Knowledge of HIV serodiscordance, transmission, and prevention among couples in Durban, South Africa

Sexual Health Behaviors and Knowledge Among Ugandan Adolescent Girls: Implications for Advancing Comprehensive Sexual Health Education Technology

Background

Adolescent girls in Uganda have four-fold HIV infections than adolescent boys. Several barriers to accessing comprehensive sexual health education exist for adolescent girls in Uganda, including unequal, social, and economic statuses, limited access to education and health care services, discrimination, and violence.

Objective

This study qualitatively examines sexual health behaviors and literacy among Ugandan adolescent girls and explores how technology may be leveraged to improve sexual and reproductive health outcomes in this population.

Methods

Four focus group discussions (FGDs) were conducted among 32 adolescent girls aged 14-17 years enrolled in Suubi mHealth. Participants were randomly selected from four secondary schools participating in a randomized clinical trial known as Suubi4Her (N = 1260). FGDs were conducted in the local language, audio-recorded, transcribed verbatim, and translated. Translated transcripts were imported into Dedoose for data management and coding. Emerging themes included Influences for Sex/Relationships, HIV Knowledge, and Sources of Sexual Health Information.

Results

Participants reported common influences for sexual engagement included seeking resource security, limited parental communication, and peer influences. Participants also demonstrated knowledge gaps, requesting information such as how to prevent unplanned pregnancies and HIV, endorsing sexual health myths, and describing limitations to accessing sexual health information.

Conclusions

Noticeable inconsistencies and limited access to information and resources regarding basic sexual health knowledge were reported, which inevitably increases adolescent girls' risks for adverse sexual and reproductive health outcomes. Developing culturally appropriate interventions may help advance the sexual and reproductive health needs of Ugandan adolescent girls.

Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings

Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data

BACKGROUND

Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia.

METHODS/DESIGN

Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics.

RESULTS

The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline.

DISCUSSION

In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.

Gender, HIV knowledge and prevention attitudes among adolescents living with HIV participating in an economic empowerment intervention in Uganda

HIV disproportionately affect adolescent girls and young women in sub-Saharan Africa. In Uganda, the HIV prevalence is four times higher in adolescent girls compared to boys. This study examined gender, HIV general and clinical knowledge, and prevention attitudes among adolescents living with HIV in Uganda. Data from a cluster randomized clinical trial were analyzed. A total of 702 adolescents (average age of 12.4) were randomized to either a control arm receiving bolstered standard of care or the treatment arm receiving bolstered standard of care plus a family economic empowerment intervention to support medication adherence. Ordinary Least Squares models that adjust for clustering of adolescents within health clinics were conducted. No gender differences were observed in HIV knowledge and prevention attitudes at baseline. However, at 12-months follow-up, boys were more likely than girls to report correct HIV general knowledge (d = 0.21), clinical knowledge (d = 0.48), and favorable prevention attitudes (d = 0.27). The intervention was not associated with any of the outcomes. Given the high HIV prevalence among adolescents, specifically girls, there is need to develop and/or tailor existing programs and interventions that equip adolescent girls with comprehensive knowledge and prevention attitudes, that are culturally appropriate, to reduce HIV transmission and reinfection within this population.

MAVSCOT: A fuzzy logic-based HIV diagnostic system with indigenous multi-lingual interfaces for rural Africa

HIV still constitutes a major public health problem in Africa, where the highest incidence and prevalence of the disease can be found in many rural areas, with multiple indigenous languages being used for communication by locals. In many rural areas of the KwaZulu-Natal (KZN) in South Africa, for instance, the most widely used languages include Zulu and Xhosa, with only limited comprehension in English and Afrikaans. Health care practitioners for HIV diagnosis and treatment, often, cannot communicate efficiently with their indigenous ethnic patients. An informatics tool is urgently needed to facilitate these health care professionals for better communication with their patients during HIV diagnosis. Here, we apply fuzzy logic and speech technology and develop a fuzzy logic HIV diagnostic system with indigenous multi-lingual interfaces, named Multi-linguAl HIV indigenouS fuzzy logiC-based diagnOstic sysTem (MAVSCOT). This HIV multilingual informatics software can facilitate the diagnosis in underprivileged rural African communities. We provide examples on how MAVSCOT can be applied towards HIV diagnosis by using existing data from the literature. Compared to other similar tools, MAVSCOT can perform better due to its implementation of the fuzzy logic. We hope MAVSCOT would help health care practitioners working in indigenous communities of many African countries, to efficiently diagnose HIV and ultimately control its transmission.

