Counselling for HIV sero-discordant couples can achieve significant reductions in sexual risk behaviour, according to the results of a Ugandan study. The prospective study involved 586 sero-discordant couples where both members were aware of their partner’s HIV infection status. Every three months, the couples receive risk reduction counselling. Condom use increased, and male partners report reductions in the number of concurrent sexual relationships.
“We demonstrated that a couples counselling intervention among mutually disclosed sero-discordant couples may be effective at increasing the proportion of couples who reported using condoms with primary and secondary partners, reducing the number of sexual partners and increasing knowledge of participants’ sexual partners serostatus,” write the investigators. “Additionally, we’d like to emphasise that these changes in behaviour did not wane over the project period.”
HIV sero-discordant couples are a major source of new infections in sub-Saharan Africa. Incidence rates among the uninfected partner can be as high as 25 per 100 person-years. There is therefore an urgent need for interventions to reduce transmission rates in sero-discordant couples.
Investigators from the Highly Active Antiretroviral therapy as Prevention (HAARP) study wanted to see that couples counselling was associated with reductions in key measures of HIV risk among sero-discordant couples. Participants were enrolled between 2009 and 2011. Every three months, the couples were provided with risk-reduction counselling. Condoms were supplied on a regular basis. The counselling was provided as part of routine care at a rural clinic.
Study outcomes were: Condom use at last sex with primary partner; number of non-primary sexual partners in the previous three months; knowledge of HIV infection status of non-primary sexual partners; and condom use at last sex with a non-primary partner.
Results were stratified according to ART use (on ART at start of study; started ART during follow-up; never received ART) and gender. Participants were followed for up to 24 months. In 44% of couples it was the female member who was HIV infected. There were 17 new HIV infections during 778 person-years of follow-up, an incidence of 2.18 per 100 person-years. The median duration of follow-up was 17 months.
Reported condom use at last sex with primary partners increased across the study population, regardless of ART use: ART at enrollment – 76% at baseline, 92% at 12 months, 89% at 24 months; started ART during study – 69% at baseline, 90% at 12 months, 93% at 24 months; no ART – 67% at enrollment, 93% at 12 months, 97% at 24 months; the proportion of individuals reporting a non-primary partner was low at enrollment (3-4%) and declined during follow-up (0-1.6% at month 24); knowledge of the HIV infection status of non-primary partners was already high at baseline (63-79%) and increased to 100% for all three ART groups at month 24; condom use with a non-primary partner was reported by between 45-66% of participants at enrollment. This increased to 50-88% by month 24, and the increase was significant for patients in the group where ART was never used (p = 0.04); analysis of results by gender showed that condom use with a primary partner increased from 71% at baseline to 92% at month 24 among men and from 73% at enrollment to 94% at the end of the study for women; there was a significant decrease in the proportion of men reporting a non-primary partner, from 7% at baseline to 1.5% at month 24; the proportion of women reporting a non-primary partner was low at enrollment (0.9%) and had fallen to zero by month 18; and knowledge of the HIV infection status of non-primary partners increased for men (71% at baseline, 93% at month 24).
The proportion of men reporting condom use with a non-primary partner increased during the study (43% at enrollment, 64% by the end of the study). Numbers were too low to perform similar analyses for women.
Both HIV-positive and HIV-negative partners reported increased condom use over time (p < 0.001). There was also a decline in the proportion of HIV-positive and HIV-negative participants reporting sex with a non-primary partner. Knowledge of the HIV status of non-primary partners increased for both HIV-positive and HIV-negative study members. The proportion of HIV-positive participants reporting condom use with a non-primary partner increased from 71% at baseline to 100% at month 24; the corresponding rates for HIV-negative participants were 68% at enrollment and 80% at the end of the study.
“We found that quarterly couples counselling sessions with sero-discordant couples as part of a study of ART and prevention…showed increases in reported condom-use for both men and women,” conclude the authors. “In this setting, where concurrent sexual partners among the general population are relatively common, widespread implementation of such counselling could result in significant reductions in HIV incidence at population level.”
We examined several measures of self-reported HIV risk behaviour in mutually disclosed sero-discordant couples over time to see if a couples counselling intervention was associated with changes in these behaviors.
We analysed data from a prospective cohort study of HIV sero-discordant couples in Jinja, Uganda collected between June 2009 and December 2011. Participants received couples counselling, at 3-monthly intervals. We examined trends in reported condom-use, number of concurrent sexual partners, knowledge of HIV serostatus of concurrent partners and condom use of concurrent partners using Generalized Estimating Equation models, comparing responses at study enrollment with responses at six, 12 18 and 24 months of follow-up.
A total of 586 couples were enrolled and the female member was HIV positive in 255 (44%) of them. The median age for female participants was 35 years and 42 years for men. Reported condom use at last sex with spouse increased over time (p<0.001) with the largest increases found among couples where the positive participant never received ART during the study(an increase from 68.8% at enrollment to 97.1% at 24 months). Male participants reported reductions in the number of concurrent sexual partners (p<0.001), increase in the knowledge of the HIV serostatus of these partners (p = 0.001) and a trend towards improved condom-use among non-primary partners (p = 0.070). Reported reduced risky behaviors did not wane over the study period.
Couples counselling resulted in increased condom use among all participants and among men the intervention resulted in reductions in risk behaviour with concurrent sexual partners. Routine counselling for serodiscordant couples should be integrated in routine ART care programs.