testing and counselling of couples quickly led to consistent condom use among
serodiscordant couples in stable relationships in South Africa, researchers report in
the advance online edition of the Journal
of Acquired Immune Deficiency Syndromes.
this secondary analysis of self-reported behavioural data of 508 HIV-infected
participants recruited into the Partners in Prevention study (aciclovir as
secondary prophylaxis in HIV/HSV-2 co-infected people to prevent HIV
transmission to their HIV-negative partner), 71% of those just learning their
HIV status reported unprotected sex, compared to a quarter who knew their
status for the full month.
month later, when all had had couples' HIV testing and counselling (HTC), and so
were aware of their discordant relationship, the proportion of those having
unprotected sex fell dramatically, from 71 to 8%.
counselling for the HIV-infected partner, quarterly individual or couples' HTC
for the uninfected partner, and condom provision for both resulted in these low
levels of unprotected sex being maintained at the end of one year.
finding that mutual awareness is more protective than individual awareness is
complemented by findings from the full trial: HIV-uninfected participants
reported less frequent unprotected sex with study partners, whose HIV status
was known, than with outside partners, whose HIV status was often unknown,” the
HTC efforts are targeted to individuals so leading to missed HIV prevention
stable HIV-discordant relationships the uninfected partner is at continued risk
of getting HIV. Biomedical
interventions (such as antiretroviral treatment [ART] taken by the infected partner or
pre-exposure prophylaxis [PrEP] by the uninfected partner) can significantly
reduce the risks of transmission. However,
in many settings the infected partner may not be eligible for ART and/or PREP
is not yet available.
of the proportion of the estimated annual incidence of 1.8 million new
infections in sub-Saharan Africa attributable
to unprotected sex within stable HIV-discordant partnerships range from 14 to
those without access to biomedical interventions, effective behavioural
interventions (individual and couples' HTC) are critical for those in discordant
relationships at risk for HIV.
couples' HTC is linked to increased condom uptake compared to individual HTC,
the timing of uptake and whether those engaging in unprotected sex engage in
fewer acts are poorly understood.
this in mind, the authors chose to look at whether HTC with ongoing counselling
and condom distribution would lead to reduced unprotected sex in serodiscordant
couples in stable relationships.
data from participants enrolled in three South African sites was analysed: Gugulethu, Orange
Farm and Soweto.
primary factor of interest was the timing of HTC for the HIV-positive participant. At baseline, the HIV-positive participant reported the date of
their first HIV-positive test. This date was subtracted from the baseline date
to determine the number of days since HTC: 0 to 7, 8 to 14, 15 to 30 or more than 30
primary outcome was unprotected sex self-reported by the HIV-positive participant. Predicted probabilities of unprotected sex in the last month were
calculated at baseline, at month one and month twelve.
HIV-positive participants were predominantly female (77%) with a mean age of 33 years. Most
(82%) had at least one child and few (4%) reported having had more than one
partner in the last month. Over 60% were married or cohabiting and 79% had been
together for more than one year.
4% of HIV-positive participants reported recent relationship violence.
baseline, 13, 26, 11 and 50% of HIV-positive participants were tested at less
than seven, 8 to 14,15 to 30 and more than 30 days, respectively, before baseline.
Newly tested is defined as 30 days and under; previously tested as over 30
baseline, the proportions of HIV-positive participants reporting more than one
sex act in the last month with their study partner
among new and previously tested were 94.1 and 96.1%, (p=0.3) respectively; at one month and at twelve
months after baseline 87.9 and 89.1% (p=0.7) and 73.6 and 78.2% (p=0.3),
respectively, reported sexual activity.
time the predicted probabilities of unprotected sex declined.
the new and previously tested, at baseline, the proportion reporting unprotected
sex in the last month was 53% compared to 25%, at one month the proportions
decreased to 9 and 13% respectively; and at one year the proportions were 6
mean numbers of unprotected sex acts among the new and previously tested were 8
and 6, 8 and 7, and 6 and 6 at baseline, one month and one year, respectively.
findings are consistent with previous studies (in Africa)
of the protective nature of couples' HTC for HIV-discordant couples and
increased condom use.
this analysis, the authors note, is one of the first showing that condom use
happens within the first week following couples' HTC.
the effectiveness of HTC in a time of rapid scale-up is critical. HTC cannot be
evaluated in a randomised trial because not providing HTC is unethical, the
authors note. So this trial “provided an opportunity to address the impact of
couples HTC on HIV prevention in an ethical, rigorous way”.
the authors knew the exact time when HIV status was learned, they only knew of
sexual behaviour within a one-month interval. So the timing of HTC and sexual
behaviour among the newly tested is unclear.
note that two aspects of their study design suggest unprotected sex was happening
Once the newly tested had been aware of their HIV status for one
month, they reported lower levels of unprotected sex.
The more time
someone was unaware of their status, the more likely they were to report
unprotected sex at baseline.
authors advise caution in generalising these findings to other than stable
of the couples were in long-term relationships with minimal levels of intimate
partner violence. The authors suggest that looking at couples' HTC within less
stable as well as more violent relationships warrants study.
findings lend support to strategies recently recommended in the World Health
Organization’s Guidance on Couples HIV
Testing and Counselling including home-based testing, supportive
HIV-disclosure counselling and partner notification.
authors conclude that their findings “add to a growing body of evidence
demonstrating that couples HTC is effective at rapidly increasing condom
uptake, facilitating on-going condom use and lowering rates of HIV
transmission…With expanding HTC capacity in Africa, decision-makers need to
consider how to reach couples. Such expansion will help a high risk group make
informed sexual health decisions and likely prevent a substantial number of HIV