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Marking a major paradigm shift in public health, the “Undetectable = Untransmittable” (“U=U”) initiative was launched in 2016 to recognize the effectiveness of combination anti-retroviral therapy (cART) to prevent the transmission of HIV [1–5]. The U.S. Department of Health and Human Services (DHHS) and the Centers for Disease Control and Prevention (CDC) have since endorsed this message, including in recent guideline changes for interventions to reduce perinatal HIV transmission in the United States [6–9]. It is now advised that for couples with same or differing HIV status that are trying to conceive (there is an estimated half a million serodiscordant couples in the United States [10,11], cART alone for the infected partner is a sufficient prevention option [6–9]. Another option includes daily medication of tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) for pre-exposure HIV prophylaxis for the uninfected partner. Approved by the FDA in 2012 under the brand Truvada®, the FDA approved a generic version of the medication in 2017, which could reduce its cost by up to 80% [12,13]. PrEP, however, is still more costly than cART alone with additional pill burden and side effects [14]. It also adds marginal benefit when the partner living with HIV is on suppressive therapy [15–17]. The revised DHHS/CDC perinatal recommendations advise the use of PrEP in cases when the partner living with HIV has not been able to achieve viral suppression or when the viral suppression status is not known [6–9]. These recommendations also advise the consideration of assisted reproduction for couples comprised of an HIV-uninfected woman and HIV-infected male partner [7,8]. Prior to PrEP, couples in this position did not have many options for safer conception apart from either sperm wash with intrauterine insemination (SW-IUI) or in-vitro fertilization (IVF) [18–20]. For IUI, processing of sperm to remove HIV includes density gradient centrifugation with an additional swim-up step in addition to PCR testing of the washed sperm fraction. Couples with reversed serodiscordancy (HIV-infected woman and HIV-uninfected male partner) alternatively do not need sperm preparation techniques; their options for safer conception are less restricted [8]. While these technologies are costly and infrequently available for HIV couples [21,22], cost-effectiveness analysis can establish the tradeoff among care options by determining the cost incurred per unit health gain for each intervention compared to an alternative. Therefore, it is important to evaluate whether, as society, we should invest in these services. While “U=U” is an important public health message that is generally applicable given the accumulated evidence on HIV transmission, a single guideline cannot address real-world heterogeneity of experiences and does not speak to nuances that could make U=U inappropriate. Specifically, the “U” of undetectable is not always certain. Notwithstanding variations in pregnancy planning preferences among couples affected by HIV, with inclined preference towards additional protective barriers [23,24], the female partner might not be in a position to negotiate their partner’s cART use, or protected intercourse. PrEP offers women autonomy and empowerment to make personal decisions affecting their health [25,26]. We therefore sought to investigate the value of PrEP for conception in the U.S. and to identify scenarios in which U=U may not be sufficient, and rather, PrEP or assisted reproduction would improve outcomes. We constructed a Markov model to investigate long-term outcomes, costs, and cost-effectiveness of strategies for HIV prevention for couples comprised of an HIV-uninfected woman and HIV-infected male partner in the U.S. seeking to conceive.

BACKGROUND With the advent of treatment as prevention of HIV infection (TasP), we assessed trends in sexual behaviours between 2000 and 2017 among HIV-infected MSM enrolled in the French ANRS PRIMO cohort. METHODS At each cohort visit, a clinical questionnaire including laboratory values was completed and a self-administered questionnaire was used to collect sexual behaviours, that is, the number, type (steady/casual) and HIV status (positive or negative/unknown) of partners, and condom use. The possible influence of viral load (undetectable/detectable) measured at the preceding visit on the evolution over time of sexual behaviour was assessed with logistic regression models fitted by generalized estimating equations (GEE), taking into account longitudinal data. RESULTS We analyzed data from 10657 follow-up visits by 1364 MSM. Overall, whatever the considered behavioural variable: at least one sexual partner, steady and/or casual, condomless sex with steady, casual partners, serodiscordant or not, we observed a calendar increase with a particularly more marked rise from 2010 (P

