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CHALLENGES OF SERODISCORDANCE AND RISK OF INFECTION INSERODISCORDANT COUPLES: THE CASE OF ZAMBIA

TASHENI ROYDAH MAKUMBIZAMBIA

44th International Course in Health DevelopmentSeptember 24, 2007-September 12, 2008

KIT (ROYAL TROPICAL INSTITUTE)Development Policy & Practice/Vrije Universiteit Amsterdam

CHALLENGES OF SERODISCORDANCE AND RISK OF INFECTION IN SERODISCORDANT COUPLES: THE CASE OF ZAMBIA

A thesis proposal submitted in partial fulfillment of therequirement for the degree of Master of Public Health

By

Tasheni Makumbi

Zambia

Declaration:Where other peoples work has been used (from a printed source,either internet or any other source) this has been carefullyacknowledged and referenced in accordance with departmentalrequirements.

Challenges of serodiscordance and risk of infection inserodiscordant couples: The case of Zambia is my own work.

SIGNATURE…………………………………………………………

44th International Course in Health Development (ICHD)September 24, 2007-september 12, 2008KIT (Royal Tropical Institute), Development Policy & Practice

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Amsterdam, Netherlands

In co-operation with:

Vrije Universiteit Amsterdam/ Free University of Amsterdam ( VU)Amsterdam, the Netherland

TABLE OF CONTENTSTABLE OF CONTENTS……………………………………………………………………………….i

ACKNOWLEDGEMENTS …………………………………………………………………………..v

DEDICATION…………………………………………………………………………………………….vi

LIST OF ABBREVIATIONS……………………………………………………………………….vii

DEFINITION OF TERMS ………………………………………………………………………….viii

LIST OF TABLES, FIGURES AND APPENDICES………………………………………..ix

ABSTRACT………………………………………………………………………………………………….x

INTRODUCTION………………………………………………………………………………………..xii

CHAPTER 1 BACKGROUND INFORMATION……………………………….1

1.1 Zambia geo-political situation…………………………………………………………..11.2 Economic profile………………………………………………………………………………..1

1.3 Demographic profile…………………………………………………………………………..2

1.4 Zambia socio-cultural background information……………………………….2

1.5 Health care services and financing…………………………………………………….2

1.6 Disease burden……………………………………………………………………………………3

CHAPTER 2 PROBLEM STATEMENT……………………………………………4iii

2.1 problem statement……………………………………………………………………………..5

2.2 General Objectives……………………………………………………………………………..5

2.2.1 Specific Objectives……………………………………………………………………………..5

2.3 Methodology………………………………………………………………………………………..5

CHAPTER 3 DYNAMICS OF HIV TRANSMISSION AND INCREASED HIV

INFECTIONS IN SERODISCORDANT COUPLES……………………….7

3.1 Prevalence and evidence of serodiscordance in SSA andZambia……73.2 Risk of transmission from positive partner to negative

partner in serodiscordantcouples………………………………………………………………………9

3.2.1 The stage of infection of the positivepartner………………………….93.2.1.1 The first stage of infection…………………………………………………………93.2.1.2 The secondary stage of infection………………………………………………10 3.2.1.3 The last stage of infection…………………………………………………………103.2.2 Frequency of sex acts……………………………………………………………….103.2.3 Presence of Co-infections …………………………………………………………113.2.4 Other risk factors that increase risk ofinfection………………………113.2.4.1 Dry sex…………………………………………………………………………………………….113.2.4.2 Non use of condoms during sexual

intercourse…………………………….123.2.4.3 Gender and violence……………………………………………………………………….133.2.4.4 Method of sex………………………………………………………………………………….133.2.4.5 Sex under the influence of alcohol and

drugs……………………………….143.2.4.6 Use of libido enhancers…………………………………………………………………143.2.4.7 Sex during menstruation………………………………………………………………143.2.4.8 Young age……………………………………………………………………………………….153.2.4.9 Lack of male circumcision………………………………………………………………153.2.4.10 Stigma and Discrimination…………………………………………………………….16

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CHAPTER 4 CHALLENGES EXPERIENCED BY SERODISCOUPLES ….174.1 Types of serodiscordant couples and their challenges……………………17

CHAPTER 5 CHALLENGES FACED BY HEALTHWORKERS AND HIV/AIDS CONTROLPROGRAMS…………………………………………….205.1 Lack of appropriate training and information………………………………….205.2 Loss of couple client contacts before disclosure………………………………215.3 Inability to prevent violence afterdisclosure…………………………………..225.4 Ill equipped Health care services……………………………………………………..225.5 Restrictive code of ethics and lack of professional support……………235.7 Non integrated Reproductive Health and TBservices……………………..235.8 Inadequate Health care policies for serodiscordantcouples……………23

CHAPTER 6 SUMMARY AND RECOMMENDATIONS……………………..25

RECOMMENDATIONS……………………………………………………………..26Policy…………………………………………………………………………………………………………….26Practice………………………………………………………………………………………………………...27Research……………………………………………………………………………………………………….28REFERENCESAPPENDICES

ACKNOWLEDGEMENTS

I wish to express my gratitude and special thanks to NUFFIC fortheir sponsorship.

Special thanks and gratitude to the entire KIT ICHD coursecoordinators and management for their unfailing support andguidance throughout my course period.

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Special thanks to my adviser for his support and guidance,patience and commitment in helping me realize and appreciate theimportance of my topic and its relevance to the Zambian HIV andAIDS situation.

I also want to sincerely thank the Zambia Open Universitymanagement specifically Professor Mwansa and Professor Ngwishafor their support and opportunity they provided for me toundertake this very valuable course.

DEDICATION

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This thesis is dedicated to my family with whose patience andlove made it possible for me to persevere and complete thecourse.

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LIST OF ABBREVIATIONS

ABC Abstinence, Be faithful and consistent condom useAIDS Acquired Immune Deficiency SyndromeART Anti Retroviral TherapyCSO Central Statistics OfficeDFID Department for International DevelopmentGTZ Germany Technical Assistance to ZambiaHIV Human Immunodeficiency VirusMCDSS Ministry of community development and social servicesMoH Ministry of HealthMoFNP Ministry of Finance and PlanningMSM Men who have Sex with MenNAC National HV/AIDS CouncilNASP National HIV/AIDS Strategic PlanNHSP National Health Strategic PlanOoP Out of PocketPEPFARE Presidents Emergency Plan for AIDS ReliefPLHIV People Living with HIV PRSP Poverty Reduction Strategy PaperCSW Commercial Sex WorkerSSA Sub Saharan AfricaSTI Sexually Transmitted InfectionsTB TuberculosisUAC Uganda AIDS CommitteeUK United KingdomUNAIDS United Nations Programme for HIV and AIDSUNDP United Nations Development ProgrammeUNHCR United Nations High Commission for RefugeesUNGASS United Nations General Assembly Special Session on AIDSUSA United States of AmericaUSAID United States of America Development AidUSD United States DollarWHO World Health Organization

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ZHDR Zambia Human Development Report

DEFINITION OF TERMS USED IN THIS STUDY

A Couple-Throughout this study a couple will be referred to as along-term intimate relationship in a cohabiting or marriage unionof two people that is governed by customary norms, religiousnorms and or statutory laws.

