Published: 2022-10-29

Sexual behaviours of HIV sero-discordant couples in the context of art: a systematic review of studies from Sub-Saharan Africa

Judith Hassan, Kate Mitchell, Uguge Basil, Babatunde Shuaib, Victor B. Oti


The impact of the use of antiretroviral therapy (ART) on the sexual behaviours of serodiscordant couples (SDC) is not well documented. This systematic review attempts to examine the strength of evidence from primary studies on the impact of ART on the sexual behaviours of serodiscordant couples in SSA. In this study, 16 studies that fit the inclusion criteria were identified. Nine were cohort studies, six cross-sectional and one randomised controlled trial. Risky sexual behaviours generally declined on several indicators used to assess them. Five within individual studies reported a decrease in unprotected sex from baseline to follow-up, while of the four that said consistent condom use, they observed a significant increase in condom use from baseline to follow-up. For the between-individual studies, one study posited that ART is significantly associated with inconsistent condom use, whereas reporting multiple and concurrent partners and self-reported symptoms of sexually transmitted infections (STIs) were associated with not being on ART. Overall, there was evidence of lower-risk sexual behaviours with ART among SDC in sub-Saharan Africa. However, this relationship was not established to be causal. Further research is required to fully explore and validate the impact of ART on the sexual practices of these couples. Behavioural programmes should be strengthened and targeted towards couple-based counselling and testing with disclosure of status and continue encouraging consistent condom use among steady couples.



Sero-discordant couple, Anti-retroviral therapy, Condom use, Sexually transmitted infections, Sub-Saharan Africa, HIV

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Lu W, Zeng G, Luo J, Duo S, Xing G, Guo-Wei D, et al. HIV transmission risk among serodiscordant couples: a retrospective study of former plasma donors in Henan, China. J Acquir Immune Defic Syndr. 2010;55(2):232-8.

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(9):1083-9.

Hugonnet S, Mosha F, Todd J, Mugeye K, Klokke A, Ndeki L, et al. Incidence of HIV infection in stable sexual partnerships: a retrospective cohort study of 1802 couples in Mwanza Region, Tanzania. J Acquir Immune Defic Syndr. 2002;30(1):73-80.

Donnell D, Baeten JM, Kiarie J, Thomas KK, Stevens W, Cohen CR, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010;375(9731):2092-8.

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493-505.

Cohen MS, McCauley M, Gamble TR. HIV treatment as prevention and HPTN 052. Curr Opin HIV AIDS. 2012;7(2):99-105.

Guidance on Couples HIV Testing and Counselling Including Antiretroviral Therapy for Treatment and Prevention in Serodiscordant Couples: Recommendations for a Public Health Approach. Geneva: World Health Organization; 2012.

Kembabazi A, Bajunirwe F, Hunt PW, Martin JN, Muzoora C, Haberer JE, et al. Disinhibition in risky sexual behavior in men, but not women, during four years of antiretroviral therapy in rural, southwestern Uganda. PLoS One. 2013;8(7):e69634.

Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review. JAMA. 2004 Jul 14;292(2):224-36.

Venkatesh KK, Srikrishnan AK, Safren SA, Triche EW, Thamburaj E, Prasad L, et al. Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery. AIDS Care. 2011;23(6):722-33.

Moatti JP, Prudhomme J, Traore DC, Juillet-Amari A, Akribi HA, Msellati P, et al. Access to antiretroviral treatment and sexual behaviours of HIV-infected patients aware of their serostatus in Côte d'Ivoire. AIDS. 2003;17(3):S69-77.

Mugwanya KK, Donnell D, Celum C, Thomas KK, Ndase P, Mugo N, et al. Sexual behaviour of heterosexual men and women receiving antiretroviral pre-exposure prophylaxis for HIV prevention: a longitudinal analysis. Lancet Infect Dis. 2013;13(12):1021-8.

Kennedy C, O'Reilly K, Medley A, Sweat M. The impact of HIV treatment on risk behaviour in developing countries: a systematic review. AIDS Care. 2007;19(6):707-20.

Berhan A, Berhan Y. Is The Sexual Behaviour Of HIV Patients On Antiretroviral Therapy Safe Or Risky In Sub-Saharan Africa? Meta-Analysis And Meta-Regression. AIDS Res Ther. 2012;9(1):14

Diabaté S, Alary M, Koffi C. Short-Term Increase In Unsafe Sexual Behaviour After Initiation Of HAART In Cote D'ivoire. AIDS. 2008;22(1):154-6

oburn BJ, Gerberry DJ, Blower S. Quantification Of The Role Of Discordant Couples In Driving Incidence Of HIV In Sub-Saharan Africa. Lancet Infectious Dis. 2011;11(4):263-4

Apondi R, Bunnell R, Ekwaru JP, Moore D, Bechange S, Khana K, et al. Sexual behavior and HIV transmission risk of Ugandan adults taking antiretroviral therapy: 3 year follow-up. AIDS. 2011;25(10):1317-27.

