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.     

Risk factors for HIV transmission among heterosexual discordant couples in South India*

Objective

To assess the risk factors associated with heterosexual HIV transmission among South Indian discordant couples enrolled in clinical care.

Methods

A nested matched case–control study of serodiscordant couples in which the HIV‐infected partner (index case) was enrolled in care. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV‐1 RNA loads were measured at enrolment and longitudinally over 12 months of follow‐up. The study included 70 cases who seroconverted during study follow‐up and 167 matched controls who remained persistently serodiscordant.

Results

The incidence of HIV infection among the initially seronegative partners was 6.52 per 100 person‐years. Persistently discordant patients were more likely to have initiated highly active antiretroviral therapy (HAART) than patients in seroconverting relationships (62.9%vs. 42.9%) (P=0.001). Patients in seroconverting relationships had significantly higher plasma viral loads (PVLs) than patients in discordant relationships at enrolment, at 6 months and at 12 months (P<0.05). Patients in seroconverting relationships were less likely to use condoms with their primary partners than patients in discordant relationships (P<0.05). Patients in relationships that seroconverted between 6 and 12 months were diagnosed more often with genital Herpes simplex than patients in discordant relationships (P=0.001). In the univariate and multivariate logistic regression, the following variables were associated with seroconversion: PVL >100 000 [odds ratio (OR): 1.82; 95% confidence interval (CI): 1.1–2.8], non‐disclosure of HIV status (OR: 5.5; 95% CI: 4.3–6.2) and not using condoms (OR: 2.8; 95% CI: 2.4–3.6).

Conclusions

Couples‐based intervention models are crucial in preventing HIV transmission to seronegative spouses. Providing early treatment for sexually transmitted infections, HAART and enhancing condom use and disclosure could potentially decrease the risk of HIV transmission within Indian married couples.

     

Low uptake of HIV testing and no HIV positivity in stable serodiscordant heterosexual partners of long-term treated HIV-infected Thais

The objective of this study was to characterize HIV-serodiscordant heterosexual couples and to evaluate acceptance for HIV testing and HIV prevalence in nonindex partners. We conducted a cross-sectional study with quantitative and qualitative components. Two cohorts of 1767 HIV-positive people were screened to identify heterosexual HIV-serodiscordant couples. HIV-positive partners (index) were administered a questionnaire; CD4, viral load (VL), and antiretroviral therapy (ART) history were gathered from clinical records. HIV-negative/unknown status partners (nonindex) were invited for a similar questionnaire and HIV testing. In-depth interviews with three HIV-serodiscordant couples were conducted. Two hundred and ninety-seven index partners agreed to enroll in this study. The median duration of the relationship was 10 years, and 81% were sexually active. All but two index partners were on ART, and 98% had VL < 1000 copies/mL. Only 111 (37%) nonindex partners came for HIV testing, and all of them tested HIV-negative. In addition, only 41% of nonindex partners had HIV testing in the last one year. The main reasons for the nonindex partners not to come for HIV testing were “no interest” (n = 117, 63%) and “nondisclosure of HIV status” (n = 46, 25%). The latter was substantiated and explained by the qualitative outcome of this study, suggesting relation to stigma against HIV-positive people. Our results support the WHO recommendation for starting ART for treatment and prevention in HIV-serodiscordant couples at any CD4 count. Furthermore, we recommend the dissemination of data showing that no HIV transmission in heterosexual couples through sex practice has been observed provided VL is suppressed. This could be a powerful tool for effective fight against stigma and self-stigma in people living with HIV.     

Maximizing the impact of HIV prevention efforts: Interventions for couples

Despite efforts to increase access to HIV testing and counseling services, population coverage remains low. As a result, many people in sub-Saharan Africa do not know their own HIV status or the status of their sex partner(s). Recent evidence, however, indicates that as many as half of HIV-positive individuals in ongoing sexual relationships have an HIV-negative partner and that a significant proportion of new HIV infections in generalized epidemics occur within serodiscordant couples. Integrating couples HIV testing and counseling (CHTC) into routine clinic- and community-based services can significantly increase the number of couples where the status of both partners is known. Offering couples a set of evidence-based interventions once their HIV status has been determined can significantly reduce HIV incidence within couples and if implemented with sufficient scale and coverage, potentially reduce population-level HIV incidence as well. This article describes these interventions and their potential benefits.     

