Eligible couples were identified from three studies conducted by the Rakai Health Sciences Programme: (1) the Rakai Community Cohort Study (RCCS); a prospective population-based surveillance study, which obtains annual data from approximately 14,000 men and women aged 15–49, resident in Rakai communities. (2) A randomized trial of male circumcision for HIV/STD prevention which enrolled 5000 uncircumcised HIV-negative men who accepted voluntary HIV counselling and testing (VCT); and (3) a randomized trial of male circumcision which enrolled 997 HIV-positive men. Female partners of men enrolled in the circumcision trials were invited to enrol into a parallel study.
Participants were informed of procedures, benefits and risks of the study in which they were enrolled, and provided written informed consent for interviews and blood sample collection. All individuals were provided with health education on HIV prevention and safe sex practices, were offered condoms and individual and couples VCT free of charge. The studies were approved by the Science and Ethics Committee of the Uganda Virus Research Institute (Entebbe, Uganda), the Committee for Human Research at Johns Hopkins University, Bloomberg School of Public Health (Baltimore, MD, USA), and the Western Institutional Review Board (Olympia, WA, USA), and the Uganda National Council of Science and Technology, the body that oversees all medical research in Uganda.
Interviews and blood collection were conducted in private by same sex interviewers to obtain socio-demographic, health and behavioural data. For participants who were currently married or cohabiting, we requested information on their partners and retrospectively linked them to identify HIV concordantly positive or negative and HIV-discordant couples. Couples were invited to attend couple meetings at the counsellor’s office in their respective communities. The invitation letters were sent to all 293 HIV-discordant couples identified, as well as randomly selected concordant HIV-infected (n = 22) and uninfected couples (n = 22) in the same communities. The concordant couples were included to mask the discordant couples’ HIV status and avoid breach of confidentiality. Attendance was extremely high, with 100% being represented by at least one partner and reasons for the other partner not present in the meeting were given by the attending partner and include: away business/official duties, away burial and away hospital among others. The attending partner assured the authors of his/her commitment to inform the absentee partner about the details of the meeting.
During the sensitization meetings, the following issues/topics were discussed: HIV sero-discordance, the benefits of HIV disclosure and couple counselling and partner communication (see for detailed outline). Couples were also informed of the availability of free HIV care and antiretroviral therapy offered by the Rakai Health Sciences Programme with funding from the United States President’s Emergency Plan for AIDS Relief (PEPFAR). After the couples’ meetings, participants were followed up either at home or at the counsellor’s office to facilitate HIV disclosure and couple counselling. For the HIV-discordant couples, the counsellor first met with the HIV- positive partner and, subject to his/her agreement, the counsellor met with the HIV-negative partner and then scheduled a meeting with the couple where both partners disclosed their results to one another in the presence of the counsellor. If one of the partners refused to share their HIV result, a record of non-disclosure was recorded.
Sample session Plan for HIV Discordant & Concordant Couples’ Sensitization Outline
After disclosure (for couples that accepted), the counsellor conducted a 45–60 minute couple counselling session to help the couple understand the implications of each other’s HIV status and map out new strategies for the future. The counsellor provided the couple with free condoms and encouraged them to collect more condoms from the Rakai Health Sciences Programme condom distribution outlet sites in the community in case they needed more supplies. Every HIV-infected individual who accepted disclosure and facilitated couple counselling was referred to the HIV clinic for on-going counselling and clinical management (CD4 screening, treatment for opportunistic infections and initiation of antiretroviral therapy if eligible) and their HIV-negative partners were counselled and provided with repeat HIV testing as appropriate (see for detailed profile).
Profile of activities during facilitated couple counselling and HIV sero-status disclosure among concordant & discordant couples and related services provided.
Also, after the disclosure and couple counselling session, the idea of forming an HIV self-help sero-discordant couple group in the community was suggested to the couple. If the couple agreed, a letter of invitation was handed to them detailing the agenda, date, time and venue of the self-help sero-discordant couple group meeting. There are currently ten such groups in the Rakai Health Sciences Programme communities and membership is open to new qualifying couples in the Rakai Health Sciences Programme cohort. Every group is led by two counsellors who facilitate group sessions as planned. Counsellors were sufficiently trained in group psychotherapy skills. The groups meet every six months to discuss, review and evaluate coping strategies and devise new plans. Each group developed its own contract (verbal ground rules) with the counsellors and during the sessions, individuals freely share experiences among themselves and discuss disputes and challenges that arise in their day-to-day living and the counsellors provide group leadership, direction and support (see for detailed outline). After every group session, counsellors make a follow-up of every member individually and as a couple either at home or at the counsellor’s office to discuss their feelings about the group and also as a follow-up on couple relational issues and provide additional support as needed.
Establishing Discordant Couple Self-help Groups in Rakai, Uganda.
In this analysis, we determined HIV disclosure by gender of the infected partner, age, education, occupation, and condom use. Tests of statistical significance included chi squaretest and Fisher’s exact test and analyses were done using STATA™ version 8.2.