Sexual behavior of HIV discordant couples after HIV counseling and testing

Syphilis treatment response among HIV-discordant couples in Zambia and Rwanda

BACKGROUND

Syphilis continues to be a common sexually transmitted infection, despite the availability of inexpensive and effective treatment. Infection in human immunodeficiency virus (HIV)-discordant couples is important because syphilis increases the risk of HIV acquisition. Current US treatment guidelines recommend 1 dose of benzathine penicillin for early syphilis, irrespective of HIV status, but data from coinfected patients are limited.

METHODS

Retrospective analysis of 1321 individuals in 2 African HIV-discordant couple cohorts was performed. Cox proportional hazards analysis and multivariable modeling were used to assess predictors of serologic response to treatment at 180 days and 400 days. Modeling was performed for all episodes of positive rapid plasma reagin (RPR) test results and on a subset with higher RPR titers (≥1:4).

RESULTS

A total of 1810 episodes of syphilis among 1321 individuals were treated with penicillin between 2002 and 2008. Although a positive RPR was more common in the HIV-infected partners, HIV infection did not impact the likelihood of serologic response to therapy (odds ratio [OR], 1.001; P = .995). By 400 days, 67% had responded to therapy, 27% were serofast, and 6.5% had documented reinfection. Prevalent infections were more likely to remain serofast than incident infections (33% vs 20% at 400 days).

CONCLUSIONS

In 2 HIV-serodiscordant couple cohorts in Africa, incident syphilis had a very good likelihood of response to penicillin therapy, irrespective of HIV infection. This supports current Centers for Disease Control and Prevention treatment guidelines. A high proportion of prevalent RPR-positive infections remain serofast despite treatment.

HIV testing and counseling leads to immediate consistent condom use among South African stable HIV-discordant couples

OBJECTIVE

Effective behavioral HIV prevention is needed for stable HIV-discordant couples at risk for HIV, especially those without access to biomedical prevention. This analysis addressed whether HIV testing and counseling with ongoing counseling and condom distribution lead to reduced unprotected sex in HIV-discordant couples.

METHODS

Partners in Prevention HSV/HIV Transmission Study was a randomized trial conducted from 2004 to 2008 assessing whether acyclovir reduced HIV transmission from HSV-2/HIV-1-coinfected persons to HIV-uninfected sex partners. This analysis relied on self-reported behavioral data from 508 HIV-infected South African participants. The exposure was timing of first HIV testing and counseling: 0-7, 8-14, 15-30, or >30 days before baseline. In each exposure group, predicted probabilities of unprotected sex in the last month were calculated at baseline, month 1, and month 12 using generalized estimating equations with a logit link and exchangeable correlation matrix.

RESULTS

At baseline, participants who knew their HIV status for less time experienced higher predicted probabilities of unprotected sex in the last month: 0-7 days, 0.71; 8-14 days, 0.52; 15-30 days, 0.49; >30 days, 0.26. At month 1, once all participants had been aware of being in HIV-discordant relationships for ≥1 month, predicted probabilities declined: 0-7 days, 0.08; 8-14 days, 0.08; 15-30 days, 0.15; >30 days, 0.14. Lower predicted probabilities were sustained through month 12: 0-7 days, 0.08; 8-14 days, 0.11; 15-30 days, 0.05; >30 days, 0.19.

CONCLUSIONS

Unprotected sex declined after HIV-positive diagnosis and declined further after awareness of HIV discordance. Identifying HIV-discordant couples for behavioral prevention is important for reducing HIV transmission risk.

Strong effects of home-based voluntary HIV counselling and testing on acceptance and equity: a cluster randomised trial in Zambia

Home-based voluntary HIV counselling and testing (HB-VCT) has been reported to have a high uptake, but it has not been rigorously evaluated. We designed a model for HB-VCT appropriate for wider scale-up, and investigated the acceptance of home-based counselling and testing, equity in uptake and negative life events with a cluster-randomized trial. Thirty six rural clusters in southern Zambia were pair-matched based on baseline data and randomly assigned to the intervention or the control arm. Both arms had access to standard HIV testing services. Adults in the intervention clusters were offered HB-VCT by local lay counsellors. Effects were first analysed among those participating in the baseline and post-intervention surveys and then as intention-to-treat analysis. The study was registered with www.controlled-trials.com, number ISRCTN53353725. A total of 836 and 858 adults were assigned to the intervention and control clusters, respectively. In the intervention arm, counselling was accepted by 85% and 66% were tested (n = 686). Among counselled respondents who were cohabiting with the partner, 62% were counselled together with the partner. At follow-up eight months later, the proportion of adults reporting to have been tested the year prior to follow-up was 82% in the intervention arm and 52% in the control arm (Relative Risk (RR) 1.6, 95% CI 1.4-1.8), whereas the RR was 1.7 (1.4-2.0) according to the intention-to-treat analysis. At baseline the likelihood of being tested was higher for women vs. men and for more educated people. At follow-up these differences were found only in the control communities. Measured negative life events following HIV testing were similar in both groups. In conclusion, this HB-VCT model was found to be feasible, with a very high acceptance and to have important equity effects. The high couple counselling acceptance suggests that the home-based approach has a particularly high HIV prevention potential.

Gender inequities in sexual risks among youth with HIV in Kigali, Rwanda

Understanding the experiences of youth living with HIV (YLH) is necessary for implementing interventions that mitigate HIV transmission. We conducted a survey of sexual behaviours and sources of knowledge among 107 youths aged 16-24 attending two HIV clinics in Kigali, Rwanda. Respondents were 72% women and 28% men, with median age 18 years. Of those sexually active in the past six months, 56% reported inconsistent condom use; 53% of sexually active respondents reported having sexually transmitted infection (STI) symptoms in the past six months. The median age difference between respondent and first sex partner was nine years for women, and 0.5 years for men (P = 0.006). Women more frequently reported being forced to have sex (29% girls versus 6.5% boys, P = 0.011) and exchanging sex for money (66% girls versus. 17% boys, P = 0.033). Strengthening female YLH's financial and material resources may reduce the number of sexual partners, asymmetries within partnerships and risk of HIV transmission.

The association between remarriage and HIV infection in 13 sub-Saharan African countries

Separated, divorced, and widowed individuals in Africa are at significantly increased risk for HIV infection. Using nationally representative data from 13 sub-Saharan African countries, this study confirms that finding and goes further by examining those who have experienced a marital dissolution and are now remarried. Results show that remarried individuals form a large portion of the population and have a higher-than-average HIV prevalence. HIV-positive remarried individuals are at risk of transmitting the infection to their spouse, because many of the couples are serodiscordant. The large number of high-risk remarried individuals is a source of vulnerability and further infection, and should be acknowledged and taken into account by prevention strategies that rarely address this population.

Diversity of HIV type 1 and drug resistance mutations among injecting drug users in Kenya

Drug use in Kenya dates back to the precolonial period but research among drug users in relation to human immunodeficiency virus (HIV)-associated risk and intervention strategies has been low. To evaluate HIV-1 diversity and drug resistance among injecting drug users (IDUs), a cross-sectional study involving 58 patients was carried out in Mombasa between February and March 2010. HIV-1 RNA was extracted from plasma and polymerase chain reaction using specific primers for HIV-1 reverse transcriptase was done. Population sequencing was done and subtypes were determined phylogenetically. The prevalent HIV-1 subtypes were A1 (52/58), D (5/58), and C (2/58). The prevalence of drug resistance was 13.8% (8/58) with detection of nucleoside reverse transcriptase inhibitor (NRTI) mutations, T215F (n=5), K219Q (n=3), M184V (n=1), and nonnucleoside RTI mutation, K103N (n=1). Antiretroviral therapy (ART) and its monitoring among infected Kenyan IDUs is feasible. Policymakers and service providers in HIV prevention initiatives should improve service delivery so as to measure ART coverage among IDUs to prevent further transmission of drug-resistant variants.

Development and validation of HIV-related dyadic measures for men who have sex with men

The purpose of this study was to develop and assess the psychometric properties of several scales that measure dyadic constructs derived from an integrated model of interdependence theory and communal coping perspectives. The scales are specific to HIV risk and men who have sex with men who are in an intimate relationship. These scales are newly developed measures of perceived severity of HIV, preferences for sexual health outcomes, outcome and couple efficacy to avoid HIV, and communal coping strategies. Scale items were created based on theoretical definitions and results from six focus groups with men who have sex with men. Face and content validity of the scales were assessed with a panel of six experts in the field of HIV prevention. Revised scales were subsequently administered to an online sample of 638 men who have sex with men, who indicated being in a relationship for at least three months. All scales showed adequate reliability, and evidence for construct validity was obtained for all scales, except for perceived severity of HIV. The results indicate that these dyadic scales are psychometrically sound and can be used in future HIV prevention research and practice with men who have sex with men couples.

