Bioethics education in Democratic Republic of Congo: Experiences and challenges.

In regions marked by socio-economic turmoil, the task of teaching bioethics to health professionals and researchers can be more challenging than elsewhere. To demonstrate this, in this article we describe some of our teaching experiences in the Democratic Republic of Congo over the past decade. A first difficulty is linguistic. Anglo-Saxon language and culture largely dominates the field of bioethics, complicating teaching and education for those who do not master the language. A second obstacle is conceptual. Bioethics is often misunderstood as reflection on technological developments in medicine, which distorts its objectives and narrows its scope, particularly in resource-constrained settings. A third difficulty is cultural and political. Ethics in this setting is difficult to distinguish from common morality and the work of moralists, who comment on problems in medicine from a religious standpoint. Moreover, when interacting with communities and institutions that are strongly hierarchical, the critical stance of bioethics can give rise to resistance and rejection. These are among the array of difficulties that undoubtedly have given rise to sharp critiques of bioethics training initiatives in developing countries, where the introduction of bioethics has been depicted as a form of Western imperialism. While taking these criticisms seriously, our experiences in the field show how these seemingly insurmountable difficulties can be transformed into (more or less) manageable challenges.

Dans les régions marquées par un contexte socioéconomique difficile, les difficultés sont plus nombreuses qu'ailleurs pour ceux qui se donnent pour tâche de former à la réflexion éthique les professionnels de la santé et les chercheurs. Pour le montrer, nous évoquons dans cet article nos expériences en République Démocratique du Congo. Une première difficulté est à chercher du côté linguistique. En effet, la langue et la culture anglo-saxonnes dominent largement la discipline, compliquant la tâche de ceux qui maîtrisent mal l'anglais. Unedeuxième difficulté à surmonter est d'ordre conceptuel. Les objectifs et le champ d'application de la bioéthique sont souvent mal compris, ce qui peut conduire à confondre les spécialistesde la discipline tantôt avec des moralistes surtout préoccupés par le progrès biotechnologique, tantôt avec des référents religieux. La troisième difficulté évoquée est de nature politique et culturelle. Lorsqu'elle entre en interaction avec des communautés très hiérarchisées et conservatrices, la posture critique de la bioéthique peut susciter des réactions de rejet. Ce sont sans doute ces difficultés qui ont alimenté certaines critiques acerbes sur la pertinence des formations à l'éthique dans des zones marquées par les urgences sanitaires et alimentaires ou certaines accusations présentant ces démarches comme un avatar de plus de l'impérialisme occidental. Tout en prenant au sérieux ces difficultés, nous montrons par nos expériences qu'elles peuvent être transformées en défis à relever.

Xpert(®) MTB/RIF for smear-negative presumptive TB: impact on case notification in DR Congo.

SETTING: The impact of Xpert(®) MTB/RIF as a follow-on diagnostic test after smear microscopy on tuberculosis (TB) notification has not yet been well defined. DESIGN: Quasi-experimental design with 86 evaluation and 49 control clinics in Kinshasa, Democratic Republic of Congo. Smear microscopy was supported at all 135 clinics, Xpert was placed in 15 evaluation clinics and a sputum transport system was implemented for 25 satellite clinics. The number of cases notified before and during the project (July 2012-June 2013) was obtained from the National TB Program. RESULTS: Of 27,147 presumptive TB cases presenting in clinics with access to Xpert, 5922 (21.8%) were smear-positive. Of 18,636 individuals with ⩾ 3 negative microscopy results, 6920 (37.1%) underwent Xpert testing, 991 (14.3%) of whom tested positive. The number of bacteriologically positive cases increased equally in evaluation clinics (15.1%, 95%CI -2.3 to 32.6) and control clinics (13.6%, 95%CI 2.6-29.3), for a difference in increase of 1.5% (95%CI -28.8 to 31.8). There was no difference in the change in smear-negative cases (-42.4%, 95%CI -111.5 to 26.6), nor in all types of TB notified (-6.1%, 95%CI -32.5 to 20.4) between the evaluation and control clinics. CONCLUSION: In part due to a restrictive algorithm, Xpert as follow-on to smear microscopy did not increase the overall number of TB notifications, nor the number of bacteriologically positive cases.

Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection.

SETTING: Five primary health care clinics in Kinshasa, Democratic Republic of Congo. OBJECTIVE: To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment. DESIGN: Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm(3) or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100-350 cells/mm(3), or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤ 350 cells/mm(3) or patient has WHO Clinical Stage 4. RESULTS: Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm(3)), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and non-disclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation. CONCLUSION: Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.

Impact of HIV on clinical presentation and outcomes of tuberculosis treatment at primary care level.

Little is known on how human immunodeficiency virus (HIV) infection impacts pediatric tuberculosis (TB) in primary care. We compared TB type, HIV care and case fatality rates between 5685 adults and 830 children with TB treated at primary care clinics in Kinshasa, Democratic Republic of Congo. Children represented a substantial burden (13%) of TB, and presented predominantly with difficult to diagnose smear-negative TB and extra-pulmonary TB. The HIV co-infection rate was lower in children than in adults, and fewer children than adults received antiretroviral therapy during anti-tuberculosis treatment. Case fatality was four times higher in HIV-infected than non-infected children. Child-friendly point-of-care TB diagnostics and decentralized pediatric TB-HIV care should receive greater attention.

Outcomes of integrated treatment for tuberculosis and HIV in children at the primary health care level.

BACKGROUND: Little is known about the integration of tuberculosis (TB) and human immunodeficiency virus (HIV) treatment in pediatric populations. METHODS: Prospective cohort of 31 HIV-infected children aged 3-18 years initiating anti-tuberculosis treatment at five primary health care (PHC) clinics in Kinshasa, Democratic Republic of Congo, to describe survival, clinical and immunological outcomes of nurse-centered integrated TB-HIV treatment. RESULTS: Almost all of the children (87.1%) were diagnosed with HIV during TB diagnosis. Most (87.0%) were successfully treated for TB. Two (6.5%) died during anti-tuberculosis treatment; both presented with low CD4 counts (36 and 59 cells/mm(3) compared to a median of 228 cells/mm(3) in the entire cohort). Most (74.2%) initiated antiretroviral therapy (ART) during anti-tuberculosis treatment. Overall, a median CD4 count increase of 106 cells/mm(3) was observed (P = 0.014), an increase of 113 cells/mm(3) among children on ART and of 71.5 cells/mm(3) in those not on ART (P = 0.78). Median body mass index increase during anti-tuberculosis treatment was 2.1 kg/m(2) overall (P = 0.002), 2.2 kg/m(2) among children on ART and 0.72 kg/m(2) in those not on ART (P = 0.08). CONCLUSION: Integrated, nurse-centered, pediatric TB-HIV treatment at the PHC level in highly resource-limited settings is feasible and effective in achieving successful outcomes, including high ART uptake, low mortality, and immunological and clinical improvement.

Feasibility Analysis of an evidence-based positive prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo.

We evaluated the feasibility of a Positive Prevention intervention adapted for youth living with HIV/AIDS (YLWH) ages 15-24 in Kinshasa, Democratic Republic of the Congo. We conducted in-depth interviews and focus group discussions with intervention facilitators and YLWH participants on the following four areas of a feasibility framework: acceptability, implementation, adaptation, and limited-efficacy. The adapted intervention was suitable, satisfying, and attractive to program facilitators and participants and able to be implemented effectively. It performed well with a new population and showed preliminary efficacy. However, we identified certain aspects of the intervention that must be addressed prior to wider implementation such as: (1) including more content on navigating marriage while living with HIV and disclosure; (2) adjusting intervention timing and session length; and (3) simplifying the more complicated content. An adapted evidencebased intervention was found to be feasible and lessons learned can be applied to YLWH in other low-resource settings.

Barriers to Provider-Delivered Sexual Behavior Counseling for Youth Living with HIV/AIDS in the Democratic Republic of the Congo.

