Women's perspectives on relationship dynamics with their partners and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use

Background: Limited information exists about relationship dynamics and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use among women in Malawi.Methods: Ninety-seven women aged 18-45 years were randomly assigned to initiate the depot medroxyprogesterone acetate injectable or levonorgestrel implant from May 2014 to April 2015 in Lilongwe, Malawi. Women were recruited after randomisation to participate in semi-structured interviews about HIV and family planning using purposive sampling. Interviews were thematically analysed using within and between group comparisons.Results: We conducted individual interviews and/or focus group discussions with 41 women: 30 (73%) women living with HIV and 11 (27%) women not living with HIV. Most women living with HIV who participated in in-depth interviews disclosed their status to their partners, and most partners agreed to get HIV tested only after disclosure. Nearly all women said their partners agreed to use condoms, but few used them consistently. Nearly all women believed their current and former partners had outside partners. Most women living with HIV who participated in in-depth interviews believed their current or other serious partners were the source of their infection. Some women thought their partner's infidelity was due to their partner's disinterest in sex with them during menstrual/ breakthrough bleeding. Some women included their partners in contraceptive decision-making when the partner was supportive.Discussion: Relationship dynamics affected decision-making for contraceptive and condom use, as well as serodisclosure for the women living with HIV in the study. All women reported challenges with consistent condom use with their male partners, although contraceptive use was generally more acceptable. Women included their partners in their decision-making concerning contraceptive use when they were supportive.

Changing Attitudes About Concurrency Among Young African Americans: Results of a Radio Campaign

We created and evaluated an 8-month campaign of provocative radio ads to change attitudes about concurrent (overlapping) sexual partnerships among young African Americans. We created a concurrency attitude scale and compared its score distributions in independent samples of African Americans, ages 18-34 years, interviewed by telephone before (n = 678) and after (n = 479) the campaign. Pre- and post-campaign samples reflected similar response rates (pre: 32.6%; post: 31.8%) and distributions of personal characteristics. Reported exposure to concurrency messages was greater after the campaign (pre: 6.3%, post: 30.9%), and mean scores indicated less acceptance of concurrency (pre: 3.40 [95% CI 3.23, 3.57]; post: 2.62 [2.46, 2.78]). Score differences were not a function of differences in composition of the samples (adjusted means: pre: 3.37 [3.21, 3.53]; post: 2.62 [2.47, 2.76]). Findings demonstrate that a carefully targeted, intensive mass media campaign can change attitudes about concurrency, which should facilitate behavior change.

Self-reported sex partner dates for use in measuring concurrent sexual partnerships: correspondence between two assessment methods

Although prevalence of concurrent sexual partnerships is increasingly investigated as a driver of HIV epidemics, its measurement varies and its role in transmission dynamics remains contested. Relying on different methods of obtaining self-reported partnership histories may lead to significant differences in prevalence. This study examined the reliability of two methods for assessing dates of sex and the implications for measuring concurrent sexual partnerships. We conducted a cross-sectional reliability study using self-reported survey data from 650 women ages 18-65 years, recruited online nationwide for human papillomavirus natural history studies from 2007 to 2012. Intermethod reliability of first and last sex with the most recent partner was assessed using weighted kappa. Intraclass correlation coefficient was estimated for intramethod reliability across two consecutive questionnaires administered 4 months apart. Point prevalence of concurrent sexual partnerships at 6 months prior to the questionnaire date was similar between the two question formats (10.5 % for categorical and 10.9 % for continuous). The range between the minimum and maximum cumulative prevalence for 12 months was larger when using the categorical questions (17.0-29.6 % compared to 27.6-28.6 % using the continuous questions). Agreement between the two question formats was moderate for the date of first sex with the most recent partner (κ = 0.56, 95 % CI 0.48-0.64) and almost perfect for the date of last sex (κ = 0.93, 95 % CI 0.91-0.94). Longitudinal agreement for date of first sex was high for the continuous date question (ICC = 0.89, 95 % CI 0.86-0.92). Results of this reliability study can be used to inform the design of future studies of concurrent sexual partnerships and their association with HIV.

Concurrent partnerships in Cape Town, South Africa: race and sex differences in prevalence and duration of overlap

Introduction

Concurrent partnerships (CPs) have been suggested as a risk factor for transmitting HIV, but their impact on the epidemic depends upon how prevalent they are in populations, the average number of CPs an individual has and the length of time they overlap. However, estimates of prevalence of CPs in Southern Africa vary widely, and the duration of overlap in these relationships is poorly documented. We aim to characterize concurrency in a more accurate and complete manner, using data from three disadvantaged communities of Cape Town, South Africa.

