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      Regional Differences in Prevalence of HIV-1 Discordance in Africa and Enrollment of HIV-1 Discordant Couples into an HIV-1 Prevention Trial

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          Abstract

          Background

          Most HIV-1 transmission in Africa occurs among HIV-1-discordant couples (one partner HIV-1 infected and one uninfected) who are unaware of their discordant HIV-1 serostatus. Given the high HIV-1 incidence among HIV-1 discordant couples and to assess efficacy of interventions for reducing HIV-1 transmission, HIV-1 discordant couples represent a critical target population for HIV-1 prevention interventions and prevention trials. Substantial regional differences exist in HIV-1 prevalence in Africa, but regional differences in HIV-1 discordance among African couples, has not previously been reported.

          Methodology/Principal Findings

          The Partners in Prevention HSV-2/HIV-1 Transmission Trial (“Partners HSV-2 Study”), the first large HIV-1 prevention trial in Africa involving HIV-1 discordant couples, completed enrollment in May 2007. Partners HSV-2 Study recruitment data from 12 sites from East and Southern Africa were used to assess HIV-1 discordance among couples accessing couples HIV-1 counseling and testing, and to correlate with enrollment of HIV-1 discordant couples. HIV-1 discordance at Partners HSV-2 Study sites ranged from 8–31% of couples tested from the community. Across all study sites and, among all couples with one HIV-1 infected partner, almost half (49%) of couples were HIV-1 discordant. Site-specific monthly enrollment of HIV-1 discordant couples into the clinical trial was not directly associated with prevalence of HIV-1 discordance, but was modestly correlated with national HIV-1 counseling and testing rates and access to palliative care/basic health care (r = 0.74, p = 0.09).

          Conclusions/Significance

          HIV-1 discordant couples are a critical target for HIV-1 prevention in Africa. In addition to community prevalence of HIV-1 discordance, national infrastructure for HIV-1 testing and healthcare delivery and effective community outreach strategies impact recruitment of HIV-1 discordant couples into HIV-1 prevention trials.

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          Most cited references30

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          Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa.

          J. Bogaerts, A Serufilira, P Van de perre … (1992)
          To determine whether HIV testing and counselling increased condom use and decreased heterosexual transmission of HIV in discordant couples. Prospective study. Kigali, the capital of Rwanda. Cohabiting couples with discordant HIV serology results. Condom use in the couple and HIV seroconversion in the negative partners. 60 HIV discordant couples were identified, of whom 53 were followed for an average of 2.2 years. The proportion of discordant couples using condoms increased from 4% to 57% after one year of follow up. During follow up two of the 23 HIV negative men and six of the 30 HIV negative women seroconverted (seroconversion rates of 4 and 9 per 100 person years). The rate among women was less than half that estimated for similar women in discordant couples whose partners had not been serotested. Condom use was less common among those who seroconverted (100% v 5%, p = 0.01 in men; 67% v 25%, p = 0.14 in women). Roughly one in seven cohabiting couples in Kigali have discordant HIV serological results. Confidential HIV serotesting with counselling caused a large increase in condom use and was associated with a lower rate of new HIV infections. HIV testing is a promising intervention for preventing the spread of HIV in African cities.
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            The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics.

            Anna Wald, Thomas C Quinn, Connie Celum … (2004)
            Increasing evidence demonstrates a substantial link between the epidemics of sexually transmitted HIV-1 and herpes simplex virus (HSV)-2 infection. More than 30 epidemiologic studies have demonstrated that prevalent HSV-2 is associated with a 2- to 4-fold increased risk of HIV-1 acquisition. Per-sexual contact transmission rates among couples from Rakai, Uganda indicate that at all levels of plasma HIV-1 RNA in the source partner, HSV-2-seropositive HIV-1-susceptible persons have a 5-fold greater risk of acquiring HIV-1 compared with HSV-2-negative persons. In vitro and in vivo studies suggest that mucosal HIV-1 shedding is more frequent and in greater amounts during mucocutaneous HSV-2 replication, including subclinical mucosal reactivations. Most HIV-1-infected persons are coinfected with HSV-2, and most experience frequent subclinical and clinical reactivations of HSV-2. Subclinical HSV reactivation elevates serum HIV-1 RNA levels, and daily therapy with acyclovir appears to reduce plasma HIV-1 RNA. These data show that greater attention to the diagnosis and treatment of HSV-2 among HIV-1-infected persons is warranted, especially those who continue to be sexually active, those not on antiretroviral therapy, or those whose disease is not well suppressed by antiretrovirals.
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              Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners.

