Sexual behavior of HIV discordant couples after HIV counseling and testing

Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behavior: a systematic review and meta-analysis

BACKGROUND

Increased global access and use of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behavior. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behavior or diagnosis of sexually transmitted infections (STIs).

METHODS

A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared with no ART use in experimental or observational studies. Primary outcomes included (1) any unprotected sexual intercourse, (2) STI diagnoses, and (3) any unsafe injecting behavior.

RESULTS

Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; 11 studies containing 16 138 participants reported STI diagnoses; and 4 studies containing 1600 participants reported unsafe injecting behavior. All included studies were observational. Unprotected sex was lower in participants receiving ART than in those not receiving ART (odds ratio [OR], 0.73; 95% confidence interval [CI], .64-.83; P < .001; heterogeneity I(2) = 79%) in both high-income (n = 38) and low-/middle-income country (n = 18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR, 0.58; 95% CI, .33-1.01; P = .053; I(2) = 92%); however, there was no difference in injecting risk-taking behavior with antiretroviral use (OR, 0.90; 95% CI, .60-1.35; P = .6; I(2) = 0%).

CONCLUSIONS

Despite concerns that use of ART might increase sexual or injecting risk-taking, available research suggests that unprotected sex is reduced among HIV-infected individuals on treatment. The reasons for this are not yet clear, although self-selection and mutually reinforcing effects of HIV treatment and prevention messages among people on ART are likely.

Risk reduction among HIV-seroconcordant and -discordant couples: the Zambia NOW2 intervention

Heterosexual HIV transmission remains the leading cause of HIV incidence in adult men and women in sub-Saharan Africa. This study assessed whether an HIV risk-reduction intervention would be more likely to increase sexual barrier acceptability and decrease risk behavior when delivered to couples in gender concordant groups or in an individual format. This study also examined the mutual impact of couple members as a source of influence on acceptability, and assessed whether product acceptability, intimate partner violence (IPV), and/or partner communication predicted sexual barrier use. HIV seroconcordant and serodiscordant couples (n=216) were recruited in Lusaka, Zambia, and randomized to a four session gender-concordant intervention. Participants were assessed at baseline, 6, and 12 months. Willingness to use barriers (p=0.012), acceptability (p<0.001), and barrier use (p<0.001) increased over time in both conditions, and were influenced by gender preferences. IPV decreased (p=0.040) and positive communication increased (p<0.001) in both conditions. Individual and gender concordant group sessions achieved similar increases in sexual barrier use following the intervention. Results highlight the influence of partners as well as product acceptability as predictors of sexual barrier use among couples in sub-Saharan Africa. Future prevention studies should consider both product acceptability and partner influence to achieve optimal sexual risk behavior outcomes.

Low antibody-dependent cellular cytotoxicity responses in Zambians prior to HIV-1 intrasubtype C superinfection

We have previously shown that HIV-1 superinfected Zambian seroconverters mount low binding and neutralizing antibody responses to their primary HIV-1 infecting virus, which could increase susceptibility to re-infection. Here, we investigated if antibody-dependent cellular cytotoxicity (ADCC), a process by which virus-infected cells are killed, was also reduced. Superinfected individuals exhibited low ADCC activity compared to non-superinfected individuals, but similar levels of CMV-reactive binding antibodies, suggesting superinfected individuals are capable of generating and maintaining virus-specific antibodies.

Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention

Large declines in HIV incidence have been reported since 2001, and scientific advances in HIV prevention provide strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public health approach to combination prevention that understands that risk is not evenly distributed and that effective interventions can vary by risk profile. Different countries have different microepidemics, with very different levels of transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies, people at highest risk for HIV, and the package of interventions that are most likely to have the largest effect in each different microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision, as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.

Four models of HIV counseling and testing: utilization and test results in South Africa

BACKGROUND

HIV Counseling and Testing (HCT) is the point-of-entry for pathways of HIV care and prevention. However, HCT is not reaching many who are HIV infected and this may be related to the HCT provision model. We describe HCT utilization and HIV diagnosis using four models of HCT delivery: clinic-based, urban mobile, rural mobile, and stand-alone.

METHODS

Using cross-sectional data from routine HCT provided in South Africa, we described client characteristics and HIV test results from information collected during service delivery between January 2009 and June 2012.

RESULTS

118,358 clients received services at clinic-based units, 18,597; stand-alone, 28,937; urban mobile, 38,840; and rural mobile, 31,984. By unit, clients were similar in terms of median age (range 28-31), but differed in sex distribution, employment status, prior testing, and perceived HIV risk. Urban mobile units had the highest proportion of male clients (52%). Rural mobile units reached the highest proportion of clients with no prior HCT (61%) and reporting no perceived HIV risk (64%). Overall, 10,862 clients (9.3%) tested HIV-positive.

CONCLUSIONS

Client characteristics varied by HCT model. Importantly, rural and urban mobile units reached more men, first-time testers, and clients who considered themselves to be at low risk for HIV.

The status of HIV testing and counseling in Kenya: results from a nationally representative population-based survey

BACKGROUND

HIV testing and counseling (HTC) is essential for successful HIV prevention and treatment programs. The national target for HTC is 80% of the adult population in Kenya. Population-based data to measure progress towards this HTC target are needed to assess the country's changing needs for HIV prevention and treatment.

METHODS

In 2012-2013, we conducted a national HIV survey among Kenyans aged 18 months to 64 years. Respondents aged 15-64 years were administered a questionnaire that collected information on demographics, HIV testing behavior, and self-reported HIV status. Blood samples were collected for HIV testing in a central laboratory. Participants were offered home-based testing and counseling to learn their HIV status in the home and point-of-care CD4 testing if they tested HIV-positive.

RESULTS

Of 13,720 adults who were interviewed, 71.6% [95% confidence interval (CI): 70.2 to 73.1] had been tested for HIV. Among those, 56.1% (95% CI: 52.8 to 59.4) had been tested in the past year, 69.4% (95% CI: 68.0 to 70.8) had been tested more than once, and 37.2% (95% CI: 35.7 to 38.8) had been tested with a partner. Fifty-three percent (95% CI: 47.6 to 58.7) of HIV-infected persons were unaware of their infection. Overall 9874 (72.0%) of participants accepted home-based HIV testing and counseling; 4.1% (95% CI: 3.3 to 4.9) tested HIV-positive, and of those, 42.5% (95% CI 31.4 to 53.6) were in need of immediate treatment for their HIV infection but not receiving it.

CONCLUSIONS

HIV testing rates have nearly reached the national target for HTC in Kenya. However, knowledge of HIV status among HIV-infected persons remains low. HTC needs to be expanded to reach more men and couples, and strategies are needed to increase repeat testing for persons at risk for HIV infection.

Determinants of HIV testing among Nigerian couples: a multilevel modelling approach

In this article we analyse the determinants of HIV testing among Nigerian couples using Demographic and Health Survey data set (2008). This study is motivated by the fact that although there is a strong willingness from the Nigerian Government to examine new HIV preventions approaches such as Pre-Exposure Prophylaxis for HIV (PrEP) and Treatment as Prevention (TasP) for HIV serodiscordant couples, the implementation of such policies would require the HIV status of each partner in the couple to be known. This is far to be achieved in the Nigerian context since in Nigeria only 6% of couples know their HIV status. In order to identify potential policies that are needed to increase HIV testing uptake, we use a three-level random intercept logistic model to separately explore the determinants of knowing HIV status among female and male partners. The use of the multilevel modelling allows including the unobserved heterogeneity at the village and state level that may affect HIV testing behaviours. Our results indicate that education, wealth, stigma, HIV knowledge and perceived risk are predictors of HIV testing among both partners while routine provider initiated testing appears to be very effective to increase HIV testing among women. The introduction of financial incentives as well as an increase in routine testing and home-based testing may be needed for large scale increase in HIV testing prior to the implementation of new HIV prevention technologies among discordant couples.

