Serodiscordant Couples in the Age of Combination Therapies

Abstract

Serodiscordant couples have faced a number of challenges over the decades of HIV/AIDS. Combination therapies added hope to the survival of the HTV positive partner, but it also has created new challenges to intimacy. What are the unique challenges, dyadic conflicts and ways of coping for these couples of mixed HTV status? This article reports on the findings from an exploratory study of twelve serodiscordant couples (both heterosexual and gay) from three different states, and five different AIDS organizations. The three emotional challenges to their relationship were identified as (1) the impact of side effects from medications, (2) safer sex conflicts, and (3) the decision-making process regarding reproductive issues and family planning. When asked how they coped, the primary source of psychological support was found in their friendships with other couples of mixed HIV status, couple counseling and individual counseling.     

The impact of HIV couple testing and counseling on social support among pregnant women and their partners in Lilongwe,Malawi: an observational study

Couples HIV testing and counseling (couple counseling) promotes safer sexual behaviors, increases communication between couples, and decreases HIV transmission. However, the impact of couple counseling on social support, critical for persons living with HIV, has not been examined. Ninety couples with a recently tested HIV-positive pregnant woman (female-positive couples) and 47 couples with a recently tested HIV-negative pregnant woman (female-negative couples) were enrolled in an observational study at an antenatal clinic in Malawi. Each couple member was assessed immediately before and one month after couple counseling for partner, family, and peer social support using the Multidimensional Scale of Perceived Social Support. Before couple counseling, social support was lower among women than men in both female-positive couples (β?=??10.00, p?<?.01) and female-negative couples (β?=??8.43, p??<?.01). After couple counseling, social support increased for women in female-positive couples (β?=?4.01, p?<?.01) and female-negative couples (β?=?4.69, p?<?.01) but not for men in either type of couple. Couple counseling could be an effective strategy to increase social support for women, including those with recent HIV diagnoses.     

“I have it just like you do”: voices of HIV-negative partners in serodifferent relationships receiving primary care at a public clinic in San Francisco

HIV transmission among serodifferent couples has a significant impact on incidence of HIV worldwide. Antiretroviral interventions (i.e., preexposure prophylaxis, post-exposure prophylaxis, and treatment as prevention) are important aspects of comprehensive prevention and care for serodifferent couples. In this study, HIV-negative members of serodifferent couples were interviewed using open-ended questions to explore their health-care needs, perceptions of clinic-based prevention services, and experience of having an HIV-infected partner. Analysis of interviews with 10 HIV-negative partners revealed the following themes: (1) health needs during joint medical visits; (2) sexual risk reduction strategies; (3) relationship dynamics; and (4) strategies for coping. This study elucidated relationship, health and health care factors that might affect development and implementation of clinic-based prevention interventions for HIV serodifferent couples. The findings point to possible relationship-centered recommendations for health-care providers who serve HIV-affected couples in clinical settings.     

Willingness to use couples voluntary counseling and testing services among men who have sex with men in seven countries

The willingness of male-male dyads to use couples voluntary HIV counseling and testing (CVCT) has not been previously investigated globally among men who have sex with men (MSM). Using online advertisements, data were collected from 3245 MSM in seven countries who were ≥18 years of age and had ≥1 male sex partner in the previous 12 months. The analysis examined associations between individual characteristics and willingness to utilize CVCT. The willingness to utilize CVCT was compellingly high, ranging from 79% in Australia and UK to 90% in Brazil. Older MSM and those who reported not knowing their sero-status reported lower odds of willingness to use CVCT. The relationship between being in a relationship and willingness to use CVCT varied across countries, perhaps reflecting varied local understandings of the nature and content of CVCT. Further work is required to examine willingness to use CVCT among a more heterogeneous population of MSM, and to examine how CVCT services are locally perceived in order to provide information vital for the development of locally appropriate messages to promote CVCT for MSM.     

Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples

Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient–provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.     

