Couple Centered Testing and Counseling for HIV Serodiscordant Heterosexual Couples in Sub-Saharan Africa

Institut de Recherche pour le Développement, Centre Population Développement (CEPED), Paris, France.
Reproductive health matters (Impact Factor: 1.43). 12/2008; 16(32):151-61. DOI: 10.1016/S0968-8080(08)32407-0
Source: PubMed


In Africa, a large proportion of HIV infections occur within stable relationships, either because of prior infection of one of the partners or because of infidelity. In five African countries at least two-thirds of couples with at least one HIV-positive partner were HIV serodiscordant; in half of them, the woman was the HIV-positive partner. Hence, there is an urgent need to define strategies to prevent HIV transmission within couple relationships. HIV counselling and testing have largely been organised on an individual and sex-specific basis, for pregnant women in programmes for prevention of mother-to-child transmission of HIV and in STI consultations and recently male circumcision for men. A couple-centred approach to HIV counselling and testing would facilitate communication about HIV status and adoption of preventive behaviours within couples. This paper reviews what is known about HIV serodiscordance in heterosexual couples in sub-Saharan Africa and what has been published about couple-centred initiatives for HIV counselling and testing since the early 1990s. Despite positive outcomes, couple-oriented programmes have not been implemented on a large scale. In order to stimulate and strengthen HIV prevention efforts, increased attention is required to promote prevention and testing and counselling for couples in stable relationships.