Adaptation of the African couples HIV testing and counseling model for men who have sex with men in the United States: an application of the ADAPT-ITT framework

To respond to the need for new HIV prevention services for men who have sex with men (MSM) in the United States, and to respond to new data on the key role of main partnerships in US MSM epidemics, we sought to develop a new service for joint HIV testing of male couples. We used the ADAPT-ITT framework to guide our work. From May 2009 to July 2013, a multiphase process was undertaken to identify an appropriate service as the basis for adaptation, collect data to inform the adaptation, adapt the testing service, develop training materials, test the adapted service, and scale up and evaluate the initial version of the service. We chose to base our adaptation on an African couples HIV testing service that was developed in the 1980s and has been widely disseminated in low- and middle-income countries. Our adaptation was informed by qualitative data collections from MSM and HIV counselors, multiple online surveys of MSM, information gathering from key stakeholders, and theater testing of the adapted service with MSM and HIV counselors. Results of initial testing indicate that the adapted service is highly acceptable to MSM and to HIV counselors, that there are no evident harms (e.g., intimate partner violence, relationship dissolution) associated with the service, and that the service identifies a substantial number of HIV serodiscordant male couples. The story of the development and scale-up of the adapted service illustrates how multiple public and foundation funding sources can collaborate to bring a prevention adaptation from concept to public health application, touching on research, program evaluation, implementation science, and public health program delivery. The result of this process is an adapted couples HIV testing approach, with training materials and handoff from academic partners to public health for assessment of effectiveness and consideration of the potential benefits of implementation; further work is needed to optimally adapt the African couples testing service for use with male-female couples in the United States.

Predictors of first follow-up HIV testing for couples' voluntary HIV counseling and testing in Ndola, Zambia

INTRODUCTION

We describe predictors of first follow-up testing for concordant negative and discordant couples seeking joint voluntary HIV counseling and testing in Ndola, Zambia, where cohabiting couples account for an estimated two-thirds of incident HIV infections.

METHODS

Demographic and serostatus data were collected from couples' voluntary HIV testing and counseling and follow-up testing services implemented in government clinics. We calculated follow-up testing rates by serostatus and compared rates before and after the introduction of a Good Health Package (GHP).

RESULTS

The follow-up testing rate from May 2011 to December 2012 was 12.2% for concordant negative (M-F-) couples and 24.5% for discordant (M+F- or M-F+) couples. Significant predictors of follow-up testing in multivariate analyses included increasing age of the man [adjusted odds ratio (aOR) = 1.02 per year] and the woman (aOR = 1.02 per year), and either partner being HIV+ (aOR = 2.57 for HIV+ man, aOR = 1.89 for HIV+ woman). The man (aOR = 1.29) and the couple (aOR = 1.22) having been previously tested for HIV were predictive of follow-up testing among concordant negative couples. Introduction of a GHP increased follow-up testing among discordant (aOR = 2.93) and concordant negative (aOR = 2.06) couples.

CONCLUSIONS

A low-cost GHP, including prevention, screening, and treatment for common causes of morbidity and mortality resulted in increased follow-up testing rates among HIV discordant and concordant negative couples. Overall follow-up testing rates remain low, and efforts to increase these rates are necessary to ensure linkage to combination prevention, reduce HIV transmission within couples, and identify seroconversions promptly. Further investigation of low-cost sustainable incentives and other factors influencing follow-up HIV testing for couples is needed.

Incidence of TB and HIV in prospectively followed household contacts of TB index patients in South Africa

Objective

To report the incidence rates of TB and HIV in household contacts of index patients diagnosed with TB.

Design

A prospective cohort study in the Matlosana sub-district of North West Province, South Africa.

Methods

Contacts of index TB patients received TB and HIV testing after counseling at their first household visit and were then followed up a year later, in 2010. TB or HIV diagnoses that occurred during the period were determined.

Results

For 2,377 household contacts, the overall observed TB incidence rate was 1.3 per 100 person years (95% CI 0.9–1.9/100py) and TB incidence for individuals who were HIV-infected and HIV seronegative at baseline was 5.4/100py (95% CI 2.9–9.0/100py) and 0.7/100py (95% CI 0.3–1.4/100py), respectively. The overall HIV incidence rate was 2.2/100py (95% CI 1.3–8.4/100py).

Conclusions

In the year following a household case finding visit when household contacts were tested for TB and HIV, the incidence rate of both active TB and HIV infection was found to be extremely high. Clearly, implementing proven strategies to prevent HIV acquisition and preventing TB transmission and progression to disease remains a priority in settings such as South Africa.

2014 European Guideline on HIV testing

Testing for HIV is one of the cornerstones in the fight against HIV spread. The 2014 European Guideline on HIV Testing provides advice on testing for HIV infection in individuals aged 16 years and older who present to sexually transmitted infection, genito-urinary or dermato-venereology clinics across Europe. It may also be applied in other clinical settings where HIV testing is required, particularly in primary care settings. The aim of the guideline is to provide practical guidance to clinicians and laboratories that within these settings undertake HIV testing, and to indicate standards for best practice.

Qualitative evaluation of a Positive Prevention training for health care providers in Mozambique

The rapid scale-up of HIV care and treatment in Mozambique has provided an opportunity to reach people living with HIV (PLHIV) with prevention interventions in HIV care and treatment settings. A three-day Positive Prevention (PP) training intervention for health care providers that focused on pressing issues for PLHIV in Mozambique was adapted and delivered at sites in three provinces. In-depth interviews were conducted with 31 providers trained in the PP curriculum. Qualitative data were used to assess the appropriateness of the training materials and approach, which lessons providers learned and were able to implement and which PP messages were still difficult to deliver. Providers reported gaining numerous insights from the training, including how to conduct a risk assessment and client-centered counseling, negotiating disclosure, partner testing, condom use, PMTCT, treatment adherence and approaches for positive living. Training topics not commonly mentioned included discordance counseling, STIs, family planning, alcohol and drug use, and frank sexual risk discussions. While areas for improvement exist, the PP training was useful in transferring skills to providers and is a viable component of HIV care. This evaluation helps identify areas where future PP trainings and specific strategies and messages can be refined for the Mozambican context.

Challenges with couples, serodiscordance and HIV disclosure: healthcare provider perspectives on delivering safer conception services for HIV-affected couples, South Africa

INTRODUCTION

Safer conception interventions should ideally involve both members of an HIV-affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa.

METHODS

We conducted six semistructured individual interviews per site (a total of 12 interviews) as well as a focus group discussion at each clinic site (a total of 13 additional participants). All interviews were coded in Atlas.ti using a grounded theory approach to develop codes and to identify core themes and subthemes in the data.

RESULTS

Managing the clinical and relationship complexities related to serodiscordant couples wishing to conceive was flagged as a concern by all categories of health providers. Providers added that, in the HIV clinical setting, they often found it difficult to balance their professional priorities, to maintain the health of their clients, and to ensure that partners were not exposed to unnecessary risk, while still supporting their clients' desires to have a child. Many providers expressed concern over issues related to disclosure of HIV status between partners, particularly when managing couples where one partner was not aware of the other's status and expressed the desire for a child. Provider experiences were that female clients most often sought out care, and it was difficult to reach the male partner to include him in the consultation.

CONCLUSIONS

Providers require support in dealing with HIV disclosure issues and in becoming more confident in dealing with couples and serodiscordance. Prior to implementing safer conception programmes, focused training is needed for healthcare professionals to address some of the ethical and relationship issues that are critical in the context of safer conception care.

Uthando Lwethu ('our love'): a protocol for a couples-based intervention to increase testing for HIV: a randomized controlled trial in rural KwaZulu-Natal, South Africa

Background

Couples-based HIV counseling and testing (CHCT) is a proven strategy to reduce the risk of HIV transmission between partners, but uptake of CHCT is low. We describe the study design of a randomized controlled trial (RCT) aimed to increase participation in CHCT and reduce sexual risk behavior for HIV among heterosexual couples in rural KwaZulu-Natal, South Africa. We hypothesize that the rate of participation in CHCT will be higher and sexual risk behavior will be lower in the intervention group as compared to the control.

Methods/design

Heterosexual couples (N = 350 couples, 700 individuals) are being recruited to participate in a randomized trial of a couples-based intervention comprising two group sessions (one mixed gender, one single gender) and four couples’ counseling sessions. Couples must have been in a relationship together for at least 6 months. Quantitative assessments are conducted via mobile phones by gender-matched interviewers at baseline, 3, 6, and 9 months post-randomization. Intervention content is aimed to improve relationship dynamics, and includes communication skills and setting goals regarding CHCT.

Discussion

The Uthando Lwethu (‘our love’) intervention is the first couples-based intervention to have CHCT as its outcome. We are also targeting reductions in unprotected sex. CHCT necessitates the testing and mutual disclosure of both partners, conditions that are essential for improving subsequent outcomes such as disclosure of HIV status, sexual risk reduction, and improving treatment outcomes. Thus, improving rates of CHCT has the potential to improve health outcomes for heterosexual couples in a rural area of South Africa that is highly impacted by HIV. The results of our ongoing clinical trial will provide much needed information regarding whether a relationship-focused approach is effective in increasing rates of participation in CHCT. Our intervention represents an attempt to move away from individual-level conceptualizations, to a more integrated approach for HIV prevention.

