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

Image courtesy of interviewee. December 2, 2024

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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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Here are five key points from the video:

1. **Early Experience with HIV in Africa**: The author arrived in Africa in late 1985 during the early stages of the HIV epidemic, having previously trained in San Francisco. They were involved in early outreach efforts in Rwanda, where significant rates of HIV were detected in pregnant women, which was shocking and revealed much about the disease's prevalence.

2. **Understanding Transmission Dynamics**: The initial understanding of HIV transmission among couples was limited. The author and their team discovered the phenomenon of "discordant couples," where one partner tested positive while the other tested negative. This led to the recommendation for couples to test together and increased focus on condom usage for prevention, especially since many couples practiced what was considered "normal marital sex."

3. **Impact of Couples' Testing and Counseling**: The author’s work emphasized the importance of joint testing for couples, leading to significant reductions in new infections and sexually transmitted infections such as gonorrhea. They utilized various strategies, including direct counseling and mass media, to promote couples testing and increase awareness about HIV.

4. **Introduction of Antiretrovirals and Evolving Counseling Strategies**: With the availability of antiretrovirals, the approach to counseling evolved to not only focus on prevention but also on the health of the positive partner and the reduction of transmission risk to the negative partner. The understanding that consistent medication could make the positive partner less likely to transmit the virus changed the way couples were counseled.

5. **Challenges and Success in Implementation**: While there was significant success in promoting couples testing, the uptake was not uniform across countries. For example, Rwanda saw a high rate of couples being tested together, while Zambia lagged behind. The video discusses the need for increased efforts in countries where couples testing is underutilized, despite it being a highly effective strategy for reducing HIV transmission and fostering open communication about health and family planning.

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Here are some key quotes extracted from the video regarding the experiences and research surrounding the HIV epidemic, especially focusing on couples testing and counseling in Africa:

1. **Initial Encounter with HIV in Africa:**
- "I first arrived in Africa when the HIV epidemic had really just started globally. ... I had been born and raised in developing countries so I was interested in tropical diseases."

2. **Shocking Statistics:**
- "We screened close to 4,000 pregnant women and found that 29% of them had antibodies. That was a shock."

3. **Understanding Transmission Dynamics:**
- "At that point, so little was understood about the dynamics of transmission. Literally, people thought, my husband has a girlfriend..."

4. **Approach to Counseling:**
- "We assumed that couples, which we call discordant couples... should use condoms, and we should explain to them why until we know more about this."

5. **Nature of HIV in Africa vs. the West:**
- "It became clear that the vast majority of existing and new infections in Africa were in cohabiting couples...very different from the epidemic in the west."

6. **Importance of Couples’ Testing:**
- "We started advising that all cohabiting couples should get tested together."

7. **Community Outreach:**
- "We opened a clinic, we promoted couples testing on the radio... trained the antenatal nurses to provide couples testing."

8. **Impact of Antiretrovirals:**
- "In 2007, antiretrovirals first, about 10 years after they became available in the US began small-scale distribution in Africa."

9. **Reduction in Transmission:**
- "The rate of transmission to that spouse dropped by two thirds just by finding out that they had HIV."

10. **Long-Term Effects on Relationships:**
- "The divorce rate or the separation rate in couples was not different... The negative partners did not abandon their positive partners when they discovered this."

11. **Cost-Effectiveness of Couples Testing:**
- "The cost was almost $600... the cost of preventing an infection in a couple that you've just counseled and told they are discordant... is almost $20,000 per infection."

12. **Advocacy for Couples Testing:**
- "Couples testing really is not happening... In countries like Zambia... three quarters don't know their joint test results."

13. **Strengthening Relationships:**
- "Couples, African couples are strong unions... they can grasp the implications of this and they can react accordingly."

14. **Joint Testing and Family Planning:**
- "We find that jointly testing couples for HIV and for family planning is extremely effective."

These quotes capture the essence of the speaker's experiences, insights, and advocacy regarding HIV testing, the importance of couple involvement, and the public health strategies that can significantly impact the transmission of the virus in Africa.

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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,

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there were different categories, of course.

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So you had the couples with two negative partners.

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You had the couples with two positive partners.

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You had the couples with a positive

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man and a negative woman.

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And the couples with a positive woman and a negative man.

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Among the HIV positive individuals, you had people

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who were taking antiretrovirals for their own health,

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and you had people who weren't either

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because they didn't yet know they had HIV or

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because, at that time,

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the criteria did not include them.

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And, what we found was

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that whether they were taking anti-retrovirals

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or not, at the time they were tested with their spouse,

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the rate of transmission to that spouse dropped

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by two thirds.

