Pregnancy and HIV transmission among HIV-discordant couples in a clinical trial in Kisumu, Kenya

Objectives

A large proportion of new HIV infections in sub‐Saharan Africa occur in stable HIV‐discordant partnerships. In some couples, the strong desire to conceive a child may lead to risky behaviour despite knowledge of discordant serostatus. Our objective was to compare HIV transmission between discordant couples who did and did not conceive during participation in a clinical trial.

Methods

Five hundred and thirty‐two HIV‐discordant couples were followed for up to 2 years in Kisumu, Kenya as part of the Partners in Prevention HSV/HIV Transmission Study. Quarterly HIV‐1 antibody and urine pregnancy test results were analysed.

Results

Forty‐one HIV‐1 seroconversions occurred over 888 person‐years of follow‐up, resulting in an annual incidence of 4.6/100 person‐years. Twenty seroconversions occurred among 186 HIV‐1‐uninfected individuals in partnerships in which pregnancy occurred (10.8% of HIV‐1‐negative partners in this group seroconverted), in comparison to 21 seroconversions among 353 uninfected individuals in partnerships in which pregnancy did not occur (5.9% of HIV‐1‐negative partners seroconverted), resulting in a relative risk of 1.8 [95% confidence interval (CI) 1.01–3.26; P<0.05].

Conclusions

Pregnancy was associated with an increased risk of HIV seroconversion in discordant couples. These data suggest that the intention to conceive among HIV discordant couples may be contributing to the epidemic.     

Sexual behavior of HIV discordant couples after HIV counseling and testing

BACKGROUND AND OBJECTIVES: Sexual behavior following voluntary HIV counseling and testing (VCT) is described in 963 cohabiting heterosexual couples with one HIV positive and one HIV negative partner ('discordant couples'). Biological markers were used to assess the validity of self-report. METHODS: Couples were recruited from a same-day VCT center in Lusaka, Zambia. Sexual exposures with and without condoms were recorded at 3-monthly intervals. Sperm detected on vaginal smears, pregnancy, and sexually transmitted diseases (STD) including HIV, gonorrhea, syphilis, and Trichomonas vaginalis were assessed. RESULTS: Less than 3% of couples reported current condom use prior to VCT. In the year after VCT, > 80% of reported acts of intercourse in discordant couples included condom use. Reporting 100% condom use was associated with 39-70% reductions in biological markers; however most intervals with reported unprotected sex were negative for all biological markers. Under-reporting was common: 50% of sperm and 32% of pregnancies and HIV transmissions were detected when couples had reported always using condoms. Positive laboratory tests for STD and reported extramarital sex were relatively infrequent. DNA sequencing confirmed that 87% of new HIV infections were acquired from the spouse. CONCLUSIONS: Joint VCT prompted sustained but imperfect condom use in HIV discordant couples. Biological markers were insensitive but provided evidence for a significant under-reporting of unprotected sex. Strategies that encourage truthful reporting of sexual behavior and sensitive biological markers of exposure are urgently needed. The impact of prevention programs should be assessed with both behavioral and biological measures.     

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.     

Partner-Provided Social Support Influences Choice of Risk Reduction Strategies in Gay Male Couples

We investigated the influence of partner-provided HIV-specific and general social support on the sexual risk behavior of gay male couples with concordant, discordant, or serostatus-unknown outside partners. Participants were 566 gay male couples from the San Francisco Bay Area. HIV-specific social support was a consistent predictor for reduced unprotected anal intercourse (UAI) with both concordant outside partners (all couple types) and outside partners of discordant or unknown serostatus (concordant negative and discordant couples). General social support was associated with increased UAI with concordant outside partners for concordant negative and concordant positive couples (i.e., serosorting). Our findings suggest that prevention efforts should target couples and identify the level of HIV-specific support that partners provide. Partner-provided support for HIV-related behaviors could be an additional construct to consider in gay male relationships, akin to relationship satisfaction and commitment, as well as an important component of future HIV prevention interventions.     