HIV discordance or serodiscordance – will be used to describe acouple with different sero or HIV statuses.

Seroconcordant negative couple- will be used to describe a couplewith both partners having negative HIV statuses.

Seroconcordant positive couple- will be used to describe a couplewith both partners having positive HIV statuses.

Concurrent sexual partnerships- will be used to describe asituation where a partner has more than one sexual partner at thesame time for long periods of time.

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LIST OF TABLES AND FIGURESTable 1: Zambia GDP PPP & GDP Growth Rates 2004 - 2008Table 2: Health workers in Zambia

APPENDICESFigure 1: Map of ZambiaFigure 2: Stages of infection and the presence of STDFigure 3: HIV prevalence in Zambia

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ABSTRACTThough the prevalence of serodiscordant couples in Zambia hasbeen noted to be at 26.2% (UNGASS, 2008) (this is according toreports from all counselling centres nationwide and not thegeneral population) Zambia’s serodiscordance prevalence isprobably not different from other SSA countries such as Uganda,and ranging from 4% to 7%. According to Dunkle’s modeling, it has been estimated that of allthe new infections taking place in the married couples in thegeneral population, 84.1% to 99.8% are taking place inserodiscordant couples every year (Dunkle, 2008). Even if theseestimates are debated and too high, Serodiscordance isundoubtedly highly risky situation.The main objective of this thesis was to describe transmissiondynamics in serodiscordant couples and how this contributes toincrease in the risk of infection to the negative partner.Further describe challenges faced by serodiscordant couples.Lastly it describes challenges that HIV/AIDS prevention andcontrol programs face in trying to help serodiscordant couplesdeal with their situation. It further provides recommendationsfor future program interventions and strategies for

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serodiscordant couples and couples in general in Zambia.

Literature review was conducted from articles, reports, andpersonal experience.

From this literature review, it was found that increase in riskof HIV infection to negative partner in serodiscordant couplesdepend on the dynamics of transmission in these couples. Theseinclude the stage of infection at which the positive partner isat, presence of co-infections/STDs in both the negative andpositive partner, the number or frequency of coital acts andother risk factors such as practice of dry sex, anal sex, non useof condoms, young age, uncircumcised male partners, gender andviolence, sex under the influence of alcohol, use of libidoenhancers, sex during menstruation and stigma and discrimination.

On challenges that serodiscordant couples face, it has been foundthat disclosure, maintaining sexual intimacy, uncertainties ofillness and planning for the future, fulfilling child wishes andreproductive health needs, learning new roles, managing finances,stigma and discrimination and managing mood states and depressionare some of the challenges that they face, depending on awarenessof one or both partners; sex of the positive partner and stage ofinfection.

Health workers and HIV and AIDS control programs working withserodiscordant couples in trying to reduce infections and helpthem deal with their situation experience difficulties inunderstanding serodiscordance, lack appropriate training,encounter ethical, professional and legal dilemmas, operate in adisintegrated reproductive health system and are in an area thatdoes not have policies and protocols to guide them. Lastly butnot the least, they lack specific health information materialsand tools.

From this thesis, many recommendations have been put forward tohelp address this issue but most important, it identifies the

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need to establish the real magnitude of the problem and be ableto know where and how to stop the increasing infections in thisgroup. More funding and resource needs to be allocated. Trainingand retraining, new policies, regulations and guidelines, andspecific programming have been recommended. Better coordinationand or integration of the different services for HIV people isneeded ; services such as legal, TB, Malaria, PMTCT, and generalreproductive health services.

INTRODUCTIONHIV continues to spread in married couples in Zambia and aroundthe world especially in the SSA countries.

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I first encountered issues of HIV discordant couples during mywork with UNDP National Volunteer programme for 3 years from 2005to 2007 as an HIV /AIDS specialist responsible for coordinatingHIV and AIDS programmes for the Ministry of Community Developmentand Social Services on a national level. One of myresponsibilities was to plan and implement micro finance projectsaimed at providing low interest soft loans to women infected andaffected by HIV in three rural districts in Zambia. The objectiveof the Project was to mitigate the impact of HIV on vulnerablewomen and children. Through Grameen Banking concept of Bangladesh(Village Banking), we provided low interest loans. During therecruitment the writer came face to face with the reality of theimpact of HIV and AIDS on families, especially young families.Many of the women and men in the project had lost a partner tothe “New Disease” (AIDS). The increasing numbers of sick anddying couples, divorcing, abandoning and separating due to mixedsero status results was worrying to elders and community leaders.The increasing number of double orphans created a situation wheremany children and the aged lived in abject poverty as youngcouples died of HIV and AIDS. It was interesting to see and hear many cases of witch huntingwhen one partner was found or suspected of being HIV positivewhile the other was negative. Communities believedserodiscordance was the work of magic or witchcraft. This furtherbroke down families and community bonds.

Communities were left with the threat of losing all theproductive young men and women. Communities watched whilepartners in married couples got sick one after another and diewithin months or few years of each other.

At the same time serodiscordance in marriages was a big issue inthe national papers in Zambia. As a country, we started havingnumerous divorce cases, family abandonments and separations dueto serodiscordance in married couples. Courts faced numerous

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cases of divorce, separation and abandonment in married coupleswhere partners had different sero statuses. The majority of caseswhere female partner was positive resulted in violence and abuse,divorce, separation and or denied support from male spouses whoin many cases did not know their own status. Children sufferedthe most as male partners who are the major support system forthe children and women withdrew their support to their childrenand positive partner. This caused public outcry from Women’sorganisations, civil organizations and NGO legal organizationsthat started receiving complaints about mistreatment of positivepartners in serodiscordant marriages.

Unfortunately, no HIV/AIDS Control programmes were not competentenough to effectively deal with serodiscordant couples. Reportsof violence, divorce by couples who visited these programsworsened the situation as many couples refrained from using themas they feared similar consequences.

Unlike HIV in the general population, serodiscordance presentedhuge challenges for these communities. The fact that they couldnot understand the dynamics of transmission of HIV in thesecouples created a big problem for couples involved. It wasdifficult to understand how a couple could have different serostatus and how other couples stayed longer before seroconvertingwhile others seroconverted within a short time. These issuescaused a lot of mistrust, suspicions and generally broke downfamilies. HIV/AIDS programs in place in these areas were nottrusted as they failed to give clear and convincing explanationson serodiscordance and failed to help serodiscordant couples dealwith psychosocial as well as health issues. With all theseproblems, serodiscordance seemed a very difficult situation todeal.These experiences as a Social Worker working with vulnerablewomen and children in Zambia, generated interest in me to try anddescribe dynamics of transmission in serodiscordant couples andthe challenges that serodiscordant couples and health workers/HIV/AIDS prevention and control programmes face in trying to deal

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with this situation. With the findings from this study, somecontributions and recommendations for interventions will be made,to help reduce and control HIV infections in this group inZambia.

