What is a discordant couple?

A discordant couple is a pair of long-term sexual partners in which one has a sexually transmitted infection and the other does not .
The term is alsocommonly used to describe a couple in which one partner is HIV positive and the other is negative. The gender orientation of the couple is not the issue in this case. Either heterosexuals or homosexual couples may be involved in a discordant relationship.
Discordant relationships are sometimes referred to as "magnetic". This is an illusion to the phenomenon that in nature positive and negative attract .
Are there many discordant couples in Africa?
Recent studies have estimated that in several sub Saharan African countries, approximately two thirds of infected couples are discordant.
According to de Walque (2007), in about 30 to 40 % of the discordant couples, the female partner is the one who is infected. Across east Africa, national representative data suggests 40 to 50 % of married HIV infected individuals have an HIV uninfected spouse (Bunnell and P. Cherutich: 2008).

Challenges faced by discordant couples

Stress in the discordant relationships

Scientific studies have proven that relationship stress increases dramatically after one partner tests positive for HIV while the other tests negative. A study conducted at the University of Medicine and Dentistry of New Jersey found that psychological distress along with drug and alcohol abuse were commonly found in discordant relationships.

Where does the stress in discordant relationships come from?

• Transmission versus care giving

In couples where both partners are HIV negative, the concern of both partners is the same: to stay HIV negative. However, in couples that have one partner negative and another positive, different issues are at hand. The positive partner is concerned about transmitting the virus to the negative partner. The negative partner commonly devotes his or her attention to their positive partner's health, becoming the caregiver in the relationship. This difference in perspective and direction causes emotional conflicts ultimately increasing the stress within the relationship.

• How did it happen?

If one partner becomes positive while in a relationship, the first burning question the other partner will have is “How did that happen?" If the new infection is the result of unprotected sex outside the relationship or a consequence of sharing needles while injecting drugs, chances are the negative partner had no idea either behavior was going on. The stress caused by the new HIV infection is compounded by feelings of anger, betrayal, and sadness as the reality of their partner's infidelity and drug use sets in.

• Overly cautious

In any discordant relationship, there is concern at the prospect of spreading the HIV infection to the negative partner. Sexually, the couple may become overly cautious and at the worst, stop any sexual or intimate contact in fear of spreading the infection. While it’s not the most important part of a relationship, sexual intimacy is a key component of any loving relationship. Without intimacy, feelings of frustration, longing, and resentment surface and in turn, the relationship suffers.

• Survivor’s guilt

Guilt can be a powerful and destructive emotion. Most often, survivor’s guilt is a product of situations such as car accidents in which one person survives while many others die. The survivor feels guilty for having lived. In a discordant relationship, the negative partner can feel guilty for being negative. The guilt increases if the positive partner becomes sick due to their HIV. In extreme cases of guilt, the negative partner wishes they too were infected, feeling their infection would relieve the guilt .
What are some of the issues facing discordant couples?

• To disclose or not to disclose

Disclosure becomes a problem when one partner wants to disclose to more people than the other partner. In this situation, one rule applies to every couple: Except in circumstances of medical emergency or necessity, when and to whom disclosure is made is the decision of the positive partner.
If the positive partner says no to disclosure, then the negative partner must abide by his or her wishes without question.

• Sharing medical information

Some People living with HIV (PLHIV) want their partner with them at every doctor's visit. Others prefer not to share medical information or discus their medical condition. Negative partners sometimes have a hard time understanding this feeling. The negative partner needs to know the positive partner is fit. Fear of the unknown can be powerful. Being left out of the medical aspect of their partner’s life spawns fear and doubt, two emotions that can undermine any relationship.

• Difference of sexual comfort and desire

In a discordant relationship, there will be issues when it comes to  sex. How much risk is each partner willing to take? What type of safer sex practices will be used? In what sexual activities is each partner willing to participate? A good rule of thumb is that if either partner does not want to engage in an activity or take a risk with unsafe sex, then that partner has the final say. Regardless, differences in sexual drive and risk taking can become divisive in a discordant relationship.

• Fear of the future

As is the case with any chronic illness, there is some fear related to the prospect of deteriorating future health. The negative partner dwells on questions like when will the positive partner get sick; how long will they live? Fortunately, advances in HIV care has resulted in more promising futures for those infected. As life spans continue to improve, couples will become more optimistic about what their future holds.
How can discordant couples prevent themselves from HIV infection?

• Discordant couples are increasingly being recognised as a priority for HIV prevention in developing countries.

