|BRIEF RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 4 | Page : 306-309
A study of HIV-concordant and -discordant couples attending voluntary counselling and testing services at a tertiary care center in North India
Bhanu Mehra1, Preena Bhalla2, Deepti Rawat3, Jugal Kishore4
1 Senior Resident, Maulana Azad Medical College, New Delhi, India
2 Director-Professor, Maulana Azad Medical College, New Delhi, India
3 Assistant Professor, Department of Microbiology, Maulana Azad Medical College, New Delhi, India
4 Professor, Community Medicine, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||17-Nov-2015|
Director Professor, Department of Microbiology, Maulana Azad Medical College, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A large number of Indian couples are exposed to the risk of heterosexual human immunodeficiency virus (HIV) transmission. The present records-based study was undertaken at the voluntary counselling and testing facility of a tertiary care hospital in New Delhi, India to determine HIV prevalence among Indian couples; to assess the magnitude of seroconcordance and discordance among HIV-affected couples; and to compare the concordant and discordant partnerships for sociodemographic determinants and cluster of differentiation 4 (CD4) counts. Of the 1309 couples included in the study, 249 (19%) were HIV-affected, and of them 113 (45.4%) were concordantly and 136 (54.6%) discordantly affected by HIV. Males were the HIV-infected partners in 72% of the serodiscordant partnerships analyzed. Seroconcordance was significantly associated with the occupation status of being a housewife (P = 0.009). The contribution of discordant partnerships to the burden of HIV/acquired immune deficiency syndrome (AIDS) is significant, warranting novel couple-targeted counselling strategies and preventive measures, including safe sexual behavior and possibly preexposure HIV prophylaxis of the uninfected partner.
Keywords: Concordant, couples, discordant, human immunodeficiency virus (HIV), India
|How to cite this article:|
Mehra B, Bhalla P, Rawat D, Kishore J. A study of HIV-concordant and -discordant couples attending voluntary counselling and testing services at a tertiary care center in North India. Indian J Public Health 2015;59:306-9
|How to cite this URL:|
Mehra B, Bhalla P, Rawat D, Kishore J. A study of HIV-concordant and -discordant couples attending voluntary counselling and testing services at a tertiary care center in North India. Indian J Public Health [serial online] 2015 [cited 2020 Apr 5];59:306-9. Available from: http://www.ijph.in/text.asp?2015/59/4/306/169664
India contributes substantially to the global burden of human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS), with nearly 2.39 million people currently affected by the disease in the country.  A number of HIV-infected individuals continue to engage in unprotected sexual activity with their HIV-negative partners.  Serodiscordant relationships account for nearly 18-31% of couples in high HIV prevalence countries.  The mechanisms that underlie HIV serodiscordance are poorly understood. Moreover, as heterosexual transmission among HIV-discordant couples could further add to the burden of the HIV epidemic, this population constitutes the target group for HIV prevention strategies. The present study was undertaken to estimate the prevalence of HIV infection among married/cohabiting couples attending an integrated counselling and testing center (ICTC) in North India; to determine the seroconcordance and discordance among the HIV-affected couples; and to compare the sociodemographic correlates and cluster of differentiation 4 (CD4) counts of HIV-infected individuals in concordant and discordant partnerships.
This cross-sectional study was conducted at the ICTC facility of a tertiary care hospital in New Delhi, India.
Clients presenting to the ICTC underwent pretest counselling, during which they were interviewed regarding sociodemographic correlates and possible high-risk behavior. Written informed consent was obtained from the patients, and venous blood samples were collected for HIV serology. Serodiagnosis of HIV was made based on three rapid chromatographic immunoassays for detecting anti-HIV antibodies. In case of HIV-reactive individuals, a blood sample was collected in ethylenediaminetetraacetic acid (EDTA) vials and a CD4 count performed by fluorescence-activated cell sorting (FACS) count system. Data were retrieved from the records of patients enrolled from January 2011 to May 2013. Couples were identified as HIV-affected when either one or both the partners were infected with HIV. They were further categorized as HIV-discordant when only one of the partners was HIV-infected and as HIV-concordant when both the partners were HIV-infected. Fifty such couples belonging to each of the two groups and enrolled at the linked antiretroviral treatment center were randomly selected from the records by simple random sampling and analyzed further. A draw- or lottery-based method was employed for the selection of the study population and the selection was done in a blinded fashion.
