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Combination Approaches: HIV Prevention for Serodiscordant Couples
I. Definition of the Prevention Area
HIV-serodiscordant couples, in which one partner is HIV-positive and the other is HIV-negative, are now recognized as a priority for HIV prevention interventions.
II. Epidemiological Justification for the Prevention Area
Although there is considerable variation across countries, recent studies in sub-Saharan Africa with mature epidemics show that up to two-thirds of infected couples are discordant. These studies seek to assess the extent to which HIV transmission within marriages was spurred by high infection rates in sub-Saharan Africa due to heterosexual transmission. One analysis estimated that 55 to 92 percent of new, heterosexually acquired HIV infections among adults occurred within serodiscordant marital or cohabiting relationships. Additionally, among discordant couples, only the female partner is infected in 30 to 40 percent of cases, dispelling a common misperception that only men, not women, are the HIV-positive partner.
According to a research review, the following factors make it more likely that a person living with HIV will transmit the virus to his or her partner: the presence of other sexually transmitted infections, particularly genital ulcerative diseases; high viral load; failure to use condoms correctly and consistently; and specific sexual practices such as a high number of sexual partners and higher frequency of sexual contact. Concurrent sexual partnership may also contribute to risk. The risk of transmission is especially high during early infection, when it is estimated to be 26 times more infectious than during later stages of infection. This makes it especially important to identify HIV infection during the acute stage.
Prevention responses also need to take into account the progress of the epidemic. One hypothesis is that in early epidemics, most discordant couples arise due to HIV infection of one partner from a preexisting relationship, whereas in more mature epidemics, a greater proportion of discordant couples initiate relationships with a new partner who is already infected.
III. Core Programmatic Components
HIV prevention programs among discordant couples are traditionally based on three types of interventions: 1) couples HIV voluntary counseling and testing—via both community-based outreach and in antenatal clinics, 2) group-based workshops with serodiscordant couples, and 3) integrated antiretroviral therapy and HIV prevention programs. These programs often include risk reduction counseling, referrals to treatment, counseling on family planning, and an avenue to further care and support services.
Couples HIV counseling and testing is the cornerstone of many discordant couple interventions; it remains the only way to identify couples in which one partner is HIV-positive and one is HIV-negative. New and innovative methods are being developed to increase uptake of couples counseling and testing as many individuals and couples do not know their status. To increase HIV testing among couples, couples testing programs will likely require integration with broader HIV programs including care, treatment, and support services; mother-to-child-transmission programs; male circumcision; condom promotion; partner reduction; and other behavior change interventions.
Effective prevention programming is necessary for serodiscordant couples, targeted both to the couple and to the individuals. One study showed that the HIV-negative partner increased their number of outside sexual partners after learning the HIV-positive status of their partner. Campbell et al. confirms this result, showing that about 27 percent of seroconverters in serodiscordant couples in the study were infected by an outside partner.
New advances in the biomedical field have demonstrated success in reducing HIV transmission among discordant couples, namely pre-exposure prophylaxis and antiretroviral therapy as prevention. These prevention methods are still under development, and their real-life applicability is currently being reviewed, but they could prove to be valuable prevention methods in the future.
IV. Current Status of Implementation Experience
Programs in developing countries aimed at reducing transmission of HIV in discordant couples are too new to evaluate for effectiveness. To date, interventions have largely been conducted within structured research protocols, so it is still uncertain whether the efficacy of such interventions will work in real-life settings, and whether such interventions can be scaled up to achieve sufficient reach to reduce overall rates of HIV transmission.
Increased Risk of HIV-1 Transmission in Pregnancy: A Prospective Study among African HIV-1-Serodiscordant Couples
Mugo, N. R., Heffron, R., Donnell, D., et al. AIDS (2011), Vol. 25 No. 15, pp. 1887–1895.
The secondary data analysis study explored how pregnancy in serodiscordant couples affected HIV-1 acquisition in women and HIV-1 transmission from women to men. Data from 3,321 African couples in seven countries who were enrolled in the Partners in Prevention HSV/HIV Transmission Study, a study that tested the effect of acyclovir herpes simplex virus type 2 suppressive therapy for the prevention of HIV transmission, was utilized. Multivariate Cox proportional hazard analysis was performed to control for any demographic, clinical, or behavioral factors. During the study period, 151 individuals seroconverted (with 61 infections occurring among women and 90 occurring among men) and there were a total of 823 pregnancies. Couples who became pregnant were younger and more likely to report unprotected sex during pregnancy. About 28 percent of women who HIV-1 seroconverted during the study were pregnant. The incidence of HIV-1 during pregnancy was 7.35 per 100 person-years compared to 3.01 per 100 person-years during nonpregnancy, but was not found to be statistically significant in multivariate analysis. About 21 percent of men who HIV-1 seroconverted during the study period did so while their partner was pregnant. The incidence of female-to-male HIV-1 transmission was 3.46 per 100 person-years during pregnancy compared to 1.58 per 100 person-years when the partner was not pregnant, and was statistically significant after multivariate analysis. In conclusion, there is an increased risk of HIV acquisition among HIV-negative women and increased risk of HIV transmission to men during pregnancy, which calls for more emphasis on risk reduction counseling, family planning, and early initiation of antiretroviral therapy during pregnancy among discordant couples.
Prevention of HIV-1 Infection with Early Antiretroviral Therapy
Cohen, M. S., Chen, Y. Q., McCauley, M., et al. New England Journal of Medicine (2011), Vol. 365 No. 6, pp. 493–505.
This article reports expanded demographic and clinical information from the HIV Prevention Trials Network 052 trial, whose interim findings, released on April 28, revealed a 96 percent reduction in the risk of HIV transmission among participants with a CD4 count between 350 and 550 cells per cubic millimeter (cells/mm³) who received antiretroviral therapy (ART) immediately upon entering the trial. Over half of the participating serodiscordant couples (54 percent, or 954 couples) came from Africa, 531 couples from Asia, and 278 couples from the Americas; 50 percent of the infected partners were men. Enrollees were randomized to receive ART immediately upon testing positive or to delay therapy until their CD4 counts dropped below 250 cells/mm³ or they acquired an AIDS-related illness. Of the total of 39 HIV transmission events, 35 occurred among participants in the delayed arm (with 82 percent occurring among African couples). A total of 61 percent of the 28 "linked" events (in which HIV transmission was directly linked to the infected study partner) occurred among individuals whose partner had a CD4 count greater than 350 cells/mm³, and 64 percent of the HIV transmissions were from female to male partners. Individuals in the immediate treatment arm experienced a 41 percent lower risk of experiencing a clinical event, such as tuberculosis, compared to those in the delayed arm. According to the authors, the most likely mechanism in preventing HIV-1 transmission was sustained suppression of HIV-1 in genital secretions—the result of ART. The authors found that early initiation of ART has clinical benefits for both HIV-1–infected individuals and their uninfected partners, and therefore must be rolled out as a prevention strategy to reduce the spread of HIV-1 infection.
HIV-1 Transmission among HIV-1 Discordant Couples Before and After the Introduction of Antiretroviral Therapy
Reynolds, S., Makumbi, F., Nakigozi, G., et al. AIDS (2011), Vol. 25 No. 4, pp. 473–477.
The observational cohort study examined the relationship between HIV-1 seroconvertion before and after antiretroviral therapy (ART). Discordant couples were indentified through the annual Rakai Community Cohort study and used data from 2004 to 2009 surveys. In 2004, all HIV-positive Rakai residents were offered free ART if their CD4 counts were at or below 250 cells/mL or were at stage IV disease as defined by the World Health Organization. HIV incidence and risk behaviors of the uninfected partners were retrospectively compared with when their partner started ART. During the 2004 to 2009 time period, 250 discordant couples were identified, of whom 32 met the criteria for initiation of ART. In 58 percent of the couples, the male was the HIV-positive index partner. It was found that before the initiation of ART, the transmission rate was 9.2/100 person-years (95 percent confidence interval, 6.59–12.36). There were no HIV-1 transmissions among the couples who started ART. There were no statistically significant differences between the two groups (ART versus non-ART). Consistent condom use with any partner increased from about 14 percent prior to ART compared to about 54 percent after ART and was statistically significant. Viral loads were found to be high. At 6 months, the majority (71.4 percent) had viral loads below 400 copies/mL. The reduced HIV-1 transmission levels among discordant couples most likely were due to the reduced viral loads of the HIV-positive partner.
Factors Associated with HIV Infection in Married or Cohabitating Couples in Kenya: Results from a Nationally Representative Study.
Kaiser, R., Bunnell, R., Hightower, A., et al. PloS One (2011), Vol. 6 No. 3, p. e17842.
