The Social Dynamics of HIV Transmission as Reflected Through Discordant Couples in Rural Uganda

Johns Hopkins University, Baltimore, Maryland, United States
AIDS (Impact Factor: 5.55). 08/1995; 9(7):745-50. DOI: 10.1097/00002030-199507000-00012
Source: PubMed


To describe the role of men and women as sources of HIV transmission and to estimate HIV incidence among discordant couples resident in diverse rural communities in Uganda.
Rakai, a rural district in Uganda, East Africa.
A population-based cohort study, which has been conducted as annual serological and behavioral surveys since 1989. Community clusters were stratified into trading centers on main roads, intermediate trading villages on secondary roads and agricultural villages off roads. In the 1990 survey round, serological data were available for 79 discordant and 411 concordant HIV-negative couples aged 13-49 years. The present analysis examines sex-specific seropositivity associated with place of residence and the incidence of seroconversion among discordant couples between 1990 and 1991.
Seventy-nine discordant couples were followed; the HIV-positive partner was male in 44 couples (57%) and female in 35 couples (43%). There was marked variation in the sex of the seropositive partner by place of residence: women were the HIV-positive partner in 57% of couples from trading centers, 52% from intermediate villages, and 20% from agricultural communities (P < 0.008). Condom use was higher in discordant couples in which the man was the uninfected partner (17.1%) rather than the woman (9.5%). HIV-positive women, but not HIV-positive men, reported significantly more sexual partners and more genital ulcers than seronegative individuals of the same sex. Seroincidence rates among men and women in discordant relationship were 8.7 and 9.2 per 100 person-years (PY), respectively, which was much higher than in concordant seronegative couples (men, 0.82; women, 0.87 per 100 PY).
In this Ugandan population, men are the predominant source of new infections in rural villages. Risk factors and preventive behaviors vary with the sex of the infected partner, and seroconversion rates are similar in both sexes.

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    • "Gender norms promote multiple concurrent sexual partners for men while women are expected to be monogamous and unquestioning of their partner’s behavior [49,65]. However, recent data from several African studies show that many women are almost as likely as men to bring HIV into the partnership [68]. Sexual negotiation or refusal by a woman may result in suspicions of infidelity and result in intimate partner violence [49], which is often tolerated by these societies [65]. "
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    ABSTRACT: Thirty years since the discovery of HIV, the HIV pandemic in sub-Saharan Africa accounts for more than two thirds of the world's HIV infections. Southern Africa remains the region most severely affected by the epidemic. Women continue to bear the brunt of the epidemic with young women infected almost ten years earlier compared to their male counterparts. Epidemiological evidence suggests unacceptably high HIV prevalence and incidence rates among women. A multitude of factors increase women's vulnerability to HIV acquisition, including, biological, behavioral, socioeconomic, cultural and structural risks. There is no magic bullet and behavior alone is unlikely to change the course of the epidemic. Considerable progress has been made in biomedical, behavioral and structural strategies for HIV prevention with attendant challenges of developing appropriate HIV prevention packages which take into consideration the socioeconomic and cultural context of women in society at large.
    AIDS Research and Therapy 12/2013; 10(1):30. DOI:10.1186/1742-6405-10-30 · 1.46 Impact Factor
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    • "SuppD) and predicted values for that chime nicely with empirical values from observational studies such as the Rakai cohort (Allen et al., 1992; Carpenter et al., 1999; Fideli et al., 2001; Glynn et al., 2003; Gray et al., 2000, 2005; Guthrie et al., 2007; Hira et al., 1997; Hugonnet et al., 2002; Kamenga et al., 1991; Roth et al., 2001; Senkoro et al., 2000; Serwadda et al., 1995; Wawer et al., 2005), though substantially higher than those found in RCTs involving sero-status disclosure and counseling (Celum et al., 2010; Cohen et al., 2011). This was achieved despite building a terse parsimonious model where all model parameters are constrained by direct empirical measures. "
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    ABSTRACT: Background Representative and precise estimates for the annual risk of HIV transmission (ϕ) from the infected to the uninfected partner in a stable HIV-1 sero-discordant couple (SDC) are not available. Nevertheless, quantifying HIV infectiousness is critical to understanding HIV epidemiology and implementing prevention programs. Materials and methods We estimated ϕ and examined its variation across 23 countries in sub-Saharan Africa (SSA) by constructing and analyzing a mathematical model that describes HIV dynamics among SDCs. The model was parameterized using empirical measures such as those of the nationally representative Demographic and Health Surveys. Uncertainty and sensitivity analyses were conducted to assess the robustness of the findings. Results We estimated a median ϕ of 11.1 per 100 person-years across SSA. A clustering based on HIV population prevalence was observed with a median ϕ of 7.5 per 100 person-years in low HIV prevalence countries (<5%) compared to 19.5 per 100 person-years in high prevalence countries (>5%). The association with HIV prevalence explained 67% of the variation in ϕ, and suggested an increase of 0.95 per 100 person-years in ϕ for every 1% increase in HIV prevalence. Conclusions Empirical measures from cohort studies appear to underestimate HIV infectiousness in SSA. The risk of HIV transmission among SDCs appears also to vary across SSA, and this may have contributed to the contrasting HIV epidemic trajectories in this continent.
    Epidemics 11/2013; 6. DOI:10.1016/j.epidem.2013.11.001 · 1.87 Impact Factor
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    • "This scenario is of particular interest because once the male partner sero-converts his chances of infecting his other spouse significantly increase during the acute stage of HIV infection (Quinn et al. 2000), especially for women (Chersich and Rees 2008). Among this sample approximately 70% of participants (men and women) report using a condom the last time they had sex with their discordant partner, which is very high in comparison to other studies that have shown condom use to be as low as 4.4 –16.5% in population level studies in Uganda (Serwadda et al. 1995; Saifuddin et al. 2001) and much more common for non-spouse partnerships (Chimbiri 2007). In our study all participants had to disclose their status to their partners, which has been shown to have a positive effect on condom use and care-seeking behaviours (King et al. 2008; Rwemisisi et al. 2008). "
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    ABSTRACT: Stable serodiscordant relationships and sexual concurrency are pathways that contribute to the HIV epidemic in sub-Saharan Africa. However whether polygyny imparts the same risks as informal concurrent relationships remains an open research question. Using data collected at enrollment from a cohort study of sero-discordant couples, this analysis investigates how polygynous relationships differ from those involving only a single female spouse and whether men involved in polygynous partnerships are more likely to report HIV-risk behaviour than those in single spouse partnerships. Of 444 enrolled couples, 111 (25%) were polygynous and 333 (75%) were single-spouse partnerships. We found that polygynous men were more likely to report controlling sexual decision-making and to report any unprotected sex with unknown sero-status partner. After controlling for potential confounders, polygynous men were still more likely to report unprotected sex with an unknown sero-status partner. In this sample of sero-discordant couples we found indication of excess HIV-risk behaviour among men involved in polygynous relationships.
    Culture Health & Sexuality 09/2011; 13(8):933-44. DOI:10.1080/13691058.2011.590901 · 1.55 Impact Factor
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