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Denominators are the group-specific number of HIV-negative participants who contributed eligible couple-years of follow-up. Branch line weight is proportional to the posterior probability. Positive control sequences comprised replicate sequences from study partners in red and sequences from confirmed transmission pairs obtained in a separate study in orange. Beloukas Virus Res ].

At baseline, couples reported condomless sex for a median of 2 years IQR, 0. Additional longer-term follow-up is necessary to provide more precise estimates of risk. There are, however, a number of gaps in currently available evidence. The most significant issue is that no data are available concerning transmission rates for anal sex when the HIV-positive partner is taking suppressive ART, even though per-act estimates of HIV transmissibility without ART are approximately 10 times higher for anal intercourse 6 - 9 compared with vaginal sex.

Condomless sex sexual activity in which condoms are not used was reported for only couple-years of follow-up across all previous studies combined, 2 - 4 , 11 - 13 which is insufficient follow-up to give precise estimates for transmission in the context of ART alone when condoms are not used.

Ethics approval was obtained in-country for all other European sites involved in the study. If both the positive and the negative partners agreed to take part, they signed separate informed consents, which included partner identification by name. The informed consent also included explicit reference to the fact that HIV-negative partners knew their partner was HIV-positive and that there was a transmission risk from condomless sex.

Clinic staff were asked to recommend consistent condom use at each study contact. Follow-up was stopped if the partnership ended, the partners moved away, or either person in the partnership withdrew consent, but not for changes in sexual behavior or use of ART although such changes could lead to the follow-up time not being eligible for the main analysis. Follow-up in heterosexual couples ended on May 31, , and remains ongoing for MSM couples.

Follow-up in this report was censored on May 31, Study data were collected on standardized case report forms after consent at baseline and then every 4 to 6 months.

Injection drug use was assessed and if needles, syringes, or any part of injection equipment was shared. HIV-negative partners were also asked if they had had condomless sex with anyone other than their HIV-positive partner since their last visit, the number of other partners, and if any were HIV-positive or of unknown serostatus. Details of the methodology used for sequencing and analysis are reported in the Supplement. Couple-years of follow-up were determined as periods delimited by HIV tests, and corresponding questionnaires on sexual behavior, in the HIV-negative partner.

A sensitivity analysis included periods of follow-up time in which the HIV-RNA load was suppressed at the beginning of the period but during which the load became elevated. This allows inclusion of periods during which a couple may continue having condomless sex until they know the HIV RNA load is elevated. Exact Poisson methods were used to calculate confidence intervals for the incidence rate of transmission. The rate of within-couple transmission was calculated restricting to couple-years of follow-up during which a certain type of sex eg, receptive anal sex with ejaculation was reported note that it was not required that this was the only type of sex the couple was having.

However, in sensitivity analysis the rate and confidence interval were calculated taking a hierarchical approach to classifying transmission risk with types of sex. Having defined such a hierarchy of risk, in referring to a specific sex act, the upper limit of the rate was estimated if this type of sex was the highest-risk sex being performed. The hierarchy from highest to lowest risk was receptive anal sex with ejaculation, receptive anal sex without ejaculation, insertive anal sex, vaginal sex with ejaculation, and vaginal sex without ejaculation.

Missing data were not imputed, and the analysis was performed only on the available data. Data were analyzed using SAS version 9. In planning the sample size it was known that the transmission rate was low, 3 and the aim was to generate a more precise estimate of the rate than was available.

The sample size was based on a hypothesized transmission rate of 1 per couple-years of condomless sex, with the choice of this very low rate based on arguments laid out in the Swiss Statement. The executive committee stopped follow-up of heterosexual couples at May 31, , at the end of phase 1 to concentrate resources on MSM couples.

Phase 2 with MSM couples only will be continued for a further 4 years to accrue additional data for anal intercourse. It was prespecified that further analysis will not be undertaken until the end of the second phase of the study in From the couples enrolled by May 31, , a total of couples had at least 1 follow-up visit by the censoring date and couples heterosexual and MSM contributed eligible couple-years of follow-up; when including periods of follow-up time in which the HIV-RNA load was suppressed at the beginning of the period but during which the load became elevated.

Median eligible years of follow-up per couple was 1. Characteristics at baseline of the participants who contributed to eligible couple-years of follow-up are reported in Table 1. Median age was 40 to 45 years in all participant groups. For heterosexual couples this was 2. The majority in all groups had CD4 cell count greater than mm 3 at baseline. Couples reported frequent condomless sex during follow-up, as illustrated by the number of condomless sex acts reported during follow-up Table 3.

The median number of condomless sex acts per year within the partnership reported by the HIV-negative partner were similar across all groups during eligible couple-years of follow-up, with MSM reporting a median of 42 condomless acts per year IQR, compared with 35 IQR, for heterosexual men and 36 IQR, for heterosexual women.

Data on prevalence of the type of condomless penetrative sex with the HIV-positive partner reported by the HIV-negative partner are shown in Figure 1. By definition, couples contributing eligible couple-years of follow-up reported condomless penetrative sex at some point during follow-up. Fifteen percent of HIV-negative women reported not using a condom because they were trying for a pregnancy.

A total of 11 of the originally HIV-negative partners were observed to acquire HIV during eligible follow-up, but there were no phylogenetically linked transmissions. Samples collected from the 2 partners of each couple were a median of 0 months apart IQR, 0. The partners who were initially HIV-positive had subtype B infection in all cases.

With couple number 7, the pairwise genetic distances of pol sequences were 0. Positive control sequences showed median genetic distances of 0. Figure 1 reports the rates of within-couple HIV transmission per eligible couple-years of follow-up by sexual behavior reported by the HIV-negative partner.

In MSM the upper confidence limit for all sex was 0. All but 3 nonlinked HIV-1 infections occurred among partners reporting condomless sex with other partners. The estimate of the overall transmission rate, and the transmission rate for anal sex, was zero. Only couples that continued to have condomless sex were included in this study, to enable focus on situations in which transmission risk without ART is highest. It is important to know how low the risk of transmission was with the use of ART alone without simultaneous use of condoms, and this study contains more than 3 times the couple-years of follow-up for condomless sex than all the other previous studies combined, including more than couple-years of follow-up of condomless anal sex.

Based on the number and type of sex acts and the cumulative probability of HIV transmission, more than transmissions would have been expected in the MSM group alone see Supplement if the HIV-positive partner had not been taking ART.

Although these results cannot directly provide an answer to the question of whether it is safe for serodifferent couples to practice condomless sex, this study provides informative data especially for heterosexuals for couples to base their personal acceptability of risk on.

In the absence of ART, receptive anal sex with ejaculation is recognized as carrying a higher risk than other forms and, despite an observed transmission rate of zero for this risk behavior, a clinically important rate of less than 2. These data are needed to provide equality of evidence between MSM and heterosexual couples, to inform both policy and also individual choice on condom use.

One-third of HIV-negative MSM in this study reported having condomless sex concurrently with other partners outside the main relationship.

A high prevalence of sexual concurrency and in particular concurrent condomless anal sex has been reported in other studies in MSM. Acquisition of an STI was not associated with risk of HIV-1 transmission within the couples under study, although power was limited to exclude a possible true effect.

This study has several limitations. The original design aimed to observe couple-years of follow-up, but only couple-years were eligible for the primary analysis. In addition, although there was a moderate degree of dropout of study participants, the reasons for dropout do not suggest that those who dropped out would have experienced a higher transmission rate while virally suppressed when taking ART. The follow-up time was relatively short, although at study entry couples reported having condomless sex with their current partner for several months to years.

Direct evidence that some individuals are particularly susceptible to early acquisition of HIV infection is currently lacking, but it remains possible that the transmission rate is higher in the initial period of condomless sex between a couple. This article was corrected online on July 12, , to correct data in the abstract and text; on July 18, , to correct a figure label; and on November 15, , to correct a figure legend. Drs Cambiano and Lundgren had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Acquisition, analysis, or interpretation of data: Critical revision of the manuscript for important intellectual content: Conflict of Interest Disclosures: Dr Phillips reported receiving grant funding from Gilead and ViiV.

No other authors reported disclosures. Hospital General de Elche: Hospital La Paz, Madrid: Hospital Universitario San Carlos, Madrid: Centro Sanitario Sandoval, Madrid: Hospital Ramon y Cajal, Madrid: Chelsea and Westminster Hospital, London: Mortimer Market Clinic, London: Coventry and Warwickshire Hospital: Edinburgh Infectious Diseases, University of Edinburgh: St Thomas Hospital, London: North Middlesex University Hospital, London: North Manchester General Hospital: Whipps Cross Hospital, London: University Clinic, Hamburg Eppendorf: Ospedale Regionale Di Lugano: Gerstoft, nurses from , T.

Helsinki University Central Hospital: Medisch Centrum Jan van Goyen, Amsterdam: Medical University of Vienna: San Paolo Hospital, Milan: Universitaria San Martino, Genova: Hospital Santa Maria, Lisabon:

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AB - As the practice of marriage and family therapy is spreading across the world, it is important for knowledge regarding marital processes and patterns to expand to countries outside of North America and Europe. Children, Youth and Family Studies. Abstract As the practice of marriage and family therapy is spreading across the world, it is important for knowledge regarding marital processes and patterns to expand to countries outside of North America and Europe.