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CHAPTER 1 BACKGROUND INFORMATION1.1 Zambia geo-political situationZambia is a large landlocked country situated in the southcentral part of Africa. It shares its borders with Zimbabwe,Botswana, Namibia, Tanzania, Malawi, Mozambique, DRC and Angola. Zambia became a sovereign state in 1964 after gaining freedomfrom the British. From the time of independence till now, Zambiahas enjoyed political peace. Zambia has nine provinces with 72districts and 150 constituencies represented by Members ofParliament. The Copperbelt province and Lusaka Province are theurban towns and main economic cities while the other seven arerural towns. About 36% of the country’s population live in urbanareas while 64% live in the rural areas.

1.2 Economic profileThough Zambia has been ranked one of the poorest countries in theworld, it has experienced a reasonable economic growth of about5% per year in recent years. Copper, Zambia’s main foreignexchange earner, has seen a steady increase in its prices on theinternational market. This has helped to increase economicactivities in Agriculture, Mining and Export industries andthereby creating a few jobs (UNDP, 2007)

GDP in billion ofUSD ppp

% GDP growthSOURCE: EIU COUNTRY DATA 2004-2008

Since the 1980s, Zambia has gone through a lot of structural1

adjustments to its economy. In 1980s, it embarked on SAP torevitalize the economy. In 1991, majority of the parastatalcompanies were privatized. This resulted in a lot of job lossesand worsened the poverty situation (CSO, 2004). To try and improve the economy, an economic recovery programmewas set up but failed to achieve its goal and thus the birth ofthe PRSP aimed at reducing poverty multi-sectorially (PRSP, 2001)So far, about 68% of Zambians still live in abject poverty. Themost affected are the rural dwellers with 78% living in povertywhile the urban areas have 53% (CSO, 2004)

1.3 Demographic profileZambia’ population is estimated at 12,160,516 million with anannual population growth rate of 2.5%. Lusaka has the highestpopulation of 1.7 million people (ZHDR, 2007). Fifty percent ofthe Zambian population is adult population. The total fertilityrate is at 6.9 in rural areas and 4.3 in urban areas (ZDHS, 2000-2001). Infant mortality is at 168 per 1000 live births. The lifeexpectancy among adults is 48.0 years for men and 52.0 years forwomen (CSO, 2002 as cited by ZSBS, 2005).The national literacy rate in Zambia is about 65% with men havinghigher rate at 81.6% than women at 60.1% (ZHDR, 2007).

1.4 Zambia socio-cultural background informationZambia has 72 tribes found in the nine provinces. English is theofficial language. The majority of Zambians are Catholics andProtestants at 33% and 30% respectively. About 17% areindependent Christians, the new born again faith while 14% aretraditionalist. The Baha’i, Islam and Hindu are the minoritygroups with only 6% in the population. Marriage has a special place in the Zambian culture andreligions. It is a main unit where family is created. There arethree types of marriages in Zambia, namely customary marriage,civil or modern law marriage and religious marriage (CSO, 2004)

1.5 Health care service and financing

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The Health Care System in Zambia faces many challenges due tohigh disease burden compounded by inadequate funding (NHSP,2005). HIV and AIDS has incapacitated the Health care serviceleaving it with a skeleton of workforce to deal with the hugedisease burden worsened by poverty (MOH 2004)

HIV and AIDS ranks among the twelve National Health prioritiesbesides malaria, ARI, T.B, Non bloody diarrhea, Trauma, eyeinfections, skin infections, nose/ear/throat infections,intestinal worms, anemia and pneumonia/respiratory infections(NHSP/MOH, 2005).While the rural areas have more Health centers than the urbanareas, they lack equipment, staff, and drugs. Urban have more ofthe hospitals that are reasonably equipped and are runningmajority of health programmes. The table below shows the numbersof health centres in Zambia by 2002.

Number of Health care centers in Zambia by 2002GRZ MISSION PRIVATE TOTAL

Hospitals53 27 17 97

Health centers 1052 61 97 1210 973 rural

237 urbanHealth posts 19 0 1 20Total 1124 88 115 1327SOURCE: CBoH, health institutions in Zambia: a listing of Healthfacilities according to levels and locations, 2002

There is no formal public/private partnership in the healthservice sector in Zambia. However, due to Government failures tomeet the needs of the people, the MOH engages private serviceproviders to help make health service accessible. Majorityprivate services operate in urban areas and shun the rural areas(MOH, 2006).As of 2006, there were 23,176 health workers against the requirednumber of 49,360 health workers (MOH, 2005). The ratio of healthworker to population is 1:524 in Zambia.

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Zambia has been able to get most of her funding for healthprograms from her multilateral and bilateral partners, with thebiggest chunk of the funds going to HIV/AIDS preventionprogrammes (NHSP, 2006). Government through the Ministry ofFinance contributes 25%, 32% comes from individual citizens outof pocket or fees while donors contribute 38% (MOH, 2006).HIV and AIDS programmes enjoy a huge funding support from WorldBank, the PEPFAR funds and other bilateral and multilateraldonors but faces threats as needs are always increasing (MOH,2005).

1.6 Disease burdenZambia’s little resources are under pressure to solve the risingcases of communicable diseases, HIV and AIDS, TB, Malaria andother opportunistic infections. HIV and AIDS have the highestmortality rates among the 15-49 age groups, while malaria is thebiggest cause of deaths in Zambia (MOH, 2006).

CHAPTER 2 PROBLEM STATEMENTIn this chapter , the problem statement, the study objectives andthe methodology will be discussed including limitations of thestudy and what the writer intends to achieve through this studyare presented.

2.1 Problem StatementSerodiscordance is a huge public health concern among otherpublic health problems in Zambia as it is one of the many riskgroups driving the HIV epidemic in Zambia (Lurie, 2003). With aprevalence of 20% of all couples passing through counsellingservices being serodiscordant, there is a large number ofnegative partners that are at risk of getting infected. Whileinfections have reduced in other risk groups such as commercialsex workers, truck drivers, uniformed workers and the youth,infections are on the rise in serodiscordant couples in Zambia.