Role of condom negotiation on condom use among women of reproductive age in three districts in Tanzania

Background

HIV/AIDS remains being a disease of great public health concern worldwide. In regions such as sub-Saharan Africa (SSA) where women are disproportionately infected with HIV, women are reportedly less likely capable of negotiating condom use. However, while knowledge of condom use for HIV prevention is extensive among men and women in many countries including Tanzania, evidence is limited about the role of condom negotiation on condom use among women in rural Tanzania.

Methods

Data originate from a cross-sectional survey of random households conducted in 2011 in Rufiji, Kilombero and Ulanga districts in Tanzania. The survey assessed health-seeking behaviour among women and children using a structured interviewer-administered questionnaire. A total of 2,614 women who were sexually experienced and aged 15-49 years were extracted from the main database for the current analysis. Linkage between condom negotiation and condom use at the last sexual intercourse was assessed using multivariate logistic regression.

Results

Prevalence of condom use at the last sexual intercourse was 22.2% overall, ranging from12.2% among married women to 54.9% among unmarried (single) women. Majority of the women (73.4%) reported being confident to negotiate condom use, and these women were significantly more likely than those who were not confident to have used a condom at the last sexual intercourse (OR = 3.13, 95% CI 2.22-4.41). This effect was controlled for marital status, age, education, religion, number of sexual partners, household wealth and knowledge of HIV prevention by condom use.

Conclusion

Confidence to negotiate condom use is a significant predictor of actual condom use among women in rural Tanzania. Women, especially unmarried ones, those in multiple partnerships or anyone needing protection should be empowered with condom negotiation skills for increased use of condoms in order to enhance their sexual and reproductive health outcomes.

Determinants of previous HIV testing and knowledge of partner's HIV status among men attending a voluntary counseling and testing clinic in Dar es Salaam, Tanzania

Voluntary Counseling and Testing (VCT) remains low among men in sub-Saharan Africa. The factors associated with previous HIV testing and knowledge of partner's HIV status are described for 9,107 men who visited the Muhimbili University College of Health Sciences' VCT site in Dar es Salaam, Tanzania, between 1997 and 2008. Data are from intake forms administered to clients seeking VCT services. Most of the men (64.5%) had not previously been tested and 75% were unaware of their partner's HIV status. Multivariate logistic regression revealed that age, education, condom use, and knowledge of partner's HIV status were significant predictors of previous HIV testing. Education, number of sexual partners, and condom use were also associated with knowledge of partner's HIV status. The low rate of VCT use among men underscores the need for more intensive initiatives to target men and remove the barriers that prevent HIV disclosure.

A conceptual framework for understanding HIV risk behavior in the context of supporting fertility goals among HIV-serodiscordant couples

Integrated reproductive health services for people living with HIV must address their fertility intentions. For HIV-serodiscordant couples who want to conceive, attempted conception confers a substantial risk of HIV transmission to the uninfected partner. Behavioral and pharmacologic strategies may reduce HIV transmission risk among HIV-serodiscordant couples who seek to conceive. In order to develop effective pharmaco-behavioral programs, it is important to understand and address the contexts surrounding reproductive decision-making; perceived periconception HIV transmission risk; and periconception risk behaviors. We present a conceptual framework to describe the dynamics involved in periconception HIV risk behaviors in a South African setting. We adapt the Information-Motivation-Behavioral Skill Model of HIV Preventative Behavior to address the structural, individual and couple-level determinants of safer conception behavior. The framework is intended to identify factors that influence periconception HIV risk behavior among serodiscordant couples, and therefore to guide design and implementation of integrated and effective HIV, reproductive health and family planning services that support reproductive decision-making.

A gp41-based heteroduplex mobility assay provides rapid and accurate assessment of intrasubtype epidemiological linkage in HIV type 1 heterosexual transmission Pairs

A critical step in HIV-1 transmission studies is the rapid and accurate identification of epidemiologically linked transmission pairs. To date, this has been accomplished by comparison of polymerase chain reaction (PCR)-amplified nucleotide sequences from potential transmission pairs, which can be cost-prohibitive for use in resource-limited settings. Here we describe a rapid, cost-effective approach to determine transmission linkage based on the heteroduplex mobility assay (HMA), and validate this approach by comparison to nucleotide sequencing. A total of 102 HIV-1-infected Zambian and Rwandan couples, with known linkage, were analyzed by gp41-HMA. A 400-base pair fragment within the envelope gp41 region of the HIV proviral genome was PCR amplified and HMA was applied to both partners' amplicons separately (autologous) and as a mixture (heterologous). If the diversity between gp41 sequences was low (<5%), a homoduplex was observed upon gel electrophoresis and the transmission was characterized as having occurred between partners (linked). If a new heteroduplex formed, within the heterologous migration, the transmission was determined to be unlinked. Initial blind validation of gp-41 HMA demonstrated 90% concordance between HMA and sequencing with 100% concordance in the case of linked transmissions. Following validation, 25 newly infected partners in Kigali and 12 in Lusaka were evaluated prospectively using both HMA and nucleotide sequences. Concordant results were obtained in all but one case (97.3%). The gp41-HMA technique is a reliable and feasible tool to detect linked transmissions in the field. All identified unlinked results should be confirmed by sequence analyses.

Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia

BACKGROUND

HIV-discordant heterosexual couples are faced with the dual challenge of preventing sexual HIV transmission and unplanned pregnancies with the attendant risk of perinatal HIV transmission. Our aim was to examine uptake of two long-acting reversible contraceptive (LARC) methods--intrauterine devices (IUD) and hormonal implants--among HIV-discordant couples in Rwanda and Zambia.

STUDY DESIGN

Women were interviewed alone or with their partner during routine cohort study follow-up visits to ascertain fertility goals; those not pregnant, not infertile, not already using LARC, and wishing to limit or delay fertility for ≥3 years were counseled on LARC methods and offered an IUD or implant on-site.

RESULTS

Among 409 fertile HIV-discordant Rwandan women interviewed (126 alone, 283 with partners), 365 (89%) were counseled about LARC methods, and 130 (36%) adopted a method (100 implant, 30 IUD). Of 787 fertile Zambian women interviewed (457 alone, 330 with partners), 528 (67%) received LARC counseling, of whom 177 (34%) adopted a method (139 implant, 38 IUD). In both countries, a woman's younger age was predictive of LARC uptake. LARC users reported fewer episodes of unprotected sex than couples using only condoms.

CONCLUSIONS

Integrated fertility goal-based family planning counseling and access to LARC methods with reinforcement of dual-method use prompted uptake of IUDs and implants and reduced unprotected sex among HIV-discordant couples in two African capital cities.

"What took you so long?" The impact of PEPFAR on the expansion of HIV testing and counseling services in Africa

HIV testing and counseling services in Africa began in the early 1990s, with limited availability and coverage. Fears of stigma and discrimination, complex laboratory systems, and lack of available care and treatment services hampered expansion. Use of rapid point-of-care tests, introduction of services to prevent mother-to-child transmission, and increasing provision of antiretroviral drugs were key events in the late 1990s and early 2000s that facilitated the expansion of HIV testing and counseling services. Innovations in service delivery included providing HIV testing in both clinical and community sites, including mobile and home testing. Promotional campaigns were conducted in many countries, and evolutions in policies and guidance facilitated expansion and uptake. Support from President's Emergency Plan for AIDS Relief and national governments, other donors, and the Global Fund for AIDS, Tuberculosis, and Malaria contributed to significant increases in the numbers of persons tested in many countries. Quality of both testing and counseling, limited number of health care workers, uptake by couples, and effectiveness of linkages and referral systems remain challenges. Expansion of antiretroviral treatment, especially in light of the evidence that treatment contributes to prevention of transmission, will require greater yet strategic coverage of testing services, especially in clinical settings and in combination with other high-impact HIV prevention strategies. Continued support from President's Emergency Plan for AIDS Relief, governments, and other donors is required for the expansion of testing needed to achieve international targets for the scale-up of treatment and universal access to knowledge of HIV status.

HIV-1 subtype C superinfected individuals mount low autologous neutralizing antibody responses prior to intrasubtype superinfection

Background

The potential role of antibodies in protection against intra-subtype HIV-1 superinfection remains to be understood. We compared the early neutralizing antibody (NAb) responses in three individuals, who were superinfected within one year of primary infection, to ten matched non-superinfected controls from a Zambian cohort of subtype C transmission cases. Sequence analysis of single genome amplified full-length envs from a previous study showed limited diversification in the individuals who became superinfected with the same HIV-1 subtype within year one post-seroconversion. We hypothesized that this reflected a blunted NAb response, which may have made these individuals more susceptible to superinfection.