Background Preexposure prophylaxis (PrEP) efficacy is highly dependent on adherence. Yet, it is unclear which adherence measures perform best for PrEP. Methods We compared three types of self-reported adherence questions (rating of ability to adhere, frequency of doses taken, percentage of doses taken) and three forms of objective adherence measurement [unannounced pill counts (UPC), electronic monitoring, plasma tenofovir levels] using data from an ancillary adherence study within a clinical trial of PrEP among East African serodiscordant couples (Partners PrEP Study). Monthly measures were assessed for the first 6 months of follow-up. Results One thousand, one hundred and forty-seven participants contributed 6048 person-months of data to this analysis. Median adherence was high: self-reported rating (90%), self-reported frequency (93%), and self-reported percentage (97%); UPC (99%); and electronic monitoring (97%). Prevalence of steady-state daily dosing (SSDD; ≥40 ng/ml) was 74% in a random subset of tenofovir samples obtained from 365 participants. Discrimination of SSDD versus less than SSDD levels was poor for self-reported rating [area under the receiver-operating curve (AROC) 0.54], self-reported frequency (AROC 0.52), self-reported percentage (AROC 0.56) and UPC (AROC 0.58), but moderate for electronic monitoring (AROC 0.70). Correlation was moderate among self-reported measures, adherence (0.61-0.66), but low for these self-reported measures compared with UPC (0.32-0.36) and with electronic monitoring (0.22-0.28). Conclusion Electronic monitoring was the only adherence measure with meaningful ability to discriminate between SSDD and less than SSDD plasma tenofovir levels. Correlation between subjective and objective measures was poor. Future research should explore novel approaches to adherence measurement as PrEP moves into demonstration projects and programmatic implementation.

OBJECTIVE: To describe the development and implementation of a safer conception service in a resource-limited setting. METHODS: Qualitative work to inform the design of a safer conception service was conducted with clients and providers at Witkoppen Health and Welfare Centre a primary health center in Johannesburg South Africa. Services began in July 2013 for HIV-affected participants planning conception within 6 months and included counseling about timed unprotected intercourse and home-based self-insemination early initiation of combined antiretroviral therapy (cART) for HIV-infected individuals pre-exposure prophylaxis for HIV-uninfected partners and circumcision for men. Participants were enrolled into an implementation science study evaluating method uptake acceptability and pregnancy and HIV transmission outcomes. RESULTS: Findings to-date from 51 qualitative participants and 128 clinical cohort participants (82 women and 46 men representing 82 partnerships) are presented. All men were accompanied by female partners whereas 56% of women attended with their male partner. Fifteen of the 46 couples (33%) were in confirmed serodiscordant relationships; however of the 36 additional women attending alone 56% were unaware of their partners HIV status or believed them to be HIV-uninfected. The majority of the HIV-infected women (86%) and men (71%) were on cART at enrollment; however only 47% on cART were virally suppressed. Timed unprotected intercourse self-insemination and cART were common choices for participants; few elected pre-exposure prophylaxis. CONCLUSIONS: Lessons learned from early implementation demonstrate feasibility of safer conception services; however reaching discordant couples cART-naive infected partners and men remain challenges. Creating demand for safer conception services among those at highest risk for HIV transmission is necessary.

OBJECTIVES: Early initiation of antiretroviral therapy (ART) - that is at higher CD4 cell counts (>350 cells/mul) - is a potent HIV prevention strategy. The WHO recommends ART initiation by all HIV-infected individuals in HIV serodiscordant relationships to prevent HIV transmission yet the acceptability of early ART among couples has not been well studied. DESIGN: Qualitative study exploring HIV serodiscordant couples attitudes toward early initiation of ART. METHODS: We conducted eight focus group discussions and 20 in-depth interviews with members of heterosexual HIV serodiscordant couples in Kenya. Investigators iteratively applied inductive and deductive codes developed matrices to identify patterns in codes and reached consensus on key attitudes (motivations and barriers) related to early ART and one central emerging theme. RESULTS: Most participants expressed interest in early initiation of ART with maintaining health and preventing HIV transmission as key benefits. However many identified personal concerns and potential barriers to wider community acceptance including side-effects adherence to life-long treatment and stigma. The meaning of ART emerged as a fundamental consideration with initiating therapy perceived as emblematic of the final stage of AIDS when one was nearing the grave. One particular challenge was what early ART might signify for someone who looks and feels healthy. CONCLUSION: HIV serodiscordant couples recognized the potential benefits of early ART but ART was frequently viewed as signifying AIDS and approaching mortality. Potential implementation of early ART presents challenges and an opportunity to re-orientate individuals toward a new image of ART as health-preserving for patients and partners.