Cost-effectiveness of couples' voluntary HIV counselling and testing in six African countries: a modelling study guided by an HIV prevention cascade framework

INTRODUCTION

Couples' voluntary HIV counselling and testing (CVCT) is a high-impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost-per-HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost-effectiveness.

METHODS

We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling-up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs-per-couple tested were also estimated based on our previous studies. We used these parameters as well as country-specific inputs to model the impact of CVCT over a five-year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics (South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone). Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs-per-HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted.

RESULTS

We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs-per-HIV infection averted were lowest in Zimbabwe ($550) and highest in South Africa ($1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country's President's Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost-per-couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access.

CONCLUSIONS

Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries' five-year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low.

Identification of serodiscordant couples, their clinical and laboratory characteristics, and vulnerabilities of HIV transmission risk in Northeastern Brazil in the era of pre-exposure prophylaxis (PrEP)

Objectives: To evaluate the frequency of HIV serodiscordants couples and their seronegative partners who were candidates for pre-exposure prophylaxis (PrPE), and the knowledge about behavioural measures to reduce virus transmission. Methods: The research was performed in Northeastern Brazil, from February 2016 to March 2017. Ninety HIV-positive individuals (Index) and their HIV-serodiscordant partners (n = 17) were submitted for epidemiological, clinical, and laboratory questionnaires, and for rapid laboratory tests for syphilis, hepatitis B and C. Results: High frequencies of HIV-syphilis (34.4%) and HIV-HBV (3.3%) coinfection were detected in the HIV-positive individuals. Three new HIV cases were detected in partners. Most participants in both groups (85.6%, Index; 94.1%, Partners) had an excellent degree of knowledge regarding HIV transmission, although nine seronegative HIV partners with a high risk of HIV infection were identified (53%). HIV-positive individuals had a high frequency of HIV-syphilis co-infection and 10% of them did not use antiretroviral by personal option. Conclusions: Adoption of PrEP and other preventive measures to prevent HIV transmission in serodiscordants couples should be studied and evaluated.

Sexual Relationship Power and Periconception HIV-Risk Behavior Among HIV-Infected Men in Serodifferent Relationships

Gender norms affect HIV risk within serodifferent partnerships. We assessed how the sexual relationship power described by men living with HIV (MLWH) associates with periconception HIV-transmission risk behavior. Quantitative surveys were conducted with 82 MLWH reporting a recent pregnancy with an HIV-negative or unknown-serostatus partner in KwaZulu-Natal, South Africa. Surveys assessed decision-making dominance (DMD) using the Pulerwitz et al. sexual relationship power scale; partnership characteristics; and HIV-risk behaviors. Multivariable logistic regression models evaluated associations between DMD score and HIV-risk behaviors. Higher male decision-making dominance was associated with non-disclosure of HIV-serostatus to pregnancy partner (aRR 2.00, 95% CI 1.52, 2.64), not knowing partner's HIV-serostatus (aRR 1.64, 95% CI 1.27, 2.13), condomless sex since pregnancy (aRR 1.92, 95% CI 1.08, 3.43), and concurrent relationships (aRR 1.50, 95% CI 1.20, 1.88). Efforts to minimize periconception HIV-risk behavior must address gender norms and power inequities.

Men's Beliefs About the Likelihood of Serodiscordance in Couples with an HIV-Positive Partner: Survey Evidence from Rural Uganda

Few studies in sub-Saharan Africa have assessed men's knowledge about the likelihood of serodiscordance in couples with an HIV-positive partner and how this is affected by antiretroviral therapy (ART). Using a Likert scale and probabilistic scale, we elicited beliefs of 2532 rural Ugandan men about the likelihood of seroconcordance in married couples with an HIV-positive female partner who is either taking ART or not taking ART. Logistic regression analyses explored associations between beliefs and various health behaviors. Probabilistic scale responses were consistent with Likert scale responses. Seroconcordance was believed to be likely in the scenarios without ART and with ART, with mean seroconcordance likelihood of 8.1 and 6.6, respectively, on a scale of 0-10. The majority of participants (57%) believed the likelihood of seroconcordance was lower in the scenario with ART. The results suggest a need for enhanced education among men about serodiscordance in stable relationships and about the preventive effects of ART.

