HIV PREVENTION FOR COUPLES

TECHNICAL BRIEF

FEBRUARY 2010

This publication was produced for review by the United States Agency for International Development. It was prepared by the AIDSTAR-One project. USAID | AIDS Support and Technical Assistance Resources Project AIDS Support and Technical Assistance Resources, Sector I, Task Order 1 (AIDSTAR-One) is funded by the U.S. Agency for International Development under contract no. GHH-I-00–07–00059–00, funded January 31, 2008. AIDSTAR-One is implemented by John Snow, Inc., in collaboration with Broad Reach Healthcare, Encompass, LLC, International Center for Research on Women, MAP International, Mothers 2 Mothers, Social and Scientific Systems, Inc., University of Alabama at Birmingham, the White Ribbon Alliance for Safe Motherhood, and World Education. The project provides technical assistance services to the Office of HIV/AIDS and USG country teams in knowledge management, technical leadership, program sustainability, strategic planning, and program implemen- tation support.

Recommended Citation: Spino, Aldo, Michele Clark, and Sharon Stash. 2010. HIV Prevention for Serodiscordant Couples. Arlington, VA. USAID | AIDS Support and Technical Assistance Resources, AIDSTAR-One Task Order 1.

The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

AIDSTAR-One John Snow, Inc. 1616 Fort Myer Drive, 11th Floor Arlington, VA 22209 USA0 Phone: 703-528-7474 Fax: 703-528-7480 E-mail: [email protected] Internet: aidstar-one.com INTRODUCTION literature relating to HIV prevention with serodis- cordant couples and the AIDSTAR-One database of IV serodiscordant couples, where one partner is good and promising programmatic practices. Some HHIV positive and the other is HIV negative, are key programs that informed this brief are highlighted increasingly being recognized as a priority for HIV pre- in text boxes. vention in developing countries (Joint United Nations Programme on HIV/AIDS [UNAIDS] 2008). PRIORITIZATION OF SERODIS- Recent studies have estimated that in several sub- CORDANT COUPLES Saharan African countries, approximately two-thirds of infected couples are serodiscordant couples (de wo-thirds of infected couples have been esti- Walque, 2007). Developing effective HIV prevention Tmated as discordant in Burkina Faso, Cameroon, interventions that target serodiscordant couples could Ghana, Kenya, and Tanzania; between 30 and 40 per- potentially contribute to reducing HIV transmission cent of the infected couples are couples where the in many countries. Moreover, provision of services to female partner only is infected (dispelling a common serodiscordant couples to help them manage their perception that it is solely men who are putting their status is an essential component of comprehensive female partner at risk) (de Walque 2007). Across east HIV responses. Africa, national representative data suggest 40 to 50 percent of married HIV infected individuals have an This brief provides a summary of prevention inter- HIV uninfected spouse (Bunnell and Cherutich 2008). ventions that are effective or showing promise in In addition, Uganda’s “modes of transmission” study developing countries toward reducing HIV sexual found that new cases of HIV infection are increas- transmission risk within serodiscordant cohabiting het- ingly occurring among married people ages 30 to 40 erosexual or married couples. (Wendo 2009).

While this brief focuses on HIV serodiscordant The high HIV infection rates attributable to hetero- couples, prevention for serodiscordant couples does sexual transmission in sub-Saharan Africa have led to not occur in isolation from programs for HIV nega- increasing efforts to assess the extent of HIV trans- tive concordant and HIV positive concordant couples, mission within marriages. One study estimates that or more broadly from other related prevention pro- between 55.1 to 92.7 percent of new heterosexually grams, such as those focused on partner reduction or acquired HIV infections among adults occurred within social marketing. Prevention messages and serodiscordant marital or cohabiting relationships. interventions need to respond to the of The same study estimates that as high as 60.3 to 94.2 both partners in the relationship. This requires ensur- percent of these new infections occurred within se- ing that partners are aware of their own and their rodiscordant relationships, when modeling takes into partners’ HIV status. account higher reported condom use with non-cohab- iting partners (Dunkle et al. 2008). However, it is im- This brief was developed to assist program planners portant to note that these estimates may include some and implementers to design, plan, and implement HIV biases, including transmission that results from sex with prevention interventions with serodiscordant couples. partners outside of the marriage, and do not take into It has been informed by a review of the published account the potential benefts of ART on transmission.