Reducing the risk of HIV infection during pregnancy among South African women: A randomized controlled trial

Mpumalanga Province, South Africa has one of the highest HIV/AIDS diagnosis rates among pregnant women (~29.4%). This study sought to enhance male involvement in pregnancy to increase HIV disclosure, sexual communication, HIV knowledge and reduce unprotected sex. Participants attending Antenatal Clinics (ANC) completed HIV counseling and testing and were enrolled with male partners (n=239 couples, 478 individuals). Twelve ANCs were randomly assigned to provide a prevention of mother-to-child transmission (PMTCT) intervention or the standard of care, health education sessions plus PMTCT. Participants were assessed at baseline and post-intervention (approximately 6–8 weeks post-baseline) on demographics, sexual behavior, HIV-related knowledge, and conflict resolution strategies. Experimental participants increased HIV knowledge, use of negotiation, and decreased intimate partner violence. Additionally, they were more likely to have increased condom use from baseline to post-intervention (OR=5.1, 95% CI=[2.0, 13.3]). Seroconversions in the control condition exceeded experimental (6 vs. 0). HIV serostatus disclosure to partner did not increase over time for men or women within the experimental or control condition. Male involvement in pregnancy may be an important strategy to reduce sexual risk behavior and HIV transmission. Results support the utility of group interventions to enhance communication and HIV knowledge among pregnant couples.     

“I never thought that it would happen … ” Experiences of HIV seroconverters among HIV-discordant partnerships in a prospective HIV prevention study in Kenya

In spite of access to behavioral and biomedical HIV prevention strategies, HIV transmission occurs. For HIV-serodiscordant couples, prevention programs can be tailored to address individual and couples’ needs to preserve their relationship while minimizing HIV risk. Programs for serodiscordant couples may benefit from learning from experiences of couples who transmit HIV. We conducted 20 individual in-depth interviews with 10 initially HIV-serodiscordant couples who transmitted HIV during prospective follow-up at a peri-urban research site in Thika, Kenya. Data were analyzed inductively to identify situations that led to prevention failure and coping mechanisms. Inconsistent condom use driven by low HIV risk perception and alcohol use often preceded seroconversion while persistent blame frequently hindered couples’ communication soon after seroconversion. In this emerging era of antiretroviral-based HIV prevention, couples’ counseling can capitalize on opportunities to foster a supportive environment to discuss initiation and adherence to time-limited pre-exposure prophylaxis and lifelong antiretroviral therapy, in addition to strategies to reduce alcohol use, diffuse blame, and use condoms.     

Attitudes towards couples HIV testing and counseling among Latino men who have sex with men in the Seattle area

Men who have sex with men (MSM) remain the most severely affected risk group in the US HIV/AIDS epidemic. One-third to two-thirds of HIV transmissions among MSM are estimated to come from primary sex partners. Couples HIV testing and counseling (CHTC), in which two individuals receive pre-test counseling, HIV testing and post-test prevention planning together, has been adapted for male couples in the USA, and is now available in more than 30 cities. Previous studies have demonstrated high levels of willingness to use CHTC among MSM, but to date no studies have explored this among Latino MSM (LMSM). To examine the willingness to use CHTC among and further cultural adaptation needed for LMSM, focus group discussions were held with men who self-identified as Latino, were in a relationship with another man, and resided in Seattle. Willingness to use CHTC was high. Participants reported that CHTC could strengthen and validate their relationships, help mitigate stigma, and provide a forum for support, protection, and information sharing. Barriers to CHTC use included fears of rejection, loneliness, and relationship dissolution, and concerns around deportation and financial burden. The high levels of reported willingness to use CHTC among this sample of LMSM point to the potential for CHTC to be further adapted to provide dyadic HIV testing services for LMSM.     

男男性行为人群艾滋病防治网络干预效果评价

目的评价利用网络平台对男男性行为人群(MSM)在艾滋病知识的认知、态度及行为学方面的干预效果。方法主要采用网络调查及网络干预的模式,对MSM人群进行艾滋病预防知识、态度、行为干预进行评价,包括两次横断面调查和为期2个月的3期网络干预。结果共调查1 293人,平均年龄为(27.6±6.0)岁,其中75%年龄在18～30岁之间;86.2%为专科或本科以上学历;64.8%目前居住在北京。干预前后,MSM人群艾滋病知识知晓情况、安全套使用及HIV检测情况等方面的差异有统计学意义(P<0.05)。但在减少过去6个月中的肛交行为、消除阻碍接受HIV检测的因素等方面,网络干预不具有显著效果(P>0.05)。结论针对MSM人群,可以尝试采用网络干预的方法来提高艾滋病防治知识,减少HIV感染的高危行为,促进接受HIV检测。     

