Emotional and Relationship Dynamics Between HIV Serodiscordance

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January 2017 Emotional and Relationship Dynamics between HIV SeroDiscordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework Amani Mwakalapuka Sokoine University of Agriculture

Ipyana Mwampagatwa The University Of Dodoma

Theodora Bali St John's University of Tanzania

Masumbuko Mwashambwa The University Of Dodoma

Stephen Kibusi The University Of Dodoma

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Recommended Citation Mwakalapuka, A., Mwampagatwa, I., Bali, T., Mwashambwa, M., Kibusi, S., Mwansisya, T. (2017). Emotional and Relationship Dynamics between HIV SeroDiscordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework. ARC Journal of Public Health and Community Medicine, 2(2), 1-14. Available at: http://ecommons.aku.edu/eastafrica_fhs_sonam/146 Authors Amani Mwakalapuka, Ipyana Mwampagatwa, Theodora Bali, Masumbuko Mwashambwa, Stephen Kibusi, and Tumbwene Mwansisya

This article is available at eCommons@AKU: http://ecommons.aku.edu/eastafrica_fhs_sonam/146 ARC Journal of Public Health and Community Medicine Volume 2, Issue 2, 2017, PP 1-14 ISSN 2456-0596 DOI: http://dx.doi.org/10.20431/2456-0596.0202001 www.arcjournals.org

Emotional and Relationship Dynamics between HIV Sero- Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework

Amani Mwakalapuka1, Ipyana Mwampagatwa2, Theodora Bali3, Masumbuko Mwashambwa4, Stephen Kibusi5, Tumbwene Mwansisya6,* 1Department of Social science, College of Humanities and Social Sciences, Sokoine University of Agriculture, P.O Box 3038, Morogoro, Tanzania 2Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, The University Of Dodoma, P.O Box 395, Dodoma, Tanzania 3Faculty of Humanities and Education, St John's University of Tanzania, P.O. Box 47, Dodoma, Tanzania 4Department of Surgery, School of Medicine and Dentistry, the University Of Dodoma, P.o Box 395, Dodoma, Tanzania 6Department of Psychiatry and Mental health, School of Nursing and Midwifery, the Aga Khan University of East Africa, P.O Box 125, Dares salaam, Tanzania

*Corresponding Author: Tumbwene E. Mwansisya, Department of Psychiatry and Mental health, School of Nursing and Midwifery, the Aga Khan University of East Africa, P.O Box 125, Dares salaam, Tanzania, E-mail: [email protected]

Received : April 18, 2017 Accepted: April 27, 2017 Published: May 25, 2017

Abstract: Tanzania is among the countries with high prevalence of HIV prevalence in the World. Despite the fact that the epidemic has been, and still is a threat to persons of all ages, recent studies have suggested that most new infections occur among couples in stable relationships. Infected couples are categorised into two: the positive concordant, where both the partners are HIV positive; and sero-discordant couples, where one partner is HIV positive while the other is negative. Recently, researchers and many other stake-holders working on the HIV/AIDS epidemic have given a remarkable attention to this astonishing reality. For instance one study in East and Southern Africa indicates that there are great variations of discordancy varying from 36% to 85%, with an overall rate of 49%. HIV couple sero-discordancy is responsible for varied levels of psychological distress including heightened levels of anxiety, poor emotional adaptation and increased or excessive substance use, most often coupled with exclusion and social isolation within family and in the neighbourhood. However, to date the influence of sero-discordancy on family and couple relationship functioning and how it differs from that among concordant couples remains elusive. Discordancy have been associated with more difficulties as compared to the seroconverted couples, these include relationship and emotional disturbances, sexual contact distancing, marital separation and disruptions. The Lazarus and Folkman’s (1984)'s Transactional Model can be helpful in understanding individuals with HIV discordancy on their emotional response, coping strategies and the ultimate decisions towards their marital relationships fate. Keywords: Couple sero-discordancy, HIV/AIDS, Theory, Emotional problems, psychosocial problems, Literature review.

