Makwe & Giwa-Osagie Sexuality and RH, in HIV Discordant Couples REVIEW ARTICLE Sexual and Reproductive Health in HIV Serodiscordant Couples Christian C. Makwe*1 and Osato F. Giwa-Osagie1 1Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos/Lagos University Teaching Hospital, P.M.B 12003, Idi-Araba Surulere Lagos, Nigeria. *For correspondence: Email: [email protected]; Phone: +234-8033358021 Abstract Serodiscordant couples are a significant source of new HIV infection in sub-Sahara Africa. The prevention of HIV transmission to the uninfected partner should be an integral part of their health care. Serodiscordant couples desire pregnancy, treatment for infertility, effective family planning services, sexual health screening, and so on. This paper reviews the sexual and reproductive health needs of heterosexual serodiscordant couples, based on current evidence and recommendations. Afr J Reprod Health 2013 (Special Edition); 17[4]: 99-106). Keywords: HIV, Serodiscordant couple, Conception, Contraception, infertility Résumé Les couples sérodiscordants sont une source importante de nouvelles infections du VIH en Afrique sub-saharienne. La prévention de la transmission du VIH au partenaire non infecté doit être une partie intégrante de leurs soins de santé. Les couples sérodiscordants désirent une grossesse, le traitement de la stérilité, des services de planification familiale efficaces, le dépistage de la santé sexuelle et ainsi de suite. Ce document passe en revue les besoins en matière de santé sexuelle et reproductive des couples hétérosexuels sérodiscordants, fondées sur des preuves et des recommandations en vigueur. Afr J Reprod Health 2013 (Special Edition); 17[4]: 99-106). Mots-clés: VIH, couple sérodiscordants, conception, contraception, l'infertilité Introduction Sub-Sahara Africa has the highest prevalence and incidence of HIV infection worldwide, mostly The human immunodeficiency virus (HIV) and attributed to heterosexual transmission7. In this acquired immune deficiency syndrome (AIDS) region, at least half of the people living with HIV have continued to be a major health challenge in stable relationships have an HIV-negative worldwide. HIV infection started as a recognized partner8, that is, one partner is HIV-positive and niche infection in California men who were the other HIV-negative (serodiscordant described as “homosexual”1. The report of the first relationship). Several studies have shown a high AIDS cases in California2 in 1981 prompted prevalence of HIV serodiscordance among additional case reports in other US cities1,3 and in heterosexual couples in Africa9-11. The proportion Europe4,5, among men who have sex with men. of serodiscordant relationship may be up to 75% in HIV infection has now become a global epidemic countries with low prevalence (<10%) of the and the mode of spread predominantly through infection8. Population-based estimate of heterosexual intercourse, mother-to-child serodiscordance ranges from 2% (in Rwanda) to transmission (MTCT), and transmission by unsafe 13% (in Zimbabwe and Lesotho)7. Among HIV- medical and cultural practices. According to Joint positive pregnant women attending antenatal clinic United Nations Programme on HIV/AIDS in Nigeria, 7.7% to 78.8% of them had HIV- (UNAIDS), about 34 million people were living negative partners10. Evidence suggests that men with HIV at the end of 2011 and about 69% of and women are equally likely to be an index (HIV- them lived in sub-Sahara Africa6. positive) partner in a serodiscordant couple12. The African Journal of Reproductive Health December 2013 (Special Edition on HIV/AIDS); 17(4): 99 Makwe & Giwa-Osagie Sexuality and RH, in HIV Discordant Couples HIV-negative partners of serodiscordant couples HIV-serodiscordant couples sometimes engage are at an extremely high risk of becoming infected. in risky sexual behaviour, especially couples who HIV-negative women may become infected twice desire pregnancy22-24. HIV transmission in as fast as men, possibly due increased biological heterosexual serodiscordant couples who are susceptibility11. attempting to conceive depends on numerous Serodiscordant couples are an important factors; most important are plasma viral load of the source of new HIV infections in sub-Sahara index partner, presence of sexual transmitted Africa. In Zambia, DNA sequencing revealed that infections (STIs), and frequency of intercourse21. 