Descriptive statistics were calculated with arithmetic mean and standard deviation for central tendencies and median for skewed distributions. Chi-square test and Fisher's exact test were used to compare categorical variables, and the Mann-Whitney U test was used to compare median values. Data were analyzed using Epi info software version 3.5.3, Centers for Disease Control and Prevention, Atlanta, GA, USA. A P value <0.05 was considered statistically significant.
A total of 1309 couples were enrolled at the ICTC facility from January 2011 to May 2013. Two hundred forty-nine (19%) of these couples were HIV-affected, and of them 113 (45.4%) were HIV-seroconcordant and 136 (54.6%) were HIV-serodiscordant. Overall, 8.63% and 10.38% of the 1309 couples were concordantly and discordantly infected with HIV, respectively. Males were the HIV-infected partners in 36 (72%) and females the HIV-infected partners in 14 (28%) of serodiscordant couples.
HIV-reactive individuals in both concordant and discordant relationships had comparable mean ages in years (34.59 ± 9.89 vs 36.52 ± 9.80; P = 0.16). HIV seroconcordance or discordance did not have a statistically significant association with education level (P = 0.05), although seroconcordance was significantly associated with the occupation status of being a housewife (P = 0.009) [Table 1]. A history of high-risk behavior in terms of casual sex with a nonregular partner was noted in only 5 (3.3%) HIV-reactive individuals, while only 2 (1.3%) gave a history of intravenous drug use.
|Table 1: Comparison of sociodemographic correlates of individuals in concordant and discordant partnerships|
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At the time of enrolling for antiretroviral treatment, concordant patients had higher median CD4 cell counts than discordant patients (266 cells/μL vs 218 cells/μL), though the difference between the two groups was not statistically significant (P = 0.1) [Table 2]. Among the individuals in concordant partnerships, HIV-reactive males had significantly lower median CD4 counts than HIV-reactive females (242.5 cells/μL vs 323.5 cells/μL; P = 0.01).
|Table 2: Comparison of CD4 counts of individuals in concordant and discordant partnerships|
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This analysis is one of the few studies to provide an insight into the dynamics of HIV transmission by analyzing the determinants at the level of couples and not individuals. In addition, while a number of studies involving HIV-affected couples have been undertaken in the southern and northeastern parts of the Indian subcontinent, to the best of our knowledge this study, though a preliminary one, is one of the few analyses that have attempted to characterize the HIV-affected couples residing in the northern part of the country.
In our study, 19% of the couples were found to be affected by HIV. Arora et al. have reported a low HIV prevalence of 0.76% among Indian married couples.  This striking contrast in HIV prevalence rates can be explained by the fact that a large proportion of our ICTC attendees are referred clients who are advised to undergo HIV testing by health-care providers because of a symptom profile suggestive of a possible HIV infection. The majority of our direct walk-in clients are individuals seeking HIV counselling and testing possibly due to their high-risk activities. On the other hand, the results of the study cited above are derived from a serosurvey of the general population.
We report a seroconcordance rate of 45.4% and a serodiscordance rate of 54.6% among HIV-affected couples. Previous Indian studies have reported 60% seroconcordance and 40% serodiscordance among affected couples.  The substantial contribution of serodiscordant partnerships to the burden of HIV/AIDS in North India highlights the fact that HIV-negative individuals in such partnerships are continually exposed to the virus and this group perhaps constitutes a major target for HIV transmission prevention strategies such as preexposure prophylaxis and HIV vaccine trials. Simple interventions such as couple-based counselling, serotesting, and provision of condoms could be highly beneficial in reducing the rates of HIV transmission in this group.
We observed that males were the index partners in the majority of HIV-discordant partnerships, which is in agreement with previously published Indian studies.  Studies suggest that men are more likely to introduce HIV infection into sexually stable partnerships, making it essential to devise male-centered counselling and prevention strategies. 
We observed a statistically significant association between seroconcordance and the occupation status of being a housewife. Previous studies have also observed similar socioeconomic differences, and discordant couples are more likely to be employed and to have higher incomes. Employment is a key indicator of an individual's socioeconomic status and thus a surrogate of a couple's willingness to adopt protective behavior once a partner's reactive HIV status is known. 
