Sarah Khanakwa

Decisions, decisions: the importance of condom use decision making among HIV sero-discordant couples in a prospective cohort study in Uganda

Objectives We examined sexual decision making type among couples in HIV sero-discordant partnerships in Uganda, and investigated how sexual decision making type changed over time and its effect on condom use. Methods Data were drawn from a longitudinal cohort of HIV sero-discordant couples, recruited through the AIDS Support Organisation in Jinja, Uganda. Sexual decision making was measured using the Sexual Relationship Power Scale, and couples’ individual self-report answers were matched to assess agreement for decision making type and condom use. Generalised linear mixed effects modelling was used to assess statistically significant differences in time trend of sexual decision making type, and to investigate the independent association of decision making type on condom use status over time. Results Of the 533 couples included in this analysis, 345 (65%) reported using condoms at last sex at study enrolment. In the time trend analysis of decision making, the proportion of couples who decided together increased over time while the proportions of couples who reported that one partner decided or no one decided/did not use condoms, decreased over time (overall p<0.001). Compared with couples who decided together, those who disagreed (adjusted OR=0.42, 95% CI 0.28 to 0.64) and those where one partner decided (adjusted OR=0.20, 95% CI 0.12 to 0.34) had significantly lower odds of condom use at last sex, even after controlling for confounders. Conclusions Couples who disagreed on decision making, or agreed that one partner decides alone, had significantly lower odds of reporting condom use compared with couples who decided together. HIV counselling interventions that encourage joint sexual decision making may improve condom use within this population.

Lack of Effectiveness of Antiretroviral Therapy in Preventing HIV Infection in Serodiscordant Couples in Uganda: An Observational Study.

Background We examined the real-world effectiveness of ART as an HIV prevention tool among HIV serodiscordant couples in a programmatic setting in a low-income country. Methods We enrolled individuals from HIV serodiscordant couples aged ≥18 years of age in Jinja, Uganda from June 2009 – June 2011. In one group of couples the HIV positive partner was receiving ART as they met clinical eligibility criteria (a CD4 cell count ≤250 cells/ μL or WHO Stage III/IV disease). In the second group the infected partner was not yet ART-eligible. We measured HIV incidence by testing the uninfected partner every three months. We conducted genetic linkage studies to determine the source of new infections in seroconverting participants. Results A total of 586 couples were enrolled of which 249 (42%) of the HIV positive participants were receiving ART at enrollment, and an additional 99 (17%) initiated ART during the study. The median duration of follow-up was 1.5 years. We found 9 new infections among partners of participants who had been receiving ART for at least three months and 8 new infections in partners of participants who had not received ART or received it for less than three months, for incidence rates of 2.09 per 100 person-years (PYRs) and 2.30 per 100 PYRs, respectively. The incidence rate ratio for ART-use was 0.91 (95% confidence interval 0.31-2.70; p=0.999). The hazard ratio for HIV seroconversion associated with ART-use by the positive partner was 1.07 (95% CI 0.41-2.80). A total of 5/7 (71%) of the transmissions on ART and 6/7 (86%) of those not on ART were genetically linked. Conclusion Overall HIV incidence was low in comparison to previous studies of serodiscordant couples. However, ART-use was not associated with a reduced risk of HIV transmission in this study.

Gendered HIV risk patterns among polygynous sero-discordant couples in Uganda

Stable serodiscordant relationships and sexual concurrency are pathways that contribute to the HIV epidemic in sub-Saharan Africa. However whether polygyny imparts the same risks as informal concurrent relationships remains an open research question. Using data collected at enrolment from a cohort study of sero-discordant couples, this analysis investigates how polygynous relationships differ from those involving only a single female spouse and whether men involved in polygynous partnerships are more likely to report HIV-risk behaviour than those in single spouse partnerships. Of 444 enrolled couples, 111 (25%) were polygynous and 333 (75%) were single-spouse partnerships. We found that polygynous men were more likely to report controlling sexual decision-making and to report any unprotected sex with unknown sero-status partner. After controlling for potential confounders, polygynous men were still more likely to report unprotected sex with an unknown sero-status partner. In this sample of sero-discordant couples we found indication of excess HIV-risk behaviour among men involved in polygynous relationships.

Safer Conception Methods and Counseling: Psychometric Evaluation of New Measures of Attitudes and Beliefs Among HIV Clients and Providers.

With data from 400 HIV clients with fertility intentions and 57 HIV providers in Uganda, we evaluated the psychometrics of new client and provider scales measuring constructs related to safer conception methods (SCM) and safer conception counselling (SCC). Several forms of validity (i.e., content, face, and construct validity) were examined using standard methods including exploratory and confirmatory factor analysis. Internal consistency was established using Cronbach’s alpha correlation coefficient. The final scales consisted of measures of attitudes towards use of SCM and delivery of SCC, including measures of self-efficacy and motivation to use SCM, and perceived community stigma towards childbearing. Most client and all provider measures had moderate to high internal consistency (alphas 0.60–0.94), most had convergent validity (associations with other SCM or SCC-related measures), and client measures had divergent validity (poor associations with depression). These findings establish preliminary psychometric properties of these scales and should facilitate future studies of SCM and SCC.

