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R.R.
Frerichs Posting
Clive Wing (April 10, 1996) and Dr. Alessio Panza (April 22, 1996) have
focused on the importance of programs to keep partners of HIV infected
persons free of infection. If others are interested, I am including 10
articles and their abstracts that address this issue, to be included as
a stored text file entitled, "Research on HIV transmission in heterosexual
couples."
1.
Dublin, S., Rosenberg, P.S., and Goedert, J.J. Patterns and predictors of
high-risk sexual behavior in female partners of HIV-infected men with
hemophilia. Aids 6(5):475-482, 1992.
OBJECTIVE:
To characterize and quantify high-risk heterosexual activity in HIV-discordant
couples. DESIGN: Analysis of cross- sectional and longitudinal questionnaire
data from 217 HIV- negative female sexual partners of HIV-infected hemophilic
men. METHODS: Comparison of prevalence rates of anal sex, oral sex, vaginal
intercourse with or without condoms, and use of other contraceptives between
1985 and 1991. Logistic regression analysis of demographic, sexual and clinical
variables to predict unprotected vaginal sex. Actuarial estimates of semi-annual
relapse rates to unsafe sex. RESULTS: The proportion of women at low risk
increased from 7 to 69% between 1985 and 1991, mainly because more women were
condoms during all acts of vaginal intercourse. Other contraceptive practices
did not change during this time. The proportion engaging in oral or anal sex
decreased (from 26 to 13% and 13 to 4%, respectively). Unprotected vaginal sex
was more common among women who enrolled earlier, had less education, engaged in
oral or anal sex, and among those whose partners had not had AIDS. Unprotected
vaginal sex before enrollment was the strongest predictor of this high-risk
activity during follow-up. Two-year rates of relapse to high-risk behavior were
significantly higher among women who enrolled at high risk compared with those
who enrolled at low risk (39 versus 8%, P = 0.005). CONCLUSIONS: Although
high-risk sexual behavior became much less prevalent in this population between
1985 and 1991, many continued to have unprotected vaginal sex occasionally.
Counseling efforts should target couples who have been the most sexually active
or have less education, and should emphasize not only initial risk reduction but
also maintenance of low-risk.
2.
Allen, S., Tice, J., Van de Perre, P., Serufilira, A., Hudes, E., Nsengumuremyi,
F., Bogaerts, J., Lindan, C., and Hulley, S. Effect of serotesting with
counselling on condom use and seroconversion among HIV discordant couples in
Africa. British Medical Journal 304:1605-1609, 1992.
OBJECTIVE
-- To determine whether HIV testing and counselling increased condom use and
decreased heterosexual transmission of HIV in discordant couples. DESIGN --
Prospective study. SETTING -- Kigali, the capital of Rwanda. SUBJECTS --
Cohabiting couples with discordant HIV serology results. MAIN OUTCOME
MEASURES--Condom use in the couple and HIV seroconversion in the negative
partners. RESULTS -- 60 HIV discordant couples were identified, of whom 53 were
followed for an average of 2.2 years. The proportion ofdiscordant couples using
condoms increased from 4% to 57% after one year of follow up. During follow up
two of the 23 HIV negative men and six of the 30 HIV negative women
seroconverted (seroconversion rates of 4 and 9 per100 person years). The rate
among women was less than half that estimated for similar women in discordant
couples whose partners had not been serotested. Condom use was less common among
those who seroconverted (100%v 5%, p = 0.01 in men; 67% v 25%, p = 0.14 in
women). CONCLUSIONS - - Roughly one in seven cohabiting couples in Kigali have
discordant HIV serological results. Confidential HIV serotesting with
counselling caused a large increase in condom use and was associated with a
lower rate of new HIV infections. HIV testing is a promising intervention for
preventing the spread of HIV in African cities.
3.
Kennedy, C.A., Skurnick, J., Wan, J.Y., Quattrone, G., Sheffet, A., Quinones,
M., Wang, W., and Louria, D.B. Psychological distress, drug and alcohol use as
correlates of condom use in HIV-serodiscordant heterosexual couples. Aids 7(11):1493-1499,
1993.