American Journal of Family Therapy , 42 2 , American Journal of Family Therapy , Vol. American Journal of Family Therapy. AU - Nunes,Nalu A. The original design aimed to observe couple-years of follow-up, but only couple-years were eligible for the primary analysis. In addition, although there was a moderate degree of dropout of study participants, the reasons for dropout do not suggest that those who dropped out would have experienced a higher transmission rate while virally suppressed when taking ART.

The follow-up time was relatively short, although at study entry couples reported having condomless sex with their current partner for several months to years. Direct evidence that some individuals are particularly susceptible to early acquisition of HIV infection is currently lacking, but it remains possible that the transmission rate is higher in the initial period of condomless sex between a couple.

This article was corrected online on July 12, , to correct data in the abstract and text; on July 18, , to correct a figure label; and on November 15, , to correct a figure legend. Drs Cambiano and Lundgren had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Acquisition, analysis, or interpretation of data: Critical revision of the manuscript for important intellectual content: Conflict of Interest Disclosures: Dr Phillips reported receiving grant funding from Gilead and ViiV.

No other authors reported disclosures. Hospital General de Elche: Hospital La Paz, Madrid: Hospital Universitario San Carlos, Madrid: Centro Sanitario Sandoval, Madrid: Hospital Ramon y Cajal, Madrid: Chelsea and Westminster Hospital, London: Mortimer Market Clinic, London: Coventry and Warwickshire Hospital: Edinburgh Infectious Diseases, University of Edinburgh: St Thomas Hospital, London: North Middlesex University Hospital, London: North Manchester General Hospital: Whipps Cross Hospital, London: University Clinic, Hamburg Eppendorf: Ospedale Regionale Di Lugano: Gerstoft, nurses from , T.

Helsinki University Central Hospital: Medisch Centrum Jan van Goyen, Amsterdam: Medical University of Vienna: San Paolo Hospital, Milan: Universitaria San Martino, Genova: Hospital Santa Maria, Lisabon: The views expressed in this article are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health.

Dr Ambrose received no compensation for his contributions. Beloukas Virus Res ] eFigure 1. Viral load and heterosexual transmission of HIV type 1. N Engl J Med. PubMed Google Scholar Crossref. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: Sexual transmission of HIV according to viral load and antiretroviral therapy: Prevention of HIV-1 infection with early antiretroviral therapy.

Accessed December 31, Per-contact risk of human immunodeficiency virus transmission between male sexual partners. Infectiousness of HIV-infected homosexual men in the era of highly active antiretroviral therapy. HIV transmission risk through anal intercourse: Those that had happened received a score of 1 and those that had not a score of 0. The mean of infidelity behaviors that occurred in this sample was Table 2 shows the means for the men and women.

The most frequent infidelity behaviors for women were " Getting dressed up and wearing nice clothes to meet the person" Flirting with the person" Hiding from your partner messages exchanged with the person" Expressing sexual attraction for the person and not for your partner" Exchanging sexual caresses with the person" Being in love with the person" Kissing the person on the mouth" The women presented a mean of For the men, the most frequent behaviors were "1.

Having sex with the person" Seeking to carry out activities to spend more time in the presence of the person" Erasing messages of sexual content exchanged with the person" The men presented a mean of When considering the 23 behaviors, a significant difference was found between the men and women for two of the behaviors: A list of aspects proposed by Goldenberg , defined by: The unfaithful subjects were asked to evaluate, from the aspects presented, what they sought in the extramarital relationship and what they recognized having in their relationship.

Both genders reported that what they found most in the current relationship was companionship The subjects were questioned as to why they were unfaithful. A total of responses were analyzed, and these were broken down into units of analysis responses of the women and of the men.

The categories were established a posteriori from the reading of the information given by the subjects who answered the questionnaire and the articles published in the area. Based on the ecological perspective Brofenbrenner, , three axes that make up the conjugal relationship provided the starting point, these being: A lack of reasons for the infidelity was reported by only 7 of the participants. This axis includes responses that relate to the subject involved in a relationship of infidelity.

This axis of analysis grouped seven categories:. Lack of affection, loneliness and insecurity: The participants reported " lack of love"; "lack of affection"; "feeling alone"; "doubt", "insecurity ". In this sample, 22 7. This category includes reasons for infidelity related to certain characteristics of the subject who committed the betrayal, such as immaturity, mental illness, impulsivity. Examples of responses from this category were " I consider myself to be immature", "I am bipolar, it was in a manic phase.

After I started the correct treatment it didn't happen again ". In this category, 10 3. Some of the examples of responses in this category were " The fire of the flesh", "Sexual need", "Passion", "Impulse ".

A total of 18 5. Desire or physical attraction: Some of the examples in this category are " Feeling attraction", "Feeling appealing to someone else.

