 to 0.97) were significantly protective relative to nonhormonal method use, whereas oral contraceptive pill (OCP) use was not (aHR = 1.08; 95% CI: 0.74 to 1.57) controlling for baseline HIV disease stage, time-varying pregnancy, time-varying breastfeeding, and year of enrollment. In a multivariate model of time-to-ART initiation, implant was significantly protective (aHR = 0.54; 95% CI: 0.31 to 0.95), whereas OCP (aHR = 0.70; 95% CI: 0.44 to 1.10) and injectable (aHR = 0.85; 95% CI: 0.55 to 1.32) were not relative to nonhormonal method use controlling for variables above, woman's age, and literacy. Pregnancy was not significantly associated with death (aHR = 1.07; 95% CI: 0.68 to 1.66) or ART initiation (aHR = 1.24; 95% CI: 0.83 to 1.86), whereas breastfeeding was protective for death (aHR = 0.34; 95% CI: 0.19 to 0.62) and ART initiation (aHR = 0.49; 95% CI: 0.29 to 0.85).

Conclusions:

Hormonal implants and injectables significantly predicted lower mortality; implants were protective for ART initiation. OCPs and pregnancy were not associated with death or ART initiation, whereas breastfeeding was protective for both. Findings from this 18-year cohort study suggest that (1) HIV-positive women desiring pregnancy can be counseled to do so and breastfeed and (2) all effective contraceptive methods, including injectables and implants, should be promoted to prevent unintended pregnancy.

Gender relations, sexual behaviour, and risk of contracting sexually transmitted infections among women in union in Uganda

BACKGROUND

Sexually transmitted infections (STIs) are a major reproductive and public health concern, especially in the era of HIV/AIDS. This study examined the relationship between sexual empowerment and STI status of women in union (married or cohabiting) in Uganda, controlling for sexual behaviour, partner factors, and women's background characteristics.

METHODS

The study, based on data from the 2011 Uganda Demographic and Health Survey (UDHS), analysed 1307 weighted cases of women age 15-49 in union and selected for the domestic violence module. Chi-squared tests and multivariate logistic regressions were used to examine the predicators of STI status. The main explanatory variables included sexual empowerment, involvement in decision making on own health, experience of any sexual violence, condom use during last sex with most recent partner, number of lifetime partners and partner control behaviours. Sexual empowerment was measured with three indicators: a woman's reported ability to refuse sex, ability to ask her partner to use a condom, and opinion regarding whether a woman is justified to refuse sex with her husband if he is unfaithful.

RESULTS

Results show that 28 % of women in union reported STIs in the last 12 months. Sexual violence and number of lifetime partners were the strongest predictors of reporting STIs. Women's sexual empowerment was a significant predictor of their STI status, but, surprisingly, the odds of reporting STIs were greater among women who were sexually empowered. Reporting of STIs was negatively associated with a woman's participation in decision-making with respect to her own health, and was positively associated with experience of sexual violence, partner's controlling behaviour, and having more than one life partner.

CONCLUSIONS

Our findings suggest that, with respect to STIs, sexual empowerment as measured in the study does not protect women who have sexually violent and controlling partners. Interventions promoting sexual health must effectively address negative masculine attitudes and roles that perpetuate unhealthy sexual behaviours and gender relations within marriage. It is also important to promote marital fidelity and better communication within union and to encourage women to take charge of their health jointly with their partners.

Identifying Risk Factors for Recent HIV Infection in Kenya Using a Recent Infection Testing Algorithm: Results from a Nationally Representative Population-Based Survey

INTRODUCTION

A recent infection testing algorithm (RITA) that can distinguish recent from long-standing HIV infection can be applied to nationally representative population-based surveys to characterize and identify risk factors for recent infection in a country.

MATERIALS AND METHODS

We applied a RITA using the Limiting Antigen Avidity Enzyme Immunoassay (LAg) on stored HIV-positive samples from the 2007 Kenya AIDS Indicator Survey. The case definition for recent infection included testing recent on LAg and having no evidence of antiretroviral therapy use. Multivariate analysis was conducted to determine factors associated with recent and long-standing infection compared to HIV-uninfected persons. All estimates were weighted to adjust for sampling probability and nonresponse.

RESULTS

Of 1,025 HIV-antibody-positive specimens, 64 (6.2%) met the case definition for recent infection and 961 (93.8%) met the case definition for long-standing infection. Compared to HIV-uninfected individuals, factors associated with higher adjusted odds of recent infection were living in Nairobi (adjusted odds ratio [AOR] 11.37; confidence interval [CI] 2.64-48.87) and Nyanza (AOR 4.55; CI 1.39-14.89) provinces compared to Western province; being widowed (AOR 8.04; CI 1.42-45.50) or currently married (AOR 6.42; CI 1.55-26.58) compared to being never married; having had ≥ 2 sexual partners in the last year (AOR 2.86; CI 1.51-5.41); not using a condom at last sex in the past year (AOR 1.61; CI 1.34-1.93); reporting a sexually transmitted infection (STI) diagnosis or symptoms of STI in the past year (AOR 1.97; CI 1.05-8.37); and being aged <30 years with: 1) HSV-2 infection (AOR 8.84; CI 2.62-29.85), 2) male genital ulcer disease (AOR 8.70; CI 2.36-32.08), or 3) lack of male circumcision (AOR 17.83; CI 2.19-144.90). Compared to HIV-uninfected persons, factors associated with higher adjusted odds of long-standing infection included living in Coast (AOR 1.55; CI 1.04-2.32) and Nyanza (AOR 2.33; CI 1.67-3.25) provinces compared to Western province; being separated/divorced (AOR 1.87; CI 1.16-3.01) or widowed (AOR 2.83; CI 1.78-4.45) compared to being never married; having ever used a condom (AOR 1.61; CI 1.34-1.93); and having a STI diagnosis or symptoms of STI in the past year (AOR 1.89; CI 1.20-2.97). Factors associated with lower adjusted odds of long-standing infection included using a condom at last sex in the past year (AOR 0.47; CI 0.36-0.61), having no HSV2-infection at aged <30 years (AOR 0.38; CI 0.20-0.75) or being an uncircumcised male aged <30 years (AOR 0.30; CI 0.15-0.61).

CONCLUSION

We identified factors associated with increased risk of recent and longstanding HIV infection using a RITA applied to blood specimens collected in a nationally representative survey. Though some false-recent cases may have been present in our sample, the correlates of recent infection identified were epidemiologically and biologically plausible. These methods can be used as a model for other countries with similar epidemics to inform targeted combination prevention strategies aimed to drastically decrease new infections in the population.