Trial registration

Study Name: Couples in Context: An RCT of a Couples-based HIV Prevention Intervention

ClinicalTrials.gov identifier: NCT01953133.

South African clinical trial registration number: DOH-27-0212-3937

Incorporating couples-based approaches into HIV prevention for gay and bisexual men: opportunities and challenges

Thirty years after the beginning of the HIV epidemic, gay, bisexual, and other men who have sex with men (collectively called MSM) bear a disproportionate burden of HIV in the United States and continue to acquire a distressingly high number and proportion of new infections. Historically, HIV prevention for MSM has been focused on individual-level behavior change, rarely intervening with MSM as part of a couple. Yet, an estimated 33–67% of HIV infections among MSM are acquired from primary sexual partners, suggesting that work with MSM as couples could be an important contributor to prevention. Given the emergence of high impact combination HIV prevention, it is timely to consider how work with the broad variety of male couples can improve both personal and community health. Couples HIV testing and counseling for MSM is an important advance for identifying men who are unaware that they are HIV-positive, identifying HIV-discordant couples, and supporting men who want to learn their HIV status with their partner. Once men know their HIV status, new advances in biomedical prevention, which can dramatically reduce risk of HIV transmission or acquisition, allow men to make prevention decisions that can protect themselves and their partners. This paper highlights the present-day challenges and benefits of using a couples-based approach with MSM in the era of combination prevention to increase knowledge of HIV status, increase identification of HIV discordant couples to improve targeting prevention services,and support mutual disclosure of HIV status.

Cost-effectiveness of provider-based HIV partner notification in urban Malawi

Provider-initiated partner notification for HIV effectively identifies new cases of HIV in sub-Saharan Africa, but is not widely implemented. Our objective was to determine whether provider-based HIV partner notification strategies are cost-effective for preventing HIV transmission compared with passive referral. We conducted a cost-effectiveness analysis using a decision-analytic model from the health system perspective during a 1-year period. Costs and outcomes of all strategies were estimated with a decision-tree model. The study setting was an urban sexually transmitted infection clinic in Lilongwe, Malawi, using a hypothetical cohort of 5000 sex partners of 3500 HIV-positive index cases. We evaluated three partner notification strategies: provider notification (provider attempts to notify indexes' locatable partners), contract notification (index given 1 week to notify partners then provider attempts notification) and passive referral (index is encouraged to notify partners, standard of care). Our main outcomes included cost (US dollars) per transmission averted, cost per new case identified and cost per partner tested. Based on estimated transmissions in a 5000-person cohort, provider and contract notification averted 27.9 and 27.5 new infections, respectively, compared with passive referral. The incremental cost-effectiveness ratio (ICER) was $3560 per HIV transmission averted for contract notification compared with passive referral. Provider notification was more expensive and slightly more effective than contract notification, yielding an ICER of $51 421 per transmission averted. ICERs were sensitive to the proportion of partners not contacted, but likely HIV positive and the probability of transmission if not on antiretroviral therapy. The costs per new case identified were $36 (provider), $18 (contract) and $8 (passive). The costs per partner tested were $19 (provider), $9 (contract) and $4 (passive). We conclude that, in this population, provider-based notification strategies are potentially cost-effective for identifying new cases of HIV. These strategies offer a simple, effective and easily implementable opportunity to control HIV transmission.

Interest in couples-based voluntary HIV counseling and testing in a national U.S. sample of gay and bisexual men: the role of demographic and HIV risk factors

Main partnerships represent one context in which HIV transmission may occur that has been insufficiently addressed to date for gay and bisexual men, but few studies have focused on the acceptability of couples-based voluntary HIV counseling and testing (CVCT) for male couples in the U.S. Our aim in this study was to explore the acceptability of CVCT among a national U.S. sample of 1,532 gay and bisexual men surveyed online using a sexual networking site. We examined the role of demographic (i.e., geographic region, age, relationship status, sexual orientation, race/ethnicity) and HIV risk (i.e., substance use, number of sexual partners, unprotected anal intercourse, sexual role identity, and sexual compulsivity) factors that may be associated with CVCT among the full sample and among partnered men separately. We found that single men expressed higher interest in CVCT than partnered men and that greater age was more strongly associated with lower interest in CVCT for partnered men than for single men. The intersection of sexual orientation and race/ethnicity was also significantly associated with CVCT interest, with a higher proportion of Black bisexual men being interested than White bisexual men. These findings suggest that the uptake of CVCT may be less impacted by HIV risk factors than by demographic factors and that young gay and bisexual men of color-for whom rates of HIV continue to rise-may be the group with the highest levels of interest in CVCT.

The prevalence of undiagnosed HIV serodiscordance among male couples presenting for HIV testing

In the United States, a substantial proportion of HIV transmissions among men who have sex with men (MSM) arise from main sex partners. Couples voluntary HIV testing and counseling (CHTC) is used in many parts of the world with male-female couples, but CHTC has historically not been available in the U.S. and few data exist about the extent of HIV serodiscordance among U.S. male couples. We tested partners in 95 Atlanta male couples (190 men) for HIV. Eligible men were in a relationship for ≥3 months and were not known to be HIV-positive. We calculated the prevalence of couples that were seroconcordant HIV-negative, seroconcordant HIV-positive, or HIV serodiscordant. We evaluated differences in the prevalence of HIV serodiscordance by several dyadic characteristics (e.g., duration of relationship, sexual agreements, and history of anal intercourse in the relationship). Overall, among 190 men tested for HIV, 11 % (n = 20) were newly identified as HIV-positive. Among the 95 couples, 81 % (n = 77) were concordant HIV-negative, 17 % (n = 16) were HIV serodiscordant, and 2 % (n = 2) were concordant HIV-positive. Serodiscordance was not significantly associated with any evaluated dyadic characteristic. The prevalence of undiagnosed HIV serodiscordance among male couples in Atlanta is high. Offering testing to male couples may attract men with a high HIV seropositivity rate to utilize testing services. Based on the global evidence base for CHTC with heterosexual couples and the current evidence of substantial undiagnosed HIV serodiscordance among U.S. MSM, we recommend scale-up of CHTC services for MSM, with ongoing evaluation of acceptability and couples' serostatus outcomes.

"Working together to reach a goal": MSM's perceptions of dyadic HIV care for same-sex male couples

INTRODUCTION

Same-sex serodiscordant male dyads represent a high-priority risk group, with approximately one to two thirds of new HIV infections among men who have sex with men attributable to main partnerships. Early initiation and adherence to highly active antiretroviral therapy is a key factor in HIV prevention and treatment; however, adherence to highly active antiretroviral therapy in the United States is low, with poor retention throughout the continuum of care. This study examines the perceptions of dyadic HIV treatment of men who have sex with men across the continuum of care to understand the preferences for how care may be sought with a partner.

METHODS

We conducted 5 focus group discussions in Atlanta, GA, with 35 men who reported being in same-sex male partnerships. Participants discussed perceptions of care using scenarios of a hypothetical same-sex male couple who recently received serodiscordant or seroconcordant HIV-positive results. Verbatim transcripts were segmented thematically and systematically analyzed to examine patterns in responses within and between participants and focus group discussions.

RESULTS

Participants identified the need for comprehensive dyadic care and differences in care for seroconcordant HIV-positive versus serodiscordant couples. Participants described a reciprocal relationship between comprehensive dyadic care and positive relationship dynamics. This combination was described as reinforcing commitment, ultimately leading to increased accountability and treatment adherence.

DISCUSSION

Results indicate that the act of same-sex male couples "working together to reach a goal" may increase retention to HIV care across the continuum if care is comprehensive, focuses on both individual and dyadic needs, and promotes positive relationship dynamics.