Background: HIV-1 subtype C has emerged as the most prevalent strain of HIV-1 worldwide, leading to speculation that subtype C may be more transmissible than other subtypes. We compared the risk of HIV-1 transmission for subtype C versus non-C subtypes (A, D, G and recombinant forms) among heterosexual African HIV-1 serodiscordant couples. Methods: We conducted a nested case-control analysis using data from two prospective cohort studies of heterosexual HIV-1 serodiscordant couples from six countries in eastern and southern Africa. Cases (N=121) included incident HIV-1 transmissions that were established as linked within the serodiscordant partnership by viral sequencing; controls (N=501) were nontransmitting HIV-1-infected partners. Subtype was determined for partial env and gag genes. Multiple logistic regression controlled for age and gender of the HIV-1-nfected partner and self-reported unprotected sex. Plasma and genital HIV-1 RNA concentrations were compared between subtype C and non-C subtypes using generalized estimating equations. Results: HIV-1 subtype C was not associated with increased risk of HIV-1 transmission compared with non-C subtypes: env adjusted odds ratio (adjOR) 1.14 [95% confidence interval (CI) 0.74-1.75, P=0.6] and gag adjOR 0.98 (95% CI 0.63-1.52, P=0.9). Plasma and genital HIV-1 RNA levels did not differ significantly for subtype C versus non-C. Conclusion: In a geographically diverse population of heterosexual African HIV-1 serodiscordant couples, subtype C was not associated with greater risk of HIV-1 transmission compared with non-C subtypes, arguing against the hypothesis that subtype C is more transmissible compared with other common subtypes. (c) 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Food and Drug Administration (FDA) recently approved a new preexposure prophylaxis (PrEP) indication for emtricitabine/tenofovir for men and women, allowing a new effective HIV prevention intervention. Recent clinical trials have demonstrated the efficacy of PrEP in reducing the risk of HIV acquisition among women. Its efficacy depends largely on adherence. Perception of HIV risk appears to drive adherence to PrEP. What motivates PrEP use is specific to the population and its unique vulnerabilities. Future interventions exploring the efficacy of PrEP must include a behavioral arm that is specific to the unique vulnerabilities of the population being studied.There are an estimated 140 000 heterosexual serodiscordant couples in the United States; approximately, half of these couples desire conception. HIV-uninfected women in serodiscordant couples seeking conception may prove to be an ideal population for PrEP. Periconceptional PrEP in highly motivated couples could be not only effective but also affordable and feasible.In order to make PrEP accessible to those populations most vulnerable to HIV infection, the following steps need to occur: PrEP needs to be affordable, particularly for those uninsured; HIV providers, primary care practitioners, and reproductive healthcare providers need to welcome PrEP as a component of their scope of practice; clinicians need to take adequate sexual histories of all their patients in order to identify those at risk and best candidates for PrEP; and identifying ways to promote adherence must include population-specific PrEP adherence interventions.

