Low HIV-1 incidence among married serodiscordant couples in Pune, India

Sexual behavior and contraceptive practices: Study among married heterosexual HIV serodiscordant couples of reproductive age group attending anti-retroviral therapy centre at a Tertiary care hospital in Mumbai, India

Background:

As many as half of people with HIV who are in a long-term sexual relationship have an HIV-negative partner. Data on sexual behavior and contraceptive needs of heterosexual serodiscordant couples are scarce in India. Keeping these facts in mind, it was considered imperative to conduct a study on sexual behavior, contraceptive practices and associated high risk factors among heterosexual serodiscordant couples.

Objectives:

The objective of the study was to assess the sexual behavior, current contraceptive practices and various risk factors of HIV transmission among married heterosexual HIV serodiscordant couples.

Materials and Methods:

Descriptive study conducted at antiretroviral therapy (ART) centre from where 100 discordant couples were included, data were collected related to their sexual practices, knowledge about different contraception methods and high risk factors related to infection transmission were recorded.

Results:

All couples had knowledge of use of condoms (100%) while consistent usage was seen only in 18%. The high risk of HIV transmission was seen among recently married serodiscordant couples. Couples engaged in daily intercourse were more likely to have high risk of transmission (P value < 0.05).

Conclusion:

This study showed various risk factors for infection transmission to the seronegative partner among serodiscordant couples. Henceforth, given conception that prevention of these factors could reduce overall seroconversion rate among such couples.

HIV transmission between spouses living in Lu'an city, Anhui province, China: a longitudinal study

This study aims to investigate the human immunodeficiency virus (HIV) transmission rate in HIV serodiscordant couples, in addition to the relevant influencing factors. From January 1999 to August 2016, patients with HIV/AIDS (index cases) along with their fixed partners were registered and monitored to determine the rate of HIV transmission between couples, as well as relevant influencing factors. A total of 231 HIV-positive couples were investigated, of these, 45-negative (19.48%) partners were infected with HIV via sexual transmission prior to diagnosis of the first case detected in couples. After diagnosis, the transmission rate between spouses was 0.39 per 100 person-years (2/507.7), and the cumulative transmission rate was 1.08% (2/186), which was significantly lower than the transmission rate before diagnosis (χ² = 35.714, P < 0.001). Among the 119 HIV/AIDS patients who received antiretroviral therapy (ART), the transmission rate was 0 (0/119), whereas the transmission rate was 2.99% (2/67) in HIV/AIDS patients who did not receive ART. In addition, HIV transmission rate in serodiscordant couples was high prior to diagnosis of the index case. However, following diagnosis, the transmission rate was reduced, and the risk of transmission in the index case with antiviral treatment was null. Therefore, a prompt intervention in HIV discordant couples with ART of index case is vital to reduce the risk of HIV transmission.

Serodiscordant partnerships and opportunities for pre-exposure prophylaxis among partners of women and men living with HIV in St. Petersburg, Russia

Objective

To describe the frequency of being partnered and having an HIV-negative partner, and whether this differed by gender, among a cohort of persons living with HIV (PLWH) who have ever injected drugs; to describe awareness of HIV pre-exposure prophylaxis (PrEP) and perceived partner interest in PrEP.

Setting

Secondary analyses of an observational cohort study of PLWH who have ever injected drugs in St. Petersburg, Russia.

Methods

Primary outcomes were 1) being partnered and 2) being in a serodiscordant partnership. The main independent variable was gender. Multivariable GEE logistic regression models were fit for binary outcomes, adjusted for age, income, education, and recent opioid use. Descriptive analyses were performed for partners’ HIV status, substance use, sex risk behaviors, and awareness of PrEP for a subset of participants.

Results

At baseline, 50% (147/296) reported being in a partnership, and of those, 35% were in a serodiscordant partnership. After adjustment, women had significantly higher odds of being partnered compared to men (aOR = 3.12; 95% CI: 1.77, 5.51), but there were no significant gender differences in the odds of being in a serodiscordant partnership (aOR = 0.58; 95% CI: 0.27, 1.24). Among a sub-sample of participants queried (n = 56), 25% were aware of PrEP for prevention of sexual HIV transmission and 14% for prevention of injection-related transmission.

Conclusion

Although half of our sample were partnered and one third of these partnerships were serodiscordant, PrEP awareness was low. Substantial opportunities for HIV prevention exist among PLWH who have ever injected drugs in Russia and their HIV-negative partners. Given the high proportion of HIV-negative partners among this ART-naïve sample, efforts to address the associated inherent risks, such as couples-based interventions, are needed to increase condom use, PrEP awareness, or uptake of other HIV-prevention modalities (e.g., ART for the HIV-positive partner).