Evaluating the risk of HIV transmission through unprotected orogenital sex

We analysed a cohort of heterosexual HIV- serodiscordant couples with the aim of evaluating the risk of transmission ascribed to unprotected orogenital intercourse. A total of 135 seronegative individuals (110 women and 25 men), whose only risk exposure to HIV was unprotected orogenital sex with their infected partner, registered 210 person-years of follow-up. After an estimated total of over 19,000 unprotected orogenital exposures with the infected partner not a single HIV seroconversion occurred.     

云南省美沙酮维持治疗门诊HIV阳性服药人员阴性配偶的高危行为及新发感染情况

目的了解云南省美沙酮门诊中,阳性服药人员阴性配偶的高危行为及其艾滋病病毒（HIV）抗体阳转情况,为开展后续的配偶间干预服务提供参考。方法在部分美沙酮门诊HIV抗体阳性服药人员的阴性配偶中,开展5次横断面调查,收集人口学特征、高危行为信息和HIV阳转原因,并抽血检测HIV抗体。使用Epidata 3.1建立数据库,使用SPSS 17.0进行数据分析。结果 5次横断面调查分别招募107名、101名、119名、136名和85名对象。各次调查中研究对象的艾滋病知识知晓率均在90%以上,最近1次性行为安全套的使用率有显著性提高（P〈0.001）。检出HIV抗体阳转男性和女性各1例,分别因共用针具和配偶间性行为没有使用安全套而感染。HIV发病密度为1.12/100人年,男、女性发病密度分别为4.17/100人年和0.65/100人年。结论共用针具以及不安全的性行为,是阳性美沙酮维持治疗人员阴性配偶发生HIV抗体阳转的主要危险因素,未来的干预中要采取相应的措施。     

HIV transmission risk behaviours among HIV-positive persons in serodiscordant relationships

As many as one in three persons living with HIV-AIDS continue to practise unprotected sexual intercourse and these practices often occur with HIV-negative or unknown HIV serostatus (serodiscordant) partners. The current study examined the rates of HIV transmission risk behaviours in non-regular (e.g. casual) and regular (e.g. steady) serodiscordant relationships. HIV positive men (n = 269) and women (n = 114) responded to measures of demographic characteristics, health and mental health status, and sexual behaviours assessed in partner-by-partner interviews. 257 (67%) participants were sexually active in the preceding three months and 182 (71%) of the sexually active persons had engaged in vaginal or anal intercourse with serodiscordant partners. Comparisons of persons with non-regular (n = 97) and regular (n = 85) serodiscordant partners showed that overall rates of unprotected and protected intercourse were greater with regular partners than non-regular partners. Disclosure of HIV status to regular and non-regular serodiscordant partners did not appear to influence the pattern of results. Mathematical modelling showed that HIV transmission estimates over a one-year horizon were significantly greater for male regular partners of HIV-positive men than non-regular partners and there was a trend toward greater HIV transmission rates from HIV-positive men to their regular serodiscordant female partners compared to non-regular partners. Results suggest an urgent need for HIV transmission risk reduction interventions for HIV serodiscordant couples, particularly for couples in established, regular relationships.     

Preexposure prophylaxis and timed intercourse for HIV-discordant couples willing to conceive a child

Many HIV-discordant couples express a strong wish to conceive a child. Insemination with processed semen is offered to these couples in many countries. Given the very low level of transmission risk during fully suppressive antiretroviral therapy, we offered timed intercourse combined with preexposure prophylaxis to further reduce the transmission risk. In 53 cases, natural conception was attempted using the proposed method. Pregnancy rates were high and reached a plateau of 75% after six cycles. Advanced age in the female partner was a predictor for infertility in these couples.     