Objectives To estimate the frequency of detectable seminal HIV-1 viral load in men with repeatedly undetectable blood viral load, in the recent past years and over a 10-year period (2002-2011) in a large cohort of HIV-1-infected men from couples requesting assisted reproduction technologies. We also searched for an association between HIV-1 RNA seminal viral load, HIV-1 RNA plasma viral load measured by ultrasensitive assay, and blood HIV-1 DNA in a subgroup of 98 patients. Methods Three hundred and four HIV-1 infected men have provided 628 paired blood and semen samples. In a subset of 98 patients for which a blood sample was available, residual viremia, HIV-1 RNA in semen and HIV-1 DNA were studied. Results Twenty of 304 patients (6.6%) had detectable HIV-1 RNA in semen, ranging from 135 to 2365 copies/ml, corresponding to 23 samples, although they had concomitantly undetectable HIV-1 RNA in blood while they were under antiretroviral therapy. This prevalence was stable over time even in recent years. There was an association between HIV-1 RNA plasma viral load measured by ultrasensitive assay and HIV-1 DNA in blood, but both were not associated with seminal HIV-1 RNA viral load. Conclusion It seems cautious individually to maintain the recommendations of safe sex and the recourse to ART, or at least to inform the couple of the residual potential risk, in serodiscordant couples desiring a child.

We have entered a new era in which antiretroviral agents have been demonstrated to be highly effective in preventing HIV-1 infection, especially in serodiscordant couples. The HPTN-052 randomized, controlled trial (RCT) of early versus delayed antiretroviral therapy (ART) for the HIV-1-infected persons in sexual partnerships with HIV-negative persons demonstrated at least a 96% reduction in HIV-1 transmission in the 1763 couples studied in Africa, Asia and South America [1]. The Partners PrEP RCT, conducted among 4758 HIV-1serodiscordant couples in Kenya and Uganda, showed that when used as preexposure prophylaxis (PrEP) by the HIV-negative partner, daily tenofovir disproxil fumerate (TDF) and daily TDF/emtricitabine (FTC) were 62 and 73% effective, respectively, in preventing HIV-1 acquisition [2]. These robust effectiveness findings provide a strong basis for the use of antiretroviral agents for prevention, both to reduce the infectiousness of HIV-1infected persons and to reduce the susceptibility of HIVnegative persons.

Physiologic and behavioral changes during pregnancy may alter HIV-1 susceptibility and infectiousness. Prospective studies exploring pregnancy and HIV-1 acquisition risk in women have found inconsistent results. No study has explored the effect of pregnancy on HIV-1 transmission risk from HIV-1-infected women to male partners.In a prospective study of African HIV-1-serodiscordant couples, we evaluated the relationship between pregnancy and the risk of HIV-1 acquisition among women and HIV-1 transmission from women to men.Three thousand three hundred and twenty-one HIV-1-serodiscordant couples were enrolled, 1085 (32.7%) with HIV-1 susceptible female partners and 2236 (67.3%) with susceptible male partners. HIV-1 incidence in women was 7.35 versus 3.01 per 100 person-years during pregnant and nonpregnant periods [hazard ratio 2.34, 95% confidence interval (CI) 1.33-4.09]. This effect was attenuated and not statistically significant after adjusting for sexual behavior and other confounding factors (adjusted hazard ratio 1.71, 95% CI 0.93-3.12). HIV-1 incidence in male partners of infected women was 3.46 versus 1.58 per 100 person-years when their partners were pregnant versus not pregnant (hazard ratio 2.31, 95% CI 1.22-4.39). This effect was not attenuated in adjusted analysis (adjusted hazard ratio 2.47, 95% CI 1.26-4.85).HIV-1 risk increased two-fold during pregnancy. Elevated risk of HIV-1 acquisition in pregnant women appeared in part to be explained by behavioral and other factors. This is the first study to show that pregnancy increased the risk of female-to-male HIV-1 transmission, which may reflect biological changes of pregnancy that could increase HIV-1 infectiousness.

