A Cross-sectional Study to Analyze the Social, Sexual, and Reproductive Challenges among Serodiscordant Couples.

INTRODUCTION: The term "serodiscordant couples" refers to an intimate partnership in which one partner is human immunodeficiency virus (HIV) positive and the other HIV negative. They form a special population which are constantly at risk of acquiring infection, require safer sexual and reproductive options, and are in constant psychological and emotional distress. AIMS: To describe the social, sexual, and reproductive issues and their impact on serodiscordant couples.
MATERIALS AND METHODS: A cross-sectional study was conducted on HIV-serodiscordant couples, admitted or attending our outpatient department, where the couples had not separated. A detailed interview of the partners on social, sexual, and reproductive issues was conducted and the data were endorsed in the pro forma.
RESULTS: Sixty-four serodiscordant couples were included in the study. Sixty-two (96.8%) males were seropositive compared to 2 (3.1%) females. Sixty-one (95.3%) patients were married and 3 (4.6%) were unmarried. Thirty-six (56.2%) patients were between the age group of 21 and 35 years, 21 (32.8%) between 36 and 55 years, and 7 (10.9%) between 56 and 70 years. Sixty-two (96.8%) patients had a heterosexual orientation compared to 2 (3.1%) patients who were homosexual. Twenty-one (32.8%) patients had a history of sexual encounter outside the relation while 27 (42.1%) were not aware of the source of infection. Fifty-one (79.6%) patients were on antiretroviral therapy (ART) compared to 13 (20.3%) patients who were not on ART. Thirty-one (48.4%) patients admitted to have a constant strain in relation while 16 (25%) were practicing safe sex. Thirty-nine (60.9%) patients had fear of disease transmission while 26 (40.6%) had fear of pregnancy. Forty-nine (76.5%) patients had children at the time of detection while 15 (23.4%) had no issue. Forty-one (64%) patients expressed desire to have children as compared to 23 (35.9%).
CONCLUSION: The unique requirements of serodiscordant couples in terms of providing them safer sexual and reproductive options to prevent the transmission of HIV to the seronegative partner or the child during pregnancy need to be addressed for better patient management.

Introduction

India contributes a significant 2.39 million people suffering from human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) to the global HIV-infected population.[1] At present, a serodiscordant relationship accounts for 18%–31% of couples in countries where the prevalence of HIV is high.[2] The term serodiscordant refers to an intimate partnership in which one person is HIV positive while the other is HIV negative. The term “couple” relationship is defined by marital, cohabitating, or coparenting status or the length of relationship (e.g., minimum of 3–6 months), intention to stay together, or reporting a certain minimum number of sexual acts with this partner within a given time frame.[3]

Serodiscordant couples are a challenging subset of the HIV-infected population having unique social, sexual, and reproductive issues which are often missed out while dealing with HIV. A unique constellation of relationship complexities among these couples and anxiety of transmitting the disease to the seronegative partner and hence restricting their desire to engage in sexual activities and to conceive are the areas which remain to be explored and addressed. At present, there is a lack of scientific data from India on the challenges faced by these couples, and no counseling guidelines exist for them. A comprehensive counseling program and a thorough understanding of the difficulties regarding their intimacy, social life, and childbearing challenges need to be understood.

Materials and Methods

This was a cross-sectional study conducted at a sexually transmitted disease center of a tertiary care hospital in northern India. All the seropositive in and out patients, whose partners tested negative for HIV, were interviewed after getting clearance from the ethics committee of the hospital. All the patients included were informed about the nature of the study and were interviewed keeping the sensitivity of the issue in mind. The couples who have legally or permanently separated or did not intend to be included in the study were excluded.

Patients were interviewed after establishing a rapport with them regarding the social issues they faced after getting detected positive for HIV. Changes in the attitude of partners for each other post detection, its effects on their intimate sexual life, various factors restricting them from engaging in sexual activities and fear of transmission of the disease in case of pregnancy was assessed. Their desire to complete their family and the causes restricting them from doing so were analysed. The data were compiled in the pro forma and were analyzed.