HIV-Negative and HIV-Discordant Gay Male Couples’ Use of HIV Risk-Reduction Strategies: Differences by Partner Type and Couples’ HIV-Status

Previous research has found that gay men and other men who have sex with men have adopted a variety of HIV risk-reduction strategies to engage in unprotected anal intercourse (UAI). However, whether gay male couples’ use these strategies within and out of their relationships remains unknown. The present national cross-sectional study collected dyadic data from an online sample of 275 HIV-negative and 58 discordant gay male couples to assess their use of these strategies, and whether their use of these strategies had differed by partner type and couples’ HIV-status. The sample used a variety of risk-reduction strategies for UAI. Some differences and patterns by partner type and couples’ HIV-status were detected about men’s use of these strategies. Findings indicate the need to bolster HIV prevention and education with gay male couples about their use of these strategies within and outside of their relationships.     

Fertility needs and funding in couples with blood-borne viral infection

Background

Couples infected with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) are increasingly seeking assisted conception. These couples avoid unprotected intercourse and use condoms at all times in order to minimize the risk of infecting their partner. As this practice inhibits pregnancy, assisted procreation is generally required for safe conception. For many couples, access to such services is restricted on ethical, geographical and financial grounds.

Objective

The aim of the study was to assess the fertility needs, geographical origin and state funding of patients with blood‐borne viral infection.

Methods

A retrospective review of the medical records of couples referred for fertility treatment between January 1999 and December 2006, where one or both partners were infected with HIV, HBV and/or HCV, was carried out.

Results

Of the 205 couples included in the study, 44% lived in London, 51% came from elsewhere in the United Kingdom and 5% travelled from outside the United Kingdom to seek treatment. Genitourinary medicine clinics were the main source of referral. 85.8% of couples had HIV infection, 15.1% were infected with HBV and 13.6% had HCV infection. Fertility screening identified a high incidence of male factor infertility (33.3%) in HIV‐infected men and tubal disease (40.8%) in HIV‐infected women. Only 23.6% of HIV‐infected couples, 20% of HBV‐infected couples and 12.5% of HCV‐infected couples obtained state funding for assisted conception.

Conclusion

Fertility screening identified a high incidence of male and tubal factor subfertility among couples living with HIV, HBV and HCV. Limited access to specialist clinics equipped to cater for these couples and restricted funding may impact negatively on couples obtaining risk‐reducing assisted reproduction treatment. This may have long‐term public health implications as individuals attempt to conceive through unprotected intercourse.     

Survey of HIV care providers on management of HIV serodiscordant couples – assessment of attitudes,knowledge, and practices

Human immunodeficiency virus (HIV) serodiscordant couples are at risk of sexual transmission of HIV between the infected and uninfected partner. We assessed New York area care providers for people living with HIV regarding attitudes, knowledge, and practice patterns toward fertility and conception in serodiscordant couples. Data were collected via a survey distributed in October 2013. Seventeen percent of respondents reported prescribing antiretroviral preexposure prophylaxis (PrEP) for a woman in a serodiscordant couple, and 38% percent of respondents reported having counseled serodiscordant couples on timed, unprotected intercourse without PrEP. Respondents who reported being “very” familiar with the data on HIV transmission in serodiscordant couples were more likely to report counseling their patients in timed, unprotected intercourse compared with those who reported less familiarity with the data (41% vs. 8%, p = 0.001). Although only 20% reported being “very” or “somewhat” familiar with the data on the safety of sperm washing with intrauterine insemination, those who did were more likely to have reported referring a patient for assisted reproductive technology (61% vs. 32%, p = 0.006). Effective patient counseling and referral for appropriate reproductive options were associated with knowledge of the literature pertaining to these options. This emphasizes the need for further provider education on reproductive options and appropriate counseling for serodiscordant couples.     

HIV in couples in South India; implications for prevention

We studied HIV prevalence in couples in Chennai, India. In 56% both partners were infected. Among discordant couples, 35 men and seven women were infected. Heterosexual intercourse is the primary risk factor. Concordance was related to sex with commercial sex workers for men and to genital ulcer disease for women. Median CD4 count was 97 cells/mm(3) among concordant men, 222 cells/mm(3) among discordant men. Condom use increased, and frequency of sexual intercourse decreased, among all couples after HIV diagnosis.     