The study explored the differences between HIV-negative couples verses HIV discordant couples, and HIV-positive concordant couples verses HIV discordant couples. Data was from the 2007 nationally representative Kenya AIDS Indicator Survey, which collected self-reported data on variables such as demographics, sexual behaviors, male circumcision, and pervious HIV test. Blood samples were also drawn to test for HIV antibodies, herpes simplex virus type 2 (HSV-2), syphilis, and CD4 counts for those who tested HIV positive. A total of 2,748 couples were in the sample and 9.6 percent were affected by HIV (3.8 percent HIV concordant; 5.8 percent HIV discordant). The woman partner was infected with HIV in about half (48.5 percent) of the couples. For HSV-2, both partners were positive in 30.4 percent of the couples and only one partner was positive in 20.7 percent of couples. Of the HIV-positive individuals who were married or cohabitating, less than half (42.8 percent) had a previous HIV test and only 16.4 percent correctly knew their status. A minority (14.9 percent) of HIV-positive individuals who were in a couple both correctly knew their status and disclosed to their partner. Factors associated with HIV discordance compared to HIV-uninfected concordance were younger age in women, increased number of lifetime partners in women, HSV-2 infection is one or both partners, and lack of male circumcision. Factors associated with HIV concordance compared to HIV discordance were HSV-2 infection in both partners and lack of male circumcision. In conclusion, more emphasis should be placed on prevention programs targeted towards married or cohabiting couples since they are a population at high risk of HIV transmission and acquisition.
Viral Linkage in HIV-1 Seroconverters and Their Partners in an HIV-1 Prevention Clinical Trial
Campbell, M. S., Mullins, J. I., Hughes, J. P. et al. PLoS One (2011), Vol. 6 No. 3, p. e16986.
The study linked the HIV-1 strains within HIV discordant couples when the uninfected partner seroconverted to determine if the infection could be epidemiologically connected to the infected partner. The data was from the Partners in Prevention HSV-2/HIV-1 Transmission Study that enrolled HIV serodiscordant couples from several African countries. A total of 3,408 discordant couples were enrolled in the study, and 155 seroconverted to HIV during the course of the trial identified through HIV-1 serology at site. A total of 151 were confirmed by a positive HIV-1 Western bolt test and included in the analysis. The majority (71.5 percent) of transmissions were linked to the infected partner, 26.5 percent were not linked to the infected partner, and 2 percent could not be determined. Seroconverters were most likely female, had a shorter average time to seroconversion than unlinked pairs (6 months versus 12 months after enrollment), and were identified within the first 3 months of the study visit compared to after 3 months. Reporting sexual activity with the infected partner was higher among those who had linked cases. Unlinked cases reported increased sexual activity with outside partners compared to linked cases, and these unlinked cases were more likely male. It was also found that the HIV-positive partner had higher baseline plasma HIV-1 RNA levels in linked cases versus unlinked cases. The results of the study underscore the necessity of HIV prevention interventions targeted toward serodiscordant couples, and messages should be uniquely tailored to gender and HIV-1 status characteristics.
Serodiscordant Couples in Sub-Saharan Africa: What Do Survey Data Tell Us?
Bishop, M., & Foreit, K. USAID/Health Policy Initiative. (2010).
Recent studies show that new HIV infections are from individuals in serodiscordant couples. Data from 10 Demographic Health Surveys and AIDS Indicator Studies were used in the analysis. Each is a population-based survey, which included biological samples to test for HIV-1 antibodies. A total of 1,107 serodiscordant couples were found in the 10 surveys, and half of the countries had less than 100 couples in its sample. It was found that serodiscordant couples shared similar characteristics to the general population. Serodiscordant couples were found in rural and urban areas, there was no male/female difference in who was the HIV-positive individual in the couple, most have never been tested for HIV and did not know their status, many individuals in serodiscordant couples had low comprehensive knowledge on how to prevent HIV transmission, and most did not use condoms. These trends were similar in the general population. Couples HIV testing and counseling needs to be strengthened to identify serodiscordant couples. Then, more targeted programming needs to be implemented to increase services and programs to promote positive health and reduce risk-taking behaviors. Lastly, policy recommendations and program implications are provided.
HIV Status in Discordant Couples in Sub-Saharan Africa: A Systematic Review and Meta-analysis
Eyawo, O., de Walque, D., Ford, N., et al. Lancet (2010), Vol. 10 No. 11, pp. 770–777.
A systematic review of peer-reviewed and unpublished data as well as a meta-analysis on 14 Demographic Health Surveys was performed to determine the gender balance of the index partner in HIV serodiscordant couples. Only African countries were included in the review and analysis. A total of 19 journal articles and 5 conference abstracts were included in the review as well as unpublished data from two cohorts from a study with The AIDS Support Organization. In the analysis, it was found that about half (47 percent) of the index partners were female. When the female was the HIV-positive partner, they were more likely an urban resident, from a country of a higher latitude (i.e., East Africa), older, from a country with more gender equality, and from a country with a lower HIV prevalence compared to others in the model. Program targeting serodiscordant couples should give equal importance to both male and females in the couples.
Cost-Effectiveness of Couple Counseling to Enhance Infant HIV-1 Prevention
John, F. N., Farguhar, C., Kiarie, J. N., et al. International Journal of STDs and AIDS (2008), Vol. 19 No. 6, pp. 406–409.
The Kenyan study examined the acceptance of couple counseling at prevention of mother-to-child transmission (PMTCT) centers and to assess if couple counseling increased uptake of PMTCT services. The cohort study was conducted from 2001 to 2003 in Nairobi, Kenya, within prenatal clinics. Data on HIV prevalence, uptake of couples voluntary counseling and testing (VCT), acceptance to testing, nevirapine use, personnel costs, and costs of supplies were collected from clinics and from the 2,833 women enrolled. It was found that 15 percent of women were HIV-1 positive. Fourteen percent were counseled as couples, and women who received couple counseling were more likely to receive nevirapine compared to those were counseled individually. Couples VCT had a higher number of women accepting HIV testing compared to the standard option. Couples VCT also resulted in more infections averted and disability-adjusted life years (DALYs) saved compared to the standard option (91 versus 88 infections averted; 2,861 versus 27,772 DALYs saved). Couples VCT was cost-effective, especially in areas of higher HIV prevalence. Increasing men's involvement in prenatal care is essential to augment HIV testing and improve PMTCT service uptake among women.
HIV-1 Prevention for HIV-1 Serodiscordant Couples
Curran, K., Baeten, J. M., Coates, T. J., et al. Current HIV/AIDS Reports (2012), Vol. 9 No. 2, pp. 160–170.
The review explores the various HIV prevention options within serodiscordant couples. Half to two-thirds of HIV-1– infected adults are in a couple with an uninfected partner; therefore, prevention interventions need to be targeted toward these relationships. The primary service is offering couples HIV testing and counseling (CHTC). Studies have shown that serodiscordant couples who participated in CHTC report increased condom use, uptake of family planning, and uptake of prevention to mother-to-child transmission (PMTCT) services. Antiretroviral therapy for the prevention of HIV is another method to reduce transmission to the uninfected partner, though efficacy is still being explored. Pre-exposure prophylaxis is a prevention option for the HIV-uninfected partner in a serodiscordant couple. The paper also details positive evidence on PMTCT, behavior change interventions, and male circumcision and its challenges. A combination of prevention interventions is necessary.
Outside Sexual Partnerships and Risk of HIV Acquisition for HIV Uninfected Partners in African HIV Serodiscordant Partnerships
Ndase, P., Celum, C., Thomas, K., et al. Journal of Acquired Immune Deficiency Syndromes (2012), Vol. 59 No. 1, pp. 65–71.
A prospective study was conducted to measure the sexual behaviors of HIV-negative individuals in serodiscordant couples. Data was from the Partners in Prevention HSV/HIV Transmission study that was carried out from 2004 to 2008 in seven African countries. The HIV-negative partners completed an interviewer-administered questionnaire on sexual behavior at enrollment and every quarter. Blood samples were also collected to genetically link the HIV subtypes of the HIV-positive partner to the newly infected partner. A total of 3,381 serodiscordant couples were enrolled in the study. Over the two years of follow-up, the number of outside partners among the uninfected individuals in the couple increased from 3.1 percent to 13.9 percent. Those who reported sex with their HIV-positive partner in the month prior to the questionnaire were less likely to have an outside partner. Uninfected partners reported less sexual activity with their infected partner during the two-year follow-up period (73.2 percent to 93.5 percent). There was also an increase of the uninfected partner reporting no sexual activity with the infected partner and an increase of sexual activity with an outside partner during the follow-up period. Condom use was more common among outside partners than with the HIV-positive partner. Of those who HIV seroconverted during the study and reported to have an outside partner, most (86 percent) had an HIV subtype that was distinct from their HIV-positive partner, which indicates that they did not acquire HIV from their primary relationship. Risk-reduction measures adopted by the HIV-negative partner should be taken into account when counseling serodiscordant couples.
What's Love Got to Do With It? Explaining Adherence to Oral Antiretroviral Pre-Exposure Prophylaxis for HIV-Serodiscordant Couples
Ware, N. C., Wyatt, M. A., Haberer, J. E., et al. Journal of Acquired Immune Deficiency Syndromes (2012), Vol. 59 No. 5, pp. 463–468.
A qualitative study was conducted to identify influences on adherence to pre-exposure prophylaxis (PrEP) from both the HIV-negative partner and -positive partner in serodiscordant couples. Participants who were enrolled in the Partners PrEP study and were from the Kabwohe Clinical Research Centre in rural Uganda were sampled for this study. Forty-five PrEP participants and fifteen of their partners were interviewed. Mean duration of the partnership was 9.8 years, and 80 percent of the couples had children. It was found that there was a dilemma between wanting to continue the relationship but fearing infection, loss of health, and early death when learning of their discordant status. PrEP offered many a means for hope and opportunity in being able to maintain the relationship while staying uninfected. In other couples, tension and anger still persisted after PrEP use, and adherence suffered. The results of the qualitative study suggest that the strength of the relationship has a direct effect on adherence. Participants also preferred to use PrEP over condoms as an HIV prevention method. It is important to understand why couples want to stay together in supporting PrEP adherence.