AIMS: The study aimed to understand providers' role in delivering HIV transmission prevention counseling to youth living with HIV (YLWH). METHODS: We conducted 14 in-depth interviews with providers in Kinshasa, DRC. RESULTS: Providers' lack of knowledge and comfort in talking to youth about sex because of cultural and religious beliefs about sexuality, coupled with confusion about legal issues related to youth and contraception, made it difficult for them to effectively counsel youth. IMPLICATIONS FOR PRACTICE AND POLICY: In order for providers to deliver effective prevention counseling to YLWH, clinics should follow adolescent-friendly clinic standards, provide counseling in an adolescent-friendly style, and institute an effective referral system for additional prevention services. CONCLUSION: HIV prevention services can be improved through the creation of an adolescent-friendly environment and by providing "values clarification" and skill-based trainings so that providers are able to assess the role of their own beliefs and learn new skills.

Adaptation of a U.S. evidence-based Positive Prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo.

Effective HIV prevention programs for people living with HIV/AIDS (PLWH) are important to reduce new infections and to ensure PLWH remain healthy. This paper describes the systematic adaptation of a U.S.-developed Evidence Based Intervention (EBI) using the Centers for Disease Control and Prevention (CDC) Map of Adaption Process for use at a Pediatric Hospital in Kinshasa, Democratic Republic of the Congo (DRC). The adapted intervention, Supporting Youth and Motivating Positive Action or SYMPA, a six-session risk reduction intervention targeted for youth living with HIV/AIDS (YLWH) in Kinshasa was adapted from the Healthy Living Project and guided by the Social Action Theory. This paper describes the process of implementing the first four steps of the ADAPT framework (Assess, Select, Prepare, and Pilot). Our study has shown that an EBI developed and implemented in the U.S. can be adapted successfully for a different target population in a low-resource context through an iterative process following the CDC ADAPT framework. This process included reviewing existing literature, adapting and adding components, and focusing on increasing staff capacity. This paper provides a rare, detailed description of the adaptation process and may aid organizations seeking to adapt and implement HIV prevention EBIs in sub-Saharan Africa and beyond.

Mortality among tuberculosis patients in the Democratic Republic of Congo.

SETTING: Kinshasa, Democratic Republic of Congo. OBJECTIVE: To identify programmatic interventions for improved survival in patients receiving treatment for tuberculosis (TB) at primary care clinics. DESIGN: Retrospective cohort of adult patients initiating anti-tuberculosis treatment between January 2006 and May 2007. RESULTS: Among 5685 patients, 390 deaths occurred during anti-tuberculosis treatment, of which half (52%) did so during the first 2 months. Patients with smear-negative pulmonary TB were at greater risk of death in the first 2 months of treatment (human immunodeficiency virus [HIV] positive HR 1.49, 95%CI 0.89-2.49; HIV-negative HR 1.77 95%CI 1.06-2.95), but not thereafter. Patients with extra-pulmonary TB were at increased risk of death in the first 2 months of anti-tuberculosis treatment if they were non-HIV-infected (HR 2.42, 95%CI 1.52-3.85), and were half as likely to die during the remainder of treatment (HIV-positive HR 0.46, 95%CI 0.22-0.97; HIV-negative HR 0.47, 95%CI 0.23-0.94). Antiretroviral therapy (ART) reduced the risk of death by an estimated 36% (HR 0.64, 95%CI 0.37-1.11). CONCLUSION: High mortality in the first months of anti-tuberculosis treatment could be reduced by addressing diagnostic delays, particularly for extra-pulmonary and smear-negative TB cases and, in HIV-infected patients, by initiation of ART soon after starting anti-tuberculosis treatment.

The process of HIV status disclosure to HIV-positive youth in Kinshasa, Democratic Republic of the Congo.

As access to HIV/AIDS treatment increases in sub-Saharan Africa, greater attention is being paid to HIV-infected youth. Little is known about how HIV-positive youth are informed of their HIV infection. As part of a larger formative study informing a treatment program in Kinshasa, Democratic Republic of the Congo, semi-structured interviews were conducted with 19 youth (10-21 years) who had previously been told their HIV status and 21 caregivers who had disclosed the youth's HIV status to the youth. Questions explored youth's and caregivers' experiences of and immediate reactions to disclosure. Youth's median age at disclosure was 15 years old, with a range of 10-18 years based on caregiver reports (n=21) and from 10-19 years based on youth reports (n=18). The most common reasons spontaneously given for disclosing were the child's adherence to their treatment regimen (5/16), the need of the child to protect her/himself or stay healthy (5/16), the child's increasing age (4/16) and so that the child would know why they are suffering (3/16). Most youth (16/19) were surprised to learn of their diagnosis; 50% (8/16) wondered about the infection's origins. A large majority felt that it is better for them to know their HIV status (88%; 15/17). HIV care and treatment programs must be prepared to address the psychosocial needs of youth and their caregivers during the disclosure process.