HIV PREVENTION FOR SERODISCORDANT COUPLES 1 Prevention interventions with serodiscordant couples The Home-Based AIDS Care Project need to give consideration to factors that may fa- Approach: Home-based antiretroviral therapy cilitate transmission. A review of research on HIV (ART) is given to HIV positive patients, plus discordant heterosexual couples identifed factors home-based HIV testing and prevention counsel- that influence transmission including sexually trans- ing to partners and household members mitted infections (STIs), particularly genital ulcerative diseases, viral load, condom use, and specifc sexual Country: Uganda practices (such as a high number of sexual partners Interventions: and higher frequency of sexual contact) (Guthrie et al. • Home-based ART 2007). The risk of transmission is especially high dur- • Home-based counseling and testing for part- ing early infection—estimated to be 26 times more ners and household members infectious than asymptomatic infection and to last for three months after seroconversion—which poses a • Development of sexual behavior plans challenge for interventions to identify acute infections Core elements: (Hollingsworth et al. 2008). • Encourage couples to receive test results to- gether Prevention responses also need to take into account • Offer HIV discordant couples enhanced cou- the progress of the epidemic. One hypothesis is that ples counseling in early epidemics, most discordant couples arise • Develop personalized couple risk reduction when HIV is introduced into a preexisting relation- plans ship; in more mature epidemics, where there are many more people who have been infected with HIV, Enabling environment: Ensure operational fea- a greater proportion of discordant couples initiate sibility (e.g., government testing protocols, labora- tory and home testing capacity, trained staff) relationships with a partner who is already infected (Guthrie et al. 2007). Results: • Ninety nine percent of household members ac- Other factors that play a role in HIV transmission cepted HIV testing within couples include migration and alcohol con- • Forty three percent of HIV positive partners sumption. The direction of spread may not be just were HIV negative, and 99 percent had not from migrant men, who become infected while away, been previously tested but also from women with absent partners who • Seventy percent reduction in risky sex (over may infect their returning migrant partner (Lurie et 85 percent of risky sexual acts occurred within al. 2003). This highlights the importance of using pre- married couples) vention to address the needs of couples rather than • Ninety eight percent reduction in the number focusing solely on individual partners. Alcohol use has of estimated seroconversions after six months also been associated with unprotected sex among HIV serodiscordant couples; interventions may need Conclusions: to include a focus on alcohol consumption (Coldiron • Detected large number of HIV discordant rela- et al. 2008). tionships • Supports arguments for incorporating couples’ HIV testing and prevention into ART programs

2 AIDSTAR-ONE TECHNICAL BRIEF PREVENTION WITH SERODIS- Couples HIV Counseling and Testing (Allen et al. 2007; Chomba et al. 2008) CORDANT COUPLES Approach: CHCT revention with serodiscordant couples is a rela- Countries: Zambia and Rwanda Ptively new area of prevention activity in many Outreach models: developing countries. Only a small number of inter- • Peer model using community workers (CW) ventions targeted at serodiscordant couples have model—trained CWs conduct door-to-door been identifed. Below are some of the key elements outreach of approaches that have proven to be effective or are • Trained Influential Network Agents (INAs) in- showing promise. Overall, there are three broad pro- vite couples for CHCT gram components: Impact of models: • Outreach by CWs resulted in increased atten- • First, the key to prevention with serodiscordant dance and attendance declined by 90 percent couples is Couples HIV Counseling and Testing when CWs outreach was discontinued (CHCT). By testing together, each partner knows • Invitations delivered in an INA’s home to both their own and their partner’s serostatus. How partners, or someone known to INA were CHCT is implemented within the feld has varied. strong indicators of uptake—14.3 percent of At times, CHCT is incorporated into antenatal clin- total invitations resulted in uptake ics, while at other times it is conducted through Challenges: outreach programs. There are, however, some com- • CWs—cost- and labor-intensive mon elements to all the approaches. • INAs—low uptake of invitations Enabling environment: Public support and en- • Second, group-based interventions are another dorsement of CHCT by community leaders important program component. Group-based in- Results following CHCT: terventions include the provision of information, • Almost 25 percent of discordant couples re- developing risk reduction strategies, and developing ported perfect condom use personal skills. • Most couples reported occasional lapses

