HIV Prevention Knowledge Base
Combination Approaches: HIV Prevention for Serodiscordant Couples
HIV-1 Prevention for HIV-1 Serodiscordant Couples
The review explores the various HIV prevention options within serodiscordant couples. Half to two-thirds of HIV-1– infected adults are in a couple with an uninfected partner; therefore, prevention interventions need to be targeted toward these relationships. The primary service is offering couples HIV testing and counseling (CHTC). Studies have shown that serodiscordant couples who participated in CHTC report increased condom use, uptake of family planning, and uptake of prevention to mother-to-child transmission (PMTCT) services. Antiretroviral therapy for the prevention of HIV is another method to reduce transmission to the uninfected partner, though efficacy is still being explored. Pre-exposure prophylaxis is a prevention option for the HIV-uninfected partner in a serodiscordant couple. The paper also details positive evidence on PMTCT, behavior change interventions, and male circumcision and its challenges. A combination of prevention interventions is necessary.
Outside Sexual Partnerships and Risk of HIV Acquisition for HIV Uninfected Partners in African HIV Serodiscordant Partnerships
A prospective study was conducted to measure the sexual behaviors of HIV-negative individuals in serodiscordant couples. Data was from the Partners in Prevention HSV/HIV Transmission study that was carried out from 2004 to 2008 in seven African countries. The HIV-negative partners completed an interviewer-administered questionnaire on sexual behavior at enrollment and every quarter. Blood samples were also collected to genetically link the HIV subtypes of the HIV-positive partner to the newly infected partner. A total of 3,381 serodiscordant couples were enrolled in the study. Over the two years of follow-up, the number of outside partners among the uninfected individuals in the couple increased from 3.1 percent to 13.9 percent. Those who reported sex with their HIV-positive partner in the month prior to the questionnaire were less likely to have an outside partner. Uninfected partners reported less sexual activity with their infected partner during the two-year follow-up period (73.2 percent to 93.5 percent). There was also an increase of the uninfected partner reporting no sexual activity with the infected partner and an increase of sexual activity with an outside partner during the follow-up period. Condom use was more common among outside partners than with the HIV-positive partner. Of those who HIV seroconverted during the study and reported to have an outside partner, most (86 percent) had an HIV subtype that was distinct from their HIV-positive partner, which indicates that they did not acquire HIV from their primary relationship. Risk-reduction measures adopted by the HIV-negative partner should be taken into account when counseling serodiscordant couples.
What’s Love Got to Do With It? Explaining Adherence to Oral Antiretroviral Pre-Exposure Prophylaxis for HIV-Serodiscordant Couples
A qualitative study was conducted to identify influences on adherence to pre-exposure prophylaxis (PrEP) from both the HIV-negative partner and -positive partner in serodiscordant couples. Participants who were enrolled in the Partners PrEP study and were from the Kabwohe Clinical Research Centre in rural Uganda were sampled for this study. Forty-five PrEP participants and fifteen of their partners were interviewed. Mean duration of the partnership was 9.8 years, and 80 percent of the couples had children. It was found that there was a dilemma between wanting to continue the relationship but fearing infection, loss of health, and early death when learning of their discordant status. PrEP offered many a means for hope and opportunity in being able to maintain the relationship while staying uninfected. In other couples, tension and anger still persisted after PrEP use, and adherence suffered. The results of the qualitative study suggest that the strength of the relationship has a direct effect on adherence. Participants also preferred to use PrEP over condoms as an HIV prevention method. It is important to understand why couples want to stay together in supporting PrEP adherence.
Optimal Uses of Antiretrovirals for Prevention in HIV-1 Serodiscordant Heterosexual Couples in South Africa: A Modeling Study
The paper describes a modeling study that tested various scenarios on the effectiveness of early initiation of pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for prevention within HIV serodiscordant couples. The model used data from three sites in South Africa that participated in the Partners in Prevention HSV/HIV Transmission Study as well as results from the specific clinical trials on PrEP and ART for prevention. Three analyses were performed: 1) four different PrEP implementation strategies, 2) starting PrEP then discontinuing use when the infected partner begins ART compared to early ART but no PrEP, and 3) various models were tested to determine the optimal combination of PrEP and ART, and cost and efficiency were reviewed as well. It was found that PrEP use at all times, whether or not the infected partner was taking ART, was the most effective out of the four scenarios in reducing transmission. For the second analysis, it was found that both scenarios increased costs and reduced infections. For the third analysis, when PrEP and ART were available, it would be most effective for higher-risk couples to offer PrEP to the uninfected partner before the infected partner started ART. For lower-risk couples, early initiation of ART would be the most cost-effective. In conclusion, PrEP and ART could be reliable combination prevention strategies to reduce transmission and acquisition for serodiscordant couples.
