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HIV Risk in Relation to Marriage in Areas With High Prevalence of HIV Infection

Authors:
Judith Glynn at London School of Hygiene and Tropical Medicine
Judith Glynn
Michel Carael at Université Libre de Bruxelles
Michel Carael
Anne Buvé at Institute of Tropical Medicine
Anne Buvé
Rosemary Musonda at Botswana Harvard AIDS Institute/Harvard School of Public Health
Rosemary Musonda
  • Botswana Harvard AIDS Institute/Harvard School of Public Health
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Abstract

In sub-Saharan Africa, the prevalence of HIV infection among young women is much higher than that among young men. Many women enter marriage HIV-infected, suggesting that men may be predominantly infected by their wives. Using data from cross-sectional surveys in Kisumu, Kenya, and Ndola, Zambia, in 1997, the prevalence of HIV infection at marriage was estimated from age at marriage and age- and sex-specific prevalence of HIV infection among unmarried individuals. Using a deterministic model, this prevalence was compared with measured concordance of HIV infection among recently married couples to estimate transmission probabilities within marriage and extramarital incidence of HIV infection. Over a wide range of assumptions, we estimated that at least one quarter of cases of HIV infection in recently married men were acquired from extramarital partnerships, and for both men and women, less than one half of cases of HIV infection were acquired from their spouse. In these sites, many infections in married men, even in those with HIV-infected wives, may be acquired from outside the marriage.
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... Despite the empirical evidence pointing to their programmatic importance, serodiscordant couples are often overlooked or, at best, only vaguely addressed in many national prevention plans. This omission may stem not only from sensitivity surrounding HIV within couples but also from misperceptions about the extent of serodiscordance and failure to understand that it is possible to prevent transmission within a stable union once one partner has become infected [4]. ...
... In Zambia, a retrospectively study of 65 couples to estimate the likely origin of HIV infection, found that at least one quarter of cases of HIV infection in recently married men were acquired from extramarital partnerships, and for both men and women, less than one half of cases of HIV infection were acquired from their spouse/husband [4]. In addition, they report that many infections in married men, even in those with HIV-infected wives, could be acquired from outside the marriage [4]. ...
... In Zambia, a retrospectively study of 65 couples to estimate the likely origin of HIV infection, found that at least one quarter of cases of HIV infection in recently married men were acquired from extramarital partnerships, and for both men and women, less than one half of cases of HIV infection were acquired from their spouse/husband [4]. In addition, they report that many infections in married men, even in those with HIV-infected wives, could be acquired from outside the marriage [4]. Furthermore, a study conduct in South Africa to investigate who was infecting whom among migrant and non-migrant within concordance as well as discordance couples, found that non-migrant men were 10 times more likely to be infected from outside their regular relationships than inside [18]. ...
A flexible method to model HIV serodiscordance among couples in Mozambique
Article
Full-text available
Whereas the number of people newly infected by HIV is continuing to decline globally, the epidemic continues to expand in many parts of the world. As the HIV/AIDS epidemic has matured in many countries, it is believed that the proportion of new infections occurring within couples has risen. Across countries, including Mozambique, a sizeable proportion of couples with HIV infection are discordant. A serodiscordant couple is a couple in which one partner has tested positive for HIV and the other has not. To describe the HIV serodiscordance among couples, a variety of association measures can be used. In this paper, we propose the serodiscordance measure (SDM) as a new alternative measure. Focus is on the specification of flexible marginal and random effects models for multivariate correlated binary data together with a full-likelihood estimation method, to adequately and directly describe the measure of interest. Fitting joint models allows examining the effects of different risk factors and other covariates on the probability to be HIV positive for each member within a couple, and estimating common effects for both probabilities more efficiently, while accounting for the association between their infection status. Moreover, the interpretation of the proposed association parameter SDM is more direct and relevant and effects of covariates can be studied as well. Results show that the HIV prevalence for the province where a couple was located as well as the union number for the woman within a couple are factors associated with HIV serodiscordance. These findings are important for the Mozambican public health policy makers to design national prevention plans, which include policies to stimulate regular HIV testing for couples as well as adolescents and young adults, prior to getting married or living together as a couple.