The role of men as partners and fathers in the prevention of mother-to-child transmission of HIV and in the promotion of sexual and reproductive health

Despite ample evidence documenting the positive impact of men on the prevention of mother-to-child transmission (PMTCT) and other sexual and reproductive health programs, men's engagement remains very low. This paper examines the current level and nature of male involvement and identifies opportunities for the advancement of men's constructive engagement in PMTCT and sexual and reproductive health. Conceptual and policy barriers have encouraged the inadvertent exclusion of men from PMTCT and other reproductive health services. The historic institutionalization of reproductive health as women's health has generally resulted in health services that are not welcoming of men and has undermined efforts to engage couples. This paper argues that to maximize the health outcomes of PMTCT and sexual and reproductive health programs for women and men, we must move beyond seeing men as simply "facilitating factors" that enable women to access health-care services. Men need to instead be recognized as a constituent part of reproductive health policy and practice. The paper proposes strategies for policy makers and program leaders to engage men and couples to foster communication and shared decision-making. This approach can both help to achieve health goals and engender more equitable relationships between men and women.

Comparisons of reported sexual behaviors from a retrospective survey versus a prospective diary in the Botswana Defence Force

This study compares self-reported sexual behaviors from a retrospective survey and a prospective diary among Botswana Defence Force (BDF) personnel. One hundred sixty-one male participants, aged 18-30, completed two weekly prospective diaries and a retrospective survey querying them about behaviors reported during the same time frame as the diaries. Most reported behaviors were similar between the two data collection methods. However, there was low agreement for reporting sex with a spouse and exchanging material goods for sex with a casual partner; frequency of sex and condom use rates (CURs) among married participants also differed. When comparing survey condom use frequencies to diary CURs, the level of agreement diminished from the always to occasionally condom use categories. Inconsistencies in reporting may be due to the frequency of the sexual behavior, question sensitivity, the data collection setting, and the interpretation of response categories. Further research is needed to improve accurate reporting of sexual behaviors.

Identification, modification, and implementation of an evidence-based psychotherapy for children in a low-income country: the use of TF-CBT in Zambia

BACKGROUND

The need to address the treatment gap in mental health services in low- and middle-income countries (LMIC) is well recognized and particularly neglected among children and adolescents. Recent literature with adult populations suggests that evidence-based mental health treatments are effective, feasible, and cross-culturally modifiable for use in LMIC. This paper addresses a gap in the literature documenting pre-trial processes. We describe the process of selecting an intervention to meet the needs of a particular population and the process of cross-cultural adaptation.

METHODS

Community-based participatory research principles were implemented for intervention selection, including joint meetings with stakeholders, review of qualitative research, and review of the literature. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) was chosen as the evidence-based practice for modification and feasibility testing. The TF-CBT adaptation process, rooted within an apprenticeship model of training and supervision, is presented. Clinical case notes were reviewed to document modifications.

RESULTS

Choosing an intervention can work as a collaborative process with community involvement. Results also show that modifications were focused primarily on implementation techniques rather than changes in TF-CBT core elements.

CONCLUSIONS

Studies documenting implementation processes are critical to understanding why intervention choices are made and how the adaptations are generated in global mental health. More articles are needed on how to implement evidence-based treatments in LMIC.

Individual- and school-level correlates of HIV testing among secondary school students in Kenya

The policy framework guiding Kenya's response to the AIDS epidemic identifies voluntary counseling and testing as crucial to risk reduction and HIV-preventive activities. Yet in Kenya, as in most sub-Saharan countries, voluntary testing rates are low, especially among young people. Using hierarchical linear models, we identify both individual- and teacher/school-level factors that affect voluntary HIV testing among secondary school students in Kenya. Results indicate that adolescents are more likely to test for HIV serostatus when they are knowledgeable about testing, have been involved in HIV/AIDS activities in primary school, have been provided with HIV information in secondary school, perceive themselves as at high risk of contracting HIV or know of someone infected with or who has died from HIV/AIDS, and have ever engaged in sexual intercourse. Barriers include fear of going to testing centers and being perceived as HIV-positive. Teacher/school-level characteristics are relevant for explaining rates of HIV testing, especially among girls. To encourage testing, policymakers should attend to teacher/school-level factors as well as individual characteristics of students.

An empiric risk scoring tool for identifying high-risk heterosexual HIV-1-serodiscordant couples for targeted HIV-1 prevention

BACKGROUND AND OBJECTIVES

Heterosexual HIV-1-serodiscordant couples are increasingly recognized as an important source of new HIV-1 infections in sub-Saharan Africa. A simple risk assessment tool could be useful for identifying couples at highest risk for HIV-1 transmission.

METHODS

Using data from 3 prospective studies of HIV-1-serodiscordant couples from 7 African countries and standard methods for development of clinical prediction rules, the authors derived and validated a risk scoring tool developed from multivariate modeling and composed of key predictors for HIV-1 risk that could be measured in standard research and clinical settings.

RESULTS

The final risk score included age of the HIV-1-uninfected partner, married and/or cohabiting partnership, number of children, unprotected sex, uncircumcised male HIV-1-uninfected partner, and plasma HIV-1 RNA in the HIV-1-infected partner. The maximum risk score was 12, scores ≥5 were associated with an annual HIV-1 incidence of >3%, and couples with a score ≥6 accounted for only 28% of the population but 67% of HIV-1 transmissions. The area under the curve for predictive ability of the score was 0.74 (95% confidence interval: 0.70 to 0.78). Internal and external validation showed similar predictive ability of the risk score, even when plasma viral load was excluded from the risk score.

CONCLUSIONS

A discrete combination of clinical and behavioral characteristics defines highest risk HIV-1-serodiscordant couples. Discriminating highest risk couples for HIV-1 prevention programs and clinical trials using a validated risk score could improve research efficiency and maximize the impact of prevention strategies for reducing HIV-1 transmission.

The seven Cs of the high acceptability of home-based VCT: results from a mixed methods approach in Zambia

HIV testing and counselling is a critical gateway to prevention and treatment. Yet, coverage remains insufficient, few couples are tested together and gender differences in access exist. We used an embedded mixed methods approach to investigate possible explanations for the high acceptance of home-based voluntary HIV counselling and testing (HB-VCT) in a pair-matched cluster-randomized trial in Zambia. A baseline survey included 1694 individuals in 36 clusters. Adults in 18 intervention clusters were offered HB-VCT by lay counsellors. Standard testing services were available in both trial arms. After the completion of the intervention, a follow-up survey was conducted in all trial clusters. In addition, 21 in-depth interviews and one focus group discussion were conducted with home-based VCT clients in the intervention arm. Informants favoured the convenience, confidentiality and credibility of HB-VCT. Counsellors were perceived as trustworthy owing to their closeness and conduct, and the consent process was experienced as convincing. Couple testing was selected by 70% of cohabiting couples and was experienced as beneficial by both genders. Levels of first-time testing (68% vs. 29%, p < 0.0001) and re-testing (94% vs. 74%, p < 0.0001) were higher in the intervention than in the control arm. Acceptance of HIV testing and counselling is dependent on stigma, trust and gender. The confidentiality of home-based VCT was essential for overcoming stigma-related barriers, and the selection of local counsellors was important to ensure trust in the services. The high level of couple counselling within HB-VCT may contribute to closing the gender gap in HIV testing, and has benefits for both genders and potentially for prevention of HIV transmission. The study demonstrates the feasibility of achieving high test coverage with an opt-in consent approach. The embedded qualitative component confirmed the high satisfaction with HB-VCT reported in the quantitative survey and was crucial to fully understand the intervention and its consequences.

Fertility Desires and Intentions and the Relationship to Consistent Condom Use and Provider Communication Regarding Childbearing Among HIV Clients in Uganda

OBJECTIVES

HIV prevention and reproductive health programs emphasize consistent condom use and preventing unplanned pregnancies, but do not account for the childbearing desires of many HIV clients. We examined the correlates of fertility desires and intentions, including condom use, among HIV clients in Uganda.

METHODS

Baseline data from a prospective cohort study of clients starting antiretroviral therapy were analyzed. All measures were self-report, except abstracted CD4 count.

RESULTS

The sample included 767 clients; 34% were men and 50% had a primary sex partner. Among those with a desire (31%) or intention (24%) for having a child in the near future, 60% had not discussed this with providers. A majority (61%) had received advise about family planning, and 27% were told by their provider that they should not bear a child because of their HIV status. In regression analysis, male gender, younger age, higher CD4, having fewer children, and having a primary partner were significantly associated with fertility desires and intentions; having been told by one's provider not to have a child was associated with intentions but not desires. Among participants with a primary partner, consistent condom use was greater among those with no fertility intentions, as was receipt of advise about family planning, while HIV disclosure to partner was greater among those with intentions. Partner HIV status was not associated with fertility desires or intentions.