Technical Assistance Needs for Successful Implementation of Couples HIV Testing and Counseling (CHTC) Intervention for Male Couples at US HIV Testing Sites

The African couples HIV testing and counseling (CHTC) model, which focuses on heterosexual couples, was adapted for same-sex male couples in the US. This paper presents the results of a follow-up survey conducted with representatives of the agencies that received CHTC training. The paper aims to understand the post-training implementation and identify critical technical assistance gaps. There are clear needs for continual learning opportunities, focused on the key skills required for CHTC, and for resources aimed at tackling agency-level concerns about service provision and integration. Central to this is the need for implementation science research that can identify the messages that are effective in encouraging couples to utilize CHTC and test models of service integration.

The male factor: Outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township

BACKGROUND

This study examined the effects of the Couples Health CoOp intervention on heavy drinking, condom use, and HIV incidence.

METHODS

Thirty neighborhoods from one South African township were cluster randomized into three intervention arms: Couples Health CoOp (CHC), Women's Health CoOp/Men's Health CoOp (WHC/MHC), or a comparison arm. We recruited 290 men from informal drinking establishments who reported drinking alcohol regularly. We also recruited their main heterosexual sex partners.

RESULTS

At 6-month follow-up, men in the CHC arm were less likely to report heavy drinking (OR 0.47, 95% CI: 0.25, 0.90) and were more likely to report consistent condom use during the past month (OR 2.66, 95% CI: 1.23, 5.76) than men in the comparison arm. At baseline, 26% of women and 13% of men were HIV-infected; at 6-month follow-up, 16 females and 5 males had seroconverted. HIV incidence was significantly lower among women in the CHC arm (IRR 0.22, 95% CI: 0.04, 1.01) than in the WHC/MHC arm.

CONCLUSIONS

A couples-based intervention focusing on intersecting risks for HIV can improve biobehavioral outcomes, underscoring the importance of engaging couples together in HIV prevention.

Mobilization for HIV Voluntary Counseling and Testing Services in Vietnam: Clients' Risk Behaviors, Attitudes and Willingness to Pay

A multi-site survey was conducted on a sample of 365 clients to assess their willingness to pay for HIV voluntary counseling and testing (VCT) services in Ha Noi and Nam Dinh province, two epicenters of Vietnam. By using contingent valuation technique, the results showed that most of respondents (95.1 %) were willing to pay averagely 155 (95 % CI 132-177) thousands Vietnam Dong (~US $7.75, 2013) for a VCT service. Clients who were female, had middle income level, and current opioid users were willing to pay less; meanwhile clients who had university level of education were willing to pay more for a VCT service. The results highlighted the high rate of willingness to pay for the service at a high amount by VCT clients. These findings contribute to the implementation of co-payment scheme for VCT services toward the financial sustainability of HIV/AIDS programs in Vietnam.

Multi-level Correlates of Safer Conception Methods Awareness and Attitudes Among Ugandan HIV Clients with Fertility Intentions

Many people living with HIV desire childbearing, but low cost safer conception methods (SCM) such as timed unprotected intercourse (TUI) and manual self-insemination (MSI) are rarely used. We examined awareness and attitudes towards SCM, and the correlates of these constructs among 400 HIV clients with fertility intentions in Uganda. Measures included awareness, self-efficacy, and motivation regarding SCM, as well as demographics, health management, partner and provider characteristics. Just over half knew that MSI (53%) and TUI (51%) reduced transmission risk during conception, and 15% knew of sperm washing and pre-exposure prophylaxis. In separate regression models for SCM awareness, motivation, and self-efficacy, nearly all independent correlates were related to the partner, including perceived willingness to use SCM, knowledge of respondent's HIV status, HIV-seropositivity, marriage and equality in decision making within the relationship. These findings suggest the importance of partners in promoting SCM use and partner inclusion in safer conception counselling.

Acceptability of Couples' Voluntary HIV Testing Among HIV-infected Patients in Care and Their HIV-negative Partners in the United States

Introduction:

Couples’ voluntary HIV counseling and testing (CHTC) is an HIV risk reduction strategy not widely available in the US.

Methods:

We assessed willingness to participate in CHTC among US HIV-infected clinic patients via tablet-based survey and among HIV-negative persons with HIV-infected partners in care via mixed-method phone interviews.

Results:

Most of the N=64 HIV-infected partners surveyed were men (89%), on antiretroviral treatment (ART) (92%), and many self-identified homosexual (62%). We observed high levels of willingness to participate in CHTC (64%) among HIV-infected partners. Reasons for not wanting to participate included perceived lack of need (26%), desire to self-disclose their status (26%), and fear of being asked sensitive questions with their partner present (17%). HIV-infected partners were interested in discussing ART (48%), other sexually transmitted infections (STIs) (44%), and relationship agreements like monogamy (31%) during CHTC sessions. All N=15 HIV-negative partners interviewed were men, most identified as homosexual (73%), and about half (54%) reported consistent condom use with HIV-infected partners. We observed high levels of willingness to participate in CHTC (87%) among HIV-negative partners, who were also interested in discussing ART (47%), other STIs (47%), mental health services (40%), and relationship agreements (33%). Most negative partners (93%) indicated that they believed their HIV-infected partner was virally suppressed, but in the event that they were not, many (73%) were willing to take pre-exposure prophylaxis (PrEP).

Conclusion:

These results indicate that CHTC for serodiscordant couples is acceptable and should emphasize aspects most pertinent to these couples, such as discussion of ART/PrEP, STIs, and relationship agreements.

Dual contraceptive method use in HIV-serodiscordant Kenyan couples

BACKGROUND

World Health Organization (WHO) guidelines recommend dual contraceptive method use with condoms and another contraceptive to reduce both incidence of HIV/sexually transmitted infection transmission and unintended pregnancies. This qualitative study assessed the barriers to and motivations for dual contraceptive use in Kenyan HIV-serodiscordant couples.

METHODS

HIV-serodiscordant couples in Nairobi, Kenya, were recruited from two longitudinal cohorts. Qualitative semistructured interviews were conducted using a semistructured questionnaire. Twelve male and 12 female members of serodiscordant couples and 10 women with incident pregnancies during the cohort studies were included.

RESULTS

Few couples reported using dual contraceptive methods, with men reporting more condom use than women. No HIV-seropositive men or HIV-seronegative women reported using non-condom contraception. Men and women agreed that men play a dominant role in decisions to use both condoms and contraception in HIV-serodiscordant couples. Participants reported that perceptions of side effects, male partner preference, and reproductive desire were critical factors in contraceptive decisions. Both men and women saw dual contraceptive method use as redundant and a sign of possible unfaithfulness. Many participants actively desired pregnancy, but few were able to accurately define monthly fertility windows.

CONCLUSIONS

Dual contraceptive method use was low in these HIV-serodiscordant couples, with some couples finding it unnecessary while using condoms, and others being more focused on conceiving a child. Biomedical HIV prevention, including male circumcision, pre-exposure prophylaxis or antiretroviral therapy to reduce HIV transmission, may be more acceptable strategies to promote safer sexual relations among HIV-serodiscordant couples and safer conception when desired.

