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Couples’ Voluntary HIV Counseling and Testing (CVCT) Followed by Treatment as Prevention (TasP) for Discordant Couples

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What is CVCT, and how does it empower couples to understand their HIV status together?

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This video describes the speaker's experiences and insights related to the HIV epidemic in Africa, starting from their arrival in late 1985. Initially training in San Francisco, they were familiar with HIV cases but were shocked to find a high prevalence (29%) of HIV antibodies among pregnant women in Rwanda shortly after the epidemic began to be recognized in Africa. The speaker notes a significant difference in how HIV was transmitted in Africa compared to the West, emphasizing that most infections occurred within cohabiting couples rather than through high-risk behaviors like drug use or sex work.

As understanding of HIV transmission evolved, the speaker and their colleagues promoted couples testing, recognizing the importance of both partners being aware of their HIV status to reduce transmission risks. The speaker details the development of educational and counseling strategies tailored to different couple dynamics, emphasizing the need for joint testing and communication about HIV status, particularly in discordant couples (where one partner is positive and the other negative).

The implementation of antiretroviral treatment began in Africa around 2007, which further shifted counseling messages towards both health maintenance for the positive partner and prevention of transmission to the negative partner. Research showed that couples testing led to a two-thirds reduction in transmission rates and that this was a more cost-effective strategy compared to solely relying on treatment as prevention.

Despite notable successes, the speaker highlights that many couples in countries like Zambia still do not receive joint testing, mainly due to a lack of national policy and resources. They conclude by advocating for the importance of couples testing in strengthening unions, facilitating discussions about family planning, and effectively addressing both HIV prevention and reproductive goals.

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I first, arrived in Africa when the HIV epidemic had,

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really just started, globally.

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So in 19, late 1985,

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I had been doing my specialty medical training in San

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Francisco, where of course, we were seeing many cases

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of, HIV.

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And, I had been born and raised in developing countries.

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So I was interested in tropical diseases.

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I had done a diploma in tropical medicine in Liverpool.

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And when the first cases of AIDS were reported,

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in Africans going to, Belgium,

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then some Belgian doctors went to, to Africa

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to see whether these same, illnesses were being found.

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And they found it. They, raised some funds

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and went to Rwanda, a former Belgian colony in 1986.

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And we, shortly

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after that, the blood testing for antibodies

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to HIV was developed

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and we screened, close to 4,000 pregnant women

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and found, 29% of them, had antibodies.

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That was a shock.

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Um, at that time, we didn't really know whether antibodies,

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for example, you can have antibodies to Hepatitis B,

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and it just means you've been

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infected and you're now immune.

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And we thought perhaps that this was the case with HIV.

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It couldn't be that 29% of these healthy pregnant women

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were, you know, infected with this fat illness.

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And it took years for us to discover that.

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In fact, that was not the case with HIV, that people

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who had a positive antibody test were in fact

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infected chronically

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because we were advising women to use condoms.

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Uh, as part of the counseling process.

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They, and most of them were married,

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having been recruited in an antenatal clinic, they said,

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well, you really must talk with our husbands.

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And, we said, you know, sure, of course, bring them in.

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Send them in. And that was when we first discovered

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that a husband and wife could have different test results.

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And, at that point,

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so little was understood about the dynamics of transmission.

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Literally, people thought, my husband has a girlfriends.

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He goes and stays over at her house,

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and the next night he comes home and he gives it to me.

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Um, that it was just that, efficiently transmitted.

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And even in the, in the health sector,

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that was a common belief.

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So at that point, we had to assume that couples that,

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which we call discordant couples, not

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because they didn't get along, but just

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because they had different test results, we thought, well,

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we should, of all couples,

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these couples really should use condoms,

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and we should explain to them why

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until we know more about this.

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And that's how the whole thing started.

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It, became clear in the ensuing couple of years,

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so this was 19 86, 87, 88, that,

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the vast majority of existing

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and new infections in Africa were in cohabiting couples.

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So it was very different from the epidemic in the west

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where it, you know, gay men, drug users,

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sex workers, and so on.

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So we had to approach it, very differently,

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because the risk behaviors were, were normal marital sex.

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Um, and so we started advising

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that all cohabiting couples should get tested together so

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that we could identify the ones that had one positive

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and one negative partner, and focus the

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prevention messages on them.

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Whilst, for couples with two negative partners,

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we emphasized how important it was not

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to bring HIV into the marriage.

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And then for couples with two positive partners, we,

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and this is now 20 years

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before anti-retrovirals were available.

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So, we emphasized the importance of good nutrition,

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of avoiding other sexually transmitted infections by

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reducing outside partners, using condoms with

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outside partners and so forth.