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Um, just by finding out that they had,

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that they had HIV, their partner had HIV,

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and, if they were already taking antivirals, a lot

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of times, you know, they, they don't live in

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houses with lots of rooms.

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You have to hide the fact that you're taking meds.

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Uh, you know, it gets tricky.

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And so being able to be open with the spouse

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and having the spouse supporting, reminding you

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to take your medication on time and so forth.

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Um, and that was, you know, almost universally the response.

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We, the, the divorce rate

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or the separation rate

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in couples was not different

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depending on their serial status.

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Unlike what a lot of people sort of anticipated.

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Um, the negative partners did not abandon their positive

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partners when they discovered this.

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And the average duration

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of union at the time they first got tested was seven years.

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They almost all had children together.

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So there had been an investment and that stuck.

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So, regardless

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of whether the person was taking antivirals prior to knowing

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that they were in a discordant couple, the rate went down

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by two thirds after knowing they were in discordant couples.

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So the, you know, just as it had been for 20 years

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before antivirals were available, the impact

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of knowing both test results was two thirds reduction.

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Uh, and that it was about a 50% reduction in couples

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with two negative partners.

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So, and the cost was about, in, in the context

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of the 300,000 couples we tested in Zambia, so that was in,

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six cities.

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In, three provinces.

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The cost was almost $600

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per infection averted by couples testing.

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In comparison, the cost

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of preventing an infection in a couple

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that you've just counseled and told, they are discordant.

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If you give the positive partner antiretrovirals strictly

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as a means of preventing transmission,

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the cost is almost $20,000 per infection of women.

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So drugs are great,

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and I'm a physician, you know, I support them.

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But as a public health frontline prevention strategy,

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treatment as prevention has always been way too expensive.

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Um, and so, and couples testing really is not happening.

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Actually, Rwanda is the only country

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that has nationalized it, since 2008.

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Now, about 85% of pregnant women are tested with partners,

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and it's entirely voluntary.

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Um, but in countries like Zambia, despite the fact

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that we've been working there for 30 years,

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because there hasn't been a concerted sort of, you know, a

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national policy, resources, which you don't need many,

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but you need some, to promote

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and provide, it, it hasn't happened.

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So in Zambia, I'd say maybe a quarter

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of couples have been tested

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Together, together, and three quarters don't know their

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joint test results, promoting couples testing

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in a blanket fashion.

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We, we have developed all kinds of ways to do it.

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It works in all kinds of countries.

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Uh, couples, African couples are, strong unions.

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They understand the implications.

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They, there's, you know, no need to sort

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of infantalize them.

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Uh, they can grasp, the implications of this

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and they can react accordingly.

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Uh, and so I think that, you know, in terms of the cost,

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in terms of the impact, and it strengthens unions

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and actually allows also discussion of fertility goals

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and, contraception,

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which is a whole nother avenue of our research.

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And, and we find that, jointly testing couples for HIV

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and for family planning is extremely effective.

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Men, I, African men un it's not true

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that they all wanna have 12 children.

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Uh, they're the ones that have to pay the bills,

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and they know, that, you know, mouths

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to feed are expensive these days.

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So, they actually have been very strong allies in,

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in, you know, planned fertility.

Early Insights into the HIV Epidemic in Africa

00:00:00 - I first, arrived in Africa when the HIV epidemic had, really just started, globally. So in 19, late 1985, I had been doing my specialty medical training in San Francisco, where of course, we were seeing many cases of, HIV. And, I had been born and raised in developing countries. So I was interested in tropical diseases. I had done a diploma in tropical medicine in Liverpool. And when the first cases of AIDS were reported, in Africans going to, Belgium,

00:00:34 - to see whether these same, illnesses were being found. And they found it. They, raised some funds and went to Rwanda, a former Belgian colony in 1986. And we, shortly after that, the blood testing for antibodies to HIV was developed and we screened, close to 4,000 pregnant women and found, 29% of them, had antibodies. That was a shock. at that time, we didn't really know whether antibodies,

00:01:06 - and it just means you've been infected and you're now immune. And we thought perhaps that this was the case with HIV. It couldn't be that 29% of these healthy pregnant women were, you know, infected with this fat illness. And it took years for us to discover that. In fact, that was not the case with HIV, that people who had a positive antibody test were in fact infected chronically because we were advising women to use condoms. as part of the counseling process.

Understanding Discordant Couples in HIV Transmission

00:01:36 - having been recruited in an antenatal clinic, they said, well, you really must talk with our husbands. And, we said, you know, sure, of course, bring them in. Send them in. And that was when we first discovered that a husband and wife could have different test results. And, at that point, so little was understood about the dynamics of transmission. Literally, people thought, my husband has a girlfriends. He goes and stays over at her house, and the next night he comes home and he gives it to me.