Results

Neutralization assays showed that autologous plasma NAb responses to the earliest, and in some cases transmitted/founder, virus were delayed and had low to undetectable titers in all three superinfected individuals prior to superinfection. In contrast, NAbs with a median IC50 titer of 1896 were detected as early as three months post-seroconversion in non-superinfected controls. Early plasma NAbs in all subjects showed limited but variable levels of heterologous neutralization breadth. Superinfected individuals also exhibited a trend toward lower levels of gp120- and V1V2-specific IgG binding antibodies but higher gp120-specific plasma IgA binding antibodies.

Conclusions

These data suggest that the lack of development of IgG antibodies, as reflected in autologous NAbs as well as gp120 and V1V2 binding antibodies to the primary infection virus, combined with potentially competing, non-protective IgA antibodies, may increase susceptibility to superinfection in the context of settings where a single HIV-1 subtype predominates.

"Maybe his blood is still strong": a qualitative study among HIV-sero-discordant couples on ART in rural Uganda

Background

HIV-negative members of sero-discordant couples are at high risk for HIV acquisition but few behavioral prevention interventions have been implemented in sub-Saharan Africa and discordance is not well understood by couples themselves.

Methods

In this nested sub-study, we interviewed 40 HIV sero-discordant couples before and after a 6-month behavioral intervention that was comprised of four group discussions on specific HIV prevention and care topics. The content of the sessions included: 1) understanding HIV serodiscordance and reducing risk, 2) couple communication, 3) reproductive health and HIV serodiscordance, 4) coping with HIV serodiscordance and ongoing support. Couple members were interviewed individually. Data were analyzed thematically using ‘Framework Analysis’ which incorporated dyadic factors to address couple issues.

Results

Analysis revealed pre-identified concepts and emergent themes that were relevant to the final conceptual model. Four major categories of factors affecting couple relations, beliefs and current risk behaviors emerged: intervention factors, structural/contextual factors, physical health factors, and past risk behavior. The topics within the intervention most relevant were communication and reproductive health. The contextual factors highlighted by couples were gender norms around sexual decision-making and multiple partnerships. Individual beliefs regarding HIV serodiscordance persisted over all time points for some couples. Interestingly, some couple members had divergent views about their HIV status; some believing the HIV-negative member was negative while others described multiple beliefs around the negative member’s blood surely being positive for HIV. Couple communication emerged as an important theme mediating beliefs and behavior.

Conclusions

In addition to biomedical and behavioral interventions, HIV-serodiscordant couple interventions must embrace the contextual complexity and cultural understanding of HIV infection and discordance as well as the dynamic nature of couple communication to influence risk behavior.

The impact of HIV testing on subjective expectations and risky behavior in Malawi

We investigate the causal impact of learning HIV status on HIV/AIDS-related expectations and sexual behavior in the medium run. Our analyses document several unexpected results about the effect of learning one's own, or one's spouse's, HIV status. For example, receiving an HIV-negative test result implies higher subjective expectations about being HIV-positive after two years, and individuals tend to have larger prediction errors about their HIV status after learning their HIV status. If individuals in HIV-negative couples also learn the status of their spouse, these effects disappear. In terms of behavioral outcomes, our analyses document that HIV-positive individuals who learned their status reported having fewer partners and using condoms more often than those who did not learn their status. Among married respondents in HIV-negative couples, learning only one's own status increases risky behavior, while learning both statuses decreases risky behavior. In addition, individuals in sero-discordant couples who learned both statuses are more likely to report some condom use. Overall, our analyses suggest that ensuring that each spouse learns the HIV status of the other, either through couple's testing or through spousal communication, may be beneficial in high-prevalence environments.

Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries

BACKGROUND

Voluntary counseling and testing (VCT) continues to play a critical role in HIV prevention, care and treatment. In recent years, different modalities of VCT have been implemented, including clinic-, mobile- and home-based testing and counseling. This review assesses the effects of all VCT types on HIV-related risk behaviors in low- and middle-income countries.

OBJECTIVES

The primary objective of this review is to systematically review the literature examining the efficacy of VCT in changing HIV-related risk behaviors in developing countries across various populations.

SEARCH METHODS

Five electronic databases - PubMed, Excerpta Medica Database (EMBASE), PsycINFO, Sociological Abstracts, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) - were searched using predetermined key words and phrases. Hand-searching was conducted in four key journals including AIDS, AIDS and Behavior, AIDS Education and Prevention, and AIDS Care; the tables of contents of these four journals during the included time period were individually screened for relevant articles. The reference lists of all articles included in the review were screened to identify any additional studies; this process was iterated until no additional articles were found.

SELECTION CRITERIA

To be included in the review, eligible studies had to meet the following inclusion criteria: 1) Take place in a low- or middle-income country as defined by the World Bank, 2) Published in a peer-reviewed journal between January 1, 1990 and July 6, 2010, 3) Involve client-initiated VCT, including pre-test counseling, HIV-testing, and post-test counseling, and 4) Use a pre/post or multi-arm design that compares individuals before and after receiving VCT or individuals who received VCT to those who did not, and 5) Report results pertaining to behavioral, psychological, biological, or social HIV-related outcomes.

DATA COLLECTION AND ANALYSIS

All citations were initially screened and all relevant citations were independently screened by two reviewers to assess eligibility. For all included studies data were extracted by two team members working independently using a standardized form.  Differences were resolved through consensus or discussion with the study coordinator when necessary. Study rigor was assessed using an eight point quality score and through the Cochrane Collaboration's Risk of Bias Assessment Tool. Outcomes comparable across studies, including condom use and number of sex partners, were meta-analyzed using random effects models. With respect to both meta-analyses, data were included from multi-arm studies and from pre/post studies if adequate data were provided. Other outcomes, including HIV-incidence, STI incidence/prevalence, and positive and negative life events were synthesized qualitatively. For meta-analysis, all outcomes were converted to the standard metric of the odds ratio. If an outcome could not be converted to an odds ratio, the study was excluded from analysis.

MAIN RESULTS

 An initial search yielded 2808 citations. After excluding studies failing to meet the inclusion criteria, 19 were deemed eligible for inclusion. Of these studies, two presented duplicate data and were removed. The remaining 17 studies were included in the qualitative synthesis and 8 studies were meta-analyzed.  Twelve studies offered  clinic-based VCT, 3 were employment-based, 1 involved mobile VCT, and 1 provided home-based VCT.  In meta-analysis, the odds of reporting increased number of sexual partners were reduced when comparing participants who received VCT to those who did not, unadjusted random effects pooled OR= 0.69 (95% CI: 0.53-0.90, p=0.007). When stratified by serostatus, these results only remained significant for those who tested HIV-positive. There was an insignificant increase in the odds of condom use/protected sex among participants who received VCT compared to those who did not, unadjusted random effects pooled OR=1.39 (95% CI: 0.97-1.99, p=0.076). When stratified by HIV status, this effect became significant among HIV-positive participants, random effects pooled OR= 3.24 (95% CI: 2.29-4.58, p<0.001).

AUTHORS' CONCLUSIONS

These findings add to growing evidence that VCT can change HIV-related sexual risk behaviors thereby reducing HIV-related risk, and confirming its importance as an HIV prevention strategy. To maximize the effectiveness of VCT, more studies should be conducted to understand which modalities and counseling strategies produce significant reductions in risky behaviors and lead to the greatest uptake of VCT.

Factors associated with HIV testing and condom use in Mozambique: implications for programs

Background

To identify predictors of HIV testing and condom use in Mozambique.

Methods

Nationally representative survey data collected in Mozambique in 2009 was analyzed. Logistic regression analysis was used for two outcomes: HIV testing and condom use.

Results

Women at a higher risk of HIV were less likely to be tested for HIV than women at a lower risk: compared to married women, HIV testing was lower among never married women (OR = 0.37, CI: 0.25-0.54); compared to women with one lifetime partner, HIV testing was lower among women with four or more lifetime partners (OR = 0.62, CI: 0.47-0.83). Large wealth differentials were observed: compared to the poorest women, HIV testing was higher among the wealthiest women (OR = 3.03, CI: 1.96-4.68). Perceived quality of health services was an important predictor of HIV testing: HIV testing was higher among women who rated health services as being of very good quality (OR = 2.12, CI: 1.49-3.00). Type of sexual partner was the strongest predictor of condom use: condom use was higher among men who reported last sex with a girlfriend (OR = 9.75, CI: 6.81-13.97) or a casual partner (OR = 11.05, CI: 7.21-16.94). Being tested for HIV during the last two years was the only programmatic variable that predicted condom use. Interestingly, being tested for HIV more than two years ago was not associated with condom use. Frequent mass media exposure was neither associated with HIV testing nor with condom use.