CONCLUSIONS

These findings highlight the need for HIV care and reproductive health programs to incorporate safer conception counseling and improve provider/patient communication regarding childbearing.

Behavioural interventions to reduce sexual risk for HIV in heterosexual couples: a meta-analysis

OBJECTIVES

The current study was conducted to synthesise evaluations of couple-based HIV prevention interventions, assess the efficacy of these interventions in reducing sexual risk, and identify moderators of intervention efficacy.

METHODS

A comprehensive literature search identified 29 interventions (22 reports; N=5168 couples) that met the inclusion criteria, including enrolment of both members of a heterosexual couple, measurement of condom use at baseline and follow-up, and sufficient statistical information to calculate effect sizes. Effect sizes were analysed using fixed-effects and random-effects assumptions; factors related to intervention efficacy were identified using metaregression.

RESULTS

Overall, there were significant increases in condom use from baseline to follow-up (d+=0.78, 95% CI 0.48 to 1.09) and significant decreases in partner concurrency (d+=0.37, 95% CI 0.13 to 0.60). Condom use increased to a greater extent when studies were conducted toward the beginning of the epidemic, were located in countries scoring lower on the Human Development Index, enrolled serodiscordant couples, and delivered intervention content in multiple contexts. Couples who had been together longer, reported higher incidence of sexually transmitted infection, were provided voluntary counselling and testing, and provided outcome measures during face-to-face interviews also reported larger increases in condom use.

CONCLUSIONS

Couple-based interventions are efficacious in reducing unprotected sex within the context of romantic relationships. Future research should continue to improve risk reduction for couples.

Paternal involvement and fetal morbidity outcomes in HIV/AIDS: a population-based study

Prior research indicates that infants with absent fathers are vulnerable to unfavorable fetal birth outcomes. HIV is a recognized risk factor for adverse birth outcomes. However, the influence of paternal involvement on fetal morbidity outcomes in women with HIV remains poorly understood. Using linked hospital discharge data and vital statistics records for the state of Florida (1998-2007), the authors assessed the association between paternal involvement and fetal growth outcomes (i.e., low birth weight [LBW], very low birth weight [VLBW], preterm birth [PTB], very preterm birth [VPTB], and small for gestational age [SGA]) among HIV-positive mothers (N=4,719). Propensity score matching was used to match cases (absent fathers) to controls (fathers involved). Conditional logistic regression was employed to generate adjusted odds ratios (OR). Mothers of infants with absent fathers were more likely to be Black, younger (<35 years old), and unmarried with at least a high school education (p<.01). They were also more likely to have a history of drug (p<.01) and alcohol (p=.02) abuse. These differences disappeared after propensity score matching. Infants of HIV-positive mothers with absent paternal involvement during pregnancy had elevated risks for adverse fetal outcomes (LBW: OR=1.30, 95% confidence interval [CI]=1.05-1.60; VLBW: OR=1.72, 95% CI=1.05-2.82; PTB: OR=1.38, 95% CI=1.13-1.69; VPTB: OR=1.81, 95% CI=1.13-2.90). Absence of fathers increases the likelihood of adverse fetal morbidity outcomes in women with HIV infection. These findings underscore the importance of paternal involvement during pregnancy, especially as an important component of programs for prevention of mother-to-child transmission of HIV.

Demographic and health surveys indicate limited impact of condoms and HIV testing in four African countries

Condom promotion and HIV testing for the general population have been major components of HIV prevention efforts in sub-Saharan Africa's high prevalence HIV epidemics, although little evidence documents their public health impact. Recent enhancements to the large, population-based demographic and health surveys (DHS) and AIDS information surveys (AIS) allow use of these data to assess the population-wide impact of these strategies. We analysed the latest DHS and AIS data from four sub-Saharan African countries with high prevalence, heterosexually transmitted HIV epidemics (Côte d'Ivoire, Swaziland, Tanzania and Zambia; N = 48 298) to answer two questions: 1) Are men and women who use condoms less likely to be HIV-infected than those who do not?; and 2) Are men and women who report knowing their HIV status more likely to use condoms than those who do not? Consistent condom use was associated with lower HIV infection rates for Swazi men but with higher HIV infection rates for women in Tanzania and Zambia; it made no significant difference in the other five sex/country subgroups analysed. Inconsistent condom use was not significantly associated with HIV status in any subgroup. Knowing one's HIV status was consistently associated with higher rates of condom use only among married people who were HIV-positive, even though condom use in this group remained relatively low. Effects of knowing one's HIV status among other subgroups varied. These results suggest that condoms have had little population-wide impact for HIV/AIDS prevention in these four countries. HIV testing appears to be associated with increased condom use mainly among people in stable partnerships who test positive. HIV testing and condom promotion may be more effective when targeted to specific groups where there is evidence of benefit rather than to general populations.

Biomarker evaluation of self-reported condom use among women in HIV-discordant couples

Self-reported condom use is a commonly collected statistic, yet its use in research studies may be inaccurate. We evaluated this statistic among women in HIV-discordant couples enrolled in a clinical trial in Nairobi, Kenya. Vaginal swabs were acquired from 125 women and tested for prostate-specific antigen (PSA), a biomarker for semen exposure, using an enzyme-linked immunosorbent assay. Ten (10%) of 98 women who reported 100% use of condoms in the previous month tested PSA positive. In a bivariate logistic regression analysis, among women who reported 100% condom use in the previous month, those with ≤8 years of school had significantly higher odds of testing PSA-positive (odds ratio [OR] = 8.39, 95% confidence interval [CI] 1.02-69.13) than women with more schooling. Our estimate may be conservative, as the ability to detect PSA may be limited to 24-48 hours after exposure. Less educated women may be a target group for counselling regarding reporting sexual behaviour in clinical trials.

Epidemiologic correlates of willingness to be tested for HIV and prior testing among married men in India

There has been limited research in India on determinants of seeking HIV testing by Indian married couples. We analyzed data obtained from husbands of married couples participating in the National Family Health Survey 2005-06. Socio-demographic and behavioural predictors for willingness to be tested and self-reported prior testing were explored, using multivariate logistic regression. Factor scores were used to summarize knowledge variables related to HIV prevention and places of testing. Sixty-nine percent of the husbands were willing to be tested as part of National Family Health Survey 2005-06, and 7% reported some form of prior testing. Our results indicate that knowledge about HIV testing in hospitals and other health/welfare centres, knowledge about transmission of HIV, poor education, religion, economic status, occupation, early sexual debut, and use of contraceptives other than barrier methods were significant predictors for reported willingness to be tested. Knowledge about routes of transmission of HIV, younger age, educational level, religion other than Hindu or Muslim, economic status, occupation, history of blood transfusion, and condom use were significant correlates of previously being tested. Strategies to improve knowledge about HIV testing sites and HIV prevention may encourage married men to be tested and reduce the spread of infection from them to their wives.

Disclosure, knowledge of partner status, and condom use among HIV-positive patients attending clinical care in Tanzania, Kenya, and Namibia

We describe the frequency of and factors associated with disclosure, knowledge of partner's HIV status, and consistent condom use among 3538 HIV-positive patients attending eighteen HIV care and treatment clinics in Kenya, Namibia, and Tanzania. Overall, 42% of patients were male, and 64% were on antiretroviral treatment. The majority (80%) had disclosed their HIV status to their partners, 64% knew their partner's HIV status, and 77% reported consistent condom use. Of those who knew their partner's status, 18% reported their partner was HIV negative. Compared to men, women were significantly less likely to report disclosing their HIV status to their sex partner(s), to knowing their partner's HIV status, and to using condoms consistently with HIV-negative partners. Other factors negatively associated with consistent condom use include nondisclosure, alcohol use, reporting a casual sex partner, and desiring a pregnancy. Health care providers should target additional risk reduction counseling and support services to patients who report these characteristics.

Trends in HIV counseling and testing uptake among married individuals in Rakai, Uganda

Background

Despite efforts to promote HIV counseling and testing (HCT) among couples, few couples know their own or their partners’ HIV status. We assessed trends in HCT uptake among married individuals in Rakai district, southwestern Uganda.

