Introduction
Since the discovery of the Ebola virus in northern Democratic Republic of Congo (at that time Zaire) in 1976, sporadic Ebola virus disease (EVD) outbreaks have been regularly reported in central Africa.1 In 2013–2016, an EVD outbreak severely hit West Africa (mostly Guinea, Liberia and Sierra Leone) and infected, over 2 years, more than 28 616 people, of whom around 11 310 died.2 The West African cohort of EVD survivors—the largest in history—is shedding new light on the disease, from a range of post-Ebola sequelae to viral persistence in immune-privileged sites.3–7 Because infectious Ebola virus can persist for more than 15 months in the semen,8 9 it can cause EVD re-emergence. After the original outbreak faded, at least 10 such episodes (ie, new infections most likely attributable to contact with infectious semen of EVD survivors) happened in all three hardest hit countries.9–13 The World Health Organization (WHO) interim advice on this topic recommends safe sexual practices for 12 months after symptom onset or until the survivor’s semen tests negative for Ebola virus twice.14 A modelling study based on 26 EVD survivors from Guinea predicted that, by July 2016, all West African EVD survivors should have experienced viral clearance in the semen.15 Viral persistence was found to be associated with age, younger men (<40 years) being more likely to test negative for Ebola virus than older ones.8 The same study also points at a positive impact of sexual health promotion on survivors’ safe sex practices.8 A qualitative study from Sierra Leone reported that EVD survivors’ knowledge about sexual transmission risk reflected counselling messages.16 However, those interventions did not include sexual partners of EVD survivors, and their level of awareness of risk of Ebola virus transmission is unknown.
Communication to EVD survivors of the viral persistence in their semen has been difficult in Guinea. Evidence that infectious virus could be hosted in the semen for longer periods of time has steadily grown throughout the outbreak. Therefore, research findings could not be easily translated in strict recommendations.6 14 17 Ebola Treatment Unit (ETU) doctors, often from NGOs like Médecins Sans Frontières, communicated the latest discoveries to EVD survivors at their release, which translated in recommendations to practice sexual abstinence or consistent condom use. First, the recommendation was for 3 months, then for 6 months, and finally 12 months or after two RT-PCR-negative semen samples. By the end of the outbreak, research programmes were coordinated by the National Coordination for the fight against Ebola (CNLEB) to ensure a nationwide semen testing programme which also informed EVD survivors on sexual health issues.7 15
To better understand the risk of EVD re-emergence due to sexual transmission after the end of an EVD outbreak, it is critical to understand the barriers that may be encountered in communicating with patients who survived EVD and have to deal with the stigma associated with it.18 We report here results from a cross-sectional study aimed at comparing sex practices and awareness of the risk of EVD sexual transmission among survivors and their sexual partners (hereafter partners).