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... Finally, this work advances understandings of the extent to which marriage may serve as a protective institution for women. While there have been a number of studies examining the marriage-HIV connection in sub-Saharan Africa (e.g., Bongaarts 2007;Clark 2004;Glynn et al. 2003;Parikh 2007), less attention has been focused on union formalization processes such as lobola (see Wojcicki et al. 2010 for an exception), which can function as a pathway through which risks and benefits may be accrued. ...
... By ruling out the possibility that HIV infection could occur through her infidelity, a married woman stakes a claim to morality. However, in reality-and reinforced by data-marriage does not confer protection from HIV for women and, in fact, may increase the risk of transmission (Bongaarts 2007;Clark 2004;Glynn et al. 2003;Parikh 2007). Thus, although marriage as a conjuncture (Johnson-Hanks 2002 provides women with respectability and a boost to their moral status, it does not reliably protect them from HIV. ...
Modernizing Marriage: Balancing the Benefits and Liabilities of Bridewealth in Rural South Africa
Article
Full-text available
  • Mar 2021
  • Qual Sociol
The payment of bridewealth or lobola is a longstanding cultural practice that has persisted in South Africa despite significant societal shifts over the past two decades. Lobola has always been a complex and contested practice that both reinforces gender inequalities and, at the same time, provides status to women and legitimacy to marriages. In this paper, we describe rural South African women’s perceptions of lobola, their experiences related to marriage and lobola, and how they reconfigure lobola to fit within modern life course aspirations and trajectories. We draw on interviews with 43 women aged 18–55 in rural South Africa to examine desires related to lobola and the meanings of lobola given current social, economic, and health (HIV) conditions in rural areas. Our findings indicate that lobola offers women a complex set of benefits and liabilities. Although women value the support, social status, and respectability lobola offers, they also lament how lobola curtails their freedom to pursue education and limits their autonomy from husbands as well as in-laws. Women also view lobola as offering a sense of security amidst the uncertainty of the local political economy and the HIV/AIDS epidemic. We conclude that the way women incorporate lobola into their desires and plans reflects tension between the expectations and aspirations of “modern” women in a post-apartheid context in which rights feature prominently but economic security is not guaranteed, and cultural scripts reinforce longstanding gender norms but also ensure social support.
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... Typically, sexual activity begins prior to marriage, and many women are HIV-positive when they get married in sub-Saharan Africa. Even though it's possible that a sizable percentage of males could have HIV before getting married, this proportion is smaller than it is for women [8]. As a crucial first step toward HIV care and treatment, HIV testing and counseling are therefore essential for preventing HIV transmission and will continue to be an integral aspect of preventive efforts [9][10][11]. ...
Spatial variation of premarital HIV testing and its associated factors among married women in Ethiopia: Multilevel and spatial analysis using 2016 demographic and health survey data
Article
Full-text available
Background Africa is the most severely affected area, accounting for more than two-thirds of the people living with HIV. In sub-Saharan Africa, more than 85% of new HIV-infected adolescents and 63% of all new HIV infections are accounted for by women. Ethiopia has achieved a 50% incidence rate reduction. However, mortality rate reduction is slow, as the estimated prevalence in 2021 is 0.8%. In sub-Saharan Africa, heterosexual transmission accounts for the majority of HIV infections, and women account for 58% of people living with HIV. Most of these transmissions took place during marriage. Thus, this study aimed to explore the spatial variation of premarital HIV testing across regions of Ethiopia and identify associated factors. Methods A cross-sectional study design was employed. A total of 10223 weighted samples were taken from individual datasets of the 2016 Ethiopian Demographic and Health Survey. STATA version 14 and ArcGIS version 10.8 software’s were used for analysis. A multilevel mixed-effect generalized linear model was fitted, and an adjusted prevalence Ratio with a 95% CI and p-value < 0.05 was used to declare significantly associated factors. Multilevel models were compared using information criteria and log-likelihood. Descriptive and spatial regression analyses (geographical weighted regression and ordinary least squares analysis) were conducted. Models were compared using AICc and adjusted R-squared. The local coefficients of spatial explanatory variables were mapped. Results In spatial regression analysis, secondary and above education level, richer and above wealth quintile, household media exposure, big problem of distance to health facility, having high risky sexual behaviour and knowing the place of HIV testing were significant explanatory variables for spatial variation of premarital HIV testing among married women. While in the multilevel analysis, age, education level, religion, household media exposure, wealth index, khat chewing, previous history of HIV testing,age at first sex, HIV related knowledge, HIV related stigma, distance to health facility, and community level media exposure were associated with premarital HIV testing among married women. Conclusions and recommendation Premarital HIV testing had a significant spatial variation across regions of Ethiopia. A statistically significant clustering of premarital HIV testing was observed at Addis Ababa, Dire Dawa, North Tigray and some parts of Afar and Amhara regions. Therefore area based prevention and interventional strategies are required at cold spot areas to halt the role of heterosexual transmission in HIV burden. Moreover, the considering the spatial explanatory variables effect in implementations of these strategies rather than random provision of service would make regional health care delivery systems more cost-effective.