Pregnancy and HIV-1 incidence in 178 married couples with discordant HIV-1 serostatus: additional experience at an HIV-1 counselling centre in the Democratic Republic of the Congo

To determine the effect of an HIV-1 counselling programme on rates of HIV-1 infection and pregnancy in a large group of married couples in Kinshasa, DRC with discordant HIV-1 infection status, we conducted a baseline cross-sectional HIV-1 seroprevalence study in two large Kinshasa businesses. We identified 178 married couples (mean duration of marriage = 12.3 years) with discordant HIV-1 serostatus (92 M+F-/86 M-F+). Seroincidence and pregnancy rates were observed during 310 person-years of follow-up (PYFU). The 92 M+F- couples had an HIV-1 incidence of 3.7/100 PYFU and a pregnancy rate of 8.6/100. The 86 M-F+ couples had a pregnancy rate of 6.8/100 PYFU and an HIV-1 incidence of 6.8/100 PYFU. Couples seeking to have children but minimize their HIV-1 transmission risk frequently had unprotected sex only during the woman's perceived monthly fertility period. This strategy resulted in the birth of 24 live-born children and only one (4%; 95% CL = 0.0-21.6%) new HIV infection in couples having a child. Only 1 of 6 women who developed HIV-1 infection (16. 7%; 95 C.L. = 0-40.4%) became pregnant. While seronegative men had more extramarital sex once their wives' positive HIV-1 infection status became known, most of these episodes involved safe sex. Divorce was rare. This study provides additional information concerning issues of safe sex in married couples with discordant HIV-1 infection status, the dynamics of HIV transmission within couples and the effect of serostatus notification on the marriage and on intramarital and extramarital sexual behaviour in Kinshasa, Congo.     

Personal or Relational? Examining Sexual Health in the Context of HIV Serodiscordant Same-Sex Male Couples

Couples’ ability to adopt a “we” orientation has been associated with optimal health outcomes. This study examined how personal and relational motivations are uniquely associated with unprotected anal intercourse (UAI), protected anal intercourse (PAI), and the absence of sexual activity within HIV-serodiscordant same-sex male couples. HIV-positive men and their HIV-negative partners (N = 116 couples, 232 men) completed questionnaires and HIV-positive men had blood drawn for viral load. Results of a multinomial logistic regression illustrated that sexual satisfaction was positively associated with PAI among HIV-negative partners and negatively associated with PAI among HIV-positive partners. Endorsing a “we” orientation was positively associated with PAI among HIV-positive partners. Findings suggest that HIV-positive partners who espouse a “we” orientation may be willing to forgo their personal interests to protect their HIV-negative partners from HIV transmission. Couples-based interventions are warranted to help strengthen relationship dynamics to enhance the sexual health of serodiscordant couples.     

Sexual Risk, Serostatus and Intimate Partner Violence Among Couples During Pregnancy in Rural South Africa

The aim of this study was to describe sexual risk behavior among 239 couples during pregnancy and to examine the relationship of sexual risk behavior with HIV serostatus and intimate partner violence. One-third (31.8 %) of pregnant women and 20.9 % of male partners were HIV positive. HIV risk factors included lack of knowledge of partners’ HIV serostatus, unprotected sexual intercourse and multiple sexual partners. Among men, multivariate logistic regression identified awareness of HIV negative partner status, multiple sexual partners and low levels of partner violence and among women Zulu or Swati ethnicity were associated with unprotected intercourse. HIV positive concordance was associated with protected sex and in multilevel analysis of couples HIV positive status and awareness of the partner’s HIV positive status were associated with protected sex. High levels of HIV risk behaviour was found among couples during pregnancy calling for HIV risk reduction interventions.     

