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Keywords:

  • Africa;
  • Congo;
  • HIV-1;
  • AIDS;
  • fertility;
  • discordant couples;
  • cohort

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Subjects and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Summary To determine the effect of an HIV-1 counselling programme on rates of HIV-1 infection and pregnancy in a large group of married couples in Kinshasa, DRC with discordant HIV-1 infection status, we conducted a baseline cross-sectional HIV-1 seroprevalence study in two large Kinshasa businesses. We identified 178 married couples (mean duration of marriage = 12.3 years) with discordant HIV-1 serostatus (92 M+F-/86 M-F+). Seroincidence and pregnancy rates were observed during 310 person-years of follow-up (PYFU). The 92 M+F- couples had an HIV-1 incidence of 3.7/100 PYFU and a pregnancy rate of 8.6/100. The 86 M-F+ couples had a pregnancy rate of 6.8/100 PYFU and an HIV-1 incidence of 6.8/100 PYFU. Couples seeking to have children but minimize their HIV-1 transmission risk frequently had unprotected sex only during the woman's perceived monthly fertility period. This strategy resulted in the birth of 24 live-born children and only one (4%; 95% CL = 0.0–21.6%) new HIV infection in couples having a child. Only 1 of 6 women who developed HIV-1 infection (16.7%; 95 C.L. = 0–40.4%) became pregnant. While seronegative men had more extramarital sex once their wives' positive HIV-1 infection status became known, most of these episodes involved safe sex. Divorce was rare. This study provides additional information concerning issues of safe sex in married couples with discordant HIV-1 infection status, the dynamics of HIV transmission within couples and the effect of serostatus notification on the marriage and on intramarital and extramarital sexual behaviour in Kinshasa, Congo.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Subjects and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

In the absence of an effective vaccine, HIV prevention activities in resource-poor sub-Saharan countries have largely focused on prompt treatment of sexually transmitted diseases and modifying high risk sexual behaviour ( Grosskurth et al. 1995 ; Abdool Karim et al. 1997 ; Darrow 1997; Hearst & Mandel 1997; Wawer et al. 1998 ). The long-term efficacy of these programmes in this region has only infrequently been evaluated. Little data are available for counselling young married couples with discordant HIV-1 serostatus who wish to have children but who must weigh this desire against the requirement to forsake condom use and place the uninfected spouse at risk of HIV-1 infection.

In a previous report from Kinshasa, Democratic Republic of Congo (formerly Zaire), we demonstrated that high rates of sexual behaviour change could be sustained in HIV-1 serodiscordant married couples for 18 months after seronotification ( Kamenga et al. 1991 ). In this report we used incident cases of HIV-1 infection and pregnancies carried to term as biological indicators of sexual behaviour activity in this same group of married couples now followed for another 12 months.

Subjects and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Subjects and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Study population

The study population has been described previously ( Ryder et al. 1990 ; Irwin et al. 1991 ; Kamenga et al. 1991 ). Briefly, married couples with discordant HIV-1 serology were identified through systematic screening of 7484 employees and the female in each married couple employed at a large textile factory and a large commercial bank in Kinshasa, Zaire. At the textile factory, all 5948 employees working on 15 March 1987 were invited to participate with their spouses in a prospective study involving HIV-1 counselling, condom use, an annual physical examination and 6-monthly HIV-1 serologic testing. At the bank, all 1536 employees working on 1 December 1987 and the wives of married employees were similarly invited to participate in the study. The study was approved by the Zairian Ministry of Health.

Counselling programme

Following informed consent, a medical, contraceptive and sexual practice history and demographic information were obtained from each study participant during a confidential personal interview conducted by a trained health worker of the same sex as the participant and speaking the tribal language most familiar to the interviewee. These interviews were conducted in the medical clinic at each business. Participants also underwent a physical examination and had a venipuncture blood sample taken for HIV-1 serology testing.

To provide continued confidential counselling to couples in whom HIV-1 infection was detected, a special HIV counselling centre was established at a central site in downtown Kinshasa away from each business and readily accessible by public transport, as described by Kamenga et al. (1991). All HIV-1 seropositive individuals and their spouses were encouraged to visit the centre. At the first visit, the couple's HIV-1 serostatus was confirmed. Each couple was then informed of their HIV-1 serology results: first, individually in a quiet room by a counsellor of the same sex, and then together with both members of the counselling team (a male Congolese physician and a female Congolese nurse). Couples were then advised about safe sex, condom use and risks associated with acquiring HIV-1 infection. Couples judged by the counselling team to be experiencing excessive psychological distress following notification of their HIV-1 serostatus (threats of harming themselves or their spouse or precipitously seeking marital separation or divorce), were subsequently seen in their homes by the female counsellor. At first, these home visits took place daily and then less frequently until the crisis appeared to have been resolved ( Kamenga et al. 1991 ).