Bunnell R, Ekwaru JP, Solberg P, Wamai N, Bikaako-Kajura W, Were W, et al. Changes In Sexual Behavior And Risk Of HIV Transmission After Antiretroviral Therapy And Prevention Interventions In Rural Uganda. AIDS. 2006;20(1):85-92

Birungi J, Min JE, Muldoon KA, Kaleebu P, King R, Khanakwa S, et al. Lack of Effectiveness of Antiretroviral Therapy in Preventing HIV Infection in Serodiscordant Couples in Uganda: An Observational Study. PLoS One. 2015;10(7):e0132182.

Wandera B, Kamya MR, Castelnuovo B, Kiragga A, Kambugu A, Wanyama JN, et al. Sexual behaviors over a 3-year period among individuals with advanced HIV/AIDS receiving antiretroviral therapy in an urban HIV clinic in Kampala, Uganda. J Acquir Immune Defic Syndr. 2011;57(1):62-8.

Reynolds SJ, Makumbi F, Nakigozi G, Kagaayi J, Gray RH, Wawer M, et al. HIV-1 transmission among HIV-1 discordant couples before and after the introduction of antiretroviral therapy. AIDS. 2011;25(4):473-7.

Dia A, Marcellin F, Bonono RC, Boyer S, Bouhnik AD, Protopopescu C, et al. Prevalence of unsafe sex with one's steady partner either HIV-negative or of unknown HIV status and associated determinants in Cameroon (EVAL ANRS12-116 survey). Sex Transm Infect. 2010;86(2):148-54.

Eisele TP, Mathews C, Chopra M, Lurie MN, Brown L, Dewing S, et al. Changes in risk behavior among HIV-positive patients during their first year of antiretroviral therapy in Cape Town South Africa. AIDS Behav. 2009;13(6):1097-105.

Venkatesh KK, Bruyn G, Lurie MN, Modisenyane T, Triche EW, Gray GE, et al. Sexual risk behaviors among HIV-infected South African men and women with their partners in a primary care program: implications for couples-based prevention. AIDS Behav. 2012;16(1):139-50.

Sarna A, Luchters SM, Geibel S, Kaai S, Munyao P, Shikely KS, et al. Sexual risk behaviour and HAART: a comparative study of HIV-infected persons on HAART and on preventive therapy in Kenya. Int J STD AIDS. 2008;19(2):85-9.

Venkatesh KK, Srikrishnan AK, Safren SA, Triche EW, Thamburaj E, Prasad L, et al. Sexual risk behaviors among HIV-infected South Indian couples in the HAART era: implications for reproductive health and HIV care delivery. AIDS Care. 2011;23(6):722-33.

Dessie Y, Gerbaba M, Bedru A, Davey G. Risky sexual practices and related factors among ART attendees in Addis Ababa Public Hospitals, Ethiopia: a cross-sectional study. BMC Public Health. 2011;11:422.

Ncube NM, Akunna J, Babatunde F, Nyarko A, Yatich NJ, Ellis W, et al. Sexual risk behaviour among HIV-positive persons in Kumasi, Ghana. Ghana Med J. 2012;46(1):27-33.

Luchters S, Sarna A, Geibel S, Chersich MF, Munyao P, Kaai S, et al. Safer sexual behaviors after 12 months of antiretroviral treatment in Mombasa, Kenya: a prospective cohort. AIDS Patient Care STDS. 2008;22(7):587-94.

Pearson CR, Cassels S, Kurth AE, Montoya P, Micek MA, Gloyd SS. Change in sexual activity 12 months after ART initiation among HIV-positive Mozambicans. AIDS Behav. 2011;15(4):778-87.

Jean K, Gabillard D, Moh R, Danel C, Fassassi R, Desgrées-du-Loû A, et al. Effect of early antiretroviral therapy on sexual behaviors and HIV-1 transmission risk among adults with diverse heterosexual partnership statuses in Côte d'Ivoire. J Infect Dis. 2014;209(3):431-40.

Osinde MO, Kaye DK, Kakaire O. Sexual behaviour and HIV sero-discordance among HIV patients receiving HAART in rural Uganda. J Obstet Gynaecol. 2011;31(5):436-40.