HIV testing and counselling couples together for affordable HIV prevention in Africa

BACKGROUND

The impact and cost-effectiveness of couples' voluntary HIV counselling and testing (CVCT) has not been quantified in real-world settings. We quantify cost-per-HIV-infection averted by CVCT in Zambia from the donor's perspective.

METHODS

From 2010 to 2016, CVCT was established in 73 Zambian government clinics. The cost-per-HIV-infection averted (CHIA) of CVCT was calculated using observed expenditures and effectiveness over longitudinal follow-up. These observed measures parameterized hypothetical 5-year nationwide implementations of: 'CVCT'; 'treatment-as-prevention (TasP) for discordant couples' identified by CVCT; and 'population TasP' for all HIV+ cohabiting persons identified by individual testing.

RESULTS

In all, 207 428 couples were tested (US $52/couple). Among discordant couples in which HIV+ partners self-reported antiretroviral therapy (ART), HIV incidence was 8.5/100 person-years before and 1.8/100 person-years after CVCT (79% reduction). Corresponding reductions for non-ART-using discordant and concordant negative couples were 63% and 47%, respectively. CVCT averted an estimated 58% of new infections at US $659 CHIA. In nationwide implementation models, CVCT would prevent 17 times the number of infections vs 'TasP for discordant couples' at 86% of the cost, and nine times the infections vs 'population TasP' at 28% of the cost.

CONCLUSIONS

CVCT is a cost-effective, feasible prevention strategy in Zambia. We demonstrate the novel, added effectiveness of providing CVCT to ART users, for whom ART use alone only partially mitigated transmission risk. Our results indicate a major policy shift (supporting development of CVCT indicators, budgets and targets) and have clinical implications (suggesting promotion of CVCT in ART clinics as a high-impact prevention strategy).

Weighing the Evidence of Efficacy of Oral PrEP for HIV Prevention in Women in Southern Africa

As oral tenofovir-based regimens for preexposure prophylaxis (PrEP) are adopted as standard of care for HIV prevention, their utilization in clinical trials among women in southern Africa will require an accurate estimate of oral PrEP efficacy in this population. This information is critical for women in choosing this prevention strategy, and in public health policy making. Estimates of the efficacy of oral PrEP regimens containing tenofovir have varied widely across trials that enrolled women, with some studies reporting high efficacy and others reporting no efficacy. Although poor adherence is strongly associated with lack of efficacy, other factors, such as mode of transmission (sexual vs. parenteral), predominant HIV subtype (C vs. non-C), intensity of exposure, and percentage of stable serodiscordant couples, may also contribute to the variation in efficacy estimates. In this article, we evaluate the evidence for PrEP efficacy in women and propose potential explanations for the observed differences in efficacy among studies. Our review emphasizes the need to continue to refine estimates of efficacy and effectiveness of tenofovir-based oral PrEP so as to best develop the next generation of HIV prevention tools, and to inform public policies directed toward HIV prevention.

Increasing partner HIV testing and linkage to care in TB settings: findings from an implementation study in Pwani, Tanzania

Couples HIV testing for tuberculosis (TB) patients and their partners may be an effective means to identify HIV-positive persons and strengthen linkage to HIV care. We evaluated an intervention to increase HIV testing and linkage to care (LTC) of newly diagnosed persons and re-linkage for TB/HIV patients in Pwani, Tanzania. In 2014, 12 TB settings within two regional clusters participated; each cluster included ≥1 referral hospital, health center, and directly observed therapy center. Three months after introducing tools to record HIV service delivery, TB clinic staff and peer education volunteers in Cluster 1 received training on HIV partner testing and linkage/re-linkage, and staff in the second cluster received training 3 months thereafter. Twelve months after tools were introduced, clinic records were abstracted to assess changes in couples HIV testing, LTC, and re-linkage. Staff interviews assessed the feasibility and acceptability of the service delivery model. HIV prevalence was high among TB patients during the study period (44.9%; 508/1132), as well as among others who received HIV testing (19.8%; 253/1288). Compared to pre-implementation, couples HIV testing increased in both clusters from 1.8% to 35.2%. Documented LTC increased (from 5.7% to 50.0%) following the introduction of the tools. Additional increases in LTC (from 57.9% to 79.3%) and re-linkage (from 32.9% to 53.7%) followed Cluster 1 training, but no additional increases after Cluster 2 training. Staff perceived little burden associated with service delivery. This study demonstrated a feasible, low-burden approach to expand couples HIV testing and linkage of HIV-positive persons to care. TB settings in sub-Saharan Africa serve populations at disproportionate risk for HIV infection and should be considered key venues to expand access to effective HIV prevention strategies for both patients and their partners. HIV services in TB settings should include HIV testing, condom distribution, and linkage to appropriate additional services.