Objective Male circumcision reduces female-to-male HIV-1 transmission risk by approximately 60%. Data assessing the effect of circumcision on male-to-female HIV-1 transmission are conflicting, with one observational study among HIV-1-serodiscordant couples showing reduced transmission but a randomized trial suggesting no short-term benefit of circumcision. Design/methods Data collected as part of a prospective study among African HIV-1-serodiscordant couples were analyzed for the relationship between circumcision status of HIV-1-seropositive men and risk of HIV-1 acquisition among their female partners. Circumcision status was determined by physical examination. Cox proportional hazards analysis was used. Results A total of 1096 HIV-1-serodiscordant couples in which the male partner was HIV-1-infected were followed for a median of 18 months; 374 (34%) male partners were circumcised. Sixty-four female partners seroconverted to HIV-1 (incidence 3.8 per 100 person-years). Circumcision of the male partner was associated with a nonstatistically significant approximately 40% lower risk of HIV-1 acquisition by the female partner (hazard ratio 0.62, 95% confidence interval 0.35-1.10, P = 0.10). The magnitude of this effect was similar when restricted to the subset of HIV-1 transmission events confirmed by viral sequencing to have occurred within the partnership (n = 50, hazard ratio 0.57, P = 0.11), after adjustment for male partner plasma HIV-1 concentrations (hazard ratio 0.60, P = 0.13), and when excluding follow-up time for male partners who initiated antiretroviral therapy (hazard ratio 0.53, P = 0.07). Conclusion Among HIV-1-serodiscordant couples in which the HIV-1-seropositive partner was male, we observed no increased risk and potentially decreased risk from circumcision on male-to-female transmission of HIV-1.

OBJECTIVES: To synthesize the evidence on the risk of HIV transmission through unprotected sexual intercourse according to viral load and treatment with combination antiretroviral therapy (ART). DESIGN: Systematic review and meta-analysis. METHODS: We searched Medline, Embase and conference abstracts from 1996-2009. We included longitudinal studies of serodiscordant couples reporting on HIV transmission according to plasma viral load or use of ART and used random-effects Poisson regression models to obtain summary transmission rates [with 95% confidence intervals, (CI)]. If there were no transmission events we estimated an upper 97.5% confidence limit. RESULTS: We identified 11 cohorts reporting on 5021 heterosexual couples and 461 HIV-transmission events. The rate of transmission overall from ART-treated patients was 0.46 (95% CI 0.19-1.09) per 100 person-years, based on five events. The transmission rate from a seropositive partner with viral load below 400 copies/ml on ART, based on two studies, was zero with an upper 97.5% confidence limit of 1.27 per 100 person-years, and 0.16 (95% CI 0.02-1.13) per 100 person-years if not on ART, based on five studies and one event. There were insufficient data to calculate rates according to the presence or absence of sexually transmitted infections, condom use, or vaginal or anal intercourse. CONCLUSION: Studies of heterosexual discordant couples observed no transmission in patients treated with ART and with viral load below 400 copies/ml, but data were compatible with one transmission per 79 person-years. Further studies are needed to better define the risk of HIV transmission from patients on ART.

Background: In Zimbabwe, socioeconomic development has a complicated and changeable relationship with HIV infection. Longitudinal data are needed to disentangle the cyclical effects of poverty and HIV as well as to separate historical patterns from contemporary trends of infection. Methods: We analysed a large population-based cohort in eastern Zimbabwe. The wealth index was measured at baseline on the basis of household asset ownership. The associations of the wealth index with HIV incidence and mortality, sexual risk behaviour, and sexual mixing patterns were analysed. Results: The largest decreases in HIV prevalence were in the top third of the wealth index distribution (tercile) in both men at 25% and women at 21%. In men, HIV incidence was significantly lower in the top wealth index tercile (15.4 per 1000 person-years) compared with the lowest tercile (27.4 per 1000 person-years), especially among young men. Mortality rates were significantly lower in both men and women of higher wealth index. Men of higher wealth index reported more sexual partners, but were also more likely to use condoms. Better-off women reported fewer partners and were less likely to engage in transactional sex. Partnership data suggests increasing like-with-like mixing in higher wealth groups resulting in the reduced probability of serodiscordant couples. Conclusion: HIV incidence and mortality, and perhaps sexual risk, are lower in higher socioeconomic groups. Reduced vulnerability to infection, led by the relatively well off, is a positive trend, but in the absence of analogous developments in vulnerable groups, HIV threatens to become a disease of the poor.