1. BACKGROUND countries, especially, the Sub-Saharan Africa. In For over three decades since its discovery in Tanzania, for example, the current survey found 1981, HIV/AIDS has continued to be a major that 5.1 percent of those tested were HIV positive. Despite the fact that the epidemic has public health concern affecting, both, social and economic development in most developing been, and still is a threat to persons of all ages, ARC Journal of Public Health and Community Medicine Page |1 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework recent studies have suggested that most new involved children or adolescent, were not infections occur among couples in stable published in English. relationships (Bishop and Fareit, 2010). Thus, 2.2 Search strategy for the identification of some couples are infected while others are not. relevant studies Infected couples are categorised into two: the A broad search strategy for potential articles positive concordant, where both the partners are was used in order to include all relevant studies. HIV positive; and sero-discordant couples, Electronic searches of Medline, EMBASE, where one partner is HIV positive while the PsycINFO, Web of Science with subject other is negative. headings including HIV status, HIV discordancy, HIV discordancy, HIV and High prevalence of HIV-discordancy in the couples, HIV Sero-status determinants, HIV world is not new. However, it was not until late discordancy and emotions. These words were 1990’s when studies from different parts of the used alone or in combination including HIV world started to seriously document AND discordanc* or concorda* AND (couple* pervasiveness of couples who lived along with a OR partner*). We also searched the different sero-status partner. Recently, scientists bibliographies of the retrieved studies and and many other stake-holders working on the published or unpublished relevant articles. Two HIV/AIDS epidemic have given a remarkable authors (AAM and TEM) independently attention to this astonishing reality. Thus, today, reviewed the articles to determine inclusion. many publications, both academic and of social Disagreements were resolved by consensus. welfare, have tried to substantiate the prevalence Each article was analyzed to determine the of discordancy, factors leading to discordancy, sample characteristics, study setting, definition and some problems that these couples go of and prevalence of discordance or through in their daily life, factors leading to concordancy, outcomes of their sero-status discordancy, unprotected sex between the disclosure, and emotional and relationship partners or lovers and unfaithfulness or functioning after disclosure of their HIV status. promiscuity. 2.3 Factors Associated with Couple Sero- Despite all the efforts done already, much discordancy remains unknown, particularly on the emotional Determinants of couple discordancy are an and psychosocial effects infected couples endure increasingly encountered phenomenon in in either concordant or discordant relationship, research and clinical management of HIV. A factors that influenced discordant couples’ number of factors have been established to ultimate decisions on their marital ends, and the explain this occurrence. Primary to this likelihood of their relationship functioning. occurrence are biological factors. Evidence from 2. METHODS various studies, (de Walque, 2006; Wilde, 2002; 2.1 Eligibility Criteria of the Studies Melo et al., 2008) indicate that when an HIV Included in the Review infected partner has a small viral load there are small chances for their seronegative spouse to Studies were selected for inclusion in this be infected. More recent studies have further review if they met the following criteria demonstrated that heterosexual transmission is a  They included any measure of Concordant or function of plasma viral load (Kumarasamy et discordant of HIV status in partners. al., 2010; Chavan et al., 2014). While many studies support this claim, there are reports in  The sample comprised participants aged 18 some other studies that indicate that partner's years and older. low viral load was not the cause of resistance to  They were published in a peer reviewed HIV, of the uninfected matched spouse journal in the English Language (Louisirirotchakul et al, 2001). They also suggest the role of the less known genetic  The studies needed to be conducted in a factors as responsible for persons' resistance to resource-limited setting, defined as low or HIV in a discordant relationship. Some studies middle-income countries. indicate that some individuals are seen to be Articles were immediately excluded if they did genetically resistant to HIV infection not involve HIV discordancy or concordancy, (Novembre, Galvani, and Slatkin, 2005; Cohn ARC Journal of Public Health and Community Medicine Page |2 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework and Weaver, 2006; Pancino et al, 2010). 