title: Extra-couple HIV transmission in sub-Saharan Africa: a mathematical modelling study of survey data.
abstract: BACKGROUND
  The proportion of heterosexual HIV transmission in sub-Saharan Africa that occurs within cohabiting partnerships, compared with that in single people or extra-couple relationships, is widely debated. We estimated the proportional contribution of different routes of transmission to new HIV infections. As plans to use antiretroviral drugs as a strategy for population-level prevention progress, understanding the importance of different transmission routes is crucial to target intervention efforts.
  
  
  METHODS
  We built a mechanistic model of HIV transmission with data from Demographic and Health Surveys (DHS) for 2003-2011, of 27,201 cohabiting couples (men aged 15-59 years and women aged 15-49 years) from 18 sub-Saharan African countries with information about relationship duration, age at sexual debut, and HIV serostatus. We combined this model with estimates of HIV survival times and country-specific estimates of HIV prevalence and coverage of antiretroviral therapy (ART). We then estimated the proportion of recorded infections in surveyed cohabiting couples that occurred before couple formation, between couple members, and because of extra-couple intercourse.
  
  
  RESULTS
  In surveyed couples, we estimated that extra-couple transmission accounted for 27-61% of all HIV infections in men and 21-51% of all those in women, with ranges showing intercountry variation. We estimated that in 2011, extra-couple transmission accounted for 32-65% of new incident HIV infections in men in cohabiting couples, and 10-47% of new infections in women in such couples. Our findings suggest that transmission within couples occurs largely from men to women; however, the latter sex have a very high-risk period before couple formation.
  
  
  CONCLUSIONS
  Because of the large contribution of extra-couple transmission to new HIV infections, interventions for HIV prevention should target the general sexually active population and not only serodiscordant couples.
  
  
  BACKGROUND
  US National Institutes of Health, US National Science Foundation, and J S McDonnell Foundation.
authors: Department of Environmental Science, Policy and Management, University of California, Berkeley, CA, USA. steve.bellan@gmail.com
authors: Steve E
authors: SE
authors: Bellan
authors: Kathryn J
authors: KJ
authors: Fiorella
authors: Dessalegn Y
authors: DY
authors: Melesse
authors: Wayne M
authors: WM
authors: Getz
authors: Brian G
authors: BG
authors: Williams
authors: Jonathan
authors: J
authors: Dushoff
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D005191:Family Characteristics; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000635:transmission*; D006679:HIV Seropositivity / Q000453:epidemiology / Q000635:transmission; D006306:Health Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D055815:Young Adult
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