High HIV prevalence predicts less HIV stigma: a cross-national investigation

Despite substantial global efforts to reduce HIV-related stigma, stigma and discrimination remain widespread and are among the most poorly understood aspects of the epidemic. However, there has been little research on whether HIV stigma in a country is associated with HIV prevalence. This article offers a socioecological perspective for understanding HIV stigma in a context of HIV prevalence. Using two international data sets (the UNAIDS 2009 HIV Epidemiological Report and the World Values Survey), we investigated whether and how HIV prevalence is associated with individual- and country-level HIV stigma. Results showed that in countries with higher HIV prevalence, people reported less HIV stigma (Studies 1 & 2). HIV knowledge mediated the relationship between HIV prevalence and stigma (Study 2). People in countries with higher HIV prevalence reported more knowledge about HIV transmission, which reduced their stigmatizing attitudes. These findings suggest that stigma-reduction programs should incorporate a socioecological perspective and consider the roles of prevalence rate of and knowledge of the disease.     

HIV/AIDS in China: 1990–2001

China is facing a major crisis because of the increasing epidemics of HIV/AIDS and other sexually transmitted diseases (STDs). The purpose of this paper is to enhance understanding of the crisis by analyzing the capacity of China's health care system, its governmental HIV/AIDS policies, and the published literature on the epidemiology of HIV/AIDS during the period 1990–2001. HIV/AIDS and other STDs are rapidly increasing. The situation is urgent and requires comprehensive preventive actions. China's health care system is decentralized and underfunded, and access to treatment by the poor is seriously limited. There is a lag in public knowledge and in knowledge among health care workers about HIV/AIDS. The HIV/AIDS epidemic emerged initially in rural areas by means of intravenous drug use. Paid blood donors and blood recipients account for a significant portion of the persons infected by the HIV virus, especially in rural areas. Sexual risk behaviors in rural and urban areas are of increasing importance as a method of transmission of the virus.     

Examining the health and health service utilization of heterosexual men with HIV: a community-informed scoping review

The prevalence of HIV infection among heterosexual men has increased. Consequently, the need for health and support services for this group is likely to increase. We conducted a scoping review of studies regarding the health and health service use of heterosexual men with HIV that was informed by research priorities identified by this community. We searched six databases from inception to August 2014. We included all English-language qualitative and quantitative studies examining the health and health service use of heterosexual men with HIV. Our search strategy yielded 2665 references, of which 70 were included in the scoping review. We summarized the research into the following domains identified by summit participants: treatment of HIV and its complications (n?=?9), health and social support services utilization (n?=?27), social determinants of health (n?=?20), prevention (n?=?11), family planning (n?=?4) and psychosocial research (n?=?33). Key findings from the review included poor mental health-related well-being, over-representation among “late presenters” to care and greater fear of disclosure of HIV status relative to men who have sex with men. In general, research conducted to date was not well aligned with the priorities identified by the community.     