• The third critical component of prevention with • Only 10 percent reported unprotected sex at each follow-up visit serodiscordant couples is the need to provide a supportive environment. Fear of stigma often acts Conclusions: CHCT prompted sustained but imperfect condom use in HIV discordant couples to impede access to services. Reducing stigma and building community support can enable prevention programs to function more effectively. In addition, logistical and fnancial obstacles often need to be grams such as care and treatment support services, overcome to further facilitate access. multiple concurrent partner and sexual exclusivity programs, condom promotion, and other behavior While this brief specifcally focuses on the compo- change communication activities. This is particularly nents required for prevention programs with serodis- important given that HIV prevention programs that cordant couples, to be effective such programs often are effective at reducing the risk of transmission require integration with broader HIV prevention pro- within serodiscordant couples are not necessarily ef-

HIV PREVENTION FOR SERODISCORDANT COUPLES 3 fective with other non-primary partners. Integration The Partner Project (Jones et al. 2005) with existing services and prevention programs will Approach: Cognition-behavioral group interven- also facilitate scale-up and provide venues in which tion messages can be reinforced. Country: Zambia Target population: HIV positive women and Couples HIV Counseling and Testing their partners The cornerstone of prevention programs with se- rodiscordant couples is ensuring couples learn if Interventions: they are HIV discordant. This knowledge is critical if • Four group sessions for women serodiscordant couples are to reduce the risk of HIV • Single or four group sessions for their male transmission to the HIV negative partner. In Uganda, partners approximately 80 percent of adults were unaware of their HIV status, and more than 90 percent were un- • Cognitive behavioral skill training on HIV/ aware of their partners’ status (Bunnell and Cherutich STIs prevention and transmission, reproduc- 2008). Yet knowledge of HIV serodiscordant status tive choice, mother-to-child, communication, has been associated with increased condom use (Bun- conflict resolution, sexual negotiation, and an nell et al. 2008). educational program to increase the use of and adherence to sexual barriers Increasingly, there has been recognition of the need Core elements: for services to work with couples, rather than just • Same gender groups with the individual partners. CHCT has been shown • Led by trained gender-congruent counselors to be an effective intervention for reducing the risk of HIV transmission among serodiscordant couples Enabling environment: (Allen et al. 2003; DeZoysa et al. 2000). As a result, • Importance of male participation couples are identifed as a priority for counseling and • Recognizing gender issues and their impact on testing in PEPFAR policy documents (PEPFAR 2009). sexual decision making Counseling couples together enables the challenging issue of disclosure to be addressed, although this re- Results: After the intervention, female partici- quires ensuring that counselors are skilled at support- pants (whose partners participated in the four- ing serodiscordant couples. session intervention) reported higher rates of condom use, more positive condom attitudes, Effective prevention with serodiscordant couples safer sex intentions, and less alcohol use requires prioritization of serodiscordant couples within existing programs and services, rather than stand-alone prevention programs. Couples need to (Farquhar, Kiarie, and Richardson 2004). Treatment be a priority for HIV counseling and testing programs, and care programs have also effectively integrated although prioritizing couples alone does not ensure counseling and testing of the partners of people with increased participation, and additional strategies to HIV within home-based ART programs (Bunnell et al. increase demand for services from couples are often 2006; Were et al. 2006). required. Likewise, couples’ testing has been integrat- ed into antenatal HIV counseling and testing programs