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Reports have shown that 75% of new infections in SSA, Zambiainclusive are taking place in married couples. According toDunkle’s modeling, it is estimated that, of all the newinfections that take place in married couples in Zambia, between88%-92.2% are taking place in serodiscordant couples. Theseestimates may be too high or unrealistic. The real situation maynot be that extreme. However, what is obvious and evident is the increased risk ofinfection to the negative partner in serodiscordant couples. Thenormal dynamics of transmission of HIV namely; stage of infectionof the positive partner, the presence of STDs, frequency ofcoital acts and other behavioural risk factors are the majordeterminants of increased infections in serodiscordant couplesand they pose a huge challenge in trying to reduce infections inthis risk group (Wawer, 2008; Cohen, 2006).Serodiscordance poses overwhelming challenges to couplesthemselves making prevention from infecting the negative partnerimpossible and difficult to achieve resulting in continued unsafesexual practices (Bunnell, 2005)To make matters worse, Health workers and health controlprogrammes that are supposed to help discordant couples developskills on how to deal with their complex situation, face so manyconstraints in their training, resources, policy and professionalcode of ethics/conduct and knowledge on serodiscordance, makingtheir efforts ineffective and inefficient (Painter, 2001)

The consequences of high infections of serodiscordant couples inZambia have dealt a heavy blow on the countries efforts todevelop economically and socially.

This has led to this writer’s interest in writing this thesis.The important thing that this thesis wishes to achieve overall isto highlight these determinants of increased risk of infection;the challenges posed to both couples and workers and then providesuggestions and recommendations on how to avoid transmissionwithin serodiscordant couples.

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2.2 GENERAL OBJECTIVE OF THE STUDYTo describe dynamics, challenges of serodiscordance among marriedcouples in Zambia and suggest recommendations for programmeinterventions and strategies

2.2.1 Specific Objectives1. To describe the dynamics of HIV transmission in HIV

discordant couples and its importance as a driver of theoverall HIV epidemic.

2. Describe and discuss the challenges of Serodiscordance forcouples

3. Describe and analyse the challenges for HIV counselors andfor prevention programs

4. To use findings to come up with recommendations to reduceHIV infections and the impact of Serodiscordance the overallHIV epidemic in Zambia.

2.3 MethodologyThis thesis is a descriptive study, mainly based on a review ofliterature and personal experiences of the writer are used whereit applies.

Literature reviewed has been sourced from published Government,United Nations, NGO and private and institutional documents andresearch studies.

Some of the websites used to search for this literature are theUNAIDS, WHO, FHI, Pub med, KIT, Guttmarcher, Science Direct,Starware and Google scholar.

a. Study limitationsAs a literature review, this study depended on publisheddocuments and studies and although there were not a lot ofstudies on Zambia. Many of the literature used therefore were onother Sub-Saharan African countries that were relevant to theZambian situation. Some European based studies relevant to theZambian situation were also used.

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HIV discordance is a complex issue and has not been fullyunderstood scientifically and is still being debated upon andtherefore not an easy subject to dwell on.

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CHAPTER 3 DYNAMICS OF HIV TRANSMISSION AND INCREASED HIVINFECTIONS IN SERODISCORDANT COUPLESIntroductionThis chapter will start by discussing the general prevalence ofserodiscordance in SSA, Zambia specifically. Then go on todiscuss how the Stages of infection, frequency of sex acts,presence of co-infections (STDs) and risky sexual behaviorscontribute to the increase of risk of infecting the negativepartner in serodiscordant couples.

3.1 Prevalence and evidence of serodiscordance.While a drop in national HIV prevalence of some SSA countriessuch as Kenya, Uganda and Zimbabwe are being recorded (UNAIDS,2007), Zambia’s national HIV prevalence seems not to show anysigns of reducing (NAC, 2007). Recently there have been reportsof decrease in HIV transmissions in identified risk groups suchas commercial sex workers, youths, military and other uniformprofessionals and mobile workers (UNGASS/NAC, 2008). Thisdecrease has however not translated in decrease in the nationalHIV transmissions. According to some studies made, this is due tothe fact that there is still large numbers of HIV infectionstaking place in married couples who have mixed status (De Walque,2006).

The prevalence of serodiscordant couples in SSA has been found tovary according to the sample being studied (Collini and Obassi,2006). Studies with general population representative samples,have reported lower prevalence rates of serodiscordant couples inSSA countries, while studies that have used clients of VCTservices (self selected samples) have reported higher HIVprevalence of serodiscordant couples in SSA. In both situationspeople do not participate fully. In population surveys nonparticipation may lead to underestimating the prevalence while in

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studies using clients of VCT services (self selected samples) nonparticipation may lead to overestimating the prevalence. Reasonsfor non participation in Zambia range from cultural restrictions,gender inequalities and stigma attached to HIV and AIDS.Generally according to the culture, a married couple is notsupposed to be seen to share or reveal marital issues to publicor strangers, and if there is need, a couple is advised toconsult trusted marriage counselors who are respected elders ofcommunity. And thus many couples refrain from taking part insurveys and VCT services which may require them to expose theirmarriage to strangers. Since these activities take place at timeswhen most male spouses are at work or away from home, many femalespouses cannot take part in these activities nor revealinformation about the couple without getting permission fromtheir male spouses. How much stigma is attached to HIV and AIDSin Zambia can sometimes be seen from the low levels of people’sparticipation in activities such as surveys and VCT services.Anyone seen to be taking part in these activities is labeled asHIV positive and HIV is still associated with prostitution and somany people fear being labeled as HIV positive and refrain fromtaking part in important such studies.

In many Demographic Health Surveys in some SSA countriesprevalence is shown as ranging from 2% to 13.6% (as cited byDunkle, 2008 from CSO, 2005-6, Zimbabwe and MOH, 2004, Lesotho).Examples of these can be seen below. ( Ethiopia 1.8%, Rwanda 2%,Burkina Faso 2.7%, Ghana 3.2%, Cote d’Ivoire 5.7%, Uganda 4.6%,Tanzania 8.0%, Kenya 7.5%, Malawi 9.7%, Zimbabwe 13% and Lesotho13.6%, (De Walque, 2006; Mishra, 2007).

However, in self selected samples, such as the multi centre studyin SSA countries, the prevalence has been found to range from 8%to 31% and from 36% to 85% (Lingappa, 2008). In a sexual surveyin South Africa among couples with migrant and non migrantpartners, from 168 couples 21% were found to be serodiscordantcouples (Lurie, 2003). In Zambia, Stanley (2002) also found that21% of the 9569 couples that had passed through one counselling

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center in Lusaka from 1994 to 2000 where serodiscordant. Chombaand colleagues (2007) found that from a population of 8,500couples, 51% were concordant negative, 26% concordant positiveand 23% discordant in Lusaka urban. While the National HIV/AIDSCouncil has estimated that 26.2% of all couples in Zambia areserodiscordant (UNGASS, 2008).

This writer has not found any data on serodiscordance in Zambiain any of the Demographic Health Surveys. However review ofliterature on the prevalence of serodiscordance in SSA hasrevealed that the prevalence in Zambia may not be so differentfrom other SSA countries that have DHS data.It is also clear that serodiscordance also poses a challenge intrying to establish its prevalence. It has been observed frommany of the studies reviewed here that constraints such asculture, myths and stigma make contribute to the nonparticipation. However, the available data though not verydependable, has highlighted the extent of serodiscordance inZambia.

From the writers point of view the need to establish surveillancesystems to track new and old infections in married population andserodiscordant couples cannot be overemphasized.