00:02:07 - And even in the, in the health sector, that was a common belief. So at that point, we had to assume that couples that, which we call discordant couples, not because they didn't get along, but just because they had different test results, we thought, well, we should, of all couples, these couples really should use condoms, and we should explain to them why until we know more about this. And that's how the whole thing started. It, became clear in the ensuing couple of years,

00:02:39 - the vast majority of existing and new infections in Africa were in cohabiting couples. So it was very different from the epidemic in the west where it, you know, gay men, drug users, sex workers, and so on. So we had to approach it, very differently, because the risk behaviors were, were normal marital sex. and so we started advising that all cohabiting couples should get tested together so

Strategies for HIV Prevention in Couples

00:03:11 - and one negative partner, and focus the prevention messages on them. Whilst, for couples with two negative partners, we emphasized how important it was not to bring HIV into the marriage. And then for couples with two positive partners, we, and this is now 20 years before anti-retrovirals were available. So, we emphasized the importance of good nutrition, of avoiding other sexually transmitted infections by

00:03:42 - outside partners and so forth. and, we started encouraging, people who were dealing, especially with, with pregnant women, to routinely invite the men in for testing, ideally with them both together, because by that time, we'd had some experiences with couples where the, the wife might have been counseled, and she sent her husband in, and he was counseled separately. And then they did not disclose accurately, to each other

00:04:13 - And, some very awkward scenarios where both partners were positive, each told the other they were negative, and then they would come in independently to us to say, help me out, you know, I'm positive, my partner's negative. And then we would look in the records and we would find, anyway, so the long and short of it was we said, the best thing to do with this, since both partners have to agree on a way forward, and certainly, you know, with the Sex Act, you, you have

Promoting Couples Testing and Condom Use in Africa

00:04:45 - And we found that actually once we, counseled couples and encourage them to use condoms, which were not very well known in Africa at the time, unlike Asia, where condoms had been used as a contraceptive for a long time, condoms were basically unknown, in Africa. It was a, it was a, you know, a tough cell, as you might imagine. but we did find that the rate of new infections went down by about two thirds. and the rate of gonorrhea in couples

00:05:19 - just with this counseling message. So we continue to do research and refine, how to promote couples testing, how to provide couples testing, how to standardize, pre and post-test counseling messages. we did a number, and at that point, in 1994, the genocide of the Tootsie in Rwanda forced us to evacuate. And we ended up in Zambia, which is in Southern Africa.

00:05:49 - We opened a clinic, we promoted couples testing on the radio. We went out to the government health centers and, trains, the antenatal nurses, to provide couples testing and to encourage it. And we, developed mass media and a variety of other promotional strategies, community health workers, and so on. and that wa was the work that we did for a long time, before antiretrovirals were available.

Implementing HIV Training and Testing in African Countries

00:06:22 - for about five years to help other countries in Africa. So we had about 20 countries, that, we had, you know, workshops and conferences in Rwanda and Zambia, depending on whether it was francophone or anglophone country that needed training. And, then we would send our teams out, to their countries to help them, you know, on a small scale. Let's see if this is feasible and how the system has to be tweaked for your particular culture.

00:06:55 - than either Rwanda or Zambia. And there is one, region of Zambia where polygamy is common, and we had established systems there. and it was actually pretty interesting. we left it to, the family unit. If the husbands and the wives wanted to be tested as separate dyads, we would do that. If they all wanted to be in the room together, we would do that.

00:07:24 - people felt was gonna work best for them. and so that work continued. And then in 2007, antiretrovirals first, about 10 years after they became available in the us, the small scale, distribution began in Africa. And, over a period of, I guess five, six years or so, you know, the numbers

Adapting HIV Counseling: Emphasizing Antiretroviral Adherence and Transmission Prevention

00:07:53 - And so we, started incorporating the messages about antiretroviral, adherence. and I remember it was some time between when antiretrovirals were provided to people who were, who had HIV and were symptomatic. So it started out with, it's a limited quantity of drugs, let's prioritize the people who are ill. and then as more and more antivirals became available, then the threshold,

00:08:26 - that sick, or your CD four count didn't have to be quite that low. The relationship between taking anti-retrovirals and being contagious, began to hit the radar. And, the, the thinking was, okay, well, in a discordant couple in particular, if the positive partner can adhere correctly to the drugs, then the likelihood that they'll transmit, to the negative partner will be reduced. And so the counseling evolved not just

00:08:57 - but also to, prevent transmission to the negative partner. And, that, led to some kind of confusing messages, because, you know, it's a little bit like, if you don't wanna get pregnant, use condoms, but you should also use a backup method if you're a woman. you know, pills, injections, depo, IUD, because condoms do have a, a, a failure rate. It was a little bit like that. It was sort

Challenges and Insights in HIV Management and Couples Testing

00:09:26 - your antiretrovirals. And this was, you know, it took a long, long time before viral load testing was widely available. so to be able to say to someone, yeah, your viral load's undetectable, you don't need to worry about being contagious. that, you know, honestly, today we are not in a position to do that in either Rwanda or Zambia. And those are two countries that are fairly advanced in terms of, you know, the, the budgetary support and so on for HIV.