Knowledge and Attitudes about Male Circumcision for HIV-1 Prevention among Heterosexual HIV-1 Serodiscordant Partnerships in Kampala, Uganda
The paper examined serodiscordant couple’s knowledge, attitudes, and understanding of male circumcision, as they are a high-risk group for HIV transmission and acquisition. Couples were recruited at a research clinic in Kampala, Uganda, for this cross-sectional study. A standardized gender-specific questionnaire was administered to each partner separately, medical records were reviewed to know their HIV serostatus, and an examination was performed to determine if the male was circumcised. The final sample size in the study was 318 couples. The majority of men were not circumcised (67.2 percent). Both men and women had a high knowledge of the protective ability of male circumcision. The majority had heard a health information message stating the benefits of male circumcision to HIV-negative men. Over 90 percent of participants had a favorable attitude about male circumcision as an HIV prevention strategy. About half (53 percent) of uninfected males expressed interest in undergoing male circumcision, while the majority (88 percent) of their female partners wished that they undergo the procedure. Uninfected males were more interested in undergoing male circumcision if they had discussed the procedure with their female partners and were knowledgeable on the positive benefits of male circumcision, compared to those who did not discuss it with their partners and were not knowledgeable. The main motivators to get circumcised were to prevent sexually transmitted infections/HIV infection and hygiene benefits. Barriers included cost of the procedure, being absent from work, fear of complications, fear of pain, and religious sentiments. The findings will aid in developing messages to promote male circumcision in Uganda.
Behavioural Interventions for HIV Positive Prevention in Developing Countries: A Systematic Review and Meta-analysis
The review explores the efficacy of prevention programs for people infected with HIV in the developing world setting. The review also seeks to explore if interventions targeting both HIV-positive and -negative individuals have varying effectiveness. Eighteen articles met the criteria for inclusion. Most (15 studies) were conducted in Sub-Saharan Africa, were in clinical settings (14 studies), and were with heterosexual populations (12 studies). Nine studies targeted both HIV-positive and HIV-negative individuals and stratified the results by target population. These nine studies were within HIV counseling and testing interventions. Ten studies evaluated behavioral interventions targeted to HIV-positive individuals. Five studies were with serodiscordant couples. When comparing behavioral interventions targeting HIV-negative and -positive individuals, it was found that condom use statistically increased among positive individuals but was not statistically significant among negative individuals. Interventions targeting serodiscordant couples increased condom use significantly. There was also a modest positive affect on reducing multiple sexual partners in behavioral interventions targeted to HIV-positive adults as well as an increase in disclosing one’s HIV-positive status. These results demonstrate the positive affect on behavioral outcomes from prevention interventions; therefore, prevention interventions should be expanded among HIV-positive individuals and serodiscordant couples.
Successful Increase in Contraceptive Uptake among Kenyan HIV-1-Serodiscordant Couples Enrolled in an HIV-1 Prevention Trial
The paper describes a successful intervention to increase uptake of family planning services among HIV-1–serodiscordant couples in Kenya. Study participants were from the Thika, Kenya, site within the Partners in Prevention HSV/HIV Transmission Study, and compared with three other Kenyan sites that did not have the supplemental family planning intervention. At the Thika study site, 213 serodiscordant couples were enrolled, and the majority (74.7 percent) of infected partners were female. Most women had one living child and were married to their study partner. A total of 1,216 couples were enrolled in the other three Kenyan sites and were similar to the Thika participants. It was found that noncondom contraceptive use increased among Thika female participants, both in infected and uninfected women. The injectable was the preferred contraceptive choice of women followed by the pill, surgical procedures, implants, and intrauterine devices. Noncondom contraceptive use did not statistically change in the other three sites. Reported condom use was high throughout the study at all sites. The incidence of pregnancy also reduced among study participants from the Thika study site and increased at the other sites. The increased utilization of contraceptives in this cohort indicates an unmet need that can be satisfied with successful comprehensive family planning interventions.
