**3. Policies and policy implementation**

South Africa has been very vigilant in the fight against HIV. For the last 20 years policy adoption and implementation has been at the foreground of HIV management. This section provides an overview of policy strategies that guide HIV management and discuss how these strategies influence the well-being of sero-discordant couples.

Since the start of the new millennium, the management of HIV was spearheaded by comprehensive, multi-sectorial action orientated National Strategic Plans for HIV/AIDS and Sexually Transmitted Infections [15]. Over the last 18 years, many gains have been made in curbing the HIV epidemic. Initiated by the health ministry in 1999 the NSP 2000–2005, in partnership with governmental and non-governmental organisations, as well as, community- and faith-based organisations priority areas related to HIV management were identified. The outcome of this discussion produced four key focus areas.

These included a focus on:

• Prevention;

sero-discordant interventions as a response to managing the HIV epidemic among couples

In sub-Saharan Africa, sero-discordance is a critical factor for the transmission of HIV [7]. Sero-discordance, refers to couples with a mixed HIV status. In such relationships one partner has a known HIV positive status while his or her partner is HIV negative [8, 9]. Hence, for the purpose of this chapter, we define a sero-discordant couple as two individuals who are in a current sexual relationship in which both partners are aware of the other's HIV status. Some authors have argued that sero-discordant sexual relationships are high risk as HIV transmis-

Despite the misconception that a greater proportion of men are likely to be the index partner, through a systematic review Eyawo et al. [13] established that nearly half (47%) of the index partners were women. This indicates that men and women are equally likely to be the index partner in sero-discordant couples in the sub-Saharan African region. These findings also speak to the prevention and marketing strategies that are meant to be gender balanced in

In regions with high HIV prevalence, proportions of sero-discordant intra-couple transmission range from 13.0 to 55% of new HIV infections [14]. For South Africa, the estimated proportion of sero-discordant couples is unclear, however, transmission among longer-term couples were estimated above 10.0% per year [15]. Thus the prevention of intra-couple HIV transmission may delay the progression of the epidemic. As such, sero-discordant couples are

South Africa has been very vigilant in the fight against HIV. For the last 20 years policy adoption and implementation has been at the foreground of HIV management. This section provides an overview of policy strategies that guide HIV management and discuss how these

Since the start of the new millennium, the management of HIV was spearheaded by comprehensive, multi-sectorial action orientated National Strategic Plans for HIV/AIDS and Sexually Transmitted Infections [15]. Over the last 18 years, many gains have been made in curbing the HIV epidemic. Initiated by the health ministry in 1999 the NSP 2000–2005, in partnership with governmental and non-governmental organisations, as well as, community- and faith-based organisations priority areas related to HIV management were identified. The outcome of this

**2. Definition and prevalence of sero-discordance globally, SADC** 

sion is more likely to happen in longer-term relationships [10–12].

a key target population in the context of HIV prevention.

strategies influence the well-being of sero-discordant couples.

**3. Policies and policy implementation**

discussion produced four key focus areas.

that goes beyond couple testing [6].

30 Advances in HIV and AIDS Control

heterosexual sero-discordant couples.

**and SA**


In essence, the NSP 2000–2005 garnered immense progress in the fight against HIV, but aetiological differences regards the epidemic between the government and civil society posed numerous challenges that curbed the progress [15]. Informed by the successes and limitations of the NSP 2000–2005, in addition to, the progress of the disease and the gains made in terms of biomedical advances, the NSP 2007–2011 continued to focus on improving prevention; treatment, care and support; research, monitoring, and surveillance; human rights and access to justice. Some primary goals were attached to each of these key priority areas. In terms of prevention, the goal was to decrease new infections by 50% with a focus on the 15–24 age year group. Even though this goal was not attained, the mother-to-child transmission was significantly reduced [16]. The treatment focused goal aimed to facilitate access to the appropriate HIV treatment to 80% of PLHIV by the end of the 5 year period. With some challenges regarding implementation, monitoring and evaluation, the decrease in the general adult mortality rates could be accredited to the increase in treatment access [16]. The third and fourth priority areas were reportedly riddled with implementation barriers and therefore did not reach all its goals. It can therefore be established that the second NSP (2007–2011) made some gains in managing HIV, but much more needs to be done at the structural level to ensure greater success.

The NSP 2012–2016, introduced a comprehensive response, which included goals and targets, linked to treatment, prevention, human rights and TB. While many goals were achieved during the 2012–2016 period, gaps were also identified. For instance, notable declines were reported in terms of reducing new HIV and TB infections, but the goal to reduce new HIV infections and new TB infections by at least 50% has not been achieved. What has become evident is that reducing incidence and stabilising prevalence, will require the scale-up of HIV/ TB prevention, testing, linkage to care and life-long adherence strategies, with a particular focus on high risk populations.

