Nominated From: University of Washington
Research Site: Kenya
Research Area: Bio stats/Epidemiology/Bioinformatics
Primary Mentor: John Kinuthia
HIV Prevention Interventions and Viral Load Monitoring among HIV-discordant Couples Desiring Pregnancy in Nairobi, Kenya
Sub-Saharan Africa remains the region most affected by HIV with nearly 70% of the global burden of infections . Discordant couples, where one partner is HIV positive and the other is negative, are an important source of new HIV infections in Africa [2, 3]. Kenyan treatment guidelines currently recommend deferring pregnancy intentions if the positive partner is not virally suppressed and providing intensive counseling for risk reduction for those who want to conceive. Yet, several HIV prevention interventions, such as pre-exposure prophylaxis (PrEP) by the uninfected partner  and early initiation of antiretroviral therapy (ART) for the infected partner, can prevent HIV transmission to the negative partner when pregnancy is desired [5- 11]. While it has been shown that ART initiation can prevent transmission in couples and some recommend PrEP for safe conception [11, 12, 16], guidelines are lacking for providers in Kenya and other parts of sub-Saharan Africa working with discordant couples. Furthermore, it is not clear what providers are currently communicating to discordant couples and whether HIV positive persons and their partners have accurate information.
Lack of adequate knowledge about the role of viral load monitoring and strategies for safer sexual relations among discordant couples can contribute to missed opportunities for HIV infection prevention,  and delayed ART initiation , especially among those couples desiring a pregnancy. Only recently has HIV viral load monitoring become routine in Kenya and it is not known how it will be integrated into HIV care and counseling on HIV transmission risk for discordant couples. A previous study found that viral load testing had no effect on condom use in discordant couples, and undetectable viral load was associated with having protected sex . For couples desiring pregnancy, viral load monitoring can improve awareness and allow for informed decision making by discordant couples , hence reducing the chance of HIV transmission to the negative partner.
In the proposed study w will survey providers and discordant couples about counseling regarding the risk of HIV transmission. Our goal is to determine providers’ familiarity with current and accurate evidence, and determine if correct information is being communicated to discordant couples, especially those desiring pregnancy, who go through counseling process. We hypothesize that participants and health care providers will have misconceptions on the current information regarding risk of HIV transmission among discordant couples desiring pregnancy, specifically regarding HIV viral load monitoring and HIV prevention interventions such as PrEP and ART.
- Determine knowledge of HIV prevention and counseling messages using a survey instrument targeting men and women in HIV-discordant couples and their providers. Messages include the importance of initiating ART regardless of CD4 count for positive partners in discordant couples, the need for viral suppression before unprotected sex and the low risk of transmission with undetectable viral load. We will also determine other common messages that are communicated about safe conception strategies, and define perceptions of discordant couples on current risk of HIV transmission.
- Catalog knowledge gaps and create recommendations for counseling of patients based on our survey results. The emphasis will be on specifically evaluating the role of HIV viral load, and determining how providers and patients are using viral load information to guide counseling for HIV-discordant couples and sexual and reproductive behavior.
We anticipate contributing data for development of counseling guidelines to allow discordant couples desiring pregnancy to become pregnant, prevent delayed ART initiation in discordant couples, and avoid missed opportunities for HIV infection prevention.