Pre-exposure prophylaxis for conception (PrEP-C) as a risk reduction strategy in HIV-positive men and HIV-negative women in the UK

Couples wishing to have biological children when one partner is HIV positive and the other is HIV negative present clinicians with complex clinical, social and ethical considerations. We established two multidisciplinary pre-conception services for HIV-positive individuals and their partners. We report the first UK use of pre-exposure prophylaxis for conception (PrEP-C) as part of an overall risk reduction strategy. Couples were counselled and written informed consent for PrEP-C was obtained. Patient demographics, HIV and medical histories were recorded. Males underwent baseline semen analysis and seminal HIV viral load testing. Females had full fertility screens. Both partners were screened for sexually transmitted infections. All couples used timed ovulatory intercourse (TOI). Tenofovir±emtricitabine was taken by the female at protocol designated times before±after TOI. Thirty-two male positive/female negative couples used the services. Thirteen couples have used PrEP-C (median age of male 41 years (range 32–56), female 31 (28–43); median CD4 533 (236–1194); all male plasma and seminal HIV viral loads were undetectable). Eleven pregnancies in 10 couples have resulted in 7 live births, 1 ongoing pregnancy and 4 miscarriages (5/40, 6/40, 10/40 and 1 twin 17/40) after a median of 2.5 attempts (range 1–5). PrEP-C was well tolerated with no discontinuations and no HIV transmissions. These data suggest that PrEP-C is a safe and effective option for serodiscordant couples wishing to conceive; a standardised protocol has been developed; data collection via a central database is under way.     

Unprotected sex and associated risk factors among young Asian and Pacific Islander men who have sex with men.

Young Asian and Pacific Islander (API) men who have sex with men (MSM) are at high risk for HIV, but little is known about their risk behavior. We examined the patterns and predictors of unprotected anal intercourse among 253 API MSM aged 15-25 recruited from gay-identified venues in Seattle, Washington, and San Diego, California, from May to August 1999. Overall, 33% reported unprotected anal intercourse in the past 3 months. Multivariate analyses found that unprotected anal intercourse was associated with self-identifying as gay or bisexual, having multiple sexual partners, having sex with a steady partner, having been tested for HIV, and not perceiving peer norms supportive of safer sex. Young API MSM engage in unprotected sex at high rates. There is an urgent need to help these men reduce sexual risk behavior by implementing HIV prevention programs that address the issue of self-accepting sexual orientation, the potential problem with using HIV testing as a risk reduction strategy, the possible risk of HIV transmission in steady relationships and multiple sexual partnerships, and the importance of establishing safer sex practices as peer norms.     

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.     

HIV-1 discordant couples in Karnataka, South India: is the sex ratio of index cases changing?

India has an estimated 2.5 million HIV infections, most of which are heterosexually transmitted. Women comprise 40% of infected adults. In India, 90% of women between the ages of 15 and 45 years are married. Previous literature has suggested that sexual intercourse with an HIV-infected husband represents a married woman's greatest risk for being infected. However, a recent meta-analysis of discordant couples from sub-Saharan Africa reported that women were the index case in half of all couples. Similar data are not available from India. This cross-sectional study describes the epidemiology of 925 discordant couples from five districts in Karnataka province, one of the high HIV prevalence provinces in India. Men were the index case in 74% of couples. However, in young couples (where the index case was aged <30 years), women were more likely to be the infected partner (64% of couples). Condom use was reported by 46% of these discordant couples. These results suggest an emerging predominance of female index case infections among younger discordant couples in India, and point to the need for focusing HIV preventive messages on youth and couples before marriage.     

Strategies for Harm Reduction Among HIV-Affected Couples Who Want to Conceive

As effective HIV treatments become more widespread, HIV-infected individuals are living longer, healthier lives. Many HIV-affected couples (sero-discordant and sero-concordant) are considering options for safer reproduction. A large body of evidence suggests that reproductive technologies can help HIV-affected couples to safely conceive with minimal risk of HIV transmission to their partner. However, for most couples such technologies are neither geographically nor economically accessible. This paper addresses the options for safer procreation among HIV-affected couples who cannot access reproductive technologies.