Sexual Risks Among Southern Thai Drug Injectors

Sexual risks for HIV transmission among injection drug users (IDUs) in Thailand are not well characterized. We surveyed 272 male IDUs about their background, sexual behaviors, and drug use at drug treatment clinics in southern Thailand. HIV seroprevalence was determined using enzyme immunoassay. Fifty-six percent of participants were sexually active, of whom 88% had sex mostly with a noninjecting regular partner (wife or steady girlfriend), reporting low rates (34%) of condom use. Among sexually active IDUs, 43% were HIV infected and only a few were aware of their HIV serostatus. Condom use was associated with history of HIV voluntary counseling and testing (VCT) and poor perceived health status in multivariate analysis. Unprotected sex with regular sexual partners is frequent among IDUs in southern Thailand, where most IDUs have not sought VCT services. AIDS prevention efforts should address access to VCT and condom promotion to sexually active couples to prevent sexual transmission of HIV.     

An assessment of HIV testing in Tanzania to inform future strategies and interventions

This study identified characteristics of Tanzanians who have never tested for HIV in order to inform localized interventions to increase HIV testing coverage and uptake. A total of 3257 randomly selected participants aged 18–49 years were surveyed in 16 Mainland regions. Those surveyed were asked about demographics, HIV risk perception, HIV testing behavior, knowledge of both their own and partner's HIV status, and if they were tested with their partner. Approximately 22% of women and 46% of men reported never testing for HIV, with those who are younger (18–24 years), single/never married, living in rural areas, less educated, and having multiple sexual partners in the past year less likely to have tested. The gender differences in HIV testing behavior identified are supported by existing research. No association was found in either gender between HIV risk perception and testing, however, those least likely to test were those with multiple sex partners. These findings can help better target localized interventions focused on younger, single people, and those with multiple sex partners.     

Uptake of HIV and syphilis testing of pregnant women and their male partners in a programme for prevention of mother-to-child HIV transmission in Uganda

Objective To describe uptake of HIV and syphilis testing in a prevention of mother‐to‐child HIV transmission programme in Uganda. Methods Analysis of data from routine HIV and syphilis testing at Entebbe Hospital antenatal services. Results A total of 20 738 women attended antenatal services. Exactly 62.8% of women, but only 1.8% of their male partners, accepted testing for HIV; 82.2% of women, but only 1.1% of their male partners accepted syphilis testing. Partners of women with positive HIV results were more likely to come for subsequent testing. Of 200 couples whose partners accepted HIV‐testing within 30 days of one another, 19 (9.5%) were HIV‐discordant, representing 65.5% of couples with at least one partner HIV‐positive. HIV prevalence was 12.6% for women and 10.8% for men; syphilis prevalence was 4.0% for women and 6.2% for men. Conclusion Uptake of HIV and syphilis testing was fairly good among pregnant women attending antenatal clinics at Entebbe Hospital, but very low among their male partners. The level of HIV‐discordant couples was high. These clinics should be made more couples‐friendly to identify both HIV‐positive men for treatment and discordant couples for HIV prevention.     

The experience and management of HIV stigma among HIV-negative adults in heterosexual serodiscordant relationships in New York City

Despite treatment advances that have improved the health and life expectancy of HIV-positive people and contribute to the prevention of HIV transmission, HIV stigma is still frequently experienced by HIV-infected individuals and those close to them. This study investigated the types of HIV-related stigma experienced by HIV-negative adults in serodiscordant heterosexual relationships when their partner’s HIV-positive status was revealed to family and friends and their strategies to manage such stigma. In-depth interviews were conducted in New York City with 56 men and 44 women who were HIV negative and had been in a relationship for at least six months with an HIV-positive partner of the opposite sex. Those who had disclosed the HIV status of their partner to family or friends experienced four main types of stigmatizing behaviours: distancing (avoidance of the participant or his/her partner for fear of infection), depreciation of the partner (being told their partner is not worthy of them), violation of privacy (people spreading the information that the partner is HIV positive), or accusations (being told that it was wrong to be in a relationship with HIV-positive people or to try to conceive with them). Participants described four main ways of managing actual or anticipated stigma: secrecy (not disclosing the HIV status of their partner to anyone), avoidance (breaking ties with people who held stigmatizing views), seeking support from their partner or the HIV-positive community (e.g., HIV-related organizations or their partner’s family or friends), or education (informing family or friends about HIV treatment and prevention). Findings show that HIV-related “courtesy” stigma is frequently experienced by HIV-negative people in serodiscordant relationships but often can be managed. Offering support to individuals in serodiscordant relationships can improve the quality of life of HIV-positive people and their HIV-negative partners and potentially reduce HIV stigma.     