• Prevention with discordant couples is a relatively new area of prevention activity in many developing countries. Only a small number of interventions targeted at discordant couples have been identified. Below are some of the key elements of approaches that have proven to be effective or are showing promise. Overally, there are three broad program components, as follows:

• First, the key to prevention with discordant couples is ‘couples HIV counseling and testing’ (CHCT). By testing together, each partner knows their own and their partner’s sero-status. How counseling and testing is implemented within the field has varied. At times, it is incorporated into antenatal clinics, while at other times it is conducted through outreach programs. There are, however, some common elements to all the approaches.

• Second, group based interventions are another important program component. Group based interventions include the provision of information, developing risk reduction strategies, and developing personal skills.

• The third critical component of prevention with discordant couples is the need to provide a supportive environment. Fear of stigma often acts to impede access to services. Reducing stigma and building community support can enable prevention programs to function more effectively. In addition, logistical and financial obstacles often need to be overcome to further facilitate access.

• Developing effective HIV prevention interventions that target discordant couples could potentially contribute to reducing HIV transmission in many countries. Moreover, provision of services to discordant couples to help them manage their status is an essential component of comprehensive HIV responses.  A review of research on HIV discordant heterosexual couples identified factors that influence transmission including sexually transmitted infections (STIs), particularly genital ulcerative diseases, viral load, condom use, and specific sexual practices (such as a high number of sexual partners and higher frequency of sexual contact) (Guthrie: 2007).

Is it important for couples to be tested and counseled together?

• The cornerstone of prevention programs with discordant couples is ensuring couples learn if they are HIV discordant. This knowledge is critical if discordant couples are to reduce the risk of HIV transmission to the HIV negative partner. In Uganda, approximately 80 percent of adults were unaware of their HIV status, and more than 90 percent were unaware of their partners’ status. Yet knowledge of HIV discordant status has been associated with increased condom use (Bunnell: 2008).

• Increasingly there has been recognition of the need for services to work with couples, rather than just with the individual partners. Counselling and Testing has been shown to be an effective intervention for reducing the risk of HIV transmission among discordant couples (Allen: 2003).  

• Counseling couples together enables the challenging issue of disclosure to be addressed, although this requires ensuring that counselors are skilled at supporting discordant couples.
• Couples need to be a priority for HIV counseling and testing programs, although prioritising couples alone does not ensure increased participation, additional strategies to increase demand for services from couples are often required.

What do people need to know?

• HIV prevention with discordant couples requires challenging misconceptions. A widespread misconception is that HIV discordancy cannot exist between couples.  Explanations for discordancy include the concept of a hidden infection not detectable by HIV tests, belief in immunity, the thought that gentle sex protected HIV negative partners, and belief in protection by God.  

• The denial of HIV discordancy is likely to increase the risk of HIV transmission to the HIV negative partner within discordant couples. Even counselors have been found to lack clear explanations for HIV discordance, highlighting the need for quality counselor training and clear counseling protocols that can ensure the needs of discordant couples are better addressed. Likewise, clear education messages need to be developed that support risk reduction within discordant couples and address misconceptions.

Key education messages that the media can focus on:-

• The media can highlight that HIV discordance is common. However, discordant couples need to continue protecting themselves against HIV infection so that the negative partner remains uninfected. HIV negative partners in discordant couples are at very high risk of infection especially if they do not use protection.

• Some important messages that the media can also share are that couples can remain discordant for a long time but no one is immune to HIV. 

• The media can educate readers, viewers or listeners that HIV transmission within discordant couples can be prevented and HIV discordance is not a sure sign of infidelity.

Sources

1.   Bunnell, R. and Cherutich, P. 2008.  Universal HIV Testing and Counselling in Africa. The Lancet.

2.   Bunnell, R.  et al. HIV Transmission Risk Behavior among HIV-Infected Adults   in Uganda: Results of a Nationally Representative Survey.

3.   Dunkle, K.  et al. 2008. New Heterosexually Transmitted HIV Infections in Married or Cohabiting Couples in Urban Zambia and Rwanda: An Analysis of Survey and Clinical Data. The Lancet.  
4.   Guthrie, B.  et al 2007. HIV-1-Discordant Couples in Sub-Saharan Africa: Explanations and Implications for High Rates of Discordancy.  Current HIV Research.
5.   Hollingsworth, T.D. et al. HIV-1 Transmission, by Stage of Infection. The Journal  of Infectious Diseases.

6. Walque, D. 2007. Sero-discordant Couples in Five African Countries: Implications for Prevention Strategies. Population and Development Review.

Internet sources

1. http://www.medterms.com/script/main/art.asp?articlekey=38933

2. http://www.sasod.org.gy/node/24