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      Beyond HIV prevention: everyday life priorities and demand for PrEP among Ugandan HIV serodiscordant couples

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          Abstract

          Introduction

          Pre‐exposure prophylaxis (PrEP) to prevent HIV infection is being rolled out in Africa. The uptake of PrEP to date has varied across populations and locations. We seek to understand the drivers of demand for Pr EP through analysis of qualitative data collected in conjunction with a PrEP demonstration project involving East African HIV serodiscordant couples. Our goal was to inform demand creation by understanding what Pr EP means – beyond HIV prevention – for the lives of users.

          Methods

          The Partners Demonstration Project evaluated an integrated strategy of Pr EP and antiretroviral therapy (ART) delivery in which time‐limited Pr EP served as a “bridge” to long‐term ART. Uninfected partners in HIV serodiscordant couples were offered Pr EP at baseline and encouraged to discontinue once infected partners had taken ART for six months. We conducted 274 open‐ended interviews with 93 couples at two Ugandan research sites. Interviews took place one month after enrolment and at later points in the follow‐up period. Topics included are as follows: (1) discovery of serodiscordance; (2) decisions to accept/decline PrEP and/or ART; (3) PrEP and ART initiation; (4) experiences of using PrEP and ART; (5) PrEP discontinuation; (6) impact of PrEP and ART on the partnered relationship. Interviews were audio‐recorded and transcribed. We used an inductive, content analytic approach to characterize meanings of PrEP stemming from its effectiveness for HIV prevention. Relevant content was represented as descriptive categories.

          Results

          Discovery of HIV serodiscordance resulted in fear of HIV transmission for couples, which led to loss of sexual intimacy in committed relationships, and to abandonment of plans for children. As a result, partners became alienated from each other. Pr EP countered the threat to the relationship by reducing fear and reinstating hopes of having children together. Condom use worked against the re‐establishment of intimacy and closeness. By increasing couples’ sense of protection against HIV infection and raising the prospect of a return to “live sex” (sex without condoms), Pr EP was perceived by couples as solving the problem of serodiscordance and preserving committed relationships.

          Conclusions

          The most effective demand creation strategies for Pr EP may be those that address the everyday life priorities of potential users in addition to HIV prevention.

          Clinical Trial Number

          NCT02775929

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          Most cited references 21

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          What's love got to do with it? Explaining adherence to oral antiretroviral pre-exposure prophylaxis for HIV-serodiscordant couples.

          Adherence may be the "Achilles heel" of pre-exposure prophylaxis (PrEP), a promising biomedical approach to HIV prevention. This article presents an explanation of PrEP adherence for African serodiscordant couples derived from qualitative data. Explaining quantitative findings is one way qualitative investigation contributes to research in medicine and public health. This qualitative interview study was nested in the Partners PrEP Study, a phase III randomized trial evaluating oral tenofovir and emtricitabine/tenofovir PrEP to prevent HIV acquisition by HIV-uninfected partners in serodiscordant heterosexual couples. In-depth qualitative interviews were provided by 60 Partners PrEP Study participants in Uganda. Interviews used open-ended questions eliciting information on adherence experiences, barriers, and facilitators. An inductive approach informed by grounded theory methodology was used to analyze study data. The proposed explanation may be summarized as follows. Serodiscordance destabilizes couples, as the HIV-negative partner reacts with anger, fear, and sadness to the implication of infidelity represented by HIV infection. A "discordance dilemma" ensues, as the desire to avoid acquiring HIV and the advantages of preserving the relationship become competing priorities. PrEP is seen as a solution-a means of safeguarding health without ending the relationship. PrEP users benefit from the support of partners, who reinforce adherence. Where discord in the relationship persists, adherence suffers. PrEP adherence in serodiscordant couples may be understood as a function of the desire to reduce risk although preserving a partnered relationship. PrEP use in stable couples may be associated with improved adherence and thus, greater effectiveness.
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            The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda.