87% of new infections in the negative partner were The viral load of the index partner is the most acquired from the HIV-positive partner13. A study powerful predictor of HIV transmission25. Studies conducted at 14 sites in Southern and Eastern have shown that there was negligible or no sexual Africa found that 64% of seroconversions could be transmission of HIV in serodiscordant couples, linked by viral sequencing to the HIV-positive where the index partner had an undetectable viral partner in long-term relationship14. Also, mode of load or a low viral load below a given transmission analysis conducted during 2007-2008 threshold25,26. The risk of HIV transmission is in Kenya, Lesotho, Mozambique, Rwanda and considerably lower in HIV-infected persons on Uganda suggested that the proportion of HIV antiretroviral therapy (ART) with completely infection arising from transmission within suppressed viraemia and long-term undetectable serodiscordant couples ranges from 10% in Kenya viral load27. Although, viral load in plasma to 56% in Rwanda15. generally correlated well to that in genital Like the general population, serodiscordant secretions; viral shedding in the genital secretion couples have reproductive health needs such as may still occur in fully suppressed HIV-infected desire for conception, treatment for persons on ART. The possibility still exists for an subfertility/infertility, need for effective HIV-infected partner on ART with long-term contraception, and rights to health care and so on. undetectable plasma viral load to sexually transmit This paper reviews the sexual and reproductive the virus to an uninfected partner28. The presence health needs of heterosexual serodiscordant of STIs increases viral load substantially in genital couples, and the management of these health secretion, even when the individual is issues based on available evidence and current asymptomatic29,30. Both ulcerative and non- recommendations. ulcerative STIs increase the risk of HIV transmission and acquisition. Risk of HIV Transmission in Serodiscordant Couples Prevention of Sexual Transmission of HIV in Serodiscordant Couples Studies conducted in Africa among heterosexual It is possible for heterosexual serodiscordant serodiscordant couples showed that HIV couples to remain serodiscordant indefinitely, if transmission from HIV-positive to HIV-negative preventive programmes are instituted. These partners was 20 – 25% per year, irrespective of interventions include couple HIV testing and whether the man or woman was the index counseling, safer sex practices by using condoms partner16-18. This rate is based on a coital frequency consistently and correctly, male circumcision and of two to three times per week and a risk of the use of antiretroviral (ARV) drugs. In HIV transmission on the order of one in 500 for each counseling and testing programmes where condom contact19,20. Some other authors have quoted the use was recommended for prevention, the annual risk of sexual transmission of HIV from male-to- risk of HIV transmission among serodiscordant female as 0.1-0.3% per act of intercourse and 7,16,31 couples can drop from 20-25% to 3-7% . female-to-male as 0.03-0.09 per act of intercourse, Circumcision of HIV-uninfected male partner provided the couples are not participating in any reduces the female-to-male transmission of HIV other forms of high-risk activities21. by 38 – 66% over 24 months, assuming adequate African Journal of Reproductive Health December 2013 (Special Edition on HIV/AIDS); 17(4): 100 Makwe & Giwa-Osagie Sexuality and RH, in HIV Discordant Couples duration of healing (at least 6 weeks) before and a 75% risk reduction in the TDF-FTC group, resuming sexual activity32-34. Male circumcision is when compared to placebo40. Another RCT recommended as a prevention strategy. conducted among heterosexual men and women showed a 62.6% reduction in risk of acquiring Antiretroviral Drugs in Serodiscordant Couples HIV in uninfected partners who had TDF-FTC39. The use of ARV drugs for treatment and In contrast, a RCT conducted among heterosexual prophylaxis in an HIV infected partner reduces the HIV-negative women did not show a significant reduction in the rate of HIV infection in the TDF- risk of HIV transmission to the uninfected partner. 41 In 2010, World Health Organization (WHO) FTC group . recommended ARV for HIV-infected persons The expressed concern about PrEP includes eligible for treatment of their own HIV infection acceptability, access, cost and availability of ARV, drug adherence and resistance, and risky sexual based on clinical and immunologic criteria (WHO 42 clinical stage 3 or 4 and CD4 count of ≤350 behaviours . The need for drug adherence in PrEP cells/µL)35. The WHO also recommended ART for should be emphasized, as available data suggest lack of efficacy in couples with low drug HIV-infected pregnant women eligible for 40,41 treatment, and ARV prophylaxis for those HIV- adherence . PrEP should be available for infected pregnant women not eligible for serodiscordant couples as a risk reduction strategy treatment36. In serodiscordant couples,