Risk Factor Associated with Negative Spouse HIV Seroconversion among Sero-Different Couples: A Nested Case-Control Retrospective Survey Study in 30 Counties in Rural China

Background

Antiretroviral therapy (ART) and condom use have been proven to reduce the risk of sexual transmission of human immunodeficiency virus (HIV) among HIV sero-different couples, but its full implementation remains a challenge. This study aims to assess HIV seroconversion rate of HIV-negative spouse and its associated risk factors among HIV sero-different couples in rural China.

Methods

An open cohort of HIV sero-different couples enrolled in 30 counties in China between October 1, 2010, and September 30, 2012, and followed-up to December 31, 2012, was constructed retrospectively. A nested case-control study of risk factors of HIV seroconversion among sero-different couples was conducted in April and May of 2013, based on the open cohort. Sero-different couples with the HIV-negative spouse seroconverting at least 3 months after the previous negative diagnosis during cohort observation period were labeled as “case couples”. The “control couples” were selected randomly from the same cohort that did not have the HIV-negative spouse seroconversion during the same period. The “case couples” and “control couples” were matched on gender, age, and region of residence. Sexual behaviors among HIV sero-different couples before and after the index spouses notifying their HIV infection status to their HIV-negative spouses were collected via face-to-face interview. Univariate and multivariate logistic regression models were used to assess factors associated with HIV seroconversion among HIV sero-different couples.

Results

Of 4481 HIV sero-different couples, a total of 53 seroconversions were observed within 5218 person-years of follow-up. The incidence rate was 1.02 (95%CI: 0.76–1.33) per 100 person-years. Forty “case couples” confirmed HIV-negative spouse seroconversions infected via marital sexual transmission, were matched to 80 “control couples”. Of the 120 couples, 81(67.5%) were receiving ART, and 70 (58.3%) reported consistently used condoms during intercourse after the index spouse was diagnosed HIV infection. Multivariate conditional logistic regression analysis showed that the desire to conceive a child (OR = 5.18, 95% CI: 1.19–22.58) significantly increased the odds of HIV seroconversion. Protective factors of spousal HIV seroconversion were currently receiving ART (OR = 0.09, 95% CI: 0.01–0.67) and consistent condom use (OR = 0.05, 95% CI: 0.01–0.28).

Conclusions

Intention to conceive a child is the most important risk factor for HIV seroconversion among sero-different couples. Specific efforts on scientific use of ART to assist sero-different couples to achieve their wish to conceive a healthy child are needed to minimize the risk of HIV transmission.

Using a 2-stage strategy with respondent-driven sampling to recruit a hard-to-reach population for a placebo microbicide gel clinical trial in Nellore, Andhra Pradesh (India)

Traditional recruitment methods for microbicide efficacy trials are labor intensive and may fail to reach high-risk hard-to-reach populations. We report duration of recruitment and lessons learned from a two-stage process to recruit female sex workers (FSWs) into a placebo microbicide trial, and examined characteristics associated with successful recruitment of peers who screened for and enrolled in the trial. FSWs were first recruited via respondent-driven sampling (RDS) to complete a survey and subsequently invited to screen for enrollment into a placebo microbicide trial taking place at a local clinic. It took 6 months to enroll 267 participants into the trial. Successful recruiters of peers who enrolled were more likely to have enrolled themselves (AOR 2.0, CI 1.3-2.9) and less likely to visit Nellore city (AOR 0.5, CI 0.3-0.9). Recruitment of FSWs via a two-stage recruitment strategy with RDS can be a good option for future clinical trials.

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

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

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

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

Variations in KIR genes: a study in HIV-1 serodiscordant couples

Background. NK cells have anti-HIV activity mediated through killer cell immunoglobulin-like receptors (KIRs). The current prospective cohort study evaluated whether variation in KIR genes is associated with HIV infection in discordant couples (DCs), where one spouse remains seronegative (HSN) despite repeated exposure to the HIV. Methods. KIR was genotyped using PCR SSP. Viral load and CD4 counts were estimated using commercially available reagents. Data were analyzed using SPSS software. Results. Among the 47 DCs, HSN spouses had significantly (P = 0.006) higher frequencies of KIR3DS1. Regression analysis revealed significant (P = 0.009) association of KIR2DS1 with low viral load. KIR2DS4 variant was associated (P = 0.032) with high viral load. Three pairs of KIR genes were in strong LD in HSNs and two pairs in HSPs. There were 60 KIR genotypes, and 16 are reported the first time in the Indian population. Exclusive genotypes were present either in HSPs (N = 22, 11 unique genotypes) or in HSNs (n = 27, 9 unique genotypes). Conclusions. This study highlights for the first time in the Indian population an association of KIR genes in HIV infection where presence of exclusive and unique genotypes indicates possible association with either HIV infection or with protection.