2012年河南省驻马店市HIV单阳家庭阴性配偶阳转情况及其影响因素分析

目的了解2012年河南省驻马店市艾滋病病毒（HIV）单阳家庭中,HIV阴性配偶的阳转情况及其影响因素。方法2012年7—12月,对河南省驻马店市单阳家庭进行横断面调查,收集HIV单阳家庭的基本信息、配偶间性行为信息、原阳者的治疗信息、CD4＋T淋巴细胞计数等,并对阴性配偶进行采血检测其HIV抗体阳转情况。结果共随访单阳家庭3850户,阴性配偶3850人,其中HIV抗体阳转17人,2012年驻马店市单阳家庭阴性配偶的HIV阳转率为0．44％。按原阳者性别分层,分别得到原阳者为男性的女性配偶阳转的危险因素为：近一年夫妻性生活不坚持使用安全套[比值比（OR）=31．176,95％可信区间（CI）：6．617-146．884,P〈0．0001]。原阳者为女性的男性配偶阳转的危险因素为：近一年夫妻性生活不坚持使用安全套（OR=37．859,95％CI：10．058～142．504,P〈0．0001）,近一年夫妻性生活频次〉2次／月（OR=5．875,95％CI：1．200～28．771,P=0．0289）,最近一次CD4＋T淋巴细胞计数≤350个／μL（OR=5．983,95％CI：1．213～29．503,P=0．0280）。综合来看,家庭内配偶间HIV传播的影响因素为：近一年夫妻性生活不坚持使用安全套（OR=32．557,95％CI：11．772-90．042,P〈0．0001）,近一年夫妻性生活频次〉2次／月（OR=5．630,95％CI：1．775-17．854,P=0．0033）,最近一次CD4＋T淋巴细胞计数≤350个／μL（OR=4．895,95％CI：1．536-15．606,P=0．0073）。结论驻马店市HIV单阳家庭阴性配偶阳转率较低,仍需要加强安全套的宣传以及CD4＋T淋巴细胞计数和病毒载量的检测工作。     

A review of interprovincial variations in HIV prevalence rates in Zimbabwe

Despite the proven remarkable decline of HIV prevalence in the sub-Saharan Africa region, both sub-regional and within-country disparities in HIV prevalence persist. This paper is a survey of literature on HIV prevalence and spread in Zimbabwe, focusing on provincial differences within the national picture of a decline in new infections. In particular, it raises the question of why prevalence and infection rates seem to be disproportionately higher in Matabeleland relative to other provinces of the country. This disparity cannot be adequately explained on the basis of national behavioural analyses as has been the case. The paper suggests possible additional nuances in the forms of analysis and proposes a change of focus in HIV-prevention strategies from national level to provincial considerations of the multiple factors influencing variations in HIV infection rates at provincial level. Using the different contextual conditions between provinces as a way to examine what might be the additional significant variables, the paper brings variations that go beyond sexual behaviour.     

Dropout from physical activity interventions in people living with HIV: a systematic review and meta-analysis

Physical activity (PA) interventions have been shown to improve the health of people living with HIV (PLWH), yet treatment dropout poses an important challenge. We conducted a meta-analysis to investigate the prevalence and predictors of treatment dropout in PA interventions in PLWH. Electronic databases were searched for records up to September 2016. Randomized control trials of PA interventions in PLWH reporting dropout rates were included. Random effects meta-analysis and meta-regression analyses were employed. In 36 studies involving 49 PA intervention arms, 1128 PLWH were included (mean age?=?41.6 years; 79.3% male; 39% White). The trim and fill adjusted treatment dropout rate was 29.3% (95% CI?=?24.5–34.7%). There was a significant lower dropout rate in resistance training interventions compared with aerobic (p?=?0.003) PA interventions, in studies utilizing supervised interventions throughout the study period (p?p?β?=?1.15, standard error (SE)?=?0.49, z?=?2.0, p?=?0.048), a lower body mass index(BMI) (β?=?0.14, SE?=?0.06, z?=?2.16, p?=?0.03), and a lower cardiorespiratory fitness (β?=?0.10, SE?=?0.04, z?=?2.7, p?=?0.006). The dropout from PA interventions is much higher in PLWH than in many other populations with chronic morbidities. Qualified professionals (i.e., exercise physiologists, physical educators, or physical therapists) should be incorporated as key care providers in the multidisciplinary care of HIV/AIDS and should prescribe supervised PA for PLWH in order to enhance adherence and reduce the burden of HIV/AIDS. Special attention should be given men, those with a higher BMI, and those with a lower cardiorespiratory fitness.     