Optimal Uses of Antiretrovirals for Prevention in HIV-1 Serodiscordant Heterosexual Couples in South Africa: A Modeling Study
Hallett, T. B., Baeten, J. M., Heffron, R., et al. PLoS Medicine (2011), Vol. 8 No. 11, p. e1001123.
The paper describes a modeling study that tested various scenarios on the effectiveness of early initiation of pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) for prevention within HIV serodiscordant couples. The model used data from three sites in South Africa that participated in the Partners in Prevention HSV/HIV Transmission Study as well as results from the specific clinical trials on PrEP and ART for prevention. Three analyses were performed: 1) four different PrEP implementation strategies, 2) starting PrEP then discontinuing use when the infected partner begins ART compared to early ART but no PrEP, and 3) various models were tested to determine the optimal combination of PrEP and ART, and cost and efficiency were reviewed as well. It was found that PrEP use at all times, whether or not the infected partner was taking ART, was the most effective out of the four scenarios in reducing transmission. For the second analysis, it was found that both scenarios increased costs and reduced infections. For the third analysis, when PrEP and ART were available, it would be most effective for higher-risk couples to offer PrEP to the uninfected partner before the infected partner started ART. For lower-risk couples, early initiation of ART would be the most cost-effective. In conclusion, PrEP and ART could be reliable combination prevention strategies to reduce transmission and acquisition for serodiscordant couples.
Knowledge and Attitudes about Male Circumcision for HIV-1 Prevention among Heterosexual HIV-1 Serodiscordant Partnerships in Kampala, Uganda
Mugwanya, K. K., Baeten, J. M., Nakku-Joloba, E., et al. AIDS Behavior (2010), Vol. 14 No. 5, pp. 1190–1197.
The paper examined serodiscordant couple's knowledge, attitudes, and understanding of male circumcision, as they are a high-risk group for HIV transmission and acquisition. Couples were recruited at a research clinic in Kampala, Uganda, for this cross-sectional study. A standardized gender-specific questionnaire was administered to each partner separately, medical records were reviewed to know their HIV serostatus, and an examination was performed to determine if the male was circumcised. The final sample size in the study was 318 couples. The majority of men were not circumcised (67.2 percent). Both men and women had a high knowledge of the protective ability of male circumcision. The majority had heard a health information message stating the benefits of male circumcision to HIV-negative men. Over 90 percent of participants had a favorable attitude about male circumcision as an HIV prevention strategy. About half (53 percent) of uninfected males expressed interest in undergoing male circumcision, while the majority (88 percent) of their female partners wished that they undergo the procedure. Uninfected males were more interested in undergoing male circumcision if they had discussed the procedure with their female partners and were knowledgeable on the positive benefits of male circumcision, compared to those who did not discuss it with their partners and were not knowledgeable. The main motivators to get circumcised were to prevent sexually transmitted infections/HIV infection and hygiene benefits. Barriers included cost of the procedure, being absent from work, fear of complications, fear of pain, and religious sentiments. The findings will aid in developing messages to promote male circumcision in Uganda.
Behavioural Interventions for HIV Positive Prevention in Developing Countries: A Systematic Review and Meta-analysis
Kennedy, C.E., Medley, A.M., Sweat, M.D., O'Reilly, K.R. Bulletin of the World Health Organization (2010), Vol. 88 No. 8, pp. 615–623.
The review explores the efficacy of prevention programs for people infected with HIV in the developing world setting. The review also seeks to explore if interventions targeting both HIV-positive and -negative individuals have varying effectiveness. Eighteen articles met the criteria for inclusion. Most (15 studies) were conducted in Sub-Saharan Africa, were in clinical settings (14 studies), and were with heterosexual populations (12 studies). Nine studies targeted both HIV-positive and HIV-negative individuals and stratified the results by target population. These nine studies were within HIV counseling and testing interventions. Ten studies evaluated behavioral interventions targeted to HIV-positive individuals. Five studies were with serodiscordant couples. When comparing behavioral interventions targeting HIV-negative and -positive individuals, it was found that condom use statistically increased among positive individuals but was not statistically significant among negative individuals. Interventions targeting serodiscordant couples increased condom use significantly. There was also a modest positive affect on reducing multiple sexual partners in behavioral interventions targeted to HIV-positive adults as well as an increase in disclosing one's HIV-positive status. These results demonstrate the positive affect on behavioral outcomes from prevention interventions; therefore, prevention interventions should be expanded among HIV-positive individuals and serodiscordant couples.
Successful Increase in Contraceptive Uptake among Kenyan HIV-1-Serodiscordant Couples Enrolled in an HIV-1 Prevention Trial
Ngure, K., Heffron, R., Mugo, N., et al. AIDS (2009), Vol. 23 No. Suppl. 1, pp. S89–S95.
The paper describes a successful intervention to increase uptake of family planning services among HIV-1–serodiscordant couples in Kenya. Study participants were from the Thika, Kenya, site within the Partners in Prevention HSV/HIV Transmission Study, and compared with three other Kenyan sites that did not have the supplemental family planning intervention. At the Thika study site, 213 serodiscordant couples were enrolled, and the majority (74.7 percent) of infected partners were female. Most women had one living child and were married to their study partner. A total of 1,216 couples were enrolled in the other three Kenyan sites and were similar to the Thika participants. It was found that noncondom contraceptive use increased among Thika female participants, both in infected and uninfected women. The injectable was the preferred contraceptive choice of women followed by the pill, surgical procedures, implants, and intrauterine devices. Noncondom contraceptive use did not statistically change in the other three sites. Reported condom use was high throughout the study at all sites. The incidence of pregnancy also reduced among study participants from the Thika study site and increased at the other sites. The increased utilization of contraceptives in this cohort indicates an unmet need that can be satisfied with successful comprehensive family planning interventions.
A Group-based Intervention to Increase Condom Use among HIV Serodiscordant Couples in India, Thailand, and Uganda
McGrath, J. W., Celentano, D. D., Chard, S. E., et al. AIDS Care (2007), Vol. 19 No. 3, pp. 418–424.
The paper describes a study among serodiscordant couples where the HIV-positive individual has to disclose their status to their partner, they have to decide together to participant in the intervention, and to test whether there are any changes in condom use among study participants. The study was conducted in one site each in India, Thailand, and Uganda. Forty-three couples were enrolled in the study, and forty couples completed all study requirements. The intervention consisted of four sessions that covered HIV, risk reduction strategies, and skill training on how to improve couple communications. Participants were interviewed at baseline and at one and three months after the intervention. All participants stated that they were satisfied with the intervention and that it helped them communicate with their partner about sex. High communication skills were also reported at the one- and three-month follow-up visits. Participants appreciated the HIV information that they received, appreciated the correct information and skills on how to use a condom, and reported to be less shy about discussing HIV topics after the intervention. The ability to refuse sex if their partner did not want to use a condom increased significantly from baseline to the three-month follow-up visit. Sexual activity also increased in the India cohort based on the resumption of sex or the increased comfort level in discussing sex. Reported condom use at all sites reached 100 percent after the intervention. The study demonstrates how an intervention targeting serodiscordant couples can be replicated in multiple settings with unique epidemics.
Willingness of Kenyan HIV-1 Serodiscordant Couples to Use Antiretroviral Based HIV-1 Prevention Strategies
Heffron, R., Ngure, K., Mugo, N., et al. Journal of Acquired Immune Deficiency Syndromes (May 2012), e-publication ahead of print.
According to the authors of this cross-sectional study, nearly 40 percent of HIV-positive Kenyans in stable serodiscordant relationships (where the partner is HIV-negative) expressed reservations about initiating early antiretroviral therapy (ART) for the purpose of treatment as prevention, particularly about the potential side effects. The HIV-negative partners expressed a high willingness (nearly 90 percent) to use pre-exposure prophylaxis (PrEP) over the long term. The authors also report that control of the method was a factor in participants' decision making since, when given a hypothetical choice, HIV-negative partners chose PrEP and HIV-positive partners chose ART if it was medically necessary. The larger PrEP study found that HIV-positive partners indicated a higher level of willingness to initiate ART when they were experiencing lower CD4 counts or symptomatic diseases, or had had personal experience with ART use. Based on these results, the authors suggest that serodiscordant couples follow a dual HIV prevention strategy, with the HIV-negative partner using PrEP until the HIV-positive partner is willing and able to initiate ART. The authors also stress the importance of understanding couples' concerns and preferences about using ART for HIV prevention, before developing treatment as prevention strategies.
HIV Testing and Counseling Leads to Immediate Consistent Condom Use among South African Stable HIV-Discordant Couples
Rosenberg, N.E., Pettifor, A.E., De Bruyn, G., et al. Journal of Acquired Immune Deficiency Syndromes (October 2012), e-publication ahead of print.