Conclusions

The focus of HIV testing should shift from married women (routinely tested during antenatal care visits) to unmarried women and women with multiple sexual partners. Financial barriers to HIV testing appear to be substantial. Since HIV testing is done without a fee being charged, these barriers are presumably related to the cost of transportation to static health facilities. Mechanisms should be developed to cover the cost of transportation to health facilities. Substantially increasing community-based counseling is one way of reducing the cost of transportation. Men should be encouraged to test for HIV periodically.

HIV status and gender: a brief report from heterosexual couples in Thailand

Although the impact of HIV falls on both partners of a married couple, the burden of stress may not be necessarily shared evenly. The researchers in this study examined the relations among HIV status, gender, and depressive symptoms among 152 married or cohabitating couples living with HIV in the northern and northeastern regions of Thailand. Depressive symptoms were assessed using a 15-item depressive symptom screening test that was developed and used previously in Thailand. Among the 152 couples, 59% were couples in which both members were people living with HIV (seroconcordant; both people living with HIV couples), 28% had only female members with HIV (serodiscordant; females living with HIV couples), and 13% had only male members with HIV (serodiscordant; males living with HIV couples). The prevalence of depressive symptoms between seroconcordant and serodiscordant groups was similar. However, females living with HIV reported significantly higher levels of depressive symptoms, regardless of their partners' HIV status. Future prevention programs focusing on serodiscordant couples should be planned to target HIV risk, as well as emphasis on mental health, with a particular focus on women's increased susceptibility to negative mental health outcomes.

The Association between Interrelationships and Linkages of Knowledge about HIV/AIDS and its Related Risky Behaviors in People Living with HIV/AIDS

The relationship between knowledge about HIV/AIDS and its associated risky behaviors is complex and has not been sufficiently explored. It is especially important to look at some of the aspects of this relationship among people living with HIV/AIDS (PLWHA) in order to develop effective intervention strategies to reduce HIV/AIDS risky behaviors. The objective of this study was to investigate the association between knowledge about HIV/AIDS and its risky behaviors among PLWHA.

Willingness of US men who have sex with men (MSM) to participate in Couples HIV Voluntary Counseling and Testing (CVCT)

Background

We evaluated willingness to participate in CVCT and associated factors among MSM in the United States.

Methods

5,980 MSM in the US, recruited through MySpace.com, completed an online survey March-April, 2009. A multivariable logistic regression model was built using being “willing” or “unwilling” to participate in CVCT in the next 12 months as the outcome.

Results

Overall, 81.5% of respondents expressed willingness to participate in CVCT in the next year. Factors positively associated with willingness were: being of non-Hispanic Black (adjusted odds ratio [aOR]: 1.5, 95% confidence interval [CI]: 1.2–1.8), Hispanic (aOR: 1.3, CI: 1.1–1.6), or other (aOR: 1.4, CI: 1.1–1.8) race/ethnicity compared to non-Hispanic White; being aged 18–24 (aOR: 2.5, CI: 1.7–3.8), 25–29 (aOR: 2.3, CI: 1.5–3.6), 30–34 (aOR: 1.9, CI: 1.2–3.1), and 35–45 (aOR: 2.3, CI: 1.4–3.7) years, all compared to those over 45 years of age; and having had a main male sex partner in the last 12 months (aOR: 1.9, CI: 1.6–2.2). Factors negatively associated with willingness were: not knowing most recent male sex partner’s HIV status (aOR: 0.81, CI: 0.69–0.95) compared to knowing that the partner was HIV-negative; having had 4–7 (aOR: 0.75, CI: 0.61–0.92) or >7 male sex partners in the last 12 months (aOR: 0.62, CI: 0.50–0.78) compared to 1 partner; and never testing for HIV (aOR: 0.38, CI: 0.31–0.46), having been tested over 12 months ago (aOR: 0.63, CI: 0.50–0.79), or not knowing when last HIV tested (aOR: 0.67, CI: 0.51–0.89), all compared to having tested 0–6 months previously.

Conclusions

Young MSM, men of color, and those with main sex partners expressed a high level of willingness to participate in couples HIV counseling and testing with a male partner in the next year. Given this willingness, it is likely feasible to scale up and evaluate CVCT interventions for US MSM.

Behavioral and biomedical combination strategies for HIV prevention

Around 2.5 million people become infected with HIV each year. This extraordinary toll on human life and public health worldwide will only be reversed with effective prevention. What's more, in the next few years, it is likely at least, that no single prevention strategy will be sufficient to contain the spread of the disease. There is a need for combination prevention as there is for combination treatment, including biomedical, behavioral, and structural interventions. Expanded HIV prevention must be grounded in a systematic analysis of the epidemic's dynamics in local contexts. Although 85% of HIV is transmitted sexually, effective combinations of prevention have been shown for people who inject drugs. Combination prevention should be based on scientifically derived evidence, with input and engagement from local communities that fosters the successful integration of care and treatment.

HIV-1 prevention for HIV-1 serodiscordant couples

A substantial proportion of HIV-1 infected individuals in sub-Saharan Africa are in stable relationships with HIV-1 uninfected partners, and HIV-1 serodiscordant couples thus represent an important target population for HIV-1 prevention. Couple-based HIV-1 testing and counseling facilitates identification of HIV-1 serodiscordant couples, counseling about risk reduction, and referrals to HIV-1 treatment, reproductive health services, and support services. Maximizing HIV-1 prevention for HIV-1 serodiscordant couples requires a combination of strategies, including counseling about condoms, sexual risk, fertility, contraception, and the clinical and prevention benefits of antiretroviral therapy (ART) for the HIV-1-infected partner; provision of clinical care and ART for the HIV-1-infected partner; antenatal care and services to prevent mother-to-child transmission for HIV-1-infected pregnant women; male circumcision for HIV-1-uninfected men; and, pending guidelines and demonstration projects, oral pre-exposure prophylaxis (PrEP) for HIV-1-uninfected partners.

HIV and dyadic intervention: an interdependence and communal coping analysis

BACKGROUND

The most common form of HIV transmission in sub-Saharan Africa is heterosexual sex between two partners. While most HIV prevention interventions are aimed at the individual, there is mounting evidence of the feasibility, acceptability, and efficacy of dyadic interventions. However, the mechanisms through which dyadic-level interventions achieve success remain little explored. We address this gap by using Lewis et al's interdependence model of couple communal coping and behaviour change to analyse data from partners participating in an HIV prevention trial in Uganda and Zambia.

METHODS AND FINDINGS

We conducted a comparative qualitative study using in-depth interviews. Thirty-three interviews were conducted in total; ten with couples and twenty-three with staff members at the two sites. The Ugandan site recruited a sero-discordant couple cohort and the Zambian site recruited women alone. Spouses' transformation of motivation is strong where couples are recruited and both partners stand to gain considerably by participating in the research; it is weaker where this is not the case. As such, coping mechanisms differ in the two sites; among sero-discordant couples in Uganda, communal coping is evidenced through joint consent to participate, regular couple counselling and workshops, sharing of HIV test results, and strong spousal support for adherence and retention. By contrast, coping at the Zambian site is predominantly left to the individual woman and occurs against a backdrop of mutual mistrust and male disenfranchisement. We discuss these findings in light of practical and ethical considerations of recruiting couples to HIV research.

CONCLUSIONS

We argue for the need to consider the broader context within which behaviour change occurs and propose that future dyadic research be situated within the framework of the 'risk environment'.

HLA-B signal peptide polymorphism influences the rate of HIV-1 acquisition but not viral load

Human leukocyte antigen alleles influence the immune response to HIV-1. Signal peptides cleaved from those alleles bind to HLA-E and mediate natural killer cell function. Signal peptides of HLA-A and HLA-C proteins carry methionine (Met) at anchor position 2 (P2); those of HLA-B carry Met or threonine (Thr). Different P2 residues alter HLA-E binding to its cognate receptors and may impact HIV-1 acquisition. Among Zambian couples (N = 566) serodiscordant for HIV-1, P2-Met accelerated acquisition in the HIV-1-negative partner (relative hazard [RH], 1.79). Among seroconverting Zambian (n = 240) and Rwandan (n = 64) partners, P2-Met also accelerated acquisition (RH, 1.47 and RH, 1.83 respectively). HLA-B alleles displaying the reportedly protective Bw4 epitope carry P2-Thr. Bw4/P2-Thr and Bw6/P2-Thr showed similar protective effects compared with Bw6/P2-Met. Neither motif was associated with viral load. The influence of HLA-B alleles on HIV/AIDS may derive from multiple motifs in and beyond the mature proteins.

