HIV status among discordant couples in sub-Saharan Africa: A meta-analysis involving more than 13,000 discordant couples

1. 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

2. Sero-discordancy and sub-Saharan Africa • 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

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5. Objectives • 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

6. Methods • 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.

7. Methods • Extensive search: we examine published and unpublished data • Secondary analysis: used supplemental data from DHS survey from 14 countries in sub-Saharan Africa

8. Methods • 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)

9. Results • 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

10. Results • 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

11. Meta-analysis Results: primary data Forest plot showing results of the random effects meta-analysis (27 studies)

12. Meta-analysis Results: primary data Forest plot showing results of the random effects meta-analysis (27 studies)

13. Meta-analysis Results: secondary data Forest plot showing results of the random effects meta-analysis (14 studies)

14. Meta-analysis Results: secondary data Forest plot showing results of the random effects meta-analysis (14 studies)

15. Results • 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

16. Important Findings • 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

17. Discussion • 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

18. Necessary Emphasis 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

19. Strength & Limitations • 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

20. Conclusions 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.