Psychosocial and behavioural interventions towards HIV risk reduction for serodiscordant couples in Africa: A systematic review

BACKGROUND

Sexual transmission of HIV frequently occurs in the context of a primary relationship between two partners; however, HIV prevention interventions generally focus on individuals at risk, rather than specifying couples as a unit of change and analysis, neglecting the crucial role that partners may play in sexual behaviour. This article reviews published scientific literature addressing couple-oriented HIV counselling and testing and other behavioural interventions using an online search for peer-reviewed papers.

METHODS

A systematic review was conducted to evaluate what has been published on psychosocial interventions in HIV serodiscordant couples in Africa. Electronic databases were searched from January 1990 to December 2015. Quality assessment of included studies was conducted using the Systematic Appraisal of Quality in Observational Research tool.

RESULTS

The electronic database searches initially retrieved 493 records; after cross-referencing, removing duplicates and applying strict inclusion and exclusion criteria, only eight papers were included in this review. All the studies under review showed that couples-focused counselling and educational programmes were associated with positive outcomes including reduced HIV transmission, reduced unprotected sex, increased rates of status disclosure and high levels of treatment adherence.

CONCLUSIONS

The literature on interventions for HIV serodiscordant couples is sparse. However, most interventions indicate that couples-focused interventions are effective in HIV risk reduction. In spite of the limited available data and repeated recommendations by different health authorities, couple-centred approaches to HIV prevention have not been implemented on a large scale.

Healthcare providers' understanding of HIV serodiscordance in South Africa and Uganda: implications for HIV prevention in sub-Saharan Africa

HIV transmission within stable heterosexual HIV serodiscordant couples accounts for almost half the new incident infections in South Africa and Uganda. Advances in HIV prevention provide opportunities to reduce transmission risk within serodiscordant partnerships (e.g., antiretroviral treatment (ART), pre-exposure prophylaxis (PrEP), medical male circumcision, and couples-based HIV counselling and testing). These interventions require a clinical encounter with a provider who recognises prevention opportunities within these partnerships. We explored healthcare provider understanding of HIV serodiscordance in a reproductive counselling study with providers in eThekwini district, South Africa, and Mbarara district, Uganda. In eThekwini, in-depth interviews (29) and focus group discussions (2) were conducted with 42 providers (counsellors, nurses and doctors) from public sector clinics. In Mbarara, in-depth interviews were conducted with 38 providers (medical officers, clinical officers, nurses, peer counsellors and village health workers). Thematic analysis was conducted using NVivo software. In eThekwini, many providers assumed HIV seroconcordance among client partners and had difficulty articulating how serodiscordance occurs. Mbarara providers had a better understanding of HIV serodiscordance. In the two countries, providers who understood HIV serodiscordance were better able to describe useful HIV-prevention strategies. Healthcare providers require training and support to better understand the prevalence and mechanisms of HIV serodiscordance to implement HIV-prevention strategies for HIV serodiscordant couples.

Factors associated with inconsistent condom use among people living with HIV/Aids

OBJECTIVE

to analyze the prevalence and factors associated with inconsistent use of condoms among people living with HIV/ Aids (PLWHA).

METHOD

it is a cross-sectional study with 228, with individual interviews conducted in 2011. A multivariate analysis was performed with a logistic regression model.

RESULTS

143 participants met the inclusion criteria, and the prevalence of inconsistent condom use was 28.7%. However, there was greater adherence among men (79.3%). In the multivariate analysis, the independent variable daily use of alcohol (OR=11.02; 95% CI 1.84, 65.92; p = 0.021) was associated with inconsistent condom use. The chance of men making consistent condom use was higher than women (OR = 0.36, 95% CI 0.15, 0.81; p = 0.015).

CONCLUSION

the prevalence of inconsistent condom male use among PLWHA was low, however, evidenced greater compliance among men over women with a statistically significant difference and the daily use of alcohol was associated with inconsistent condom use.