3.2 Risk of transmission from positive to negative partners inserodiscordant couples.The risk of transmission in serodiscordant couples cannot begeneralised because there are many factors that HIV transmissionin serodiscordant couples depend on. These factors are identifiedin the following transmission dynamics;

1. Stage of infection of the positive partner2. Frequency of sex acts3. Presence of co-infections and 4. Other risk factors

3.2.1 The stage of infection of HIV positive partner

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3.2.1.1 The first stage of infectionAccording to Cohen (2006) the first stage is the most infectiousstage when the positive partner has the highest viral load thatcould be transmitted to a negative partner with a few coitalacts. Hollingsworth et al, 2008, noted that the positive partneris 26 times more infectious in this stage than in any otherstage, while Cohen (2006) found this stage 10 times moreinfectious than the second stage and 7 times more infectious thanthe last stage.

The fact that one partner becomes positive while the other isnegative is a sure sign of the positive partner’s involvement inconcurrent sexual relationships. Concurrent sexual partnership isdefined as ‘a sexual partnership in which one or more of thememberships has other sexual partners with repeated sexualactivity with at least the original partner’ (Gorbach(2002).It is from this relationship that they will contract the HIVinfection while still maintaining sexual contact with theirregular negative partner. This increases the risk of the negativepartner getting infected as sexual contact is maintained duringthe most infectious stage of the positive partner.

According to Hudson, (1996), the phenomenon of concurrent sexualrelationships, helps to spread HIV rapidly as many people areexposed to the newly infected partner while in the primary stage.In serodiscordant couples, the positive partner’s continuedsexual contacts with regular partner while having concurrentsexual relationships, entails that as soon as they get infectedfor outside, while in their primary stage of infection, the riskof infecting the negative partner is very high.

In a study on concordant positive couples, both the indexpositive partner and negative partner in majority couples thathad seroconverted from HIV discordant to concordant positivereported being involved in concurrent sexual relationships(Allen, 2007; 2003; 1997).

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3.2.1.2 The secondary stage of infection This is the least infectious stage of a positive partner(Skurnick, 1998; Cohen, 2005; Klasse, 2006). The positive partnerhas very low viral load and would require more coital acts ofabout 1000 to infect one negative partner (Skurnick, 1998).Because of its low viral load, the risk of infecting the negativepartner is moderate.

3.2.1.3 The last stage of infection This stage is the second most infectious in the stages ofinfection of the positive partner. The positive partner’s viralload is higher than the viral load in the secondary stage ofinfection but less than that in the primary stage (Cohen, 2005).In this stage in serodiscordant couples, peculiar things happeneven though the viral load is high and presents a higher riskthan in the secondary stage, the fact that the positive partnerstarts to show symptoms and becomes less attractive and lessdesirable results in less sexual contacts with their negativepartner and thereby reduces the risk of infection to the negativepartner. However, the risk of infection may come from outside therelationship when the negative partner seeks sexual gratificationfrom someone else.On the other hand, with the availability of ARTS, the risk ofinfection may come from inside the relationship though this riskis very low. With recent treatment successes, ART has been ableto lower viral load, suppress AIDS symptoms, improve generalhealth and prolong the lives of PLHIV (Bunnell, 2006). It hasbeen used to reduce or stop HIV transmission to negativepartners. However, this success depends on adherence totreatment. Considering that in Zambia, reaching satisfactoryadherence levels is a challenge due to the shortages of drugs,trained treatment supporters, long distance to health carecentres, poverty and stigma, gender inequalities anddiscrimination attached to HIV and AIDS.

3.2.2 Frequency of sex acts 12

Increased risk of infection to the negative partner inserodiscordant couples is also dependent on the numbers of coitalacts preformed (Cohen, 2006). Every coital act that aserodiscordant couples performs presents risk of infecting thenegative partner, therefore the less the coital acts, the lessthe risk of infection and vice versa.

3.2.3 Presence of Co-infectionsThe presence of STDs in either partner increases the risk ofinfection to the negative partner in serodiscordant couples(Padian, 1997; Nzila, 1991; Freeman, 2004; Telzak, 1993). So farstudies done have confirmed that STDs have contributed to theincreased risk of infecting the negative partner inserodiscordant couples in Zambia and other SSA countries withhigh prevalence’s of serodiscordance (Skurnick, 1997,1998; Allen1992; Hira 1997; Dunkle, 2008; Senkoro; Orroths’ 2007; Mehendale,2006). The possibility of the negative partner being infected byHIV is increased by about 10 to 20 times higher than inconcordant negative couples with STDs (Wawer, 2005, Allen, 1993;Hester, 2003). Other studies that followed up concordant positive couples andnewly seroconvert, also established that in the majority of thesecases, STDs were a major risk factor for HIV infection (Hesterand Kennedy, 2003; Friedman, undated).Buchacz and colleagues(2004) said STDs increased the risk of infection because theyincreased viral load in the genital areas and decreased CD4 cellsthat are meant to help the body fight infections in the negativepartners. Open sores increase the presence of viral load in thegenital areas in the positive partner and provide easy entry forthe virus in the negative partner (Gray, 2001; Freeman, 2006). Though the studies cited above may not be fully relied upon dueto the fact that the samples used were clients of STD clinicservices, the results of these studies could still be used tounderstand the role STDs play in increasing risk of infectingnegative partners with HIV.

3.2.4 Other risk factors that increase risk of13

transmission.Generally all risk behaviors do increase the risk transmittingHIV to the negative partner. The following risk factors mentionedbelow increase the risk but more importantly in serodiscordantcouples.

3.2.4.1 Dry sex Dry sex increases the already existing risk of infection inserodiscordant couples. In Zambia dry sex is commonly practicedamong married women as it is a cultural belief that women need tobe tight and dry to make their husbands sexually satisfied. It ismore practiced by the older women of marriage age than in theyoung women (Sandala, 1995). Men also tend to believe that a wetwoman with a lot of “water” fluids is a loose woman or has an STD(Kun, 1998) and no man wants to be associated with such a woman. Though studies that have been done to establish the relationbetween drying agents and HIV transmission have not found anyscientifically proven relationship (Sandala, et al, 1995),vaginal drying agents cause drying and tightening of the vaginaso that during sexual intercourse there will be friction thatwill result in swelling, tiring and open wounds. In aserodiscordant couple, the risk of infection to the negativepartner is then increased. There are variety of herbs andchemicals used by women to dry out their private parts and manyof these are erosive herbs and chemicals that damage the vaginallining.