OBJECTIVE:
To investigate the relationship between psychological distress, alcohol, drug
and condom use in HIV-serodiscordant heterosexual couples. METHODS: Structured
interviews were conducted to collect demographic information, detailed data on
psychological distress, drug and alcohol use and sexual behavior. RESULTS:
Analyses were based on 106 pairs of sexually active discordant couples.
Significant differences among heterosexual condom users and non-users varied
according to gender and HIV serostatus. Affect domains of interpersonal
sensitivity and hostility were significant, as were the variables of regular
drug or alcohol use combining sex with drugs or alcohol. Employment was strongly
associated with condom use in HIV-negative women whose regular sexual partners
were HIV-positive men. CONCLUSION: The risk of vaginal sex without condoms in
HIV-serodiscordant heterosexual couples may be reduced by specific psychological
counseling and attention to drug and alcohol use as risk factors. Further
research on the effect of employment of HIV-negative women is required.
4.
Padian, N.S., O'Brien, T.R., Chang, Y., Glass, S., and Francis, D.P. Prevention
of heterosexual transmission of human immunodeficiency virus through couple
counseling. Journal of Acquired Immune Deficiency Syndromes 6(9):1043-1048,
1993.
In
the absence of an effective vaccine, behavior change remains the most effective
means to prevent the spread of HIV. We examined behavior change over time and
rates of HIV seroconversion in a cohort of HIV individuals and their
heterosexual partners recruited since 1985. Participants were recruited from
various HIV counseling and testing sources throughout California and were
usually interviewed and tested in their own homes. Couple counseling and risk
assessments were conducted at average intervals of six months. Data from 144
couples who were discordant for HIV serostatus are reported. Of the index cases,
78% were men. Most male index cases were bisexuals, and most female index cases
were infected through heterosexual intercourse with a previous sexual partner.
The mean duration of the relationship for the couple at intake was 5.6 years.
Both condom use and sexual abstinence increased over time (p < 0.001 for
both), and most behavior change occurred between intake and first follow-up
visit. We observed no seroconversion after 193 couple-years of follow-up. Couple
counseling in combination with social support appears to be an effective means
to promote and sustain behavior change among HIV-infected individuals and their
heterosexual partners.
5.
Saracco, A., Musicco, M., Nicolosi, A., Angarano, G., Arici, C., Gavazzeni, G.,
Costigliola, P., Gafa, S., Gervasoni, C., Luzzati, R., Peccinino, F., Puppo, F.,
Salassa, B., Sinicco, A., Stellini, R., Terelli, U., Turbessi, G., Vigevani, G.M.,
Visco, G., Zerboni, R., and Lazzarin, A. Man-to-woman sexual transmission of
HIV: longitudinal study of 343 steady partners of infected men. Journal of
Acquired Immune Deficiency Syndromes 6(5):497-502, 1993.
To
study incidence and risk factors of heterosexually transmitted HIV infection, we
followed a cohort of 343 seronegative women, stable, monogamous partners of
infected men whose only risk of acquiring HIV was sexual exposure to the
infected partner. Nineteen seroconversions occurred in 529.6 person years (py)
of observation, yielding an incidence rate of 3.6 per 100 py. The incidence rate
was 7.2 per 100 py among women who did not always use or never used condoms and
1.1 among those who always used them [relative risk (RR) 6.6, 95% confidence
interval (CI) 1.9-21.9]. Anal sex was associated with a risk increase in only
those women not always using condoms (RR 1.4, 95% CI 0.4-4.8). No
seroconversions were observed among 22 women using oral contraceptives. One of
the women using intrauterine devices seroconverted. In couples who did not
always use condoms, seroconversions occurred more frequently in partners of men
with symptomatic diseases, with a low CD4+ cell number (< 400 per mm3) or
with a detectable p24 antigen. In couples not always using condoms and where the
man had a low CD4+ cell count, the joint presence of blood viral antigens and
AIDS symptoms conditioned a fivefold increased risk of seroconversion of the
woman (RR 5.4, CI 1.4-20.3). At multivariate analysis, women with longer
relationships (> or = 1 year) showed a lower risk of seroconversion (RR 0.3,
CI 0.1-0.8), and those partners of men positive for p24 antigen in serum had an
increased risk of seroconversion (RR = 4.0, CI 0.1-0.8).
