HIV status among discordant couples in sub-Saharan Africa: A meta-analysis

involving more than 13,000 discordant couples

Oghenowede Eyawo,1 Damien de Walque,2 Nathan Ford,3 Gloria Gakii,4 Richard Lester,5 Edward Mills6

1)Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada; 2) Development Research Group, The World Bank, Washington DC, USA; 3) Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa; 4)Pumwani Sex-worker Cohort, University of Nairobi, Nairobi, Kenya; 5)Department of Microbiology, Faculty of Medicine, University of Nairobi, Nairobi, Kenya; 6)Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada

Sero-discordancy and sub-Saharan Africa

The first Demographic and Health Survey (DHS) suggest: in at least two thirds of couples where at least one of the

partners is HIV-positive, only one person is infected Sero-discordant couples make up a significant number

(2/3) of infected couples A substantial # of infections continue to occur within

individuals living in a stable relationship Persons in sero-discordant couple relationship are at

particularly high risk of becoming infected

Social Marketing: prevention

Social Marketing: prevention

Objectives

The relative HIV-burden within heterosexual discordant partnerships in sub-Saharan Africa is, in fact, poorly understood.

The objective of this study is to determine the gender balance of index case infections among sero-discordant couples in sub-Saharan Africa

Methods

We undertook a systematic review of sero-discordancy in stable relationships to determine the gender balance of index case infections in the region.

HIV-discordancy in a relationship: as one existing among married as well as unmarried couples that are in a stable habitual relationship.

Methods

Extensive search: we examine published and unpublished data

Secondary analysis: used supplemental data from DHS survey from 14 countries in sub-Saharan Africa

Methods

We conducted a random effects meta-analysis and meta-regression analysis to evaluate overall proportion of HIV-index cases

We examined gender gap score by country, urban vs. rural populations, HIV prevalence, mean age difference between men and women

We conducted a sensitivity analysis of pooled cohort proportion to ensure there was no duplication

Analysis: StatsDirect (version 2.7.6, Manchester) and STATA (version 10.0, College Station, TX)

Results

Primary data: 25 distinct cohorts in 7 countries + 3 multi-country cohorts, totaling 12,865 couples

Ave. follow-up: 27.3 months (range 9-84)

Secondary data: DHS data from 14 countries totaling 1,145 couples

Results

Pooled overall DerSimonian-Laird analysis (primary data):

F+ M- couples in stable heterosexual sero-discordant relationships at 47% (95% CI: 43-52%)

Demonstrates no significant difference in the # of female +ve couples compared to male +ve sero-discordant couples

Meta-analysis Results: primary data

Forest plot showing results of the random effects meta-analysis (27 studies)

Meta-analysis Results: primary data

Forest plot showing results of the random effects meta-analysis (27 studies)

Meta-analysis Results: secondary data

Forest plot showing results of the random effects meta-analysis (14 studies)

Meta-analysis Results: secondary data

Forest plot showing results of the random effects meta-analysis (14 studies)

Results

Large variability Meta-regression primary analysis: association

with effect size: Urban vs. rural residence Latitude Gender equity Older age

DHS data: meta-regression Gender equity Decreased HIV prevalence

Important Findings

A significant proportion of infected couples have women as the infected partner

On average, women are as likely to be the index partner as men in a sero-discordant couple

Discussion

These findings seem counter-intuitive to the large body of opinion demonstrating male sexual behaviours and risk taking

Reflects research bias in part

Relatively fewer studies examine women sexual risk taking in stable relationships

Necessary Emphasis

It is important to emphasise that:

This study is not aimed at assigning blame to either gender

We hope this study will stimulate a more gender-balanced approach in the orientation of behavioural research and prevention interventions

Strength & Limitations

We searched extensively both published and unpublished data

We are aware that there are many more unpublished cohorts existing within routine programme, including cohorts in which discordant couples may not be aware of their status

We supplemented our searches with DHS data

Conclusions

Implications for Prevention Strategies This review provide a fresh basis for discussions

and action points that can guide HIV/AIDS programming.

Sero-discordant couples, especially uninfected partners should be a priority prevention target group

In particular, programmes focusing on sero-discordant couples should be planned to equally target both men and women alike.