Antiretroviral therapy for prevention of HIV transmission: implications for Europe

The aim of this review is to summarise the evidence on the population-level effect of antiretroviral therapy (ART) in preventing HIV infections, and to discuss potential implications in the European context of recommending starting ART when the CD4 count is above 350 cells/mm3. The ability of ART to reduce the risk of HIV transmission has been reported in observational studies and in a randomised controlled trial (HPTN 052), in which ART initiation reduced HIV transmission by 96% within serodiscordant couples. As yet, there is no direct evidence for such an effect among men having sex with men or people who inject drugs. HPTN 052 led international organisations to develop recommendations with a higher CD4 threshold for ART initiation. However, there remains a lack of strong evidence of clinical benefit for HIV-positive individuals starting ART with CD4 count above 350 cells/mm3. The main goal of ART provision should be to increase ART coverage for all those in need, based on the current guidelines, and the offer of ART to those who wish to reduce infectivity; increased HIV testing is therefore a key requirement. Other proven prevention means such as condom use and harm reduction for people who inject drugs remain critical.

Heterosexual HIV-1 infectiousness and antiretroviral use: systematic review of prospective studies of discordant couples

BACKGROUND

Recent studies have estimated the reduction in HIV-1 infectiousness with antiretroviral therapy (ART), but high-quality studies such as randomized controlled trials, accompanied by rigorous adherence counseling, are likely to overestimate the effectiveness of treatment-as-prevention in real-life settings.

METHODS

We attempted to summarize the effect of ART on HIV transmission by undertaking a systematic review and meta-analysis of HIV-1 infectiousness per heterosexual partnership (incidence rate and cumulative incidence over study follow-up) estimated from prospective studies of discordant couples. We used random-effects Poisson regression models to obtain summary estimates. When possible, the analyses were further stratified by direction of transmission (man-to-woman or woman-to-man) and economic setting (high- or low-income countries). Potential causes of heterogeneity of estimates were explored through subgroup analyses.

RESULTS

Fifty publications were included. Nine allowed comparison between ART and non-ART users within studies (ART-stratified studies), in which summary incidence rates were 3.6/100 person-years (95% confidence interval = 2.0-6.5) and 0.2/100 person-years (0.07-0.7) for non-ART- and ART-using couples, respectively (P < 0.001), constituting a 91% (79-96%) reduction in per-partner HIV-1 incidence rate with ART use. The 41 studies that did not stratify by ART use provided estimates with high levels of heterogeneity (I statistic) and few reported levels of ART use, making interpretation difficult. Nevertheless, estimates tended to be lower with ART use. Infectiousness tended to be higher for low-income than high-income settings, but there was no clear pattern by direction of transmission (man-to-woman and woman-to-man).

CONCLUSIONS

ART substantially reduces HIV-1 infectiousness within discordant couples, based on observational studies, and could play a major part in HIV-1 prevention efforts. However, the non-zero risk from partners receiving ART demonstrates that appropriate counseling and other risk-reduction strategies for discordant couples are still required. Additional estimates of ART effectiveness by adherence level from real-life settings will be important, especially for persons starting treatment early without symptoms.

HIV-1 discordant couples in Karnataka, South India: is the sex ratio of index cases changing?

India has an estimated 2.5 million HIV infections, most of which are heterosexually transmitted. Women comprise 40% of infected adults. In India, 90% of women between the ages of 15 and 45 years are married. Previous literature has suggested that sexual intercourse with an HIV-infected husband represents a married woman's greatest risk for being infected. However, a recent meta-analysis of discordant couples from sub-Saharan Africa reported that women were the index case in half of all couples. Similar data are not available from India. This cross-sectional study describes the epidemiology of 925 discordant couples from five districts in Karnataka province, one of the high HIV prevalence provinces in India. Men were the index case in 74% of couples. However, in young couples (where the index case was aged <30 years), women were more likely to be the infected partner (64% of couples). Condom use was reported by 46% of these discordant couples. These results suggest an emerging predominance of female index case infections among younger discordant couples in India, and point to the need for focusing HIV preventive messages on youth and couples before marriage.

Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery

The current study examines sexual behaviors among HIV-infected Indians in primary care, where access to highly active antiretroviral therapy (HAART) has recently increased. Between January and April 2008, we assessed the sexual behaviors of 247 HIV-infected South Indians in care. Multivariable logistic regression models were used to determine predictors of being in a HIV-seroconcordant primary relationship, being sexually active, and reporting unprotected sex. Over three-fourths (80%) of participants were HAART-experienced. Among the 58% of participants who were currently in a seroconcordant relationship, one-third were serodiscordant when enrolling into care. Approximately two-thirds (63.2%) of participants were sexually active; 9.0% reported unprotected sex. In the multivariable analyses, participants who were in a seroconcordant primary relationship were more likely to have children, use alcohol, report unprotected sex, and have been enrolled in care for >12 months. Sexually active participants were more likely to be on HAART, have a prior tuberculosis diagnosis, test Herpes simplex type 2 antibody seropositive, and have low general health perceptions. Participants who reported unprotected sex were more likely to be in a seroconcordant relationship, be childless, want to have a child, and use alcohol. We did not document an association between HAART and unprotected sex. Among HIV-infected Indians in primary care, predictors of unprotected sex included alcohol use and desire for children. Prevention interventions for Indian couples should integrate reproductive health and alcohol use counseling at entry into care.

Study of HIV-1 subtypes in serodiscordant couples attending an integrated counselling and testing centre in Mumbai using heteroduplex mobility analysis and DNA sequencing

AIMS

To determine the prevalent subtypes of HIV-1 in serodiscordant couples.

SETTING

Integrated Counselling and Testing Centre (ICTC), Department of Microbiology.

STUDY DESIGN

Prospective pilot study.

PARTICIPANTS

Thirty HIV-1 serodiscordant couples.

INCLUSION CRITERIA

a) Documentation of HIV-1 infection in one partner and seronegative status in the other, current history of continued unprotected sexual activity within the partnership, demonstration that they have been in a partnership for at least 1 year and are not currently on highly active antiretroviral therapy HAART; b) willingness of both partners to provide written informed consent including consent to continued couple counselling for 3 months.

MATERIALS AND METHODS

HIV-1 subtyping was carried out by heteroduplex mobility analysis (HMA) by amplifying env region; and DNA sequencing by amplifying gag region.

RESULTS

HIV-1 env gene was amplified successfully in 10/30 samples; gag gene, in 25/30 samples; and both env and gag gene were amplified successfully in 5/30 samples. HIV-1 subtype C was detected from 21 samples; subtype B, from 7; and subtype A, from 2. Sample from 1 positive partner was detected as subtype C by env HMA and subtype B by gag sequencing.

CONCLUSION

HIV-1 subtype C was found to be the predominant subtype of HIV-1 in serodiscordant couples attending our ICTC, followed by HIV-1 subtype B and HIV-1 subtype A, respectively. DNA sequencing was found to be the most reliable method for determining the subtypes of HIV-1.

HIV transmission risk among serodiscordant couples: a retrospective study of former plasma donors in Henan, China

OBJECTIVES: To estimate the HIV incidence and assess the behavioral, clinical, and quality-of-life risk factors for HIV transmission among serodiscordant couples from Henan Province, China. METHODS: Between January 2006 and December 2008, initially seronegative spouses were tested for HIV at six month intervals. Retrospectively identified subjects were interviewed through face-to-face questionnaire. Cox proportional-hazards model was used to assess the relationship between risk factors and HIV seroconversion. RESULTS: Out of 1927 couples, 84 (4.3%) seroconversions occurred, representing a seroconversion rate of 1.71 per 100 person-years. Seroconversion rates increased over time. Not always using condoms (RR=8.42; 95% CI, 4.83-14.67), sexual activity ≥ 4 times per month (RR=5.24; 95% CI, 2.55-10.77), not switching anti-retroviral treatment regimen (RR=1.99; 95% CI, 0.85-4.65), and a quality of life score <12 on the psychological domain (RR=2.33; 95% CI, 1.21-4.48) were associated with increased risk of seroconversion. Seventy one percent of index spouses were on ART. There was no association between rate of HIV seroconversion and last recorded CD4 cell count level of the index spouse. CONCLUSIONS: Effective HIV prevention interventions targeting discordant couples should focus on sustaining health education, increasing psychosocial support services, and increasing medication adherence monitoring.

