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• W2159739304 abstract "Kristin Dunkle and colleagues (June 28, p 2183)1Dunkle KL Stephenson R Karita E et al.New heterosexually transmitted infections in married or cohabitating couple in urban Zambia and Rwanda: an analysis of survey and clinical data.Lancet. 2008; 371: 2183-2191Summary Full Text Full Text PDF PubMed Scopus (392) Google Scholar address a profoundly important question for HIV prevention: the source of new infections in generalised epidemics. However, their modelling has at least two crucial weaknesses. First, Dunkle and colleagues assume an annual rate of infection from one infected partner to another of 20%. Of the two older studies they reference, the first2Hira SK Nkowane BM Kamanga J et al.Epidemiology of human immunodeficiency virus in families in Lusaka, Zambia.J Acquir Immun Defic Syndr. 1990; 3: 83-86PubMed Google Scholar was predominantly based on individuals with advanced disease (AIDS and AIDS-related complex) who are highly infectious and hence not representative. The other study3Allen S Tice J Van de Perre P et al.Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa.BMJ. 1992; 302: 1605-1609Crossref Scopus (383) Google Scholar had no direct data on uncounselled couples, but imputed a rate of infection indirectly. By contrast, evidence from the well observed cohort studies in Rakai, Masaka, and Mwanza from the 1990s are all consistent in finding infection rates of about 5–10% in the multiyear latent phase of infection. Dunkle and colleagues discount such estimates, arguing that participants might have been aware of their HIV status. However, in the case of Rakai,4Matovu JKB Gray RH Makumbi F et al.Voluntary HIV counseling and testing acceptance, sexual risk behavior and HIV incidence in Rakai, Uganda.AIDS. 2005; 19: 503-511Crossref PubMed Scopus (122) Google Scholar knowing ones status had no effect on HIV acquisition even with counselling. The second major flaw is to assume no infections occur over the course of a year within “couples” where both are uninfected. In reality, rapid transmission occurs among people who have concurrent partnerships, as one highly infectious new infection begets another. Such transmission probably drives much of the generalised epidemics. Seroprevalence data clearly rebut both assumptions. For example, in Rwanda,5Institut National de la Statistique du Rwanda (INSR) and ORC Macro 2006Rwanda demographic and health survey 2005.http://www.measuredhs.com/pubs/pub_details.cfm?ID=594&ctry_id=35&SrchTp=typeGoogle Scholar among couples in whom at least one partner is infected, 44% involve partners who both have HIV. If the intracouple infection rate were 20% per year, in a mature epidemic, the proportion of couples in which both are infected should be far higher than 44%. Additionally, if virtually all infections occur within established discordant partnerships, where did the large proportion of couples with only one infected partner (56%) come from? Clearly many infections are occurring outside of established dyads. We agree with Dunkle and colleagues' interpretation that counselling and testing among couples should be promoted, but their modelling greatly overestimates its potential benefit. We declare that we have no conflict of interest. Source of new infections in generalised HIV epidemics – Authors' replyIn our paper, we concluded that (1) most new HIV infections in urban Zambia and Rwanda are acquired from cohabiting partners, and (2) many infections could be prevented with couples' HIV counselling and testing (CVCT). Full-Text PDF" @default.
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• W2159739304 title "Source of new infections in generalised HIV epidemics" @default.
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• W2159739304 doi "https://doi.org/10.1016/s0140-6736(08)61545-7" @default.
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