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Um, and, we started encouraging, people

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who were dealing, especially with, with pregnant women,

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to routinely invite the men in for testing,

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ideally with them both together,

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because by that time, we'd had some experiences with couples

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where the, the wife might have been counseled,

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and she sent her husband in,

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and he was counseled separately.

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And then they did not disclose accurately, to each other

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because they were afraid.

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And, some very awkward scenarios

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where both partners were positive,

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each told the other they were negative,

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and then they would come in independently to us to say,

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help me out, you know, I'm positive, my partner's negative.

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And then we would look in the records

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and we would find, anyway, so the long

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and short of it was we said, the best thing to do

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with this, since both partners have

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to agree on a way forward,

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and certainly, you know, with the Sex Act, you, you have

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to have cooperation, between the, the, the partners.

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And we found that actually once we, counseled couples

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and encourage them to use condoms,

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which were not very well known in Africa at the time,

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unlike Asia, where condoms had been used as a contraceptive

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for a long time,

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condoms were basically unknown, in Africa.

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It was a, it was a, you know,

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a tough cell, as you might imagine.

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Um, but we did find that the rate

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of new infections went down by about two thirds.

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Um, and the rate of gonorrhea in couples

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with two positive partners also went down by about half,

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just with this counseling message.

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So we continue to do research

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and refine, how to promote couples testing, how

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to provide couples testing, how to standardize, pre

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and post-test counseling messages.

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Uh, we did a number,

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and at that point, in 1994, the genocide

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of the Tootsie in Rwanda forced us to evacuate.

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And we ended up in Zambia, which is in Southern Africa.

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And, we set up the same sort of system there.

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We opened a clinic, we promoted

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couples testing on the radio.

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We went out to the government health centers

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and, trains, the antenatal nurses,

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to provide couples testing and to encourage it.

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And we, developed mass media

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and a variety of other promotional strategies,

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community health workers, and so on.

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Um, and that wa was the work that we did

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for a long time, before antiretrovirals were available.

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Um, we had a grant from the Centers for Disease Control

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for about five years to help other countries in Africa.

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So we had about 20 countries, that, we had,

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you know, workshops and conferences in Rwanda

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and Zambia, depending on whether it was francophone

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or anglophone country that needed training.

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And, then we would send our teams out,

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to their countries to help them,

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you know, on a small scale.

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Let's see if this is feasible

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and how the system has to be tweaked

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for your particular culture.

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Uh, so for example, west Africa has far more, polygamy,

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than either Rwanda or Zambia.

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And there is one, region of Zambia

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where polygamy is common,

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and we had established systems there.

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Uh, and it was actually pretty interesting.

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Um, we left it to, the family unit.

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If the husbands

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and the wives wanted to be tested

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as separate dyads, we would do that.

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If they all wanted to be in the

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room together, we would do that.

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We, we just adapted to whatever,

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people felt was gonna work best for them.

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Um, and so that work continued.

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And then in 2007, antiretrovirals first, about 10 years

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after they became available in the us, the small scale,

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distribution began in Africa.

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And, over a period of, I guess five, six years

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or so, you know, the numbers

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of people on antivirals rapidly increased.

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And so we,

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started incorporating the messages about

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antiretroviral, adherence.

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Um, and I remember it was some time between

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when antiretrovirals were

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provided to people who were, who had HIV

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and were symptomatic.

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So it started out with, it's a limited quantity of drugs,

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let's prioritize the people who are ill.

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Um, and then as more

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and more antivirals became available, then the threshold,

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drops, you know, so, you didn't have to be quite

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that sick, or your CD four count didn't

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have to be quite that low.

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The relationship between taking anti-retrovirals

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and being contagious, began to hit the radar.

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And, the, the thinking was, okay, well,

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in a discordant couple in particular,

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if the positive partner can adhere correctly to the drugs,

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then the likelihood that they'll transmit,

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to the negative partner will be reduced.

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And so the counseling evolved not just

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to preserve the health of the HID positive partner,

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but also to,

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prevent transmission to the negative partner.

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And, that, led to some kind of confusing messages,

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because, you know, it's a little bit like,

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if you don't wanna get pregnant, use condoms,

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but you should also use a backup method if you're a woman.

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Uh, you know, pills, injections, depo, IUD,

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because condoms do have a, a, a failure rate.

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It was a little bit like that. It was sort

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of like a discordant couple if you take

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your antiretrovirals.

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And this was, you know, it took a long, long time

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before viral load testing was widely available.

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Uh, so to be able to say to someone, yeah,

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your viral load's undetectable, you don't need

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to worry about being contagious.

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Um, that, you know, honestly, today we are not in a position

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to do that in either Rwanda or Zambia.

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And those are two countries that are fairly

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advanced in terms of, you know, the,

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the budgetary support and so on for HIV.

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So, you still had, it was like, take your medicines

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as you should, don't miss any doses.

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But also if you, are in a discordant couple,

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you should use condoms.