Effect of Couples Counselling on Reported HIV Risk Behaviour among HIV Serodiscordant Couples by ART Use, HIV Status and Gender in Rural Uganda.

Background We examined several measures of self-reported HIV risk behaviour in mutually disclosed sero-discordant couples over time to see if a couples counselling intervention was associated with changes in these behaviors. Methods We analysed data from a prospective cohort study of HIV sero-discordant couples in Jinja, Uganda collected between June 2009 and December 2011. Participants received couples counselling, at 3-monthly intervals. We examined trends in reported condom-use, number of concurrent sexual partners, knowledge of HIV serostatus of concurrent partners and condom use of concurrent partners using Generalized Estimating Equation models, comparing responses at study enrollment with responses at six, 12 18 and 24 months of follow-up. Results A total of 586 couples were enrolled and the female member was HIV positive in 255 (44%) of them. The median age for female participants was 35 years and 42 years for men. Reported condom use at last sex with spouse increased over time (p<0.001) with the largest increases found among couples where the positive participant never received ART during the study(an increase from 68.8% at enrollment to 97.1% at 24 months). Male participants reported reductions in the number of concurrent sexual partners (p<0.001), increase in the knowledge of the HIV serostatus of these partners (p = 0.001) and a trend towards improved condom-use among non-primary partners (p = 0.070). Reported reduced risky behaviors did not wane over the study period. Conclusion Couples counselling resulted in increased condom use among all participants and among men the intervention resulted in reductions in risk behaviour with concurrent sexual partners. Routine counselling for serodiscordant couples should be integrated in routine ART care programs.

‘He said, she said’: assessing dyadic agreement of reported sexual behaviour and decision-making among an HIV sero-discordant couples cohort in Uganda

Background The intimate nature of sexuality makes it challenging to accurately measure sexual behaviour. To assess response reliability, we examined agreement between couples in heterosexual HIV sero-discordant partnership on survey questions regarding condom use and sexual decision-making. Methods Data for this analysis come from baseline data from a cohort study of HIV sero-discordant couples in Jinja, Uganda. We examined the degree of agreement between male and female partners on standard measures of sexual behaviour using the kappa (κ) statistic and 95% confidence intervals (95% CIs). Results Among 409 couples, the median age for the male partner was 41 [interquartile range (IQR) 35–48] years and the female partner was 35 (IQR 30–40) years. Among 58.2% of the couples, the male was the HIV-positive partner. Questions with high or substantial couple agreement included condom use at last sex (κ=0.635, 95% CI 0.551–0.718) and frequency of condom use (κ=0.625, 95% CI 0.551–0.698). Questions with low or fair couple agreement included decision-making regarding condom use (κ=0.385, 95% CI 0.319–0.451), wanting more biological children (κ=0.375, 95% CI 0.301–0.449) and deciding when to have sex (κ=0.236, 95% CI 0.167–0.306). Conclusions Survey questions assessing condom use had the highest level of couple agreement and questions regarding sexual decision-making and fertility desire had low couple agreement. Questions with high agreement have increased reliability and reduced measurement bias; however, questions with low agreement between couples identify important areas for further investigation, particularly perceived relationship control and gender differences.

Gendered sexual risk patterns and polygamy among HIV sero-discordant couples in Uganda

Background Multiple sexual partnerships and HIV sero-discordant relationships are among the most at-risk for HIV transmission. Polygamy is a common form of multiple-partnered relationships in Eastern Uganda. We investigated the association between HIV risk patterns and polygamy among HIV sero-discordant couples at The AIDS Support Organization in Jinja, Uganda Methods Participants were enrollees in a prospective cohort of HIV sero-discordant couples, the Highly Active Antiretroviral therapy as Prevention (HAARP) Study at TASO Jinja. Descriptive and bivariate analyses to compare sexual risk patterns among HIV sero-discordant men; in polygamous as compared to single-spouse relationship. Results Polygamous Vs Single-spouse couples ≥ 2w ives 1w ife P value N = 241 56 185 Male HIV+ve 38 (68%) 99 (54%) 0.065 Male-controlled sexual decision making 34 (61%) 66 (36%) 0.001 Male-controlled condom use 33 (59%) 51 (28%) <0.001 Condom last time had sex 45 (80%) 128 (69%) 0.086 Financial support 45 (80%) 152 (82%) 1.00 HIV positive partner on ART 24 (37%) 88 (48%) 0.143 Median age (IQR) 44 (39– 50) 43 (37– 50) 0.451. Conclusion This study demonstrates continued gendered risks for women in HIV sero-discordant relationships in subSaharan Africa. In particular, men with 2 or more wives are more likely to make decisions about when to have sex or when to use a condom. However, we found no differences in condom use at last sex by polygamy status.