开远市暗娼人群参加HIV检测后咨询关联因素的前瞻性流行病学调查

目的了解开远市娱乐场所暗娼人群参加艾滋病病毒（HIV）检测后咨询的情况及影响因素,为艾滋病预防控制工作提供参考依据。方法采用外展招募方式,对符合纳入标准的暗娼,进行一对一的检测前咨询和问卷调查,并预约HIV检测后4周接受HIV检测后咨询服务。结果 57.4%（412/718）的暗娼通过参加HIV检测后咨询获取了HIV检测结果。多因素Logistic回归模型分析显示,来源于中低档服务场所（OR=0.57）、HIV抗体检测阴性（OR=0.51）、年龄〈25岁（OR=0.61）和艾滋病知识得分较低（〈14分）（OR=0.66）,是暗娼人群参加HIV检测后咨询的重要妨碍因素（P〈0.05）。结论暗娼人群参加HIV检测后咨询的比例较低,卫生部门在扩大HIV检测数量和范围的同时,需加强对暗娼开展有针对性的健康宣传教育,提高其参加HIV检测后咨询的比例,切实降低暗娼人群HIV相关高危行为。     

Feasibility and acceptability of Project Connect: A couples-based HIV-risk reduction intervention among young couples in Johannesburg,South Africa

Given the importance of couples to the transmission of HIV, interventions focusing on both members of a partnership can play an important role in its prevention. We adapted and pilot-tested Project Connect, an evidence-based HIV prevention intervention for couples, to determine its acceptability and feasibility among a sample of young urban South African couples. We recruited couples from a clinic in inner-city Johannesburg to take part in the study. Interviewer-administered questionnaires were conducted at baseline and postintervention; an in-depth interview (IDI) was also conducted postintervention. Of 75 couples screened, 15 were eligible and enrolled. An important reason for ineligibility was a recent history of intimate partner violence (IPV). Couples attended, on average, five of the seven sessions. Overall, the intervention was acceptable and showed signs of potential efficacy. Couples reported enjoying Connect and feeling comfortable with its content. Participants also reported learning important communication and problem-solving skills, which resulted in more effective engagement in HIV prevention behaviors. However, the number of sessions and strict eligibility criteria proved challenging to the feasibility of the study. We recommend future couples' interventions have fewer sessions and enroll couples with a history of IPV.     

Achieving pregnancy safely: perspectives on timed vaginal insemination among HIV-serodiscordant couples and health-care providers in Kisumu,Kenya

In female-positive HIV-serodiscordant couples desiring children, home timed vaginal insemination (TVI) of semen during the fertile period along with consistent condom use may reduce the risk of HIV transmission when the man is HIV-uninfected. In sub-Saharan Africa, up to 45% of HIV-infected women desire to have more children. HIV viral load assessment is not routinely available in low-resource countries for monitoring adherence and response to antiretroviral therapy. Therefore, in these settings, timed unprotected intercourse without assurance of HIV viral suppression may pose unnecessary risks. TVI, a simple and affordable intervention, can be considered an adjunct method and option of safer conception for HIV prevention with treatment of the HIV-infected partner and/or pre-exposure prophylaxis. We conducted five mixed and single-sex focus group discussions comprised of 33 HIV-serodiscordant couples and health-care providers in the Nyanza region of Kenya to assess the acceptability and feasibility of TVI as a safer method of conception. The transcribed data were analyzed using a grounded theory approach. We found that educating and counseling HIV-serodiscordant couples on TVI could make it an acceptable and feasible safer conception method when associated with frequent communication and home visits by health-care providers. The findings of this study indicate that implementation studies that integrate training and counseling of HIV-serodiscordant couples and health-care providers on TVI combined with consistent condom use are needed. Acknowledging and supporting the reproductive choice and needs of female positive, male negative HIV-serodiscordant couples who desire children should also include the use of assisted reproductive services at the same time as pharmaceutical options that prevent sexual HIV transmission.     

