Couples HIV testing and counselling prompts rapid switch to consistent condom use in South African study

HIV 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. 

In 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.

One 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%. 

Monthly 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.

“The 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 authors comment. 

Most HTC efforts are targeted to individuals so leading to missed HIV prevention opportunities.

In 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.

Estimates 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 94%.

For those without access to biomedical interventions, effective behavioural interventions (individual and couples' HTC) are critical for those in discordant relationships at risk for HIV.

While 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.

With 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.

Behavioural data from participants enrolled in three South African sites was analysed: Gugulethu, Orange Farm and Soweto.

The 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 days.

The 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.

Only 4% of HIV-positive participants reported recent relationship violence.

At 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 days.

At 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.

Over time the predicted probabilities of unprotected sex declined.

Among 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 and 14%.

The 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.

These findings are consistent with previous studies (in Africa) of the protective nature of couples' HTC for HIV-discordant couples and increased condom use.

However, this analysis, the authors note, is one of the first showing that condom use happens within the first week following couples' HTC.

Understanding 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”.

While 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.

They note that two aspects of their study design suggest unprotected sex was happening before HTC:

1. Once the newly tested had been aware of their HIV status for one month, they reported lower levels of unprotected sex.

2. The more time someone was unaware of their status, the more likely they were to report unprotected sex at baseline.

The authors advise caution in generalising these findings to other than stable relationships.

Most 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.

Their 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.

The 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 infections.”

Rosenberg NE et al. HIV testing and counselling leads to immediate consistent condom use among South African stable HIV-discordant couples. Advance online edition J Acquir Immun Defic Syndr, doi:10.1097/QAI.0b013e312827971ca, 2012.