Risk factors for incident HIV infection among antenatal mothers in rural Eastern Cape, South Africa

BACKGROUND

The prevalence of HIV among antenatal clients in South Africa has remained at a very high rate of about 29% despite substantial decline in several sub-Saharan countries. There is a paucity of data on risk factors for incident HIV infection among antenatal mothers and women within the reproductive age bracket in local settings in the Eastern Cape, South Africa.

OBJECTIVE

To establish the risk factors for incident HIV infection among antenatal clients aged 18-49 years attending public antenatal clinics in rural Eastern Cape, South Africa.

DESIGN

This was an unmatched case-control study carried out in public health antenatal clinics of King Sabata District Municipality between January and March 2014. The cases comprised 100 clients with recent HIV infection; the controls were 200 HIV-negative antenatal clients. Socio-demographic, sexual, and behavioral data were collected using interviewer-administered questionnaires adapted from the standard DHS5 women's questionnaire. Multivariate logistic regression models were used to identify the independent risk factors for HIV infection. A p<0.05 was considered statistically significant.

RESULTS

The independent risk factors for incident HIV infection were economic dependence on the partner, having older male partners especially among women aged ≤20 years, and sex under the influence of alcohol.

CONCLUSIONS

Therefore, effective prevention of HIV among antenatal mothers in KSDM must target the improvement of the economic status of women, thereby reducing economic dependence on their sexual partners; address the prevalent phenomenon of cross-generation sex among women aged <20 years; and regulate the brewing, marketing, and consumption of alcohol.

Prevalence and predictors of HIV sero-discordance among cohabiting couples tested in northern Tanzania

Introduction

In sub-Saharan Africa where HIV/AIDS epidemic is predominantly generalized, majority of HIV infections occur among heterosexual couples. The majority of people do not know their sero-status. Thus, utilisation of Couples’ HIV Counselling and Testing (CHCT) services remain to be critical in preventing new infections. The objective was to establish prevalence and predictors of HIV sero-discordance among cohabiting couples presenting for CHCT services in northern Tanzania.

Methods

A cross-sectional study inteveviewed 1,333 couples aged 18-49 years tested from 2005 to 2007 in Kilimanjaro and Arusha regions. A CHCT checklist was used to collect data from couples. Data were analyzed using STATA 10.

Results

Generally, 220(16%) out of 1,333 couples were HIV sero-discordant. In sero-discordance unions, women were likely to be HIV positive than men (71% versus 29% respectively p<0.001). HIV sero-discordant relationship was associated with age (35-45 years) for both men and women (Adjusted Odds Ratio (AOR): 2.3, 95% Confidence Interval (CI): 1.7-3.2) and (AOR: 2.6, 95% CI 1.9-3.7) respectively. Women with older men partners were less likely to be in HIV sero-discordance relationships (AOR: 0.5 95% CI 0.3-09). Arusha couples were likely to be HIV sero-discordant than those of Kilimanjaro (AOR: 2.3 95% CI 1.7-3.2). Couples living far away from CHCT centres were less likely to be sero-discordant than those live nearby (AOR: 0.4 95% CI 0.2-0.9).

Conclusion

HIV sero-discordance prevalence is high among our participants. Thus, we recommend CHCT utilization should widely be promoted as entry point in treatment as prevention strategy in order to protect uninfected partners in HIV sero-discordance relationships.

Official invitation letters to promote male partner attendance and couple voluntary HIV counselling and testing in antenatal care: an implementation study in Mbeya Region, Tanzania

Background

The benefits of male partner involvement in antenatal care (ANC) and prevention of mother-to-child transmission of HIV (PMTCT) for maternal and infant health outcomes have been well recognised. However, in many sub-Saharan African settings, male involvement in these services remains low. Previous research has suggested written invitation letters as a way to promote male partner involvement.

Methods

In this implementation study conducted at three study sites in southwest Tanzania, acceptability of written invitation letters for male partners was assessed. Pre-study CVCT rates of 2–19 % had been recorded at the study sites. Pregnant women approaching ANC without a male partner were given an official letter, inviting the partner to attend a joint ANC and couple voluntary counselling and testing (CVCT) session. Partner attendance was recorded at subsequent antenatal visits, and the invitation was repeated if the partner did not attend. Analysis of socio-demographic indices associated with male partner attendance at ANC was also performed.

Results

Out of 318 women who received an invitation letter for their partner, 53.5 % returned with their partners for a joint ANC session; of these, 81 % proceeded to CVCT. Self-reported HIV-positive status at baseline was negatively associated with partner return (p = 0.033). Male attendance varied significantly between the rural and urban study sites (p < 0.001) with rates as high as 76 % at the rural site compared to 31 % at the urban health centre. The majority of women assessed the joint ANC session as a favourable experience, however 7 (75 %) of women in HIV-positive discordant or concordant relationships reported problems during mutual disclosure. Beneficial outcomes reported one month after the session included improved client- provider relationship, improved intra-couple communication and enhanced sexual and reproductive health decision-making.

Conclusion

Official invitation letters are a feasible intervention in a resource limited sub-Saharan African context, they are highly accepted by couple members, and are an effective way to encourage men to attend ANC and CVCT. Pre-intervention CVCT rates were improved in all sites. However, urban settings might require extra emphasis to reach high rates of partner attendance compared to smaller rural health centres.

Effect of Couples Counselling on Reported HIV Risk Behaviour among HIV Serodiscordant Couples by ART Use, HIV Status and Gender in Rural Uganda

Background

We examined several measures of self-reported HIV risk behaviour in mutually disclosed sero-discordant couples over time to see if a couples counselling intervention was associated with changes in these behaviors.

Methods

We analysed data from a prospective cohort study of HIV sero-discordant couples in Jinja, Uganda collected between June 2009 and December 2011. Participants received couples counselling, at 3-monthly intervals. We examined trends in reported condom-use, number of concurrent sexual partners, knowledge of HIV serostatus of concurrent partners and condom use of concurrent partners using Generalized Estimating Equation models, comparing responses at study enrollment with responses at six, 12 18 and 24 months of follow-up.

Results

A total of 586 couples were enrolled and the female member was HIV positive in 255 (44%) of them. The median age for female participants was 35 years and 42 years for men. Reported condom use at last sex with spouse increased over time (p<0.001) with the largest increases found among couples where the positive participant never received ART during the study(an increase from 68.8% at enrollment to 97.1% at 24 months). Male participants reported reductions in the number of concurrent sexual partners (p<0.001), increase in the knowledge of the HIV serostatus of these partners (p = 0.001) and a trend towards improved condom-use among non-primary partners (p = 0.070). Reported reduced risky behaviors did not wane over the study period.

Conclusion

Couples counselling resulted in increased condom use among all participants and among men the intervention resulted in reductions in risk behaviour with concurrent sexual partners. Routine counselling for serodiscordant couples should be integrated in routine ART care programs.

How reliable are self-reports of HIV status disclosure? Evidence from couples in Malawi

INTRODUCTION

The majority of research on human immunodeficiency virus (HIV) disclosure utilizes the perspective from a single individual, which cannot be substantiated in the absence of supporting data such as from a primary partner.