Mitigating intimate partner violence among South African women testing HIV positive during mobile counseling and testing

South African women continue to suffer disproportionately from the interlinked epidemics of HIV and intimate partner violence (IPV). Effective strategies are needed to mitigate HIV-related IPV, which often creates barriers to successful engagement along the HIV continuum of care. More information is needed on how IPV impacts women's safety following mobile HCT diagnosis, and the HIV IPV Risk Assessment & Safety-planning (HIRS) protocol was developed to address several related gaps in knowledge. The sample included 255 black South African women experiencing IPV and testing HIV+ during mobile HCT in Gauteng province. Outcomes were compared between a standard of care (SOC) group and an Experimental group with two dosage levels (D1, D2). Of the total sample and in the last year, 99.2% had experienced non-violent control, 40.7% physical abuse, 44.8% sexual abuse, and 67.3% physical or sexual abuse. There were no significant differences in pre/post safety scores, or for satisfaction or acceptability items. The overall linkage rate was 45.8% (M = 12.97 days), and the Experimental group had more links to care in certain age groups-the highest in those aged ≤23 years in D1 (70%). The lowest linkage rate was for those aged 33-43 years in the SOC (22.2%). Almost two thirds of participants reported using the safety plan (61.9%), with 80% reporting it was helpful, and 80% using ≥1 safety strategy. The Experimental group reported significantly less violence upon partner notification of serostatus, but all groups felt significantly less safe getting to medical appointments by post-test. Overall, the study indicates the HIRS protocol is safe and helpful, brief to administer, and may mitigate violence during partner notification of serostatus, but further investigation is needed before implementing it as a standard of care.

Why don't urban youth in Zambia use condoms? The influence of gender and marriage on non-use of male condoms among young adults

BACKGROUND

Zambia experiences high unmet need for family planning and high rates of HIV, particularly among youth. While male condoms are widely available and 95% of adults have heard of them, self-reported use in the past 12 months is low among young adults (45%). This study describes factors associated with non-use of male condoms among urban young adults in Zambia.

METHODS

A household cross-sectional survey in four urban districts was conducted from November 2015 to January 2016 among sexually active young adults ages 18-24 years. A random walk strategy was implemented in urban areas; eligible, enrolled participants were administered a survey on household characteristics, health access, and knowledge, attitudes and practices related to contraception. Relative risk regression models were built to determine factors associated with the decision to not use a male condom (non-use) at most recent sexual intercourse.

RESULTS

A total of 2,388 individuals were interviewed; 69% were female, 35% were married, and average lifetime sex partners was 3.45 (SD±6.15). Non-use of male condoms was 59% at most recent sexual intercourse. In a multivariate model, women were more likely to report non-use of a male condom compared with men (aRR = 1.24 [95% CI: 1.11, 1.38]), married individuals were more likely to report non-use compared with unmarried individuals (aRR = 1.59 [1.46, 1.73]), and those residing in the highest poverty wards were more likely to report non-use compared with those in the lowest poverty wards (aRR = 1.31 [1.16, 1.48]). Those with more negative perceptions of male condom use were 6% more likely to report non-use (aRR = 1.06 [1.03, 1.09]). Discussion regarding contraception with a partner decreased non-use 13% (aRR = 0.87 [0.80, 0.95]) and agreement regarding male condom use with a partner decreased non-use 16% (aRR = 0.84 [0.77, 0.91)]).

DISCUSSION

Non-use of male condoms is high among young, married adults, particularly women, who may be interested in contraception for family planning but remain at risk of STI infection. Effective marketing strategy of dual protection methods to this population is critical.

'People say that we are already dead much as we can still walk': a qualitative investigation of community and couples' understanding of HIV serodiscordance in rural Uganda

Background

Stable, co-habiting HIV serodiscordant couples are a key population in terms of heterosexual transmission in sub-Saharan Africa. Despite the wide availability of antiretroviral treatment and HIV educational programs, heterosexual transmission continues to drive the HIV epidemic in Africa. To investigate some of the factors involved in transmission or maintenance of serodiscordant status, we designed a study to examine participants’ understanding of HIV serodiscordance and the implications this posed for their HIV prevention practices.

Methods

In-depth interviews were conducted with 28 serodiscordant couples enrolled in a treatment-as-prevention study in Jinja, Uganda. Participants were asked questions regarding sexual behaviour, beliefs in treatment and prevention, participants’ and communities’ understanding and context around HIV serodiscordance. Qualitative framework analysis capturing several main themes was carried out by a team of four members, and was cross-checked for consistency.

