How discordant couples can live happily together

Your wife announces that she is pregnant and you are excited. Soon, you make your way to the hospital for the first antenatal visit. You are asked to do Voluntary Counselling (VCT) and Testing for HIV/AIDS. Much to your surprise (or maybe not), when the results come back, one of you is found to be HIV-positive while the other is HIV-negative. You learn that you are an HIV serodiscordant couple. This is a very common way of identifying serodiscordant couples, explains Dr Jean Olivier Rwema Twahirwa, the Discordant Couple and Condom Promotion Senior Officer at Rwanda Biomedical Centre (RBC). “Most serodiscordant couples are identified during antenatal visits because that’s when most sexually active couples do VCT,” he explains. How does serodiscordance come about? By definition, serodiscordance, commonly known as discordance, is a situation where two people are cohabitating (and sexually active) but one of them is HIV-positive while the other is HIV-negative. But how is this possible? We have all heard that when you have unprotected sex with someone who is infected with HIV, you are at very high risk of contracting the virus. Dr Aimable Mbituyumurenyi, the Director of other Blood Borne infections and STIs Unit at RBC, explains that having sex with an infected person doesn’t always lead to an infection. “There are many explanations for HIV discordance. Firstly, transmission depends on the number of viruses in your blood. The higher the viral load, the higher the risk of transmission. The lower the viral load, the lower the risk of transmission. Additionally, if either partner has other Sexually Transmitted Infections such as gonorrhoea, it can facilitate transmission.” he explains. Dr Mbituyumurenyi also says that if the infected person is under Antiretroviral Therapy (ART), the risk of transmission is low. Indeed, studies show that use of ART can reduce the risk of transmission by over 90% if used consistently and correctly. This is because ART reduces the viral load in the fluids of a person with HIV. According to experts, viral load is a gauge of the level of HIV in the body. It is the number of copies of HIV-1 per millimetre of blood plasma. The lowest level of detectable viral load is 40-75 copies/ml while the highest measure is 500, 000 copies/ml. There are other explanations for discordance such as male circumcision which reduces the risk of infection and of course condom use. It is often assumed that HIV among married couples is as result of unfaithfulness. This notion is not wrong. Unfaithfulness indeed contributes a large percentage of HIV infections among cohabitating couples. However, there are instances when a couple gets married when one of them is already HIV-positive. In this case, they are able to take preventative measures right from the start. There are other people who, because of their line of work, are exposed to the risk of contracting the HIV virus. Health workers fall in this category. Therefore, Dr Eugene Rugira, the Senior Officer, Other Prevention at RBC explains that HIV infection and even discordance can happen to anyone. Discordance in Rwanda In a recent interview with The New Times, Dr Sabin Nsazimana, the Director of National HIV programme at RBC, revealed that 3% of couples in Rwanda are discordant. He also revealed that 65% of the infection rate is among stable couples and that it is the main contributor to that number of serodiscordant couples. There are more than 5,000 discordant couples in Rwanda. Measures for discordant couples Surely, suddenly finding out that your partner is HIV-positive must be a blow to the head, right? “Not necessarily,” says Dr Twahirwa. “We provide pre-test counselling, explaining the different scenarios. They could both be positive (concordant positive), they could both be negative (seroconcordant-seronegative) or they could be serodiscordant. There are packages for each scenario,” he says. Having discovered discordance, post-test counselling is done to help a couple to work through the confusions and challenges. Of course, it’s not all rosy because there are accusations and disappointments but counselling experts and medical doctors work to encourage a positive environment. “We don’t focus on who is at fault. We try to show them how to proceed with their lives,” says Dr Twahirwa. Having done that, the couple is enrolled in a follow-up programme. In Rwanda, approximately 500 health centres have discordant follow-up programmes. The infected partner is immediately put on AntiRetroviral Therapy regardless of his/her CD4 count. They are encouraged to go for treatment on a monthly basis. Normally, when a person contracts the HIV virus, they only qualify for ART if their CD4 count is below 500. However, for discordant couples, the infected partner starts on ART regardless of their CD4 count. In Rwanda, this measure started in 2012. According to experts, ART is helpful in keeping the CD4 count high, thereby reducing the risk of infections which facilitate the transmission of HIV. CD4 count is the number of cells per cubic millimetre of blood. CD4 cells are white blood cells that fight infection. They are the most important indicator of how well the immune system is functioning. Without ART, the CD4 count of an infected person is likely to be distorted by HIV, thereby opening up room for a lot of infections. This is not only dangerous to the infected person but to their partners as