Central Clinical Research in HIV/ AIDS

Review Article *Corresponding author Kate Coleman-Sarfo, Department of ; 37 Military Hospital, Burma Camp, , P.O. Box CT Challenges Faced by HIV 1516, Cantonments, Accra, , Tel: 233-244- 254-148; Email:

Positive Partners Living in Submitted: 10 July 2017 Accepted: 08 August 2017 Published: 15 August 2017 Discordance with HIV Negative Copyright © 2017 Coleman-Sarfo et al. Partners: A Case Study of 37 OPEN ACCESS

Keywords Military Hospital • Antiretroviral therapy • Challenges Kate Coleman-Sarfo1* and Emmanuel DeGraft Klo2 • Discordant couples 1Department of Pharmacy, 37 Military Hospital, Ghana • Health support 2Department of Medical Stores, 37 Military Hospital, Ghana

Abstract Background: According to the HIV Sentinel Survey 2015, there has been a gradual decrease in the trend prevalence of HIV in Ghana. Studies conducted in the African sub-region have however identified the phenomenon of discordance as the main driving force in the incidence of the disease. Discordance in HIV refers to a pair of long-term sexual partners in which one is retroviral positive and the other is not. Interestingly, some of these studies have estimated that over 70% of new infections occur in serodiscordant marital/co-habiting relationships. Regardless of the cause of discordance, some of these couples, upon disclosure, encountered challenges such as the disintegration of the union, negotiations for sexual relations, job losses, stigmatization by family and friends, financial strains due to ill health, fear of infecting the children/partner and the fear of dying. This study aimed at critically analyzing the possible challenges encountered by discordant couples in their relationship and ascertained if the demographic details of the positive partners being on ARVs had any correlation on the challenges encountered. Methods: A sample of 40 patients living in discordance was drawn purposively from the patients attending the ART Clinic (Antiretroviral Therapy) at the 37 Military Hospital in Accra, Ghana. Questionnaires were administered and the data compiled and analyzed using STATA 13. Descriptive statistics, including percentages and frequencies were used to capture and analyze the various challenges faced by such couples. Further, Chi-square tests, Fisher’s exact test and multiple regressions where necessary was used to examine whether socio-demographic characteristics like gender, age, educational level and religion had a significant association on challenges faced by the discordant couples. Results and Conclusions: Fear of infecting their kids, dying, financial strain and inconsistent use of condoms were some of the main challenges encountered by respondents. There was, however, a significant correlation between gender and challenges such as financial strainp=0.01 ( ) and fear of infecting kids (p=0.001). We find that most of the HIV-positive respondents who have had some form of education claim that their negative partners are supportive and committed to staying in the relationship. More Christians than Muslim respondents appeared not to be confronted by constant threats of separation/divorce (p=0.02) from their negative partners. We posit that our findings highlight relevant issues relating to discordance which, though important have received little attention. For example, our finding that regular use of condoms by discordant couples appeared to be a real challenge in spite of the risk of transmission to the negative partner suggests the need for more education. Overall, our findings suggest that more work and resources need to be pumped into awareness creation of the potential welfare challenges faced by discordant couples with an emphasis on preventive strategies to forestall transmission among such couples, thereby mitigating both physical and psychological stresses they may be facing.

ABBREVIATIONS Fund for Women; VMMC: Voluntary Medical Male Circumcision; WHO:INTRODUCTION World Health Organization AIDS: Acquired Immune Deficiency Syndrome; ART: Antiretroviral Therapy; ARVs: Antiretrovirals; CD4: Cluster Differentiation 4 Cells/T4 Helper; HIV: Human Immunodeficiency Discordance in HIV may be defined as a couple involved in a Virus; NGO: Non- Governmental Organization; PLHIV: Persons long-term sexual relation where one has the HIV infection and the living with HIV; STD: Sexually Transmitted Disease; STI: Sexually other does not [1]. Research conducted in 2010 by Ewayo et al. Transmitted Infections; UNAIDS: United Nations Acquired had pointed to the role of discordance in driving the incidence of Immune Deficiency Syndrome; UNFPA: United Nations Fund for HIV in Africa and found that the higher the percentage of persons Population Activities; UNIFEM: United Nations Development in stable discordant relationships the higher the incidence. They Cite this article: Coleman-Sarfo K, DeGraft Klo E (2017) Challenges Faced by HIV Positive Partners Living in Discordance with HIV Negative Partners: A Case Study of 37 Military Hospital. Clin Res HIV/AIDS 4(2): 1041. Coleman-Sarfo et al. (2017) Email:

