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Undiagnosed HIV Infection and Couple HIV Discordance Among Household Members of HIV-Infected People Receiving Antiretroviral Therapy in Uganda
Global Health Sciences Literature Digest
Published September 27, 2006
Journal Article

Were WA, Mermin JH, Wamai N, Awor AC, Bechange S, Moss S, Solberg P, Downing RG, Coutinho A, Bunnell RE. Undiagnosed HIV Infection and Couple HIV Discordance Among Household Members of HIV-Infected People Receiving Antiretroviral Therapy in Uganda. J Acquir Immune Defic Syndr. 2006 Sep;43(1):91-5.

Objective

To identify HIV-infected members and HIV-discordant couples in households of individuals on antiretroviral therapy (ART) in an effort to reduce HIV transmission and improve ART adherence.

Study Design

This was a cross-sectional study of voluntary counseling and testing (VCT) uptake, HIV prevalence and HIV discordance among couples, set within a larger randomized controlled trial evaluating different ART monitoring regimens through home-based ART care and follow up.

Setting

The study took place in rural eastern Uganda between May 2003 and December 2004.

Participants

All HIV-infected adults aged 18 and older, eligible for ART, and attending an AIDS care support organization were eligible for enrollment in the study. These index participants then consented to have study staff visit their homes and offer VCT to all of their household members.

Intervention

There was no intervention in this study.

Primary Outcomes

Uptake of VCT, HIV prevalence among household members, ART eligibility among HIV-positive household members, and discordance among couples were assessed.

Results

VCT was offered to 2373 household members of 730 index clients. Overall, 2348 (99%) accepted VCT, and HIV prevalence among household members was 7.5%. Prevalence was highest in the 25-44 year age group (37.1%) and lowest among those age 6 to 24 years (2.9%). Of the 176 household members who tested HIV-positive, 74% had not been previously tested. The most common barrier to testing cited by household members was having no perceived risk of infection. Thirty percent of the household members who tested HIV-positive were eligible for ART. Of the 120 spouses of HIV-positive index participants starting ART and living in the households, 99% had never been tested for HIV and 52 (43%) were HIV-positive.

Conclusions

The authors conclude that provision of VCT to family members of people in HIV care and treatment programs is an important intervention for case finding and prevention of HIV transmission, especially among discordant couples.

Quality Rating

There is no standardized quality rating for this type of study. The authors note that high acceptance rates of VCT were in the context of provision of ART, and therefore may not be applicable in other settings where ART is not being offered.

In Context

Generally, uptake of VCT seems to be higher during home visits than in clinics. Facility-based PMTCT programs have shown that only between 3 and 15% of partners of pregnant women received testing,(1) and two general population studies in Uganda showed two-to-four-fold increases in receipt of HIV test results when provided to participants at home as opposed to through a clinic.(2,3,4,5) In addition, providing couples with VCT may decrease risky sexual behavior and HIV transmission among HIV-discordant couples.(6,7,8)

Programmatic Implications

The authors note that implementation of home-based VCT is feasible in Uganda, especially now that the Ugandan Ministry of Health has changed its counseling and testing guidelines to include testing using a rapid finger-stick test. However, cost-effectiveness analyses are needed. In addition, the authors state that evaluation of home-based testing in more urban settings where acceptance rates of VCT may differ is necessary, as are studies of the potential negative social consequences of in-home partner VCT.

References

  1. Farquhar C, Kiarie JN, Richardson BA, Kabura MN, John FN, Nduati RW, Mbori-Ngacha DA, John-Stewart GC. Antenatal couple counseling increases uptake of interventions to prevent HIV-1 transmission. J Acquir Immune Defic Syndr. 2004 Dec 15;37(5):1620-6.
  2. Were W, Mermin J, Bunnell R, Ekwaru JP, Kaharuza F. Home-based model for HIV voluntary counselling and testing. Lancet 2003; 361:1569.
  3. Matovu JK, Kigozi G, Nalugoda F, Wabwire-Mangen F, Gray RH. The Rakai Project counselling programme experience. Trop Med Int Health. 2002 Dec;7(12):1064-7.
  4. Wolff B, Nyanzi B, Katongole G, Ssesanga D, Ruberantwari A, Whitworth J. Evaluation of a home-based voluntary counselling and testing intervention in rural Uganda. Health Policy Plan. 2005 Mar;20(2):109-16.
  5. Mermin J, Lule J, Ekwaru JP, Downing R, Hughes P, Bunnell R, Malamba S, Ransom R, Kaharuza F, Coutinho A, Kigozi A, Quick R. Cotrimoxazole prophylaxis by HIV-infected persons in Uganda reduces morbidity and mortality among HIV-uninfected family members. AIDS. 2005 Jul 1;19(10):1035-42.
  6. Kamenga M, Ryder RW, Jingu M, Mbuyi N, Mbu L, Behets F, Brown C, Heyward WL. Evidence of marked sexual behavior change associated with low HIV-1 seroconversion in 149 married couples with discordant HIV-1 serostatus: experience at an HIV counselling center in Zaire. AIDS. 1991 Jan;5(1):61-7.
  7. Allen S, Meinzen-Derr J, Kautzman M, Zulu I, Trask S, Fideli U, Musonda R, Kasolo F, Gao F, Haworth A. Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS. 2003 Mar 28;17(5):733-40.
  8. Allen S, Serufilira A, Bogaerts J, Van de Perre P, Nsengumuremyi F, Lindan C, Carael M, Wolf W, Coates T, Hulley S. Confidential HIV testing and condom promotion in Africa. Impact on HIV and gonorrhea rates. JAMA. 1992 Dec 16;268(23):3338-43.