Couples at risk for HIV infection in Southern India: characteristics of HIV-infected patients in concordant and discordant heterosexual relationships

The aim of the article is to compare the clinical and behavioural characteristics of HIV-infected South Indian patients in concordant and discordant heterosexual relationships. A cross-sectional analysis of married couples in concordant and discordant relationships was carried out. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were assessed. A total of 839 concordant patients and 996 discordant patients were included in this analysis. Significantly more men were in discordant than concordant relationships (97% versus 59%; P = 0.002). More discordant patients had never initiated highly active antiretroviral treatment (HAART) than concordant patients (14.1% versus 8.5%; P = 0.004). Concordant patients had significantly higher CD4 cell counts than discordant patients at the time of enrolling to care (205 versus 139 cells/μL; P = 0.001). Discordant patients had significantly higher plasma viral loads than concordant patients (100,000 copies/mL versus 89,154 copies/mL; P = 0.002). Discordant patients were more likely to use condoms with their spouses than concordant patients (49% versus 28.8%; P = 0.01).

In conclusion, couples-based interventions and the provision of HAART could substantially decrease behavioural and clinical correlates of HIV transmission among discordant South Indian married couples. The spouses of HIV-infected index patients are at increased risk for HIV infection, and further preventive measures are needed.

Risk factors for HIV transmission among heterosexual discordant couples in South India

OBJECTIVE

To assess the risk factors associated with heterosexual HIV transmission among South Indian discordant couples enrolled in clinical care.

METHODS

A nested matched case-control study of serodiscordant couples in which the HIV-infected partner (index case) was enrolled in care. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were measured at enrollment and longitudinally over 12 months of follow-up. The study included 70 cases who seroconverted during study follow-up and 167 matched controls who remained persistently serodiscordant.

RESULTS

The incidence of HIV infection among the initially seronegative partners was 6.52 per 100 person-years. Persistently discordant patients were more likely to have initiated highly active antiretroviral therapy (HAART) than patients in seroconverting relationships (62.9%vs. 42.9%) (P=0.001). Patients in seroconverting relationships had significantly higher plasma viral loads (PVLs) than patients in discordant relationships at enrolment, at 6 months and at 12 months (P<0.05). Patients in seroconverting relationships were less likely to use condoms with their primary partners than patients in discordant relationships (P<0.05). Patients in relationships that seroconverted between 6 and 12 months were diagnosed more often with genital Herpes simplex than patients in discordant relationships (P=0.001). In the univariate and multivariate logistic regression, the following variables were associated with seroconversion: PVL >100,000 [odds ratio (OR): 1.82; 95% confidence interval (CI): 1.1-2.8], non-disclosure of HIV status (OR: 5.5; 95% CI: 4.3-6.2) and not using condoms (OR: 2.8; 95% CI: 2.4-3.6).

CONCLUSIONS

Couples-based intervention models are crucial in preventing HIV transmission to seronegative spouses. Providing early treatment for sexually transmitted infections, HAART and enhancing condom use and disclosure could potentially decrease the risk of HIV transmission within Indian married couples.

Evaluation design for large-scale HIV prevention programmes: the case of Avahan, the India AIDS initiative

BACKGROUND

Closing the HIV prevention gap to prevent HIV infections requires rapid, worldwide rollout of large-scale national programmes. Evaluating such programmes is challenging and complex, requiring clarity of evaluation purpose and evidential approaches substantively different to those employed for pilots and small programmes.

OBJECTIVES

This paper describes the evaluation design for the implementation phase of Avahan, the India AIDS initiative, a large HIV prevention programme funded by the Bill and Melinda Gates Foundation. Avahan, which began in December 2003, has a 10-year charter to impact the Indian epidemic and its response by implementing an HIV prevention programme targeting core and bridge groups in 83 districts of six Indian states, transferring the programme to the Government of India, and disseminating programme learning.

METHODS

The foundation commissioned an external process to design Avahan's evaluation framework. An independent advisory group oversees and guides course corrections in the execution of this framework.

RESULTS

Avahan's evaluation framework comprises: trend and synthetic analysis of data from core, bridge and household biobehavioural surveys in a subset of intervention districts, denominator estimates and programme monitoring from all intervention districts, and government's antenatal surveillance (two sites per district in all districts); bespoke transmission dynamics modelling to estimate infections averted (subset of districts); cost effectiveness studies (subset of districts). In addition, there are other knowledge-building and quality-monitoring activities.

CONCLUSION

Rather than a small set of monofocal outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution.