|Year : 2020 | Volume
| Issue : 2 | Page : 91-95
Seroprevalence and seroconversion rates of human immunodeficiency virus discordant couples attending a tertiary care center: A prospective cohort study
KP Arjun Bal1, Lourembam Robin Singh1, Salam Kenny Singh1, Manna Bhattacharjee1, N Biplab Singh1, Sabin Barun Rai1, Namanandi Ashwini1, Phillip Laishram2
1 Department of Medicine, RIMS, Imphal, Manipur, India
2 ART Counselor, ART CoE RIMS Imphal, Manipur, India
|Date of Submission||26-Jun-2020|
|Date of Decision||28-Aug-2020|
|Date of Acceptance||18-Nov-2020|
|Date of Web Publication||25-Jan-2021|
Third year Junior Resident, Department of Medicine, RIMS Imphal, Manipur
Salam Kenny Singh
Assistant professor, Department of Medicine, RIMS, Imphal
Source of Support: None, Conflict of Interest: None
Background: Serodiscordant couples are an important population group that needs to be addressed in human immunodeficiency virus (HIV) prevention. However, the exact magnitude of the problem is often underestimated even among health care workers.
Methods: This prospective cohort study was conducted in the Regional Institute of Medical Sciences, Imphal for a period of 2 years, to estimate the prevalence and seroconversion rates of HIV discordant couples in this population.
Results: Among the 90 discordant couples under follow-up, 2 HIV-negative partners seroconverted with a seroconversion rate of 1.14 hundred person-years. The average age of the study population was 36.99 years. Eighty percent of the HIV positive partners were males Seventy-six out of 90 patients were educated at primary school level and above. Intravenous drug use was the main risk factor.
Keywords: ART, human immunodeficiency virus, Seroconversion, serodiscordant couples
|How to cite this article:|
Arjun Bal K P, Singh LR, Singh SK, Bhattacharjee M, Singh N B, Rai SB, Ashwini N, Laishram P. Seroprevalence and seroconversion rates of human immunodeficiency virus discordant couples attending a tertiary care center: A prospective cohort study. J Med Soc 2020;34:91-5
|How to cite this URL:|
Arjun Bal K P, Singh LR, Singh SK, Bhattacharjee M, Singh N B, Rai SB, Ashwini N, Laishram P. Seroprevalence and seroconversion rates of human immunodeficiency virus discordant couples attending a tertiary care center: A prospective cohort study. J Med Soc [serial online] 2020 [cited 2021 Mar 2];34:91-5. Available from: https://www.jmedsoc.org/text.asp?2020/34/2/91/307908
| Introduction|| |
According to the World Health Organization (WHO) estimates in 2018, 37.9 million (32.7–44 million) people globally were living with human immunodeficiency virus (HIV) and 1.7 million (1.4–2.3) people became newly infected with HIV. The national adult HIV prevalence in India is estimated to be around 0.22% (0.16%–0.3%). Among the States/UTs, in 2017, Mizoram has the highest estimated adult HIV prevalence of 2.04% (1.57%–2.56%), followed by Manipur 1.43% (1.17–1.75), and Nagaland1.15% (0.92–1.41). The term “serodiscordant couple” refers to an intimate partnership/couple in which one person is HIV-positive and the other is HIV-negative. The “couple” relationship may be marital, cohabitating, or co-parenting status or by the length of relationship (e.g., minimum of 3–6 months), intention to stay together, or reporting a certain minimum number of sexual acts with this partner within a given timeframe. Serodiscordant couples play a role in maintaining the global HIV epidemic. Large numbers of serodiscordant couples are detected in concentrated epidemics. HIV transmission within serodiscordant couples can contribute substantially to the high prevalence of the disease.
It is important to remember that even if one partner is HIV-negative, this does not mean that this partner is “immunized” or protected against getting HIV in future. It is of paramount importance for serodiscordant couples to avoid transmission to the HIV-negative partner. It is possible only by practicing safer sex using male and female condoms. The annual risk of transmission of HIV from an infected partner to an uninfected partner in serodiscordant couples can be reduced from 20%–25% to 3%–7% in programs where condom use is recommended for prevention. Treating the HIV-positive partner may also be effective in reducing the risk.
Despite growing evidence of its importance, the concept of “serodiscordance” and the frequency of its occurrence is poorly understood in most communities. Often, policymakers and health workers, too, are unaware of its high frequency and importance, resulting in insufficient emphasis on offering couples HIV testing and counseling and on supporting the testing of partners of people who have been through individual HIV testing and counseling. Population surveys in 2007–2008 in low- and middle-income countries revealed that knowledge of HIV status is still low among people with HIV, with a median of 40% in ten countries. Furthermore, the majority of men and women in relationships are unaware of their partner's status, and many people with an HIV-positive partner are not aware of their own status, leaving many people unknowingly vulnerable to HIV infection.
The amount of studies assessing the demographic characteristics of serodiscordant couples in North East India is limited. As Manipur is the state with the second-highest estimated adult prevalence for HIV infection in India, the findings of this study may help to get an idea about the distribution of serodiscordant couples in this population.
The aim of this study were to determine the prevalence of discordant couples among PLWHA and to calculate the incidence of new HIV infections (seroconversion rates) among discordant couples.
| Methods|| |
Study design: Prospective cohort study with cross sectional component
The study was conducted in the Department of Medicine, Centre of Excellence (CoE) ART Centre (jurisdiction includes Manipur, Mizoram, Nagaland, Meghalaya, Tripura, Arunachal Pradesh), Regional Institue of Medical Sciences, Imphal.
This study was carried out for 2 (two) years from September 2017 to August 2019.
Couples attending ART center of excellence (4969 as per the records in ART CoE June 2017).
HIV-positive patients with HIV-negative partners, of age >18 years and who are in a relationship minimum of 3 months were included after obtaining consent.
Those who refused to participate in the study were excluded from this study.
Estimated sample size for 85, determined using Cochran's sample size formula, with an estimated prevalence of discordant couples in a concentrated epidemic such as India as 6% (Muessig K et al.) and permissible error as 5%.
Independent variables were age, gender, education, risk factor for HIV infection, baseline CD4 count, duration as a couple, frequency of sexual contacts per month, and usage of condoms.
Dependent variables were seroconversion of negative partner to positive status (Diagnosis of HIV infection done as per the NACO Guidelines using ELISA/Rapid Kit.), the prevalence of discordant couples among HIV-positive population.
Study tools were pretested questionnaires, confirmation of HIV-using ELISA/rapid kit, CD4 count-sysmex five-part cell counter, RANDOX Rx IMOLA auto analyzer, fluorescence-activated cell sorter.
The following working definitions were adopted from Guidance on Couples HIV Testing and counseling including antiretroviral therapy for treatment and prevention in serodiscordant couples: Recommendations for a Public Health Approach published by the WHO; on 2012.
- Couple: Two persons in an on-going sexual relationship; each of these persons is referred to as a “partner” in the relationship
- Seroconcordant uninfected couple-a couple in which neither partner is infected with HIV
- Serodiscordant couple-a couple in which one partner is HIV-positive and one partner is HIV-negative
- Seroconversion– period of time during which HIV antibodies develop and become detectable.
Ethical approval for this study was obtained from the Research Ethics Board, Regional Institute of Medical Sciences, Imphal. Permission was obtained from project director CoE, RIMS. After obtaining informed written consent (Annexures I and II), the information regarding the serostatus of the couples was collected from patient records. This data were be used to calculate the prevalence of discordant couples in the study population. Out of the total 135 discordant couples, 90 couples satisfying the inclusion criteria were included for follow-up. Data were collected from them using pre-tested questionnaires.
Following enrollment, these patients were reassessed at 6 monthly intervals for a period of 2 years to assess the serostatus of the negative partner. This was be used to calculate the seroconversion rates. All the data collected were documented and analyzed statistically to draw a useful conclusion. Confidentiality was maintained by coding of patient's data and safe storage throughout the study. Descriptive and inferential statistical analysis was carried out in the present study.
| Results|| |
The study was conducted among serodiscordant Couples aged 18 years up to 60 years who attended ART COE, RIMS Hospital during the study period of 2 years (September 1, 2017–August 31, 2019). It was a prospective cohort study and relevant information was obtained from a predesigned interview schedule, patient's documents, and investigations available in the hospital.
The total number of people living with HIV (PLHIV) in ART CoE was 7149 on August 31, 2019. A total of 135 serodiscordant couples were identified from this population. The estimated prevalence of discordant couples was 1.8%.
Ninety discordant couples satisfying the inclusion criteria were enrolled for follow-up. Majority (93.4%) of the couples were married for more than 10 years, with a mean duration of 36.99 years and a standard deviation of 6.52. 64.4% of the couples (n = 58) belonged to the age group of 41–50 years of age 72 of the HIV-positive partners were males and 18 were female. Most of the couples had their education at least till primary school level (76 out of 90 patients). IV drug use was the main risk factor of HIV acquisition among discordant couples (45 patients; 52.9%), followed by heterosexual transmission (31 patients; 36.5%) and blood transfusion (7 patients, 8.2%) [Figure 1]. Fifty-two out of 80 positive partners had CD4 count <200 cells/μl with a mean baseline CD4 count, was 204.88 cells/μl (standard deviation 160.32). The lowest CD4 count in the study population was 13 cells/μl and the highest was 769 cells/μl [Figure 2].
|Figure 1: Distribution of risk factors for human immunodeficiency virus infection among patient population (N=90)|
Click here to view
Ninety discordant couples enrolled at the initial month of the study were followed up at 6 month intervals for 2 years. The retention rates at 6, 12, 18, and 24 months were 98.9%, 98.9%, 97.78%, and 97.78%, respectively [Table 1]. Of the 90 couples enrolled 90 (100%) returned for at least one follow-up visit resulting in 180 person-years of followup. 10% of the study population had a low frequency of sexual contacts. 53 of 90 had 1–3 sexual contacts per month and 28 out of 85 had <1 sexual contact per month [Figure 3]. Fifty-eight out of 90 participants had consistent usage of condoms, however, 30.06% of couples had unprotected intercourse [Table 2]. By the end of the study period, 2 out of 88 patients seroconverted, final data was missing for 2 out of 90 patients due to loss of follow-up [Table 1]. The calculated seroconversion rate was 1.14 hundred person-years.
|Figure 3: Distribution of frequency of sexual contacts per month among patients|
Click here to view
| Discussion|| |
Currently, there is a dearth of studies addressing demographic trends of serodiscordant couples in North East India, especially Manipur. Chemaitelly et al. in his cross-sectional study on distinct HIV discordancy patterns by epidemic size in stable sexual partnerships noted that in regions where HIV prevalence is <10%, the estimated prevalence of serodiscordant couples with respect to the total HIV-infected population ranged from 0 to 4%. This finding matches with the present study, where the estimated prevalence of discordant couples among the total HIV infected population was 1.8% (with a prevalence of HIV in Manipur being 1.43%).
The calculated seroconversion rate of the present study was 1.14 per 100 person-years. This was similar to the findings observed by Mehendale et al. where the seroconversion rate was 1.22/100 person-years. On reviewing the published literature on HIV incidence among discordant couples, it was observed that seroconversion rates among the Indian population are lower compared to what has been previously reported in the literature. This can be explained by adherence to biological and behavioral interventions. 68.89% of the study population had low frequency of sexual contacts (<4 per month). A similar finding was seen in the study by Yang et al. in a study among discordant couples in Hubei province China where 605 out of 713 couples had a low frequency of sexual contacts (<4 contacts per month for the last six months). A large percentage of patients in our study used condoms consistently. Allen et al. conducted a study on the effects of serological testing with counseling on condom use and seroconversion among HIV discordant couples in Africa. It was observed that the proportion of discordant couples using condoms increased from 4% to 57% after 1 year of follow-up. Our study population has a higher percentage of people using condoms. This can be explained by the adherence to counseling and a high percentage of follow-up per each visit (The retention rates at 6, 12, 18, 24 months was 98.9%, 98.9%, 97.78%, and 97.78%, respectively). The implementation of antiretrovirals for all HIV-positive individuals irrespective of the clinical or immunological stage is also an important contributing factor.
Socioeconomic factors also may play a role in HIV serodiscordance among couples. 93.4% of the couples were married for >10 years. The mean duration of marital relationship was 12.61 years (Range 4–24 years and standard deviation 6.52). A similar finding was observed in a study by Ravikumar and Balakrishna where the mean duration was 10.7 years (Range 1 year 3 months to 26 years).According to a study by Mehendale et al. among discordant couples in Pune, 380 out of 457 of the participants had received formal education. In the present study, 71 out of 85 (73.53%) had attended primary school and above. The higher literacy among this population may explain better adherence to the behavioral and biological interventions for HIV prevention. IV drug use was the main risk factor among discordant couples (45 patients; 52.9%) followed by Heterosexual transmission (31 patients; 36.5%) in our study. A similar finding was seen in the study by Jebasingh et al. among serodiscordant couples in Manipur where 84% of patients had IV drug use as a risk factor. Only four patients had infection through heterosexual behavior. The impact of these social and economic factors in HIV serodiscordance is a topic that deserves further research.
| Conclusion|| |
Results of this study revealed that a large number of discordant couples exist among PLHIV/AIDS population in Manipur. This calls for further interventions such as maintenance of a couple's registry and follow-up of these couples. This would facilitate the proper implementation of behavioral and biological interventions among them. The study also showed that the seroconversion rates among discordant couples in Manipur were low compared to those seen in other parts of the world such as Sub Saharan Africa. This could be explained by the adherence to ART among this group, low frequency of sexual contacts, and consistent usage of condoms.
The authors would like to thank Medical Superintendent, RIMS Imphal for the kind permission to undertake the study. We also extend our heartiest thanks and gratitude to Programme Director, CoE ART Centre, RIMS Imphal and Research Ethics Board, RIMS Imphal for allowing us to conduct the study. We are also thankful to all the patients for their valuable cooperation.
The study was approved by the Institutional Ethics Committee.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Annexure I: Participants Information Sheet|| |
| Introduction|| |
We are collecting data for a study on Seroprevalence and seroconversion rates among discordant couples in people living with human immunodeficiency virus (HIV)/AIDS: A RIMS study and you are requested for participation by chance and not for any other reason. This consent form gives you information about the study. You are requested to think about your participation in this study through this information form. It is necessary for you to receive complete information about this to participate in it. Therefore, you have to read this form or somebody will read it out to you. If you are willing to participate in this study, you will put today's date and sign this consent form. If you cannot or do not wish to sign, you can opt-out of this study.
| Purpose of the Study|| |
The study is designed to assess the prevalence of discordant couples (a couple in which one partner is HIV-positive and one partner is HIV negative) and the rate of seroconversion (other partner becoming HIV positive). The study also assesses the biological and behavioral factors associated with seroconversion.
| Procedure of the Study|| |
If you are willing to participate in the study, I will ask some personal questions about you, your habits, sexual behavior, substance use, and marital history, etc., I will examine you clinically and also ask you to undergo certain investigations to know better about your problem and to determine the severity of your disease. You may participate, only if you are willing to. You may choose not to answer certain questions if you choose not to. The findings, implications, and laboratory reports will be made available to you and interpreted and explained if you wish so. The results will not be discussed with any other person without your knowledge and consent.
| Who is Eligible?|| |
HIV positive couples whose partner is negative are included in the study. Participants should be above the age of 18 years.
| Risk and Benefit of Participating in the Study|| |
You may not feel comfortable discussing personal things about you, and also being thoroughly examined. Some of the tests require pricking to collect blood sample which may also be painful. You may also get a bruise or swelling where the skin is pricked.
| If you Decide not to Participate in the Study|| |
You may decide not to participate in the study or withdraw from the study anytime. However, you will continue to receive the services from your local intervention program, if you were receiving them, and your routine medical care.
| Compensation for Participation|| |
There will not be any personal gain or monetary compensation for participation in this study. There is no cost to you to participate in the study. No other compensation will be provided to you. However, any complication arising because of blood collection will be taken care of with available resources at center.
| Privacy and Confidentiality|| |
The privacy of the patient will be respected. The collected data sheets will be kept locked in the wardrobe of investigator's hostel room. All your personal information will be keep confidential & coded. If required, data will be revealed only to the Guide of the study, IEC RIMS & law as required. However, collective data without identifiers will be presented and may be published.
| Problem about the Study|| |
If you have any doubt about this study, or in case of research-related queries, contact
Dr Arjun Bal K P, Dr Manna Bhattacharjee
Ph -8787883857 ;email: [email protected]
Consent form for participating in the study Seroprevalence and seroconversion rates among discordant couples in people living with HIV/AIDS: A RIMS study
...................................................district........................................................state have read/have been read out this information form and I fully understand it. I understand that I may or may not participate in the study if I choose to. I, hereby, give my full valid & informed consent to participate in this study.
I have been offered a copy of my consent form and I want/do not want a copy. I understand that I can contact the investigator any time in case of doubt. I am not under any threat and I am participating by my own free will.
Witness ( sister on duty/ART medical officer)
| References|| |
World Health Organization. Guidance on Couples HIV Testing and Counselling IncludingAntiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples: Recommendations for a Public Health Approach. World Health Organization; 2012. Available from: http://www.who.int/hiv/pub/guidelines/9789241501972/en/
. [Last accessed on 2017 Jul 14].
Muessig KE, Cohen MS. Advances in HIV prevention for serodiscordant couples. Curr HIV/AIDS Rep 2014;11:434-46.
Chemaitelly H, Cremin I, Shelton J, Hallett TB, Abu-Raddad LJ. Distinct HIV discordancy patterns by epidemic size in stable sexual partnerships in sub-Saharan Africa. Sex Transm Infect 2012;88:51-7.
Mehendale SM, Ghate MV, Kishore Kumar B, Sahay S, Gamble TR, Godbole SV, et al
. Low HIV-1 incidence among married serodiscordant couples in Pune, India. J Acquir Immune Defic Syndr 2006;41:371-3.
Yang R, Gui X, Xiong Y, Gao S, Yan Y. Five-year follow-up observation of HIV prevalence in serodiscordant couples. Int J Infect Dis 2015;33:179-84.
Allen S, Meinzen-Derr J, Kautzman M, Zulu I, Trask S, Fideli U, et al
. Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS 2003;17:733-40.
Ravikumar B, Balakrishna P. Discordant HIV Couple: Analysis of the Possible Contributing Factors. Indian J Dermatol 2013;58:405.
] [Full text]
Jebasingh F, Ningshen R, Singh B, Devi S, Devi T. An insight on HIV-1 discordant couples -A RIMS study. J Med Society 2011;25:20-24.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]