Results

A total of 64 (128 patients) serodiscordant couples were included in the study. Sixty-two (96.9%) males were seropositive compared to 2 (3.1%) females. Of the total 64 couples, 61 (95.3%) were married and 3 (4.7%) were unmarried partners in a constant relationship. Thirty-six (56.3%) patients were in the age group of 21 and 35 years, 21 (32.8%) between 36 and 55 years, and 7 (10.9%) between 56 and 70 years. Sixty-two (96.9%) patients had a heterosexual orientation while 2 (3.1%) patients had a homosexual orientation. Twenty-one (32.8%) patients had a history of sexual encounter outside the relation, 9 (14.1%) had a history of blood transfusion, 7 (10.9%) had intravenous drug abuse history, and 27 (42.2%) could not give any history on possible source of infection. Fifty-one (79.7%) patients were on antiretroviral therapy (ART) compared to 13 (20.3%) patients who were ART naïve at the time of the interview. Table 1 illustrates the demographic profile of these patients. The duration of the partnership ranged from 21 (32.8%) patients between 2 and 5 years, 15 (23.4%) between 1 and 2 years, 11 (17.1%) for more than 5 years, 9 (14.1%) between 9 months and 1 year, and 8 (12.5%) were in relationship for the last 6 months.

Table 1

Demographic profile of patients

Parameters	n (%)
Gender of the affected patients
Male	62 (96.9)
Female	2 (3.1)
Marital status
Married	61 (95.3)
Unmarried	3 (4.7)
Age distribution (years)
21-35	36 (56.3)
36-55	21 (32.8)
56-70	7 (10.9)
Sexual orientation
Heterosexual	62 (96.9)
Homosexual	2 (3.1)
Route of infection
Through sexual route	21 (32.8)
Blood transfusion	9 (14.1)
IV drug abuse	7 (10.9)
Unknown	27 (42.2)
Patients on ART
Yes	51 (79.7)
No	13 (20.3)
Duration of the marital/consistent relationship
6-9 months	8 (12.5)
9 months-1 year	9 (14.1)
1-2 years	15 (23.4)
2-5 years	21 (32.8)
>5 years	11 (17.2)

ART: Antiretroviral therapy, IV: Intravenous

The status of sexual and intimate relation between the partners is shown in Table 2. The result includes the partners who had these issues irrespective of serostatus. Eleven (17.1%) seronegative partners almost decided to get separated from the infected partner, but eventually stayed in the relationship due to personal, social, and financial issues. Thirty-one (48.4%) patients admitted to have a constant strain in relation after the detection of HIV in one of the partners. Thirty-seven (57.8%) patients felt that their intimacy is affected after the detection and 17 (26.5%) were practicing abstinence compared to 16 (25%) patients who were practicing safe sex.

Table 2

Effect on intimacy and sexual relationship*

Status of sexual intimacy	n (%)
Decided to get separated from partner postdetection	11 (17.1)
Constant strain in relationship	31 (48.4)
Intimacy affected postdetection	37 (57.8)
Abstinence	17 (26.5)
Practicing safe sex	16 (25)

*Both seropositive and seronegative partners interviewed. Figures reflect the partners with positive feelings irrespective of serostatus

On questioning the apprehensions among these couples, 39 (60.9%) patients gave a history of fear of disease transmission to the seronegative partner, which was shared by both the partners. Twenty-six (40.6%) patients had a fear of pregnancy and its outcome and 17 (26.5%) seronegative partners had issues because of real or perceived infidelity of the HIV-positive partner. Twenty-nine (45.3%) patients complained of issues due to condom usage in terms of lack of spontaneity or satisfaction. Eighteen (28.1%) patients admitted to have lost interest in their spouses after they were detected seropositive. Seventeen (26.5%) patients had social issues as they were not received well within the family and society due to the retropositive status of the partner. Only 12 (18%) couples were aware of the safer sexual practices. Table 3 gives a detailed account of the above findings and includes the partners who had these issues irrespective of serostatus.