Effect of home-based HIV counselling and testing on stigma and risky sexual behaviours: serial cross-sectional studies in Uganda

Background

A large, district-wide, home-based HIV counselling and testing (HBHCT) programme was implemented in Bushenyi district of Uganda from 2004 to 2007. This programme provided free HBHCT services to all consenting adults of Bushenyi district and had a very high uptake and acceptability. We measured population-level changes in knowledge of HIV status, stigma and HIV-risk behaviours before and after HBHCT to assess whether widespread HBHCT had an effect on trends of risky sexual behaviours and on stigma and discrimination towards HIV.

Methods

Serial cross-sectional surveys were carried out before and after the implementation of HBHCT programme in Bushenyi district of Uganda. A total of 1402 randomly selected adults (18 to 49 years) were interviewed in the baseline survey. After the implementation, a different set of randomly selected 1562 adults was interviewed using the same questionnaire. Data was collected on socio-demographic characteristics, sexual behaviour, whether respondents had ever tested for HIV and stigma and discrimination towards HIV/AIDS.

Results

The proportion of people who had ever tested for HIV increased from 18.6% to 62% (p<0.001). Among people who had ever tested, the proportion of people who shared HIV test result with a sexual partner increased from 41% to 57% (p<0.001). The proportion of persons who wanted infection status of a family member not to be revealed decreased from 68% to 57% (p<0.001). Indicators of risk behaviour also improved; the proportion of people who exchanged money for sex reduced from 12% to 4% (p<0.001), who used a condom when money was exchanged during a sexual act increased from 39% to 80% (p<0.001) and who reported genital ulcer/discharge decreased from 22% to 10% (p<0.001).

Conclusion

These data suggest that HBHCT rapidly increased the uptake of HCT and may have led to reduction in high-risk behaviours at population level as well as reduction in stigma and discrimination. Because HBCT programmes are cost-effective, they should be considered for implementation in delivery of HIV services especially in areas where access to HCT is low.

Factors associated with intention to conceive and its communication to providers among HIV clients in Uganda

Persons living with HIV/AIDS (PLHA) must discuss their fertility intentions with healthcare providers to receive the support needed to have children safely and limit transmission risks. However, few quantitative studies have examined correlates of fertility intentions, let alone the communication of such intentions with providers. We examined the prevalence and correlates of intentions to have children, and comfort discussing such plans with one's providers, in HIV clients at two HIV clinics in Uganda. Cross-sectional self-report data were collected from 233 patients who had primary partners. Bivariate correlates significant at the P < 0.10 level were included in logistic regression analysis. Of the 233 participants, 103 (44%) reported an intention to conceive a child in the near future. In multivariate analysis, younger age of both the patient and their partner, better physical health functioning and higher internalized HIV stigma were associated with having fertility intentions. One-third (35%) of those with fertility intentions expressed having difficulty discussing these intentions with their providers, which was associated with receiving care at the rural clinic and greater internalized HIV stigma. These findings highlight the need for reproductive health services that help clients accept themselves as PLHA and their fertility rights, thus promoting patient-doctor communication needed to promote safe child conception and delivery outcomes.

Barriers to involvement of men in ANC and VCT in Khayelitsha, South Africa

We used qualitative methods to assess pregnant women and men's attitudes, feelings, beliefs, experiences and reactions to male partners' involvement in antenatal clinic (ANC) in Khayelitsha, Cape Town, South Africa. The aims of these studies were to determine barriers to male partners' attendance of ANC with their pregnant female partners and to identify possible strategies to overcome these barriers. Findings from the qualitative studies demonstrated that pregnant women were keen to invite their male sexual partners and that men would attend if invited. The main barrier to male participation was lack of awareness and the healthcare facility environment. The findings of these studies emphasized the need to increase awareness among men in Khayelitsha of the need for male attendance of ANC and the need to address the barriers to male attendance of ANC. It was clear that community sensitization programmes coupled with improvement of the health facility environment to be receptive to men are essential for increasing male attendance of ANC.

Timing and source of subtype-C HIV-1 superinfection in the newly infected partner of Zambian couples with disparate viruses

Background

HIV-1 superinfection occurs at varying frequencies in different at risk populations. Though seroincidence is decreased, in the negative partner of HIV-discordant couples after joint testing and counseling in the Zambia Emory HIV Research Project (ZEHRP) cohort, the annual infection rate remains relatively high at 7-8%. Based on sequencing within the gp41 region of each partner's virus, 24% of new infections between 2004 and 2008 were the result of transmission from a non-spousal partner. Since these seroconvertors and their spouses have disparate epidemiologically-unlinked viruses, there is a risk of superinfection within the marriage. We have, therefore, investigated the incidence and viral origin of superinfection in these couples.

Results

Superinfection was detected by heteroduplex mobility assay (HMA), degenerate base counting of the gp41 sequence, or by phylogenetic analysis of the longitudinal sequences. It was confirmed by full-length env single genome amplification and phylogenetic analysis. In 22 couples (44 individuals), followed for up to five years, three of the newly infected (initially HIV uninfected) partners became superinfected. In each case superinfection occurred during the first 12 months following initial infection of the negative partner, and in each case the superinfecting virus was derived from a non-spousal partner. In addition, one probable case of intra-couple HIV-1 superinfection was observed in a chronically infected partner at the time of his seroconverting spouse's initial viremia. Extensive recombination within the env gene was observed following superinfection.

Conclusions

In this subtype-C discordant couple cohort, superinfection, during the first year after HIV-1 infection of the previously negative partner, occurred at a rate similar to primary infection (13.6% [95% CI 5.2-34.8] vs 7.8% [7.1-8.6]). While limited intra-couple superinfection may in part reflect continued condom usage within couples, this and our lack of detecting newly superinfected individuals after one year of primary infection raise the possibility that immunological resistance to intra-subtype superinfection may develop over time in subtype C infected individuals.

HIV diagnosis and sexual risk behavior intentions among couple VCT clients in Ethiopia

This research examines whether members of HIV affected couples are more likely to change their abstinence and condom intentions than members of HIV- couples during couple voluntary counseling and testing (VCT). A total of 1260 couple VCT clients in Ethiopia were asked about their sexual risk behavior intentions for the next two months after pre-test and post-test counseling. Multinomial logistic regression was used to determine whether the couple's HIV status was associated with changed intentions to abstain or use condoms between pre-test and post-test. Individuals belonging to male HIV+ serodiscordant couples (aRRR = 7.98, p < 0.001), female HIV+ serodiscordant couples (aRRR = 5.85, p < 0.001), and HIV+ concordant couples (aRRR = 3.12, p = 0.05) were more likely to have increased their intentions to abstain or use condoms in the next two months than individuals in HIV- concordant relationships. The couple's HIV status was not associated with decreased intentions to abstain or use condoms in the next two months. Counseling for all HIV affected couples should include practical information on obtaining and using condoms. This includes HIV affected couples who intend to abstain from sex, whether for a short or long period of time, so that they are prepared to have protected sex if their intentions change.

Reproductive health options among HIV-infected persons in the low-income Niger Delta of Nigeria

Background

With the advent and widespread use of highly active antiretroviral therapy for the treatment of human immunodeficiency virus (HIV), persons living with HIV/acquired immune deficiency syndrome (AIDS) are living good quality, longer, and healthier lives. Many couples affected by HIV, both serodiscordant and seroconcordant, are beginning to consider options for safer reproduction. The aim of this study was to assess the reproductive health concerns among persons living with HIV/AIDS in the Niger Delta of Nigeria.

Methods and results

The subjects were aged 18–58 (mean 41.25 ± 11.50) years, with 88 males (45.1%) and 107 females (54.9). Of the 195 subjects studied, 111 (56.9%) indicated a desire to have children. The main reasons for wanting to procreate included ensuring lineage continuity and posterity (52.3%), securing relationships (27.0%), and pressure from relatives to reproduce (20.7%). Single subjects were more inclined to have children (76.3%) compared with married (51.5%), widowed (18.2%), and separated/divorced subjects (11.1%, P = 0.03). Of the 111 subjects who indicated their desire to have children, women were more inclined to have children (64.5%) than men (47.7%). The major concern among the 84 (43.1%) subjects not desiring more children were the fear of infecting a serodiscordant partner and baby (57.1%), fear of dying and leaving behind orphans (28.6%), and fear that they may become too ill and unable to support the child financially (14.3%). Persons with no formal education were more likely to have children irrespective of their positive HIV status (66.7%) than persons educated to tertiary education level (37.0%, P = 0.01). Of 111 subjects who desired to have children, only 58% had attended reproductive health counseling with HIV counselors. Reasons for not seeking advice were anticipated negative reactions and discrimination from counselors. A significant number of subjects were only aware of some of the reproductive health options available to reduce the risk of infecting their partners and/or baby, such as artificial vaginal insemination, intrauterine insemination, cesarean section, avoidance of breast feeding, and offering prenatal pre-exposure prophylaxis to the fetus. They were unaware of other options, such as sperm washing, in vitro fertilization, and intracytoplasmic sperm injection. Of the 43.1% not anticipating more children, 36.9% were anticipating adoption.