Objective: To examine the safety and effectiveness of assisted reproduction using sperm washing for HIV-1-serodiscordant couples wishing to procreate where the male partner is infected. Design and methods: A retrospective multicentre study at eight centres adhering on the European network CREAThE and involving 1036 serodiscordant couples wishing to procreate. Sperm washing was used to obtain motile spermatozoa for 3390 assisted reproduction cycles (2840 intrauterine inseminations, 107 in-vitro fertilizations, 394 intra-cytoplasmic sperm injections and 49 frozen embryo transfers). An HIV test was performed in female partners at least 6 months after assisted reproduction attempt. The outcome measures recorded were number of assisted reproduction cycles, pregnancy outcome and HIV test on women post-treatment. Results: A total of 580 pregnancies were obtained from 3315 cycles. Pregnancy outcome was unknown in 47 cases. The 533 pregnancies resulted in 410 deliveries and 463 live births. The result of female HIV testing after assisted reproduction was known in 967 out of 1036 woman (7.1% lost to follow-up). All tests recorded were negative. The calculated probability of contamination was equal to zero (95% confidence interval, 0‐0.09%). Conclusion: This first multicentre retrospective study of assisted reproduction following sperm washing demonstrates the method to be effective and to significantly reduce HIV1 transmission risk to the uninfected female partner. These results support the view that assisted reproduction with sperm washing could not be denied to serodiscordant couples in developed countries and, where possible, could perhaps be integrated into a global public health initiative against HIV in developing countries.

Objectives: To describe knowledge of primary and secondary sexual partner's HIV serostatus and sexual practices, including serosorting, among men who have sex with men (MSM) living in California. Methods: Men who self-identified as gay/bisexual in the 2001 California Health Interview Survey, a statewide biennial random-digit-dial survey interviewing more than 50000 adults on a variety of health topics, were recontacted in 2002 and interviewed by telephone about injection drug use, their own and partner's HIV serostatus, and sexual risk behaviors. Results: Among 220 men who reported a primary partner, 86% [95% confidence interval (Cl): 77-92] knew their primary partner's serostatus; 62% (95% Cl, 52-70) of the 250 men who reported a secondary partner knew their most recent secondary partner's HIV serostatus. Knowledge of one's most recent secondary partner's HIV serostatus was inversely related to history of injecting recreational drugs (odds ratio, 0.22; P < 0.01), and reporting a primary partner in the past year (odds ratio, 0.37; P < 0.05). Two-fifths (41%) of HIV-positive men and three-fifths (62%) of HIV-negative men engaged in serosorting (serocordant unprotected anal intercourse) with their primary partners, whereas 33% HIV-positive men and 20% HIV-negative men did so with their most recent secondary partners. Conclusions: This population-based survey documented the extent to which MSM know their partners' serostatus and practice serosorting behaviors. The findings emphasize the need for studies to report serocordant and serodiscordant unprotected anal intercourse separately, as the former presents significant lower risk of HIV transmission.

Men were followed prospectively to identify demographic and behavioural characteristics associated with HIV seroconversion. Thirty-six HIV cases were identified (HIV incidence 1.9/100 person-years). Unprotected receptive anal sex with HIV-positive partners and with casual partners regardless of serostatus was associated with seroconversion. Having ever been in prison or in a psychiatric ward were predictive of seroconversion. HIV prevention efforts should address issues related to mental and social stability and serodiscordant relationships to reduce the risk of seroconversion.

We analysed a cohort of heterosexual HIV- serodiscordant couples with the aim of evaluating the risk of transmission ascribed to unprotected orogenital intercourse. A total of 135 seronegative individuals (110 women and 25 men), whose only risk exposure to HIV was unprotected orogenital sex with their infected partner, registered 210 person-years of follow-up. After an estimated total of over 19,000 unprotected orogenital exposures with the infected partner not a single HIV seroconversion occurred.