2.4 The Magnitude and Sex Ratio of Sero- Presence of broadly studied genes and their discordancy mutations, such as Chemokine Receptors Generally, as suggested by Bishop and Foreit, (CCR5 and other variants) and Killer (2010), HIV prevalence among couples is Immunogloblin-like Receptors (KIR) has been similar to that in the general population. Many associated with some individuals' susceptibility other studies, however, suggest great variations or resistance to contracting the HIV and disease in the proportions of discordancy to that of progression (Michael, 1997; Kumar et al., 2006; concordancy. In Thailand, discordance rate is Chavan et al, 2014; Zwolinska et al., 2016). estimated at 58% (Rojanawiwat et al., 2001), Geographic mapping, however, suggest that whereas, in India, current studies indicate a such mutation as CCR5 are more prevalent in 54.6% discordant rate (Mehra et al., 2015) from the northern hemisphere, particularly northern 40% in the previous studies (Marfatia et al., Europe and some parts of Asia Novembre, 2013). A major study by Lingappa et al., (2008) Galvan and Slatkin, 2005). These, however, in twelve partner sites in East and Southern may not adequately explain the pervasiveness of Africa indicates great variations of discordancy discordance in sub-Saharan Africa, where such the Region, varying from 36% to 85%, with an mutations are said to be rare. So, it is most overall rate of 49%. Chemaitelly et al. (2012)'s likely that many cases of sero-discordancy the meta-analysis of DHS data from sub-Saharan Region are not genetically determined; they are Africa suggests that where HIV prevalence is thus temporal, leaving the negative couple less than ten percent, the vast majority in stable susceptible to contracting the virus. These relationships were discordant, ranging between factors are both immunological and virological, 48.4% and 87.8% (Chemaitelly, 2012). The thereby, the viral subtype, stage of infection, study further suggests that countries with HIV shared human leukocyte and a few more are prevalence rates greater than ten percent had seen to contribute to negative couples’ discordancy ranging between 36.3% and 58.5 susceptibility or resistance to HIV infection. %. Despite the variations observed in these and Nevertheless, their actual contribution is not other studies, it remains universal that the known yet (Bruyn, Badenzi, Dladla & Gray, proportion of couples in stable relationships 2006). who are discordant is undeniably substantial, Male circumcision is yet another factor. A thus, the need for effective prevention strategies report from a South African based HIV clinic of the negative partner and promotion of indicates that most uncircumcised male partners wellbeing among both the partners. This has were much more susceptible to contracting the pushed the international community to strategise virus even though reasons behind this are not on preventive measures. Thus, in 2013, the very clear yet (Bruyn, Badenzi, Dladla & Gray, WHO offered guidelines for sero-discordant 2006; WHO/UNAIDS, 2013). A number of couples on issues related to couple counselling, randomised trials (Gray et al., 2007; Desgrees- ARV treatment and Pre-Exposure prophylaxis, du- Lou and Orne-Gliemann, 2008; to mention just a few, all geared to promote Mackelprang et al., 2012; Kimanga 2014) have prevention efforts against new infections among continued to bring in evidence of the reduced negative discordant couples. HIV transmission rates among male partners In a study in seven African countries including who are circumcised. The implication is that Tanzania, Uganda, Kenya, Cameroon, Botswana certain couples may have sustained the and Lesotho, de Walque, (2006) observes that discordant serostatus because the circumcised the proportion of couples who are sero- male partner in a relationship is either less likely discordant is higher than that in which both to infect his female partner or he is less likely to couples are positive with the exception of be infected by his positive female partner. Other Swaziland. De Walque, (2006) observes that the factors for couple discordancy include prior proportion of male partners who are sero- exposure to sexually transmitted infections such positive in Lesotho is twice as high as that as HSV-2 which has closely been associated where the woman is sero-positive. The same with HIV-1 cases. Despite the evidence to study indicates that in Kenya and Tanzania, the minimise HIV transmission, the actual proportion of sero-discordant couples is at least contribution of male circumcision to couple twice as high as that of sero-concordant couples. HIV discordancy is yet to be substantiated. Contrarily, significantly higher proportions of