Follow-up

After notification of their HIV-1 serostatus, couples were followed monthly at the counselling clinic. Difficulties couples were encountering in their marriage were probed during each visit, and efforts to resolve them were pursued by the counselling team. At each clinic visit women were asked about menstrual irregularities, evidence of becoming pregnant or vaginal discharge which they might have observed since their last visit to the counselling centre. Pregnancy testing was readily available. Women who had become pregnant were asked about the progress of their pregnancy at each visit. All pregnant women were also seen monthly in a dedicated antenatal clinic ( Ryder et al. 1994 ). The research project funded all labour and delivery costs at a private maternity, hence all pregnant study participants delivered there. All pregnancies were carried to term and resulted in live births. No spontaneous or induced abortions were reported.

All participants were asked to maintain a daily sexual activity diary. Methods associated with use and validation of these diaries have been previously described ( Kamenga et al. 1991 ). Couples failing to keep their scheduled clinic visits were discretely visited in their homes. The reasons for failure to appear were discussed and a repeat appointment made. Couples failing to appear at the counselling centre after three successive home visits were dropped from the study. Only couples who presented to the centre at least twice with no more than 30 days between each of these visits were included. An individual who arrived at the clinic for a routine follow-up visit without his/her partner was not seen until he/she returned with his/her spouse. Follow-up was terminated if a couple divorced or was lost.

Although monthly follow-up activities were censored on 30 August 1990, we were able to determine pregnancy outcomes for all women who had become pregnant but had not delivered by this date. The date of HIV-1 seroconversion was calculated as the mid-point between the date of the last HIV-1 seronegative serum sample and the date of the first HIV-1 seropositive sample which had been confirmed in a sample obtained within 30 days of the first positive sample.

Laboratory methods

Serologic tests for HIV-1 were performed with an enzyme-linked immunosorbent assay (ELISA; HIV-1, Vironostika, Organon Teknika, Turnhout, Belgium). Specimens repeatedly reactive on ELISA were confirmed by HIV-1 Western Blot (HTLV-III Western Blot, DuPont deNemours, Geneva, Switzerland) if at least two of the bands corresponding to p24, gp41, or gp120/gp160 were visualized ( Centers for Disease Control 1989). HIV-1 seronegative individuals were systematically tested by ELISA and Western Blot every 6 months. During the last 2 months of the study a venipuncture blood sample was obtained from all HIV-1 seronegative individuals still being actively followed. Serologic and Western Blot results which suggested that the individuals were possibly undergoing seroconversion were reconfirmed in a second serum sample obtained within 1 month of the first.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Subjects and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

During the initial enrolment period, 4487 married couples underwent HIV-1 serologic testing. 4248 [94.7%] couples were concordantly HIV-1 seronegative, 204 [4.5%] couples had discordant HIV-1 serologic status and 35 [0.8%] couples were concordantly HIV-1 seropositive. Of the 204 couples (114 M+F- and 90 M-F+) with discordant baseline HIV-1 serologic status, 178 (88%) agreed to participate in the study. Follow-up results of these couples are shown in Table 1. The mean age and duration of marriage are presented in Table 2. Couples attended nearly 75% of their scheduled monthly visits (months in which scheduled clinic appointments were kept/total numbers of possible monthly visits between enrolment date and the date when the study was censored). During follow-up, 6 M+F- and 10 M-F+ couples seroconverted for an incidence of 3.7 and 6.8 per 100 person-years of observation, respectively. The 10 men who developed HIV-1 infection may have acquired their infection during unprotected sex with their spouse or with an extramarital partner. Of the 6 women who seroconverted only one became pregnant (16.7%; 95% C.L. = 0–40.4%). As previously reported, the HIV-1 incidence in the study cohort during the first 18 months of follow-up was 3.1 per 100 person-years of follow-up ( Kamenga et al. 1991 ).

Table 1.  Outcome of 204 couples with HIV-1 discordant serostatus at baseline during 30 months of follow-up Thumbnail image of
Table 2.  Characteristics of couples with discordant HIV-1 serostatus according to baseline HIV-1 serostatus Thumbnail image of

Among the discordant couples, men with a negative baseline HIV-1 serologic status had significantly more extramarital sex than those with a positive baseline HIV-1 serologic status (1.36 episodes/year vs. 0.55 episodes/year; P < 0.05). During these episodes of extramarital sex, HIV-negative men were more likely to use condoms than HIV-positive men (1.2 episodes of penetrative extramarital sex using condoms/year for men HIV-seronegative at baseline vs. 0.4 episodes/year for men HIV-seropositive at baseline; P < 0.05). Husbands who were HIV-1 seronegative at baseline used condoms during 88% of their episodes of extramarital sex compared with a usage rate of 73% for husbands who were HIV-1 seropositive at baseline (P > 0.05). Rates of condom rupture during penetrative episodes of marital sex were not significantly different in men with positive baseline HIV-1 serostatus (1.1 ruptures/100 episodes of penetrative sex with their spouse) and in men with negative baseline HIV-1 serostatus (1.6 rupture/100 episodes) (P > 0.05).

