High discordance rates among Ugandan ART clients require new prevention approaches

High rates of discordant HIV status between people receiving antiretroviral therapy in Uganda and their partners have been reported in two studies presented on Tuesday at the 2006 Implementers Conference of the US President’s Emergency Plan for AIDS Relief in Durban, South Africa.

The studies were carried out amongst clients of the AIDS Support Organisation (TASO), which began a home-based antiretroviral therapy programme supported by PEPFAR in 2004.

The first study reported on progress towards HIV testing among the partners and family members of all those receiving treatment though the programme. By March 31st 2006 21,613 family members had been counselled as a result of home visits by counsellors. Ninety-five per cent agreed to test, of whom 88% were first time testers. The total HIV prevalence was 6.5%.

Three different types of counselling session were carried out according to the circumstances of family members: individual, couple or child/family counselling. Family members received pre and post-test counselling, and fingerprick rapid HIV antibody tests were carried out.

640 individuals approached were spouses of individuals receiving antiretroviral therapy, of whom 93% agreed to an HIV test. This compared to a 10% acceptance rate when spouses were invited to come into the ART clinic for testing. Fifty-one per cent were first time testers, of whom 60% were HIV-positive. Amongst those who had tested previously, 40% were found to be HIV-positive.

“This is a way of leveraging treatment to support prevention,” said Muhamed Mulongo of TASO Uganda.

TASO is now scaling up home-based counselling and testing, with priority given to spouses of those already on treatment. TASO is also establishing discordant couples’ clubs to reduce stigma and promote positive behaviours, but the very high demand for HIV testing is placing a strain on the existing staff, who must travel long distances to reach the homes of clients. The desire to have children in discordant partnerships remains a challenge for couples and counsellors, and discussion after the presentation highlighted the need for clear guidance to be formulated for discordant couples who wish to have children safely.

The home-based testing programme also lays a foundation for good adherence, Mulongo said, since it allows people who may need treatment to begin identifying obstacles to adherence and to identify treatment supporters before they need to start treatment. It also permits HIV diagnosis before individuals become seriously ill, increasing the chance that an eventual response to ART will be successful.

A second TASO study, conducted by the US Centers for Disease Control, questioned 1092 clients of TASO in the Jinja district of Uganda. The study did not distinguish between people receiving antiretroviral therapy and those who remained untreated. The researchers found that:

• 42% were currently sexually active (within the last three months)
• 69% had disclosed their HIV status to their most recent sexual partner

Disclosure of HIV status was associated with:

• being married (p
• more years as a TASO client (p
• increased condom use (p
• increased sexual activity in the past three months (p=0.01)
• knowledge of partner’s HIV status (p

Focus group discussion among 47 TASO clients found that only four individuals reported negative consequences of disclosure, but many reported difficulties in finding the right way to disclose their HIV status to partners.

CDC researchers recommended that post-test counselling for HIV-positive individuals needs to include clear messages on various methods that clients can use to disclose their HIV status that are likely to minimise the negative consequences, together with the development of a disclosure plan. Couples counselling should also be promoted more strongly, they recommended.