ARC Journal of Public Health and Community Medicine Page |3 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework couples (60%) where the female is the infected 2.6 New HIV-Infections and Susceptibility of partner is observed in Kenya. A study in Quang Sero-conversion among Sero-Discordant Ninh Province in Vietnam indicates that the Couples proportion of discordant couples in the study Quite a number of studies indicate that most was 58%, with discordancy rates being higher HIV infections occur in stable relationships among men (71%) than among women (18%), (Allen et al., 2007; Chomba, 2008; Matovu, (Tam et al., 2016). The marked gender 2010; Mujugira et al., 2011; UNAIDS, 2014). differences may have a lot to do with socio- Dunkle et al., (2008) estimate two thirds of new economic and socio-cultural dynamics in these infections in Lusaka-Zambia as occurring in regions which are yet to be substantiated. In any stable unions. Available Demographic and case, the magnitude and sex suggests that the Health Surveys (DHS) and AIDS Survey Index need for preventive efforts against new HIV (ASI) from various countries continue to infections and sexual health focus among sero- indicate large proportions of new HIV infections discordant couples cannot be overemphasised. as occurring in stable unions (WHO, 2013), thus 2.5 HIV/AIDS and the Marital Life increasing the numbers of HIV concordancy. Based on the socio-cultural relations in There two views regarding HIV discordancy: Tanzania, most marital relations start at age 18- the retrospective and prospective views. In the 40 which is the sexually active group. While first view, perceives discordancy by looking some studies such as Idele et al., (2014) indicate back in time to focus on its origin (Champredon, that young people are the most vulnerable as far Bellan and Dushoff, 2013). In this view, a high as HIV infection is concerned, evidence from level of discordancy is perceived as resulting carious studies suggest that many adults, from HIV infection external to the couple. For especially married couples, are at a higher risk instance, Lurie at al., (2003), in a study of being infected (UNAIDS, 2013; Kaiser, involving migrant workers in South Africa, 2011; Chemaitelly, Awad and Abu-Raddad, suggests that migrant men acquire HIV infection 2014). in which they work, then bring it to their partners back in their villages, thus the The 2011-2012 Malaria and AIDS Indicators introduction of discordancy in their Survey report reveals a significant difference in relationships. I relation to the prospective view, HIV prevalence based on marital status. While discordancy is viewed as a potential risk factor the never married individuals had a prevalence for infection of the uninfected partner (Allen et rate of 3.3% and 1.2% among women and men, al., 2007; Grabowski et al., 2014). Essentially, respectively, couples, either married or both the views help conceptualise, first, the cohabiting, had an average rate of 5.2 in women contribution of partner's infection as initially and 5.4 in men. The separated or divorced external to the couple during or prior to their couples had higher HIV prevalence rates (15.2 union. Second, they serve to explicate the in women, 8.9 in men) and the highest rates propensity of sero-conversion that the negative were observed among the widows/widowers partner is constantly exposed to in a discordant (24.7 in women, 27.9 in men) (TACAIDS, relationship. In this view, introduction of HIV to 2013). Introduction of HIV infection in a a partner in a stable sexual relationship presents couple, and the resulting concordancy and sero- potential susceptibility to infection of the conversion have been associated with emotional negative partner in a discordant relationship and psychosocial challenges between the (Chemaitelly et al., 2014). partners (Malamba et al., 2005). This has increased their emotional disarray in discordant Carpenter et al., (1999), in their seven year relationships (Reshmi & Sekar, 2011), and has study of 2,200 adults in rural Uganda who tested also elevated the uninfected partners' their HIV status once annually, establish that susceptibility of contracting HIV (Mujugira et sero-conversion was responsible for new al., 2011). Couples, therefore, in whatever kind infections among couples in union. A more of sexual relations, present a focal point for revealing study is that by Trask et al., (2002) on prevention and treatment effort against molecular analysis of seroconverted discordant HIV/AIDS at community, national and global couples' blood. The study substantiates that out levels. of all the seroconversions, only 13% were intra- ARC Journal of Public Health and Community Medicine Page |4 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework couple, while 87% were significantly