4 AIDSTAR-ONE TECHNICAL BRIEF Group-based Interventions Address Environmental Factors In addition to prioritizing prevention for serodiscor- Prevention programs do not occur in isolation; they dant couples within existing programs, there is a need are more effective when they occur within the con- for group-based interventions. Small group-based text of a supporting environment. The stigma associ- interventions working with both partners in a sero- ated with HIV acts as a signifcant impediment to cou- discordant relationship have proven to be effective at ples’ willingness to access services (Allen et al. 2007). reducing risk (Jones et al. 2005; McGrath, Celentano, Government and community leaders need to support and Chard 2007). Group-based interventions have and endorse initiatives that work with couples, as well also highlighted male partner influence in the adop- as work toward reducing the stigma associated with tion of risk reduction strategies for serodiscordant HIV. Some prevention interventions also require build- couples (Jones et al. 2005). ing community support to challenge cultural attitudes and beliefs. For CHCT to be effective within antenatal Group-based interventions can be integrated with clinical settings, the perception that antenatal care is other services. The addition of a male-focused coun- only for women needs to be addressed. seling program (an educational video followed by a facilitated group discussion) to the standard testing Another key factor that contributes to a supportive and generic counseling services normally offered as environment is ensuring financial and logistical barri- part of counseling and testing was effective at increas- ers are overcome and that they do not prevent cou- ing dramatically the rates of condom use for serodis- ples from accessing programs and services. Barriers cordant couples when the male partner participated might include transport, testing costs, childcare, hours in the program (Roth et al. 2001). of services, and lack of time. Financial and logistical is- sues have often been cited as reasons as to why there Prevention with serodiscordant couples includes is low demand for CHCT. In situations where partners focusing on information and education, personal and family members are offered free and convenient risk reduction strategies, and skills development. access (e.g., home-based) to HIV counseling and test- Group-based interventions often focus on a mixture ing and where other obstacles are overcome (e.g., of all three strategies. The development of personal transport, childcare), uptake can be improved (Chom- risk reduction strategies has often occurred as part ba et al. 2008; Farquhar, Kirarie, and Richardson 2004; of counseling with serodiscordant couples. Another Wanyenze et al. 2008). positive outcome from group-based interventions is that serodiscordant couples have reported that the interventions provide social support and reduce isola- CHALLENGES tion (McGrath, Celentano, and Chard 2007). Project Eban, currently being conducted in the Unites States, or prevention with serodiscordant couples to be is one the largest interventions conducted to date to Feffective, a range of challenges and barriers need evaluate the effcacy of a couples-based intervention to be overcome. Below is a summary of some of the designed for HIV serodiscordant couples (Center for common challenges that prevention programs have Mental Health Research on AIDS, National Institutes experienced and how these have been overcome. of Health 2008). Upcoming fndings may provide valu- able lessons for the development of effective group- Increasing partner participation rates: One of the based interventions. signifcant challenges is low couple demand for CHCT,

HIV PREVENTION FOR SERODISCORDANT COUPLES 5 even when incorporating mass media promotion or a Knowledge of HIV Serodiscordancy peer outreach model. This may be due to fear of stig- HIV prevention with serodiscordant couples requires ma, lack of knowledge of CHCT, and lack of familiarity challenging misconceptions. A widespread misconcep- about where CHCT is available (Allen et al. 2007). tion is that HIV serodiscordancy cannot exist between Demand has increased by using home-based services, couples (Bunnell et al. 2005). Explanations for discor- door-to-door outreach, and community leaders to dancy include the concept of a hidden infection not promote access. The delivery of home-based HIV detectable by HIV tests, belief in immunity, the thought testing to household members of HIV positive people that gentle sex protected HIV negative partners, and taking ART resulted in 99 percent uptake in a study in belief in protection by God (Maman et al. 2002). The Uganda (Were et al. 2006). denial of HIV discordancy is likely to increase the risk of HIV transmission to the HIV negative partner with- Provider-initiated HIV counseling and testing of hospi- in serodiscordant couples. Even counselors have been tal patients and their family members has proved high- found to lack clear explanations for HIV discordance, ly acceptable; 93 percent of family members accepted highlighting the need for quality counselor training and the offer of testing in a study in Uganda (Wanyenze et clear counseling protocols that can ensure the needs al. 2008). Within antenatal clinics, there has been less of serodiscordant couples are better addressed. Like- success with only 3 to 15 percent of partners receiving wise, clear education messages (see box below) need testing (Farquhar, Kirarie, and Richardson 2004). The to be developed that support risk reduction within low partner participation rates may be due to a lack serodiscordant couples and address misconceptions. of community awareness of CHCT and a cultural belief that antenatal care is only for women. One strategy that has been recommended to address this Key Education Messages (Bunnell et al. 2005) involves clinics sending personalized letters directly to husbands rather than relying on the wife to convince • HIV discordance is common. the husband to attend (Mlay, Lugina, and Becker, 2008). • Couples can remain discordant for a long time. • HIV discordance is not a sure sign of infdelity. Gender inequality: Gender power imbalances have an • HIV is not transmitted on every exposure. impact on sexual relations and HIV transmission. HIV positive women in discordant couples are especially • Viral load is important in transmission, but it likely to face separation or divorce more than women changes over time. in other HIV status couples (Porter et al. 2005). • No one is immune from HIV. Women with HIV were signifcantly more likely to • HIV negative partners in discordant couples are have experienced physical violence, sexual violence, or at very high risk of infection. both with their current partner (Maman et al. 2002). HIV disclosure can be a challenge for HIV positive • Effective risk reduction options exist. women. These challenges may be partially addressed • HIV transmission within discordant couples can by ensuring couples are counseled jointly. This requires be prevented. ensuring staff are trained to provide the appropriate support to serodiscordant couples.