Conclusion

Our study has shown that a significant number of HIV-infected persons in the Niger Delta of Nigeria desire to have children irrespective of their positive serostatus. There is the need to support the sexual and reproductive rights of HIV-infected individuals. Additional training needs to be offered to HIV counselors on evidence-based best and affordable practices regarding reproductive health issues among persons living with HIV. Policies that support availability and accessibility to relevant reproductive and sexual health services, including contraception and procreation, need to be developed. Public enlightenment programs on HIV are needed to reduce the stigmatization that HIV-infected persons face from family members and their communities.

Prevalence of seroconversion symptoms and relationship to set-point viral load: findings from a subtype C epidemic, 1995-2009

OBJECTIVE

To describe symptoms, physical examination findings, and set-point viral load associated with acute HIV seroconversion in a heterosexual cohort of HIV-discordant couples in Zambia.

DESIGN

We followed HIV serodiscordant couples in Lusaka, Zambia from 1995 to 2009 with HIV testing of negative partners and symptom inventories 3 monthly, and physical examinations annually.

METHODS

We compared prevalence of self-reported or treated symptoms (malaria syndrome, chronic diarrhea, asthenia, night sweats, and oral candidiasis) and annual physical examination findings (unilateral or bilateral neck, axillary, or inguinal adenopathy; and dermatosis) in seroconverting vs. HIV-negative or HIV-positive intervals, controlling for repeated observations, age, and sex. A composite score comprised of significant symptoms and physical examination findings predictive of seroconversion vs. HIV-negative intervals was constructed. We modeled the relationship between number of symptoms and physical examination findings at seroconversion and log set-point viral load using linear regression.

RESULTS

Two thousand, three hundred and eighty-eight HIV-negative partners were followed for a median of 18 months; 429 seroconversions occurred. Neither symptoms nor physical examination findings were reported for most seroconverters. Seroconversion was significantly associated with malaria syndrome among nondiarrheic patients [adjusted odds ratio (aOR) = 4.0], night sweats (aOR = 1.4), and bilateral axillary (aOR = 1.6), inguinal (aOR = 2.2), and neck (aOR = 2.2) adenopathy relative to HIV-negative intervals. Median number of symptoms and findings was positively associated with set-point viral load (P < 0.001).

CONCLUSION

Although most acute and early infections were asymptomatic, malaria syndrome was more common and more severe during seroconversion. When present, symptoms and physical examination findings were nonspecific and associated with higher set-point viremia.

Influence network effectiveness in promoting couples' HIV voluntary counseling and testing in Kigali, Rwanda

OBJECTIVE

To identify predictors of promotion of couples' HIV voluntary counseling and testing (CVCT) in Kigali, Rwanda.

DESIGN

Analysis of CVCT promotional agent [influential network leaders (INLs), influential network agents (INAs)], and couple/invitation-level predictors of CVCT uptake.

METHODS

Number of invitations and couples tested were evaluated by INL, INA, and couple/contextual factors. Multivariable logistic regression accounting for two-level clustering analyzed factors predictive of couples' testing.

RESULTS

Twenty-six INLs recruited and mentored 118 INAs who delivered 24 991 invitations. 4513 couples sought CVCT services after invitation. INAs distributed an average of 212 invitations resulting in an average of 38 couples tested/agent. Characteristics predictive of CVCT in multivariate analyses included the invitee and INA being socially acquainted [adjusted odds ratio (aOR) = 1.4; 95% confidence interval (CI) 1.2-1.6]; invitations delivered after public endorsement (aOR = 1.3; 95% CI 1.1-1.5); and presence of a mobile testing unit (aOR = 1.4; 95% CI 1.0-2.0). In stratified analyses, predictors significant among cohabiting couples included invitation delivery to the couple (aOR = 1.2; 95% CI 1.0-1.4) and in the home (aOR = 1.3; 95% CI 1.1-1.4), whereas among noncohabiting couples, predictors included invitations given by unemployed INAs (aOR = 1.7; 95% CI 1.1-2.7). Cohabiting couples with older men were more likely to test, whereas younger age was associated with testing among men in noncohabiting unions.

CONCLUSIONS

Invitations distributed by influential people were successful in prompting couples to seek joint HIV testing, particularly if the invitation was given in the home to someone known to the INA and accompanied by a public endorsement of CVCT. Mobile units also increased the number of couples tested. Country-specific strategies to promote CVCT programs are needed to reduce HIV transmission among those at highest risk for HIV in sub-Saharan Africa.

Determinants of condom uptake among HIV voluntary counselling and testing clients: experiences from a hospital-based study in south India

Background

HIV voluntary counselling and testing was a key HIV prevention strategy brought to scale by India's National AIDS Control Organization. Condom uptake is an essential metric of intervention impact given the expansion of the epidemic into an increasingly diverse population. With only 20% of first-time counselling and testing clients at the largest HIV treatment hospital in south India reporting previous condom use, the question of intervention impact on condom use deserves investigation. In this study, we track intervention impact across various demographic groups and identify the added value of more thorough counselling.

Methods

Data were collected from 8,865 individuals who attended counselling multiple times at the Tamil Nadu Government Hospital of Thoracic Medicine over the years 2004-2009. Counsellors recorded client demographic characteristics, HIV risk behaviours reported, and counselling services provided after each counselling session. Matching and regression methods were used to determine the probability of condom uptake by serostatus, gender, and receipt of personalized risk reduction counselling while controlling for other characteristics.

Results

HIV counselling and testing was associated with condom uptake among 29.2% of HIV positive women (CI 24.5-34.4%), 31.7% of HIV positive men (CI 27.8-35.4%), 15.5% of HIV negative women (CI 11.2-20.8%), and only 3.6% of HIV negative men (CI 1.9-5.9%) who had previously never used condoms. Personalized risk reduction counselling increased impact in some groups; for example an additional 18% of HIV negative women (CI 11.3-24.4%) and 17% of HIV positive men (CI 10.9-23.4%) started using condoms. The number of sexual partners was not associated with the impact of counselling completeness.

Conclusions

Because the components of testing and counselling impact the condom use habits of men and women differently, understanding the dynamics of condom use negotiation between partners is essential to optimizing impact on Indian couples. Clients' predicted condom uptake ranged between 4% and 47% depending on factors like gender, serostatus, and services provided. Personalized risk reduction counselling is associated with increased chance of condom use, with larger gains in HIV negative women and HIV positive men. HIV negative men are least likely to start using condoms and least impacted by additional counselling.

Promotion of couples' voluntary HIV counselling and testing in Lusaka, Zambia by influence network leaders and agents

OBJECTIVES

Hypothesising that couples' voluntary counselling and testing (CVCT) promotions can increase CVCT uptake, this study identified predictors of successful CVCT promotion in Lusaka, Zambia.

DESIGN

Cohort study.

SETTING

Lusaka, Zambia.

PARTICIPANTS

68 influential network leaders (INLs) identified 320 agents (INAs) who delivered 29 119 CVCT invitations to heterosexual couples.

INTERVENTION

The CVCT promotional model used INLs who identified INAs, who in turn conducted community-based promotion and distribution of CVCT invitations in two neighbourhoods over 18 months, with a mobile unit in one neighbourhood crossing over to the other mid-way through.

PRIMARY OUTCOME

The primary outcome of interest was couple testing (yes/no) after receipt of a CVCT invitation. INA, couple and invitation characteristics predictive of couples' testing were evaluated accounting for two-level clustering.