              A. Kamali Asl, Alexander J. Whitworth, S S Malamba … (1999)
              To assess the efficacy of transmission of HIV-1 within married couples in rural Uganda according to the sero-status of the partners. Estimation of HIV incidence rates for 2200 adults in a population cohort followed for 7 years comparing male-to-female with female-to-male transmission and sero-discordant with concordant sero-negative couples. Each year, adults (over 12 years of age) resident in the study area were linked to their spouses if also censused as resident. The HIV sero-status was determined annually. At baseline 7% of married adults were in sero-discordant marriages and in half of these the man was HIV-positive. Among those with HIV-positive spouses, the age-adjusted HIV incidence in women was twice that of men (rate ratio (RR) = 2.2 95% confidence interval (CI) 0.9-5.4) whereas, among those with HIV-negative spouses, the incidence in women was less than half that of men (RR = 0.4, 95% CI 0.2-0.8). The age-adjusted incidence among women with HIV-positive spouses was 105.8 times (95% CI 33.6-332.7) that of women with HIV-negative spouses, the equivalent ratio for men being 11.6 (95% CI 5.8-23.4). Men are twice as likely as women to bring HIV infection into a marriage, presumably through extra-marital sexual behaviour. Within sero-discordant marriages women become infected twice as fast as men, probably because of increased biological susceptibility. Married adults, particularly women, with HIV-positive spouses are at very high risk of HIV infection. Married couples in this population should be encouraged to attend for HIV counselling together so that sero-discordant couples can be identified and advised accordingly.
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                Author and article information

                Contributors
                : Role: Academic Editor
                Journal
                Journal ID (nlm-ta): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2008
                Publication date (Electronic): 9 January 2008
                Volume: 3
                Issue: 1
                Electronic Location Identifier: e1411
                Affiliations
                [1 ]University of Washington, Department of Medicine, Seattle, Washington, United States of America
                [2 ]University of Washington, Department of Epidemiology, Seattle, Washington, United States of America
                [3 ]Center for Microbiology Research Kenya Medical Research Institute, Nairobi, Kenya
                [4 ]Kenyatta National Hospital, Nairobi, Kenya
                [5 ]Infectious Disease Institute, Makerere University Medical School, Kampala, Uganda
                [6 ]Rwanda-Zambia HIV Research Group (RZHRG), Ndola, Zambia
                [7 ]Rwanda-Zambia HIV Research Group (RZHRG), Kitwe, Zambia
                [8 ]RZHRG and Emory University, Rollins School of Public Health, Atlanta, Georgia, United States of America
                [9 ]University of Nairobi, Department of Obstetrics and Gynecology, Nairobi, Kenya
                [10 ]Botswana-Harvard Partnership, Gaborone, Botswana
                [11 ]Moi University, Department of Reproductive Health, Eldoret, Kenya
                [12 ]Kilimanjaro Christian Medical Centre, Moshi, Tanzania
                [13 ]Infectious Disease Epidemiology Unit, University of Cape Town, Cape Town, Republic of South Africa
                [14 ]Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, Republic of South Africa
                [15 ]Reproductive Health Research Unit, University of Witwatersrand, Johannesburg, Republic of South Africa
                [16 ]University of Washington, Department of Laboratory Medicine, Seattle, Washington, United States of America
                Institute of Human Virology, United States of America
                Author notes
                * To whom correspondence should be addressed. E-mail: lingappa@ 123456u.washington.edu

                Conceived and designed the experiments: CC WK JL JK EB KN LK MI SA EW DC Gd SD NM PN. Performed the experiments: CC WK JL AM BL EB KN LK MI JM EW RM DC Gd SD NM AM PN. Analyzed the data: JL BL. Contributed reagents/materials/analysis tools: SA. Wrote the paper: CC WK JL AM JK BL EB KN LK MI SA JM EW RM DC Gd SD NM AM PN.

                Article
                Publisher ID: 07-PONE-RA-02347
                DOI: 10.1371/journal.pone.0001411
                PMC ID: 2156103
                PubMed ID: 18183292
                SO-VID: 5fa44047-0459-4e16-8356-45633a8bb110
                Copyright © Lingappa et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 28 September 2007
                Date accepted : 12 November 2007
                Page count
                Pages: 5
                Categories
                Subject: Research Article
                Subject: Infectious Diseases/HIV Infection and AIDS

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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