Adherence to Combination Antiretroviral Therapy among Pregnant Women Enrolled in a HIV Prevention Program in Rural North-central Nigeria

OBJECTIVE

Adherence to combination antiretroviral therapy (ART) among pregnant women is essential to attaining the goal of eliminating mother-to-child HIV transmission. The objective of this study was to determine which factors affect adherence to ART among HIV-positive women enrolled in a large prevention of mother-to-child HIV transmission (PMTCT) trial in rural north-central Nigeria.

METHODS

The parent study included 372 HIV-positive pregnant women enrolled in a cluster-randomized control trial conducted at 12 health facilities in Nigeria between 2013 and 2015. This secondary analysis included HIV-positive women (and their infants) from the original trial with documented adherence data (n=210, 56.5%). The primary outcome was maternal adherence to ART, determined by self-report and based on the visual analogue scale (VAS) of a validated medication adherence tool. Participants with a VAS score of ≥ 95% were classified as adherent. We employed multivariate logistic regression to evaluate the predictors of maternal ART adherence in the study sample.

RESULTS

Approximately 61.0% of study participants (128/210) were adherent to ART. The majority of adherent participants (62.5%, 80/128) were enrolled in the trial intervention arm. The most common cited response for non-adherence was fear of status disclosure. Adherence to ART was associated with study arm (intervention arm vs. control arm, adjusted Odds Ratio (aOR) [95% CI]: 16.95 [5.30-54.23]), maternal ethnicity (Gwari vs. Other, aOR = 0.13 [0.05-0.38]), and partner HIV status (HIV-positive vs. unknown, aOR = 3.14 [1.22-8.07]).

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Adherence to ART among a cohort of pregnant women enrolled in a PMTCT trial in rural North-Central Nigeria was associated with trial arm, maternal self-reported ethnicity, and partner's HIV status. Increased understanding of the interplay between these factors will enable the development of more targeted and effective interventions.

Increasing sero-discordancy among young HIV infected pregnant women from India: a likely pointer of changing transmission dynamics

The flat-lining of HIV incidence in India has raised concerns about the presence of emerging risk groups. As HIV prevalence among pregnant women is reflective of the situation in general population, its closer scrutiny provides valuable insights about the evolving epidemic. The present study assesses temporal trends of sero-discordance (where woman is HIV infected and husband is uninfected), among pregnant women living with HIV (pWLHIV) from India. Data of program for prevention of parent to child transmission of HIV was analyzed. Statistical analysis was done using Cochrane-Armitage trend test and logistic regression. Of the 1209 currently married pWLHIV, 302 (25%) were sero-discordant. The proportion increased from 16% in 2007 to 36% in 2016-17 (p = 0.000). The likelihood of sero-discordance was higher for women aged 18-20 (OR: 2.68, CI: 1.30-5.83) and 21-23 (OR: 1.98, CI: 1.01-4.15) years compared to 36-40 years; and for primi-parous women (OR: 1.84, CI: 1.31-2.58) compared to women pregnant for second/third time. The findings are indicative of changing HIV transmission dynamics. Steeper rise in sero-discordance in younger women implies an increasing risk of HIV in unmarried women population. A better understanding of HIV specific vulnerabilities of young women, married and unmarried, is warranted.

The Effect of Partner Serostatus and Relationship Duration on HIV Medication Adherence

High adherence rates to antiretroviral medications are necessary for people living with HIV/AIDS. The current study focuses on relationship-level predictors of HIV medication adherence by testing whether adherence rates differ by dyadic serostatus (seroconcordant vs. serodiscordant couples) among individuals with HIV in romantic relationships. Results showed a significant interaction between dyadic serostatus and relationship duration on adherence, such that individuals in long-term serodiscordant relationships reported better adherence than short-term serodiscordant relationships or seroconcordant partners in long-term relationships. Future research is needed to understand what relationship dynamics explain differences in adherence rates based on dyadic serostatus.