RESULTS

INAs delivered invitations resulting in 1727 couples testing (6% success rate). In multivariate analyses, INA characteristics significantly predictive of CVCT uptake included promoting in community-based (adjusted OR (aOR)=1.3; 95% CI 1.0 to 1.8) or health (aOR=1.5; 95% CI 1.2 to 2.0) networks versus private networks; being employed in the sales/service industry (aOR=1.5; 95% CI 1.0 to 2.1) versus unskilled manual labour; owning a home (aOR=0.7; 95% CI 0.6 to 0.9) versus not; and having tested for HIV with a partner (aOR=1.4; 95% CI 1.1 to 1.7) or alone (aOR=1.3; 95% CI 1.0 to 1.6) versus never having tested. Cohabiting couples were more likely to test (aOR=1.4; 95% CI 1.2 to 1.6) than non-cohabiting couples. Context characteristics predictive of CVCT uptake included inviting couples (aOR=1.2; 95% CI 1.0 to 1.4) versus individuals; the woman (aOR=1.6; 95% CI 1.2 to 2.2) or couple (aOR=1.4; 95% CI 1.0 to 1.8) initiating contact versus the INA; the couple being socially acquainted with the INA (aOR=1.6; 95% CI 1.4 to 1.9) versus having just met; home invitation delivery (aOR=1.3; 95% CI 1.1 to 1.5) versus elsewhere; and easy invitation delivery (aOR=1.8; 95% CI 1.4 to 2.2) versus difficult as reported by the INA.

CONCLUSIONS

This study demonstrated the ability of influential people to promote CVCT and identified agent, couple and context-level factors associated with CVCT uptake in Lusaka, Zambia. We encourage the development of CVCT promotions in other sub-Saharan African countries to support sustained CVCT dissemination.

Condom use in the context of sex research: a commentary

This commentary highlights some recent trends in sex research that have particular relevance for research on condom use, including studies investigating the meaning of sexual arousal, desire and pleasure; a focus on couple-level investigations; and the relevance of individual differences and personality characteristics to sexual risk-taking. Although historically, sexuality-related issues have received little systematic attention in the field of public health, researchers are now paying more attention to the role of pleasure and sexual arousal in condom use. It is argued that a better integration of findings from the area of sex research into the HIV and sexually transmissible infection (STI) field is needed to develop and improve programs to reduce the risk of STIs and unintended pregnancy.

Sexual risk behaviors among HIV-infected South African men and women with their partners in a primary care program: implications for couples-based prevention

We studied 1163 sexually-active HIV-infected South African men and women in an urban primary care program to understand patterns of sexual behaviors and whether these behaviors differed by partner HIV status. Overall, 40% reported a HIV-positive partner and 60% a HIV-negative or status unknown partner; and 17.5% reported >2 sex acts in the last 2 weeks, 16.4% unprotected sex in the last 6 months, and 3.7% >1 sex partner in the last 6 months. Antiretroviral therapy (ART) was consistently associated with decreased sexual risk behaviors, as well as with reporting a HIV-negative or status unknown partner. The odds of sexual risk behaviors differed by sex; and were generally higher among participants reporting a HIV-positive partner, but continued among those with a HIV-negative or status unknown partner. These data support ART as a means of HIV prevention. Engaging in sexual risk behaviors primarily with HIV-positive partners was not widely practiced in this setting, emphasizing the need for couples-based prevention.

Local residents trained as 'influence agents' most effective in persuading African couples on HIV counseling and testing

Couples in sub-Saharan Africa are the largest group in the world at risk for HIV infection. Couples counseling and testing programs have been shown to reduce HIV transmission, but such programs remain rare in Africa. Before couples counseling and testing can become the norm, it is essential to increase demand for the services. We evaluated the effectiveness of several promotional strategies during a two-year program in Kitwe and Ndola, Zambia. The program attracted more than 7,600 couples through the use of radio broadcasts, billboards, and other strategies. The most effective recruiting technique was the use of local residents trained as "influence agents" to reach out to friends, neighbors, and others in their sphere of influence.

The future role of rectal and vaginal microbicides to prevent HIV infection in heterosexual populations: implications for product development and prevention

OBJECTIVES

To compare the potential impact of rectal (RMB), vaginal (VMB) and bi-compartment (RVMB) (applied vaginally and protective during vaginal and anal intercourse) microbicides to prevent HIV in various heterosexual populations. To understand when a RMB is as useful than a VMB for women practicing anal intercourse (AI).

METHODS

Mathematical model was used to assess the population-level impact (cumulative fraction of new HIV infections prevented (CFP)) of the three different microbicides in various intervention scenarios and prevalence settings. We derived the break-even RMB efficacy required to reduce a female's cumulative risk of HIV infection by the same amount than a VMB.

RESULTS

Under optimistic coverage (fast roll-out, 100% uptake), a 50% efficacious VMB used in 75% of sex acts in population without AI may prevent ∼33% (27, 42%) new total (men and women combined) HIV infections over 25 years. The 25-year CFP reduces to ∼25% (20, 32%) and 17% (13, 23%) if uptake decreases to 75% and 50%, respectively. Similar loss of impact (by 25%-50%) is observed if the same VMB is introduced in populations with 5%-10% AI and for RR(RAI)=4-20. A RMB is as useful as a VMB (ie, break-even) in populations with 5% AI if RR(RAI)=20 and in populations with 15%-20% AI if RR(RAI)=4, independently of adherence as long as it is the same with both products. The 10-year CFP with a RVMB is twofold larger than for a VMB or RMB when AI=10% and RR(RAI)=10.

CONCLUSIONS

Even low AI frequency can compromise the impact of VMB interventions. RMB and RVMB will be important prevention tools for heterosexual populations.

High acceptability of HIV voluntary counselling and testing among female sex workers: impact of individual and social factors

OBJECTIVES

Voluntary counselling and testing (VCT) for HIV infection is an important tool for prevention of HIV infection and AIDS in high-risk groups. Our goal was to describe the acceptability and consequences of VCT among a stigmatized and vulnerable group, female sex workers (FSWs), in Conakry, Guinea.

METHODS

Acceptance of the test and return for test results at baseline and consequences of testing 1 year later were described. The perceived risk of HIV infection and perceived benefits and barriers to testing were examined using quantitative and qualitative methods.

RESULTS

All 421 FSW participants agreed to undergo VCT and most participants (92%) returned for their results. The main reason cited for VCT acceptance was the wish to know their HIV status. However, some managers of FSW worksites urged FSWs to be tested, curtailing FSWs' free decision-making. One year later, status disclosure was common (90% of the 198 individuals who knew their results among those who participated in the follow-up part of the study). Positive consequences of testing were far more frequently reported than negative consequences (98% vs. 2%, respectively). Negative life events included banishment from the worksite (one case) and verbal abuse (two cases).

CONCLUSION

Acceptability of VCT appears high in the FSW population in Conakry as a consequence of both perceptions of high individual risk and social pressures.

Condom use within marriage: an assessment of changes in South Africa and Uganda

The aim of the study is to measure trends in condom use in marital and cohabiting relationships in South Africa and Uganda. The data for the study come from two cross sectional surveys conducted in 1998 and 2008 among adult men and women and their partners in KwaZulu-Natal, South Africa and the Jinja district, Uganda. The findings suggest that consistent condom use has risen substantially in both countries. The percentage reporting consistent condom use in the South African sample of husbands increased from 2.5% in 1998 to 12% in 2008 and from 5.5 to 12.5% among wives. In Uganda, the corresponding trends are 1.1-8.3% for husbands and 4-8.6% for wives. In both countries, condom use was considerably higher among the minority of couples where one or both partners were thought to be HIV positive. Increasingly, in both countries condoms are also used for contraceptive purposes. Condoms play a role in preventing HIV infection but the challenge is for prevention programs to broaden their focus toward meeting the needs of married and cohabiting couples.

Understanding couples' attitudes on prenatal HIV testing in the Democratic Republic of Congo

BACKGROUND

The prevalence of HIV-serodiscordant couples is increasing. In these couples, one member is infected with HIV and the other one is not, so HIV testing for both members of the couple remains one of the significant challenges in the prevention of sexual transmission of HIV within the couple. The aim of this study was to analyze couples' attitudes toward HIV testing after prenatal HIV testing offered to pregnant women and analyze the males' behavior with regard to their own HIV testing.

METHODS

One hundred and forty-three pregnant women and their partners were interviewed in the Lubumbashi health district in the Democratic Republic of the Congo. The usual descriptive statistics were applied.

RESULTS

Seventy-one percent of the couples declared that they accepted the HIV testing proposed to the woman and approximately 64% of the couples said they had discussed the HIV testing proposed in prenatal healthcare clinics. However, this dialogue seemed to have a poor impact on the HIV testing of the male partner: no male partner was tested in spite of the high proportion of men encouraged to do so. Nearly 30% and 50% of the couples disagreed on systematic condom use and the need for the husband's permission to undergo HIV testing, respectively. Twenty-nine percent of the couples did not wish to have the male sexual partner present at the prenatal consultation.