Table 3

Issues experienced by sexual partners*

Issues	n (%)
Fear of disease transmission	39 (60.9)
Fear of pregnancy	26 (40.6)
Real/perceived infidelity	17 (26.5)
Problems due to condom usage	29 (45.3)
Lack of interest in partner	18 (28.1)
Social issues	17 (26.5)
Awareness of safer sexual practices	12 (18)

*Both seropositive and seronegative partners interviewed. Figures reflect the partners with positive feelings irrespective of serostatus

Issues related to the society were experienced by most of the couples as shown in Table 4. Twenty-six (40.6%) couples did not receive any support from the family while 19 (29.6%) said that their family was indifferent when told about the seropositive status. Twelve (18.7%) couples experienced isolation in public gatherings while 11 (17.1%) said that they were constantly probed by people regarding the source of infection. Thirteen (20.3%) couples said that their children were isolated in school due to the seropositive status of the parent and 8 (12.5%) had a feeling of guilt and worthlessness resulting from the behavior of the society toward the patients and their family. Seven (10.9%) couples experienced isolation at workplace while only 8 (12.5%) were satisfied by the support extended to the couple by the society, friends, and family.

Table 4

Impact of human immunodeficiency virus detection on societal status

Outcome of detection	n (%)
No support from family/friends	26 (40.6)
Indifference by family/friends/neighbor	19 (29.6)
Satisfied with support from society	8 (12.5)
Isolated in social gatherings	12 (18.7)
Constantly probed to know the source of infection	11 (17.1)
Constant criticism leading to feeling of guilt/worthlessness	8 (12.5)
Social alienation of children at school	13 (20.3)
Isolation at workplace	7 (10.9)

Forty-nine (76.6%) couples had children at the time of detection while 15 (23.4%) had no issue. Forty-one (64.1%) couples expressed a desire to have children as compared to 23 (35.9%). The reason for avoiding pregnancy was the fear of an infected child in 34 (53.1%) patients, while 29 (43.4%) couples were apprehensive about the treatment the child would receive from the society and family due to the seropositive status of one of the parents. Twenty-two (34.3%) patients were worried about the social stigma attached to conceive a child after being tested positive for HIV. Nineteen (29.6%) patients had a feeling of guilt due to which they had lack of interest in planning a pregnancy while 16 (25%) couples were unsure about their life expectancy and quality and were not prepared to take responsibility of a child at this stage. One (1.65%) patient was pregnant at the time of conducting the interview and was in her third trimester. She claimed to have no knowledge about the seropositive status of the spouse at the time of planning and conceiving. Fifty-five (85.9%) couples had no knowledge of safe conception methods while 9 (14.1%) had satisfactory knowledge of the same as shown in Table 5.

Table 5

Impact on reproductive status

Factors	Number of patients (%)
Started family
Yes	49 (76.6)
No	15 (23.4)
Desire to have children
Yes	41 (64.1)
No	23 (35.9)
Reason for avoiding pregnancy
Fear of infected child	34 (53.1)
Social stigma	22 (34.3)
Social alienation of the child	29 (45.3)
Uncertainty of life	16 (25)
Feeling of guilt	19 (29.6)
Pregnant at present	1 (1.65)
Information of safer conception methods
Yes	9 (14.1)
No	55 (85.9)

Discussion

Preventing new cases of HIV infection through the identification of high-risk groups supplemented by substantial care and support for the patients has widely been recognized as a significant interventional approach in fighting the battle against HIV.[45] However, even today, a large group of highly vulnerable category of serodiscordant couples remains unaddressed, and the issues concerning these couples are not adequately studied and intervened till date.[6] Serodiscordant couples have a unique subset of challenges such as difficulty in managing their familial relationships, dilemma of childbearing and rearing, risk of disease transmission to partner or child, forced patterns of changed sexual life, lack of familial and societal support, and unreliable livelihood.[7] Unless this special group with unique demands is identified as a risky population and systemically and programmatically targeted, serodiscordance leads to a familial crisis in case all the family members are seropositive. This study was undertaken to bridge the existing gaps to focus and explore the explanation for discordance, challenges of living in discordant relationship, and the coping strategies along with public and societal response to the seropositive status of the patients.