Two years prior to the end of the NSP 2012–2016 term, South Africa adopted the global 90-90- 90 treatment strategy. With its focus on treatment, the strategy targets aims to facilitate the necessary processes so that 90% of people living with HIV can know their status, 90% of those who tested HIV positive can receive sustained antiretroviral therapy and that 90% of those receiving antiretroviral therapy reach and maintain viral suppression by 2020 (see **Figure 1**).

According to Bain et al. [17] the success of the strategy would "… result in 73% of people with HIV achieving viral suppression, a crucial step in ending the AIDS epidemic by 2030 "(p. 1). With this strategy in place, the South African National AIDS Council (SANAC) [18] recently

social determinants of HIV and TB. Because of the changing nature of the epidemics, research on social determinants will always be relevant. However, at this stage in the fight against HIV and TB, developing and testing robust behavioural intervention models should be at the foreground of our national HIV/TB response. Furthermore, what the current NSP lacks is a clear strategy that marries bio-medical and socio-behavioural models to improve the HIV/

Achieving 90-90-90: A Focus on Sero-Discordant Couples

http://dx.doi.org/10.5772/intechopen.78313

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For instance, with 6.8 mil PLHIV, more comprehensive work should be prioritised. An example of such work could include a socio-behavioural intervention among sero-discordant couples. The NSP highlights a focus on family, but fail to clearly define possible intervention entry points that could help achieve the 90-90-90 goals within the family. A family- or couplefocused intervention may include encouraging home-based testing, family participation in

This section provides an overview of existing prevention and intervention programmes, that are implemented in the public and private health care systems as well as those implemented

The prevalence of sero-discordance among romantic relationships is growing in South Africa for various reasons [6]. What is concerning is the fact that, in the country and globally, it has been documented that HIV is most commonly transmitted between partners who are in a committed relationship [6]. This ultimately raises important issues including the risk of infection, reproductive choices and stress and change in the relationship dynamics. Despite the salience of couple relationships, existing HIV prevention interventions mainly focus on individuals instead of couples as a unit [19]. This negates the significant influence that couples play on each other's behaviour. There is growing agreement on the fact that prevention interventions and research should be aimed at couples as a unit to bring about change and maintain discordance. Couples-focused programs could concurrently include both dyad members, target each member separately and alone, in other instances might involve a combination of both modalities. The World Health Organisation has set out specific prevention interventions for couples with respect to their sero-status [20]. **Figure 3** lists the interventions that are specific

**4. Existing prevention interventions for sero-discordant couples**

for sero-discordant couples be it whether the male or female is the index partner.

Paying closer attention to literature pertaining to HIV Testing Services, couples counselling and testing are especially important for identifying HIV sero-discordant status among couples. Many men and women who are in relationships with a partner who is HIV positive do not know their own HIV status let alone their partner's [21]. In settings with a generalised HIV epidemic, research shows that in the context of sero-discordant relationships women

*4.1.1. Case identification through HIV testing services (HTS) for couples*

TB-related outcomes for the country.

by civil society organisations.

achieving adherence and ultimately viral suppression.

**4.1. Current couple-centred HIV prevention services**

**Figure 1.** Key targets of the 90-90-90 HIV treatment strategy.

reported that among adults aged 15–59 years old, 86.0% were aware of their HIV status, of those 65.0% were currently on treatment, while of those who are on treatment 81% were virally suppressed (see **Figure 2**).

The current 2017–2022 NSP proposes a focus on social and behavioural aspects of HIV/AIDS and TB that prioritises a research agenda. This includes a commitment to having dedicated research funding for these health issues, build capacity to conduct research, and to identify better ways to collect and disseminate research findings. In addition, the plan acknowledges that we cannot simply treat our way out of the HIV epidemic, but that prevention strategies would offer the best response to curbing the HIV and TB epidemic.

While the NSP 2017–2022 stipulates the importance of Social Science and Humanities research in the 5 year plan, the proposed research foci continue to hover around understanding the

**Figure 2.** Progress towards the 90-90-90 HIV treatment strategy.

social determinants of HIV and TB. Because of the changing nature of the epidemics, research on social determinants will always be relevant. However, at this stage in the fight against HIV and TB, developing and testing robust behavioural intervention models should be at the foreground of our national HIV/TB response. Furthermore, what the current NSP lacks is a clear strategy that marries bio-medical and socio-behavioural models to improve the HIV/ TB-related outcomes for the country.

For instance, with 6.8 mil PLHIV, more comprehensive work should be prioritised. An example of such work could include a socio-behavioural intervention among sero-discordant couples. The NSP highlights a focus on family, but fail to clearly define possible intervention entry points that could help achieve the 90-90-90 goals within the family. A family- or couplefocused intervention may include encouraging home-based testing, family participation in achieving adherence and ultimately viral suppression.
