Home-based, voluntary counselling and testing has found that over 2% of cohabiting couples in the Bushenyi region of Uganda are serodiscordant for HIV. The men in these partnerships are more likely than the women to be HIV-positive, and condom use in these couples is very low, according to a presentation to the Fifteenth Conference on Retroviruses and Opportunistic Infections in Boston on Wednesday.
Many of Africa's voluntary counselling and testing (VCT) programmes are urban-based and do not reach all of the people who would like to be tested. Home-based VCT programmes are a growing model in which trained counsellors offer VCT to people in their own homes. Such home-based programmes have been extremely successful, with upwards of 95% of individuals accepting VCT in some studies. Such programmes serve all household members including adults and children, and also serve as an entry point for care, support, and prevention efforts.
In 2004, Uganda's Integrated Community Based Initiatives (ICOBI) was funded by the US Centers for Disease Control Global AIDS Program to deliver home-based VCT to 250,000 residents of Uganda's rural Bushenyi District over a period of two years. ICOBI's Stephen Asiimwe reported to CROI on the activities of this project, particularly with regard to serodiscordant couples (those in which only one partner is HIV-positive).
Bushenyi is a region in southwest Uganda with a population of approximately 800,000 people and just under 143,000 households. Twenty-nine outreach teams, each including a counselor and a laboratory assistant, moved from home to home through this area. Rapid HIV testing with pre- and post-test counselling was available for all residents 15 years of age or over, and basic care, including ART eligibility assessment, available for those who tested positive.
A total of 296,431 individuals were eligible for testing, of whom 264,966 (89%) were tested and all but 13 received their results. The median age of the individuals tested was 26 years, 47% were male, and 52% were married or cohabiting. There were 11,359 (4.3%) HIV-positive results overall; HIV was more prevalent in women tested (5.2%) than in men (3.4%).
Serodiscordant couples
A total of 35,833 couples received VCT. While both partners were HIV-negative in 95% and both were HIV-positive in 1.6%, there were 925 (2.6%) serodiscordant couples. Serodiscordant couples represented 61.6% of the couples in which one or both partners were HIV-positive.
A total of 1,785 individuals were involved in serodiscordant relationships – 860 men and 925 women (65 of the men were involved in more than one relationship, which could include both concordant and discordant relationships). HIV prevalence rates were considerably higher in men (55.4%) than in women (33.0%) in serodiscordant relationships.
Eight hundred and eighty individuals in discordant relationships reported sexual activity in the past three months. Among these, the women were much younger, with a median age of 30 years versus 40 years for men. Condoms were very rarely used: 94% reported never using condoms, and over 96% of both men and women did not use condoms in their last sexual encounter.
The presentation concluded by noting that universal, home-based VCT has had extremely high uptake, and has been very successful at identifying HIV-positive individuals and couples with mixed HIV status in this rural area of Uganda. Such discordant partnerships are relatively frequent, with males more often HIV-positive than women. Condom use between these couples is extremely low, and prevention strategies need to be promoted to protect the uninfected partners in these high-risk partnerships.
Tumwesigye E et al. High HIV prevalence among males in discordant partnerships in a full access door-to-door VCT programme in rural Uganda. Fifteenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 129LB, 2008.