CONCLUSION

The majority of men considered that their wife's HIV testing gives them information about their own HIV status and this makes HIV testing difficult for both members of the couple. Better management of the couple in HIV screening and prevention programs therefore seems necessary.

Optimal uses of antiretrovirals for prevention in HIV-1 serodiscordant heterosexual couples in South Africa: a modelling study

BACKGROUND

Antiretrovirals have substantial promise for HIV-1 prevention, either as antiretroviral treatment (ART) for HIV-1-infected persons to reduce infectiousness, or as pre-exposure prophylaxis (PrEP) for HIV-1-uninfected persons to reduce the possibility of infection with HIV-1. HIV-1 serodiscordant couples in long-term partnerships (one member is infected and the other is uninfected) are a priority for prevention interventions. Earlier ART and PrEP might both reduce HIV-1 transmission in this group, but the merits and synergies of these different approaches have not been analyzed.

METHODS AND FINDINGS

We constructed a mathematical model to examine the impact and cost-effectiveness of different strategies, including earlier initiation of ART and/or PrEP, for HIV-1 prevention for serodiscordant couples. Although the cost of PrEP is high, the cost per infection averted is significantly offset by future savings in lifelong treatment, especially among couples with multiple partners, low condom use, and a high risk of transmission. In some situations, highly effective PrEP could be cost-saving overall. To keep couples alive and without a new infection, providing PrEP to the uninfected partner could be at least as cost-effective as initiating ART earlier in the infected partner, if the annual cost of PrEP is <40% of the annual cost of ART and PrEP is >70% effective.

CONCLUSIONS

Strategic use of PrEP and ART could substantially and cost-effectively reduce HIV-1 transmission in HIV-1 serodiscordant couples. New and forthcoming data on the efficacy of PrEP, the cost of delivery of ART and PrEP, and couples behaviours and preferences will be critical for optimizing the use of antiretrovirals for HIV-1 prevention. Please see later in the article for the Editors' Summary.

Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world

There have been dramatic increases in access to antiretroviral therapy (ART) across the developing world, and growing public health attention has focused on the possibility of utilizing ART as a means of slowing the global HIV epidemic. The preventive impact of ART will likely depend on decreasing levels of sexual risk behaviors following treatment initiation. The current review study examines the impact of wider access to ART on sexual risk behaviors among HIV-infected individuals in the developing world. The observational studies to date demonstrate that ART is associated with a significant reduction in unprotected sex following treatment initiation. Although data on the impact of ART on possible risk compensation are rapidly expanding across the developing world, more evidence is still needed before we can safely conclude expanded treatment will result in durable decreases in sexual risk behaviors.

High levels of acceptability of couples-based HIV testing among MSM in South Africa

The acceptability of couples-based voluntary HIV counseling and testing (CVCT) has not been previously investigated among men who have sex with men (MSM) in South Africa. Using online advertisements, data were collected from 486 MSM, who were 18 years of age or older with a current residence in South Africa and had at least one male sex partner in the previous 12 months. The analysis examined associations between individual characteristics and willingness to utilize CVCT services. The willingness to utilize CVCT services was compellingly high (89%) among this sample of mostly White/European African (89%) and HIV-negative (83%) men. MSM who reported higher numbers of completed school years were less likely to report willingness to use CVCT. Willingness did not vary significantly across other individual demographic or behavioral characteristics. Our results show an overwhelmingly high acceptance of CVCT services. Future studies should survey a more heterogeneous population of MSM, explore the complex nature of same-sex male relationships, and why respondents would or would not use these HIV testing services.

Genetic variations and heterosexual HIV-1 infection: analysis of clustered genes encoding CC-motif chemokine ligands

Several CC-motif chemokine ligands (CCLs) can block HIV-1-binding sites on CC-motif chemokine receptor 5 (CCR5) and inhibit viral entry. We studied single-nucleotide polymorphisms (SNPs) in genes encoding three CCR5 ligands (CCL3 (MIP-1a), CCL4 (MIP-1b)and CCL5 (RANTES)) along with an adjacent gene encoding a CCR2ligand (CCL2 (MCP-1)) to identify candidate markers for HIV-1 infection and pathogenesis. Analyses of 567 HIV-1 serodiscordant Zambian couples revealed that rs5029410C (in CCL3 intron 2) was associated with lower viral load (VL) in seroconverters, adjusted for gender and age (regression β=-0.57 log(10), P=4x10(-6)). Inaddition, rs34171309A in CCL3 exon 3 was associated with increased risk of HIV-1 acquisition in exposed seronegatives(hazard ratio=1.52, P=0.006 when adjusted for VL of the initially seropositive partner and genital ulcer/inflammation). SNPrs34171309 encodes a conservative Glu-to-Asp substitution. Fiven eighboring SNPs in tight linkage disequilibrium with rs34171309all showed similar associations with HIV-1 acquisition. How these multiple CCL3 SNPs may alter the occurrence or course of HIV-1 infection remains to be determined [corrected].

Characteristics of HIV-1 serodiscordant couples enrolled in a clinical trial of antiretroviral pre-exposure prophylaxis for HIV-1 prevention

Introduction

Stable heterosexual HIV-1 serodiscordant couples in Africa have high HIV-1 transmission rates and are a critical population for evaluation of new HIV-1 prevention strategies. The Partners PrEP Study is a randomized, double-blind, placebo-controlled trial of tenofovir and emtricitabine-tenofovir pre-exposure prophylaxis to decrease HIV-1 acquisition within heterosexual HIV-1 serodiscordant couples. We describe the trial design and characteristics of the study cohort.

Methods

HIV-1 serodiscordant couples, in which the HIV-1 infected partner did not meet national guidelines for initiation of antiretroviral therapy, were enrolled at 9 research sites in Kenya and Uganda. The HIV-1 susceptible partner was randomized to daily oral tenofovir, emtricitabine-tenofovir, or matching placebo with monthly follow-up for 24–36 months.

Results

From July 2008 to November 2010, 7920 HIV-1 serodiscordant couples were screened and 4758 enrolled. For 62% (2966/4758) of enrolled couples, the HIV-1 susceptible partner was male. Median age was 33 years for HIV-1 susceptible and HIV-1 infected partners [IQR (28–40) and (26–39) respectively]. Most couples (98%) were married, with a median duration of partnership of 7.0 years (IQR 3.0–14.0) and recent knowledge of their serodiscordant status [median 0.4 years (IQR 0.1–2.0)]. During the month prior to enrollment, couples reported a median of 4 sex acts (IQR 2–8); 27% reported unprotected sex and 14% of male and 1% of female HIV-1 susceptible partners reported sex with outside partners. Among HIV-1 infected partners, the median plasma HIV-1 level was 3.94 log₁₀ copies/mL (IQR 3.31–4.53) and median CD4 count was 496 cells/µL (IQR 375–662); the majority (64%) had WHO stage 1 HIV-1 disease.

Conclusions

Couples at high risk of HIV-1 transmission were rapidly recruited into the Partners PrEP Study, the largest efficacy trial of oral PrEP. (ClinicalTrials.gov NCT00557245)

Diagnosis of latent tuberculosis infection among HIV discordant partners using interferon gamma release assays

BACKGROUND

There is limited data on the effect of HIV status and CD4 counts on performance of Interferon-g Release assays (IGRAs) for diagnosis of latent tuberculosis infection (LTBI).

METHODS

A cross sectional study was conducted to assess the prevalence of and risk factors for a positive diagnostic test for LTBI, using tuberculin skin test (TST) and IGRAs among HIV-discordant couples in Zambia.

RESULTS

A total of 596 subjects (298 couples) were enrolled. Median CD4 count among HIV positive persons was 388 cells/μl, (range 51-1330). HIV negative persons were more likely than their HIV positive partner, to have a positive diagnostic test for LTBI with TST (203 vs 128), QFT (171 vs 109) and TSPOT (156 vs. 109). On multivariate analysis, HIV negative status was an independent predictor for a positive QFT (OR = 2.22, 95% CI 1.42- 3.46) and TSPOT (OR = 1.79, 95% CI 1.16-2.77). Among HIV positive subjects a CD4 count ≥ 388 cells/μl was associated with a positive TST (OR = 1.76 95% CI 1.10-2.82) and QFT (OR = 1.71 95% CI 1.06-2.77) but not TSPOT (OR = 1.20 95% CI 0.74-1.94).

CONCLUSIONS

Persons with HIV had significantly fewer positive diagnostic tests for LTBI with TST, QFT and TSPOT. Persons with a CD4 count < 388 cells/μl were less likely to have a positive TST or QFT, but not less likely to have a positive TSPOT. TSPOT may perform better than TST or QFT in HIV positive individuals.