Counseling and testing TB patients for HIV: evaluation of three implementation models in Kinshasa, Congo.

SETTING: Kinshasa, Democratic Republic of Congo. OBJECTIVES: To evaluate the implementation of three models of provider-initiated HIV counseling and testing (CT) for tuberculosis (TB) patients. METHODS: HIV CT was offered to all TB patients aged > or =18 months registered for treatment at three project clinics between August 2004 and June 2005. HIV CT was performed at the TB clinic, the health center or the freestanding voluntary counseling and testing (VCT) center. HIV-infected patients received cotrimoxazole prophylaxis. RESULTS: Uptake of HIV CT was high (95-98%) when performed at the TB clinic or primary health care center, but significantly lower (68.5%) among patients referred to a free-standing VCT center. The overall HIV prevalence among the 1088 patients tested for HIV was 18.8%. HIV was associated with female sex (aOR 1.91), recurrent TB (aOR 2.74), extra-pulmonary TB (aOR 1.97) and age. CONCLUSIONS: Implementation of provider-initiated routine HIV CT by the TB nurse or health care worker at the primary health care center results in a higher uptake compared to referral of patients with TB to freestanding VCT clinics. Provider-initiated HIV CT is only a first step and needs to be linked to access to HIV care, support and treatment.

Patient and provider perspectives on implementation models of HIV counseling and testing for patients with TB.

SETTING: TB clinics in Kinshasa, Democratic Republic of Congo. OBJECTIVES: To identify an acceptable approach to human immunodeficiency virus (HIV) counseling and testing (CT) for patients with tuberculosis (TB) from health care worker (HCWs) and patient perspectives. DESIGN: A qualitative evaluation was conducted of three models of routine provider-initiated HIV CT: off-site referral to a freestanding voluntary counseling and testing (VCT) center, on-site referral for HIV CT at the primary health care center to which the TB clinic belongs and HIV CT by the TB nurse. RESULTS: Incorporating HIV CT into routine TB care was supported by HCWs (96%) and patients (99%). The trusting patient-provider relationship was a primary reason why most HCWs (74%) and patients (68%) preferred the HIV CT by TB nurse model. Patients also cited continuity of care and potential optimisation of the management of HIV co-infected patients as reasons. Some patients and HCWs were concerned about confidentiality issues (HIV status documentation and privacy of counseling) and the potential difficulty of refusing routine HIV CT when it was offered by TB nurses. Some HCWs also expressed worry about the increased workload. CONCLUSION: Qualitative data provided insight into reasons for the high uptake observed of routine HIV CT offered by TB nurses and identified potential concerns when implementing this model.

Sputum smear microscopy: evaluation of impact of training, microscope distribution, and use of external quality assessment guidelines for resource-poor settings.

Sputum smear microscopy is the main and often only laboratory technique used for the diagnosis of tuberculosis in resource-poor countries, making quality assurance (QA) of smear microscopy an important activity. We evaluated the effects of a 5-day refresher training course for laboratory technicians and the distribution of new microscopes on the quality of smear microscopy in 13 primary health care laboratories in Kinshasa, Democratic Republic of Congo. The 2002 external QA guidelines for acid-fast bacillus smear microscopy were implemented, and blinded rechecking of the slides was performed before and 9 months after the training course and microscope distribution. We observed that the on-site checklist was highly time-consuming but could be tailored to capture frequent problems. Random blinded rechecking by the lot QA system method decreased the number of slides to be reviewed. Most laboratories needed further investigation for possible unacceptable performance, even according to the least-stringent interpretation. We conclude that the 2002 external QA guidelines are feasible for implementation in resource-poor settings, that the efficiency of external QA can be increased by selecting sample size parameters and interpretation criteria that take into account the local working conditions, and that greater attention should be paid to the provision of timely feedback and correction of the causes of substandard performance at poorly performing laboratories.