3.2.4.2 Non use of condoms Non condom use increases the risk of infection to the negativepartner in serodiscordant couples.Unfortunately, use of condoms in couples has not been an easypractice all over Sub Saharan Africa. Cultural beliefs, myths,misconceptions and stigma attached to condom use lead to none orlow use of condoms in marriages. Though many studies have shownproof of reduced HIV infection in serodiscordant couples throughcondom use by 60% (Medical news, 2008), still many studies areshowing low levels of condom use among serodiscordant couples in

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Zambia (Dunkle, 2008; Allen 2007 and Malamba 2005). Even indeveloped countries such as the USA, where condoms are readilyavailable, it has been found to be the least preferred sexualbehavior in reducing the risk of transmitting HIV (Remien et al,1995; Schiltz; Traore, 2006; Allen et al, 2003). In Zambia, only5.5% of married couples use condoms (NAC, 2006). The extent ofnon use of condoms in serodiscordant couples can be seen in aUgandan study where, from 36,000 couples tested, 96% of thesexually active serodiscordant couples reported not using condomsduring sexual intercourse (IRIN, 2008). The consequences of noncondom use in serodiscordant couples have been highlighted inDunkle’s (2008) and Lingappa’s (2008) study. The study attributed60% to 80% infections in the serodiscordant to non use of condoms(Medical News, 2008).Condoms use is a complex issue in serodiscordant couples. Theneed to fulfill their wishes to have children, religiousteachings that forbid condom use as a sign of being faithful anda sign of infidelity, stigma attached to condoms as used only bycommercial sex workers because of the belief that this group islikely to have HIV and cultural beliefs that forbid women frominitiating condoms and gender inequality that prevent women frominitiating condom use even when they know they are at risk ofinfection are some of the reasons for non use of condom use inserodiscordant couples. Others are social acceptance of riskpractices in marriages such as long-term concurrent sexualrelationships which are considered part of the stable family.

3.2.4.3 Gender and violencePartners who experience violence have an increased risk of HIVinfection (Dunkle, 2004, Van Straten, 1998 as cited by Odhiambo,2007)In serodiscordant couples, gender violence such as rape andforced sex increase the risk of infection to the negativepartner. During rape and forced, there is no possibility ofnegotiating for the use of condoms. Because it is forced sex,there is a lot of trauma to the genital organs resulting in cuts,swelling and bruises. These will increase the risk of

15

transmitting HIV. Though there are no specific studies found by this writer onsexual violence in Zambia, reviewing the 2000 population surveyon sexual behaviors in Zambia revealed that a good number ofmarried couples experienced sexual violence. Generally in thepopulation, 68.5% of Zambian married women reported havingexperienced violence. Though Gender based violence is common among couples in Zambia,it is not widely talked about or reported because our culturetolerates it, especially if it is in marriage. Fears ofrepercussions by the victims make it difficult for them to reportor get help. It thus continues to be one of the major factorsthat put victims to risk of HIV infection but still in the closet(ZHDR, 2007; writer’s experience). This may have also resulted inlow uptake of these important programmes (NAC, 2005) Adejuyigbe,2006).

3.2.4.4 Method of sex practiceGroups involved in penetrative sexual intercourse such as vaginaland anal sex are found to be at increased risk of infecting ortransmitting HIV to negative partners than those practicing nonpenetrative sex such as oral sex in serodiscordant couples(Kennedy, 1993).

Though there are no studies specifically targeting serodiscordantcouples in Zambia on the method of sex practice and the risk oftransmitting HIV to negative partner, studies in USA couplesrevealed that serodiscordant couples engaging in vaginal and analsex where found to have an increased risk of transmitting HIV totheir negative partners than those engaged in oral sex or othernon penetrative sex (Schiltz: Sandfort, 2000).

Unfortunately, practice of oral sex is mostly reported among sexworkers in Zambia and rarely mentioned in married couples thoughthis is taking place (Bond; Dover, 1997). Many Zambians shun theuse of less risky sexual methods such as oral sex, and mutualmasturbation because of culture beliefs, myths and misconceptions

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about these methods. It is believed that when a spouse of acouple that has engaged in oral sex dies, the ghost of thepartner will haunt the surviving spouse until she/ he also dies.This cultural belief is so strong that many couples do notentertain any other sexual method but vaginal sex only. The useof dildos and other sex objects is not possible as policies donot allow for these gadgets to be available and if found to ownany of these, it is considered as pornography which carries ajail term or heavy fine.

3.2.4.5 Sex under the influence of drugs/alcohol It has been found that serodiscordant couples who have reportedsex while under the influence of alcohol or drugs tend to havemore positive results for concordance than the serodiscordantcouples who do not use alcohol during sex. This is so becausealcohol and drugs make people less careful with regard toprecautions or safe sex (Skurnick, 2006; Kennedy, 1993).

Depending on the level of Alcohol and drugs consumed, this actioncan result in high sexual libido and thus allowing rough sex actsthat may result in tiring of tissues. These actions inserodiscordant couples will increase the risk of infecting thenegative partner (Schiltz, 2007; Coldiron, 2006; McKirman, 1996;Lightfoot, 2005; Buchacz, 2000)The increased risk of infection due to alcohol and drug use canbe seen in one study in Lusaka and Kigali that reported all 6women and 2 men who seroconverted as having had sex while one orboth partners were under the influence of alcohol (Allen et al2007).

3.2.4.6 Use of libido enhancersUse of libido enhancers increases the risk of infection tonegative partner as it enables partners to perform sexualintercourse for long duration of time. This may result inbruising and swelling of genital parts and thereby increasing therisk of transmitting HIV.From the author’s observations, having sexual intercourse that

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lasts for long duration of time is seen as a sign of virility andpotency for men and it is well encouraged among married peers.Culturally encouraged is the taking of sex enhancers amongmarried people. They are meant to provide strength, prolong andmaintain erections for a long time for men. 3.2.4.7 Sex during menstruationSex during menses increases the risk of infection to the negativepartner in serodiscordant couples (Coulaud, 1993 as cited byFreeman, 2004; Allen, 1992) But in the only study that referred to this phenomenon in Zambia,the four cities study, it was found that the city with thehighest HIV prevalence (Ndola) reported the lowest practice ofsex during menstruation. Only 2 out of 42 couples who hadseroconverted had reported having sex during menstruation inNdola (Freeman, 2004). This indicates that, sex duringmenstruation may not be as risky in serodiscordant couples. Butagain, one may have to look at the sample that was being used inthis study. This was a conveniently selected sample of subjectsthat were attending clinical services and it was also too small asample in which diverse populations may not be reached. And sincesex during menstruation is taboo in the Zambian culture, manycouples would not reveal taking part in this sexual practice forfear of being frowned upon. In reality this practice is quitecommon among Zambian couples believing that having sex whilemenstruation would prevent pregnancy. 3.2.4.8 Young age Being young and serodiscordant can increase the risk of infectionto the negative partner. Being young they have wishes to havechildren and make up families. For the young female partners,they are not biologically capable of withstanding trauma orpressure to the genital areas and thereby have increased risk ofgetting infected if and when in a serodiscordant relationship(UNAIDS 2002).As young serodiscordant couples strive to have a family, theyincrease in their coital acts that are unprotected exposing the

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negative partner to infection (Gray, 2001). According to findings by Chomba (2007) and Carpenter (1999) olderserodiscordant couples had less risk of transmitting HIV to thenegative partner than the young couples. There could be severalexplanations to this finding. Maybe the older couples selectedwhere those that had less frequent sex encounters within theirmarriages. As this is usually the case according to the writer’sexperience. 3.2.4.9 Lack of Male circumcision Lack of male circumcision increases risk of infecting thenegative partner in serodiscordant couples (Weiss, 2000; Baeten,2005). In the Kenya, Uganda studies, it was found that circumcisiondecreased the chances of getting infected by between 51% and 53%in serodiscordant relationships (Fauci, 2007). In the Ndola studyit was found that the majority serodiscordant couples that hadseroconverted to concordant positive, had a large number of menwho were not circumcised (Auvert et al, 2001; Freeman and Glynn,2002).