This study explored condom use and number of unprotected sexual acts among long-term HIV serodiscordant couples after HIV testing and counseling and one-month follow-up visits. Participants were from the Partners in Prevention HSV/HIV Transmission Study, a randomized, placebo-controlled trial to assess the impact of twice-daily acyclovir use on HIV-1 disease progression in HIV-1/HSV-2 co-infected persons. The 508 HIV-positive participants and their partners were followed for two years. Couples received risk reduction counseling and were provided with free condoms each month, and the HIV-negative partner was tested for HIV quarterly. Interviewer-administered questionnaires collected demographic and behavioral data at baseline and monthly visits. The study compared the sexual behavior of newly and previously tested persons at baseline as well as at months one, six, and twelve. It was found at baseline that for those who recently tested for HIV (less than seven days earlier), odds of reporting unprotected sex were greater than for those who had most recently been tested more than 30 days before; the odds became comparable at the one month mark and remained constant at the sixth and twelfth months. The odds of unprotected sex were lower at month one, six, and twelve compared to baseline. The authors conclude that HIV counseling and testing results in a reduction of sexual risk among HIV serodiscordant couples.
Sexual Life and Fertility Desire in Long-Term HIV Serodiscordant Couples in Addis Ababa, Ethiopia: A Grounded Theory Study
Hailemariam, T.G., Kassie, G.M., Sisay, M.M. BMC Public Health (2012), Vol. 12 No. 900.
A qualitative study was conducted in Addis Ababa, Ethiopia, to better understand HIV serodiscordant couples' view of fertility and sexual relations in long-term relationships. Participants were selected from among those receiving services for antiretroviral therapy and prevention of mother-to-child transmission at three public hospitals. Thirty-six informants were recruited from two groups—individuals in serodiscordant relationships and health professionals who care for them. The study found the core category of the "struggle to maintain (the) relationship." After couples learned that one partner was HIV positive, they either separated or strove to maintain the relationship. Those who wanted to maintain the relationship experienced a period of transition to become comfortable with their new status. Challenges arose when one partner wanted a child or more children and the other did not, or when both wanted a child but feared transmitting the virus to the uninfected partner. Participants also noted: a change in their desire to have sex; sacrificing of self-interest for the benefit of their family; nondisclosure or selective disclosure of their status to family and friends; and increasing focus of attention on existing children. The authors conclude that in order for HIV serodiscordant couples to maintain their relationship they have to develop a variety of strategies.
HIV Prevention for Serodiscordant Couples: Technical Brief
Spino, A., Clark, M., & Stash, S. 2010. AIDSTAR-One.
The technical brief provides an overview of the research on HIV prevention for serodiscordant couples including an introduction on the epidemiological significance in targeting this population and key prevention interventions. There are three broad categories of prevention interventions among discordant couples: couples HIV counseling and testing, group-based interventions, and a supportive environment. Several successful programs are highlighted through the document. The challenges and barriers to implementing prevention programs for serodiscordant couples are listed, and their solutions are discussed. These include how to involve the partners in the intervention, gender imbalances, increasing knowledge about what it means to be discordant, and guaranteeing that the quality of interventions is high. Clear messages are outlined such as stating that HIV discordance is common, couples can remain discordant for a long time, discordance does not necessarily mean the partner is unfaithful, no one is immune to HIV, the HIV-negative partner is at high risk of HIV, and effective risk reduction options do exist. Four common questions that are pertinent to implementation are asked and answered in the brief. Additional resources are provided.
Guidance on Oral Pre-Exposure Prophylaxis (PrEP) for Serodiscordant Couples, Men and Transgender Women Who Have Sex with Men at High Risk of HIV: Recommendations for Use in the Context of Demonstration Projects
World Health Organization (2012).
PrEP clinical trials have been successful in two populations--men and transgender women who have sex with men (MSM-TG) and serodiscordant heterosexual couples. However, translating these results to real world settings is less known. WHO recommends that countries implement demonstration projects that will offer advice on key safety, effectiveness, adherence, and sustainability questions surrounding PrEP interventions. The guidance provides an overview of the research conducted to date and recommendations on PrEP for serodiscordant couples, MSM-TG, and other groups. The guidance lists nine key points to guide demonstration projects including assuring the HIV-negative status of participants, monitoring the safely of participants, supporting high levels of adherence, and developing transition mechanism for those who want/need to discontinue treatment. It is planned that WHO will review and revise its guidance in 2015.
Debate Three: Discordant Couples and HIV Transmission
The World Bank and the U.S. Agency for International Development. 2010.
The co-sponsored World Bank and U.S. Agency for International Development debate was centered around the statement: "Intracouple HIV transmission between couples in long term stable partnerships drive a majority of HIV transmission and should receive the majority of HIV prevention funding." Two experts argued for and two argued against the statement. The summary report can be found at the site as well as additional materials including the program, supplemental information, flyer for the debate, and links to various pages on the AIDSTAR-One Prevention Knowledge Base. Viewers can also watch the debate in four parts through the website.
Related AIDSTAR-One Publications
- Technical Brief | HIV Prevention for Serodiscordant Couples: A systematic review of core programmatic components (PDF, 297 KB)
- Spotlight on Prevention: The Astonishing Neglect of an HIV Prevention Strategy
Related Pages
- Related Practice (G3P): Couples HIV Counseling and Testing, Rwanda and Zambia


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2014 Southern Premier League Central U14 Champions
2014 Battleground Tournament U15 Black Champions
2014 Tennessee Cup U14 Gold Champions
2014 D1 Tennessee State U13 Champions
2014 Tennessee Nike Invitational U13 Vapor Champions
2014 Red Diamond Vulcan Cup U13 Gold I Champions
2013 Battleground Tournament U13 Black Champions
Vestavia Hills, AL -- The Tennessee Soccer Club 19 Girls clinched the Southern Regional Premier League Central this afternoon by defeating Huntsville Football Club 2-0. Faith Gober buried both goals, one on a well-placed assist by Molly Thorne.
The team will play their last league game of the season tomorrow morning against Vestavia Hills Attack Black for a chance at an undefeated record in their first foray into the SRPL.
Phone: 615-300-6839
TSC 19 2014 D1 State Champions


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The 28-year old is entering his ninth season on Merseyside where he has made 210 appearances since joining from Brondby in 2006, establishing himself as a regular in the process.
Various reports have linked the Denmark international with a move to Barcelona this summer, but he says he is content to stay where he is.
"I've said it so many times; I like it here and my family like it here. Not only the football but also living here, we fit in here and that's important for me," Agger told the Liverpool Echo.
"Take the tour to Asia this summer - that shows how big a club this is. You could say we haven't been good enough in the last couple of years to achieve what we want to.
"But that's definitely something I will try to help to change because this club belongs at the top.
"Everywhere we travel it's the same. The amount of people who were there was unbelievable, especially when you consider how we haven't performed in the last couple of years. You have to respect that."
Vice-captaincy honour
Since the retirement of Jamie Carragher at the end of last season, Agger has been promoted to vice-captain and he says it was an honour to be handed the role.
"Not many people have the success to become a professional footballer and not many people get the vice-captaincy so that's a big thing for me. It's so difficult to describe," he said.
"I always have responsibility, no matter if you're vice-captain or not. You have to always be there, always be at the front and, of course, try to help some of the young players.
"Now I have been here for almost eight years and Stevie has been the captain all the way. He is an amazing captain. He is the one I will look at."


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Building Digital Capability
Organizations embark on the digital journey with a fond hope of staying ahead of the competition. Their decision to go digital is often influenced by the desire to use contemporary technology & methods, peer pressure, persuasion of the CIO or other business heads or advise of consultants. Whatever the reason to go digital, the start of the journey should always be marked with careful thought and planning to avoid subsequent hiccups.
Taking up the project without a careful assessment of capabilities and resources could land the organization in trouble. With a focus on technology and its possible benefits, companies often forget that organizational readiness is important. They need to consider factors such as the organization culture – to see if it supports digitization, orientation of the senior management – whether they have been briefed and taken on board, capabilities of the key staff members – to assess if they have the right skills & attitudes, and a capable IT organization – if they have the right set up and capability of handling digital information. Let us discuss each of these factors.
Organization culture : Companies undergoing business transformation often ignore the risks of non-adoption when they fail to address cultural issues, either assuming that people would align themselves on their own or that they could be forced to fall in line. These measures, however, do not work and the proposed change remains a hostage to the work methods and behavior patterns of various people groups. It is important therefore to work on the cultural aspects and have the HR department hold transformational programs to bring about a change in the mindsets or even relocate staff members who do not fit the bill.
Orientation of the senior management : The C-level executives should be the driving force for digitization but they could also be the hindering factor. Their participation is important as they are expected to provide direction to the operational staff who work with them. The Board or the CEO should take these senior members into confidence and discuss the entire plan with them and buy their commitment and support. It is important for them to realize that their success as business heads hinges on the successful roll out of the digitization initiatives. Wherever possible they should be exposed to the contemporary methods by getting them over to visit companies that run such digitization programs. Once they are convinced, they will themselves champion the cause and work for it.
Capability of key staff members : This is an area generally not given much attention to. We often see staff not adequately qualified, short on capability, not skilled or differently skilled, not trained or wrong on attitude. It is important to assess this aspect of readiness and address the issue before the start of the digitization project. This is a transformational program and therefore needs thorough assessment. This involves selection of the right people, relocation of those not fit, training, skilling or reskilling them, taking them through motivational and soft skills programs, empowering them to act independently and make them customer centric. Where the required talent does not exist within the organization, immediate steps should be taken to acquire talent from outside. Reorganization and restructuring of functions and changing of reporting relationships might be necessary along with defining new job descriptions and this need to be carefully worked out, taking external help where necessary.