Validity of self-reported 'safe sex' among female sex workers in Mombasa, Kenya--PSA analysis.

We assessed the validity of self-reported sex and condom use by comparing self-reports with prostate-specific antigen (PSA) detection in a prospective study of 210 female sex workers in Mombasa, Kenya. Participants were interviewed on recent sexual behaviours at baseline and 12-month follow-up visits. At both visits, a trained nurse instructed participants to self-swab to collect vaginal fluid specimens, which were tested for PSA using enzyme-linked immunosorbent assay (ELISA). Eleven percent of samples (n = 329) from women reporting no unprotected sex for the prior 48 hours tested positive for PSA. The proportions of women with this type of discordant self-reported and biological data did not differ between the enrolment and 12-month visit (odds ratio [OR] 1.1; 95% confidence interval [CI] 0.99, 1.2). The study found evidence that participants failed to report recent unprotected sex. Furthermore, because PSA begins to clear immediately after exposure, our measures of misreported semen exposure likely are underestimations.

Acceptability and feasibility of continuous diaphragm use among sex workers in Madagascar.

OBJECTIVES: The diaphragm, a woman controlled, reusable contraceptive device, might prevent some sexually transmitted infections (STIs). We assessed the acceptability and feasibility of use of silicone Wide-Seal Arcing Diaphragms (Milex Products, Chicago, IL, USA) by sex workers in Madagascar. METHODS: Over 8 weeks, we evaluated method acceptability by examining patterns of and problems with women's diaphragm use. We also evaluated several measures of study feasibility, including recruitment and follow up methods. RESULTS: 91 women from three cities (Antananarivo, Tamatave, and Mahajanga) participated, and 87 (96%) completed follow up. At enrolment, participants reported a median of six sex acts with five clients in the previous week. During the follow up period, participants reported a median of three sex acts with three clients during the previous 2 days, and self reported continuous diaphragm use during the previous day increased from 87% to 93%. Seven women became pregnant (incidence 53 pregnancies per 100 woman years). Self reported use of male condoms and diaphragms was fairly constant over the study period: women reported condom use in 61% to 70% of acts and diaphragms in 95% to 97% of acts. The number of participants reporting diaphragm problems decreased from 15 (16%) at the first visit to six (7%) at the final visit. 20 women (22%) needed replacement devices during follow up because their original diaphragms were lost, were the wrong size, or became seriously damaged. CONCLUSIONS: Given the high use and steady decrease in reported problems during the study, we believe diaphragms are acceptable and feasible in this resource poor, low education sex worker population.

Laboratory diagnosis of sexually transmitted infections in women with genital discharge in Madagascar: implications for primary care.

Women seeking care in Madagascar for genital discharge (n = 1,066) were evaluated for syphilis seroreactivity; bacterial vaginosis (BV) and trichomoniasis. Chlamydial infection was assessed by ligase chain reaction (LCR) and by direct immunofluorescence (IF); gonorrhoea by direct microscopy, culture and LCR. Leucocytes were determined in endocervical smears and in urine using leucocyte esterase dipstick (LED). Gonococcal isolates were tested for minimal inhibitory concentrations. BV was found in 56%, trichomoniasis in 25%, and syphilis in 6% of the women. LCR detected gonorrhoea in 13% and chlamydial infection in 11% of the women. Detection of Gram(-) intracellular diplococci in endocervical smears, and gonococcal culture were respectively 23% and 57% sensitive and 98% and 100% specific compared to LCR. Chlamydia antigen detection by IF was 75% sensitive and 77% specific compared to LCR. Leucocytes in endocervical smears and LED testing lacked precision to detect gonococcal and chlamydial infections. Of 67 gonococcal strains evaluated, 19% were fully susceptible to penicillin, 33% to tetracycline; all were susceptible to ciprofloxacin, ceftriaxone, and spectinomycin. Patients who present with genital discharge in Madagascar should be treated syndromically for gonococcal and chlamydial infections and screened for syphilis. Gonorrhoea should be treated with ciprofloxacin.