6 AIDSTAR-ONE TECHNICAL BRIEF Ensuring the Quality of Interventions reach among serodiscordant couples; and the qual- Attention needs to be given to the quality of preven- ity of services cannot be compromised as a result of tion interventions if they are to be effective at facilitat- increasing reach. By way of an example, small group ing behavior change. Increasing access to CHCT needs interventions have shown to be effective at reducing to occur without reducing the quality of counseling risk for participating couples, yet for a population- available to couples. While programs targeting couples wide reduction in transmission rates, a large number need to increase their reach, the quality of interven- of serodiscordant couples would need to participate tions needs to be maintained. In real world settings, in such programs and the quality of the programs there is already concern that the counseling and test- would need to be maintained. In many countries, ca- ing focus is often on testing, with little focus on coun- pacity development will be required to strengthen the seling for behavior change (Shelton 2008). To assist quality of counseling services and to teach counselors counselors working with couples, the U.S. Centers for new skills required to work with couples. More effec- Disease Control (CDC) has developed a CHCT cur- tive methods of increasing awareness of serodiscor- riculum in response to growing demand for the feld dancy and created demand for couples services are (CDC 2009). also needed.

Can ART reduce overall rates of HIV QUESTIONS AND ANSWERS transmission within serodiscordant couples? ART may reduce the transmission risk at a personal Can prevention interventions reach those most level for serodiscordant couples, yet whether ART can in need? play a role in reducing the risk of infection within the The interventions that have informed this brief have overall population is contentious (Garnett and Gaz- frequently used participants and couples who have zard 2008; Wilson et al. 2008). It has been predicted already sought out health services. In seeking out such that ART may be unlikely to have an impact on the services, these participants may be more receptive to epidemic at the population level in sub-Saharan Africa prevention messages and behavior change than those (Gray et al. 2003). Most individuals do not start ART serodiscordant couples who do not seek out services. during acute infection, when it is hypothesized that a To be effective, prevention efforts also need to reach large proportion of forward transmission occurs. In those serodiscordant couples who may be unaware of settings with limited access to ART and where only their serodiscordant status and who may not already people with advanced disease receive therapy, any be in contact with services. therapy benefts could be offset by behavioral disinhi- bitions. If patients increase after Can prevention with serodiscordant couples starting ART because they believe they are no longer reduce overall rates of HIV transmission? able to transmit HIV, the prevention effect of ART HIV prevention targeting couples may be effective could be negated, although recently the Home-Based at reducing individual risk of HIV transmission with AIDS Care project reported no behavioral disinhibi- serodiscordant couples, but it may have no overall im- tion among uninfected household members of ART pact on reducing the overall rate of HIV transmission patients (Bechange et al. 2008). Furthermore, individu- at a population level. Two factors that may influence als on ART are more likely to be sexually active for whether or not HIV prevention has a population-wide longer periods of time given their improved health, impact are as follows: services must achieve suffcient increasing the length of time partners can be exposed