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acknowledged that this is country specific with the prevalence the influence of ARVs use on sexual relations. The researchers being much higher in some countries than others [2]. Another concluded that there is a decrease in unprotected sex among relevant study by Dunkle et al. reports that 75% of all new persons living with HIV (PLHIV) on ARVs [12]. infections occur in stable relationships and marriages [3]. Despite The EUROSUPPORT IV study conducted in Western Europe such findings, there has been a dearth of studies which go further established that children living with the virus or living with to study the challenges faced by people in such relationships. infected parent(s) require special care due to psychological Recent awareness drives and increased attention given to issues that may arise (www.eurosupportstudy.net) [13]. Another HIV-reduction strategies in Ghana, West Africa, has positioned the study conducted in the United States also showed that a good country as a suitable case for HIV- related studies. The population number of children go through emotional turmoil and stress of Ghana as at the end of 2015 was recorded as 27.4 million with when they realize a parent is infected with the virus [14]. Other a growth rate of 2.35% and a fertility rate of 4.09 (see www. studies further report that psychological stress is heightened tradingeconomics.com). According to the National HIV Sentinel when children end up with the duty of taking care of a sick parent surveys conducted, there has been a downward prevalence [15]. Further, a grounded study conducted in Ethiopia concluded trend from 3.6% in 2003 to 1.9% in 2011. The HIV prevalence that HIV discordant couples relationship revolves around the varies within geographical areas, gender, age and residence. The fear of being infected and fear of infecting their children [16]. national prevalence is obtained from 40 sentinel sites with the Although there is growing evidence of the importance of better prevalence in the urban sites higher than that in the rural sites understanding the challenges faced by discordant couples, there [4]. In Ghana, an exact percentage of discordance has not yet been is limited work in this area, and more so in Sub-Saharan African established, but Ewayo et al. using mathematical models based countries. on the HPTN 052 study [5] results, pegs the level of discordance In Ghana, there is hardly any work on the issues encountered at 2%.Research in Africa had suggested that up to two-thirds by discordant couples and as such it would be instructive to of HIV-infected couples are discordant [6]. It appeared male to explore to what extent socio-demographic characteristics like; female ratio of affected individuals was 1:1 in Sub-Saharan Africa age, gender, educational background and religion influence the against 19:1 in the United States and Europe [7]. effect of the main challenges on such couples in the Ghanaian Intuitively, the incidence of HIV discordance in cohabiting setting. This may contribute to better the understanding of these couples come with its own challenges. Some of these challenges MATERIALchallenges in Ghana. AND METHODS may confront the partners as a couple, whilst some of the Study area challenges may extend to their children, extended family, and friends. Interestingly, how these challenges are handled by all parties connected to the discordant couple goes a long way to either uphold or break the relationship, sometimes with dire Our study enrolled patients from the 37 Military Hospital consequences for the couple, their children and other close which is a referral facility in the Ayawaaso Sub- Metro district associates. Gitonga et al., in a study conducted in Kenya found of the Greater Accra region of Ghana. The Hospital was set up that the main challenge confronting discordant couples was in 1941 to cater for military personnel and their families but sexual. These included negotiations for sex, lack of interest in sex, is currently open to the general public as well and has a bed issues on reproduction and being a risk to their families. Other capacity of almost 500. Additionally, the Hospital caters to about challenges they highlighted included the psychological stress of a thousand patients daily on an outpatient basis. The ART centre coping with the discordance and the blame game [8]. Against the was initiated at the Hospital in December 2006 and currently background of such potential challenges encountered by such manages a little over 2000 adults and about 100 paediatric couples, some important questions arise. These may include: patients.Study participants a) Would the relationship remain intact or disintegrate? b) Would the couple be able to persistently and consistently The study used data from retroviral positive patients use c)condoms to decrease the risk of transmission? attending ART clinic at the 37 Military Hospital from March to April 2017, whose status is in discordance with the partner. In Would the intake of antiretrovirals (ARVs) by the d) Ghana, exact numbers of discordant HIV partners has not yet been positive partner influence their sexual relations? established, however mathematical models employed by Ewayo What are the effects, if any on the children once et al. [2], from the results of the HPTN 052 study [5], estimated discordance has been established? a prevalence of 2% for Ghana. With a total population of a little over 2000 patients visiting the antiretroviral clinic at the Military Some studies done in the past have addressed some of the Hospital, employing a 2% prevalence rate at a significance level questions above. Gitonga et al., Were et al., and Senyonjo et al., of 5%, a minimum of 31 patients is anticipated using Epi Info for example, ascertained that in spite of the challenges, most Version 7. Based on that premise, a sample size of 40 PLHIV discordant relationships remained intact [8-10]. Another living in discordance with negative partners was purposively research conducted in rural Uganda discovered that discordant enrolled. To be recruited into the study, the respondenthadto couples do not use condoms consistently inspite of the risk of be a regular attendant at the ART clinic, be the positive partner transmission [11]. A systematic review and meta-analysis of 58 living in discordance with a negative partner and must have a studies conducted by Doyle et al., addressed the question on child/children with the negative partner. Clin Res HIV/AIDS 4(2): 1041 (2017) 2/11 Coleman-Sarfo et al. (2017) Email:

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Ethical clearance Table 1: Number Percentage (%) Background characteristic of respondents. Gender Consent was first sought from eligible patients and confidentiality was assured before being interviewed with a Male 14 35.0 standard questionnaire during an ART counselling session. The Age Female 26 65.0 study was approved by the 37 Military Hospital Institutional ReviewData management Board. and analysis 26-35years 14 35.0 36-45years 12 30.0 Educational level 46 years and above 14 35.0 All data obtained were entered into Microsoft Excel and exported to STATA 13 for analyses. Patient information was identified with serial numbers. The descriptive analysis which No Education 3 7.5 includes Percentages and Frequencies was used to describe Primary 10 25.0 Secondary 18 45.0 the various challenges of the discordant couples. Others were Religion reported using pie charts. Chi-square or Fisher’s exact test Tertiary 9 22.5 where necessary was used to examine if socio demographic characterizes such as gender, age, educational level and Christian 34 85.0 religion have a significant association on challenges faced by Muslim 6 15.0 Fear of losing job the discordant couples. Multiple logistic regressions were fitted for the challenges faced by the discordant couples and socio demographic characteristic. Overall model fit was assessed using the log- likelihood ratio (LR) in which test statistic follows Another notable challenge was fear of losing their means a Chi-square distribution with the degree equal to the number of livelihood. Nineteen respondents admitted to being afraid of losing their job when the infection is discovered. More of the HIV- of parameters that are constrained. Only models 1 which1 were statistically significant (p<0.05) were reported . We note positive malesp=0.046 (10 out of 14) go through this emotional stress that while these empirical tests suffice for our sample size and than the HIV-positive females (9 out of 26) which was statistically the aims of our study, a larger sample of participants would significantFear of infecting ( ). their children have allowed for more rigorous empirical regressions and disaggregated analyses based on various demographics, which would potentially yield even more interesting and informative Results obtained indicated that about half of the respondents RESULTSresults. i.e. 21 (52.5%) were not afraid of infecting their kids. Twelve respondents representing 30% admitted to being afraid Socio-demographic characteristics of respondents sometimes ofp= infecting0.002 their children, whilst 4 (10%) lived in constant fear of infecting their children. This was statistically significant ( ) as it appears more of the infected women Respondents enrolled consisted of 26 (65%) women and were afraid of infecting their kids than the infected men in the 14 (35%) men with the age range being between 29 years union. However, three of the children representing 7.5% were and 56 years. Eighteen PLHIV (45%), forming the majority alreadyThreat infected of separation with the virus. of the respondents have been educated up to the secondary level, whilst 10 (25%), 9 (22.5%) and 3 (7.5%) have had up to primary, tertiary and no education at all respectively. Out of the Ten males and 17 females totaling 27 (67.5%) respondents 40 respondents (Table 1), 34 (85%) profess Christianity whilst 6 claimed that there was absolutely no threat of separation after (15%)Consistent are of theuse Moslem of condoms faith. disclosure to their spouses. Ten (25%) respondents made up of 4 men and 6 women admitted that their partners threatened separation only when they have a serious misunderstanding, The results show that issues pertaining to sex are not a whilst only 3 (7.5%) respondents claimed that their partners serious challenge for the discordant couples. Thirty-nine (39) constantlyStigmatization threaten by them family with andseparation friends after the disclosure. out of the 40 still engage in consistent sexual activities with their negative couples. During intercourse, 16 of positive respondents claim they engage in unprotected sex with their negative partners In all eleven respondents representing 27.5% complained always whilst only one admitted to using condoms sometimes of being stigmatized by family and friends who were aware of (TableFinancial 2). strain their status, whilst 29 respondents (72.5%) said they lived free ofFear stigma of dying from family and friends.

Financial stress appears to be the most challenging issue faced. Twenty-five (62.5%) respondents interviewed admitted to When asked if they were afraid of dying prematurely having some financial challenges in their relationshipp=0.005 due) to their from complications of the retroviral infection, nine (22.5%) infection. More of the positive males faced such challenges than respondents expressed constant fear of dying. Nineteen (47.5%) the females (13out of 14 as against 12 out of 26, claimed they are sometimes fearful of dying prematurely whilst Clin Res HIV/AIDS 4(2): 1041 (2017) 3/11 Coleman-Sarfo et al. (2017) Email:

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Table 2: Total (%) Male (%) Female (%) P-value Association between gender and challenges of discordant couples. Supportive Partner

0.836 Very supportive 32(79.5) 11(84.6) 20(76.9) Somehow supportive 6(15.4) 2(15.4) 4(15.4) Threat of separation Not Supportive 2(5.1) 0(0.0) 2(7.7) 0.742 Yes, constantly 3(7.5) 0(0.0) 3(11.5) Only when there is misunderstanding 10(25.0) 4(28.6) 6(23.1) Financial strain Not at all 27(67.5) 10(71.4) 17(65.4) 0.01 Big strain 7(17.5) 4(28.6) 3(11.5) Little strain 18(45.0) 9(64.3) 9(34.6) Stigmatization by family members No strain at all 15(37.5) 1(7.1) 14(53.9) 0.061 Yes 11(27.5) 1(7.1) 10(38.5) Afraid of losing Job No 29(72.5) 13(92.9) 16(61.5) 0.046 Yes 19(47.5) 10(71.4) 9(32.6) Fear of Infecting Kids No 21(52.5) 4(28.6) 17(65.4) 0.001 Not at all 21(56.8) 13(92.9) 8(30.8) Fear of Dying Afraid 16(43.2) 1(7.1) 15(65.2) 0.296 Not at all 12(30.0) 2(14.3) 10(38.5) Sometimes 19(47.5) 8(57.1) 11(42.3) Consistent use of Condom Very afraid 9(22.5) 4(28.6) 5(19.2) 0.12 Yes 23(57.5) 11(78.6) 12(46.2) Sometimes 1(2.5) 0(0.0) 1(3.9) Years with HIV No 16(40.0) 3(21.4) 13(50.0) 1 1-5years 20(50.0) 7(50.0) 13(50.0) 6-10years 16(40.0) 6(42.9) 10(38.5) Above 10years 4(10.0) 1(7.1) 3(11.5) Table 3: No education (%) Primary (%) Secondary (%) Tertiary (%) P-value Association between Educational level and challenges of discordant couples. Supportive Partner