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... Evidence suggests that sexual relationships in Africa often include long-term concurrent sexual partnerships involving high rates of coital risk exposures among secondary partners (Harrison and O'Sullivan 2010;Morris et al. 2010). Indeed, research has found that a woman's risk of infection is greatest when married (Bongaarts 2007;Clark et al. 2009;Glynn et al. 2003). Because of these patterns, some advocates speak publicly about the potential dangers of marriage. ...
Towards Gender Equity in Development
Article
Full-text available
  • Oct 2018
As a result of widespread mistreatment and overt discrimination in all dimensions of their lives, women lack significant autonomy. The central preoccupation of this book is to explore key sources of female empowerment and discuss the current challenges and opportunities for the future. Schematically, three main domains are distinguished. The first is marriage and women’s relative bargaining position within the household. Since in developing countries marriage is essentially universal and generally arranged by the parents, women have little say in the choice of their partner and largely depend on their husband for their livelihoods and well-being. How marriage, divorce, and remarriage practices have evolved and with what effects for women, is therefore of crucial concern. The second domain is the set of options available to women outside of marriage and in the context of their community. Given the importance of household dynamics in determining female well-being, a crucial step towards women’s empowerment consists of improving such options, economic and collective action opportunities in particular. The third domain belongs to the realm of over-arching discriminatory laws and cultural norms. Can the government acting as lawmaker contribute to modifying norms and practices that disadvantage women? Or, to be effective, do legal moves need to be complemented by other initiatives such as the expansion of economic opportunities for women? Do discriminatory social norms necessarily dissolve with improved legal status for women? These questions, and other related issues, are tackled from different perspectives, by top scholars with well-established experience in gender-focused economic and social research.
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... Evidence suggests that sexual relationships in Africa often include long-term concurrent sexual partnerships involving high rates of coital risk exposures among secondary partners (Harrison and O'Sullivan 2010;Morris et al. 2010). Indeed, research has found that a woman's risk of infection is greatest when married (Bongaarts 2007;Clark et al. 2009;Glynn et al. 2003). Because of these patterns, some advocates speak publicly about the potential dangers of marriage. ...
Making Marriages Last: Trust is Good, But Credible Information Is Better
Chapter
Full-text available
  • Oct 2018
As a result of widespread mistreatment and overt discrimination in all dimensions of their lives, women lack significant autonomy. The central preoccupation of this book is to explore key sources of female empowerment and discuss the current challenges and opportunities for the future. Schematically, three main domains are distinguished. The first is marriage and women’s relative bargaining position within the household. Since in developing countries marriage is essentially universal and generally arranged by the parents, women have little say in the choice of their partner and largely depend on their husband for their livelihoods and well-being. How marriage, divorce, and remarriage practices have evolved and with what effects for women, is therefore of crucial concern. The second domain is the set of options available to women outside of marriage and in the context of their community. Given the importance of household dynamics in determining female well-being, a crucial step towards women’s empowerment consists of improving such options, economic and collective action opportunities in particular. The third domain belongs to the realm of over-arching discriminatory laws and cultural norms. Can the government acting as lawmaker contribute to modifying norms and practices that disadvantage women? Or, to be effective, do legal moves need to be complemented by other initiatives such as the expansion of economic opportunities for women? Do discriminatory social norms necessarily dissolve with improved legal status for women? These questions, and other related issues, are tackled from different perspectives, by top scholars with well-established experience in gender-focused economic and social research.
