Missed Opportunities for HIV Infection Prevention in HIV Sero-Discordant and X-Negative Concordant Couples

Abstract

Most HIV-1 transmission in Africa occurs among HIV-1-discordant couples (in which one partner is HIV-infected while the other one is not) who are unaware of their discordant HIV1 serostatus (1). HIV-negative individuals living in stable HIV-discordant partnerships are twice as likely to get infected with HIV as those living in concordant HIV-negative relationships (2). The percentages of couples in HIV sero-discordant relationships range from 5 to 31% in the various countries of Africa (3). In a study conducted at five sub-Saharan HIV affected countries, at least two thirds of the infected couples are discordant couples. Between 30 and 40 percent of the infected couples are couples where the female partner only is infected (4). The risk of HIV transmission through sexual intercourse from an HIVpositive male to an HIV-negative female was estimated as being around 1 in 10 for less than 10 unprotected contacts and around 1 in 4 after 2,000 contacts(5). What accounts for high rates of HIV-1 discordance and why some individuals remain uninfected despite repeated sexual exposure to HIV-1 is unknown. StudyingHIV-1-discordant couples may contribute to understanding correlates of HIV-1 immunity and acute infection. Additionally, HIV-1discordant couples are an important population for prevention efforts. Consequently, HIV1-discordant couples are increasingly viewed as a valuable source of participants for HIV vaccine and prevention trials(6). Misconceptions about discordance are widespread among clients and counselors. Common explanations includes: the concept of a hidden infection not detectable by HIV tests, belief in immunity, the thought that gentle sex protected HIV-negative partners. Such explanations for discordance reinforce denial of HIV risk for the negative partner within discordant couples and potentially increases transmission risk. Couples identify negotiation of sexual relations as their most formidable challenge. Discordant couples represent a critical risk group and improved counseling protocols that clearly explain discordance, emphasize high risk of transmission, and support risk reduction are need(7) The need for conception seems to lead couples to HIV infection. HIV sero-discordant couples with strong desire for childbearing have a dilemma of risking HIV infection or