Perspectives of healthcare providers and HIV-affected individuals and couples during the development of a Safer Conception Counseling Toolkit in Kenya: stigma,fears, and recommendations for the delivery of services

Reproduction is important to many HIV-affected individuals and couples and healthcare providers (HCPs) are responsible for providing resources to help them safely conceive while minimizing the risk of sexual and perinatal HIV transmission. In order to fulfill their reproductive goals, HIV-affected individuals and their partners need access to information regarding safer methods of conception. The objective of this qualitative study was to develop a Safer Conception Counseling Toolkit that can be used to train HCPs and counsel HIV-affected individuals and couples in HIV care and treatment clinics in Kenya. We conducted a two-phased qualitative study among HCPs and HIV-affected individuals and couples from eight HIV care and treatment sites in Kisumu, Kenya. We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) to assess the perspectives of HCPs and HIV-affected individuals and couples in order to develop and refine the content of the Toolkit. Subsequently, IDIs were conducted among HCPs who were trained using the Toolkit and FGDs among HIV-affected individuals and couples who were counseled with the Toolkit. HIV-related stigma, fears, and recommendations for delivery of safer conception counseling were assessed during the discussions. One hundred and six individuals participated in FGDs and IDIs; 29 HCPs, 49 HIV-affected women and men, and 14 HIV–serodiscordant couples. Participants indicated that a safer conception counseling and training program for HCPs is needed and that routine provision of safer conception counseling may promote maternal and child health by enhancing reproductive autonomy among HIV-affected couples. They also reported that the Toolkit may help dispel the stigma and fears associated with reproduction in HIV-affected couples, while supporting them in achieving their reproductive goals. Additional research is needed to evaluate the Safer Conception Toolkit in order to support its implementation and use in HIV care and treatment programs in Kenya and other HIV endemic regions of sub-Saharan Africa.     

Correlates of HIV Test Results Seeking and Utilization of Partner Counseling Services in a Cohort of Male Factory Workers in Zimbabwe

Correlates of individual HIV test results-seeking and utilization of partner counseling services were identified among male factory workers who participated in a longitudinal HIV prevention intervention study in Harare, Zimbabwe. Men working at participating factories were offered HIV voluntary counseling and testing (VCT) for themselves and their partners. While risk assessment counseling was offered in the workplace, result disclosure and partner counseling occurred at an off-workplace location. Of the 3,383 men undergoing risk assessment and testing, 1,903 (56%) chose to receive their test results and 230 (7%) brought their partners for VCT. Factors associated with receiving test results were history of STD and lower salary. Factors associated with bringing a partner for VCT were history of STD, being married, being employed at a factory with a peer educator, lower salary, and no prostitute contact. Incorporating VCT into STD treatment services is likely to reach a large number of men and their partners at highest risk for both types of infections. Because men are often the main decision-makers in sexual and reproductive matters, VCT must be easily accessible to urban, working African men.     

Sexual communication self-efficacy,hegemonic masculine norms and condom use among heterosexual couples in South Africa

Hegemonic masculine norms (HMN), which promote sexual risk-taking among males and the subordination of women, are believed to play a key role in the HIV epidemic among heterosexual couples in South Africa (SA). Sexual communication self-efficacy (SCSE) (i.e., a couple's confidence in their ability to communicate about HIV prevention) may be a key leverage point for increasing HIV prevention behaviors among this population. We interviewed 163 sexually active heterosexual couples in Soweto, SA to investigate the association between SCSE, HMN, and consistent condom use. We collected information on demographics, relationship dynamics, and sexual activity. We utilized the SCSE scale to measure couples' SCSE, and a subscale of the Gender Equitable Men scale to measure HMN among males. We performed bivariate and multivariable analyses to determine the association of consistent condom use with couples' SCSE as well as the male partner's endorsement of HMN. We found that couples with higher SCSE have greater odds of consistent condom use (adjusted odds ratio [AOR]?=?1.30, 95% CI: 1.15–1.47). Furthermore, male endorsement of HMN was found to be negatively associated with consistent condom use among couples (AOR?=?0.47, 95% CI: 0.24–0.89). Joint HIV serostatus was not significantly associated with the outcome. Future interventions that equip heterosexual couples with sexual communication skills, while simultaneously promoting more gender equitable norms, may increase consistent condom use and thereby reduce the transmission of HIV among this at-risk population.