A capable IT organization : Many companies are still unclear about the best way to set up their IT organizations and develop the tools and talent required to manage digital information and establish and maintain online services and automated processes. The traditional set up is usually carried along with some superficial changes. Such an attempt would not work and may derail progress. Most do not properly acknowledge that many of the critical resources required to facilitate this transition may not be available in-house. The right talent may be in short supply and may often take years to build such capability. It is therefore necessary to hunt for talent outside and also consider outsourcing a few tasks where the required skills do not exist within.
Before taking on the digitization programs companies would do well to assess their level of preparedness and build capabilities to successfully implement and derive benefits on a sustained basis. Companies need to identify the business domains and activities that would most benefit from rapid digitization, and should manage those projects separately from their conventional IT projects.
Digitization Efforts Need Good LeadershipDigitization, Enterprise architecture, Leadership
Digitization efforts in many organizations do not fully yield results that are desired. While reasons could be many, one of the main factors for poor showing is ITs lack of alignment with business. Initiatives that are localized at the level of the IT or taken up by stray business heads hardly ever bear fruit. These initiatives may result in some improvements but they are insignificant and remain within a small sphere. Large organizations manage to steer clear of this trouble because of good professionals on board, but the gap is more pronounced in small and medium sized organizations. SMEs find it extremely hard to manage technology deployment without the right people and therefore their digital journey lacks clear direction.
One way of overcoming this problem is to seek advice from an external source and employ management or technology consultants to draw up a road map and suggest a plan of action. The consultants may be reputed firms or accomplished individuals but the success lies in making right use of them and it here that many are found lacking.
Let me cite a few examples from my engagements with clients over the last three years. In most places it was the lack of effective leadership that resulted in sub-optimal use of technology. Though the CEO is best placed to give it a right direction, any other senior person nominated by him can also deliver if he can think from the CEOs perspective, but that rarely happens. The following examples would go on to show that many organizations do need to wake up and bring in greater professionalism in the work place.
Where the CFO takes charge : It is customary in most organizations to make IT department report to the CFO. I cite an example of a mid-sized manufacturing company which decided to seek advice and their CFO called me over for a discussion. Since they had already decided on an ERP, I helped them through the implementation process with suitable business process changes and help streamline the functioning of IT. However to make effective use of their investment in technology I suggested they use business intelligence to strengthen decision making. The CFO, I guess felt uncomfortable with the idea as he was already getting his usual reports and did not feel the need to proceed further. The CEO never got involved directly but got briefing from the CFO. The company therefore was stay put at that level and lost an opportunity to build up on their initial work.
When the CEO calls for review but delegates responsibility – We often say a job well begun is half done. However, if the direction changes after the start, the job remains half-done. It played true for a fairly large company in the auto parts sector. The CEO was concerned about the efficacy of its IT and its contribution to business and hence was himself present for the initial discussion. He wanted me to do a quick study and share with him my broad findings. After this stage, the command passed over to the CFO, who along with the CIO tried to resist changes. Some of my first recommendations like centralization of the IT, IT governance and enterprise portal required some investment. The CFO cited lack of funds and wanted to defer these actions. I was insulated me from the CEO and he did not get the right status update. This was again a case of opportunity lost.
Where the CEO initiates but does not participate – These situations are also not uncommon. I was called in by the head of an institution who had taken the initiative to modernize work both in the academic function and the administrative area. Products were then selected and the work began in the right earnest. The initial enthusiasm could not however drive the project further due to the organization culture which was slow-paced and had informal work methods. The initial enthusiasm faded as the institutional head thought it was not necessary for him to participate and that technology should be dealt with by IT. The responsibility then was placed on the IT administrator to drive the projects on his own. Due to lack of direct participation by the head, adoption of new methods by employees, discussions on new initiatives, work cooperation, data discipline etc. suffered. Small superficial successes seem to provide satisfaction to the institutional head and the management. Instead of being an advisor to the management, I ended up being an advisor to the IT administrator. Technology could not therefore be gainfully deployed and benefits in terms of governance and better running of the institution could not be realized.
When the CEO keeps himself at an arm's distance – A subsidiary of a MNC doing well in India decided to automate work to handle their expanding business. I worked with them to draw an overall plan to introduce ERP and other applications, connect with all stakeholders, mobility solutions etc., which was approved by the CEO. The CEO was perhaps advised internally to appear only for the steering committee meetings and therefore maintained a distance from the project. Internal contradictions in the form of cross functional problems arose at regular intervals which affected work but did not surface well during the steering committee meetings. Compromises at various stages resulted in a sub-optimal solution. Without a direct contact with the consultants, the CEO got colored information from his internal team and therefore could not get from technology what he would have wanted.
From the above examples it is clear that right leadership is critical to steer the digital journey of any organization. Unless the digital plan is driven by organization strategy, objectives and goals, work meanders taking care of a few procedural issues but leaving the main purpose behind. Organization heads need to realize that they are in a digital age and should directly confront technology and not just view it from the corners of their eyes.
When CEOs Falter on Technology DeploymentCEO, IT Strategy, Key management, Management
In my last post I had discussed how important for it is for the CIO to get his CEO on board for his plans for technology deployment. I had said that CIOs should learn the art of influencing those who matter and be persistent with the task in spite of early failures. Best efforts however come to a naught when the incumbent CEO refuses to play ball and proves a hard nut to crack. The poor CIO keeps banging the door that refuses to open. I have encountered such situations and often wondered how to wade my way through. On some occasions I managed to address the situation but at other times I was left without answers.
The CEOs that I handled, both as a CIO then and as a consultant now, were accomplished men in their own ways but were not really cut out for handling the play of technology in their businesses. They had their own characteristics, background, understanding and orientation and therefore needed different approaches to make them come around to listen to me. Instead of being a guide and a motivator, many a times, they acted as speed breakers and did not assist in the absorption of technology into business. I would classify such CEOs into four distinct types viz. :
Not technology literate : These are old time CEOs, ones from the earlier generation, who may have spent their entire lifetime without the help of IT and therefore do not understand this clamor for technology. Wary of gizmos with smart guys running fingers on them, these CEOs tend to keep technology away at an arms distance. Any proposal on technology is promptly and automatically passed over to the CFO or some other functionary for consideration. His only concern is the expense on capital or revenue account and availability of budgets. There is very little that the CIO can expect of them and the CIO would do well to keep out of his away. For instance in my last outing as a CIO, I had to report directly to the CEO as I handled two functions but whenever I spoke of technology he would re-direct me to the CFO and lose further interest in the meeting. I soon learnt and decided not to put him through this torture and be a little more kind to him.
Use technology a bit but still indifferent : They know and use technology say for sending or receiving mails, opening an excel sheet or a word document, but that is where it all ends. Technology beyond this point is not their area of interest and they cannot comprehend the tall talk of a technology revolution and its likely impact. Decisions on technology are sometimes conveniently deferred, referred to an expert or forwarded to the executive committee. They would not directly participate but may really not act a spoilsport. However they are happy so long as they get their mail messages and periodic reports they ask for. In one of the organizations that I worked with, the only question that the CEO would ask me was whether the systems were working alright and if I took up a point for discussion he would advise me to put it up in the next executive committee meeting.
Have a function bias : These are functional experts who get elevated to the position of CEO but continue to retain a strong functional bias. Though they discuss various issues, any reference to their parent area evokes an immediate response whereas other matters get less than an enthusiastic response. Discussing technology plans therefore becomes so much more difficult. Reporting to the CEO who had come from operations, I struggled to get through initiatives on dealer management, CRM, treasury management etc. but a proposal for streamlining Supply Chain management got his instant approval. In another case, the CEO from Finance gave a green signal for ERP implementation but asked us to cover only finance and commercial applications along with inventory accounting. For them technology is just one another activity and not as important as the functions that they are comfortable with.
Those who believe in delegation : They are ostensibly great leaders who believe in participative management. They are masters in delegation and distribute responsibility on various matters. Information technology obviously doesn't figure in the list of tasks that they directly look into and therefore pass it onto some functionary of their choice. In one of the companies I recently rendered advice to, I was called in and spoken to by the CEO but he later delegated the responsibility to the CFO and what happened thereafter was the usual, and the objective with which I was called for was not fully served.
So friends, here we are. Pray that you get to work with a CEO whom you can talk to – a CEO who can lend you an ear and at least absorb a little of what you say. Even if he or she were to be covered with a shell, you would wish it is not too hard to pierce through. It is important to win him over and those who can do so can ride rough seas with relative ease. For those who are not able to, the best way is to make friends with the COO or the next in line and use his influence to wade your way through.
Getting the CEO on boardBusiness strategy
It is always our endeavor to see that IT deployment in our companies have clear purpose and direction. As CIOs we often struggle to place our IT plans on the right path. The IT plan drawn is not for the IT function alone but one for the organization. Such a plan therefore has to be accepted and absorbed by the senior management especially the person at the top.