To evaluate my power of seduction, attraction and conquest ". Seeking freedom, adventure and valorization: A response example of this category was: Of the participants, 21 Many of the participants referred to emotional involvement as one of the reasons for the infidelity.

Examples of responses are: I was caught, hooked by another man In this sample, 31 A total of 7 2. This axis had The category "physical desire or attraction" was the reason for infidelity most used as justification by women, followed by "emotional involvement".

This axis includes contents that refer to aspects of the companion and the marital relationship established. Revenge, anger, or hostility: In this sample, 8 2. The presence of violent behavior, rudeness, excesses of jealousy, dissatisfaction with the physical aspects or lack of empathy on the part of the partner are other behaviors that are part of this category, in which infidelity is attributed to the way the companion treats the person who committed infidelity.

In this category, 72 Some of the responses of the respondents related to this category were: My distinct desires in relation to sexuality, greater than hers ". A total of 24 participants 7. Even though it was the most frequent in both sexes, there were differences in the means of responses of the men and women.

A total of 6 1. Two female participants attributed this factor as a reason for their infidelity. The respondents mentioned "Opportunity", "Occasion". There was a period of physical distance for professional reasons we lived in different cities for a long time ", "Because he travels a lot for work and I stay home alone", "I travel alone, I went out one night and I had drunk a lot ".

Regarding this reason, 25 8. The reasons related to the context were the least cited by the participants as reasons for the infidelity In fact, the reason "escape from problems" was only mentioned by two women. In this axis, there was no difference between the men and women in any of the categories. The results show that in considering all loving relationships, men and women are unfaithful to the same extent, evidencing certain changes in relation to the phenomenon in the present times.

Regarding sexual, emotional and virtual behaviors linked to the breach of an exclusivity agreement, the results also revealed that there were few differences between men and women, except for sexual infidelity behavior and virtual sexual infidelity. In these cases, men showed more behaviors of exchanging sexual caresses and masturbation over the internet when compared to the women.

However, in the other 21 sexual, emotional and virtual behaviors, there was no difference between the genders. Thus, if in the past there was talk of higher rates of sexual infidelity in men and emotional infidelity in women, these data show another scenario where men and women presented similar infidelity behaviors. A closer look at the results of the women reveals that the most frequent infidelity behaviors among women were more subjective and discrete and may sometimes not even have been perceived as infidelity.

However, for men, the behaviors were more explicit, there being more protagonism of the subjects, that is, they could more clearly be considered infidelities, such as kissing, exchanging sexual caresses and flirting, while the women showed greater discretion in their infidelity behaviors, such as wearing nice clothing and hiding certain messages from the partner. Regarding sexual behavior, the men and women did not complain about the lack of sex in their relationship and did not seek sex in the extramarital relationship.

On the contrary, both men and women revealed that they sought affection, understanding and attention in the extramarital relationship and reported not finding these feelings in their conjugal relationship. In this way, neither the men and women in this sample had the sexual need or dissatisfaction in their relationship as their main reason for infidelity. Both reported dissatisfaction with the relationship, although the mean of the women for dissatisfaction with the partner or the relationship was higher than that of the men in explaining being unfaithful to the partner.

Considering that the boundaries between infidelity behaviors among men and women are increasingly blurred, the common idea that when men do not find sex at home they seek it elsewhere is out of date. Thus, even if men are satisfied with their sexual life with their partner, they may commit infidelity due to the pursuit of something new, freedom and adventure, and it may even be a way to compensate for affective dissatisfaction in their relationship.

Women, in turn, are also motivated by sexual factors such as desire and attraction for the other. In this sample, both men and women were motivated by factors of dissatisfaction with the relationship and sought affection, understanding and attention, expressing that their partner was not providing satisfactory levels of attention and intimacy. The infidelity began most frequently between the 2 nd and 5 th years of cohabitation and decreased throughout the relationship.

In addition, lower levels of marital adjustment were found in those with higher frequencies of infidelity. These results lead to the association between infidelity and the level of maturity that is expressed in the age and in the length of relationship that can decrease the infidelity behavior.

Thus, when couples deepen their level of knowledge, both personal and relational, they may present greater resources to cope with the difficulties of the relationship, which reflects in better levels of marital adjustment. In this way, it can be thought that infidelity can be used by some as a way to address difficulties in the relationship, such as an escape from problems and seeking satisfaction in another relationship, leading to the idea of infidelity as a symptom of low marital adjustment.

It can be seen that the studies of the 's and 's tended towards a dichotomy between sexual and emotional infidelity and different results for men and women. The current results demonstrate that we are dealing with a phenomenon that encompasses a complexity of behaviors: However, there is a single phenomenon that is difficult to divide into types.

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