well. Additionally, the couple is provided with a range of family planning methods to choose from. This, Dr Twahirwa says, is intended to provide them with dual protection. Of course, medical experts take care to provide the appropriate family planning methods since some of them are not safe for people living with HIV. The couple is also provided with free condoms and they can pick them at will. For the HIV negative partner, there is free testing every six months. In Rwanda, all the aforementioned services are free. Dr Rugira says that this is aligned with the national strategic plan of reducing the number of new infections by two-thirds by 2018. “We keep pushing for prevention,” he says. Challenges faced by couples It is clear that there are healthcare measures which go a long way in helping discordant couples move forward with their lives. Still, the reality is that there are a number of challenges that discordant couples will be faced with. In the article “HIV prevention with serodiscordant couples: a changing paradigm” James Wilton, the coordinator of the Biomedical Science of HIV prevention project at CATIE, a Canadian centre for information on HIV and hepatitis C, highlighted the challenges faced by discordant couples. Firstly, he pointed out the fact that sometimes anti-HIV medicines may have a negative psychological effect on the person because they make them feel weak or even affect their mood. This could affect the way they relate with their partner. One specific negative effect may be the lowering of sexual drive. Wilton also pointed out the fact that the infected partner may focus on taking measures to keep his/her partner safe while the uninfected partner may focus on caring for the infected partner. This may cause imbalance in other aspects of their lives. On the other hand, the uninfected partner may be in constant fear of being infected which may interfere with his/her sexual relations with his/her partner. Several studies have also shown that discordant couples have to put up with stigma from friends and family. There are rumours, speculations, and some people even keep a distance. Yes, HIV/AIDS has been with us for over three decades but still, some people still attach so much fear and judgement to the disease. Risky behaviour among couples Fear of being stigmatised partly explains the reason why some couples do not continue with the routine checkups required to keep them healthy. “When a discordant couple moves to a new place, they might be reluctant to try and access the health services there,” Dr Twahirwa explains. This discovery is made during home visits. Home visits are usually made when a couple fails to show up for routine check-up or when the infected person doesn’t show up for treatment as required. The reason why the infected partner may stop coming for routine testing is because some of them, after a few tests, they start to believe that they are immune to HIV. Experts say this is a wrong attitude since HIV infection can happen at any moment.Healthcare givers also observe resistance to condom use among couples. The explanation given by some of the couples is that “it is not fun.” The couples are therefore inconsistent in using them despite the fact that they are free. Dr Rugira says that this is not only a problem for discordant couples but that it is a general problem. He says that another reason why people don’t make use of condoms is because they don’t want people to know that they are having sex. “This is not wise because it is a matter of life and death. You shouldn’t be ashamed to protect your life,” Dr Rugira cautions. What would you do if you found out that your spouse is HIV-positive? Vincent Ndabikunze, Kimironko resident Vincent Ndabikunze First I would try to be patient and listen to her. My reaction would then depend on her feedback. Since I love her, I would continue staying with her but we would agree to using protection whenever we have sex. We would seek help from the counsellors on how to work through the challenges. Irene Uwamahoro, student Irene Uwamahoro I’m not yet married but if I found out that the person I was intending to marry had the HIV virus, I would have to first know where he got it from. If he got it through other means and not sex, we would work it out using the help of medical experts. Venuste Uwakurikiza, married with children Venuste Uwakurikiza For the sake of our children and the fact that we have stayed together for a couple of years, I would have a conversation with her and find out how she acquired the virus. I would continue living with her but I would let her know that I would not have sex with her because I would have to protect myself. Lilian Uwera, a Kabuga resident Lilian Uwera Leaving him will be the best solution for me, because the more I continue living with him the higher the risk of contracting the disease. I would just thank God for saving my life and try to be more careful. Venuste Munyeshya, a teacher Venuste Munyeshya If I found out that my spouse is HIV positive, I would definitely separate from her and move on with my life. I would also continue going for VCT for about a year, just to make sure I’m still safe. Marie Chantal Tuyshimire, parent Marie Chantal Tuyshimire I would try to be sympathetic by helping him seek the proper medication. After that, I would pack my bags and go to start a new life because I couldn’t possibly bear the stress of living with someone I don’t trust. Compiled by Lydia Atieno