Results

It was found that most couples had difficulty explaining the phenomenon of serodiscordance and tended to be confused regarding prevention. Many individuals still held beliefs in pseudoscientific explanations for HIV susceptibility such as blood type and blood “strength”. The participants’ trust of treatment and medical services were well established. However, the communities’ views of both serodiscordance and treatment were more pessimistic and wrought with mistrust. Stigmatization of serodiscordance and HIV-positive status were reported frequently.

Conclusions

The results indicate that despite years of treatment and prevention methods being available, stigmatization and mistrust persist in the communities of HIV-affected individuals and may directly contribute to new cases and seroconversion. We suggest that to optimize the effects of HIV treatment and prevention, clear education and support of such methods are sorely needed in sub-Saharan African communities.

Extent of Knowledge about HIV and Its Determinants among Men in Bangladesh

Background

Bangladesh is currently a low human immunodeficiency virus (HIV) prevalent country. However, the risk factors are widespread and the number of at-risk population is also rising, which warrants special policy attention. The risks of transmission were shown to be correlated with the level of HIV knowledge of individuals. In this study, we aimed to explore the level and influencing factors of HIV knowledge among adult men in Bangladesh.

Methodology

Data for the present study were collected from the sixth round of Bangladesh Demographic and Health Survey. Participants were 3305 men between 15 and 54 years of age regardless of HIV status. The primary outcome variable was the HIV knowledge score, which was calculated by responses to questions regarding general concepts and the mode of transmission of HIV. Association between the HIV knowledge score and the explanatory variables were analyzed by binary logistic regression methods.

Result

The mean HIV knowledge score was 7.2 (SD 1.3). Results indicate that being an urban resident [p < 0.001; odds ratios (OR) = 0.56, 95% confidence intervals (CI) = 0.48–0.64], having secondary/higher educational level (p < 0.001 OR = 0.56, 95%CI = 0.48–0.64), reading newspaper [p = 0.006; OR = 0.76, 95%CI = 0.62–0.92], and communication with community health workers (CHWs) (p = 0.05; OR = 0.77, 95%CI = 0.60–10.00) were significantly associated with a high (equal or above mean value) HIV knowledge level.

Conclusion

The level of HIV knowledge among Bangladeshi men is low. Leveraging HIV awareness programs targeting adult men to prevent future expansion of the epidemic should be a high priority. Revitalization and restructuring of the education sector and strengthening CHW’s engagement to improve knowledge about HIV transmission among men could generate beneficial returns for HIV prevention programs.

Implementation and Operational Research: Evolution of Couples' Voluntary Counseling and Testing for HIV in Rwanda: From Research to Public Health Practice

BACKGROUND

Couples' voluntary HIV counseling and testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda.

METHODS

From 1988 to 1994 in Rwanda, pregnant and postpartum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and sexually transmitted infection rates, particularly among HIV-discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were reintroduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the prevention of mother-to-child transmission program expanded to >400 clinics. In 2009, the GoR adopted joint posttest counseling procedures, and in 2010 a quarterly follow-up program for discordant couples was established in government clinics with training and technical assistance. An estimated 80%-90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections.

CONCLUSIONS

Rwanda is the first African country to have established CVCT as standard of care in antenatal care. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators, and budgets. Governments, bilateral, and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections.

Promotion of couples' voluntary HIV counseling and testing: a comparison of influence networks in Rwanda and Zambia

BACKGROUND

Many African adults do not know that partners in steady or cohabiting relationships can have different HIV test results. Despite WHO recommendations for couples' voluntary counseling and testing (CVCT), fewer than 10 % of couples have been jointly tested and counseled. We examine the roles and interactions of influential network leaders (INLs) and influential network agents (INAs) in promoting CVCT in Kigali, Rwanda and Lusaka, Zambia.

METHODS

INLs were identified in the faith-based, non-governmental, private, and health sectors. Each INL recruited and mentored several INAs who promoted CVCT. INLs and INAs were interviewed about demographic characteristics, promotional efforts, and working relationships. We also surveyed CVCT clients about sources of CVCT information.

