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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 Mills 6

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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
Sero-discordancy and sub-Saharan Africa meta-analysis involving more than 13,000 discordant couples

  • 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


Social marketing prevention
Social Marketing: prevention meta-analysis involving more than 13,000 discordant couples


Social marketing prevention1
Social Marketing: prevention meta-analysis involving more than 13,000 discordant couples


Objectives
Objectives meta-analysis involving more than 13,000 discordant couples

  • 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
Methods meta-analysis involving more than 13,000 discordant couples

  • 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.


Methods1
Methods meta-analysis involving more than 13,000 discordant couples

  • Extensive search: we examine published and unpublished data

  • Secondary analysis: used supplemental data from DHS survey from 14 countries in sub-Saharan Africa


Methods2
Methods meta-analysis involving more than 13,000 discordant couples

  • 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
Results meta-analysis involving more than 13,000 discordant couples

  • 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


Results1
Results meta-analysis involving more than 13,000 discordant couples

  • 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
Meta-analysis Results: primary data meta-analysis involving more than 13,000 discordant couples

Forest plot showing results of the random effects meta-analysis (27 studies)


Meta analysis results primary data1
Meta-analysis Results: primary data meta-analysis involving more than 13,000 discordant couples

Forest plot showing results of the random effects meta-analysis (27 studies)


Meta analysis results secondary data
Meta-analysis Results: secondary data meta-analysis involving more than 13,000 discordant couples

Forest plot showing results of the random effects meta-analysis (14 studies)


Meta analysis results secondary data1
Meta-analysis Results: secondary data meta-analysis involving more than 13,000 discordant couples

Forest plot showing results of the random effects meta-analysis (14 studies)


Results2
Results meta-analysis involving more than 13,000 discordant couples

  • 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
Important Findings meta-analysis involving more than 13,000 discordant couples

  • 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
Discussion meta-analysis involving more than 13,000 discordant couples

  • 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
Necessary Emphasis meta-analysis involving more than 13,000 discordant couples

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
Strength & Limitations meta-analysis involving more than 13,000 discordant couples

  • 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
Conclusions meta-analysis involving more than 13,000 discordant couples

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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