Evidence from observational studies in sub-Saharan Africa has shown that circumcised men have lower risk of acquiring HIV infection than uncircumcised men. In Sydney Australia a study examined the relationship between circumcision and HIV transmission in homosexual men. 74 subjects were interviewed shortly after their diagnosis with HIV infection between 1993-99. Men were asked to nominate an event of unprotected anal intercourse (UAI) with a serodiscordant or HIV status-unknown partner during which they believe they became HIV infected. Findings of the study indicate that 17% of the homosexual men reported insertive UAI as their highest risk activity. However no association is found between circumcision status and infection by insertive UAI. Furthermore findings suggest that circumcision is not strongly protective against HIV infection in homosexual men.

Introduction The results of the Voluntary HIV-1 Counselling and Testing Efficacy Study support the efficacy and cost-effectiveness of HIV voluntary counselling and testing (VCT) for reducing risk behaviors in three developing countries. Methods This report explores the social consequences of HIV VCT by examining the incidence of positive and negative life events at the first follow-up (an average of 7.3 months after recruitment). The incidence of positive and negative life events was compared between: (i) those who were randomly assigned to HIV VCT versus health information (HI); (ii) those who tested seronegative and those who tested seropositive; and (iii) those who disclosed their serostatus and those who did not. Results The occurrence of most negative life events was rare (0--4%); positive life events were more common (17--39%). With few exceptions, those assigned to HIV VCT were no more likely to experience negative life events than those who were assigned to HI. For individuals, positive serostatus was associated with increased support from health professionals, the break-up of a marriage and being neglected or disowned by their family. Serodiscordant couples with an HIV-positive woman were most likely to report the break-up of a marriage (20 versus 0--7% for other groups) and the break-up of a sexual relationship (45 versus 22--38% for other groups). Disclosure was associated with strengthening of a sexual relationship except for HIV-seropositive women. Conclusion These findings, in combination with findings supporting the efficacy and cost-effectiveness of HIV VCT, support the dissemination of HIV VCT with appropriate support services in developing countries.

Objective: Because syphilis can raise the likelihood of HIV transmission and acquisition, syphilis prevention in the USA has the potential benefit of reducing the number of new cases of HIV. We developed a simplified transmission model to estimate the annual number and cost of new, heterosexually-acquired HIV cases in the USA attributable to syphilis. Design: We estimated the number of heterosexual, HIV serodiscordant partnerships in which syphilis was present in 1996. The model included the probability of transmission of HIV (with and without the presence of syphilis) and other parameters based on data from recent literature. Published direct costs (HIV treatment costs including antiretroviral therapy) and indirect costs (e.g., lost productivity) per case of HIV were used to estimate the annual cost of HIV cases attributable to syphilis. The potential savings in averted HIV costs related to syphilis were used to estimate the potential benefits of a syphilis elimination program. Results: In 1996, an estimated 1082 new heterosexual cases of HIV in the USA could be attributed to syphilis. These cases represented direct costs of US$ 211 million and indirect costs of US$ 541 million; yielding US$ 752 million in total costs. Over 15 years, a syphilis elimination program could save over US$ 833 million (discounted at 3% annually) in averted direct medical costs of syphilis-related HIV infections. Conclusions: If the only benefit of syphilis elimination were to prevent new HIV cases attributable to syphilis, a national syphilis elimination program costing less than US$ 833 million would probably pay for itself.

OBJECTIVE To ascertain the extent of family member support to heterosexual HIV-serodiscordant couples, and to identify associated sociodemographic and clinical characteristics. DESIGN Discordant couples enrolled in a cohort study of heterosexual HIV transmission were interviewed with structured questionnaires to obtain sociodemographic data, family member awareness of HIV and perceived support from family members. Clinical characteristics were established by medical history, physical examination and laboratory tests. RESULTS Awareness and support of family members were associated with sex of family member and HIV seropositivity, sex, education, and race of the partner. HIV-seropositive partners were more likely to have a sister aware than were HIV-negative partners (P = 0.01). More educated HIV-positive partners had fewer aware family members than less educated HIV-positive individuals (P = 0.02). Mothers of HIV-positive women were more often aware than mothers of all other partners (P = 0.04). Black HIV-negative partners had fewer aware family members than whites or Hispanics (P = 0.02). CONCLUSION This research shows both encouraging and disturbing patterns of family awareness of HIV and support to serodiscordant partners.