Rapid point-of-care HIV testing in pregnant women: a systematic review and meta-analysis

Rapid, point-of-care human immunodeficiency virus (HIV) testing has the potential to enhance strategies to prevent mother-to-child transmission (MTCT) of HIV infection. Rapid tests need minimal laboratory infrastructure and can be performed by health workers with minimal training. In our systematic review and meta-analysis, we aimed to summarize the overall diagnostic accuracy of rapid HIV tests in pregnancy, and outcomes such as acceptability, patient preference, feasibility and impact of rapid testing. We searched four major databases, identified and screened 1377 citations, and included 17 studies that met our eligibility criteria. Analyses of these studies suggested that the overall sensitivity and specificity of blood-based rapid tests was high compared with oral rapid tests. A two-step testing strategy, particularly parallel testing, was found to be superior to single-test strategy in labour and delivery settings. Acceptability of rapid tests and patient preference was variable across studies. Overall, rapid HIV testing was highly accurate compared with conventional tests and offer a clear advantage of enabling the implementation of timely interventions to reduce MTCT of HIV. To improve diagnostic accuracy and to reduce false-positive results, it may be necessary to use two rapid tests during labour and delivery.     

Gender inequality and the risk of HIV among married couples in North India

This study investigated the distribution and determinants of HIV risks among married couples in North India. Gender inequality emerged as a potential driver of HIV risks in this region. Data collection took place in 2003 in a probability survey of 3385 couples living in India's most populous state – Uttar Pradesh – and Uttaranchal. Couples' analyses utilizing generalized estimating equations showed that compared with husbands, wives were less knowledgeable about HIV (OR = 0.31, 95% CI = 0.27–0.36), more likely to consider themselves at risk for infection (OR = 6.86, 95% CI = 4.65–10.13), and less likely to feel that a wife had the right to refuse sex with her husband (OR = 0.50, 95% CI = 0.44–0.58). The proportion of husbands reporting non-marital sex in the past year was 7.1% and transactional sex in the past year, 2.2%. Among their wives, 73.4% were unaware of their husbands' non-marital sexual behaviors and only 28.9% of husbands reported condom use during their last non-marital sexual encounter. Logistic regression analyses showed that husbands' alcohol use, husbands' mobility, and urban residence were positively associated with husbands' non-marital sexual behaviors adjusting for other covariates. The data demonstrate that HIV prevention programs among couples in North India should consider both sexual risks and gender inequalities which potentially fuel HIV spread in this region.     

Pilot evaluation of the Making Employment Needs [MEN] Count intervention: Addressing behavioral and structural HIV risks in heterosexual Black men

Few community-based HIV interventions exist for Black men at heterosexual risk for HIV. None focus on structural HIV risks such as unemployment and unstable housing. This study involved a pilot evaluation of the MEN (Making Employment Needs) Count HIV intervention, a three session peer counselor-delivered program of HIV risk reduction and gender-equity counseling, and employment and housing case management. A single-arm intervention trial of MEN Count was conducted with Black men recruited from a community men's clinic and social services program. Eligible men were those who reported two or more sex partners in the past six months and current unemployment and/or recent homelessness. Most participants (68%) had a history of incarceration. Participants (N = 50) were surveyed on outcomes at baseline (Time 1), posttest (Time 2; 60–90 days after baseline), and two-month follow-up (Time 3). The majority of participants were retained in the program (86%) and the final follow-up survey (76%). McNemar tests revealed significant reductions in the past 30-day unprotected sex from Time 1 (74%) to Time 2 (47%) and to Time 3 (47%), and in homelessness from Time 1 (58%) to Time 3 (32%). Significant increases in employment from Time 1 (8%) to Time 2 (29%) and Time 3 (32%) were also seen. Participants completed a brief participant satisfaction survey at posttest. Most (n=28, 65%) rated the program as excellent, and an additional 10 (23%) rated it as good. Although there was no significant reduction in multiple sex partners, a trend was observed from Time 1 (56%) to Time 2 (44%) and Time 3 (42%). Findings suggest that the MEN Count model is a feasible and promising HIV prevention program for Black men at heterosexual risk for HIV. Larger scale implementation and more rigorous evaluation of MEN Count are needed to confirm the study findings.     

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.     

