Harvard Public Health Review
Spring 2006






Saving Lives, Two by Two

Preventing AIDS in stable couples whwere one partner is HIV-positive

A staggering three quarters of all new HIV infections in sub-Saharan Africa arise not from tainted blood or casual sex, but within stable sexual partnerships. Ugandan physician Patrick Ndase, who's working on a master's degree at the Harvard School of Public Health, knows this statistic better than most.

It was while coordinating a study in Botswana on the prevention of mother-to-child transmission of HIV in 2001 that Ndase began looking closely at couples, a population most researchers had, until then, ignored. At the time, prevention and testing throughout Africa was narrowly focused on young, single people and pregnant women; clinicians and researchers were examining individuals outside the context of any sexual relationships they might have. "It makes it seem like the man has no role," says Ndase.

Wondering just how many men would be willing to test for HIV, Ndase took advantage of his study to find out. As women signed up for testing, counselors asked them to invite their spouses in, too. Only about 5 percent brought in men in response to this low-key tactic. But of 150 couples whose HIV status was unknown, 23 percent proved discordant, meaning one partner was HIV-positive while the other tested negative. Ndase realized that the HIV-prevention systems were failing to protect people who were in committed relationships but still vulnerable to infection.

"Testing people individually perpetuates the assumption that if we are stable sexual partners, your HIV status is my status," says Ndase. "But that's not the case." It is, however, becoming increasingly so. Among adults 25-49 years of age, HIV prevalence in Botswana has shot up, from under 15 percent in 1992 to nearly 43 percent in 2003. "But the battle's not yet lost," says Ndase, pointing to studies that show that for every 100 adults known to be HIV-positive, 40 have a negative partner who can be protected.

Counseling dos and don'ts
"There's a terrific problem in how to involve men in the HIV education process," says Max Essex, the John Laporte Given Professor of Infectious Diseases, who chairs the Harvard School of Public Health AIDS Initiative (HAI) and is Ndase's advisor. In 1996, Essex launched the Botswana-HSPH AIDS Initiative Partnership for HIV Research and Education, or "BHP," which employed Ndase between 2001 and 2005.

In Botswana, women often fail to disclose their positive status to male partners for fear they'll be rejected or accused of infidelity. And many men don't get tested, a fact widely attributed to stigma.

Ndase doesn't quite buy the stigma theory. He says too many health care providers just assume men and couples won't come to HIV-testing centers, and don't even try to get them there. "You cannot blame low testing rates on stigma when we haven't made an effort to put the pie out to see if people will eat it," he says.

In 2003, Ndase saw a chance to integrate couples into Botswana's AIDS prevention strategy. As co-investigator for a study of HIV transmission among discordant partners, Ndase urged non-governmental organizations, public health providers, and district- and state-level policy makers to make couples testing a priority. He then devised a program to train HIV counselors in the dos and don'ts of couples counseling. For example: do make sure couples understand that discordance most often results not from infidelity but from infection that predates the relationship; don't reveal a partner's HIV status without the other being present.

Ndase recruited couples at a faster rate than any other site, winning a Site Director of the Year award in 2005. Study leader Connie Celum, an infectious diseases professor and epidemiologist at the University of Washington, says she was "impressed by Patrick's inquisitive mind and his due diligence--not leaving any rock unturned."

Getting things to move
Ndase grew up in the small town of Iganga, in central Uganda. Neither his mother, a homemaker, nor his father, a shop owner, went to high school, but they worked hard to put three children through school and college. With his government's help, Ndase went on to study medicine. Having grown up watching his peers skip school to care for family members who couldn't pay doctor fees, he saw medicine as a way of keeping illness and poverty at bay.

Then AIDS engulfed his world. Ndase first heard rumors about a "slim disease" wiping out families in central Uganda in 1986. The government declared AIDS a crisis, and there were HIV-education shows on the radio, posters on the streets, and free condoms on offer. Nonetheless, Ndase lost his sister, brother-in-law, uncle, and stepbrother to AIDS. As the crisis eased in Uganda, he decided to take his skills to a country suffering more than his own. In 2001, he moved with his family to Gaborone, Botswana's capital, where he joined the BHP.

Ndase chose to study at HSPH, he says, because "HIV is one problem that requires leadership right from the top." He is the first beneficiary of a fellowship funded by HAI supporter Florence Koplow, who visited Botswana to see the BHP at work with Max Essex, HSPH Dean Barry Bloom, and others in 2004. After Ndase graduates in June, he will return to Africa, though not to the discordant couples study; instead, he will explore HIV prevention strategies in cultures in which polygamy is condoned. "Seeing things moving," he says, "is not as challenging for me as getting things to move."

Katharine Dunn writes about science, medicine, and technology for the Boston Globe, Science and Spirit, and Technology Review.

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