View
... Evidence suggests that sexual relationships in Africa often include long-term concurrent sexual partnerships involving high rates of coital risk exposures among secondary partners (Harrison and O'Sullivan 2010; Morris et al. 2010). Indeed, research has found that a woman's risk of infection is greatest when married (Bongaarts 2007;Clark et al. 2009;Glynn et al. 2003). Because of these patterns, some advocates speak publicly about the potential dangers of marriage. ...
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... There is a common perception that these SDPs are larger than expected 31,32 , given the intuitive argument that intercourse between stable serodiscordant partners should rapidly produce positive concordance. Heuristic arguments have attributed large SDPs to high extramarital transmission 29,31,32 , heterogeneity in HIV infectiousness or susceptibility 8,29,[33][34][35] , population-level HIV prevalence 29 , and AIDS-related mortality 36 . However, the relative impacts of these factors on SDP remain poorly understood 29 . ...
Couple serostatus patterns in sub-Saharan Africa illuminate the relative roles of transmission rates and sexual network characteristics in HIV epidemiology
Article
Full-text available
  • Apr 2018
HIV prevalence has surpassed 30% in some African countries while peaking at less than 1% in others. The extent to which this variation is driven by biological factors influencing the HIV transmission rate or by variation in sexual network characteristics remains widely debated. Here, we leverage couple serostatus patterns to address this question. HIV prevalence is strongly correlated with couple serostatus patterns across the continent; in particular, high prevalence countries tend to have a lower ratio of serodiscordancy to concordant positivity. To investigate the drivers of this continental pattern, we fit an HIV transmission model to Demographic and Health Survey data from 45,041 cohabiting couples in 25 countries. In doing so, we estimated country-specific HIV transmission rates and sexual network characteristics reflective of pre-couple and extra-couple sexual contact patterns. We found that variation in the transmission rate could parsimoniously explain between-country variation in both couple serostatus patterns and prevalence. In contrast, between-country variation in pre-couple or extra-couple sexual contact rates could not explain the observed patterns. Sensitivity analyses suggest that future work should examine the robustness of this result to between-country variation in how heterogeneous infection risk is within a country, or to assortativity, i.e. the extent to which individuals at higher risk are likely to partner with each other.
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HIV Status in Sero-Discordant Couples: Prevalence and Pattern among Pregnant Women in Plateau State, Nigeria
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Full-text available
  • Aug 2018
Nigeria is one of the high-burden countries in sub-Saharan Africa for HIV/AIDS and contributes to reproductive health morbidities and mortalities. This study was aimed at determining the prevalence of HIV-discordant rate among pregnant women in Plateau state Nigeria. The study sought to determine the prevalence and trend of HIV sero-discordance among pregnant women in Plateau state, Nigeria. The study was a 5-year descriptive analysis of HIV sero-discordance among pregnant women accessing prenatal care and their partners in Plateau state, Nigeria based on data generated between January 2012 and December 2016. The data was disaggregated by year, HIV concordant negative, HIV concordant positive, and HIV sero-discordant prevalence in the software and analysis were done using excel to obtained the proportions and trend of HIV sero-discordant prevalence among the antenatal population. Out of a total of 7,851 partners of pregnant women studied, 969 (16.3%) were HIV sero-discordant, 5,795 (73.8%) were HIV concordant negative, and 773 (9.9%) were HIV concordant positive. HIV sero-discordant positive males accounted for 12.3% while females were 4.0%. The prevalence of HIV sero-discordance was low with a high proportion of HIV positive male partners in Plateau state with grave public health implications for new HIV infections among partners and eroding the gains made in the Prevention of mother-to-child transmission of HIV.