Epidemiological, clinical, and immunological profile of cases at the time of HIV testing (a clinic-based observational cross-sectional study)

Introduction

With the availability of free antiretroviral therapy (ART), HIV/AIDS has become a chronic manageable disease, but its transmission still continues. Early testing, though desirable, is still a far-fetched goal.

Materials and Methods

Forty-six newly detected HIV cases attending skin and sexually transmitted disease (STD) outpatient department (OPD) were studied. Careful inquiry was made to know the reason for HIV testing, marital status, concordance rate in married couples, and CD4 count at the time of presentation.

Results

Of the 46 cases, 27 (59%) cases were in the age range of 20-40 years with 41% females and 59% males. Forty-one cases were married and cohabiting, out of which 19 were seroconcordant. Condom was used by 5/19 cases in seroconcordant group and 3/22 cases in serodiscordant group. Fourteen (30.4%) cases were tested for an epidemiologic reason (the most common being spouse positivity and antenatal care testing). Of the remaining 32 cases, the reason for testing was mucocutaneous manifestations in 16 cases, STD in 10 cases, and systemic illnesses (fever of unknown origin and weight loss) in 6 cases. Mean CD4 count was 336/cumm, with 17 cases having CD4 count <250/cumm.

Conclusion

Except one, all cases were tested either because they were symptomatic or were referred by health-care provider for epidemiologic reasons. The presence of mucocutaneous manifestations including STD and systemic illnesses as the reason for testing as well as low CD4 count at the time of testing suggest less and late testing. Low condom use and high STD rate in married couple imply continued intramarital transmission. Although HIV seropositivity offers an entry point into continuum of comprehensive care package which includes free ART, it appears that HIV testing is still less and late.

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

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

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.

Leveraging microfinance to impact HIV and financial behaviors among adolescents and their mothers in West Bengal: a cluster randomized trial

Microfinance can be used to reach women and adolescent girls with HIV prevention education. We report findings from a cluster-randomized control trial among 55 villages in West Bengal to determine the impact of non-formal education on knowledge, attitudes and behaviors for HIV prevention and savings. Multilevel regression models were used to evaluate differences between groups for key outcomes while adjusting for cluster correlation and differences in baseline characteristics. Women and girls who received HIV education showed significant gains in HIV knowledge, awareness that condoms can prevent HIV, self-efficacy for HIV prevention, and confirmed use of clean needles, as compared to the control group. Condom use was rare and did not improve for women. While HIV testing was uncommon, knowledge of HIV-testing resources significantly increased among girls, and trended in the positive direction among women in intervention groups. Conversely, the savings education showed no impact on financial knowledge or behavior change.

Sexual risk behaviour, marriage and ART: a study of HIV-positive people in Papua New Guinea

Background

The prevention of intimate partner transmission of HIV remains an important component of comprehensive HIV prevention strategies. In this paper we examine the sexual practices of people living with HIV on antiretroviral therapy (ART) in Papua New Guinea (PNG).

Method

In 2008, a total of 374 HIV-positive people over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. This accounted for around 18% of adults on ART at the time. A further 36 people participated in semi-structured interviews. All interviews were thematically analysed using NVivo qualitative data analysis software.

Results

Less than forty per cent (38%) of participants reported having had sexual intercourse in the six months prior to the survey. Marital status was by far the most important factor in determining sexual activity, but consistent condom use during vaginal intercourse with a regular partner was low. Only 46% reported consistent condom use during vaginal intercourse with a regular partner in the last six months, despite 77% of all participants reporting that consistent condom use can prevent HIV transmission. Consistent condom use was lowest amongst married couples and those in seroconcordant relationships. The vast majority (91.8%) of all participants with a regular heterosexual partner had disclosed their status to their partner. Qualitative data reinforced low rates of sexual activity and provided important insights into sexual abstinence and condom use.

Conclusions

Considering the importance of intimate partner transmission of HIV, these results on the sexual practices of people with HIV on ART in PNG suggest that one-dimensional HIV prevention messages focussing solely on condom use fail to account for the current practices and needs of HIV-positive people, especially those who are married and know their partners’ HIV status.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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