Methods

We analysed data for 21,798 married individuals aged 15-49 years who were enrolled into the Rakai Community Cohort Study (RCCS) between 2003 and 2009. Married individuals were interviewed separately but were retrospectively linked to their partners at analysis. All participants had serologic samples obtained for HIV testing, and had the option of receiving HCT together (couples’ HCT) or separately (individual HCT). Individuals were categorized as concordant HIV-positive if both partners had HIV; concordant HIV-negative if both did not have HIV; or HIV-discordant if only one of the partners had HIV. We used χ² tests to assess linear trends in individual and couples’ HCT uptake in the entire sample and conducted multinomial logistic regression on a sub-sample of 10,712 individuals to assess relative risk ratios (RRR) and 95% Confidence Intervals (95% CI) associated with individual and couples’ HCT uptake. Analysis was done using STATA version 11.0.

Results

Uptake of couples’ HCT was 27.2% in 2003/04, 25.1% in 2005/06, 28.5% in 2006/08 and 27.8% in 2008/09 (χ² for trend = 2.38; P = 0.12). Uptake of individual HCT was 57.9% in 2003/04, 60.2% in 2005/06, 54.0% in 2006/08 and 54.4% in 2008/09 (χ² for trend = 8.72; P = 0.003). The proportion of couples who had never tested increased from 14.9% in 2003/04 to 17.8% in 2008/09 (χ² for trend = 18.16; P < 0.0001). Uptake of couples’ HCT was significantly associated with prior HCT (Adjusted [Adj.] RRR = 6.80; 95% CI: 5.44, 8.51) and being 25-34 years of age (Adj. RRR = 1.81; 95% CI: 1.32, 2.50). Uptake of individual HCT was significantly associated with prior HCT (Adj. RRR = 6.26; 95% CI: 4.24, 9.24) and the female partner being HIV-positive (Adj. RRR = 2.46; 95% CI: 1.26, 4.80).

Conclusion

Uptake of couples’ HCT remained consistently low (below 30%) over the years, while uptake of individual HCT declined over time. These findings call for innovative strategies to increase demand for couples’ HCT, particularly among younger couples and those with no prior HCT.

Should home-based HIV testing and counseling services be offered periodically in programs of ARV treatment as prevention? A case study in Likoma (Malawi)

To reduce HIV incidence, prevention programs centered on the use of antiretrovirals require scaling-up HIV testing and counseling (HTC). Home-based HTC services (HBHTC) increase HTC coverage, but HBHTC has only been evaluated during one-off campaigns. Two years after an initial HBHTC campaign ("round 1"), we conducted another HBHTC campaign ("round 2") in Likoma (Malawi). HBHTC participation increased during round 2 among women (from 74 to 83%, P < 0.01). New HBHTC clients were recruited, especially at ages 25 and older. Only 6.9% of women but 15.9% of men remained unreached by HBHTC after round 2. HIV prevalence during round 2 was low among clients who were HIV-negative during round 1 (0.7%), but high among women who received their first ever HIV test during round 2 (42.8%). The costs per newly diagnosed infection increased significantly during round 2. Periodically conducting HBHTC campaigns can further increase HTC, but supplementary interventions to enroll individuals not reached by HBHTC are needed.

Optimizing PMTCT service delivery in rural North-Central Nigeria: protocol and design for a cluster randomized study

Nigeria has more HIV-infected women who do not receive needed services for the prevention of mother-to-child transmission of HIV (PMTCT) than any other nation in the world. To meet the UNAIDS/WHO goal of eliminating mother-to-child HIV transmission by 2015, multiple interventions will be required to scale up PMTCT services, especially to lower-level, rural health facilities. To address this, we are conducting a cluster-randomized controlled study to evaluate the impact and cost-effectiveness of a novel, family-focused integrated package of PMTCT services. A systematic re-assignment of patient care responsibilities coupled with the adoption of point-of-care CD4 + cell count testing could facilitate the ability of lower-cadre health providers to manage PMTCT care, including the provision and scale-up of antiretroviral therapy (ART) to pregnant women in rural settings. Additionally, as influential community members, male partners could support their partners' uptake of and adherence to PMTCT care. We describe an innovative approach to scaling up PMTCT service provision that incorporates considerations of where and from whom women can access services (task-shifting), ease of obtaining a CD4 + cell count result (point-of-care testing), the degree of HIV service integration for HIV-infected women and their infants, and the level of family and community involvement (specifically male partner involvement). This systematic approach, if proven feasible and effective, could be scaled up in Nigeria and similar resource-limited settings as a means to accelerate progress toward eliminating mother-to-child transmission of HIV and help women with HIV infection take ART and live long, healthy lives (Trial registration: NCT01805752).

The effect of marriage and HIV risks on condom use acceptability in rural Malawi

A large and increasing proportion of HIV transmissions in sub-Saharan Africa occur within marriage. Condom use within marriage could, therefore, be an important prevention strategy, but there is considerable debate about whether married couples would be willing to use condoms. This paper contributes to this debate by identifying key factors that affect the acceptability of condom use within marriage and actual condom use among men and women in rural Malawi, using three waves of longitudinal data from 2004, 2006 and 2008. Specifically, we focused on the effect of (1) entry into first marriage, (2) respondent's HIV status, HIV perceptions, and risk behaviors, and (3) spouse's HIV characteristics on condom use acceptability within marriage and actual condom use with a spouse or steady partner. Using fixed-effects regression, we found that getting married coincides with a pronounced attitudinal shift regarding the acceptability of condom use within marriage that cannot be explained by differences in fertility status or selection into marriage. In addition, we found that, for women, perceived HIV status of the respondent and spouse generally had greater influence than actual HIV status on the acceptability of condom use within marriage and actual condom use with a spouse or steady partner, even after HIV status is known; while actual HIV status and HIV risk behaviors are generally more important among men. Although condom use within marriage remained low, these findings suggest that attitudes about and use of condoms are susceptible to change and that both marital status and perceptions of risk are important influences on condom use.

Willingness to use couples voluntary counseling and testing services among men who have sex with men in seven countries

The willingness of male-male dyads to use couples voluntary HIV counseling and testing (CVCT) has not been previously investigated globally among men who have sex with men (MSM). Using online advertisements, data were collected from 3245 MSM in seven countries who were ≥ 18 years of age and had ≥1 male sex partner in the previous 12 months. The analysis examined associations between individual characteristics and willingness to utilize CVCT. The willingness to utilize CVCT was compellingly high, ranging from 79% in Australia and UK to 90% in Brazil. Older MSM and those who reported not knowing their sero-status reported lower odds of willingness to use CVCT. The relationship between being in a relationship and willingness to use CVCT varied across countries, perhaps reflecting varied local understandings of the nature and content of CVCT. Further work is required to examine willingness to use CVCT among a more heterogeneous population of MSM, and to examine how CVCT services are locally perceived in order to provide information vital for the development of locally appropriate messages to promote CVCT for MSM.

Voluntary HIV testing and risky sexual behaviours among health care workers: a survey in rural and urban Burkina Faso

Background

Voluntary counselling and testing (VCT) together with a safe sexual behaviour is an important preventive strategy in the control of HIV. Although Health care workers (HCWs) are critical in the response to HIV, little is known about VCT and high risk behaviours (HRB) among this group in West Africa. This study aims to assess the prevalence of VCT and HRB among HCWs in Burkina Faso.

Methods

We collected data through a questionnaire in urban areas (Ouagadougou and Bobo-Dioulasso) and rural areas (Poni and Yatenga) among HCWs from 97 health care facilities. Urine samples were collected, screened for HIV using a Calypte® test kit and confirmed by Western Blot. Multiple logistic regression analysis was performed to identify factors associated with the use of VCT services and with high-risk sex behaviour.

Results

About 92.5% of eligible HCWs participated (1570 out of 1697). Overall, 38.2% of them (34.6% of women and 42.6% of men) had ever used VCT services. About 40% of HCWs reported that fear of knowing the test result was the main reason for not doing the HIV test. Male HCWs (p = 0.001), laboratory workers (p < 0.001), those having two years or more experience (p = 0.03), and those who had multiple partners (p = 0.001) were more likely to have tested for HIV. One fifth of HCWs reported multiple partners. Of these, thirteen percent did not use condoms. HCWs who had multiple partners were significantly more likely to be men, single, living in rural areas, and under the age of 29 years.

Conclusion

VCT was still very low among HCWs in Burkina Faso, while HRB was high.

These findings suggest that ‘HCW-friendly’ VCT centres should be implemented, securing confidentiality among colleagues. In addition, refreshment courses on HIV risk reduction, counselling and testing are certainly required during the professional career of HCWs.