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The Effect of Economic Hardship on AntiretroviralTherapy among Patients with HIV/AIDS
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  • Feb 2009
The purpose of this study was to explore the relationship of economic hardship to individual’s ability to seek antiretroviral medication among patients with HIV/AIDS in a resource-poor country. A total of 77 patients residing in five marginalized communities of South Eastern region of Nigeria participated in a study that tested three hypotheses. Results indicated, that an inverse relationship exist of poverty status, household poverty, and Poor standard of Living, to individual’s ability to seek antiretroviral therapy among HIV/AIDS patients as predicted. Result suggests that economic hardship negates the ability of people living with HIV/AIDS One implication of our findings is that improvements in the continuity of care of patients with HIV/AIDS may be realized through further development of social assistance programs aimed at alleviating the poverty conditions leading to economic empowerment of patients with HIV/AIDS in resource poor countries to seek voluntary antiretroviral therapy. Socioeconomic index of poverty were used to measure individuals’ economic hardship.
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Epidemiology of Human Immunodeficiency Virus in Families in Lusaka, Zambia
Article
Full-text available
  • Feb 1990
  • J Acquir Immune Defic Syndr
Persons living in the same household as index patients with AIDS or ARC in Lusaka, Zambia were clinically and serologically evaluated for HIV-1 infection. In the 150 households of male index cases, 92 (61.3%) of their spouses were infected, compared with 57 (73.1%) of the spouses of the 78 female index cases. The more advanced the clinical stage of illness in the index cases, the greater the probability of HIV infection in the spouse (RR = 4.44), and the more likely the spouse was symptomatic. Four of the 11 spouses who seroconverted to HIV had also had sexual intercourse at a time when their HIV-infected partner had genital ulcers (RR = 7.45). Of 144 children under 5 years of age, 36 (25.0%) were infected, all had infected mothers and were the last to be borne in all but one household. Three of 120 children 5 to 10 years of age were also infected, presumably through perinatal transmission. Forty-six of 52 discordantly infected couples followed for 1 year continued to have unprotected vaginal intercourse, and 11 (21.2%) of these seroconverted to HIV. There were no HIV infections that could be attributed to transmission by other means than heterosexual intercourse between spouses or by perinatal infection in children borne of infected mothers. The study suggests that there is an increasing risk of HIV heterosexual transmission as infection progresses in the infected partner, and that more effective counseling is needed to prevent it.
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Studying dynamics of the HIV epidemic
Article
  • Jul 1998
Objectives: To establish population-based HIV survey data in selected populations, and to assess the validity of extrapolation from HIV sentinel surveillance amongst antenatal clinic attenders (ANC) to the general population. Methods: In a population survey, adults aged ≥ 15 years were selected by stratified random cluster sampling (n = 4195). The survey was carried out in catchment populations of clinics used for national HIV surveillance. The methodology allows detailed comparisons of HIV infection patterns to be made in two areas (urban and rural). Whereas the sentinel surveillance used serum-based HIV testing, the population survey used saliva (93.5% consented to provide a saliva sample). Results: Surveillance of ANC tended to underestimate the overall HIV prevalence of the general population, but differences were not statistically significant. In the urban area, the adjusted overall HIV prevalence rate of ANC (aged 15–39 years) was 24.4% [95% confidence interval (CI), 20.9–28.0] compared with 26.0% (95% CI, 23.4–28.6) in the general population. The respective rural estimates were 12.5% (95% CI, 9.3–15.6) versus 16.4% (95% CI, 12.1–20.6). Age-specific prevalence rates showed ANC to overestimate infection in teenagers (aged 15–19 years), whereas in the reverse direction of those aged ≥ 30 years. Teenagers analysed by single year of age revealed both ANC and women in the general population with about the same steep increase in prevalence by age, but the former at consistently higher rates. Extrapolations might be biased substantially due to the higher pregnancy rates amongst uninfected individuals. Conclusions: ANC-based data might draw a rather distorted picture of current dynamics of the HIV epidemic. Even though representing an obvious oversimplification, extrapolations of overall prevalence rates may correlate with that of the general population.