OBJECTIVES

The objectives of this study were to evaluate: (1) the extent to which self-reported HIV disclosure was confirmed by a primary partner; (2) individual and relationship-level predictors of self-reported versus confirmed disclosure; and (3) whether confirmed disclosure was a stronger predictor of correctly assessing a partner's HIV status compared to self-reported disclosure.

METHODS

As part of an 8-wave longitudinal study from 2009 to 2011 in southern Malawi, 366 individuals (183 couples) were interviewed about their primary relationship (wave 3), individually tested for HIV (wave 4), and then asked whether they disclosed to their primary partner (wave 5).

RESULTS

While 93% of respondents reported that they disclosed, only 64% of respondents had confirmed reports from their partner. Having communicated with partner about HIV was positively associated with self-reported disclosure; this association remained significant but became more precise in the models for confirmed disclosure. Confirmed disclosure, but not self-report, was a significant predictor of correctly assessing a partner's HIV status. Being male, having lower perceived partner infidelity, having higher relationship unity, and testing HIV-negative were positively and significantly associated with correct assessment. Dyadic data from two partners provide an improved measure of disclosure as compared to a single individual's self-report and could be used to identify behavioral and biomedical opportunities to prevent HIV transmission within couples.

Partner HIV serostatus disclosure and determinants of serodiscordance among prevention of mother to child transmission clients in Nigeria

Background

Serodiscordance exists when the known HIV result of one member of a couple pair is positive while that of his/her partner is negative. In sub-Saharan Africa, in stable long-term couple partnerships (married or cohabiting), serodiscordance is a growing source of HIV-transmissions. This study aimed to ascertain across Nigeria, serodiscordance prevalence, partner HIV status disclosure and explore associations between suspected determinants and serodiscordance among PMTCT enrolled HIV positive pregnant women and their partners.

Methods

A retrospective Quality of Care performance evaluation was conducted in July 2013 among 544 HIV positive pregnant enrolees of PMTCT services in 62 comprehensive facilities across 5 of Nigeria’s 6 geo-political zones. Data of client-partner pairs were abstracted from pre-existing medical records and analysed using chi-square statistics and logistic regression.

Results

A total of 544 (22 %) of 2499 clients with complete partner details were analysed. Clients’ age ranged from 15 to 50 years with a mean of 30 years. Serodiscordant prevalence was 52 % and chi-square test suggests no significant difference between serodiscordant and seroconcordant clients and their partners (p = 0.265). Serodiscordant rates were closely associated trend wise with national HIV sero-prevalence rates and the median CD4+ count was 425 ul/mm³ (IQR: 290–606 ul/mm³). Similar proportion of clients (99 %) received testing and agreed to disclose status to their partners. Yet, there was no association between clients agreement to disclose HIV status to their partners and these partners getting tested and receiving results (p = 0.919). Significantly, 87 % of clients in concordant HIV positive relationships appeared to be symptomatic (WHO clinical stage 3 or 4) compared to 13 % clients in HIV-discordant relationships (p < 0.003). Client’s age and CD4+ count did not aptly predict serodiscordance (Wald = 0.011 and 0.436 respectively). However, the WHO clinical staging appeared to be a better predictor of serodiscordance and concordance than other variables (Wald = 3.167).

Conclusions

The results suggest that clinical staging (WHO) could be a better predictor of client- partner pair discordant or concordant HIV serostatus. Early partner testing and notification can avert seroconversion, hence properly designed and mainstreamed interventions that target serodiscordant couples are essential.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2155-x) contains supplementary material, which is available to authorized users.

Advances in HIV prevention for serodiscordant couples

Serodiscordant couples play an important role in maintaining the global HIV epidemic. This review summarizes biobehavioral and biomedical HIV prevention options for serodiscordant couples focusing on advances in 2013 and 2014, including World Health Organization guidelines and best evidence for couples counseling, couple-based interventions, and the use of antiviral agents for prevention. In the past few years, marked advances have been made in HIV prevention for serodiscordant couples and numerous ongoing studies are continuously expanding HIV prevention tools, especially in the area of pre-exposure prophylaxis. Uptake and adherence to antiviral therapy remains a key challenge. Additional research is needed to develop evidence-based interventions for couples, and especially for male-male couples. Randomized trials have demonstrated the prevention benefits of antiretroviral-based approaches among serodiscordant couples; however, residual transmission observed in recognized serodiscordant couples represents an important and resolvable challenge in HIV prevention.

Who Knows Their Partner's HIV Status? Results From a Nationally Representative Survey in Uganda

OBJECTIVE

We examine the extent to which Ugandans accurately know their HIV status and that of their partners.

METHODS

The 2011 Uganda AIDS Indicator Survey (UAIS) was a nationally representative study of 15-59 year olds that tested 21,366 individuals for HIV. We compared self-reported HIV status with UAIS-determined HIV status for respondents. We were able to link 3285 couples in the survey, and in this group, we compared the reported HIV status of partners with that determined by UAIS. Multiple logistic regression analysis was used to identify factors associated with inaccurate knowledge of HIV status.

RESULTS

An estimated 55.8% of adult Ugandans reported having had an HIV test. Of 1495 HIV-infected Ugandans, 59.1% were unaware of their HIV infection. Among 3285 linked couples in this analysis, 273 couples (8.3%) had at least 1 infected partner, with 96 couples (2.9%) having both members infected and the remaining 177 couples (5.4%) being HIV discordant. This meant that 369 persons in the linked couple group had an HIV-infected partner. One hundred ten (29.8%) of this group knew that their partner was HIV infected. In multiple logistic regression analysis, accurately knowing that ones partner was HIV infected was strongly associated with couple HIV testing [adjusted odds ratio (AOR): 4.3, 95% confidence interval (CI): 2.2 to 8.4] and reporting oneself to be HIV positive versus reporting HIV negative (AOR: 7.3, 95% CI: 3.8 to 14.3) or HIV status unknown (AOR: 30.6, 95% CI: 3.8 to 263.4).

CONCLUSIONS

Respondents may be reporting the HIV status of their partners based on their own HIV status. Campaigns to inform people about the prevalence of serodiscordance in conjunction with further promotion of couple counseling may help increase the proportion of Ugandans who know their own HIV status and that of their partners.