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Available from: Annabel Desgrées du Loû
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    • "We cannot abandon behavioral approaches because even as biomedical innovations for HIV prevention show great promise in efficacy trials, they likely cannot be fulfilled without behavioral interventions to support their adoption and dissemination [9]. Barriers evident in individual level prevention approaches have led to increased testing of couple-based strategies which are often found to be more efficacious in promoting HIV counseling and testing [10,11] and supporting medication adherence [12], but which may require more complex implementation strategies [13,14]. Given the promise of couple-focused approaches (e.g., balancing attention to the dyad, positive reinforcement for relationship-based behaviors, conflict management) [15], scientists have called for improved efforts at examining their dissemination [13]. "
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    ABSTRACT: Background Despite great need, the number of HIV prevention implementation studies remains limited. The challenge for researchers, in this time of limited HIV services agency resources, is to conceptualize and test how to disseminate efficacious, practical, and sustainable prevention programs more rapidly, and to understand how to do so in the absence of additional agency resources. We tested whether training and technical assistance (TA) in a couple-based HIV prevention program using a Web-based modality would yield greater program adoption of the program compared to training and TA in the same program in a manual-based modality among facilitators who delivered the interventions at 80 agencies in New York State.Methods This study used a cluster randomized controlled design. Participants were HIV services agencies (N¿=¿80) and up to 6 staff members at each agency (N¿=¿253). Agencies were recruited, matched on key variables, and randomly assigned to two conditions. Staff members participated in a four-day, face-to-face training session, followed by TA calls at two and four months, and follow-up assessments at 6, 12, and 18 months post- training and TA. The primary outcomes examined number of couples with whom staff implemented the program, mean number of sessions implemented, whether staff implemented at least one session or whether staff implemented a complete intervention (all six sessions) of the program. Outcomes were measured at both the agency and participant level.ResultsOver 18 months following training and TA, at least one participant from 13 (33%) Web-based assigned agencies and 19 (48%) traditional agencies reported program use. Longitudinal multilevel analysis found no differences between groups on any outcomes at the agency or participant level with one exception: Web-based agencies implemented the program with 35% fewer couples compared with staff at manual-based agencies (IRR 0.35, CI, 0.13-0.94).Conclusion Greater implementation of a Web-based program may require more resources and staff exposure, especially when paired with a couple-based modality. Manual-based and traditional programs may hold some advantage or ease for implementation, particularly at a time of low economic resources.Trial identifier: NCT01863537.
    Full-text · Article · Sep 2014 · Implementation Science
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    • "On the other hand, local tailoring in each country context may be the best approach for developing effective solutions to address these widespread barriers. That said, there will also likely be regional similarities in the applicability of the solutions/facilitators among target populations: fishermen based in the Lake Victoria region in Tanzania and Uganda share characteristics with Kenyan fishermen working in the Bondo area [41-48]; widows in Bondo have commonalities with widows in other countries in sub-Saharan Africa [49-53]; female sex workers in other parts of Kenya and sub-Saharan Africa have similarities with the female sex workers discussed here for Kenya [54-62]; and serodiscordant couples in all regions of sub-Saharan Africa tend to share similar characteristics [63-66]. The four broader groups across sub-Saharan Africa may therefore be affected by the clinical requirements for oral PrEP use in similar ways. "
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    ABSTRACT: Background As pre-exposure prophylaxis (PrEP) moves closer to availability in developing countries, practical considerations for implementation become important. We conducted a consultation with district-level community stakeholders experienced in HIV-prevention interventions with at-risk populations in Bondo and Rarieda, Kenya to generate locally grounded approaches to the future rollout of oral PrEP to four populations: fishermen, widows, female sex workers, and serodiscordant couples. Methods The 20 consultation participants represented the Ministry of Health, faith- and community-based organizations, health facilities, community groups, and nongovernmental organizations. Participants divided into breakout groups and followed a structured discussion guide asking them to identify barriers to implementing HIV-prevention interventions (including PrEP) with each population. Questions also solicited solutions for addressing these barriers, as well as other facilitators for PrEP implementation. In particular, questions focused on how to encourage people to screen for PrEP eligibility by having HIV and other blood tests and how to encourage compliance with ongoing HIV testing. Results The barriers and facilitators/solutions discussants provided were frequently population-specific, but there were also broad-level similarities across populations. Service delivery barriers to HIV-prevention interventions concerned the need for staff trained to address the needs of particular populations. Service delivery facilitators to provision of ongoing HIV testing consisted of offering testing options besides facility-based testing. Stigma was the main community-level barrier for all groups, whereas barriers at the level of target populations included mobility; lifestyle and life circumstances, especially cultural norms among fishermen and widows; and fears, lack of awareness, and misinformation. Proposed facilitators and strategies for addressing community- and population-level barriers included topic-specific education within the populations and community, involvement of partners and family members, mass HIV testing, and peer educators. Barriers to PrEP uptake included non-adherence to pill taking and missing clinic visits. For drug adherence, facilitators were counselling and involving family members. Discussants suggested that client reminders, e.g., home visits, were needed to encourage clients to keep their clinic appointments. Conclusions Strategies for encouraging eligibility screening and ongoing HIV testing will have local and population-specific aspects. Our results nonetheless apply to similar populations throughout sub-Saharan Africa and reach beyond oral PrEP to other ARV-based PrEP formulations.
    Full-text · Article · May 2014 · BMC Health Services Research
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    • "Nonetheless, couple counseling is an upcoming strategy for MI as it has been reported that couples are at a high risk of HIV infection and transmission because rarely are preventive behaviors such as condom use practiced within a couple setting (50, 51). A review of studies on couple-centered HIV testing in sub-Saharan Africa revealed that such services, in spite of the documented benefits and acceptability of the service, have not been rolled out on a larger scale (52). "
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    ABSTRACT: Background: Despite the documented benefits of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) services, the uptake remains low in sub-Saharan Africa. The lack of male involvement (MI) may be one of the reasons for this. However, there are limited data on strategies for MI in PMTCT. Objective: The objective of this study was to identify strategies that may promote MI in PMTCT services in antenatal care (ANC) services in Blantyre, Malawi. Study design: An exploratory qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) in Blantyre, Malawi. It consisted of six face-to-face key informant interviews (KIIs) with healthcare workers and four focus group discussions (FGDs) with 18 men and 17 pregnant women attending ANC at SLHC. The FGDs were divided according to sex and age. All FGDs and KIIs were digitally recorded and simultaneously transcribed and translated verbatim into English. Data were analyzed using thematic content analysis. Results: Three major themes with several subcategories emerged. Theme 1 was a gatekeeping strategy with two subcategories: (1) healthcare workers refusing service provision to women accessing antenatal clinic without their partners and (2) women refusing ANC attention in the absence of a partner. Theme 2 comprised extending invitations and had six subcategories: (1) word of mouth, (2) card invites, (3) woman's health passport book invites, (4) telephonic invites, (5) use of influential people, and (6) home visits. Theme 3 was information education and communication, such as health education forums and advertisements. Of all the strategies, an invitation card addressed to the male partner was most preferred by study participants. Conclusions: There are several strategies by which men may be involved in PMTCT. Healthcare workers should offer a pregnant woman all strategies available for MI for her to select the appropriate one. Further research and consultations with men should continue to achieve higher levels of MI.
    Full-text · Article · Dec 2013 · Global Health Action
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