A Group-based Intervention to Increase Condom Use among HIV Serodiscordant Couples in India, Thailand, and Uganda
The paper describes a study among serodiscordant couples where the HIV-positive individual has to disclose their status to their partner, they have to decide together to participant in the intervention, and to test whether there are any changes in condom use among study participants. The study was conducted in one site each in India, Thailand, and Uganda. Forty-three couples were enrolled in the study, and forty couples completed all study requirements. The intervention consisted of four sessions that covered HIV, risk reduction strategies, and skill training on how to improve couple communications. Participants were interviewed at baseline and at one and three months after the intervention. All participants stated that they were satisfied with the intervention and that it helped them communicate with their partner about sex. High communication skills were also reported at the one- and three-month follow-up visits. Participants appreciated the HIV information that they received, appreciated the correct information and skills on how to use a condom, and reported to be less shy about discussing HIV topics after the intervention. The ability to refuse sex if their partner did not want to use a condom increased significantly from baseline to the three-month follow-up visit. Sexual activity also increased in the India cohort based on the resumption of sex or the increased comfort level in discussing sex. Reported condom use at all sites reached 100 percent after the intervention. The study demonstrates how an intervention targeting serodiscordant couples can be replicated in multiple settings with unique epidemics.
Willingness of Kenyan HIV-1 Serodiscordant Couples to Use Antiretroviral Based HIV-1 Prevention Strategies
According to the authors of this cross-sectional study, nearly 40 percent of HIV-positive Kenyans in stable serodiscordant relationships (where the partner is HIV-negative) expressed reservations about initiating early antiretroviral therapy (ART) for the purpose of treatment as prevention, particularly about the potential side effects. The HIV-negative partners expressed a high willingness (nearly 90 percent) to use pre-exposure prophylaxis (PrEP) over the long term. The authors also report that control of the method was a factor in participants’ decision making since, when given a hypothetical choice, HIV-negative partners chose PrEP and HIV-positive partners chose ART if it was medically necessary. The larger PrEP study found that HIV-positive partners indicated a higher level of willingness to initiate ART when they were experiencing lower CD4 counts or symptomatic diseases, or had had personal experience with ART use. Based on these results, the authors suggest that serodiscordant couples follow a dual HIV prevention strategy, with the HIV-negative partner using PrEP until the HIV-positive partner is willing and able to initiate ART. The authors also stress the importance of understanding couples’ concerns and preferences about using ART for HIV prevention, before developing treatment as prevention strategies.
HIV Testing and Counseling Leads to Immediate Consistent Condom Use among South African Stable HIV-Discordant Couples
This study explored condom use and number of unprotected sexual acts among long-term HIV serodiscordant couples after HIV testing and counseling and one-month follow-up visits. Participants were from the Partners in Prevention HSV/HIV Transmission Study, a randomized, placebo-controlled trial to assess the impact of twice-daily acyclovir use on HIV-1 disease progression in HIV-1/HSV-2 co-infected persons. The 508 HIV-positive participants and their partners were followed for two years. Couples received risk reduction counseling and were provided with free condoms each month, and the HIV-negative partner was tested for HIV quarterly. Interviewer-administered questionnaires collected demographic and behavioral data at baseline and monthly visits. The study compared the sexual behavior of newly and previously tested persons at baseline as well as at months one, six, and twelve. It was found at baseline that for those who recently tested for HIV (less than seven days earlier), odds of reporting unprotected sex were greater than for those who had most recently been tested more than 30 days before; the odds became comparable at the one month mark and remained constant at the sixth and twelfth months. The odds of unprotected sex were lower at month one, six, and twelve compared to baseline. The authors conclude that HIV counseling and testing results in a reduction of sexual risk among HIV serodiscordant couples.
Sexual Life and Fertility Desire in Long-Term HIV Serodiscordant Couples in Addis Ababa, Ethiopia: A Grounded Theory Study
A qualitative study was conducted in Addis Ababa, Ethiopia, to better understand HIV serodiscordant couples’ view of fertility and sexual relations in long-term relationships. Participants were selected from among those receiving services for antiretroviral therapy and prevention of mother-to-child transmission at three public hospitals. Thirty-six informants were recruited from two groups—individuals in serodiscordant relationships and health professionals who care for them. The study found the core category of the “struggle to maintain (the) relationship.” After couples learned that one partner was HIV positive, they either separated or strove to maintain the relationship. Those who wanted to maintain the relationship experienced a period of transition to become comfortable with their new status. Challenges arose when one partner wanted a child or more children and the other did not, or when both wanted a child but feared transmitting the virus to the uninfected partner. Participants also noted: a change in their desire to have sex; sacrificing of self-interest for the benefit of their family; nondisclosure or selective disclosure of their status to family and friends; and increasing focus of attention on existing children. The authors conclude that in order for HIV serodiscordant couples to maintain their relationship they have to develop a variety of strategies.