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And, the Rwandan couples, interestingly,

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were the first ones to pick up on the fact that

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if the drugs aren't working, either

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because you're not taking them the way you should or

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because they don't always work,

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sometimes resistance develops.

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Then if you don't use condoms,

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you could transmit a resistant virus

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and your spouse then will not respond

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to the therapeutic drugs that are out there.

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And, it was fairly sophisticated, thinking,

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but, and accurate.

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Um, so we continue

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to incorporate all of those kind of messages.

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And, in our most recent publication, we looked at the,

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at the cost of, providing couples testing,

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and then the impact of doing it on the incidents

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of new infections, and then the cost per infection averted

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so that it could be compared to other strategies.

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What we found was, as couples were coming in,

237
00:11:08.995 --> 00:11:11.385
there were different categories, of course.

238
00:11:11.405 --> 00:11:13.345
So you had the couples with two negative partners.

239
00:11:13.345 --> 00:11:15.265
You had the couples with two positive partners.

240
00:11:15.725 --> 00:11:17.225
You had the couples with a positive

241
00:11:17.245 --> 00:11:18.305
man and a negative woman.

242
00:11:18.405 --> 00:11:20.985
And the couples with a positive woman and a negative man.

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00:11:22.715 --> 00:11:26.305
Among the HIV positive individuals, you had people

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00:11:26.305 --> 00:11:28.745
who were taking antiretrovirals for their own health,

245
00:11:28.765 --> 00:11:30.785
and you had people who weren't either

246
00:11:30.785 --> 00:11:33.505
because they didn't yet know they had HIV or

247
00:11:33.505 --> 00:11:35.865
because, at that time,

248
00:11:36.005 --> 00:11:37.625
the criteria did not include them.

249
00:11:39.185 --> 00:11:41.645
And, what we found was

250
00:11:41.645 --> 00:11:44.525
that whether they were taking anti-retrovirals

251
00:11:44.525 --> 00:11:47.125
or not, at the time they were tested with their spouse,

252
00:11:48.225 --> 00:11:51.045
the rate of transmission to that spouse dropped

253
00:11:51.265 --> 00:11:52.565
by two thirds.

254
00:11:53.585 --> 00:11:57.445
Um, just by finding out that they had,

255
00:11:57.445 --> 00:12:00.245
that they had HIV, their partner had HIV,

256
00:12:01.025 --> 00:12:05.685
and, if they were already taking antivirals, a lot

257
00:12:05.685 --> 00:12:07.805
of times, you know, they, they don't live in

258
00:12:08.265 --> 00:12:09.525
houses with lots of rooms.

259
00:12:09.745 --> 00:12:12.005
You have to hide the fact that you're taking meds.

260
00:12:12.505 --> 00:12:14.085
Uh, you know, it gets tricky.

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00:12:14.985 --> 00:12:17.525
And so being able to be open with the spouse

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00:12:17.525 --> 00:12:19.765
and having the spouse supporting, reminding you

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00:12:19.765 --> 00:12:21.725
to take your medication on time and so forth.

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00:12:22.225 --> 00:12:26.045
Um, and that was, you know, almost universally the response.

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00:12:26.065 --> 00:12:27.725
We, the, the divorce rate

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00:12:27.825 --> 00:12:29.165
or the separation rate

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00:12:29.905 --> 00:12:31.925
in couples was not different

268
00:12:31.955 --> 00:12:33.445
depending on their serial status.

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00:12:33.865 --> 00:12:36.325
Unlike what a lot of people sort of anticipated.

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00:12:36.625 --> 00:12:40.445
Um, the negative partners did not abandon their positive

271
00:12:40.445 --> 00:12:41.885
partners when they discovered this.

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00:12:42.145 --> 00:12:43.285
And the average duration

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00:12:43.285 --> 00:12:45.445
of union at the time they first got tested was seven years.

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00:12:45.445 --> 00:12:47.005
They almost all had children together.

275
00:12:47.065 --> 00:12:50.285
So there had been an investment and that stuck.

276
00:12:51.615 --> 00:12:53.075
So, regardless

277
00:12:53.135 --> 00:12:56.275
of whether the person was taking antivirals prior to knowing

278
00:12:56.305 --> 00:12:59.395
that they were in a discordant couple, the rate went down

279
00:12:59.415 --> 00:13:02.435
by two thirds after knowing they were in discordant couples.

280
00:13:02.495 --> 00:13:05.555
So the, you know, just as it had been for 20 years

281
00:13:05.555 --> 00:13:09.195
before antivirals were available, the impact

282
00:13:09.375 --> 00:13:13.635
of knowing both test results was two thirds reduction.

283
00:13:14.335 --> 00:13:17.635
Uh, and that it was about a 50% reduction in couples

284
00:13:17.635 --> 00:13:18.875
with two negative partners.