Syndromic treatment of gonococcal and chlamydial infections in women seeking primary care for the genital discharge syndrome: decision-making.

The syndromic treatment of gonococcal and chlamydial infections in women seeking primary care in clinics where resources are scarce, as recommended by WHO and implemented in many developing countries, necessitates a balance to be struck between overtreatment and undertreatment. The present paper identifies factors that are relevant to the selection of specific strategies for syndromic treatment in the above circumstances. Among them are the general aspects of decision-making and caveats concerning the rational decision-making approach. The positive and negative implications are outlined of providing or withholding treatment following a specific algorithm with a given accuracy to detect infection, i.e. sensitivity, specificity and predictive values. Other decision-making considerations that are identified are related to implementation and include the stability of risk factors with regard to time, space and the implementer, acceptability by stakeholders, and environmental constraints. There is a need to consider empirically developed treatment algorithms as a basis for policy discourse, to be evaluated together with the evidence, alternatives and arguments by the stakeholders.

Sexually transmitted infections and associated socio-demographic and behavioural factors in women seeking primary care suggest Madagascar's vulnerability to rapid HIV spread.

OBJECTIVES: To examine sexually transmitted infections (STIs) and associated socio-demographic and behavioural factors in women seeking care for genital discharge syndrome in Antananarivo, Madagascar. METHODS: One thousand and sixty-six consecutive symptomatic women were interviewed and examined; bacterial vaginosis (BV), vulvovaginal candidiasis, trichomoniasis (TV), cervical infection (CI) due to chlamydial or gonococcal infections, and syphilis seroreactivity were determined by laboratory diagnosis. Associations between STIs and individual characteristics were evaluated using bivariate and logistic regression analyses. RESULTS: The prevalence of BV, TV, CI, and syphilis seroreactivity was, respectively, 85%, 16%, 49%, 16% in 94 prostitutes; 70%, 18%, 30%, 13% in 96 occasional sex traders; and 53%, 24%, 17%, and 4% in 876 general women. CI was independently and positively associated with a symptomatic partner, new sex partner in last 3 months, unfaithful partner, prostitution, joblessness and being < 25 years old. Syphilis was associated with low schooling, young age at coital debut, sex trading, and > 1 sex partner in the previous 3 months. CONCLUSIONS: These high STI rates and associated characteristics suggest the local vulnerability to rapid HIV spread and show the need for prevention efforts that involve youth, prostitutes, occasional sex traders, sex clients, and men who have concurrent sexual partnerships.

Pregnancy and HIV-1 incidence in 178 married couples with discordant HIV-1 serostatus: additional experience at an HIV-1 counselling centre in the Democratic Republic of the Congo.

To determine the effect of an HIV-1 counselling programme on rates of HIV-1 infection and pregnancy in a large group of married couples in Kinshasa, DRC with discordant HIV-1 infection status, we conducted a baseline cross-sectional HIV-1 seroprevalence study in two large Kinshasa businesses. We identified 178 married couples (mean duration of marriage = 12.3 years) with discordant HIV-1 serostatus (92 M+F-/86 M-F+). Seroincidence and pregnancy rates were observed during 310 person-years of follow-up (PYFU). The 92 M+F- couples had an HIV-1 incidence of 3.7/100 PYFU and a pregnancy rate of 8.6/100. The 86 M-F+ couples had a pregnancy rate of 6.8/100 PYFU and an HIV-1 incidence of 6.8/100 PYFU. Couples seeking to have children but minimize their HIV-1 transmission risk frequently had unprotected sex only during the woman's perceived monthly fertility period. This strategy resulted in the birth of 24 live-born children and only one (4%; 95% CL = 0.0-21.6%) new HIV infection in couples having a child. Only 1 of 6 women who developed HIV-1 infection (16. 7%; 95 C.L. = 0-40.4%) became pregnant. While seronegative men had more extramarital sex once their wives' positive HIV-1 infection status became known, most of these episodes involved safe sex. Divorce was rare. This study provides additional information concerning issues of safe sex in married couples with discordant HIV-1 infection status, the dynamics of HIV transmission within couples and the effect of serostatus notification on the marriage and on intramarital and extramarital sexual behaviour in Kinshasa, Congo.