Many a times seemingly good IT plans get stuck at various junctures due to lack of adequate support from various constituents in the organization. Reasons could be many and the blame could fall on one or the other. The CIO could be at fault at times, not being able to understand the need of business, priorities or the processes but at other times factors like cultural issues, lack of proper orientation of the people who matter, and displaced priorities of executives could derail the program. Though the CIO can take various measures to engage with the people and explain the plans, his best bet will be to reach out to the CEO and try to get him on board. In my opinion the CEO is the single most important person whom we should have on our side. It is great to have his support but the story can be complete only if he/she participates in the execution process. Let us consider the ways in which the CEO can add value :
- Guidance : He can guide and lead us in a proper direction by articulating his vision, objectives, goals and priorities. He can also refer us to the management team for further details and can provide a lot of clarity for us to follow-up with further study and analysis,
- Being a catalyst : His buy-in into our initiative sets off a trigger reaction making other senior executives to fall in line. Those executives who could have set low priorities otherwise come around and start discussing. Co-operation then runs down the line as people are instructed to share documents and data. Engaging with users gets easier.
- Helping through problems : The CEO could really help when stuck with problems that act as hurdles in performance of systems. His gentle nudge to the reluctant user, or conducting a review of work on the project, passing clear directives or resolving cross functional contentious issues could pave the way for a smooth run.
- Helps obtain resources : When we face a resource crunch impacting our project, there could be no better a person than the CEO to help us fight through the maze of tedious processes, budgets and botched priorities to get resources like funds, manpower, working space, facilities etc.
The question, of course is how to get him on board and make him take our side especially when there could be many others seeking his attention. The task is not easy and there are no clear formulae that work. It depends on how we position technology in the organization, on how we build up rapport with senior people and on how we evoke confidence in others. Let us consider a few steps here :
Educate the CEO : When the CEO is IT savvy, it is a cake-walk but if he is not, we will have to seize an opportunity to explain a few simple terms to him. Rushing him into quick learning may not be a good idea and we have to exercise patience to let him catch up. If necessary we can seek services of a consultant or get a senior person from the IT vendor organization to speak and update him on the current trends.
Be pro-active : Offer to make a presentation to the management committee and place your plan to buoy up business. Speak the language of business and don't try to impress with technical jargons. If we just concentrate on familiarization without seeking approvals it will not put the people on the defensive.
Making a business case : When putting up proposals for approval include a short summary explaining the purpose and the likely impact on business. While the accompanying details could be comprehensive, the objective, proposed solution, work plan and the outcome should make a compelling case for the CEO to appreciate and approve. What he is convinced of will receive his encouragement and support.
Maintaining a high success rate : What if you were to complete a critical project successfully and on time and repeat the performance on your next project. If you keep a close watch and demonstrate measurable impact to business, the CEO would not only give you support but also trust you with more responsibilities.
Digitizing the EnterpriseDigital engagement, Digital initiatives, Digital transformation, Digitization
In my last post I talked about Digital Enterprises and why companies must adopt this new approach to remain competitive in today's world. Let me now talk about methods that organizations can adopt to digitize their operations and do it in a manner that benefits the enterprise.
It is not a question of when to start but how to get going with modernizing of our businesses. Putting the debate aside, it may be prudent to think holistically and work out solutions that are appropriate for the organization. Organizations are often flat footed in adopting new methods and this provides an opportunity for the CIO to take lead in digitizing the enterprise.
Current status in Indian enterprises
Many CEOs are generally aware of this new approach and do enquire and seek to understand. Competitive pressures today force companies to consider and leverage new digital channels like social media and mobile computing to further their business. As digitization rides the hype cycle, companies are often unsure of their approach and therefore hire consultants to advise them on the subject. While some work out clear strategies others tend to get carried away by consultants' ambitious projections. I have heard from quite a few of my friends about their digital initiatives but I find many of them lacking a concerted and a well-defined approach. Many initiatives fall short of the targets as they simply introduce mobility or get onto social networks or move a part of their applications to a cloud environment, as separate initiatives. This is where they fail to realize the full benefit of digitization.
Digital Strategy
When companies embark upon their digital journey the first thing they have to do is define the purpose and direction of this exercise. There could be many organization priorities like addressing the issue of growth, enhancing productivity, meeting customer expectations, increasing market share, revamping distribution channels etc. Many a times these business priorities are not clearly articulated and factored in the IT plans. The digital strategy here should address both the short term and long term plans of the organization. The business strategy should clearly indicate the role of IT. Specific roles and responsibilities to support the business and IT strategies should be well defined. The governance structure, processes and practices need to be laid down and practiced. The infrastructure that is needed to support this initiative should also be well thought out and planned and therefore an appropriate enterprise architecture should be drawn out to put in comprehensive plans that would support the organization into the foreseeable future. The trouble is that CIOs often install incremental facility in the form of hardware/virtualization or move a part of the applications to the cloud saying they are preparing for digitization. This belies a lack of vision or absence of strategy. One needs to create a future road map and build up to the final state slowly over time.
Challenges to overcome
Cultural issues are usually impediments to adopting digital initiatives. This requires adequate education and awareness programs to make people aware of the moves and the impact that this may have on them. Readiness is required even at the top so that they provide the right leadership and the right organization structure and policies to make implementation easier. Those at the top have also to manage and resolve all the conflicts and struggles that this may create at various levels of management. Poor understanding of the potential of these initiatives and lack of accountability of personnel involved in the efforts could derail the process and need to be addressed. Another problem often faced is the lack of talented people to drive these initiatives and to handle the changed processes. Re-skilling of the available staff and induction of new talent may be a necessity. It is also essential for the company to have a capable and empowered IT cell which can work alongside the business team to add strength to the efforts.
Digitization should therefore be viewed as a significant and strategic management program which can make a great impact on business and make it ready to face the future. Half-hearted initiatives or those lead by the IT teams may result in minor gains without providing a competitive edge to business.
The Digital EnterpriseDigital business, Digital disruption, Digital initiatives, Digital transformation
Much has been written about Digital Enterprises of late and enough buzz has been generated on digitization, which seems to have taken the industry by storm. As happens with most new technologies and new practices, digitization too has gone through the hype cycle generating noise and creating visibility. People have been told this is the future and those who don't follow this route may find themselves doomed.
I met a few CIOs and broached this subject with them. Though some were clear others displayed an air of understanding though would talk no further. They speak in generalities and say they are at the stage of planning. Some were adventurous enough to claim complete digitization in their organizations, simply meaning that they have automated a lot of stuff. I had the opportunity to teach this subject as an introduction to students of a management institution, however in the ensuing exams, half of the students described digital enterprises as ones who practice extensive automation.
It is perhaps not fair to blame them since the industry has not explained the subject rationally to people but created a buzz around the subject. Vendors would serve better selling the concept rather than their wares and develop partnership with customers. Let me attempt to demystify this topic and explain this in simple terms.
What is a Digital Enterprise (DE) ?
Digital Enterprise is an IT driven business model created in response to the emerging market place and value chains which are going digital. Companies can either take a pro-active stance and create a competitive advantage or quickly react to moves by competitors. The Digital Enterprise is built upon the use of IT to automate the processes (both internal and external) to create a digital boundary enabling all stakeholder interactions. An immense amount of information is created which needs to be consumed and acted upon. In other words 'DE' is an organization that uses technology as a competitive advantage in its internal and external operations.
There is an enabling environment which makes this shift feasible. Customers and employees today, particularly those who are digital aware, expect a new style of commerce, content and collaboration. They look for anytime, anywhere access and any-device convenience. They interact with companies through multiple channels and therefore it becomes important for companies to access these channels to understand their behavior. Vast amount of market and customer data need to be analyzed for understanding opportunities and trends. This calls for companies to be agile and to have IT infrastructure that is flexible and scalable.
The way to go
In order to take care of these requirements in this emerging scenario, organizations have to go the 'SMAC' way ; SMAC stands for 'social', 'mobility, 'analytics' and 'cloud'. These are the four pillars of a Digital Enterprise. Let me explain these terms briefly :
Social : This covers all interactions on the digital social platforms with individual users and groups which Include tweeting, texting, instant messaging and posts in blogs and on the company's website. These are important indicators for the company to address.
Mobility : There is a distinct shift towards mobility and therefore important to capture transactions from all portable devices including laptops, smart phones via wireless networks (WLAN, GSM,GPRS etc.). Policies and procedures have to be geared to meet this requirement.
Analytics : A huge amount of data is likely to be collected in the form of structured, semi-structured and unstructured data which would need analysis to draw meaning out of them. Several technologies such as Big Data, Business Intelligence (BI) can help analyze and summarize to draw conclusions and aid decision-making. This can provide huge amount of learning about customers and markets.
Cloud : For meeting all the above requirements we would need an Infrastructure that is flexible and scalable. Rather than building, it could be far more convenient and cost effective to work on infrastructure and applications as acquired services. This is where cloud computing comes in as an essential part.
It is the combination of these four themes that gives it meaning – its a catchword or an acronym but represents a comprehensive view of the solution. It is about viewing the customers through a multitude of channels and working out suitable responses. What we need is a holistic approach to digitization and a choosing an effective way to attain competitive advantage.
Managing ChangeBusiness strategy, Change management, Digital strategy, it management
We see changes that take place all around us and realize that nothing remains static. The Earth moves around in space and so do all objects in the Universe. Situations change, so does the environment people change and so do businesses. With so much going around can we afford to sit pretty and resist change? Perhaps not.
We also get bombarded with lots of phrases like 'change is the only constant', 'perish or change', 'run even if you want to stand at the same place', 'embrace change if you wish to survive' and so on. Management jargons and clichés thrown at the CIO make him run for cover. Facing such intimidation, the poor CIO reluctantly decides to go for a change. He may not be quite clear what he has to change but he knows he has to. This is where the problem takes its shape.