6.
Seidlin, M., Vogler, M., Lee, E., Lee, Y.S., and Dubin, N. Heterosexual
transmission of HIV in a cohort of couples in New York City [published erratum
appears in AIDS 1993 Nov;7(11): following 1541]. Aids 7:1247-1254, 1993.
OBJECTIVE:
Since heterosexual transmission of HIV in the United States is occurring at an
increasing rate, especially among black and Hispanic couples and those in which
one member has a history of intravenous drug use, we sought to study the
heterosexual transmission of HIV in couples. DESIGN: Multiple logistic
regression analysis of risks for HIV infection in female partners. METHODS: We
enrolled 158 non-intravenous drug user (IVDU) steady heterosexual partners of
HIV-infected individuals (indexes) in this study. Of these, 93% were women, 54%
were Hispanic whites, 23% were black and 65.6% were partners of IVDU. RESULTS:
In a multiple logistic regression analysis of risks for HIV infection in female
partners, the strongest predictors of transmission were AIDS or AIDS-related
complex (ARC) in the index [adjusted odds ratios (OR), 16.81; P < 0.001 and
12.53; P = 0.003, respectively], a history of anal intercourse (adjusted OR,
10.81; P < 0.001) and bleeding as a result of intercourse (adjusted OR, 4.90;
P < 0.05). Female-to-male transmission was detected in seven out of 11
couples at risk. Ethnicity, number of episodes of vaginal intercourse, number of
other sexual partners and history of sexually transmitted infections were not
significantly associated with transmission to women. CONCLUSION: Our study
demonstrates that health of the index, anal intercourse and bleeding as a result
of intercourse are the major determinants of sexual transmission of HIV to women
in couples.
7.
Foley, M., Skurnick, J.H., Kennedy, C.A., Valentin, R., and Louria, D.B. Family
support for heterosexual partners in HIV-serodiscordant couples. Aids 8(10):1483-1487,
1994.
OBJECTIVE:
To ascertain the extent of family member support to heterosexual HIV-serodiscordant
couples, and to identify associated sociodemographic and clinical
characteristics. DESIGN: Discordant couples enrolled in a cohort study of
heterosexual HIV transmission were interviewed with structured questionnaires to
obtain sociodemographic data,family member awareness of HIV and perceived
support from family members. Clinical characteristics were established by
medical history, physical examination and laboratory tests. RESULTS: Awareness
and support of family members were associated with sex of family member and HIV
seropositivity, sex, education, and race of the partner. HIV- seropositive
partners were more likely to have a sister aware than were HIV-negative partners
(P = 0.01). More educated HIV- positive partners had fewer aware family members
than less educated HIV-positive individuals (P = 0.02). Mothers ofHIV- positive
women were more often aware than mothers of all other partners (P = 0.04). Black
HIV-negative partners had fewer aware family members than whites or Hispanics (P
= 0.02). CONCLUSION: This research shows both encouraging and disturbing
patterns of family awareness of HIV and support to serodiscordant partners.
8.
Nicolosi, A., Correa Leite, M.L., Musicco, M., Arici, C., Gavazzeni, G., and
Lazzarin, A. The efficiency of male-to-female and female-to-male sexual
transmission of the human immunodeficiency virus: a study of 730 stable couples.
Italian Study Group on HIV Heterosexual Transmission [see comments].
Epidemiology. 5:570-575, 1994.
To
compare the efficiency of male-to-female and female-to- male sexual transmission
of human immunodeficiency virus (HIV), we studied 524 female partners of
HIV-infected men and 206 male partners of HIV-infected women in 16 Italian
clinical centers. All of the partners had had a sexual relationship with the
index case lasting for at least 6 months and presented no other risk factor than
sexual exposure to the HIV-infected partner. Among the 730 couples, 24% of the
female partners were HIV positive, in comparison with 10% of the male partners.
