Counseling HIV-Serodiscordant Couples: Key ART and PrEP Messages

Approximately 65% of all new HIV infections occur in Sub-Saharan Africa.¹ Half of those infections occur within HIV-serodiscordant couples, in which 1 partner is HIV-positive and the other is HIV-negative.²

The recent Partners Demonstration Project showed that the integrated delivery of antiretroviral therapy (ART) for HIV-positive partners and time-limited preexposure prophylaxis (PrEP) for negative partners reduces risk for HIV transmission.^3,4 Researchers took these data a step further to determine that standardized counseling messages are essential for consistent adherence to PrEP and successful ART among HIV-serodiscordant couples, according to a study⁵ published in the Journal of Acquired Immune Deficiency Syndrome.

The Partners Demonstration Project took place in Uganda and Kenya, and involved 1013 HIV-serodiscordant couples who were followed for 2 years.⁶ HIV-positive partners received ART and HIV-negative partners received PrEP before and during their partners’ first 6 months of ART. Researchers conducted individual and group discussions with counseling staff and developed, refined, and tested standardized messages to be shared in counseling sessions with couples receiving ART and PrEP.⁵

The counseling framework consisted of 4 main topic areas: HIV serodiscordance, ART use, PrEP use, and the coadministration of PrEP and ART to HIV-serodiscordant couples. The following key messages were concluded to be most useful for encouraging widespread PrEP by HIV-negative partners as a “bridge” to consistent ART adherence by HIV-positive partners:

• ART as HIV treatment: ART as a “long-term strategy to treat and prevent HIV,” and the importance of immediate ART initiation and adherence without interruptions (to avoid resistance)
• ART as HIV prevention: Adherent ART as a “commitment to the relationship and the HIV-negative partner,” and the role of ART in reducing viral load and risk for HIV transmission
• Pregnancy and ART use: Safety of ART during pregnancy and breast-feeding, and the role of ART in preventing HIV transmission to the fetus
• PrEP use as HIV prevention: Role of PrEP in preventing HIV infection, the importance of PrEP “during periods of highest HIV risk,” and PrEP discontinuation
• Appropriate PrEP use: Importance of daily PrEP adherence to prevent HIV infection and of regular HIV tests every 3 months to confirm negative HIV status, and stopping PrEP if becoming HIV-positive to avoid developing drug resistance
• Pregnancy and PrEP use: Increased risk for HIV transmission and safety of PrEP during pregnancy
• Commonalities in PrEP and ART messages: Choosing routine times to take medication, importance of condoms in preventing HIV and other sexually transmitted infections during pregnancy, dissipation of adverse effects within the first 2 months of treatment, and differences between and noninterchangeability of ART and PrEP
• Integrated delivery of Art and PrEP: Supporting one another’s adherence, importance of ART adherence to reduce HIV risk, eventual PrEP discontinuation, continued PrEP if ongoing HIV risk, prevention strategies, relationship strengthening, and ongoing encouragement of HIV-positive partner to continue ART beyond PrEP discontinuation by the HIV-negative partner

According to study researcher Renee Heffron, PhD, MPH, from the Department of Global Health and the Department of Epidemiology at the University of Washington in Seattle, the study findings “uphold our understanding of key points that couples want to learn and need to be iterated to help couples understand the importance of these interventions and how they can be integrated. With multiple large-scale programs for PrEP delivery to HIV-serodiscordant couples on the horizon in Kenya and other countries, the results will be directly useful in provider training sessions and as part of the PrEP delivery program.”

This study was limited by the lack of a formal message development procedure and the inability to track fidelity among couples. Study researchers concluded that incorporating their counseling framework and key messages into programs delivering ART and time-limited PrEP to HIV-serodiscordant couples may help maximize HIV prevention.

References

1. HIV/AIDS Basic statistics. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/basics/statistics.html. Updated November 30, 2016. Accessed January 12, 2017.
2. Dunkle KL, Stephenson R, Karita E, et al. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Lancet. 2008;371:2183-2191. doi: 10.1016/S0140-6736(08)60953-8
3. Baeten JM, Heffron R, Kidoguchi L, et al; Partners Demonstration Project Team. Integrated delivery of antiretroviral treatment and pre-exposure prophylaxis to HIV-1-serodiscordant couples: a prospective implementation study in Kenya and Uganda. PLoS Med. 2016;13:e1002099. doi: 10.1371/journal.pmed.1002099
4. Baeten J, Heffron R, Kidoguchi L, et al. Integrated delivery of PrEP and ART results in sustained near elimination of HIV transmission in African HIV-serodiscordant couples: final results from the Partners Demonstration Project. Paper presented at: 21st International AIDS Conference (AIDS 2016); July 18-22, 2016; Durban, South Africa.
5. Morton JF, Celum C, Njoroge J, et al; Partners Demonstration Project Team. Counseling framework for HIV-serodiscordant couples on the integrated use of antiretroviral therapy and pre-exposure prophylaxis for HIV prevention. J Acquir Immune Defic Syndr. 2017;74(Suppl 1):S15-S22. doi: 10.1097/QAI.0000000000001210