The change program
The CIO sometimes takes this change business a little too seriously. When he joins a new organization he notices that IT has still not achieved the star status that is should have with the previous incumbent. Loaded with the knowledge that 'change' does the trick, he tries his hand at making changes all around him. He relooks at the hardware and network architecture, changes IT vendors that the organization has been dealing with, reworks the application priority list and starts fresh dialogue with some users. If he has been in the same place for a while, he tries to reshuffle his team, rework user interface screens and may be try to aggressively introduce new technologies. However when all these measures do not seem to impress the management, the poor CIO looks crestfallen not knowing what more he could do. The same is the experience when I see CIOs executing their role as members of professional associations ; they bring about changes and when they don't work, they blame the CIO community, the vendors, the industrial environment etc.
I agree that their predicament is genuine. An era where 'change' is touted as the most powerful tool of governance, how is it that the changes carried out by him are not accepted by the organization that he works for. While he may not have the answers some others may have.
Untangling the mystery
Now let us look at a some of the reasons why organizations adopt changes ;
- Change in the marketplace – New challenges often crop up in the form of new players, new products, price wars, new methods of distribution etc. to which the organization develops its responses.
- Change in consumer behavior – Customers needs change over time and they may have different demands to which the company has to respond to.
- Internal drive to excel – When companies try to get better, improve its working and want to scale new heights.
- Change in circumstances – Like new laws, political and geographical changes etc.
- Technology developments – Necessitate use of technology to ride a few notches above the competitors.
Now when organizations set on this journey of change and in the right manner, they are aware of the objectives they are trying to meet. They are clear about their purpose and targets they are pursuing.
The lesson
CIOs can take a cue from this illustration and work out their change program to lend it purpose. A change for the sake of change leads us nowhere. It is important to have an agenda for change. He has to ask a few questions of himself when taking on this task. For example he can look at the unfulfilled business needs from the technology standpoint, he can assess if the technology infrastructure is the bottleneck, he can seek external advice to reorient his IT plans, he can find out delivery failures or inefficiencies etc. and devise programs to tackle these problems. If he finds that no IT Plan or strategy exists he should work to prepare a new document.
In the end a change has to have some end purpose which acts as a beacon to guide their path. The CIO has to define a specific business purpose that he is attempting to tackle and one that is in line with the business objectives and goals. Just making a few technology changes or restructuring his organization without a business purpose in mind does not find purchase from the management. A change is a powerful tool which could either help meet a challenge, scale new peaks or win over competition, only if it is properly targeted.
The blurring lines between Telecom and IT
We witnessed the telecom revolution over the last two decades which altered the way people communicated with each other, a change that impacted the daily lives of people. The information technology boom and the advent of internet did something similar by significantly redefining the way people dealt with tasks on a day-to-day basis and the way businesses functioned. Development on both these fronts initially went along in parallel.
The convergence of telecommunications and computing has been noted and commented on for some time now. However, there is a much richer interrelationship at present than at any time in the past. In fact, one can argue that the very terms "telecommunications" and "computing" are losing their relevance as separate identities, and also that these fields will become virtually indistinguishable in the near future.
Merging of computing, communication and entertainment has changed the landscape. Emergence of the acronym 'ICE' really signified this move towards convergence. The boundaries between telecom and computing have really been blurred with significant overlap between the two. The traditional use of a telephone to talk and use of computers to access the net & to do other tasks is giving way to a scene where we increasingly use computers and applications like skype, hangout, yahoo messenger etc. to talk to people on a audio or a video chat and use our handset for accessing our mails, for using the social; networking sites, read news and for general browsing – a role reversal of sorts.
Impact on telecom companies
Telcos have been reporting fall in the 'average revenue per user' (ARPU) and this is understandable. There has been an increasing usage of free apps like viber, jumblo, skype to talk to others riding on the web and thereby starving telcos of revenue through voice calls. Widespread use of chat facility on whatsapp, yahoo messenger, hangout etc., for messaging has resulted in revenue loss for telcos for such value-added services. Revenue from long distance calls has also seen significant drop as people use skype, hangout etc., to set up video calls connecting with anyone around the world.
Let me share my experience of communicating and net browsing when travelling abroad recently. I purchased a country specific card from one of the telecom service providers which carried call lower tariffs than international roaming charges for my regular number, and also an internet service pack. At the end of my trip I incurred very little expense over and above the fixed charges. At most places I could find access wi-fi connection like in the hotels that we stayed, most airports, train stations, shopping malls and even in the long distance bus that we were travelled. I could fetch my mails, post entries in facebook, linkedIn and twitter, send messages on whatsapp and speak to people using viber without incurring any extra charges. I am sure telcos would be ruing this revenue loss and may already be revisiting their business models to plug such loss to business.
The future scenario
While describing the current state of convergence and as we speculate what it may mean in the coming years, one can argue that as a result of the horizontal integration of all media (voice, audio, video, animation, data) in a common network and terminal infrastructure, telecommunications and networked-computing applications will no longer be distinguishable.
We are going to see cities with wi-fi connect at public places and chances are that many big cities may sport widespread free wi-fi connects covering a good part of the city. As more people use this facility, tariffs for telephone networks and internet bandwidth may undergo revision to become more realistic. Telecom companies have been charging indecently high rates for international roaming but I am sure this would change soon.
Taking the argument further it is not clear whether we would use our telecom handset for talking to others or we would use a gadget connected to the internet instead. In other words I am not sure if we will be using a phone of a telecom company which also gives access to internet or that we will we use a gadget connected to the internet and do away with the phones altogether.
Recognizing Vendor ContributionVendor management
Vendors form an essential part of our team that strives to excel in our organizations and vendors play a prominent role in the implementation of our IT plans. The vendors include those who supply and install hardware, those who put in our networks, develop software, help implement application systems, consultants, outsourcing vendors, security reviewers, audit partners etc. They work for us and work with us to ensure completion of the tasks that we work on. They do contribute to our success and do so in different measures depending on the role that they have been assigned. It will therefore be in order to acknowledge contributions made by them.
There is no doubt that vendors are bound by the contract and have to perform for the fee that they charge. However the quality of work done by them depends to a large extent on the work environment that we create. When vendors are enthused, they put their heart out and accomplish more than what we would have bargained for.
We are all advised to treat vendors as partners and to work together with them to create new solutions that work for us. Vendors may be many, some who perform critical tasks, some who carry out small and odd jobs and others who perform routine but important operations, but all play a role in our success. They are worthy of being called partners and we should be treated as such. Such an approach goes on to improve relationships and thereby their performance.
Vendor management
It is important to have a formal process to manage vendors so that we get the best out of them. The vendor base should be rationalized and there should be a defined process for vendor evaluation, selection, contract execution and their deployment. Subsequent processes including project management with periodic reviews and mapping results to the agreed deliverables are essential to ensure successful completion of projects.
Vendors Recognition
To keep vendors motivated it is important to acknowledge whatever good work that they do. While we may have punitive measures to make vendors perform, rewarding them for good work is more positive and goes on to ensure their full participation. There are multiple ways to acknowledge them. For example calling some of the critical vendors to a company function gives them a feeling of being a part of the company. Awards, rewards and recognition programs are wonderful ways of acknowledging their work. You could institute an award and choose the best vendor every year, or call over and honor a vendor if he really has been a partner in your progress and has contributed significantly. Some companies treat IT vendors on par with the material and other main suppliers and include them in their vendor conferences.
One other requirement of vendors is that we become their reference clients and speak positively about them to their potential customers. By agreeing to do so we get their appreciation and they stay committed to us. I remember whenever we had become reference points, vendors not only gave us heightened attention, they also charged us lesser so as to ensure out continued support.
Does it work ?
Well, it does. I have heard great stories from others and I have experienced it too. A small recognition goes a long way in keeping the partner enthusiastic and committed to the task. The focus should not be limited to ensuring their performance on the current projects but to keep in mind future relationships. Such vendors come back on their own to help even after they have completed their tasks and are no longer actively engaged. If they have helped us, it is but fair to acknowledge their contribution.
Big Data – Is it too big to comprehend ?Big Data, Big Data analytics, Business Intelligence
Not so long ago, while we were still grappling with the implementation of Business Intelligence and trying to shape up for Business Analytics, the concept of 'Big Data' hit the market like many other technologies do. We know most new introductions come in with a high dose of publicity and shrill marketing which tries to sell but does very little to explain what it means. For example when 'cloud computing' arrived with all fanfare it did create a stir but it took quite a while for glamour to fade away and for the reality to hit the user. The constant bombardment of the scene with new terms leaves the users bewildered.
The truth is that I am also confused and trying to make sense of this new concept in town. Let me therefore try to arrive at some understanding to help remove the haze from our vision. I remember the time I had started with Business Intelligence long ago trying to support business with new found knowledge from analyzing business data and making information easily accessible. While I was happy with what we did, we were suddenly stumped with the term 'business analytics' which took us on a tizzy till we got back our senses. When we are adjusting to the new definition we were teased again with the new term 'Big Data'. I am sure many of our friends are also trying to comprehend this new development. I will make an attempt to understand the differentiation between these terms.
