Abstract
BackgroundIn order to inform prevention programming, we analyzed HIV discordance and concordance within couples in the Kenya AIDS Indicator Survey (KAIS) 2007.MethodsKAIS was a nationally representative population-based sero-survey that examined demographic and behavioral indicators and serologic testing for HIV, HSV-2, syphilis, and CD4 cell counts in 15,853 consenting adults aged 15–64 years. We analyzed interview and blood testing data at the sexual partnership level from married or cohabitating couples. Multivariable regression models were used to identify factors independently associated with HIV discordant and concordant status.ResultsOf 3256 couples identified in the survey, 2748 (84.4%) had interview and blood testing data. Overall, 3.8% of couples were concordantly infected with HIV, and in 5.8% one partner was infected, translating to 338,000 discordant couples in Kenya. In 83.6% of HIV-infected Kenyans living in married or cohabitating couples neither partner knew their HIV status. Factors independently associated with HIV-discordance included young age in women (AOR 1.5, 95% CI: 1.2–1.8; p<0.0001), increasing number of lifetime sexual partners in women (AOR 1.5, 95% CI: 1.3–1.8; p<0.0001), HSV-2 infection in either or both partners (AOR 4.1, 95% CI: 2.3–7.2; p<0.0001), and lack of male circumcision (AOR 1.6, 95% CI: 1.0–2.5; p = 0.032). Independent factors for HIV-concordance included HSV-2 infection in both partners (AOR 6.5, 95% CI: 2.3–18.7; p = 0.001) and lack of male circumcision (AOR 1.8, 95% CI: 1.0–3.3; p = 0.043).ConclusionsCouple prevention interventions should begin early in relationships and include mutual knowledge of HIV status, reduction of outside sexual partners, and promotion of male circumcision among HIV-uninfected men. Mechanisms for effective prevention or suppression of HSV-2 infection are also needed.
Highlights
Sub-Saharan Africa has the highest prevalence and incidence of HIV infection worldwide, mostly attributable to heterosexual transmission [1]
HIV transmission in couples has been associated with high HIV viral load [10], lack of male circumcision [11], extramarital sex [5], low literacy [12], ignorance of self or partner’s HIV status [8], limited understanding that HIV discordance can exist within couples [13], and other sexually transmitted infections [14,15]
Modeling suggests that HIV transmission in heterosexual partnerships is reduced by antiretroviral treatment (ART) [16], and there are a number of observational studies that have shown this empirically [17,18]
Summary
Sub-Saharan Africa has the highest prevalence and incidence of HIV infection worldwide, mostly attributable to heterosexual transmission [1]. In Africa, there is increasing evidence that a large proportion of new HIV infections occur in cohabitating couples [2,3], many of whom are unaware of both partners’ sero-status [4,5]. In East Africa, 40–50% of married or cohabitating HIV-infected persons are in an HIV-discordant partnership [6]. In Kenya, Uganda and Malawi, over 80% of all unprotected sex acts by HIV-infected persons occur with spouses or cohabitating partners [7,8]. A high proportion of incident HIV infections occur within married or cohabitating heterosexual couples, e.g., in Uganda 65% (2004– 5) [9] and in Zambia (2001–2) and Rwanda, an estimated 52– 93% (2005) [3]. In order to inform prevention programming, we analyzed HIV discordance and concordance within couples in the Kenya AIDS Indicator Survey (KAIS) 2007
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