hiv status among discordant couples in sub-saharan africa: a meta-analysis involving more than...
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HIV status among discordant couples in sub-Saharan Africa: A meta-analysis
involving more than 13,000 discordant couples
Oghenowede Eyawo,1 Damien de Walque,2 Nathan Ford,3 Gloria Gakii,4 Richard Lester,5 Edward Mills6
1)Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada; 2) Development Research Group, The World Bank, Washington DC, USA; 3) Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa; 4)Pumwani Sex-worker Cohort, University of Nairobi, Nairobi, Kenya; 5)Department of Microbiology, Faculty of Medicine, University of Nairobi, Nairobi, Kenya; 6)Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
Sero-discordancy and sub-Saharan Africa
The first Demographic and Health Survey (DHS) suggest: in at least two thirds of couples where at least one of the
partners is HIV-positive, only one person is infected Sero-discordant couples make up a significant number
(2/3) of infected couples A substantial # of infections continue to occur within
individuals living in a stable relationship Persons in sero-discordant couple relationship are at
particularly high risk of becoming infected
Objectives
The relative HIV-burden within heterosexual discordant partnerships in sub-Saharan Africa is, in fact, poorly understood.
The objective of this study is to determine the gender balance of index case infections among sero-discordant couples in sub-Saharan Africa
Methods
We undertook a systematic review of sero-discordancy in stable relationships to determine the gender balance of index case infections in the region.
HIV-discordancy in a relationship: as one existing among married as well as unmarried couples that are in a stable habitual relationship.
Methods
Extensive search: we examine published and unpublished data
Secondary analysis: used supplemental data from DHS survey from 14 countries in sub-Saharan Africa
Methods
We conducted a random effects meta-analysis and meta-regression analysis to evaluate overall proportion of HIV-index cases
We examined gender gap score by country, urban vs. rural populations, HIV prevalence, mean age difference between men and women
We conducted a sensitivity analysis of pooled cohort proportion to ensure there was no duplication
Analysis: StatsDirect (version 2.7.6, Manchester) and STATA (version 10.0, College Station, TX)
Results
Primary data: 25 distinct cohorts in 7 countries + 3 multi-country cohorts, totaling 12,865 couples
Ave. follow-up: 27.3 months (range 9-84)
Secondary data: DHS data from 14 countries totaling 1,145 couples
Results
Pooled overall DerSimonian-Laird analysis (primary data):
F+ M- couples in stable heterosexual sero-discordant relationships at 47% (95% CI: 43-52%)
Demonstrates no significant difference in the # of female +ve couples compared to male +ve sero-discordant couples
Meta-analysis Results: primary data
Forest plot showing results of the random effects meta-analysis (27 studies)
Meta-analysis Results: primary data
Forest plot showing results of the random effects meta-analysis (27 studies)
Meta-analysis Results: secondary data
Forest plot showing results of the random effects meta-analysis (14 studies)
Meta-analysis Results: secondary data
Forest plot showing results of the random effects meta-analysis (14 studies)
Results
Large variability Meta-regression primary analysis: association
with effect size: Urban vs. rural residence Latitude Gender equity Older age
DHS data: meta-regression Gender equity Decreased HIV prevalence
Important Findings
A significant proportion of infected couples have women as the infected partner
On average, women are as likely to be the index partner as men in a sero-discordant couple
Discussion
These findings seem counter-intuitive to the large body of opinion demonstrating male sexual behaviours and risk taking
Reflects research bias in part
Relatively fewer studies examine women sexual risk taking in stable relationships
Necessary Emphasis
It is important to emphasise that:
This study is not aimed at assigning blame to either gender
We hope this study will stimulate a more gender-balanced approach in the orientation of behavioural research and prevention interventions
Strength & Limitations
We searched extensively both published and unpublished data
We are aware that there are many more unpublished cohorts existing within routine programme, including cohorts in which discordant couples may not be aware of their status
We supplemented our searches with DHS data
Conclusions
Implications for Prevention Strategies This review provide a fresh basis for discussions
and action points that can guide HIV/AIDS programming.
Sero-discordant couples, especially uninfected partners should be a priority prevention target group
In particular, programmes focusing on sero-discordant couples should be planned to equally target both men and women alike.
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