SURPRISING RESULTS: HIV TESTING AND CHANGES IN CONTRACEPTIVE PRACTICES AMONG YOUNG WOMEN IN MALAWI

This study uses eight waves of data from the population-based Tsogolo la Thanzi study (2009-2011) in rural Malawi to examine changes in young women's contraceptive practices, including the use of condoms, non-barrier contraceptive methods and abstinence, following positive and negative HIV tests. The analysis factors in women's prior perceptions of their HIV status that may already be shaping their behaviour and separates surprise HIV test results from those that merely confirm what was already believed. Fixed-effects logistic regression models show that HIV testing frequently affects the contraceptive practices of young Malawian women, particularly when the test yields an unexpected result. Specifically, women who are surprised to test HIV positive increase their condom use and are more likely to use condoms consistently. Following an HIV-negative test (whether a surprise or expected), women increase their use of condoms and decrease their use of non-barrier contraceptives; the latter may be due to an increase in abstinence following a surprise negative result. Changes in condom use following HIV testing are robust to the inclusion of potential explanatory mechanisms, including fertility preferences, relationship status and the perception that a partner is HIV positive. The results demonstrate that both positive and negative tests can influence women's sexual and reproductive behaviours, and emphasize the importance of conceptualizing of HIV testing as offering new information only insofar as results deviate from prior perceptions of HIV status.

The Impact of Visual Aids and Enhanced Training on the Delivery of Positive Health, Dignity, and Prevention Messages to Adult Patients Living with HIV in Rural North Central Mozambique

Introduction

Positive health, dignity, and prevention (PHDP) interventions target people living with HIV and AIDS (PLHIV) to promote well-being and prevent onward transmission. Concern that increased life expectancy and improved well-being would lead to increased risky sexual behaviour and subsequent HIV transmission motivated researchers to test novel strategies to support treatment adherence, encourage safer sex, STI treatment and partner testing, prevention of mother to child transmission, and support uptake of family planning.

Methods

We assessed the number and type of PHDP messages delivered to PLHIV before and after the implementation of an educational intervention for health providers combined with the distribution of visual job aids and monthly technical assistance.

Results

From April 21, 2013 to March 20, 2014, we documented 54,731 clinical encounters at three rural health centres in Zambézia province, Mozambique from 9,248 unique patients. The percentage of patients who received all seven PHDP messages during their last three visits was 1.9% pre-intervention vs. 13.6% post- intervention (p=<0.001). Younger patients (25 years vs. 35) and those with a recent HIV diagnosis (two weeks vs. two years) had higher odds of receiving any PHDP message (Odds Ratio [OR]: 1.22 and 2.79, respectively). Patients >59 days late collecting medications were not more likely to receive adherence messages than adherent patients (p=0.17).

Discussion

Targeting HIV prevention efforts to PLHIV is an effective HIV prevention approach to eliminate HIV transmission. Despite intensive training and support, PHDP message delivery remained unacceptably low in rural Mozambique. Patients at high risk for treatment abandonment were not more likely to be counselled about adherence and support measures, something that needs to be addressed.

Conclusions

We need to develop novel strategies to motivate health care providers to deliver these messages more consistently to all patients and develop a system that assists counsellors and clinicians to quickly and effectively determine which messages should be delivered.

Implementation of couples' voluntary HIV counseling and testing services in Durban, South Africa

Background

Couples’ voluntary HIV counseling and testing (CVCT) is an evidence-based intervention that significantly reduces HIV incidence in couples. Despite the high prevalence of HIV and HIV couple serodiscordance in South Africa, there are few CVCT services.

Methods

From February-June 2013, The Rwanda Zambia HIV Research Group provided support, training, and technical assistance for local counselors and promoters to pilot CVCT services in five hospital-based clinics in Durban, South Africa. Client-level data (age, gender, years cohabiting, pregnancy status, previous testing, antiretroviral treatment (ART) status, neighborhood, and test site) collected as a component of routine CVCT service operation is presented stratified by couple serostatus.

Results

Twenty counselors and 28 promoters completed training. Of 907 couples (1,814 individuals) that underwent CVCT, prevalence of HIV was 41.8 % and prevalence of HIV serodiscordance was 29.5 % (19.3 % M-F+, 10.3 % M + F-). Most participants were 25–34 years of age, and this group had the highest prevalence. Previous individual HIV testing was low (50 % for men, 63 % for women). Only 4 % of couples reported previous CVCT. Most (75 %) HIV+ partners were not on ART, and HIV+ individuals in discordant couples were more likely to be on ART than those in concordant positive couples. Pregnancy among HIV+ women was not associated with previous HIV testing or ART use.

Conclusions

Implementation of standard CVCT services was found to be feasible in Durban. The burden of HIV and couple serodiscordance in Durban was extremely high. CVCT would greatly benefit couples in Durban as an HIV prevention strategy.

Factors associated with HIV counseling and testing and correlations with sexual behavior of teachers in primary and secondary schools in Addis Ababa, Ethiopia

Background

The HIV/AIDS pandemic is a global crisis that affects the lives of millions of people. Although HIV counseling and testing (HCT) serves as the entry point for HIV prevention, treatment, and care, it remains a low priority in many settings. The aim of this study, therefore, was to assess the factors associated with HCT and their correlation with the sexual behavior of primary and secondary school teachers in Addis Ababa.

Methods

A comparative cross-sectional study was conducted among primary and secondary school teachers in Addis Ababa, Ethiopia. A multistage sampling technique was used to select a representative sample of 1,136 teachers. HCT and sexual health behavior-related data were collected using a self-administered questionnaire. Binary logistic regression was employed to examine the relationships between HCT, sociodemographics, and risky sexual behavior-related variables.

Results

Of the 1,136 eligible study participants, 1,034 (91.0%) teachers completed the self-administered anonymous questionnaire. The proportion of teachers who had ever tested for HIV was 739/1,034 (71.5%; 95% confidence interval [CI] 69.1–74.2). Multivariate logistic regression analyses showed that being male (adjusted odds ratio [AOR] 0.63; 95% CI 0.44–0.90) was associated with a 37% decrease in odds of being ever tested for HIV compared with being female. Married teachers were less likely to have had HIV testing (AOR 0.30; 95% CI 0.19–0.47) compared with unmarried teachers. Being aged ≥45 years (AOR 4.05; 95% CI 1.82–9.03), having high HCT-related knowledge (AOR 3.56; 95% CI 1.73–7.32), and having a perceived risk of HIV (AOR 1.43; 95% CI 1.04–1.96) were positively associated with HCT. Moreover, regarding the correlation of HCT with the sexual behavior of teachers, those teachers who never had HCT were more likely to have multiple sexual partners than those who had ever had HCT (AOR 1.85; 95% CI 1.08–3.15). In contrast, teachers who had ever been tested for HIV were less likely to have used condoms consistently than those who had never been tested (AOR 0.55; 95% CI 0.32–0.96).

Conclusion

No significant differences were observed between primary and secondary school teachers regarding factors associated with HCT and its correlation with sexual behavior. Gender, age, marital status, knowledge of HCT, and perceived risk were found to be factors associated with HCT uptake. Correlations between being faithful to a partner, inconsistent use of condoms, and HCT uptake of teachers were also observed. Thus, strengthening the current practice of HCT services in the education sector with due emphasis on the observed factors could play a pivotal role in bringing about positive changes in the sexual behavior of school community.