Unfortunately Zambia is among SSA countries with the lowestpercentage of male population that is circumcised (Medical News,2008). It has less than 20% prevalence of male circumcision(jhpiego, undated). Only one tribe, the Luvale tribe and Muslimswho are a minority practice male circumcision in Zambia leavingmajority of men uncircumcised.

3.2.4.10 Stigma and discriminationStigma and discrimination can increase the risk of transmittingHIV to the negative partner. Fear of the consequences of stigmaand discrimination may lead couples into continued risk behaviorand or bad health seeking behavior. Admassu (2000) and Denning, Michael and Campsmith (2005)established that one of the reasons the majority of HIV positivepartners in serodiscordant couples continued having unprotectedsex even when they knew their status was due to fear of being

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found out by the world outside their partnerships. In addition tothis in Zambia, the stigma attached to HIV is still high and forone to reveal the couples status would attract ridicule. If it isa male negative couple, the man will be seen as weak for stayingwith a wife that had cheated on him with other men and gotinfected. This is because culture frowns upon women who are seento unfaithful but support men in their concurrent relationships(own observation)If it is a female negative partner couple, families to the malepartner have been known to accuse the female partner ofwitchcraft and they face taunting accusations and being draggedinto witch hunting to prove they bewitched their husbands.

CHAPTER 4 CHALLENGES EXPERIENCED BY SERODISCORDANTCOUPLES IntroductionSerodiscordant couples face many challenging issues in theirpersonal and family lives. Disclosure, sexual intimacy, illness,planning, reproductive health, roles and responsibility, moodstates and depression and violence are some of the issues thatthey face (Remien, 2003; Bunnell, 2005; Rolland, 1994). However,these challenges do not apply to all types of serodiscordantcouples. There are specific challenges to every specific type and

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stages of serodiscordant couples. But as Cichocki (2007)reported, serodiscordant couples in general experience stress,anxiety, fear and concern caused by the situation of having twodifferent HIV statuses, a situation which is not easy to manageand a situation that gives way to a lot of negative reactions.This chapter will discuss types of serodiscordant couples andtheir specific challenges.The following are some of the types and/ or stages identified bythis writer;

Unaware serodiscordant couples. These are not aware of theirsero status. This type of couple does not experience anychallenges as they are not aware of their status and thushave not come face to face with what it means to beserodiscordant.

Unaware serodiscordant couple with an symptomatic positivepartner raising suspicions about the presence of HIV in thecouple. Both these partners are unaware, but emergingsymptoms in one partner who is actually positive will evokesuspicions in the other partner or in both. As the symptoms begin to show, it becomes difficult tomaintain sexual intimacy. The positive partner begins tofeel shame about their illness and tend to withdraw fromsexual intimacy as they go through suspicions about theirsymptoms and begin to suspect HIV. They worry about beingHIV positive and dread the time their partners would requestto find out why they have such symptoms. Suggesting for atest would seem like they accept being unfaithful andpositive. While the other partner will also dread the ideaof finding out what is causing the symptoms in case they areaccused of implying that their partner is HIV positive. Theyboth worry about how to bring up the issue of VCT withoutaccusing each other.

Serodiscordant couple with aware HIV positive partner andunaware HIV negative partner and may or may not suspect thepresence of HIV. They may not face challenges as a couple

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but the aware positive partner will suffer guilty feelingsabout putting the other at risk of infection every time theyhave coital contacts. Withdrawing from sexual intimacy willbring about suspicions. The positive partner will agonizeover how to disclose their status without causing a lot ofproblems. They will worry over what reaction to expect fromfamily and friends. If it the female positive partner,issues of divorce, separation, violence will be paramountworry to them if found out and the possibilities of havinguninfected children.

Aware Serodiscordant couple with both partners aware oftheir serodiscordant status. Challenges experienced in thiscouple will differ according to which sex is sero-positiveand which one is sero negative. The positive partner willstress over how and when they might have gotten infected andby who and how to explain the source of the infection totheir partner. They will suffer feelings of shame and try byall means to not disclose to others for fear of stigma fromfamily, friends and employers. They will stress over whenthe AIDS stage will be and what will happen then. If it isthe female partner who is positive, they will sufferanxieties over being divorced, separated and loss of supportas women are not expected to be promiscuous. The malenegative partner will withdraw from sexual intimacy aspunishment and even support. While if it is the malepositive partner, the female partner will be threatened withviolence, divorce or loss of financial support if theywithdraw from sexual intimacy. The positive partner willsuffer loss of trust and blame by the negative partner forbringing HIV in the home. Both couples will be forced toplan for the future of their family through writing of will(which is taboo in Zambian communities as it meanspredicting one’s own death) and having Bank savings(difficult due to economic situation). They will also worryover ensuring that the negative partner does not getinfected and therefore be forced to learn new safe sexual

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practices.

Aware serodiscordant couple with positive partner on ARVtreatment. Couples have to deal with side effects of ARTswhich are sometimes psychological and physical. For thepositive partner they will face possibilities of becomingdrug resistant and thus worry over what will happen if theyseroconvert themselves. They will endure unpredictable moodchanges and depressive moods. For the female positivepartner they will worry over the effects of treatment ontheir possibilities of having normal pregnancy and thoughthey may have uninfected children the possibility of ARTsnegatively affecting the pregnancy and unborn baby willcause a lot of anxieties. They will face stigma from family,friends and health workers. Being female, family and friendswill pressure the male partner to divorce or separate from apromiscuous woman and thus they may face the future alonewith no support to enable them continue treatment. They mayalso not be able to follow strict adherence to treatment asthey will be under strict instructions from their malepartners not to be open or be seen to seek treatment locallyand thus have to walk or travel long distances to seektreatment or just not seek treatment at all. In themeantime. Male positive partner, since they have thefinancial power, will be able to privately seek treatment.

Aware serodiscordant couple with a chronically ill positivepartner. Facing and accepting death becomes a real issue andfrightening for the couple as the positive partner becomesweaker and chronically ill.Maintaining sexual intimacy is a big challenge as thepartner becomes unattractive and less appealing. At thisstage negative spouses have to learn or taking up new rolesthat they were not used to before. If it is the femalespouse who is positive, they will worry over who will carefor the children and family generally. While the negativemale partner will have to become the sole carer of the

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children both financially and physically doing the chores ofthe wife and risk being laughed upon by family, friends andcommunity. If it is a male spouse who is positive, they willworry over the possibility of losing their work and thus putthe family in financial doldrums which may result inchildren getting out of school. At work, he will face thepossibility of losing his position to a less position orbeing placed on half salary and told to stay home till he iswell enough.

