Kenly Sikwese Treatment Advocacy And Literacy Campaign Representing GNP+

1. Ethical considerations and community issues for implementing CHTC and ART for serodiscordant couples Kenly Sikwese Treatment Advocacy And Literacy Campaign Representing GNP+

2. Why CHTC • HIV transmission occurs frequently within stable relationships, including married couples…. Even when they are aware of their and their partners status

3. Increased risk of HIV transmission in serodiscordant couples wishing to conceive • “Harm reduction interventions to avoid HIV transmission in heterosexual, serodiscordant couples who wish to have children are urgently needed", Dr Sara Brubaker, Kenya • Kisumu, Kenya – serodiscordant couples continue to conceive despite knowledge of serostatus, couples who conceived were at 80% increased risk of HIV transmission between the partners. • CHTC studies in central Africa have shown that condom use increases when couples learn about their discordant status but 20- 43% couples continue to have unprotected intercourse despite knowledge of their serostatus - often motivated by the desire to have children. • 10.8% of individuals who conceived or whose partner conceived acquired HIV, compared to only 5.9% in those where no pregnancy occurred.

4. Behavioural interventions are important but other choices are needed • VCT centre Lusaka, Zambia (Susan A. et al) • 963 cohabiting discordant heterosexual couples were assessed for sexual behaviour following VCT • <3% of couples reported current condom use prior to VCT. • After VCT, > 80% of reported acts of intercourse with condom use. • Reporting 100% condom use was associated with 39-70% reductions in biological markers; • 50% of sperm and 32% of pregnancies and HIV transmissions were detected when couples had reported "always using condoms". • DNA sequencing confirmed that 87% of new HIV infections were acquired from the spouse.

5. The study concluded… • Joint VCT prompted sustained but imperfect condom use in HIV discordant couples. • Biological markers were insensitive but provided evidence for a significant under-reporting of unprotected sex. • The impact of prevention programs should be assessed with bothbehavioural and biologicalmeasures.

6. Key points… • CHTC is effective, necessary and needs scaling-up • Discordant couples do have unprotected sex • HIV between discordant couples does occur • A range of choices needed

7. Opportunity for CHTC abound across different modes of testing • In ANC/PMTCT • In clinical settings • In VCT

8. But what are some of the ethical Issues… • In ANC/PMTCT • Informed Consent more than just signing a piece of paper… • Pretest counseling – full information including treatment options for results whether sero-discordant or sero concordant relationships • Disclosure must be supportive and decided by the client without coercion • Follow-up must be provided to prevent gender based violence • Mishandling… can affect others e.g. children get infected… then face stigma and discrimination from their peers or rejection by one’s own family • Full complement of family planning services and choices must be given • Proactively seek to involve men

9. Good counselling essential • “I also told him that it doesn’t matter who gave who what, that I would stick by him regardless. He said the same, and he’s been supportive ever since.” • “As soon as I told him that the nurse said he must come with me for my next antenatal visit, he asked me why and said if it is HIV, it is you who infected me” (Client in an adherence counselling session Lusaka)

10. Ethical issues in clinical settings • Non-judgmental • Non-discriminatory nor stigmatising • Conception options must be given as a routine SRHR • Sensitive to the needs of patients/clients • Prevention strategies must be offered that include behaviour change and biomedical options

11. Ethical issues in VCT • “It was a horrible experience, the counsellor did not tell me very much, it was as if she was interviewing me, reading off the paper and not looking at me. There was no personal connection between myself and her, and I didn’t feel reassured when she told me I was positive.” • Empathy… empathy… empathy

12. PHDP and CHCT • The primary goals of Positive Health, Dignity and Prevention are to improve the dignity, quality and length of life of people living with HIV which, in turn, will have a beneficial impact on partners, families and communities, including reducing the likelihood of new infections. • Specifically, this requires promoting and affirming the empowerment of people living with HIV

13. Parting notes… • Policy makers, programme managers must involve PLHIV in formulation, design and implementation of CHTC • Counsellors must be retrained and routinely retrained to ensure QA • Rights based approach • CHTC must be scaled up in many settings • Treatment for prevention and PreP must be provided as a right to discordant couples • CHTC works and countries will have to decide how to prioritise – Zambia is making choices • Lancet notes …unethical for a medical practitioner not to offer treatment for prevention given the HPTN 052 results