Correlates of Use of Timed Unprotected Intercourse to Reduce Horizontal Transmission Among Ugandan HIV Clients with Fertility Intentions

We examined the correlates of use of safer conception methods (SCM) in a sample of 400 Ugandan HIV clients (75 % female; 61 % on antiretroviral therapy; 61 % with HIV-negative or unknown status partners) in heterosexual relationships with fertility intentions. SCM assessed included timed unprotected intercourse, manual self-insemination, sperm washing, and pre-exposure prophylaxis (PrEP). In the 6 months prior to baseline, 47 (12 %) reported using timed unprotected intercourse to reduce risk of HIV infection (or re-infection), none had used manual self-insemination or sperm washing, and two had used PrEP. In multiple regression analysis, correlates of use of timed unprotected intercourse included greater perceptions of partner's willingness to use SCM and providers' stigma of childbearing among people living with HIV, higher SCM knowledge, and desire for a child within the next 6 months. These findings highlight the need for policy and provider training regarding integration of couples' safer conception counselling into HIV care.

Knowledge of HIV serodiscordance, transmission, and prevention among couples in Durban, South Africa

Objective

Couples’ voluntary HIV counseling and testing (CVCT) significantly decreases HIV transmission within couples, the largest risk group in sub-Saharan Africa, but it is not currently offered in most HIV testing facilities. To roll out such an intervention, understanding locale-specific knowledge barriers is critical. In this study, we measured knowledge of HIV serodiscordance, transmission, and prevention before and after receipt of CVCT services in Durban.

Design

Pre- and post-CVCT knowledge surveys were administered to a selection of individuals seeking CVCT services.

Methods

Changes in knowledge scores were assessed with McNemar Chi-square tests for balanced data and generalized estimating equation methods for unbalanced data.

Results

The survey included 317 heterosexual black couples (634 individuals) who were primarily Zulu (87%), unemployed (47%), and had at least a secondary level education (78%). 28% of couples proved to be discordant. Only 30% of individuals thought serodiscordance between couples was possible pre‐CVCT compared to 95% post-CVCT. One-third thought there was at least one benefit of CVCT pre‐CVCT, increasing to 96% post‐CVCT. Overall, there were positive changes in knowledge about HIV transmission and prevention. However, many respondents thought all HIV positive mothers give birth to babies with AIDS (64% pre-CVCT, 59% post-CVCT) and that male circumcision does not protect negative men against HIV (70% pre-CVCT, 67% post-CVCT).

Conclusions

CVCT was well received and was followed by improvements in understanding of discordance, the benefits of joint testing, and HIV transmission. Country-level health messaging would benefit from targeting gaps in knowledge about serodiscordance, vertical transmission, and male circumcision.

Willingness to use couples HIV testing and discussion of sexual agreements among heterosexuals

Couples HIV Testing and Counseling (CHTC) has been used as an HIV prevention strategy in Africa for over 20 years where the HIV epidemic is largely concentrated among sexually active heterosexuals. In recent years, CHTC has been adapted for men who have sex with men (MSM) in the US. A central element of the CHTC intervention as adapted for male couples in the US is the discussion of sexual agreements by the dyad during the CHTC session. Given the success of CHTC for heterosexual couples in Africa, it seems appropriate that CHTC could also be provided to heterosexual couples in the US. However, little is known about heterosexual’s willingness to utilize CHTC services including discussion of sexual agreements. This small, preliminary qualitative study sheds new light on the potential for CHTC adoption among heterosexuals in the US. Four focus groups were conducted with heterosexual men and women attending a publicly-funded STI clinic, to explore the potential feasibility and acceptability of CHTC with heterosexuals. The results are similar to those seen for MSM: high levels of willingness to use CHTC, perceptions of the advantages of using CHTC, and willingness to discuss sexual agreements; all necessary conditions for the successful roll-out of CHTC. Further work is now needed with larger samples of high-risk heterosexuals to more completely understand the typologies of sexual agreements and the common language used for sexual agreements in heterosexual relationships. These early data show great promise that CHTC can achieve the same levels of willingness, fit, and acceptability among heterosexual couples as currently experienced by male couples in the US.

Using provider performance incentives to increase HIV testing and counseling services in Rwanda

Paying for performance provides financial rewards to medical care providers for improvements in performance measured by utilization and quality of care indicators. In 2006, Rwanda began a pay for performance scheme to improve health services delivery, including HIV/AIDS services. Using a prospective quasi-experimental design, this study examines the scheme's impact on individual and couples HIV testing. We find a positive impact of pay for performance on HIV testing among married individuals (10.2 percentage points increase). Paying for performance also increased testing by both partners by 14.7 percentage point among discordant couples in which only one of the partners is an AIDS patient.

The Flawed Reliance on Randomized Controlled Trials in Studies of HIV Behavioral Prevention Interventions for People Who Inject Drugs and Other Populations

This article discusses ways in which randomized controlled trials do not accurately measure the impact of HIV behavioral interventions. This is because: 1. Such trials measure the wrong outcomes. Behavior change may have little to do with changes in HIV incidence since behavior change in events between HIV-concordant people have no impact on incidence. Even more important, the comparison of HIV incidence rates between study arms of individual-level RCTs does not measure the true outcome of interest-whether or not the intervention reduces HIV transmission at the community level. This is because this comparison cannot measure the extent to which the intervention stops transmission by HIV-infected people in the study to those outside it. (And this is made even worse if HIV-infected are excluded from the evaluation of the intervention.) 2. There are potential harms implicit in most cognitively oriented behavioral interventions that are not measured in current practice and may not be measurable using RCTs. Intervention trials often reinforce norms and values of individual self-protection. They rarely if ever measure whether doing this reduces community trust, solidarity, cohesion, organization, or activism in ways that might facilitate HIV transmission. 3. Many interventions are not best conceived of as interventions with individuals but rather with networks, cultures of risks, or communities. As such, randomizing individuals leads to effective interventions that diffuse protection through a community; but these are evaluated as ineffective because the changes diffuse to the control arm, which leads to systematic and erroneous reductions in the evaluated effectiveness as RCTs measure it. The paper ends by discussing research designs that are superior to individual-level RCTs at measuring whether an intervention reduces or increases new HIV transmission.

Perceived vulnerability and HIV testing among youth in Cape Town, South Africa

The importance of perceived vulnerability to risk-reducing behaviors, including HIV testing, is fairly established, especially among youth in sub-Saharan Africa. Yet, the majority of studies that examined this important relationship used cross-sectional data that inherently assume that perceived vulnerability does not change. While these studies have been useful, the assumption of perceived vulnerability as time invariant is a major flaw and has largely limited the practical usefulness of this variable in AIDS prevention and programing. Using longitudinal data and applying random-effects logit models, this study makes a major contribution to scholarship by examining if changes in perceived vulnerability associate with a change to test for HIV among 857 young people in Cape Town, South Africa. Results show that female youth who changed their risk perceptions were more likely to also change to test for HIV, but the effects were completely attenuated after controlling for theoretically relevant variables. No significant relationships were observed for males. Also, females who were virgins at wave 2 but had sex between waves were significantly more likely to have changed to test for HIV. Of most importance was that sexual behavior eliminated the effects of change in risk perceptions suggesting that a change in perception may have occurred as a result of changes in sexual behavior. AIDS prevention programs must pay particular attention to helping youth become aware of their vulnerability to HIV risks, especially as these have implications for risk-reducing behaviors, especially for females who are burdened.