00:09:59 - as you should, don't miss any doses. But also if you, are in a discordant couple, you should use condoms. And, the Rwandan couples, interestingly, were the first ones to pick up on the fact that if the drugs aren't working, either because you're not taking them the way you should or because they don't always work, sometimes resistance develops. Then if you don't use condoms,

00:10:28 - and your spouse then will not respond to the therapeutic drugs that are out there. And, it was fairly sophisticated, thinking, but, and accurate. so we continue to incorporate all of those kind of messages. And, in our most recent publication, we looked at the, at the cost of, providing couples testing, and then the impact of doing it on the incidents

Impact of Couples Testing on HIV Transmission Rates

00:11:00 - so that it could be compared to other strategies. What we found was, as couples were coming in, there were different categories, of course. So you had the couples with two negative partners. You had the couples with two positive partners. You had the couples with a positive man and a negative woman. And the couples with a positive woman and a negative man. Among the HIV positive individuals, you had people who were taking antiretrovirals for their own health,

00:11:30 - because they didn't yet know they had HIV or because, at that time, the criteria did not include them. And, what we found was that whether they were taking anti-retrovirals or not, at the time they were tested with their spouse, the rate of transmission to that spouse dropped by two thirds. just by finding out that they had, that they had HIV, their partner had HIV,

00:12:05 - of times, you know, they, they don't live in houses with lots of rooms. You have to hide the fact that you're taking meds. you know, it gets tricky. And so being able to be open with the spouse and having the spouse supporting, reminding you to take your medication on time and so forth. and that was, you know, almost universally the response. We, the, the divorce rate or the separation rate in couples was not different

Impact of Couples Testing on HIV Transmission Rates

00:12:33 - Unlike what a lot of people sort of anticipated. the negative partners did not abandon their positive partners when they discovered this. And the average duration of union at the time they first got tested was seven years. They almost all had children together. So there had been an investment and that stuck. So, regardless of whether the person was taking antivirals prior to knowing that they were in a discordant couple, the rate went down by two thirds after knowing they were in discordant couples.

00:13:05 - before antivirals were available, the impact of knowing both test results was two thirds reduction. and that it was about a 50% reduction in couples with two negative partners. So, and the cost was about, in, in the context of the 300,000 couples we tested in Zambia, so that was in, six cities. In, three provinces. The cost was almost $600

00:13:38 - In comparison, the cost of preventing an infection in a couple that you've just counseled and told, they are discordant. If you give the positive partner antiretrovirals strictly as a means of preventing transmission, the cost is almost $20,000 per infection of women. So drugs are great, and I'm a physician, you know, I support them. But as a public health frontline prevention strategy,

Challenges and Successes of Couples HIV Testing in Africa

00:14:12 - and so, and couples testing really is not happening. Actually, Rwanda is the only country that has nationalized it, since 2008. Now, about 85% of pregnant women are tested with partners, and it's entirely voluntary. but in countries like Zambia, despite the fact that we've been working there for 30 years, because there hasn't been a concerted sort of, you know, a

00:14:43 - but you need some, to promote and provide, it, it hasn't happened. So in Zambia, I'd say maybe a quarter of couples have been tested Together, together, and three quarters don't know their joint test results, promoting couples testing in a blanket fashion. We, we have developed all kinds of ways to do it. It works in all kinds of countries. couples, African couples are, strong unions.

00:15:10 - They, there's, you know, no need to sort of infantalize them. they can grasp, the implications of this and they can react accordingly. and so I think that, you know, in terms of the cost, in terms of the impact, and it strengthens unions and actually allows also discussion of fertility goals and, contraception, which is a whole nother avenue of our research. And, and we find that, jointly testing couples for HIV and for family planning is extremely effective.

Balancing Family Size and Economic Realities

00:15:57 - that they all wanna have 12 children. they're the ones that have to pay the bills, and they know, that, you know, mouths to feed are expensive these days. So, they actually have been very strong allies in, in, you know, planned fertility.

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