Using logistic regression analysis, including gender and controlling for condom
use, frequency of intercourse, anal sex, partner's CD4+ cell count and clinical
stage, sexually transmitted diseases, genital infections, and contraceptive use,
we found that the efficiency of male-to-female transmission was 2.3 (95%
confidence interval = 1.1-4.8) times greater than that of female-to-male
transmission. Between-gender differences in the contact surfaces and the
intensity of exposure to HIV during sexual intercourse are possible reasons for
the difference in efficiency of transmission.
9.
Nicolosi, A., Musicco, M., Saracco, A., and Lazzarin, A. Risk factors for
woman-to-man sexual transmission of the human immunodeficiency virus. Italian
Study Group on HIV Heterosexual Transmission. Journal of Acquired Immune
Deficiency Syndromes 7(3):296-300, 1994.
A
cross-sectional study of stable monogamous couples, recruited from16 clinical
and surveillance centers in Italy between 1987 and 1992, was carried out to
investigate the risk factors of woman-to-man sexual transmission of human
immunodeficiency virus (HIV). The male partners of all HIV-infected women
attending the centers were invited to participate in the study. Of the 275 male
partners who were tested for HIV and interviewed with use of a structured
questionnaire, 51 were excluded because they had other possible risk factor for
HIV infection, no established risk factor was found in the index case, or they
had stopped engaging in sexual intercourse. Fourteen of the 224 men (6.3%) were
seropositive for HIV. At logistic regression, the highest risks of transmission
were for men practicing peno-anal intercourse [odds ratio (OR), 4.6; 95%
confidence interval (CI), 1.0-22.2] and for men whose partner had acquired
immune deficiency syndrome (AIDS) or a CD4+ lymphocyte count of < or =
400/mm3. No seropositive men were observed among those who were aware of the
woman's HIV seropositivity since the beginning of the relationship or were
partners of a zidovudine-treated woman. The results suggest that the risk
factors described in man-to-woman and man-to-man HIV sexual transmission also
operate in woman-to- man transmission.
10.
Guimaraes, M.D., Munoz, A., Boschi-Pinto, C., and Castilho, E.A. HIV infection
among female partners of seropositive men in Brazil. Rio de Janeiro Heterosexual
Study Group. American Journal of Epidemiology 142:538-547, 1995.
A
heterosexual partner study was carried out in Rio de Janeiro, Brazil, from
August 1990 to December 1991. The main objectives were to determine the rate of
male-to-female transmission of human immunodeficiency virus (HIV) and to
determine risk factors. Male index cases were recruited according to the
following criteria: 1) confirmed HIV positivity, 2) 18 years old or older; 3)
heterosexual contact within the past year. Only female partners who reported not
to have other risk factors but to have had sexual contact with the index case
were invited to participate. Couples were interviewed for risk factors and had
blood collected for laboratory studies. The overall prevalence of HIV infection
was 45 percent among 204 female partners in the study. Using logistic
regression, the authors found the following factors to be independently (p <
0.05) associated with HIV infection: 1) anal sex (odds ratio (OR) = 3.74, 95%
confidence interval (CI) 1.87-7.45); 2) condom use during vaginal sex sometimes
(OR = 1.45, 95% CI 1.07-1.96), rarely (OR = 2.10, 95% CI 1.15-3.83), or never
(OR = 3.04, 95% CI 1.23-7.50) as compared with always; 3) frequency of sexual
contacts in the year prior to interview (100+) (OR = 2.00, 95% CI 1.03-3.91);
and 4) oral contraceptive use (OR = 2.04, 95% CI 0.97-4.29). In addition to a
borderline significance of oral contraceptive use, there was a strong suggestion
of an interaction with history of sexually transmitted diseases.
Once married couples learn from HIV antibody testing that one partner
is infected and the other is not, there is much that they can do to avoid
transmission. The problems facing officials in developing countries are
how to make such tests more widely available, how to educate discordant
couples (i.e., one is a carrier and the other is not) on ways to prevent
the virus from infecting the susceptible partner, and how to get communities
to be more accepting of those found to be infected.
The studies I have
cited on heterosexual discordant couples offer many insights, including
the importance of knowing your HIV status, always using condoms, practicing
withdrawal before ejaculation, and avoiding anal sex. They do not, however,
address how HIV testing should best be offered, or how HIV infected persons
can appropriately be accepted and integrated into the community. |