Business Intelligence
BI is not a new concept. Data warehouses, data mining, and database technologies have existed in various forms for years and we have been using them merrily. Big data as a term might be new, but many IT professionals have worked with large amounts of data in various industries for years. Business Intelligence (BI) encompasses a variety of tools and methods that can help organizations make better decisions by analyzing "their" data. Therefore, Data Analytics in my opinion should be a part of BI. Is BI then the mother concept and the other off-shoots of it ?
Business analytics (BA)
BA is comprised of solutions used to build analysis models and simulations to create scenarios, understand realities and predict future states. Business analytics includes data mining, predictive analytics, applied analytics and statistics, and is delivered as an application suitable for a business user. These analytics solutions often come with prebuilt industry content that is targeted at an industry business process (for example, claims, underwriting, financial analysis or a specific regulatory requirement). BA therefore could be a specialized tool that analyses data in depth and makes multiple correlations to unravel stories that not visible from a simple analysis. This perhaps puts BA in a slightly different league and has a leg up when compared with BI.
Big Data
Big data may not just be about large amounts of data, as the name may suggest. Going beyond the conventional process of analyzing structured data as present in our databases, this approach involves digging and analyzing a lot of semi-structured and unstructured data. Fifteen years ago, we didn't analyze email messages, PDF files, or videos. The Internet was just a fad; all information there was of a secondary nature there were no social networking sites or other discussion groups that give valuable information and insights into consumer behavior. Similarly, wanting to predict the future isn't a new concept, but being able to access and store all the data that is created is new.
Various sources claim that 90 percent of the data that exists today is only two years old. And that data is growing fast. If 90 percent of all the data in the world was created in the past two years, what does that say about the data?
Now organizations with huge amounts of data would find it hard and time consuming to analyze and interpret them to generate meaningful information on time. Old technology platforms are slow and inefficient and now we need computer systems and technologies that can handle big data and solve the velocity-volume-variety problem. The new in-memory systems technologies provide a breakthrough solution for big data analytics.
The way ahead
We are therefore in a new era where information processing dons a new dimension and acquires the capability of accepting, storing, processing and huge and a diverse set of data and putting them through any complex analysis to generate meaningful information for business. It requires our skills in making use of this technology to our benefit.


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Doug Franz College Football Playoff - Week 6
The week 6 standings are out for the BCS.
In case you don't know from the things I've said on air. I hate the BCS but I don't have a problem with the BCS formula. I just don't want it used to narrow the field from 124 to 2.
Although I'm thrilled we will have a 4-team playoff soon. I've always wanted a 16 team playoff. I'm not being greedy because the new system will be so much better than the BCS. I just want to implement some of the greatness of March Madness while rewarding conference champions.
I put before you the Doug Franz College Football Playoff. The "DFCFP" makes every non-conference game vital to each conference because each game determines conference strength. Conference strength determines conference rank versus the other conferences. The DFCFP improves on the NCAA basketball tournament because teams don't get in the playoff just by winning their conference. They have to win one of the conferences ranked in the top 8 (as opposed to the NCAA basketball tournament where every conference champion is in).
Every week the BCS rankings will change, therefore changing the teams making the playoff. Check in each week and see how things have changed. At the end of the season, it's up to you to pick the winners of each game and set in motion the championship challenge.
If you want an explanation for the way my formula works, check the bottom of the blog.
Here's the playoff pairings if the regular season ended today:
16) Utah State @ 1) Notre Dame
15) Kent State @ 2) Alabama
14) Rutgers @ 3) Georgia
13) Nebraska @ 4) Florida
12) South Carolina @ 5) Oregon
11) Clemson @ 6) Kansas St
9) Texas A& M @ 8) Stanford
Obviously, the current system proponents try to say a playoff destroys the integrity of the regular season. Not true it enhances it. How did Alabama's loss to LSU in 2011 hurt them last year? It didn't. In the DFCFP, Alabama goes from playing the WAC champion to hosting a top 25 team.
The SEC has six teams in the DFCFP. No other conference has more than two.
I love the Nebraska road trip. The best fans in college football trying to buy tickets in the Swamp would be classic.
The irony of the ol' ball Coach, who shook up the SEC by throwing the ball everywhere 25 years ago, coaching against the newest young innovator in Chip Kelly is the story of the first round.
If Oregon wins, they'd have to go to Spurrier's alma mater.
Since I'll never get sick of LSU/Bama, we get that match-up again in the second round.
By ranking every team 1-124, you get a true representation of the best conference by taking the average BCS rank of every team in the conference. This playoff system makes every college football game in the country vital because it rewards teams and conferences alike.
Here's the ranking of the conferences after week 1 of the BCS and the average BCS rank of the teams in the conference.
2) Big 12: 37
3) Pac-12: 45.59
4) Big 10: 48.25
5) Big East: 60.25
9) Sun Belt: 77.7
The money line is being one of the top eight conferences (explanation below). The pressure on every team in conferences 7-10 is intense because every game could determine if your conference champion gets in the playoff.
At this point in the season, one non-conference win by any team in the conference could move your champion into the playoff.
The gap between the 8th and 9th conference is only 0.08 points. Meaning Kent State as the MAC champion is in and the Sun Belt champ is out. The MAC has specialized in Big 10 upsets this year. Take one of those away and Arkansas State is in the DFCFP.
The Mountain West and Sun Belt are right on the heels of the MAC. Boise State is ranked higher than Kent State but the overall rating of the teams in the MAC keeps their champ in the playoff. The big difference is the MAC has 3 teams ranked 100-124 while the Mountain West has 5, proving it's a harder conference to win.
The WAC would be talking so much trash if this truly worked out. Not only did a faction of teams breakaway from the WAC to form the Mountain West in the first place, but also Boise State and Nevada just left the WAC for the MWC with the goal of having better access to the post-season. If Boise State would have stayed, they'd be in but now their new conference drags them down.
Is Kansas slightly over matched? The Big 12 is impressive but it could be so much more. The 9th best team in the conference is WVU at #50. The conference falls off a cliff to get to its tenth team as KU is #101. If it wasn't for KU, the average Big 12 team would be in the Top 30.
The Pac-12 used to have an average in the 50's. This year it's a tougher conference than the Big 10.
The magic of the DFCFP is how it highlights the regular season more than any other system. Here's the process for coming up with the teams for the playoff.
1) Rank all D-1 (FBS) teams 1-124 (from Alabama to Southern Miss)
2) Rank all the conferences 1-11 based on the average BCS rank of the teams in the conference.
3) Reward the first place team in the top eight conferences with an automatic bid.
1. Georgia
2. Kansas St
3. Stanford
4. Nebraska
5. Rutgers
6. Florida State
7. Utah State
8. Kent State
4) Independents�this means you Notre Dame�get no special treatment. If you're not in a conference, earn a wild card bid or join a conference.
5) Select 8 wild-card teams based on BCS rank excluding those already selected with an automatic bid.
1. Notre Dame
2. Alabama
3. Florida
4. Oregon
6. Texas A&M
7. Clemson
8. South Carolina
6) Rank the 16 teams based on BCS rank with no regard to status as an automatic qualifier or wild-card entry. The tournament would follow a bracket format. Although re-seeding would be a better way to reward the regular season, nothing is better than filling out a basketball bracket and I want that momentum and attention on college football.
7) First two rounds are at the home of the better seed.
8) Final Four and Championship game are played at a rotation among Fiesta, Cotton, Sugar, Rose.
I'm aware that after the first two rounds there are three games left at neutral sites with four bowl game hosts. This is leverage in case the Rose wants to stick to tradition. If they duck out I've got three games and three bowls. If the Rose does want to stay involved, there would be a new bowl game created for the two teams that just missed out on the playoff. This week would be Oklahoma vs Oregon State.
I give you the extra bowl game just to prove that the bowls don't have to die. Oklahoma vs Oregon State is still a great college football game with great fans.
We wouldn't have 35 bowl games anymore -- sorry Pinstripe Bowl -� but some of the big ones with tradition don't have to go anywhere. If you're an Arizona or Arizona State fan are you saying you wouldn't go to the Holiday bowl against Oklahoma State? You'd still get the benefit of extra practices to prepare for your bowl game. Players would still get to enjoy the goodies they receive for participating. As for the fans, we get a real champion.
Feel free to ask me any questions or give me your opinions and I'll put it in the mailbag: firstname.lastname@example.com.


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Friday, June 13, 2014
Fetter Health Care Network has welcomed Brandi Allen as the new Director of Operations.
Her primary responsibilities will include the daily operations of seven Fetter locations in Berkeley, Charleston, Colleton and Dorchester counties.
She will report directly to the Chief Operations Officer.
Brandi Allen comes via Detroit where she held various operations roles, primarily in support services and medical education.
Allen completed her Administrative Fellowship in Healthcare Administration at Henry Ford Health System. Her various roles and project work spanned clinical quality and patient safety, process improvement, support services management, hospital operations, medical education administration, and diversity and inclusion.
She served on the Corporate Diversity Council, chaired the Generation Y employee resource group, and was recognized as a Health Equity Ambassador.
She was also recognized by Crains Detroit Business as one of their 20 Executives in their 20s, being the first ever honoree from healthcare.
Allen is a native of Charleston. She attended the University of South Carolina where she obtained a Bachelors in Psychology and Health Promotion, Education, and Behavior and a Masters in Healthcare Administration. She is currently pursuing a Doctorate of Healthcare Administration, with an expected completion date in 2015 focusing on Leadership in Healthcare.
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