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Probability of HIV-1 Transmission per Coital Act in Monogamous, Heterosexual, HIV-1-Discordant Couples in Rakai, Uganda
Article
  • Apr 2001
The probability of HIV-1 transmission per coital act in representative African populations is unknown. We aimed to calculate this probability overall, and to estimate how it is affected by various factors thought to influence infectivity. 174 monogamous couples, in which one partner was HIV-1 positive, were retrospectively identified from a population cohort in Rakai, Uganda. Frequency of intercourse and reliability of reporting within couples was assessed prospectively. HIV-1 seroconversion was determined in the uninfected partners, and HIV-1 viral load was measured in the infected partners. Adjusted rate ratios of transmission per coital act were estimated by Poisson regression. Probabilities of transmission per act were estimated by log-log binomial regression for quartiles of age and HIV-1 viral load, and for symptoms or diagnoses of sexually transmitted diseases (STDs) in the HIV-1-infected partners. The mean frequency of intercourse was 8.9 per month, which declined with age and HIV-1 viral load. Members of couples reported similar frequencies of intercourse. The overall unadjusted probability of HIV-1 transmission per coital act was 0.0011 (95% CI 0.0008-0.0015). Transmission probabilities increased from 0.0001 per act at viral loads of less than 1700 copies/mL to 0.0023 per act at 38 500 copies/mL or more (p=0.002), and were 0.0041 with genital ulceration versus 0.0011 without (p=0.02). Transmission probabilities per act did not differ significantly by HIV-1 subtypes A and D, sex, STDs, or symptoms of discharge or dysuria in the HIV-1-positive partner. Higher viral load and genital ulceration are the main determinants of HIV-1 transmission per coital act in this Ugandan population.
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Age- and sex-specific HIV-1 prevalence in the urban community setting of Addis Ababa, Ethiopia
Article
  • Feb 1998
Objective: To estimate the age and sex-specific prevalence of HIV infection in the population of Addis Ababa, Ethiopia. Design: Two-stage cluster sampling of the population aged 0-49 years of Addis Ababa, using kebeles (urban dwelling associations) as clusters. Methods: The sera used for this study were collected in an earlier study (1994) on the rate of acquisition of antibodies against measles, rubella, and hepatitis B. After separate approvals were obtained from the institutional ethics committees, sera were tested by enzyme-linked immunosorbent assay confirmed by Western blot. Age- and sex-specific HIV prevalence rates were estimated. The prevalence of HIV in men and women over 15 years of age was compared by calculating age-standardized HIV prevalence, using the age distribution of the census population as the standard. A time-dependent catalytic model was used to obtain crude estimates of HIV incidence from age-prevalence data. Results: A total of 3853 sera were available for analysis. The prevalence of HIV in adults was 6.0% [95% confidence interval (CI), 4.5-7.4%] for men and 6.9% (95% CI, 5.3-8.5%) for women, with peak prevalence in the 25-29 year age group of 16.3 and 11.8%, respectively. After standardization for age using the direct method, the HIV prevalence ratio comparing adult men with women was 0.97: 1 (95% CI, 0.70: 1 - 1.35: 1). Three children aged less than 5 years were HIV-positive. The prevalence of HIV among adults ranged from 0-21.3% in different clusters, indicating the heterogeneity of the spread of HIV in the city. HIV prevalence estimates among the antenatal clinic patients of Addis Ababa in 1996 far exceeded the estimates obtained during the community survey, particularly in the youngest age group (15-24 years). Estimates of HIV incidence (per susceptible person per annum) for the age group 16-22 years ranged from 1.3-2.25% for men and from 2.1-2.4% for women. Conclusion: By 1994, a substantial proportion of the adult population of Addis Ababa was infected with HIV. Promotion of behavioural changes and the control of sexually transmitted diseases should be strongly supported to limit the spread of the HIV epidemic in Ethiopia.