Relationship Agreements and Willingness to Participate in Couples HIV Testing and Counseling Among Heterosexuals in the U.S

Couples HIV testing and counseling (CHTC) has been used for more than 20 years in African settings and more recently among men who have sex with men in the United States, but little is known about willingness of heterosexuals in the U.S. to use CHTC. We conducted an online survey of heterosexuals in sexual relationships to assess willingness to use CHTC and willingness to discuss relationship agreements within a couples counseling session. We found moderate levels of willingness to use CHTC and somewhat higher levels of willingness to discuss relationship agreements in a couples counseling session. The most frequently cited reason people were not willing was that they did not perceive themselves or their partners to be at risk for HIV. These results will be useful in planning for CHTC implementation for heterosexuals in the U.S.

Physicians' perceived barriers to management of sexually transmitted infections in Vietnam

Background

Sexually transmitted infections (STIs) are a public health problem in Vietnam with sub-optimal care in medical practice. Identifying practitioners’ perceived barriers to STI care is important to improve care for patients with STIs.

Methods

A cross-sectional survey was conducted among 451 physicians. These physicians were dermatology and venereology (D&V) doctors, obstetrical/gynaecological (Ob/Gyn) doctors, general practitioners, and assistant doctors working in health facilities at provincial, district and communal levels in three provinces in Vietnam.

Results

Almost all (99%) respondents mentioned at least one barrier to STI care. The barriers were “lack of STI training” (57%), “lack of professional resources” (41%), “lack of time” (38%), “lack of reimbursement” (21%), “lack of privacy/confidentiality” (17%), “lack of counselling” (15%), and “not the role of primary care provider” (7%). Multivariable logistic regression analysis showed that “lack of professional resources” was associated with respondents being in medical practice for ten years or under (vs. 11–20 years), and working at district or communal health facilities (vs. provincial facilities); “lack of time” were associated with respondents being female, seeing more than 30 patients a week (vs. <15 patients/week); and “lack of privacy/confidentiality” was associated with physicians’ seeing more than 30 patients a week (vs. <15 patients/week).

Conclusion

The study has identified several barriers to STI care in medical practice in Vietnam. Results of the study can be used to improve areas in STI care including policy and practice implications.

Attitudes of serodiscordant couples towards antiretroviral-based HIV prevention strategies in Kenya: a qualitative study

Introduction

Transmission in serodiscordant couples (SDCs) accounts for approximately half of all new HIV infections, both in Kenya and the wider sub-Saharan region [1]. With evidence to suggest inconsistent condom use within this population [2], the World Health Organization has recommended two new methods of HIV prevention for SDCs: Treatment as Prevention (TasP) and Pre-Exposure Prophylaxis (PrEP). However, there has been little research about the attitudes of SDCs towards these strategies [3, 4]; knowledge that is paramount for successfully predicting the acceptability and efficacy of each method, as well as for informing decisions regarding HIV policy changes in Kenya.

Methods

An exploratory, qualitative study was conducted in the Muhoroni constituency of Nyando district, Kenya from January to March 2013. Purposive sampling was predominately used to recruit 21 HIV-positive and 17 HIV-negative individuals in a serodiscordant relationship from four hospitals and health centres. During face-to-face semi-structured interviews, topic guides were used to elicit information about participants’ attitudes and preferences towards TasP and PrEP. Collected data underwent framework analysis, allowing the development of overarching categories, sub-themes and inductive interpretation.

Results

The majority of participants, irrespective of gender and HIV status, found TasP more acceptable than PrEP. A key factor influencing this decision was HIV-negative participants’ limited motivation to take and adhere to antiretrovirals (ARVs), primarily due to a predominantly external health locus of control, a lack of cultural acceptance of prophylactic medication and concerns about side effects. In addition to this, the likely health improvements TasP offers HIV-positive partners, as well as the attitude that the sick individual should be the first to receive HIV medication, also contributed to this conclusion. Issues of risk compensation were raised, with some HIV-negative partners indicating a desire to stop using condoms if ARV-based prevention methods were available.

Conclusions

Findings from the study indicate that TasP may represent a more viable approach to HIV prevention in Kenya than PrEP. Couples’ preferences, however, may differ depending on local attitudes towards prophylaxis and health locus of control.

Prevalence of "HIV/AIDS related" parental death and its association with sexual behavior of secondary school youth in Addis Ababa, Ethiopia: a cross sectional study

BACKGROUND

Human immunodeficiency virus infection is a global crisis that represents a serious health threat, particularly among younger people. Various studies show that both orphan and non-orphan adolescents and youths experience vulnerability to HIV. Nevertheless, the findings hitherto are mixed and inconclusive. The aim of this study, therefore, was to assess the prevalence of parental death and its association with multiple sexual partners among secondary school students for evidence based interventions.

METHODS

A cross-sectional study was conducted among secondary school youth in Addis Ababa, Ethiopia. A multistage sampling technique was used to select a representative sample of 2,169 school youths. Sexual health behavior related data were collected using self-administered questionnaire. Binary logistic regression was employed to examine the relation between parental death and multiple sexual partners.

RESULTS

Among the 2,169 eligible study participants 1948 (90%) completed the self-administered questionnaires. Of those 1,182(60.7%) were females. The overall prevalence of parental death was 347(17.8%.) with 95% CI (16.2%, 19.6%). The HIV/AIDS proportionate mortality ratio was 28% (97/347).A multivariate logistic regression analysis showed that high HIV/AIDS related knowledge (AOR = 0.39; 95% CI, 0.18-0.84), positive attitude towards HIV prevention methods (AOR = 0.48; 95% CI, 0.23-0.97), being tested for HIV (AOR = 0.52; 95% CI, 0.31-0.87) and chewing Khat (AOR = 2.59; 95% CI,1.28-5.26)] were significantly associated with having multiple sexual partners among secondary school youths.

CONCLUSIONS

Significant proportion of secondary school youths had lost at least one parent due to various causes. High knowledge of HIV/AIDS, positive attitude towards 'ABC' rules for HIV prevention, being tested for HIV and chewing khat are more likely to be factors associated with multiple sexual partnership among secondary school students in Addis Ababa.Therefore, the school based interventions against the HIV/AIDS epidemic should be strengthened with particular emphasis on the effects of HIV/AIDS related knowledge, attitude towards preventive measures, mechanisms for improving HIV Counseling and Testing coverage and the associated prevailing risk factors.