            Sixty percent of new HIV infections in Uganda occur in stable relationships between HIV discordant couples. Given the importance of fertility in Uganda, we hypothesized that unsafe sexual practices may be used to found a family/replace a dead child. Thus, we explored sexual practices to understand to what extent these are influenced by the desire to have children and the implications for HIV transmission among discordant couples. A cross-sectional survey of 114 HIV discordant couples in Kampala, and in-depth interviews with 15 purposively selected couples. Quantitative data were analysed using STATA. Multivariate logistic regression analysis done to identify factors associated with consistent condom use. Thematic content analysis of qualitative data was done using NVIVO 2. Participants wanting children and those with multiple sexual partners were less likely to use condoms (Adj OR 0.51, and 0.36 respectively). Three of the five types of sexual practices used by couples do not allow pregnancy to occur. Main reasons for wanting a child included: ensuring lineage continuity and posterity, securing relationships and pressure from relatives to reproduce. Challenges included: risk of HIV transmission to partner and child, lack of negotiating power for safer sex, failure of health systems to offer safe methods of reproduction HIV sero-discordant couples with strong desire for childbearing have a dilemma of risking HIV infection or infecting their spouse. Some risk transmission of HIV infection to reproduce. We need to address gender issues, risky behaviour and reproductive health services for HIV sero-discordant couples.
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              An empiric risk scoring tool for identifying high-risk heterosexual HIV-1-serodiscordant couples for targeted HIV-1 prevention.

              Heterosexual HIV-1-serodiscordant couples are increasingly recognized as an important source of new HIV-1 infections in sub-Saharan Africa. A simple risk assessment tool could be useful for identifying couples at highest risk for HIV-1 transmission. Using data from 3 prospective studies of HIV-1-serodiscordant couples from 7 African countries and standard methods for development of clinical prediction rules, the authors derived and validated a risk scoring tool developed from multivariate modeling and composed of key predictors for HIV-1 risk that could be measured in standard research and clinical settings. The final risk score included age of the HIV-1-uninfected partner, married and/or cohabiting partnership, number of children, unprotected sex, uncircumcised male HIV-1-uninfected partner, and plasma HIV-1 RNA in the HIV-1-infected partner. The maximum risk score was 12, scores ≥5 were associated with an annual HIV-1 incidence of >3%, and couples with a score ≥6 accounted for only 28% of the population but 67% of HIV-1 transmissions. The area under the curve for predictive ability of the score was 0.74 (95% confidence interval: 0.70 to 0.78). Internal and external validation showed similar predictive ability of the risk score, even when plasma viral load was excluded from the risk score. A discrete combination of clinical and behavioral characteristics defines highest risk HIV-1-serodiscordant couples. Discriminating highest risk couples for HIV-1 prevention programs and clinical trials using a validated risk score could improve research efficiency and maximize the impact of prevention strategies for reducing HIV-1 transmission.
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                Author and article information

                Contributors
                norma_ware@hms.harvard.edu
                Journal
                J Int AIDS Soc
                J Int AIDS Soc
                10.1002/(ISSN)1758-2652
                JIA2
                Journal of the International AIDS Society
                John Wiley and Sons Inc. (Hoboken )
                1758-2652
                18 January 2019
                January 2019
                : 22
                : 1 ( doiID: 10.1002/jia2.2019.22.issue-1 )
                Affiliations
                [ 1 ] Department of Epidemiology and Biostatistics Makerere University College of Health Sciences Kampala Uganda
                [ 2 ] STD Clinic/Ward 12 Mulago Hospital Kampala Uganda
                [ 3 ] Department of Global Health and Social Medicine Harvard Medical School Boston MA USA
                [ 4 ] Harvard Global Cambridge MA USA
                [ 5 ] Infectious Diseases Institute Makerere University Kampala Uganda
                [ 6 ] Kabwohe Clinical Research Centre Kabwohe Uganda
                [ 7 ] Departments of Global Health, Medicine, and Epidemiology School of Medicine and School of Public Health University of Washington Seattle WA USA
                [ 8 ] Department of Medicine Makerere University Kampala Uganda
                [ 9 ] Department of Medicine Brigham & Women's Hospital Boston MA USA
                Author notes
                [* ] Corresponding author: Norma C Ware, Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, Massachusetts, USA. Tel: 1 617 432‐2554. ( norma_ware@ 123456hms.harvard.edu )
                [†]

                These authors have contributed equally to the manuscript.

                Article
                JIA225225
                10.1002/jia2.25225
                6338102
                30657642
                © 2019 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 0, Tables: 2, Pages: 8, Words: 7352
                Product
                Funding
                Funded by: US National Institutes of Health
                Award ID: R01 MH101027
                Funded by: National Institute of Mental Health of the US National Institutes of Health
                Award ID: R01 MH095507
                Funded by: Bill & Melinda Gates Foundation
                Award ID: OPP1056051
                Funded by: US Agency for International Development
                Award ID: AID‐OAA‐A‐12‐00023
                Categories
                Research Article
                Research Articles
                Custom metadata
                2.0
                jia225225
                January 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.5.6 mode:remove_FC converted:18.01.2019

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