Mrs ABCD was tested positive for HIV in one of our clinics. She has been counseled and enrolled for treatment as soon as the test confirmed her status. On several occasions she was adviced to tell her husband so he also can get tested too and be placed on appropriate drug depending on the test outcome. However, for years now, this lady wouldn't disclose her HIV status to her husband who was totally oblivious of her own status despite they are both living under the same roof and still very much married. 

Fast forward to several months later, she stopped receiving ARV in our clinic in order to avoid seeing the counselor who continues to remind her of the importance of telling her HIV status to her husband so he can get tested too. 

To cut the long story short, after months of not coming to the clinic and efforts to reach her failed (because she gave a fake address and probably changed her contact phone number). She suddenly on her own volition returned to the clinic one day with a man because he was ill. Test revealed that her husband is positive. Due to counseling and unknowingly to the husband, he requested that she knows her status too. Both of them were counseled and relevant tests were conducted. 

 

It was a big drama when the test result came out! She shouted, screamed and cried in "surprise" as if it was her first time of knowing her status. This amazed me at the level at which couples even living under same roof can conceal their HIV status from each other. So many married partners are facing similar challenges and finding it difficult to reveal their HIV status to their partner. In the words of Magic Johnson, the famous MBA player who was tested positive for HIV "the worst moment from all of these was driving home from that doctor's office, to tell my wife that I was HIV positive". This challenge exist in many homes and had become a burden in my heart to write about it. Though not exhaustively, i would try to highlight the issues as much as possible.

Firstly, who are serodiscordant couple? 
Simply put, serodiscordant couples are those where one partner is positive for HIV and the other is not.

The challenges:

For the purpose of this discussion, I will focus more on couples in which one of them is tested positive for HIV. However, for those who are yet to be married, there is a lot to learn from this writeup. 

Before we continue further, lets think about these few questions as we progress in the discussion. 

Can you tell your spouse that you are tested positive for HIV? 

How long will it take before you can reveal your HIV status to your wife/husband? 

What would you do if your spouse tells you s/he is HIV positive?

How well can you take such information and will you be willing to continue in the marriage?

Or does that mean end of marriage? 

Like I said, this issue happens often in clinics when you try to counsel a spouse who is tested positive for HIV and s/he tells you that s/he cannot disclose the status to the spouse. Some of them continue to take ARV for years as seen above while s/he refuse to disclose his/her HIV status to the spouse! 

Some reasons why serodiscordant couples refuse to reveal their HIV status to their spouse. 

1. The misconception that testing positive for HIV means being promiscuous. 
This is often common especially when the female spouse is the one tested positive for HIV. You often hear comments like, "she don carry, she dey waka waka"etc. 
Such misconception that a person living with HIV is promiscuous is dangerous and has serious negative implications especially towards revealing ones HIV status for serodiscordant couples.

Though many are aware that other options of HIV acquisition or transmission exist such as sharing unsterilised sharp object with infected person, mother-to-child -transmission etc. My findings from focused group discussions done among people of reproductive ages show that a vast majority of people often rule out the possibility of HIV acquisition from other options like sharing unprotected sharp objects with infected person. 

It is however no doubt that unprotected sexual contact is the predominant means of HIV acquisition/transmission. When people are faced with someone who is living with HIV, there is a quick conclusion that such person got infected because of his/her promiscuity or infidelity thereby outrightly ruling out other possible chance of transmission. 

More implication of such life threatening assumption is that it creates fear in those spouse who are HIV positive and prevent them from disclosing their status to their partner. Often times they refuse to disclose their status even when they know that their partner is at risk of being infected. This is because of the spousal, family and societal assumptions that s/he must have become HIV positive due to sexual immorality. Thus many spouse live with HIV for years without revealing to their partner. 

2. Confidentiality:
Confidentiality is key when providing healthcare services as its the duty of the healthcare provider to ensure 
confidentiality always. Some spouse after testing positive and following counseling, they come to clinics to get antiretrovirals (ARV) and continue to take medication for themselves for years without disclosing their status to the partner. The situation is even worse when the wife is HIV positive and cannot negotiate safe sex with her husband. The husband continues to have unprotected sex with his wife and become eventually infected. This endangers the partner who most times get to know his/her status at late stage often when critically ill. But as best practice, the healthcare provider can only continue to counsel and provide necessary support to the spouse to disclose his/her status to the partner, however, the health worker cannot breach confidentiality to disclose the status without the spouse consent. 

3. Religion:
I will start by asking. What religion are you? 
If that deeply religious wife/husband or even neighbour is tested positive for HIV, what would be your first impression of him or her? 

Sometimes, we are too deeply religious that we forget that religious people can get infected too. Often times deeply religious people come to seek healthcare services at late stage of illness: usually after several all-nights, fasting and praying. At this time the health situation is in a state where little can be done.

When some deeply religious spouse paradventure get to know their status and is told that s/he is tested positive for HIV . What you find in most cases are verbal abuse on the service provider. I have had a case that instead of the spouse conducting a confirmatory test and taking her partner to conduct HIV test to know their status together, she said " HIV is not my portion" and went away without doing any confirmatory test. Most times, the counselor tester may want to stress more on the need for confirmatory HIV test. This often lead to comments like "its you/ your mother/ father that have HIV". Such situation occurs especially when the tester is much younger than the spouse being tested. 

However, It is worthy to note that I believe in having and upholding one's faith; infact its a key component of my religion. But i am of the school of thought that instead of staying without drugs or avoiding medical tests, you can take your drugs or get tested as prescribed and have faith that it will keep you well. In this case, its possible that your active faith joined with the drugs gives you goodhealth! 

4. Our culture; the Nigerian culture. 

The indigenous Nigerian culture is rich, diverse and also structured in a way that facilitates gender inbalance. I will briefly highlight the implication of this imbalance to serodiscordant couples. 

Our culture does not support married female having extramarital affairs. But same culture does not frown at married men who tend to be "culturally licensed" to have extramarital affairs. What this then mean is that; while this "cultural license" increases the risk of HIV acquisition in men due to multiple sexual partners especially from extramaritals . Thus for married men who are HIV positive, their wives are often victims of HIV acquisition as it is often a challenge and near impossible for most married women to negotiate safe sex with their spouse due to cultural dominance of males. If such woman eventually gets to know her HIV status before her husband, she may become reluctant to disclose her status due to cultural factors that may tag her as being promiscuous or put her at risk of losing her marriage. 

4. Lack of female empowerment:

A female child is often less empowered than her male counterparts. Lack of empowerment on most married females make them overdependent on their partners. The implication is that if such women become positive to HIV, they fear the risk of reduced or total elimination of spousal support (financial) and are more likely to be sent out of their matrimonial homes or become neglected by their spouse (due to stigma, infidelity claims etc). Since they are not self sustaining financially, they tend to conceal their HIV status from their partners irrespective of the health consequences of doing so. 

5. Stigmatisation:

A successful fight against HIV/AIDS would mean a successful fight against stigmatisation. People often stigmatize against people living with HIV. This bias the way we relate or act towards them simply because of their HIV status. Worst still, people living with HIV experience such stigma even from spouse, close relations, friends, coworkers etc who are supposed to provide supportive environment for them. 

There are other underlying factors not captured here. For concerns or suggestions,  please send mail to Orobosa Enadeghe, Bsc (Hons) ,  Msc Epid. 

 CYFI Fellow.  [email protected]