0.017 Very supportive 3(100.0) 6(60.0) 18(100.0) 5(55.6) Somehow supportive 0(0.0) 3(30.0) 0(0.0) 3(33.3) Threat of separation Not Supportive 0(0.0) 1(10.0) 0(0.0) 1(11.1) 0.176 Yes, constantly 0(0.0) 1(10.0) 1(5.6) 1(11.1) Only when there is misunderstanding 0(0.0) 5(50.0) 2(11.1) 3(33.3) Financial strain Not at all 3(100.0) 4(40.0) 15(83.3) 5(55.6) 0.186 Big strain 1(33.3) 3(30.0) 2(11.1) 1(11.1) Little strain 0(0.0) 6(60.0) 7(38.9) 5(55.6) Stigmatization by family members No strain at all 2(66.7) 1(10.0) 9(50.0) 3(55.6) 0.258 Yes 0(0.0) 4(40.0) 3(16.7) 4(44.4) Afraid of losing Job No 3(100.0) 6(60.0) 15(83.3) 5(55.6) 0.331 Yes 1(33.3) 6(60.0) 6(33.3) 6(66.7) No 2(66.7) 4(40.0) 12(66.7) 3(33.3)

Clin Res HIV/AIDS 4(2): 1041 (2017) 4/11 Coleman-Sarfo et al. (2017) Email:

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Fear of Infecting Kids

0.537 Not at all 2(66.7) 7(77.58) 8(47.1) 4(50.0) Fear of Dying Afraid 1(33.3) 2(22.2) 9(52.9) 4(50.0) 0.376 Not at all 3(100.0) 2(20.0) 5(27.8) 2(22.2) Sometimes 0(0.0) 6(60.0) 9(50.0) 4(44.4) Consistent use of Condom Very afraid 0(0.0) 2(20.0) 4(22.2) 3(33.3) 0.742 Yes 2(66.7) 6(60.0) 9(50.0) 6(66.7) Sometimes 0(0.0) 1(10.0) 0(0.0) 0(0.0) Years with HIV No 1(33.3) 3(30.0) 9(50.0) 3(33.3) 0.534 1-5years 2(66.7) 4(40.0) 7(38.9) 7(77.8) 6-10years 1(33.3) 4(40.0) 9(50.0) 2(22.2) Above 10years 0(0.0) 2(20.0) 2(11.1) 0(0.0) (p=0.142), (p=0.247), (p (p=0.784) p=0.880 =12 0.296 (30%) indicated that they don’t believe they will die from the stress stigmatization by family fear of losing infection. It appears fear of dying is not influenced by gender a job and fear of dying ( ) appear not to be Educational). level and Challenges of discordant influencedFear of by infecting age (Table 5). kids and Socio demographic couples characteristics

Results obtained showed that respondents who had hadp=0.017 some From Table 7, males have less odds of being afraid to affect form of education (primary, secondary or tertiary) appeared their children than their female counterparts (OR=0.02, 95%CI, to have partners who were somehow supportive ( ). 0.0 – 0.7).This is an indication that, females are much more Threats of separation,(p=0.176, financial p=0.186, strain as p=0.258 well as respectively stigmatization afraid of infecting their children than the males. Table 6 did not by family members all did not appear to be influenced by the show any association between financial strain and demographic level of education p=0.331 ). In characteristicsFear of losing job with Socio demographic addition, we find that educationalp=0.376 level did not significantly affect characteristics challengesp=0.742 like fear of a losing job ( ), fear of infectingp=0.534 kids) (p=0.537), fear of dying ( ), consistent use of condoms ( ), and the number of years of living with HIV ( Table 8 shows that males had higher odds of been afraid of Religion(Table 3). and Challenges of discordant couples job losses than the females respondents (OR=10.5, 95%CI, 1.2– 91.5).This indicates that the males were highly afraid of losing p=0.091 theirPartner’s jobs than reaction the females. after disclosure It may appear from the results that religion significantly influenced whether a partner was supportive or not ( ). Out of the 34 Christians interviewed, 33 (97.1%) claimed to have Immediately supportive, anger, quiet resignation and shock a supportive partner whilst only one respondent (2.9%) did are the initial reactions the respondents admitted to after not receive support. The 6 Muslims included in the samplep=0.024 had disclosure to their partners. It appears 13 (32.5%) respondents 5 out of 6 that showed support (88.3%). Further, the threat of out of the 40 enrolled had partners who were immediately separation proved significant between the religions ( ), supportive after the disclosure, whilst 5 (12.5%) respondents with 25 (75.5%) of Christians not facing threats of separation angered their partners upon disclosure. Ten respondents from their unions as against 33.3% Muslims. representing 25% said their partners accepted the disclosure p=0.844 p=1.000 with quiet resignation whilst 12 (30%) claimed their partners p=1.000Religion, however, did not significantlyp=0.680 affect financialp=0.232 strain receivedChildren the awareness news with shock. of discordance ( ), stigmatization byp=0.325 family ( ), fear of losing job ( p=0.120), fear of infecting kids ( ), fear of dying ( ), constant use of condoms ( ) and years of living with the virusAge and ( challenges) (Table 4). of discordant couples The majority of respondents, 32 (80%) claimed their children have no knowledge of their HIV status, whilst the remaining 8 (20%) admitted that their children know their discordant retroviralDISCUSSION status. Respondentsp=0.000 in the lower age bracket (26-36years) seem to be more afraid of(p=0.015) infecting their kids than those in the higher age bracket ( p=0.028). Again age seems to significantly influence the Although the 40 HIV positive respondents living in discordance use of condoms(p=0.963), and the number of(p=0.746), years living with the virus ( ). However challenges like whether a partner with their negative partners experienced all the aforementioned was supportive treat of separation financial challenges, some socio-demographic characteristics like gender, Clin Res HIV/AIDS 4(2): 1041 (2017) 5/11 Coleman-Sarfo et al. (2017) Email:

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Table 4: Christian (%) Muslim (%) P-value Association between Religion and challenges of discordant couples. Supportive Partner

0.091 Very supportive 29(85.3) 3(50.0) Somehow supportive 4(11.8) 2(33.3) Threat of separation Not Supportive 1(2.9) 1(16.7) 0.024 Yes, constantly 1(2.9) 2(33.3) Only when there is misunderstanding 8(23.5) 2(33.3) Financial strain Not at all 25(75.5) 2(33.3) 0.844 Big strain 6(17.7) 1(16.7) Little strain 16(47.1) 2(33.3) Stigmatization by family members No strain at all 12(35.3) 3(50.0) 1 Yes 9(26.5) 2(33.3) Afraid of losing Job No 25(73.5) 4(66.7) 1 Yes 16(47.1) 3(50.0) Fear of Infecting Kids No 18(52.9) 3(50.0) 0.68 Not at all 17(54.8) 4(66.7) Fear of Dying Very afraid 14(45.2) 2(33.3) 0.232 Not at all 11(32.4) 1(16.7) Sometimes 14(41.2) 5(83.3) Consistent use of Condom Very afraid 9(26.5) 0(0.0) 0.325 Yes 21(61.7) 2(33.3) Sometimes 1(2.94) 0(0.0) Years with HIV No 12(35.3) 4(66.7) 0.12 1-5years 17(50.0) 3(50.0) 6-10years 15(44.1) 1(16.7) Above 10years 2(5.9) 2(33.3) Table 5 26-35years (%) 36-45years (%) 46years and above (%) P-value : Association between Age and challenges of discordant couples. Supportive Partner

0.963 Very supportive 12(85.7) 9(75.0) 11(78.6) Somehow supportive 2(14.3) 2(16.7) 2(14.3) Threat of separation Not Supportive 0(0.0) 1(8.3) 1(7.1) 0.746 Yes, constantly 0(0.0) 1(8.3) 2(14.3) Only when there is misunderstanding 3(21.4) 3(25.0) 4(28.6) Financial strain Not at all 11(78.6) 8(66.7) 8(57.1) 0.142 Big strain 1(7.1) 1(8.3) 5(35.7) Little strain 6(42.9) 5(41.7) 7(50.0) Stigmatization by family members No strain at all 7(50.0) 6(50.0) 2(14.3) 0.247 Yes 6(42.9) 3(25.0) 2(14.3) Afraid of losing Job No 8(57.1) 9(75.0) 12(85.7) 0.784 Yes 6(42.9) 5(41.7) 8(57.1) No 8(57.1) 7(58.3) 6(42.9) Clin Res HIV/AIDS 4(2): 1041 (2017) 6/11 Coleman-Sarfo et al. (2017) Email:

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Fear of Infecting Kids

0.000 Not at all 2(18.2) 6(50.0) 13(92.9) Fear of Dying Very afraid 9(81.8) 6(50.0) 1(7.1) 0.880 Not at all 5(35.7) 4(33.3) 3(21.4) Sometimes 7(50.0) 5(41.7) 7(50.0) Consistent use of Condom Very afraid 2(14.3) 3(25.0) 4(28.6) 0.015 Yes 4(28.6) 7(58.3) 12(85.7) Sometimes 1(7.1) 0(0.0) 0(0.0) Years with HIV No 9(64.3) 5(41.7) 2(14.3) 0.028 1-5years 4(28.6) 8(66.7) 8(57.1) 6-10years 10(71.4) 3(25.0) 3(21.4) Above 10years 0(0.0) 1(8.3) 3(21.4) Table 6: Table 8:

Multiple logistic regression financial strain with socio Multiple logistic regression fear of losing job with socio Covariate OR(95%CI) P-value Covariate OR(95%CI) P-value demographic characteristics. demographic characteristics. Gender Gender

Female 1(Ref) Female 1(Ref) MaleAge 7.3(0.5 to 110.9) 0.154 MaleAge 10.5(1.2 to 91.5) 0.033

26-35yeare 1(Ref) 26-35yeare 1(Ref) 36-45years 1.3(0.2 to 8.1) 0.788 36-45years 0.8(0.1 to 4.8) 0.772 46Educational years and abovelevel 7.2(0.2 to 222.3) 0.258 46Educational years and abovelevel 0.4(0.04 to 3.6) 0.418

No education 1(Ref) No education 1(Ref) Primary 86.6(0.7 to 10259.1) 0.067 Primary 2.5(0.1 to 49.0) 0.555 Secondary 5.1(0.1 to 249.0) 0.413 Secondary 0.8(0.5 to 13.3) 0.87 ReligionTertiary 11.2(0.2 to 659.2) 0.247 ReligionTertiary 4.7(0.2 to 93.5) 0.314