inter- from a positive discordant male couple to the couple. A recent study by Campbell, (2011) on negative female partner with the risk of sero- viral linkage, involved 3,408 discordant couples, conversion ranging from 0.1 to 0.2 percent in a in which, 155 couples seroconverted. The study single act of unprotected sexual contact (Mastro, further reveals that 71.5% of the new infections 1996). In their study involving 198 female were confirmed to be inter-couple, 26.5% were couples cohabiting with sero-positive German not linked, while 2% were indeterminate. The men, Rockstroh, Ewig, Bauer, Luchters, Oldenburg, Bailly et al., (1995) observe that ten large of proportion that are linked with HIV percent of the sero-negative couples became infections among sero-converting partners infected by their partners and acquired their confirm the claim that most new HIV infections spouses’ positive sero-statuses. occur in stable unions. Recent studies indicate that chances of a Some studies have attempted to approximate the discordant male couple to infect his negative probability of HIV transmission among female partner are one in ten for less than ten heterosexual couples. Two studies in Rakai- unprotected sexual contacts, and around one in Uganda estimate an average of 0.0011/coital act four after two thousand unprotected sexual (Gray et al., 2001) and 0.0012/coital act (Wawer contacts (Downs & De Vincenzi, 1996). Other et al., 2005). In Zambia Hira et al., (1997) studies indicate 0.0015 chances per coital act estimates transmission rate at 0.0009/coital act. (Wawer, 2005). No matter how minimal the rate These rates may indicate that the probability of may seem, chances are the negative partner is a partner to catch HIV from their spouse is low. However, Guthrie, (2007)'s study on discordant constantly exposed to the risk of HIV couples sex-specific HIV transmission rate of contraction from their spouse. To minimize the 1.2 to 19 per person year further indicates a chances of catching HIV from the positive significant health threat that calls for practical discordant male couple by the negative female intervention strategies among couples with couple who seeks to find children with an unlike HIV statuses. infected partner, studies suggest attempt of unprotected sexual contact during ovulation 2.7 Child-Bearing among Infected Couples (Mandelbrot et al., 1997). Out of the ninety two Starting a family and or having healthy children sero-discordant couples who were involved in of their own are among the major concerns the study of positive male couples against their infected couples have (Marfatia et al., 2013). In negative spouses, only four women were sero- the traditional African way, child bearing is as converted; two in third trimester of pregnancy, important as marriage itself and the one and and two in the period following delivery only natural way to conceive is sexual (Mandelbrot et al., 1997). In another study intercourse. Chen et al., (2001) report, in a study involving 28 discordant couples in Cardiff, UK, involving 1421 HIV infected adults, that 28% to 26 children were born over a period of 15 years, 29% of these adults indicated a strong desire to and no sero-conversion was reported have children of their own. Women needed (Ramsahoye, Collins, Davies & Walkers, 1998). children to regain their sense of womanhood and Again, at the Royal Free Hospital in London, sexuality, and to give purpose to life. UK, 14 discordant couples gave birth to 19 Conceiving and giving birth to an uninfected children; sero-conversion was reported for only baby, has become particularly challenging one female partner, while all the children were among infected couples. This is exacerbated by negative (Yee et al.,1999). the fact that unprotected sexual contact with infected partner is the main way by which HIV Recent studies, however, revealed that is contracted in Sub-Saharan Africa (UNAIDS, unprotected sexual contact among child-seeking 2008). Infected couples are thus left with limited discordant couples during ovulation may only choices, some of which are too expensive for apply to men with normal correlation between ordinary people. their blood viral loads to semen viral load, the latter of which is normally 10 times lower than Semen produced by a man during copulation the former. Exception is among some male contains together with other things, the male discordant couples whose semen viral loads reproductive cells-Spermatozoa. These cells, even exceed their blood viral loads (Quinn et al., which make only about 10 percent of the semen, 2000; Wilde, 2002). Viral suppression and may thinly be responsible for HIV transmission sperm washing are also the other methods. ARC Journal of Public Health and Community Medicine Page |5 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework

Positive female couples are likely to infect their Despite all the uncertainties therewith, studies unborn babies normally at birth (UNAIDS, indicate that not all couples choose to separate 2007). To minimize these chances, a centre for or divorce; not all opt to bear the fear of the HIV/AIDS Research at Muhimbili National unthinkable danger to the negative couple: some Hospital in Tanzania is running a special have separated, some divorced, some have programme to help such couples have a safe experienced weakened intimacy and sexual motherhood. These mothers are given special infidelity (Bunnell et al., 2011), some sustained a normal relation, some reported heightened treatment during pregnancy and at delivery, levels of intimacy than ever before. Certainly, which helps the baby to be delivered uninfected. there are factors, be they social, psychological, In their study on HIV-1 Transmission risk in socio-economic or cultural which determine the African countries (Mugo, et al., 2011) chances of infected couples fight (sustain) or concluded that there is an increased risk of HIV flight (refrain from) the uneventful realities of acquisition among pregnant negative women discordancy. and increased transmission risk to men during pregnancy, which is also supported by Brubaker 2.9 Psycho-social Issues Associated with et al.,(2011) whose study revealed that chances HIV Sero-Discordance and of re-conversion almost doubled in couples Concordance where pregnancy occurred (5.9% vs 10.8%). HIV infection is a source of emotional and Child-seeking women are at even a higher risk physiological stress (Faul-stich, 1987). The of transmitting and or getting infected of HIV. stress level of the person affected depends on Having little or no control over their sexual their knowledge and skills, attachment to negotiations often push them to the dilemma of significant others, intimacy with their spouses choice between prevention against HIV and self-efficacy; when a person's stress infection and performing their reproductive condition is persistent, it adds up to increased roles. symptomatology and hastens disease progression (Van Erk et al., 1996). Other studies 2.8 Emotional Experiences of Sero- have indicated heightened levels of anxiety, discordant Couples in Marital Relations poor emotional adaptation, increased substance HIV couple sero-discordancy, depending on the use, social isolation among HIV infected couples’ knowledge, skills, attachment, intimacy couples (Rispel et al., 2009; Collini and Obasi, and self-efficacy, is responsible for varied levels 2006; Eyayo et al., 2010), as well as distancing and sexual avoidance (Reis and Gir, 2010). of psychological distress (Atibioke amd These conditions, however, as observed by Osinowo, 2013), heightened levels of anxiety, Reshmi and Sekar, (2011), are more pronounced poor emotional adaptation and increased or among couples with unstable income. excessive substance use, most often coupled with exclusion and social isolation within family Despite the emotional and psychosocial and in the neighbourhood (Rispel, et al., 2009; responses described above, Bunnell, et al., Collini and Obasi, 2006), more so among (2005) who compared 49 positive concordant couples with unstable income (Reshmi & Sekar, and 126 discordant couples in couple 2011) and those without sufficient family counselling in Kampala Uganda have a rather support (Elwin et.al, 2006 & Eyavo et al, 2010). astounding observation. Their findings reveal that partners in a positive concordant Discordancy is reported to have caused marital relationship were more likely to be living separation and disruptions. Various studies have together than those in a discordant relationship. indicated that the evidently high risk of HIV This is exhibited in higher separation, infidelity, sero-conversion and uncertainty of the lack of social support and divorce rates among uninfected couple’s sero-status permanence discordant couples, compared to those in a sero- have prompted discordant couples to difficulties concordant relationship. Nevertheless, little is related to sexual practices observed in known on the extent to which concordant distancing and avoidance of partner, which couples differ from discordant couples in their further elevate the tensions between worrying emotional responses to psychosocial challenges. about being infected and keeping their sexual Two major issues are noted as significant life active (Reis and Gir, 2010). following these revelations; first, the negative ARC Journal of Public Health and Community Medicine Page |6 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework partner in a discordant relationship is constantly making, self-efficacy, social support and power, in fear of the adverse risk of catching the virus lack of which may be exhibited with emotional from partner, thus, only a few of them are more and depression symptoms. This brought up the or less likely to carry on with a functional question; who exhibits more depressive relationship. Second, relationship instability and symptoms between positive concordant and sexual avoidance among discordant couples may discordant couples, and why? The dynamics of substantially attract extramarital relationships infected couples, their distinguishing coupled with inconsistent condom use characteristics, their self-efficacy and individual (Mujugira, Baeten, Donnell, Ndase, Mugo et al., psycho-social responses towards the concordant 2011), which may be responsible for further or discordant relationship very much determine infections (of others). how their relationships function (Merson, Dayton & O’Reilly, 2000). However, what These findings significantly point out to the fact discordant couples consider the most important that there is a need for married or cohabiting determining factors to their marital ends, heterosexual couples to be mainstreamed within following their knowledge of sero-magnetism, the broader prevention framework. That has required a thorough investigation. been practiced in the developed countries, including the use of Pre-Exposure Prophylaxis Other studies have looked into various aspects (PrEP), or use of condom which is a commonly involving discordant couples such as stigma used measure but with a lot of challenges on (Mujugira et al., 2011), weakened intimacy and consistence. PrEP was initially introduced sexual infidelity (Bunnell et al., (2008), distress, among homosexual men with unlike sero- anxiety and depression (Reis, R.K and E. Gir, statuses in the U.S by the United States Centre 2010; Hand, Phillip and Dudgeon, 2006) and for Disease Control in 2011. UNAIDS, (2013) high divorce and separation rates (Malamba et reports a significant reduction in transmission of al., 2005), just to mention a few. However, very HIV among those who adhered to the therapy few of these studies have looked into the consistently, and the programme was thus influence of sero-discordancy on family and adopted, in the U.S. for use among heterosexual couple relationship functioning and how it couples in 2012. Access to such therapy would differs from that among concordant couples. most likely be of similar effect among Furthermore, little is known as to how resource discordant couples, elsewhere. access, both physical and psychosocial, influences the partner's appraisal of, and their When it is empirically established that new ultimate decision on their discordant infections in a mature epidemic occur among relationship. discordant couples, understanding the dynamics of discordancy against those of concordancy 3. THEORETICAL FRAMEWORK may be key to mechanising practical Human life is composed with many challenges, intervention programmes to prevent infections internal and external, negative and delightful, among the negative partner in a discordant immediate and delayed. The Lazarus and relationship (Bishop and Foreit, 2010). It is Folkman’s (1984)'s Transactional Model asserts imperative therefore, to find out whether that individuals live in a continuum of discordant couples share any distinguishing transaction with the various settings in which characteristics in their relationships, unlike they spend time, running their day to day life those of concordant couples, which may (Bloom, 1996). In this transaction, individuals improve intervention programmes such as relate with the environment, their significant effective couple counselling, treatment and care others, and institutions. While transacting, to prevent inter-couple HIV transmissions. people meet situations, such as knowledge of 2.10 HIV Sero-discordance and their HIV infection, which create demands upon Emotional problems them. These demands become challenges and can create stress (Mujugira et al., 2011; Lewis, Reshmi and Sekar, (2011) suggest that 1998) In this view, any situation characteristics emotional and psycho-social problems are more of stressful experiences whose demands exceed persistent among disenfranchised infected the adaptive responses available in a given couples. This is indicative of gender-based system are challenges (Selye, 1976). These determinants of the couple’s marital ends which challenges can become a stress to one person may include; ownership, education, decision and strenuous to another at the same time ARC Journal of Public Health and Community Medicine Page |7 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework

(Bloom, 1996). Challenges are never-ending in habitually. There are individual differences in life: some represent delightful situations that the tendency to engage in evaluation (Franzoi, relish life, others push for adaptive responses 2000). This also results in the difference in the beyond limit. Thus, when faced with challenges, decisions infected couples make to the ends of individuals require a supplementary resource, be their relationships, and how their relationship it physical, financial or psycho-social, so as to functions thereafter. In other words, the couples’ sustain a functional livelihood. In absence of appraisal and evaluation of the discordant these supplementary resources, a person may be situation determines whether the situation lured into, and start to reveal physiological, represents harm or loss, viewed as threat to physical or psychosocial symptomatology one’s well-being or merely delightful an episode (Atibioke amd Osinowo, 2013). In other in one’s life (Lazarus, 1980). extreme situations an individual may die (Lewis, Explaining other significant differences in 1998). appraising and evaluating, Janis, (1958) posits According to Lewis, Sperry and Calson, (1993) that a person’s appraisal is influenced by a and Lewis, (1998), the severity of how a person couple of factors, including one's personal perceives a challenge, such as seroconcordancy morale or efficacy, motivation, values and or discordancy, as stressful depends on various culture, resource accessibility and situational factors, including one’s own view of one’s factors. In his view, Janis believes that ability to handle new demands, previous success situational factors encompass predictability, in dealing with similar situations, the degree to manageability and severity of a stressful which one feels in control of events, one’s situation such as discordancy and concordancy. perception of being overloaded or having So, having perceived a sero-discordant situation conflicting needs and the standards one sets for as problematic, analysed and evaluated it as one’s own performance. threat or loss, harmful or delightful, an infected couple enters into a second stage of coping, Essentially, coping decisions begin with a namely determining the cause of action. In this person perceiving an external factor which is stage, the individual decides which action to independent of the actor as problematic take-fight or flight, and what kind of (Lazarus & Folkman, 1984; Bloom, 1996). A supplementary resources are needed and person’s cognition of their cognitive difficulties available (Lewis, 1998; Janis, 1958; Bloom, and emotional burdens they experience 1996). determines not only what coping style they need to adopt, but also the severity of damage that is Thus, people develop a typical style of adapting likely to face the person. Individuals’ perception also known as coping style. The Lazarus and and evaluation of a stressful and challenging Folkman, (1984)'s transactional model situation is primary and vital in the whole distinguishes two aspects of coping, namely, process of decision making. Lazarus and problem-focused coping and emotion-focused or Folkman call this-situational appraisal. A palliative coping. Problem-focused coping refers person’s appraisal of being an infected couple to an effort to make such changes in persons, shapes one’s view of the severity of the problem objects or relationships so as to resolve the and a kind of coping styles they may need to stressful challenge. For instance, a sero-positive take, which are specific to that challenge discordant couple’s husband may choose to (Lazarus & Folkman 1986). abstain from sex with spouse so as to avoid her Nearly all cognitions and perceptions are possible sero-conversion. evaluative; rarely do people see things without evaluating them (Markus & Zajonc, 1985). The On the other hand, emotion-focused or palliative concept of appraisal further explains individual coping refers to thoughts or actions whose goal differences in perception, evaluation, perceived is to reduce the emotional effect of a stressful severity and intensity of consequent challenge, which appears in physiological physiological responses, as well as the disturbances (Lewis, 1998; Hand, 2006). So uniqueness of the coping strategy a person is while problem-focused coping depends on likely to choose in the course of action. In that, resources availability, and external objects, though all people can appraise and evaluate emotion-focused coping depends on cognitive situations, they will not do so impulsively and and emotional state of the actor. The current