In our study, HIV-reactive individuals (both males and females) in concordant relationships had higher median CD4 cell counts than those in discordant relationships. Similar findings were reported by Kumarasamy et al. in their study, where concordant patients had significantly higher CD4 cell count than discordant patients at the time of enrolling to care.  It is still not clear why, despite having lower CD4 counts in comparison to concordant partnerships, these discordant partnerships do not progress to seroconcordance. We hypothesize that HIV transmission and acquisition in partnerships involves interplay of several biological correlates, such as the genetic makeup of the individuals, their immune profiles, and the presence of other concomitant sexually transmitted diseases (STDs).  Viral load, disease stage, and antiretroviral therapy are other determinants that have a significant impact on the infectivity of the HIV-reactive partner and thereby on the risk of HIV transmission. Moreover, reduced frequency of sexual activity and the adoption of safe sexual behavior after the seropositivity of the reactive partner was known can partially explain why some discordant relationships are spared while others progress to concordance. 
Another important observation in our study was that males in concordant partnerships had significantly lower median CD4 counts than their female partners. Thus, even in concordant partnerships, men are likely to be infected first, present at more advanced stages of disease, and be the more infective HIV-positive partners.
Our study has a few limitations. Ours was a cross-sectional observational study, thus the duration for which the HIV-reactive individuals were harboring the infection was not known. The study was based on self-reporting of behaviors, an important reason why we could not elicit a history of high-risk behavior in the majority of our clients. Moreover, this was a records-based analysis and therefore a number of important variables that could influence the patterns of concordance and discordance within sexual partnerships (condom use, presence of other STDs, rates of sexual activity within partnerships, types of sexual behavior, rates of disclosure of HIV serostatus) could not be characterized. A prospective study with a larger sample size, including the determinants mentioned above, and with assessment of laboratory parameters such as plasma viral loads, human leukocyte antigen (HLA) typing, lymphocyte responses, and cytokine profiling will provide better insight into the pathogenesis of HIV-concordant and -discordant partnerships.
Based on our finding that HIV-discordant partnerships contribute substantially to the burden of HIV-affected couples in North India, we recommend early integrated counselling and testing of Indian couples, that the partners disclose their HIV status to each other, and early adoption of safe sexual practices by discordant couples to reduce the proportion of such couples transforming into concordant partnerships. We also suggest that seronegative partners in discordant relationships be considered potential candidates for preexposure HIV prophylaxis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bouhnik AD, Préau M, Lert F, Peretti-Watel P, Schiltz MA, Obadia Y, et al
.; VESPA Study Group. Unsafe sex in regular partnerships among heterosexual persons living with HIV: Evidence from a large representative sample of individuals attending outpatients services in France (ANRS-EN12-VESPA study). AIDS 2007;21:S57-62.
Phase III Randomized Placebo-Controlled Trial of HSV-2 Suppression to Prevent HIV Transmission Among HIV-Discordant Couples. Available from: http://www.depts.washington.edu/hsvhiv/
. [Last accessed on 2013 Dec 1].
Arora P, Nagelkerke N, Sgaier SK, Kumar R, Dhingra N, Jha P. HIV, HSV-2 and syphilis among married couples in India: Patterns of discordance and concordance. Sex Transm Infect 2011;87:516-20.
Marfatia YS, Naik E, Singhal P, Naswa S. Profile of HIV seroconcordant/discordant couples a clinic based study at Vadodara, India. Indian J Sex Transm Dis 2013;34:5-9.
Rogers MC, Gopalakrishnan G, Kumarasamy N, Flanigan TP, Carpenter CC, Mayer KH, et al
. HIV in couples in South India; implications for prevention. Int J STD AIDS 2005;16:442-5.
Carpenter LM, Kamali A, Ruberantwari A, Malamba SS, Whitworth JA. Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners. AIDS 1999;13:1083-9.
Skurnick JH, Kennedy CA, Perez G, Abrams J, Vermund SH, Denny T, et al
. Behavioral and demographic risk factors for transmission of human immunodeficiency virus type 1 in heterosexual couples: Report from the Heterosexual HIV Transmission Study. Clin Infect Dis 1998;26:855-64.
Kumarasamy N, Venkatesh KK, Srikrishnan AK, Prasad L, Balakrishnan P, Murugavel KG, et al
. Couples at risk for HIV infection in Southern India: Characteristics of HIV-infected patients in concordant and discordant heterosexual relationships. Int J STD AIDS 2010;21:96-100.
Kaul R, Cohen CR, Chege D, Yi TJ, Tharao W, McKinnon LR, et al
. Biological factors that may contribute to regional and racial disparities in HIV prevalence. Am J Reprod Immunol 2011;65:317-24.
[Table 1], [Table 2]