HIV PREVENTION FOR SERODISCORDANT COUPLES 7 to the virus. Finally, the up-front cost of expanding and • CHCT studies conducted by The Rwanda- sustaining ART programs is likely to be substantial. Zambia HIV Research Group: http://www.rzhrg.org/ Are the prevention interventions effective in real life settings? • World Health Organization (WHO) The interventions that informed this brief were often conducted within controlled research settings and for • HIV testing and counseling toolkit: http://www. limited time periods. Questions remain as to whether who.int//topics/vct/toolkit/en/index.html the effcacy of such interventions will work in real life settings, particularly in resource-poor settings. Imple- • Guidance on provider-initiated HIV testing and mentation of the existing research models on a large or counseling in health facilities: http://www.who.int/ national programmatic scale would be costly. In addition, hiv/pub/vct/pitc2007/en/index.html interventions that have a positive effect with serodiscor- dant couples do not necessarily produce perfect behav- • World Bank Policy Research Working Paper ior change in all couples; there is also a valid concern that (no. 3956) on discordant couples: http://econ. participants in research studies may be providing socially worldbank.org desirable responses. Even when interventions appear effective at promoting positive behavior change, most research only monitors behavior in the short term (a REFERENCES year or less), leaving questions unresolved as to whether long-term behavior change can be maintained. Allen, S., et al. 2003. Sexual Behavior of HIV Discordant Couples after HIV Counseling and Testing. AIDS 17(5): 733–40. Allen, S., et al. 2007. Promotion of Couples’ Voluntary Counseling and Testing for HIV through Influential Networks in Two African RESOURCES Capital Cities. BMC 7: 349. Bechange, S., et al. 2008. Two Year Follow-Up of Sexual Behavior For more information on the following topics, please among HIV-Uninfected Household Members of Adults Taking visit the Web sites listed below: Antiretroviral Therapy in Uganda: No Evidence of Disinhibition. AIDS and Behavior. Oct 24 (epub ahead of print). Bunnell, R., and P. Cherutich. 2008. Universal HIV Testing and Coun- • UNAIDS voluntary counseling and testing selling in Africa. Lancet 371: 2148–50. information: http://data.unaids.org/Publications/ Bunnell, R., et al. 2005. Living with Discordance: Knowledge, Chal- IRC-pub01/jc379-vct_en.pdf lenges, and Prevention Strategies of HIV-Discordant Couples in Uganda. AIDS Care 17(8): 999–1012. • CDC CHCT intervention and training cur- Bunnell, R., et al. 2006. Changes in Sexual Behavior and Risk of HIV Transmission after Antiretroviral Therapy and Prevention Inter- riculum: http://cdc.gov/globalaids/CHCTintervention/ ventions in Rural Uganda. AIDS 20(1): 85–92. Bunnell, R., et al. 2008. HIV Transmission Risk Behavior among HIV- • The intervention curricula for the volun- Infected Adults in Uganda: Results of a Nationally Representative tary HIV-1 counseling and testing random- Survey. AIDS 22: 617–24. ized trial in Kenya, Tanzania, and Trinidad Center for Mental Health Research on AIDS, National Institutes of Health. 2008. NIMH Multisite HIV/STD Prevention Trial for Afri- (The Voluntary HIV-1 Counseling and Test- can American Couples Group. Journal of AIDS 49(Supplement 1): ing Efficacy Study Group): s1–s74. http://www.caps.ucsf.edu/projects/VCT