ARC Journal of Public Health and Community Medicine Page |8 Emotional and Relationship Dynamics between HIV Sero-Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework study model has borrowed immensely from the individual regardless of their status. The Transactional Model. individual's access to socio-economic and psychological resources determines their Borrowing from the Lazarus and Folkman, rational attribution of discordancy and the (1984)'s Transaction Model, the proposed model outcome of their coping is a product of a for this study assumed that socioeconomic calculated transaction with the available resources, on one hand, and psycho-social on resources. the other are independent variables mediated by the concordant or discordant partner's status and Discordancy have been associated with more coping strategies. Marital resolution difficulties as compared to the concordant encompasses the dependent variables. It was couples, these include relationship and thought that understanding what motivates emotional disturbances, sexual contact infected couples to decide on their marital ends distancing, marital separation and disruptions. have got a lot to do with the external and The Lazarus and Folkman’s (1984)'s internal forces around them, how they appraised Transactional Model can be helpful in their HIV situation, the extent and amount of understanding individuals with HIV discordancy resources they required and those availed to on their emotional response, coping strategies and the ultimate decisions towards their marital them, self-efficacy, psycho-social skills they relationships fate. have attained and their ability to reason out their actions and the ultimate decisions towards their REFERENCES marital relationships fate. [1] Allen, S., Karita, E., Chomba, E., Roth, D. L., Telfair, J., Zulu, I. and Haworth, A. (2007), Promotion of Couples’ Voluntary Counselling and Testing for HIV Through Influential Networks in Two African Capital Cities. BMC Public Health, 7, 349. [2] Allen, S., Meinzen-Derr, J., Kautzman, M., Zulu, I., Trask, S., Fideli, U. And Haworth, A. (2003), Sexual Behavior of HIV-discordant Couples after HIV Counselling and Testing. AIDS (London, England), 17(5), 733–740. [3] Atibioke, P., & Osinowo, O. (2013), Psychological Trauma Following Disclosure of HIV Status to Significant Others in Women Living With HIV and AIDS, Research on Humanities and Social Sciences. 3(1), 156– 161. [4] Bishop, M and Foreit, K., (2010), Serodiscordant Couples in Sub-Sahara Africa: Figure1: The Lazarus and Folk man (1984)’s What do the Survey Data Tell Us? Washington, transactional Model From “Stress, Appraisal and DC: Future Group, Health Policy Initiative, Coping” by Lazarus and Folk man, 1984. Task Order 1. [5] Bloom, M. (1996), Primary Prevention Whereas discordancy is associated with Practices.Thousands Oaks. CA: SAGE. increased distress, anxiety, depression, [6] Brubaker, S. G., Bukusi, E. a., Odoyo, J., seroconversion and poor emotional adaptation Achando, J., Okumu, A., and Cohen, C. R. (Atibioke amd Osinowo, 2013; Carpenter et al., (2011), Pregnancy and HIV Transmission 2011), Malamba et al., (2005) and Reshmi and among HIV-discordant Couples in a Clinical Sekar, (2011) observe that this is more severe Trial in Kisumu, Kenya. HIV Medicine, 12(5), among disenfranchised couples. In this view, 316–321. http://doi.org/10.1111/j.1468-1293. infected couples' access to resources is likely to 2010. 00884.x. influence their health and emotional wellbeing. [7] Bruyn, G., Badenzi, N., Dladla, S. and Gray, G. Thus, the individuals’ ability to appraise their (2006), HIV-Discordant Couples: an Emerging sero-discordancy is primarily influenced by their Issue in Prevention and Treatment. The South physical and financial, on one hand, and African Journal of HIV Medicine, 12, 25-28. psychosocial on the other. And that the [8] Bujan, L., Hollander, L., Coudert, M., Gilling- availability of these resources favours an Smith, C., Vucetich, A., Guibert, J., and

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Citation: Amani Mwakalapuka, Ipyana Mwampagatwa, Theodora Bali, Masumbuko Mwashambwa, Stephen Kibusi, Tumbwene Mwansisya, Emotional and Relationship Dynamics between HIV Sero- Discordance and Concordance Couples: A Narrative Literature Review and Theoretical Framework. ARC Journal of Public Health and Community Medicine. 2017; 2(2):1-14. doi:dx.doi.org/10.20431/2456- 0596.0202001. Copyright: © 2017 Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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