Prevalence of inconsistent condom use and associated factors among HIV discordant couples in a rural county in China

A random sample consisting of 88 sexually active people living with HIV (PLWH) and their HIV negative spouses in rural China were interviewed. Data of 68 couples (77.2 %) who gave identical responses to whether they had been using condoms consistently in the last 12 months (n = 136) were analyzed. The results showed that 27.9 % of the discordant couples used condom inconsistently in the last year. Condom non-availability was the most commonly given main reason for not using condoms. Free condoms should be made available to these low-income couples. Suicidal ideation of the PLWH and the spouse's perception on 'whether someone could contract HIV via unprotected sexual intercourse with a HIV positive person' were significantly associated with inconsistent condom use in the last year. Education program should change the cognition about the risk for HIV transmission via unprotected sex. Integrated psychological services to reduce suicidal ideation are greatly warranted.

STD coinfection and reinfection following HIV diagnosis: evidence of continued sexual risk behavior

In 2004, 424 incident cases of HIV were reported to Baltimore City Health Department. Of them, 53 (12.5%) cases were diagnosed with a sexually transmitted disease following HIV diagnosis. The factors that were statistically significantly associated with coinfection were being a man who has sex with men, commercial sex work, and age under 25 years.

Predictors of HIV Serodiscordance among Couples in Southwestern Ethiopia

BACKGROUND

With transmission of HIV occurring mainly through heterosexual contact, it is paramount to identify serodiscordant couples and implement preventive strategies that will protect the negative partner. The burden of serodiscordance and its predictors in Ethiopia is not clearly understood due to the dearth of data.

OBJECTIVE

To assess the prevalence and predictors of HIV serodiscordance among couples tested in Jimma University Specialized Hospital (JUSH) Voluntary Counseling and Testing (VCT) center.

METHODS

The study employed a case-control study design conducted at VCT center of JUSH in all registered serodiscordant couples and seroconcordant couples that were selected from the registered clients in the period from 2003 to 2010. A pretested structured questionnaire was used for data collection using medical chart abstraction. Data were entered, cleaned, and coded using Statistical Package of Social Sciences (SPSS) version 16.

RESULTS

The prevalence of serodiscordance in the study population was found to be 8.4%. Male and female discordants accounted for 5.8% (137) and 2.6% (62), respectively. Rare use of condom (adjusted odds ratio [AOR] = 7.2; 95% confidence interval [CI] = 1.59-32.54) and active tuberculosis (TB) at enrollment (AOR= 17.7; 95% CI = 2.3-139.2) were significantly found to be the predictors of serodiscordance.

CONCLUSION

The prevalence of serodiscordance in the study area was found to be low, but it contributes to a clinically significant population that mandates implementation of preventive strategy. Sero-positive individuals who use condoms rarely should be encouraged to have their partners tested, and the association between active TB and serodiscordance underscores the need for further study.

Maximizing the impact of HIV prevention efforts: interventions for couples

Despite efforts to increase access to HIV testing and counseling services, population coverage remains low. As a result, many people in sub-Saharan Africa do not know their own HIV status or the status of their sex partner(s). Recent evidence, however, indicates that as many as half of HIV-positive individuals in ongoing sexual relationships have an HIV-negative partner and that a significant proportion of new HIV infections in generalized epidemics occur within serodiscordant couples. Integrating couples HIV testing and counseling (CHTC) into routine clinic- and community-based services can significantly increase the number of couples where the status of both partners is known. Offering couples a set of evidence-based interventions once their HIV status has been determined can significantly reduce HIV incidence within couples and if implemented with sufficient scale and coverage, potentially reduce population-level HIV incidence as well. This article describes these interventions and their potential benefits.

Contraceptive practices amongst HIV-positive women on antiretroviral therapy attending an ART clinic in South Africa

Background

Effective contraceptive practices amongst HIV-positive women of reproductive age have been shown to reduce mother-to-child transmission of HIV by preventing unplanned pregnancies. However, most antiretroviral therapy (ART) programmes focus on treatment, neglecting comprehensive contraceptive services. This results in a high frequency of pregnancies amongst HIV-positive women attending the ART clinic of a regional hospital north of Durban.

Objectives

This research aimed to explore contraceptive use amongst HIV-positive women attending an ART clinic by determining, (1) prevalence of contraceptive use, (2) pregnancy rate, (3) contraceptive preferences and (4) factors associated with contraceptive use.

Methods

In this observational, analytical, cross-sectional study of 420 women, aged 15 to 49 years, participants were selected by systematic random sampling. They completed standardised questionnaires.

Results

Of all participants, 95% of the participants used contraception. Factors associated with contraceptive practice were knowledge of HIV status 292 (72.8%), health worker advice 84 (20.9%), and spousal insistence 33 (8.2%). Of the 130 women (31%) who had fallen pregnant whilst on ART, 73 (56.2%) said that the pregnancy had been unplanned, whilst 57 (43.8%) had wanted to fall pregnant because of: partner's insistence (45.6%), desire for a child (36.8%), desire to conceal HIV status (15.8%), not wanting to die childless (5.3%), and death of a previous child (1.8%).

Conclusion

Contraceptive use amongst these women was high but the number of pregnancies is a cause for concern. Information regarding contraceptive use should therefore be provided at all ART clinics.

Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data

BACKGROUND

The proportion of heterosexual HIV transmission in sub-Saharan Africa that occurs within cohabiting partnerships, compared with that in single people or extra-couple relationships, is widely debated. We estimated the proportional contribution of different routes of transmission to new HIV infections. As plans to use antiretroviral drugs as a strategy for population-level prevention progress, understanding the importance of different transmission routes is crucial to target intervention efforts.

METHODS

We built a mechanistic model of HIV transmission with data from Demographic and Health Surveys (DHS) for 2003-2011, of 27,201 cohabiting couples (men aged 15-59 years and women aged 15-49 years) from 18 sub-Saharan African countries with information about relationship duration, age at sexual debut, and HIV serostatus. We combined this model with estimates of HIV survival times and country-specific estimates of HIV prevalence and coverage of antiretroviral therapy (ART). We then estimated the proportion of recorded infections in surveyed cohabiting couples that occurred before couple formation, between couple members, and because of extra-couple intercourse.

FINDINGS

In surveyed couples, we estimated that extra-couple transmission accounted for 27-61% of all HIV infections in men and 21-51% of all those in women, with ranges showing intercountry variation. We estimated that in 2011, extra-couple transmission accounted for 32-65% of new incident HIV infections in men in cohabiting couples, and 10-47% of new infections in women in such couples. Our findings suggest that transmission within couples occurs largely from men to women; however, the latter sex have a very high-risk period before couple formation.

INTERPRETATION

Because of the large contribution of extra-couple transmission to new HIV infections, interventions for HIV prevention should target the general sexually active population and not only serodiscordant couples.

FUNDING

US National Institutes of Health, US National Science Foundation, and J S McDonnell Foundation.

Attitudes toward couples-based HIV counseling and testing among MSM in Cape Town, South Africa

Couples-based voluntary HIV counseling and testing (CVCT) allows couples to receive their HIV test results together and has been demonstrated to be effective in reducing HIV transmission, increasing and sustaining condom use, and reducing sexual risk-taking among at-risk heterosexual couples. However, the acceptability of CVCT among MSM has yet to be evaluated in an African setting. The results from seven focus group discussions and 29 in-depth interviews conducted in Cape Town, South Africa exhibit overwhelmingly high acceptance of CVCT. Participants were attracted to the counseling components of the service, stating that these would allow for the couple to increase their commitment and to explore methods of how to effectively reduce their risk of acquiring or transmitting HIV in the presence of a trained counselor. These results suggest CVCT would be highly welcomed and could work to fill the significant lack of services available and accessible to MSM couples in Cape Town.

Increasing HIV testing among male partners

OBJECTIVE

Couple-oriented posttest HIV counselling (COC) provides pregnant women with tools and strategies to invite her partner to HIV counselling and testing. We conducted a randomized trial of the efficacy of COC on partner HIV testing in low/medium HIV prevalence settings (Cameroon, Dominican Republic, Georgia, India).

METHODS

Pregnant women were randomized to receive standard posttest HIV counselling or COC and followed until 6 months postpartum. Partner HIV testing events were notified by site laboratories, self-reported by women or both combined. Impact of COC on partner HIV testing was measured in intention-to-treat analysis. Socio-behavioural factors associated with partner HIV testing were evaluated using multivariable logistic regression.

