The HIV cascade of care among serodiscordant couples in four high HIV prevalence settings in sub-Saharan Africa

Abstract

HIV-negative individuals in a serodiscordant relationship are at high risk of HIV transmission. This risk of infection may increase if: (i) the partner living with HIV is not aware of their HIV status; [1,2] (ii) the partner living with HIV is not on antiretroviral therapy (ART), and therefore has an unsuppressed viral load (VL); and (iii) the couple is practising unsafe sex. Serodiscordant couples are thought to be a major source of HIV transmission in the sub-Saharan Africa region, [3] with studies estimating their contribution to be ~30% of all new infections occurring in this region. [4,5] There has recently been increasing evidence that the risk of HIV transmission to HIV-negative partners decreases when the positive partner is on ART. [6][7][8][9][10][11][12][13][14][15] A systematic review and meta-analysis [9] that assessed the risk of HIV transmission through unprotected sex according to VL and ART status, using data from 11 cohort studies between 1996 and 2009, found zero transmission among serodiscordant couples where the positive partner was on ART with a VL <400 copies/mL. In addition, other studies have shown the benefits of high ART coverage and VL suppression (VLS) in reducing the risk of transmission. [11,12,16] Results from the HIV Prevention Trials Network 052 trial showed that the risk of sexual transmission to the negative partner is greatly reduced if treatment is started early. [6,8] In 2012, the World Health Organization (WHO) released guidelines recommending that positive partners in discordant couples be started on ART regardless of CD4 cell count, [17] and the WHO 2015 guidelines [18] recommending universal ART irrespective of disease severity were at least partly aimed at reducing HIV transmission by achieving VLS in all people living with HIV (PLHIV). ObjectivesWhile there have been many studies quantifying the prevalence of serodiscordant couples, a limited number of publications have assessed the HIV cascade of care of PLHIV in serodiscordant relationships, especially in African countries and in the context of universal ART eligibility. Using population-level survey data, we quantified the prevalence of heterosexual HIV serodiscordant couples and evaluated the HIV cascade of care of PLHIV in serodiscordant relationships in four high HIV prevalence settings in sub-Saharan Africa to identify gaps in the cascade of care for this group. This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Frequency of HIV serodifferent couples within TB-affected households in a setting with a high burden of HIV-associated TB

“…In addition, four prevalence surveys conducted in Ndhiwa (Kenya), Chiradzulu (Malawi), Gutu (Zimbabwe) and Nsanje (Malawi), found an overall prevalence of 10.9% [26]. These estimates were comparable to the population-based AIS study in Uganda and lower than the estimate from our study.…”

“…Comparing to other settings, the prevalence of HIV serodifference among couples estimated from a population-based survey in Kenya was 5.8% [25]. In addition, four prevalence surveys conducted in Ndhiwa (Kenya), Chiradzulu (Malawi), Gutu (Zimbabwe) and Nsanje (Malawi), found an overall prevalence of 10.9% [26]. These estimates were comparable to the population-based AIS study in Uganda and lower than the estimate from our study.…”

Psychosocial support for HIV serodiscordant couples

“…The UNAIDS ( 2021 ) reported that in 2020, 65% of all new infections were from key populations and their partners. In addition, Chihana et al ( 2021 ) indicate that HIV-serodiscordant couples contribute 30% of all new infections in sub-Saharan Africa. Related to this, Ayele, Tegegne, Damtie, Chanie, and Mekonen ( 2021 ) state that heterosexual transmission within serodiscordant relationships is one of the major sources of new HIV infections, however, there is low condom use among these couples.…”

Frequency of HIV serodifferent couples within TB-affected households in a setting with a high burden of HIV-associated TB

“…Comparing to other settings, the prevalence of HIV serodifference among couples estimated from a population-based survey in Kenya was 5.8% [25]. In addition, four prevalence surveys conducted in Ndhiwa (Kenya), Chiradzulu (Malawi), Gutu (Zimbabwe) and Nsanje (Malawi), found an overall prevalence of 10.9% [26]. These estimates were comparable to the population-based UAIS study in Uganda [22] and lower than the estimate from our study.…”