285
00:13:19.575 --> 00:13:24.195
So, and the cost was about, in, in the context

286
00:13:24.215 --> 00:13:28.035
of the 300,000 couples we tested in Zambia, so that was in,

287
00:13:28.615 --> 00:13:29.635
six cities.

288
00:13:30.055 --> 00:13:31.955
In, three provinces.

289
00:13:32.255 --> 00:13:34.115
The cost was almost $600

290
00:13:34.655 --> 00:13:37.955
per infection averted by couples testing.

291
00:13:38.735 --> 00:13:40.995
In comparison, the cost

292
00:13:41.095 --> 00:13:43.795
of preventing an infection in a couple

293
00:13:43.825 --> 00:13:47.235
that you've just counseled and told, they are discordant.

294
00:13:48.375 --> 00:13:51.755
If you give the positive partner antiretrovirals strictly

295
00:13:51.895 --> 00:13:53.995
as a means of preventing transmission,

296
00:13:54.575 --> 00:13:57.475
the cost is almost $20,000 per infection of women.

297
00:13:58.805 --> 00:13:59.825
So drugs are great,

298
00:14:00.125 --> 00:14:03.465
and I'm a physician, you know, I support them.

299
00:14:04.085 --> 00:14:07.145
But as a public health frontline prevention strategy,

300
00:14:07.735 --> 00:14:11.865
treatment as prevention has always been way too expensive.

301
00:14:12.525 --> 00:14:16.905
Um, and so, and couples testing really is not happening.

302
00:14:17.185 --> 00:14:18.545
Actually, Rwanda is the only country

303
00:14:18.545 --> 00:14:22.185
that has nationalized it, since 2008.

304
00:14:22.285 --> 00:14:25.745
Now, about 85% of pregnant women are tested with partners,

305
00:14:26.045 --> 00:14:27.425
and it's entirely voluntary.

306
00:14:28.525 --> 00:14:31.985
Um, but in countries like Zambia, despite the fact

307
00:14:31.985 --> 00:14:34.785
that we've been working there for 30 years,

308
00:14:34.785 --> 00:14:38.065
because there hasn't been a concerted sort of, you know, a

309
00:14:38.665 --> 00:14:42.905
national policy, resources, which you don't need many,

310
00:14:43.005 --> 00:14:45.225
but you need some, to promote

311
00:14:45.225 --> 00:14:47.585
and provide, it, it hasn't happened.

312
00:14:47.605 --> 00:14:49.465
So in Zambia, I'd say maybe a quarter

313
00:14:49.565 --> 00:14:50.625
of couples have been tested

314
00:14:50.945 --> 00:14:53.485
Together, together, and three quarters don't know their

315
00:14:53.535 --> 00:14:56.365
joint test results, promoting couples testing

316
00:14:57.745 --> 00:14:58.845
in a blanket fashion.

317
00:14:59.065 --> 00:15:01.405
We, we have developed all kinds of ways to do it.

318
00:15:01.505 --> 00:15:03.445
It works in all kinds of countries.

319
00:15:04.065 --> 00:15:08.725
Uh, couples, African couples are, strong unions.

320
00:15:08.875 --> 00:15:10.725
They understand the implications.

321
00:15:10.755 --> 00:15:12.885
They, there's, you know, no need to sort

322
00:15:12.885 --> 00:15:13.885
of infantalize them.

323
00:15:14.465 --> 00:15:17.245
Uh, they can grasp, the implications of this

324
00:15:17.305 --> 00:15:19.005
and they can react accordingly.

325
00:15:19.505 --> 00:15:22.685
Uh, and so I think that, you know, in terms of the cost,

326
00:15:22.705 --> 00:15:25.725
in terms of the impact, and it strengthens unions

327
00:15:25.725 --> 00:15:28.565
and actually allows also discussion of fertility goals

328
00:15:29.305 --> 00:15:30.885
and, contraception,

329
00:15:30.895 --> 00:15:33.805
which is a whole nother avenue of our research.

330
00:15:33.905 --> 00:15:37.565
And, and we find that, jointly testing couples for HIV

331
00:15:37.785 --> 00:15:40.805
and for family planning is extremely effective.

332
00:15:41.025 --> 00:15:44.165
Men, I, African men un it's not true

333
00:15:44.235 --> 00:15:45.805
that they all wanna have 12 children.

334
00:15:46.625 --> 00:15:48.445
Uh, they're the ones that have to pay the bills,

335
00:15:48.545 --> 00:15:51.445
and they know, that, you know, mouths

336
00:15:51.445 --> 00:15:52.965
to feed are expensive these days.

337
00:15:53.105 --> 00:15:56.925
So, they actually have been very strong allies in,

338
00:15:57.745 --> 00:15:59.765
in, you know, planned fertility.

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