RESULTS

Among 1943 pregnant women enrolled, partner HIV testing rates (combined indicator) were 24.7% among women from COC group versus 14.3% in standard posttest HIV counselling group in Cameroon [odds ratio (OR) = 2.0 95% CI (1.2-3.1)], 23.1 versus 20.3% in Dominican Republic [OR = 1.2 (0.8-1.8)], 26.8 versus 1.2% in Georgia [OR = 29.6 (9.1-95.6)] and 35.4 versus 26.6% in India [OR = 1.5 (1.0-2.2)]. Women having received COC did not report more conjugal violence or union break-ups than in the standard posttest HIV counselling group. The main factors associated with partner HIV testing were a history of HIV testing among men in Cameroon, Dominican Republic and Georgia and the existence of couple communication around HIV testing in Georgia and India.

CONCLUSION

A simple prenatal intervention taking into account the couple relationship increases the uptake of HIV testing among men in different socio-cultural settings. COC could contribute to the efforts towards eliminating mother-to-child transmission of HIV.

Prevalence and correlates of HIV discordance and concordance among Chinese-Burmese mixed couples in the Dehong prefecture of Yunnan province, China

BACKGROUND

Many people from Burma have migrated to Dehong prefecture and married local residents during the past decades; however, little is known about HIV risk-taking behaviours and HIV prevalence among these mixed couples. We investigated factors correlated with HIV discordance and concordance within Chinese?Burmese mixed couples in Dehong prefecture, Yunnan province, China.

METHODS

A cross-sectional study with face-to-face questionnaire interviews and HIV blood testing was conducted.

RESULTS

Of 5742 couples, 1.6% couples were HIV-infected concordant, 2.2% were HIV serodiscordant with an HIV-infected male spouse and 0.9% were HIV serodiscordant with an HIV-infected female spouse. HIV discordance with an HIV-infected male spouse was significantly associated with characteristics of the male spouse, including being aged =30 years, non-Han ethnic minority, a marital relationship of <3 years, commercial sex and injection drug use by the male spouse. HIV discordance with an HIV-infected female spouse was significantly associated with an education level of primary school (v. illiterate); a marital status of being in their second marriage, widowed or divorced; a history of sexually transmissible infection diagnosis of the female spouse; noncommercial extramarital sex by the female spouse or by both spouses; and injection drug use by the male spouse. A marital relationship of =3 years was the only significant independent correlate of HIV-infected seroconcordance.

CONCLUSIONS

The study findings underscore the importance of premarital HIV counselling and testing for this population, and the need for targeted interventions among HIV serodiscordant mixed couples to reduce secondary transmission as early as possible when the relationship begins.

Effectiveness of a community-based positive prevention intervention for people living with HIV who are not receiving antiretroviral treatment: a prospective cohort study

In Mombasa, Kenya, a community-based HIV risk-reduction intervention effectively reached people living with HIV who were not receiving antiretroviral treatment (ART)—a difficult-to-reach population because they often fall outside the ambit of health care services—and succeeded in reducing reported risky sex behavior and increasing ART uptake.

Background: We report effectiveness of an HIV-prevention intervention delivered by community health workers (CHWs) in Mombasa, Kenya, to PLHIV who have not initiated or who have discontinued ART—an often difficult-to-reach population because they fall outside the ambit of health care and prevention services.

Methods: A 2-arm cohort study assessed a structured risk-reduction intervention involving at least 4 one-to-one counseling sessions and personalized support. The control group received standard prevention services. CHWs recruited treatment-naïve people living with HIV (PLHIV) or those who had previously taken antiretroviral drugs. Data were analyzed using a Propensity Score Matched (PSM)-sample to control for baseline differences between the groups.

Results: 634 PLHIV were recruited and followed for 6 months. Median age was 35 years, and 74.3% were female. Participants in the intervention group reported reduced risky sexual behaviors both at endline compared with baseline and compared with the control group. At endline, in the PSM analysis, participants in the intervention arm were less likely than participants in the control group to report unprotected sex with a spouse (Odds Ratio [OR] = 0.08, 95% confidence interval [CI] = 0.03-0.24), and they reported fewer unprotected sex acts (12.3% versus 46.0%, respectively; OR = 0.16, 95% CI = 0.09-0.29; P<0.001). Further, 92.4% of participants in the intervention group reported zero unsafe sex acts (with partners of negative or unknown HIV status) compared with 70.8% in the control group (P<0.001), and more participants in the intervention arm were receiving ART (34.3% versus 12.7%, respectively; P<0.001).

Conclusion: CHWs effectively reached PLHIV who had never received or who had discontinued ART, and they delivered a risk-reduction intervention that led to declines in reported sexual risk behaviors, as well as to increases in ART uptake. A scaled-up intervention warrants consideration.

Changes in sexual behaviors among HIV-infected individuals after their HIV diagnosis in a rural prefecture of Eastern China

OBJECTIVE

To describe changes in sexual behaviors among HIV-infected individuals after their HIV diagnosis.

METHODS

All HIV-infected individuals diagnosed by the end of 2009 in Taizhou Prefecture were invited to participate in this 12-month prospective study. Assessments including the total number and types of sexual contacts, and condom use details for up to their most familiar eight sexual contacts were collected both at enrollment and 12-month follow-up.

RESULTS

262 HIV-infected individuals were eligible for analysis. The total number of sexual contacts reported by participants was 4,017, 1,496 and 356 during the 12- month period prior to HIV diagnosis (T1), the 12-month period prior to the baseline survey (T2), and the 12-month follow-up period (T3), respectively. The difference in the number of sexual contacts between T2 and T1 was -5 in median (IQR -1, -14), and the difference between T3 and T2 was 0 in median (IQR: 0, -6). A larger proportion of spousal or long-term heterosexual contact was reported from T1(27.7%) to T2(42.5%) to T3(76.1%), whereas a smaller proportion of commercial heterosexual contacts was reported from T1 (48.6%) to T2 (33.2%) to T3 (7.0%) as well as a smaller proportion of non-commercial casual homosexual contacts was reported from T2 (8.4%) to T3 (3.8%).The proportion of consistent condom use increased significantly from T1 (9.3%) to T2 (35.3%) to T3 (91.5%).

CONCLUSION

Sexual behaviors did not change in a uniform manner for the participants in our study. Sexual behaviors and sexual networks vis-à-vis HIV diagnosis and follow-up were associated with the participant's characteristics and HIV infection and treatment status. The overall lesson is that individuals who are unaware of their HIV infection are the main drivers of secondary transmission. Early identification of HIV infection and access to antiretroviral therapy (ART) are both key strategies to the control and prevention.

Couple experiences of provider-initiated couple HIV testing in an antenatal clinic in Lusaka, Zambia: lessons for policy and practice

BACKGROUND

Couple HIV testing has been recognized as critical to increase uptake of HIV testing, facilitate disclosure of HIV status to marital partner, improve access to treatment, care and support, and promote safe sex. The Zambia national protocol on integrated prevention of mother-to-child transmission of HIV (PMTCT) allows for the provision of couple testing in antenatal clinics. This paper examines couple experiences of provider-initiated couple HIV testing at a public antenatal clinic and discusses policy and practical lessons.

METHODS

Using a narrative approach, open-ended in-depth interviews were held with couples (n = 10) who underwent couple HIV testing; women (n = 5) and men (n = 2) who had undergone couple HIV testing but were later abandoned by their spouses; and key informant interviews with lay counsellors (n = 5) and nurses (n = 2). On-site observations were also conducted at the antenatal clinic and HIV support group meetings. Data collection was conducted between March 2010 and September 2011. Data was organised and managed using Atlas ti, and analysed and interpreted thematically using content analysis approach.

RESULTS

Health workers sometimes used coercive and subtle strategies to enlist women's spouses for couple HIV testing resulting in some men feeling 'trapped' or 'forced' to test as part of their paternal responsibility. Couple testing had some positive outcomes, notably disclosure of HIV status to marital partner, renewed commitment to marital relationship, uptake of and adherence to treatment and formation of new social networks. However, there were also negative repercussions including abandonment, verbal abuse and cessation of sexual relations. Its promotion also did not always lead to safe sex as this was undermined by gendered power relationships and the desires for procreation and sexual intimacy.

CONCLUSIONS

Couple HIV testing provides enormous bio-medical and social benefits and should be encouraged. However, testing strategies need to be non-coercive. Providers of couple HIV testing also need to be mindful of the intimate context of partner relationships including couples' childbearing aspirations and lived experiences. There is also need to make antenatal clinics more male-friendly and responsive to men's health needs, as well as being attentive and responsive to gender inequality during couselling sessions.