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The Social Dynamics of HIV Transmission as Reflected Through Discordant Couples in Rural Uganda
Article
  • Aug 1995
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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For the European Study Group of Heterosexual Transmission of HIV “A Longitudinal Study of Human Immunodeficiency Virus Transmission by Heterosexual Partners”
Article
  • Sep 1994
Worldwide, the predominant mode of human immunodeficiency virus (HIV) transmission is heterosexual intercourse, but the risk of heterosexual transmission and the effectiveness of measures to prevent it are not well defined. We conducted a prospective study of HIV-negative subjects whose only risk of HIV infection was a stable heterosexual relationship with an HIV-infected partner. Every six months the subjects were interviewed, tested for HIV, and counseled about safe sexual practices. A total of 304 HIV-negative subjects (196 women and 108 men) were followed for an average of 20 months. During the study, 130 couples (42.8 percent) ended their sexual relationships, most often because of the HIV-infected partner's illness or death. Of the 256 couples who continued to have sexual relations for more than three months after enrollment in the study, only 124 (48.4 percent) used condoms consistently for vaginal and anal intercourse. Among these couples, none of the seronegative partners became infected with HIV, despite a total of about 15,000 episodes of intercourse. Among the 121 couples who used condoms inconsistently, the rate of seroconversion was 4.8 per 100 person-years (95 percent confidence interval, 2.5 to 8.4). Eleven couples refused to answer questions about condom use. The risk of transmission increased with advanced stages of HIV infection in the index partners (P < 0.02) and with genital infection in the HIV-negative partners (P < 0.04). Withdrawal to avoid ejaculation in the vagina had a protective effect in uninfected women (P < 0.02). Consistent use of condoms for heterosexual intercourse is highly effective in preventing the transmission of HIV. Among couples not using condoms regularly, the risk of HIV transmission varies widely.
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Sentinel Surveillance and Cross Sectional Survey on HIV Infection Prevalence: A Comparative Study
Article
  • Jun 1996
  • East Afr Med J
Despite widespread use of sentinel surveillance systems in monitoring the magnitude of HIV-1 infection in populations, little is known of how the trends they produce compare with those of the larger populations which they support to represent. The objective of this study, therefore, was to assess how useful sentinel surveillance data on HIV-1 infection might be in estimating the magnitude of HIV-1 infection in the general population. To achieve this, results from a population based study on HIV-1 infection in Bukoba town were compared with those from antenatal mothers and blood donors, all from the same town. The studies were done during the period of 1987-90. The overall HIV-1 prevalence was highest in the general population sample at 24.2% (95% CI 20.6-27.8) followed by that in antenatal mothers at 22.4% (95% CI 20.6-25.2) and lowest in blood donors at 11.9% (95% CI 9.1-15.3). Seroprevalence among antenatal clinic attenders was significantly lower than that of females from the general population sample (p = 0.016). Prevalence among female blood donors did not differ significantly from that of females from the general population sample (p = 0.06). Blood donor males had a lower HIV-1 seroprevalence when compared to that from the general population males (p = 0.038). The age group 25-34 years had the highest prevalence of HIV-1 infection in all the three populations indicating that this group is at the highest risk of HIV infection and that the three populations show a similar trend of age specific prevalence. From these findings, it is noted that female blood donors as a sentinel population represents more closely estimates of HIV-1 seroprevalence of females in the general population than antenatal clinic attenders or male blood donors. Further studies are proposed in different settings in order to come up with guidelines on the methodology of using sentinel surveillance populations in monitoring HIV-1 infection.
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Heterosexual Transmission of Human Immunodeficiency Virus (HIV) in Northern California: Results from a Ten-year Study
Article
  • Aug 1997
  • AM J EPIDEMIOL
To examine rates of and risk factors for heterosexual transmission of human immunodeficiency virus (HIV), the authors conducted a prospective study of infected individuals and their heterosexual partners who have been recruited since 1985. Participants were recruited from health care providers, research studies, and health departments throughout Northern California, and they were interviewed and examined at various study clinic sites. A total of 82 infected women and their male partners and 360 infected men and their female partners were enrolled. Over 90% of the couples were monogamous for the year prior to entry into the study; < 3% had a current sexually transmitted disease (STD). The median age of participants was 34 years, and the majority were white. Over 3,000 couple-months of data were available for the follow-up study. Overall, 68 (19%) of the 360 female partners of HIV-infected men (95% confidence interval (CI) 15.0-23.3%) and two (2.4%) of the 82 male partners of HIV-infected women (95% CI 0.3-8.5%) were infected. History of sexually transmitted diseases was most strongly associated with transmission. Male-to-female transmission was approximately eight-times more efficient than female-to-male transmission and male-to-female per contact infectivity was estimated to be 0.0009 (95% CI 0.0005-0.001). Over time, the authors observed increased condom use (p < 0.001) and no new infections. Infectivity for HIV through heterosexual transmission is low, and STDs may be the most important cofactor for transmission. Significant behavior change over time in serodiscordant couples was observed.
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Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners
Article
  • Jul 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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