云南省德宏州2010年婚检人群的HIV感染率及其影响因素

目的了解云南省德宏州2010年婚检人群的艾滋病病毒(HIV)感染状况及其影响因素。方法利用德宏州2010年参加婚前体检人群的婚检资料,对该人群HIV感染率及相关因素进行分析。结果 23 223名婚前体检者HIV感染率为0.78%(180人),其中HIV单阳性比例为70.0%;83.3%(150/180)是通过异性性行为感染。婚检人群中有56.1%(13 025人)有婚前性行为,11.9%(1 340人)的女性婚检者已怀孕。Logistic多因素回归分析显示:HIV感染率为有吸毒行为者高于无吸毒行为者,25岁以上者高于25岁以下者,无业者高于农民,缅甸籍高于国内者。结论 2010年德宏州婚检人群的HIV感染率仍较高,吸毒、高年龄、无业与缅甸籍等因素与HIV感染有关。婚前检查作为发现HIV感染者及控制HIV传播的有效手段之一,应该在艾滋病流行地区大力推广。     

Sex practice correlates of human immunodeficiency virus transmission and acquired immunodeficiency syndrome incidence in heterosexual partners and offspring of U.S. hemophilic men

We assessed the risk of human immunodeficiency virus (HIV) transmission from heterosexual seropositive hemophilic men to their female sex partners through an HIV serosurvey and questionnaire study conducted during 1984-1987. Five percent of 21 female partners of asymptomatic men and 11% of 35 partners of HIV-symptomatic (acquired immunodeficiency syndrome [AIDS], AIDS-related complex [ARC], peripheral generalized lymphadenopathy [PGL]) hemophilic men had been infected when first tested. One of 19 seronegative women tested about 1 year later reportedly seroconverted. Only 18% of a sample of the serosurvey women responding to sex practices questions said their partners used condoms "nearly always." Over 60% engaged in oral/genital sex in addition to vaginal intercourse. Only 12% of still-seronegative women followed the preventive strategy of consistent avoidance of oral/genital sex, together with consistent condom use by the male partner. Further evidence for heterosexual transmission comes from the CDC national AIDS surveillance reports showing 25 women who acquired HIV infection through heterosexual contact with U.S. hemophilic men (September 6, 1988). Seven (28%) were diagnosed and reported in the first 6 months of 1988. Their ages range from 20 years to more than 70 years. The dates of infection for the women are unknown but must have been at least 5 years before AIDS diagnosis for at least one. Only approximately 30% of their male partners had already manifested any HIV-associated illness. Through May 18, 1988, six cases of AIDS have occurred in children whose infection was acquired through exposure of the mother to a hemophilic partner. Four were diagnosed in latter 1987. The median age at diagnosis was 4.5 months. Four had died. None of their mothers is as yet diagnosed.     

Cognitive impairment in HIV and HCV co-infected patients: a systematic review and meta-analysis

Cognitive impairment has been well documented in human immunodeficiency virus (HIV) and hepatitis C virus (HCV) mono-infections. However, in the context of HIV/HCV co-infection the research is more limited. The aim of this systematic review was to describe the characteristics of cognitive impairment in HIV/HCV co-infection and to examine the differences in cognitive performance between HIV/HCV and HIV and HCV mono-infected patients. Of the 437 records initially screened, 24 papers met the inclusion criteria and were included in the systematic review. Four studies were included in the meta-analysis. Most studies indicated that HIV/HCV co-infected patients had a higher level of cognitive impairment than HIV mono-infected patients. Meta-analysis also indicated that HIV mono-infected patients had a significantly lower global deficit score than co-infected patients. The results also indicated that co-infected patients were more likely to be impaired in information processing speed than HIV mono-infected patients. These findings can be challenged by biasing factors such as the small number of included studies, heterogeneity of the samples and a large diversity of methodological procedures. Future research with consistent and comprehensive neuropsychological batteries and covering a greater diversity of risk factors is needed, in order to clarify the effects of both viruses on cognitive function and the mechanisms that underlie these effects. Because cognitive impairments may pose significant challenges to medication adherence, quality of life and overall functioning, such knowledge may have important implications to the planning and implementation of effective interventions aimed at optimising the clinical management of these infections.