Systematic review of couple-based HIV intervention and prevention studies: advantages, gaps, and future directions

We conducted a systematic review of couple-based HIV biobehavioral (skills-building, VCT, and adherence) and biomedical (ART, circumcision) prevention and intervention studies designed to reduce sexual- and drug-risk behaviors and HIV transmission and acquisition. Of the 11,162 papers identified in the search, 93 peer-reviewed papers met the inclusion criteria and yielded a total of 33 studies conducted globally. Biobehavioral couple-based prevention and intervention studies have been efficacious in reducing sexual- and drug-risk behaviors, increasing access to HIV testing and care, and improving adherence. Biomedical couple-based studies were found to reduce HIV incidence among HIV-negative sex partners and viral load among HIV-positive partners. Despite much progress, couple-based HIV prevention and intervention studies remain limited; a number of methodological gaps exist and studies focusing on MSM, people who inject drugs, and sex workers are scarce.

Individual and interpersonal characteristics that influence male-dominated sexual decision-making and inconsistent condom use among married HIV serodiscordant couples in Gujarat, India: results from the positive Jeevan Saathi study

Approximately 40 % of new infections occur among married women. No studies have examined the factors that may contribute to HIV transmission among HIV-negative wives in HIV serodiscordant relationships in Gujarat, India. In 2010, a cross-sectional survey with 185 HIV serodiscordant, married couples (i.e. 185 HIV-positive husbands and their 185 HIV-negative wives) in Gujarat was conducted. Socio-demographic, individual, and interpersonal characteristics of HIV-positive husbands and their HIV negative wives were examined. The association of these characteristics with inconsistent condom use and male-dominated sexual decision-making, were examined using multivariate logistic regression analyses. Approximately 10 % of couples reported inconsistent condom use in the past 3 months and 20 % reported intimate partner violence (IPV). Reports of IPV were associated with a higher odds of inconsistent condom use among HIV-positive husbands (aOR = 6.281). Husbands who reported having received couples counseling had a lower odds of male-dominated decision making about condom use (aOR = 0.372). HIV-negative wives who reported sex communication had a lower odds of male-dominated decision making about condom use (aOR = 0.322) with their HIV-positive husbands. Although condom use is a traditional measure of risk behavior, other factors that facilitate risk, such as male-dominated sexual decision-making need to be considered in analyses of risk.

"Men are always scared to test with their partners … it is like taking them to the Police": Motivations for and barriers to couples' HIV counselling and testing in Rakai, Uganda: a qualitative study

INTRODUCTION

Uptake of couples' HIV counselling and testing (couples' HCT) can positively influence sexual risk behaviours and improve linkage to HIV care among HIV-positive couples. However, less than 30% of married couples have ever tested for HIV together with their partners. We explored the motivations for and barriers to couples' HCT among married couples in Rakai, Uganda.

METHODS

This was a qualitative study conducted among married individuals and selected key informants between August and October 2013. Married individuals were categorized by prior HCT status as: 1) both partners never tested; 2) only one or both partners ever tested separately; and 3) both partners ever tested together. Data were collected on the motivations for and barriers to couples' HCT, decision-making processes from tested couples and suggestions for improving couples' HCT uptake. Eighteen focus group discussions with married individuals, nine key informant interviews with selected key informants and six in-depth interviews with married individuals that had ever tested together were conducted. All interviews were audio-recorded, translated and transcribed verbatim and analyzed using Nvivo (version 9), following a thematic framework approach.

RESULTS

Motivations for couples' HCT included the need to know each other's HIV status, to get a treatment companion or seek HIV treatment together - if one or both partners were HIV-positive - and to reduce mistrust between partners. Barriers to couples' HCT included fears of the negative consequences associated with couples' HCT (e.g. fear of marital dissolution), mistrust between partners and conflicting work schedules. Couples' HCT was negotiated through a process that started off with one of the partners testing alone initially and then convincing the other partner to test together. Suggestions for improving couples' HCT uptake included the need for couple- and male-partner-specific sensitization, and the use of testimonies from tested couples.

CONCLUSIONS

Couples' HCT is largely driven by individual and relationship-based factors while fear of the negative consequences associated with couples' HCT appears to be the main barrier to couples' HCT uptake in this setting. Interventions to increase the uptake of couples' HCT should build on the motivations for couples' HCT while dealing with the negative consequences associated with couples' HCT.

A Pilot Intervention to Promote Safer Sex in Heterosexual Puerto Rican Couples

Although the sexual transmission of HIV occurs in the context of an intimate relationship, preventive interventions with couples are scarce, particularly those designed for Hispanics. In this article, we present the effect of a pilot intervention directed to prevent HIV/AIDS in heterosexual couples in Puerto Rico. The intervention was theory-based and consisted of five three-hour group sessions. Primary goals included increasing male condom use and the practice of mutual masturbation as a safer sex method, and promoting favorable attitudes toward these behaviors. Twenty-six couples participated in this study. Fifteen were randomly assigned to the intervention group and eleven to a control group. Retention rates at post-intervention and follow-up were 82% for the whole sample. Results showed that there was a significant increase in the use of male condoms with main partners in the intervention group when compared with the control group. Couples in the intervention group also had better scores on secondary outcomes, such as attitudes toward condom use and mutual masturbation, HIV information, sexual decision-making, and social support. We found that these effects persisted over the three month follow up. A significant effect was also observed for the practice of mutual masturbation, but not for sexual negotiation. These results showed that promoting male condom use in dyadic interventions among heterosexual couples in Puerto Rico is feasible. Our findings suggest that because vaginal penetration has been constructed as the sexual script endpoint among many Hispanic couples, promoting other non-penetrative practices, such as mutual masturbation, may be difficult.

The heterogeneous effects of HIV testing

An extensive multi-disciplinary literature examines the effects of learning one's HIV status on subsequent risky sexual behaviors. However, many of these studies rely on non-experimental designs; use self-reported outcome measures; or both. In this study, we investigate the effects of a randomly assigned home based HIV testing and counseling (HTC) intervention on risky sexual behaviors and schooling investments among school-age females in Malawi. We find no overall effects on HIV, Herpes Simplex Virus (HSV-2), or achievement test scores at follow-up. However, among the small group of individuals who tested positive for HIV, we find a large increase in the probability of HSV-2 infection, with this effect being stronger among those surprised by their test results. Similarly, those surprised by HIV-negative test results have significantly higher achievement test scores at follow-up, consistent with increased returns to investments in human capital.

"I may not say we really have a method, it is gambling work": knowledge and acceptability of safer conception methods among providers and HIV clients in Uganda

In this qualitative study, researchers assessed knowledge, acceptability, and feasibility of safer conception methods (SCM; timed unprotected intercourse [TUI], manual self-insemination, and sperm washing) among various health care providers (n = 33) and 48 HIV clients with recent or current childbearing intentions in Uganda. While several clients and providers had heard of SCM (especially TUI), few fully understood how to use the methods. All provider types expressed a desire to incorporate SCM into their practice; however, this will require training and counseling protocols, sensitization to overcome cultural norms that pose obstacles to these methods, and partner engagement (particularly by men) in safer conception counseling.