Reframing HIV Prevention in Sub-Saharan Africa Using Couple-Centered Approaches

Despite modest prevention successes, 2.7 million new human immunodeficiency virus (HIV) infections occurred worldwide in 2008 and there were at least 2 million HIV-associated deaths.¹ Nearly 3 million persons in sub-Saharan Africa are now taking antiretroviral therapy (ART)¹ —an impressive accomplishment. The urgency of sustaining treatment for these patients, and reaching more than 15 million persons with unmet care and treatment needs,¹ underscores the need to reduce HIV incidence. HIV testing and counseling among serodiscordant couples has been associated with reduced transmission, increased condom use, and reduction in sex acts with outside partners^{2 - 3} as well as increased ART uptake among pregnant women in antenatal clinics.⁴ Reframing HIV prevention using a couple-centered approach could help enhance current prevention efforts.

Sexual HIV transmission occurs within couples. Couple types vary widely and may be polygamous or monogamous; casual or formal; between cohabiting or noncohabiting partners; among heterosexual, same-sex, or transgender persons; and among low-risk or higher-risk individuals such as injecting drug users and sex workers. Yet, to best identify viable HIV prevention options, all couple members should know the answers to 2 questions: what is my HIV status and what is my partner's HIV status?

Fundamental as these questions are for HIV prevention, few individuals can answer them. Among responding countries in sub-Saharan Africa, only 22% of adults aged 15 to 49 years know their HIV status.⁵ Cohabitation ranges from 56% in South Africa to more than 70% of adults in East Africa, and condom use within regular partnerships is very low.⁶ In East Africa, nearly half of cohabiting HIV-infected individuals are in an HIV-discordant relationship,⁷ and modeling suggests that 55% to 93% of new HIV infections occur within cohabiting relationships.^{3 ,8} Most transmissions occur within couples unaware of their HIV status.

Barriers to couples-centered testing are social, systemic, programmatic, and historical. Most HIV prevention, care, and treatment programs have focused on individuals rather than couples, making disclosure and partner testing a challenge. Many counselors and health care workers lack couples counseling skills, and introducing couples-centered services may strain overburdened staff. Most HIV care and treatment programs enroll individuals without partner testing. Programs to prevent mother to child HIV transmission test women in an antenatal clinic environment that is inconvenient and unwelcoming to male partners. Women who test alone in antenatal clinics bear the burden of disclosing their HIV status to male partners in settings where gender-based violence is pervasive and support services are sparse. In addition, men lack knowledge on discordance, face stigma, and may be more likely to have multiple partners, creating more barriers to couples HIV testing and counseling.

Currently expanding male circumcision programs appropriately target men but miss opportunities to make these services couple-centered. Much of Africa has experienced decades of messages suggesting marriage is safe from HIV, which reinforced low condom use rates among married persons. This status-blind HIV prevention approach resulted in messages such as “zero-grazing” and “love faithfully,” which may have unknowingly increased risk within serodiscordant couples. The largest barrier to HIV testing among undiagnosed HIV-affected couples in Kenya is their perception that they are at low risk, and many have low knowledge about HIV discordance.⁷

Multiple examples suggest that these barriers, while formidable, are surmountable. Although couples testing has not been associated with increased partner violence,⁹ fears about adverse consequences persist. Couples HIV testing and counseling expansion provides opportunities to address gender-imbalanced power dynamics, including relieving the burden of disclosure. Within couples HIV testing and counseling, prevention messages about partner reduction and condom use with any external partnerships can be integrated into counseling scripts for all couples; this is important because up to 29% of new HIV infections within serodiscordant couples may come from external partners.⁸ In Rwanda, where couples testing was integrated into the national prevention of mother to child transmission program in 2007 through performance-based financing for health centers and community mobilization, more than 80% of male partners of women attending antenatal clinics nationally were tested in 2009.¹⁰ Rwanda is now improving follow-up support services for serodiscordant couples, including strengthened record keeping and provision of comprehensive prevention, care, and treatment services for maintaining serodiscordance. Home-based HIV testing and counseling programs have achieved high couples rates, perhaps by creating new community norms around testing and ensuring that men can participate in couples HIV testing and counseling privately, without stigma, and at a convenient time.

Uganda has adopted national home-based HIV testing and counseling guidelines. Kenya has included partner HIV testing in national tuberculosis registers and is expanding partner testing using lay counselors in all tuberculosis, care and treatment, and antenatal care programs as part of a “Prevention with Positives” program. National-level implementation requires upfront training investment for persons providing couples HIV testing and counseling, but once implemented, couples HIV testing and counseling may increase efficiency and decrease costs of overall testing and counseling service delivery by counseling 2 individuals simultaneously and reducing time spent counseling individuals about partner disclosure.

A couple-focused approach to HIV prevention also provides opportunities for delivering comprehensive maternal and child health services, facilitating the new programmatic emphasis on maternal and child health. Prevention of mother to child transmission programs in a couples setting improves antiretroviral uptake among pregnant women,⁴ thereby reducing both sexual and vertical HIV transmission and providing an opportunity to address large unmet family planning needs. Male circumcision is an important option for HIV-negative men in discordant partnerships or with continued risk behavior, and involving female partners not only in couples testing but also in healing and condom use may improve outcomes following surgery. Moreover, because successful viral suppression can virtually eliminate transmission risk within discordant couples, ART provision and adherence is a critical long-term component of couples-based prevention. With ART, patients with HIV live much longer and may form new partnerships; HIV programs should provide ongoing partner testing services, not just at enrollment.

Follow-up services should be offered to couples based on their HIV serostatus and should include enrollment in care and treatment, routine retesting for HIV-uninfected partners, ongoing risk reduction counseling including reduced frequency of sex, condom provision, prevention of mother to child transmission services, family planning, and male circumcision for HIV-uninfected males in accordance with World Health Organization guidance. For couples in which gender-based violence is a concern, additional resources may be needed for ongoing services. For all couples, risk reduction with concurrent external partners either through abstinence or consistent condom use is important, and individuals with multiple partners may be encouraged to attend couples HIV testing and counseling with each partner.

Because only HIV-infected persons can spread HIV, prevention resources could be maximized by reaching HIV-infected persons and reducing transmission to their spouses and outside partners. Prioritizing scale-up by focusing on areas with high HIV prevalence could help maximize identification of HIV-affected couples. Ministries of Health should consider national policies and health systems approaches that strategically support identification of serodiscordant and concordant positive couples. This positive prevention approach could include the following: testing partners of patients receiving HIV care and treatment by using home and facility-based approaches; integrating partner testing into clinician-initiated HIV testing and counseling in health facilities, including tuberculosis and sexually transmitted disease clinics, inpatient and outpatient wards, and prevention of mother to child transmission programs; instituting door-to-door HIV testing in areas of high prevalence; and developing wide-scale, general HIV testing and counseling campaigns.

Globally, many incident HIV infections occur in established couples and millions of HIV-affected couples are unaware of their HIV status. Widespread implementation of couples HIV testing and counseling could increase universal knowledge of both individual and partner HIV status, alter societal and cultural norms around HIV prevention, and reduce HIV incidence. Couples-centered approaches to HIV prevention, care, and treatment may be critical for sustaining the historic investment and gains made in HIV treatment.