RESULTS

In Zambia, 53 INAs and 31 INLs were surveyed. In Rwanda, 33 INAs and 27 INLs were surveyed. Most (75 %-90 %) INAs believed that INL support was necessary for their promotional work. Zambian INLs reported being more engaged with their INAs than Rwandan INLs, with 58 % of Zambian INLs reporting that they gave a lot of support to their INAs versus 39 % in Rwanda. INAs in both Rwanda and Zambia reported promoting CVCT via group forums (77 %-97 %) and speaking to a community leader about CVCT (79 %-88 %) in the past month. More Rwandan INAs and INLs reported previous joint or individual HIV testing compared with their Zambian counterparts, of which more than half had not been tested. In Zambia and Rwanda, 1271 and 3895 CVCT clients were surveyed, respectively. Hearing about CVCT from INAs during one-on-one promotions was the most frequent source of information reported by clients in Zambia (71 %). In contrast, Rwandan couples who tested were more likely to have heard about CVCT from a previously tested couple (59 %).

CONCLUSIONS

CVCT has long been endorsed for HIV prevention but few couples have been reached. Influential social networks can successfully promote evidence-based HIV prevention in Africa. Support from more senior INLs and group presentations leveraged INAs' one-on-one promotions. The INL/INA model was effective in promoting couples to seek joint HIV testing and counseling and may have broader application to other sub-Saharan African countries to sustainably increase CVCT uptake.

Effect of Couples Counselling on Reported HIV Risk Behaviour among HIV Serodiscordant Couples by ART Use, HIV Status and Gender in Rural Uganda

Background

We examined several measures of self-reported HIV risk behaviour in mutually disclosed sero-discordant couples over time to see if a couples counselling intervention was associated with changes in these behaviors.

Methods

We analysed data from a prospective cohort study of HIV sero-discordant couples in Jinja, Uganda collected between June 2009 and December 2011. Participants received couples counselling, at 3-monthly intervals. We examined trends in reported condom-use, number of concurrent sexual partners, knowledge of HIV serostatus of concurrent partners and condom use of concurrent partners using Generalized Estimating Equation models, comparing responses at study enrollment with responses at six, 12 18 and 24 months of follow-up.

Results

A total of 586 couples were enrolled and the female member was HIV positive in 255 (44%) of them. The median age for female participants was 35 years and 42 years for men. Reported condom use at last sex with spouse increased over time (p<0.001) with the largest increases found among couples where the positive participant never received ART during the study(an increase from 68.8% at enrollment to 97.1% at 24 months). Male participants reported reductions in the number of concurrent sexual partners (p<0.001), increase in the knowledge of the HIV serostatus of these partners (p = 0.001) and a trend towards improved condom-use among non-primary partners (p = 0.070). Reported reduced risky behaviors did not wane over the study period.

Conclusion

Couples counselling resulted in increased condom use among all participants and among men the intervention resulted in reductions in risk behaviour with concurrent sexual partners. Routine counselling for serodiscordant couples should be integrated in routine ART care programs.

Implementation of couples' voluntary HIV counseling and testing services in Durban, South Africa

Background

Couples’ voluntary HIV counseling and testing (CVCT) is an evidence-based intervention that significantly reduces HIV incidence in couples. Despite the high prevalence of HIV and HIV couple serodiscordance in South Africa, there are few CVCT services.

Methods

From February-June 2013, The Rwanda Zambia HIV Research Group provided support, training, and technical assistance for local counselors and promoters to pilot CVCT services in five hospital-based clinics in Durban, South Africa. Client-level data (age, gender, years cohabiting, pregnancy status, previous testing, antiretroviral treatment (ART) status, neighborhood, and test site) collected as a component of routine CVCT service operation is presented stratified by couple serostatus.

Results

Twenty counselors and 28 promoters completed training. Of 907 couples (1,814 individuals) that underwent CVCT, prevalence of HIV was 41.8 % and prevalence of HIV serodiscordance was 29.5 % (19.3 % M-F+, 10.3 % M + F-). Most participants were 25–34 years of age, and this group had the highest prevalence. Previous individual HIV testing was low (50 % for men, 63 % for women). Only 4 % of couples reported previous CVCT. Most (75 %) HIV+ partners were not on ART, and HIV+ individuals in discordant couples were more likely to be on ART than those in concordant positive couples. Pregnancy among HIV+ women was not associated with previous HIV testing or ART use.

Conclusions

Implementation of standard CVCT services was found to be feasible in Durban. The burden of HIV and couple serodiscordance in Durban was extremely high. CVCT would greatly benefit couples in Durban as an HIV prevention strategy.