HIV is widely regarded as a disease mainly transmitted through sexual intercourse, mostly to people who participate in unusual sexual activities either with their partner or outside their relation.[89] Stigma against patients and families of HIV-infected patients is one of the major challenges mentioned for HIV infection. It leads to a social process which results in isolation, rejection, blame, or devaluation and deleteriously affects the lives of these families, preventing them access to treatment and care, disclosure, seeking support, social interaction, identity, and their human rights.[1011121314] Table 6 tabulates some studies evaluating the impact of social support on people living with HIV.[15161718]

Table 6

Some studies highlighting the impact of social circumstances on HIV infected patients

Study	Sample	Aim of the study	Key findings
Adewuya et al.[15]	88 HIV-positive and 87 non-HIV patients	To estimate the prevalence of psychiatric disorders in HIV patients compared to control group	Poor social support was significantly associated with psychiatric disorders; those who had poor support were up to 11 times more likely to develop disorders
Wang et al.[16]	755 AIDS orphans, 466 children of infected partners	To examine the relationship between protective factors for depressive symptoms	Social support, trusting relationships, and future orientation mediate the outcome of stigma and depression
Rotheram-Borus et al.[17]	409 HIV-positive patients	To examine the influence of family, social relationships, and disclosure on health of patients with HIV	Disclosure has a significant and positive association with social support and familial functioning. Social support has a better quality of life and less depressive symptoms
Khumsaen et al.[18]	120 HIV-positive patients	To examine the relation between psychosocial factors and quality of life	High level of social support and living with family had a positive relation with quality of life

HIV: Human immunodeficiency virus

The risk of HIV transmission among serodiscordant couples varies depending on the type and frequency of sexual activity and the plasma viral load of the seropositive partner. The common modes of prevention such as condoms, antiretroviral drugs for pre-exposure prophylaxis, treatment with ART for HIV infection, and circumcision are known to reduce the risk of disease transmission among serodiscordant couples.[1920] Despite these options, living with HIV/AIDS serodiscordance implies that these couples have to deal with several intimacy-related difficulties due to the possibility of transmitting the disease to the seronegative partner, resulting in multiple forced changes in their sexual practices including abstinence. The sexual behavior of these patients has received little attention till date as sexual life seemed to be a secondary issue as compared to health.[21] The fear of disease transmission is one of the main issues encountered by these couples, which negatively influences their sexual life. We also encountered this fear among our study group quite consistently in both the partners. Many couples develop various strategies to deal with the issue of transmission such as denial and rationalization, using more than one barrier, and leading a life devoid of sexual activity. The entire spectrum of these adjustments was observed in our study as well. The use of condoms was associated with issues of trust on its protective aspect, difference in acceptance, lack of spontaneity, and alteration of sexual gratification. Similar findings were seen by us in the couples who used a condom. Many patients experience a feeling of uncertainty, insecurity, and fear in sexual relation restricting the sexual activity. Despite these challenges, some couples manage to build their sexual life after dealing with the initial phase of guilt and fear.

In the Indian scenario, where childbearing is a pressure on the couples, these partners may engage in risky sexual behavior to conceive, particularly in women, where it is a sign to regain their self-status and a proof of recovery and regained self-control. However, existing data suggest that HIV-serodiscordant couples seldom know the practices which can be used to reduce the periconceptional sexual transmission and in order to conceive, couples may engage in risky sexual behavior despite having knowledge of HIV transmission.[22] A desire for childbirth varies from 20% to 50% of HIV-infected individuals in various studies, while we found that 64% of our patients expressed their desire to have children.[23] Mother-to-child transmission (MTCT) remains the main mode of HIV transmission in children <15 years of age and can occur during pregnancy, childbirth, and breastfeeding.[24] Globally, it is estimated that 5%–10% of MTCT occurs during pregnancy, 10%–20% during labor and delivery, and around 10%–20% transmission during breastfeeding. Transmission is reported to occur in 15-45% patients when no intervention is done as compared to only 5% when interventions in the form of ART prophylaxis to pregnant women, during labour is given. ART to infant within first week of life, adopting safe obstetric and feeding practices are other ways to reduce the risk of transmission considerably.[252627]

In this study, we found that the uncertainty of life, fear of societal support, giving birth to an infected child, and lack of financial support were the key elements which determined the attitude of the couple toward reproduction.

Conclusion

Providing care about sexuality, rehabilitation, and conception guidelines to the serodiscordant couples who unfortunately remain marginalized in the society despite increased knowledge and awareness about this disease require conscious efforts by both the health-care providers and patients themselves. At present, serious gaps exist in our knowledge regarding the sexual and reproductive issues faced by these couples. A comprehensive, all-encompassing set of guidelines are the need of the hour to provide a full range of support at all levels in facilitating these couples to live their life happily and healthily. Providing them a long life devoid of these basic human requirements is not the way ahead to deal with this modern epidemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.