Methods

We conducted a sexual behaviour survey (n=878) from June 2011 to February 2012 in Cape Town, using Audio Computer-Assisted Self-Interviewing to collect sexual relationship histories on partners in the past year. Using the beginning and end dates for the partnerships, we calculated the point prevalence, the cumulative prevalence and the incidence rate of CPs, as well as the duration of overlap for relationships begun in the previous year. Linear and binomial regression models were used to quantify race (black vs. coloured) and sex differences in the duration of overlap and relative risk of having CPs in the past year.

Results

The overall point prevalence of CPs six months before the survey was 8.4%: 13.4% for black men, 1.9% for coloured men, 7.8% black women and 5.6% for coloured women. The median duration of overlap in CPs was 7.5 weeks. Women had less risk of CPs in the previous year than men (RR 0.43; 95% CI: 0.32–0.57) and black participants were more at risk than coloured participants (RR 1.86; 95% CI: 1.17–2.97).

Conclusions

Our results indicate that in this population the prevalence of CPs is relatively high and is characterized by overlaps of long duration, implying there may be opportunities for HIV to be transmitted to concurrent partners.

Concurrent partnerships, acute infection and HIV epidemic dynamics among young adults in Zimbabwe

This paper explores the roles of acute infection and concurrent partnerships in HIV transmission dynamics among young adults in Zimbabwe using realistic representations of the partnership network and all published estimates of stage-specific infectivity. We use dynamic exponential random graph models to estimate partnership network parameters from an empirical study of sexual behavior and drive a stochastic simulation of HIV transmission through this dynamic network. Our simulated networks match observed frequencies and durations of short- and long-term partnerships, with concurrency patterns specific to gender and partnership type. Our findings suggest that, at current behavior levels, the epidemic cannot be sustained in this population without both concurrency and acute infection; removing either brings transmission below the threshold for persistence. With both present, we estimate 20-25% of transmissions stem from acute-stage infections, 30-50% from chronic-stage, and 30-45% from AIDS-stage. The impact of acute infection is strongly moderated by concurrency. Reducing this impact by reducing concurrency could potentially end the current HIV epidemic in Zimbabwe.

Assessing effectiveness and cost-effectiveness of concurrency reduction for HIV prevention

We estimated the effectiveness and cost-effectiveness of changes in concurrent sexual partnerships in reducing the spread of HIV in sub-Saharan Africa. Using data from Swaziland, Tanzania, Uganda and Zambia, we estimated country-specific concurrency behaviour from sexual behaviour survey data on the number of partners in the past 12 months, and we developed a network model to compare the impact of three behaviour changes on the HIV epidemic: (1) changes in concurrent partnership patterns to strict monogamy; (2) partnership reduction among those with the greatest number of partners; and (3) partnership reduction among all individuals. We estimated the number of new HIV infections over 10 years and the cost per infection averted. Given our assumptions and model structure, we find that reducing concurrency among high-risk individuals averts the most infections and increasing monogamy the least (11.7% versus 8.7% reduction in new infections, on average, for a 10% reduction in concurrent partnerships). A campaign that costs US$1 per person annually is likely cost-saving if it reduces concurrency by 9% on average, given our baseline estimates of concurrency. In sensitivity analysis, the rank ordering of behaviour change scenarios was unaffected by potential over-estimation of concurrency, though the number of infections averted decreased and the cost per HIV infection averted increased. Concurrency reduction programmes may be effective and cost-effective in reducing HIV incidence in sub-Saharan Africa if they can achieve even modest impacts at similar costs to past mass media campaigns in the region. Reduced concurrency among high-risk individuals appears to be most effective in reducing HIV incidence, but concurrency reduction in other risk groups may yield nearly as much benefit.

In the absence of marriage: long-term concurrent partnerships, pregnancy, and HIV risk dynamics among South African young adults

In KwaZulu/Natal, South Africa, where HIV prevalence is among the world's highest, a longitudinal qualitative study of partnership dynamics and HIV preventive behaviors was conducted. 47 young adults aged 18-24 participated in in-depth interviews, and 29 were re-interviewed 2 years later. Five analytical domains emerged: primary partnerships, love and romance; secondary partnerships; pregnancy/parenthood; condom use/prevention; and contextual influences, including schooling and future aspirations. Primary relationships were long-lasting, with most men and women in the same relationship at 2-year follow-up. Secondary, casual partnerships were common for men and women, although these were shorter and changed frequently. Love and marriage aspirations were not viewed as incompatible with secondary partners. Condom use increased over time in some primary relationships, but decreased in others, and was nearly universal with non-primary partners. Pregnancy, school drop-out, and economic need strongly influence young people's lifecourse. These findings suggest the need to focus prevention efforts on the partnership context, including partner reduction, and structural factors that impede or enhance prevention success.