8 AIDSTAR-ONE TECHNICAL BRIEF Centers for Disease Control and Prevention (CDC). 2009. CHCT Mlay, R., H. Lugina, and S. Becker. 2008. Couple Counseling and Test- Intervention and Training Curriculum. Available at http://cdc.gov/glo- ing for HIV at Antenatal Clinics. Views from Men, Women and balaids/CHCTintervention/ (accessed February 12, 2009). Counselors. AIDS Care 20(3): 356–60. Chomba, E., et al. 2008. Evolution of Couples’ Voluntary Counsel- Porter, L., et al. 2005. HIV Status and Union Dissolution in Sub-Saha- ing and Testing for HIV in Lusaka, Zambia. Journal of AIDS 47(1): ran Africa: The Case of Rakai, Uganda. Demography 41(3): 454–82. 108–15. Roth, D., et al. 2001. Sexual Practices of HIV Discordant and Con- Coldiron, M., et al. 2008. The Relationship between Alcohol Con- cordant Couples in Rwanda: Effects of a Testing and Counselling sumption and Unprotected Sex among Known HIV-Discordant Programme For Men. International Journal of STD & AIDS 12: Couples in Rwanda and Zambia. AIDS and Behavior 12(4): 181–88. 594–603. Shelton, J. 2008. Counseling and Testing for HIV Prevention. Lancet de Walque, D. 2007. Sero-discordant Couples in Five African Coun- 372: 273–75. tries: Implications for Prevention Strategies. Population and Devel- U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). 2009. opment Review 33(3): 501–23. HIV Counseling and Testing. Available at http://www.pepfar.gov/ DeZoysa, I., et al. 2000. The Voluntary HIV-1 Counseling and Testing press/76382.htm (accessed February, 09, 2009). Effcacy Study Group. Effcacy of Voluntary HIV-1 Counselling and Wanyenze, R., et al. 2008. Acceptability of Routine HIV Counseling Testing in Individuals and Couples in Kenya, Tanzania, and Trinidad: and Testing, and HIV Seroprevalence in Ugandan Hospitals. Bul- A Randomised Trial. Lancet 356: 103–12. letin of the World Health Organization 86: 302–9. Dunkle, K., et al. 2008. New Heterosexually Transmitted HIV Infec- Wendo, C. 2009. Uganda: New HIV Cases Alarm Doctors. AllAfrica. tions in Married or Cohabiting Couples in Urban Zambia and com, Available at http://allafrica.com/stories/200901090004.html Rwanda: An Analysis of Survey and Clinical Data. Lancet 371: (accessed January 8, 2009). 2183–91. Were, W., et al. 2006. Undiagnosed HIV Infection and Couple Farquhar, C., J. Kiarie, and B. Richardson. 2004. Antenatal Couple HIV Discordance among Household Members of HIV-Infected Counseling Increases Uptake of Interventions to Prevent HIV-1 People Receiving Antiretroviral Therapy in Uganda. Journal of Transmission. Journal of AIDS 37(5): 1620–26. AIDS 43(1): 91–95. Garnett, G., and B. Gazzard. 2008. The Risk of HIV Transmission in Wilson, D., et al. 2008. Relation between HIV Viral Load and Infec- Discordant Couples. Lancet 372: 270–71. tiousness: A Model-Based Analysis. Lancet 372: 314–20. Gray, R., et al. 2003. Stochastic Simulation of the Impact of Anti- retroviral Therapy and HIV Vaccines on HIV Transmission, Rakai, Uganda. AIDS 17(13): 1941–51. Guthrie, B., et al. 2007. HIV-1-Discordant Couples in Sub-Saharan Africa: Explanations and Implications for High Rates of Discor- dancy. Current HIV Research 5: 414–29. Hollingsworth, T. D., et al. 2008. HIV-1 Transmission, by Stage of In- fection. The Journal of Infectious Diseases 198(5): 687–93. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2008. AIDS Outlook: World AIDS Day. Geneva: UNAIDS. Jones, D., et al. 2005. Influence of Partner Participation on Sexual Risk Behavior Reduction among HIV Positive Zambian Women. Journal of Urban Health 82(3): iv92–iv100. Lurie, M., et al. 2003. Who Infects Whom? HIV-1 Concordance and Discordance among Migrant and Non-Migrant Couples in South Africa. AIDS 17(15): 2245–52. Maman, S., et al. 2002. HIV-positive Women Report More Lifetime Partner Violence: Findings from a Voluntary Counseling and Test- ing Clinic in Dar es Salaam, Tanzania. American Journal of Public Health 92(8): 1331–37. McGrath, J. W., D. D. Celentano, and S. E. Chard. 2007. A Group- Based Intervention to Increase Condom Use among HIV Se- rodiscordant Couples in India, Thailand, and Uganda. AIDS Care 19(3): 418–24.

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