During follow-up, 24 women (14 HIV-1 seronegative at baseline and 10 HIV-1 seropositive at baseline) delivered a live-born child for a live pregnancy rate of 8.6 per 100 women-years for women with a negative baseline HIV-1 serostatus and 6.8 for women with a positive baseline HIV-1 serostatus (P > 0.05) ( Table 3). All 24 women who became pregnant during the study carried their children to term. HIV-1 seroconversion occurred in only one (7%) of the 14 women with a negative baseline HIV-1 serostatus who also became pregnant during follow-up. None of the 10 men with a negative baseline HIV-1 serostatus who had a wife who was HIV-1 seropositive at enrolment and who became pregnant seroconverted. Women who became pregnant were significantly younger than women who did not (mean age of 27.3 years vs. 31.4 years; P < 0.005) and had been married for a shorter period of time (8.6 years vs. 12.0 years; P < 0.05). Women who became pregnant had a mean number of 8.4 acts of penetrative sex/month (43% protected) with their spouse compared with a mean of 2.5 (95% protected) in women who did not become pregnant. For women who became pregnant, 85% of unprotected sex acts with their spouse occurred when she thought she was in her fertile period.

Table 3.  Descriptive characteristics of women according to their pregnancy status during follow-up Thumbnail image of

During the 30-month follow-up period, seven couples divorced or permanently separated. In three of these discordant couples the woman was HIV-1 seropositive at baseline. In two of the three M-F+ couples, the husband interpreted his wife's positive HIV-1 serostatus as an indicator of her being unfaithful, a status which he found unacceptable. The third couple with M-F+ serostatus had lost all three of their children, and the husband felt that his wife's positive HIV-1 serostatus was responsible for their death. He divorced in order to find a new wife who could bear him children. In the other four couples who divorced or separated, the husband was the HIV-1 seropositive member, and either the wife or her parents were concerned that her HIV-1 seropositive husband might infect her.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Subjects and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The results of this study help clarify several concerns especially germane to married couples with discordant HIV-1 infection who desire to have children. Our safe sex message had a marked and persistent impact on intramarital and extramarital sexual behaviour. Although several discordant couples elected to practice unsafe sex (particularly during a woman's monthly period of increased fertility), the HIV-1 incidence rate during the 12 months of follow-up in M+F- couples (5.6) and in M-F+ couples (3.5) is not markedly different from the 3.1 incidence figure noted in the first 18 months of follow-up ( Kamenga et al. 1991 ). After 30 months of follow-up, 73% of seropositive men and 88% of seronegative men were reporting the use of condoms during extramarital sex.

Our study also provides useful information on safe sex practices and how they can be modified for married couples with discordant HIV-1 infection status who desire children. Couples who desired a child and who practiced safe sex except during a woman's estimated monthly fertility period were remarkably successful at having a child while at the same time avoiding HIV-1 transmission to the uninfected partner. In this prospective study 24 women (13.5%) of 178 couples with discordant baseline HIV infection status became pregnant and delivered a live-born child. Only 1 (4%) of these 24 (4%; 95% C.L. = 0.0–21.6%) couples seroconverted and became concordantly HIV infected. Discordant couples who did not become pregnant during follow-up used condoms for 95% of episodes of penetrative sex. Discordant couples who became pregnant during follow-up had significantly higher rates of nonprotected penetrative sex than couples who did not become pregnant. Nearly all unprotected penetrative sex took place during a woman's perceived fertile period.

Finally, our study confirms earlier findings concerning the effect which HIV-1 infection status has on marriage and sexual behaviour. During an additional year of follow-up involving over 225 person-years, only three more divorces occurred. Knowledge that their wife was HIV-1 seropositive clearly accounted for an increased rate of extramarital sex but in over 80% of these episodes the husband used condoms.

Our results may have been biased in several ways. Couples who continued in our study clearly differed from couples who elected not to enroll. At the start of the study 26 couples elected not to participate in our longitudinal study (22 M+F-; 4 M-F+); a disproportionately large number of M+F- couples refused to participate. Nine couples were lost to follow-up between 18 and 30 months of the study. These exclusion biases certainly had an effect on our results. The lack of any reports of abortion (spontaneous or induced) in any of our cohort women is surprising. Women who may have experienced an abortion may have been more inclined to drop out of the study. We also relied on sexual activity diaries as the source of information on sexual activity and condom use. Each participant kept his/her own diary. Recall bias may have compromised the accuracy of these diaries.

We had a relatively low HIV-1 incidence rate even in couples known to have had multiple episodes of unprotected sexual intercourse. None of our cohort subjects experienced any episodes of sexually transmitted disease. Several studies have shown that the risk of heterosexual HIV transmission in persons with a low viral load and no STD is very low. ( Lee et al. 1996 ; Operskalski et al. 1997 ; Ragni et al. 1998 ; Quinn et al. 2000 ). Our study provides additional information concerning issues of safe sex in married couples, sex in married couples with discordant HIV-1 infection status and the effect of serostatus notification on the marriage and intramarital and extramarital sexual behaviour in Kinshasa, Congo.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Subjects and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The authors would like to acknowledge the assistance of Alvara McBean, Charlene Whiteman and Ephrem Mpozayo.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Subjects and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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