Muslim 1(Ref) Muslim 1(Ref) Christian 8.2(0.2 to 277.8) 0.242 Christian 0.3(0.03 to 3.3) 0.334 Table 7: Table 9: Percentage Multiple logistic regression fear of infecting kids with socio Negative Partners Initial ReactionNumber after disclosure. Covariate OR(95%CI) P-value (%) demographic characteristics. Gender Partners reaction after disclosure

Female 1(Ref) Anger 5 12.5 Age Male 0.02(0.0 to 0.7) 0.031 Quiet resignation 10 25 Shock 12 30 Awareness of children about the Immediately Supportive 13 32.5 26-35yeare 1(Ref) discordance 36-45years 0.08(0.0 to 1.4) 0.080 Educational level 46 years and above 0.02(0.0 to 1.2) 0.064 Yes 8 20 No 32 80 No education 1(Ref) Primary 1.2(0.02 to 80.6) 0.948 age, the level of education and religion appeared to influence Secondary 8.2(0.2 to 370.3) 0.279 Religion these challenges to varying degrees. More women (65%) were Tertiary 7.1(0.1 to 458.0) 0.359 enrolled as compared to males (35%) with the majority being in the age range 31-40 years. This may well be so because most Muslim 1(Ref) of these women were diagnosed during pregnancy at the time Christian 1.13(0.03 to 44.6) 0.947 when they were assessing antenatal services. This has been Clin Res HIV/AIDS 4(2): 1041 (2017) 7/11 Coleman-Sarfo et al. (2017) Email:

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possible at the 37 Military Hospital because of the introduction of conducted in Bushenyiz, Uganda confirmed that over 94% of 880 a comprehensive strategy known as the ‘Prevention of Mother to individuals living in discordance admitted that they rarely use Child Transmission’ (PMTCT) of HIV by the National Aids Control condomsSupportive [11]. partners Program (NACP) in collaboration with their global partners in 2010 [17]. This strategy has been a huge success especially at the 37 Military Hospital and has drastically decreased the number Although receiving support from the uninfected partner of infected babies being born to retroviral positive mothers has been perceived by many as a challenge facing discordant attending antiretroviral clinics at the hospital [18]. We note that couples, this study proved otherwise. Out of the 40 respondents, other studies have established that there are almost twice as only 2 did not receive support from their partners and these many positive females living in discordance with negative males; were incidentally women. Thirty-one (79.5%) and 6 (15.4%) aNumber case in point of years was a of study living conducted with HIV in Enugu, Nigeria [19]. respondents received full support and partial support respectively. This was reflected in the study when 27 (67.5%) respondents made up of 17 females and 10 males responded With the intensive campaign on awareness of HIV, diagnostic categorically that there was no threat of divorce or separation testing and PMTCT strategy in Ghana, there has been an increase when they were asked about their negative partners’ reaction in people becoming aware of their status in recent years. The after disclosure. Ten (23%) respondents made up of 4 men and 6 HIV Sentinel Survey (HSS) system which was set up in Ghana in women claimed their negative partners threaten separation and 1992, has the general objective of providing HIV prevalence data divorce only when they have a serious misunderstanding. Three for monitoring, planning and evaluation of the HIV/AIDS-related (7.5%) respondents, however, claimed they consistently suffer activities. Overall the national median prevalence for 2016 threats of divorce and separation from their negative spouses was 2.4% [20]. The report also indicated that 38% of women since disclosure. Other prominent studies conducted in Sub- aged 15-49 years and men aged 15-49 years who are currently Saharan Africa confirmed the findings of this study, establishing among PLHIV were newly diagnosed. About 80% (36) of the that the rate of divorce and separation among discordant couples respondents have been aware of their HIV status between one to remain surprisingly low [6,7,10]. The phrase from the Christian ten years whilst the remaining 20% (4) have lived with the virus wedding vows “For better and for worse “appear to hold true in for over 10 years. All of the 40 respondents have been initiated HIV-discordantFinancial strain relationships. onConsistent antiretroviral. use of condoms

Over 25 out of the 40 respondents admitted to financial All but one of the 40 respondents claims they regularly have challenges due to the acquisition of HIV. From the results, infected sex with their uninfected partner with 16 (40%) admitting men appear to face that challenge more than infected women and to having unprotected sex consistently. Twenty-three of this was statistically significant. This may appear quite normal respondents, however, claimed they consistently use condoms since in most communities globally more men assume the roles Fear of infecting kids with one acknowledging the use of condoms sometimes. Research of bread winners for the family [24]. has established that consistent use of condoms requires the cooperation of men who may refuse to use them [21]. This study shows that out of the 16 respondents who engage in unprotected Most men do not think their kids are in danger of acquiring sex, 13 of them are women. Their male partners knowing full well the infection from them. This may well be so because it is the status of their female partner still prefer to have unprotected mothers who usually handlep=0.002 the children more and so are more sexual relations with them. Most of these uninfected male afraid of passing any kind of infection on to them. This assertion partners often doubt the status of their wives since they feel the is statistically significant ( ) since study reveals that women look the same to them. Some also reason that since they fifteen female respondents as against one male respondent had expressed being very afraid or sometimes afraid of infecting their have always had unprotected sex with their so called infected children. About half of the 15 women are breastfeeding mothers women and have not contracted the disease, they are not likely to with babies under a year old. Although various studies have contract it now. A few also believe that they are divinely protected concluded that mothers stable on ARVs are not likely to pass on from acquiring the virus. This belief has been corroborated in the infection during the lactation period [25], some lactating HIV- another study conducted in rural Uganda [11]. Indeed the fact that infected mothers would prefer not to breastfeed their babies. some of these infected women get pregnant after disclosure of This, however, may not be an option for them since the cultural their status to their negative male partners proves this. Although setting in Ghana’s extended family system expects new mothers research has shown that consistent use of condoms by discordant to breastfeed their babies. Use of artificial feeds by new mothers couples decreases transmission of the virus by over 95% [22], is frowned upon with subsequent chastisement from family other studies, however, report the inconsistent use of condoms members who all appear to have a stake in the well-being of the among discordant couples, clearly validating the findings of this newStigmatizatio member of then family [26]. study. A qualitative research carried out by Bunnell et al., on discordant clients in Kampala clearly showed that couples either inconsistently used condoms or do not use it all [23]. The study Most respondents according to the study were not stigmatized Clin Res HIV/AIDS 4(2): 1041 (2017) 8/11 Coleman-Sarfo et al. (2017) Email:

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by family members. Seventy-two and a half percent (72.5%) about why they have to take medications every day. Eventually, as against 27.5% of respondents appear not to have suffered psychological problems may set in, with these positive children any form of discrimination from family and friends. Those who wondering if living with HIV is worth it. Sometimes the prospect suffered discrimination often cite instances of family members of taking medications for life gives rise to feelings of hopelessness, not wanting to involve them in family activities and actually depressionReligion and and challengessuicidal ideations. shunning their very presence. Stigmatisation suffered from family members seems to be the most painful form of discrimination suffered by PLHIV. The UNAIDS in 2015 published that in 35% Although this study showed an association between being of nations worldwide, over 50% of people admitted to having Christian and remaining in a discordant relationship as against discriminatory attitudes towards PLHIV [27]. Studies recently being Muslim, the sample size may be too small to draw a definite published indicated that some PLHIV are shunned by family and conclusion. There hasn’t also been any published study with friends whilst others are discriminated against in educational definite conclusions about such an association. It may be more Fearand work of dying settings, clearly causing psychological damage [27,28 ]. informative to conduct a study with a bigger sample which would potentiallyLimitations provide more definite conclusions.

Seventy percent of respondents claimed they were either very afraid or sometimes afraid of dying from HIV and its Although the findings of the study are informative and have complications. However, 30% of respondents claim they are not highlighted the importance of the largely-ignored challenges at all afraid of dying from the disease since they believe in the facing couples in discordant relationships, it is instructive to potency of the ARVs they have been stabilized on. Gender does note some potential limitations of the study. First, the challenges not appear to influence respondents’ fear of dying from the outlined and analyzed in this study are solely from the perspective infection. Indeed, in recent years, the life expectancy of PLHIV has of the HIV-positive partner and as such there could be some bias increased significantly globally mainly due to the development in their responses. The potential for such bias was reduced by andPartner’s availability initial of potent reaction antiretrovirals [29]. informing the participants of the aims and importance of the study and encouraging them to be as truthful as possible. Second, we have also noted above that a larger sample size of participants Our study showed varied responses of negative partners would have allowed for more rigorous empirical analyses. upon disclosure. About a third were immediately supportive, However, for this study, the current sample size of 40 and the with another third being shocked and confused. About 12% were empirical analyses we conduct are adequate and yield significant extremely angry whilst 25% quietly accepted the news. Those results. These limitations notwithstanding, the findings of the who expressed anger felt their partners have been unfaithful and study should be informative for improving the well-being of CONCLUSIONS AND RECOMMENDATIONS ought to be blamed and punished emotionally or verbally whilst discordant couples and their families. the rest chose to remain somehow supportive and receptive in spite of a deep belief that infidelity has occurred in their Challenges confronting HIV positive persons living in relationship. Studies conducted in Uganda reported an immense discordance with negative partners are widespread and varied. support from family and friends after disclosure [30]. Another However, the extant literature on this is sparse, particularly for study carried out in Malawi found that disclosure of HIV status developing countries. This study, conducted in Ghana, has sought to a spouse was quite common among Malawians living in rural to investigate and discuss these often down-played challenges. areas, with women finding it more difficult to disclose than men Our findings underscore the need for such studies and, further, [31].Awareness of children we find that socio-demographic characteristics like age, gender, educational level and religion seem to influence the challenges faced by these couples living in discordance. Our findings suggest Most of the children of the discordant couples in this study that notable among these challenges include the fear of infecting were not aware of their parents’ discordance mainly because they their kids by an HIV- positive mother, financial stress and fear of are too young and immature to comprehend the situation being job losses experienced mainly by the HIV- positive male partner. under 10 years of age. However, 8 (20%) of the respondents had We also find that most Christian respondents claim their partners children who know of their parents’ discordant relationship. are supportive and they report fewer threats of separation Some of the grown-up children even attend ART clinics with as compared to Muslim respondents, which underscores the the infected parent. Children as young as 12 years have been relevance of religion in this matter. Furthermore, consistent reported to physically care for their sick parents especially in Sub- use of condoms also appeared to be a real challenge, with most Saharan nations where there are hardly any social interventions respondents not afraid of dying from HIV- related complications to support families living in poverty [26]. Some of these children because they were on ARVs. Specifically, this highlights the are forced to grow up too quickly. Unfortunately also, some of importance of further education so as to limit the potential for the children born to discordant couples test positive and have avoidable infections and deaths. to be put on ARVs. There were 3 of such in this study. As these children grow older, they begin to question parents and carers Based on our findings, some recommendations are instructive. Clin Res HIV/AIDS 4(2): 1041 (2017) 9/11 Coleman-Sarfo et al. (2017) Email:

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In order to effectively prevent transmission of the virus especially Stakeholders perception of HIV sero-discordant couples in western Kenya. East Afr Med J. 2008; 85: 326-333. among discordant couple in Ghana, based on the significance of the religion dimension, we suggest that churches and mosques 10. Senyonjo M, Atenu E. Report on Findings from the Formative Research must be encouraged to spearhead the drive since the country on HIV Discordance. Health Communication Partnership. 2011 has about 75% of its population professing Christianity, and Kampala. 20% Islam. Other strategies including the introduction of the 11. Tumwesigye E, Asiionwe S, Muganzi E, Achom M,Kabatesi D, Tappero use of pre-exposure prophylaxis, promotion of the consistent J. HIV Prevalence Among Males in Discordant Partnerships in a Full use of condoms, as well as the incorporation of stigma reduction Access Door-to-Door VCT Programme in Rural Uganda: Fifteenth Conference on Retroviruses and Opportunistic Infections. Boston MA. strategies into the educational curriculum of school children USA. 2008. right from the primary school should be encouraged. Mandated bodies including the NACP, Ghana AIDS Commission and Non- 12. Doyle JS, Degenhardt L, Pedrana AE, McBryde ES, Guy RJ, Stoové MA, et al. Effects of HIV antiretroviral therapy on sexual and injecting risk- Governmental Organizations (NGOs) operating in Ghana in the taking behavior: a systematic review and meta-analysis. Clin Infect area of HIV/AIDS should introduce more programs aimed at Dis. 2014; 59: 1483-1494. handling the psychological needs of children living with HIV or 13. Euro Support IV Study. Improving Sexual and Reproductive Health of in HIV families. The concerns and challenges of these children Persons Living with HIV in Europe. 2002-2004. should, as much as possible, be handled on an individual level because the affected children are from different backgrounds and 14. Hough ES, Brumitt G, Templin T, Saltz E, Mood D. A model of mother- child coping and adjustment to HIV. Soc Sci Med. 2003; 56: 643-655. mayACKNOWLEDGEMENTS be facing different combinations of these challenges. 15. Rotheram-Borus MJ, Lester P, Wang P, Shen Q. Custody Plans among Parents Living with Human Immunodeficiency Virus Infection. Grace Quaye, Patricia Bruce-Tagoe and Yaa Ofei helped with Archives of Paediatric & Adolescent . 2004; 158: 327-332. the various stages of data collection. Eric Boahene helped with 16. Hailemariam TG, Kassie GM, Sisay MM. Sexual life and fertility desire research advice and analysis and Dr. Simeon Coleman helped in long-term HIV serodiscordant couples in Addis Ababa, Ethiopia: a withAuthor the editing.Contribution grounded theory study. BMC Public Health. 2012; 12: 900. 17. MOH, NACP. National Guidelines for Prevention of Mother to Child Transmission of HIV. 2010. Kate Coleman-Sarfo worked on the conception, data collection 18. Coleman-Sarfo K, Kuranchie P. Assessing the Effectiveness of the and discussion of results. Kate Coleman-Sarfo and Emmanuel Klo Strategy for the Prevention of Mother to Child Transmission of HIV workedCompliance on study with design, Ethical methods, Standards results and analysis. at the 37 Military Hospital, Accra. Clin Res HIV/AIDS. 2016; 3: 1-12. Ethical approval: 19. Okafor II, Asimadu EE, Okenwa WO. Prevalence of Couple Human Immunodeficiency Virus (HIV) Discordance and Prevention of New Ethical approval for the study was obtained HIV Infection in the Negative Partner in Enugu, South East Nigeria. from the Institutional Review Board of the 37 Military Hospital. Gynaec & Obstet (Sunnyvale). 2015; 5: 337. ReferenceREFERENCES {37MH-IRB IPN 133/2017}. 20. Dapaah JM, Spronk R. When the clinic becomes a home. Successful VCT and ART services in a stressful environment. SAHARA J. 2016; 13: 142-151. 1. Smith R. Magnetic Marriages When Positive and Negatives Attract. Body Positive. 1996. 21. UNFPA, UNAIDS, UNIFEM, Women and HIV/AIDS: Confronting the Crisis. 2004. 2. Eyawo O, de Walque D, Ford N, Gakii G, Lester RT, Mills EJ. HIV status in discordant couples in sub-Saharan Africa: a systematic review and 22. Weller SC, Davis-Beaty K. Condom Effectiveness in Reducing meta-analysis. Lancet Infect Dis. 2010; 10: 770-777. Heterosexual HIV Transition. Review of the Cochrane Library. 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Cite this article Coleman-Sarfo K, DeGraft Klo E (2017) Challenges Faced by HIV Positive Partners Living in Discordance with HIV Negative Partners: A Case Study of 37 Military Hospital. Clin Res HIV/AIDS 4(2): 1041.

Clin Res HIV/AIDS 4(2): 1041 (2017) 11/11