Serodiscordant couples like any other PLWH, experience stigma byHealth workers. It is common to hear health workers blaming illpeople for their predicament. Even the way they treat them is soobvious about the way they do not approve of their illness. Theyhave I don’t care attitude and are mostly rough and use bitterwords about how they make their work difficult. Serodiscordantcouples have to cope with this type of behavior every time theygo for their treatment at clinics. They have to deal with healthworkers who openly discriminate against them, most of the timesserving them last. They visit health clinics which have no drugsto treat their symptoms and have no time to attend to their otherconcerns.

CHAPTER 5 CHALLENGES FACED BY HEALTH WORKERS AND HIV/AIDS CONTROLPROGRAMMES

IntroductionIn trying to help serodiscordant couples deal with theirsituation, health workers as well as control programmes face manydifficulties that make their efforts ineffective resulting infailure to reduce HIV infections in serodiscordant couples.

Health care services and control programmes are part of thefactors that can influence sexual decision making inserodiscordant couples (Bunnell, 2005). And thereforeserodiscordant couples need the support of health services tohelp them manage their condition effectively (El-Bassel, 2003).

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Through the provision of Couple counselling and other servicesthat go with it, these services are known to be the mosteffective way of addressing increasing infections in marriedcouples (Painter, 2001). The importance of having these serviceswell tailored and accessible to this risky group cannot besufficiently emphasized. However, this is not the case in Zambiaas the environment itself is not conducive to provide effectivehelp to serodiscordant couples and other couples in general.

This chapter discusses the challenges faced by Health careworkers and HIV and AIDS control programmes.

5.1 Lack of appropriate training and informationSerodiscordance is a complex situation. The fact that it is amarried couple involved makes it even more challenging. In tryingto help serodiscordant couples resolve daily issues theyencounter, one has to be responsive to real issues pertaining toserodiscordance and marriage. Since the counsellors concern is tohelp couples deal with the source of infection, risk reductionstrategies, safer sex negotiations and care and support, one needto be cultural sensitive, understand and appreciate behaviordynamics in married couples. This is not so in Zambian couplecounselling services. Due to their type of training, manycounsellors are not aware about the significance of culturebeliefs and practices in marriage. They fail to appreciate andconsider issues of gender, violence in homes, unequal powerpositions of man and wife, economic dependence of women on menand how these affect women’s ability to make decisions, to seektreatment and generally protect themselves against infection orprotect their spouses from getting infected. Counsellors furtherfail to incorporate traditional ways of dealing with maritalissues that would be more effective. An example of this is whenyoung unmarried counsellors are made to counsel couples.Counsellors’ approach to counselling couples is so technical.They depend on theory learnt and what the handbook stipulateother than practical issues. They fail to appreciate theimportance of cultural and traditional norms and practices. An

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example of where they expect equal power for both wife andhusband when culturally and practically men are considereddecision makers. So practically men will speak first and womenonly speak when they are given the go ahead by male partner as asign of respect. It is common to find counsellors trying toencourage spouses to disclose their status without understandingor trying to help resolve client concerns about the consequencessuch as violence, divorce, shame and stigma. They ignore the factthat there is gender inequality, gender violence and strictcultural norms and values that make disclosure almost impossible;their only concern is prevention. Counsellors end up encounteringproblems such as resistance to disclose, continued practice ofunsafe sex behavior and just plain avoidance of VCT services bycouples.

Counsellors are faced with the problems of having many individualpartners consulting them for VCT other than as couples. In thissituation, they are faced with the task of ensuring that theirclients disclose to their partners which is almost impossibleespecially considering consequences expected from disclosure. Itis difficult to have couples go for counselling at the same time.Counsellors face situations where they have individual partnersas individual clients and they have to ensure they do not breakconfidentiality by revealing information to any of thesepartners. And when couples manage to go for counselling together,it is hard work for counsellors to have them talk openly abouttheir sex and sexuality. The feeling of exposing their intimatelives to a stranger makes it difficult to be trusted ascounsellor. Culturally, married couples have to consulttraditional elders to help sort out issues if needed and for acouple to be seen to consult a stranger for their marital issuesis frowned upon. In these traditional sessions, couples presenttheir problems and solutions are made for them by elders while inthe modern counselling, they need to come up with their solutionswhich they are not used to do.

5.2 Loss of couple client contacts before disclosure 26

Post test counselling itself is forced disclosure, becausecouples are expected to reveal their results when they get them.So when the counsellor presents the results they encounter manycouples refusing to know the results as they may not be ready todisclose and decide to postpone knowing the results later and thecouple may never come back. This means continuous risk sexualbehavior which the counsellor has no power to do anything aboutand this is frustrating for counsellors whose aim is to protectthe negative partner from infection.

5.3 Inability to prevent violence after disclosure (Ethicaldilemma)Counsellors face ethical dilemmas where they cannot do anythingabout impending violence and refusal to disclose. Even if peoplehave consented at pretest and post test, they may feeldifferently about disclosing in a couple and may refuse todisclose.Within the counselling sessions, after disclosure, even thoughcounsellors do not observe any threats of violence, separation,abandonment or divorce between a couple, the possibilities thatthese will take place is always in their minds but they areunable to prevent them because it happens after couples returnhome and counsellors have no control over what happens at thecouple’s home. The victim spouse cannot be protected beyond theoffice of the counsellor. Even when they finally report to thecounsellor on the abuse and violence they have suffered afterdisclosure, the counsellors have no tangible solutions such asplacement homes or safe homes for such victims and end up sendingclients back to their homes

5.4 Ill equipped health care services Though Counsellors would like to provide quality services tocouples, which need time and patience, this is not possible asthe profession of counselling is adversely understaffed. Zambiais reportedly having only 3000 counselors for the estimated1,477,000 PLHIV (Mwila, 2007). There are times when clients aremade to see different counselors maybe because their counsellor

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is busy, or has resigned or just not available makingconfidentiality and privacy difficult to maintain.

Counsellors stress over their inability to provide safe andsecure counselling rooms for couples. Unfortunately their workingrooms are not planned to provide private enough privacy andconfidentiality for couples. Counselling rooms are shared withother services other than counselling. They are situated in busyareas and open spaces and are inadequately furnished for couplescounselling (As cited by Mwila, 2007). This creates constantworry as they risk legal action from clients who may claim breachof confidentiality.

In dealing with serodiscordant couples, supportive or follow upservices is important in helping them maintain their status.Unfortunately counsellors operate without any funding for theseactivities (FHI, 2001; Gbikpi, 2000). They are made to improvise,sometimes using their own meager resources in order to helpserodiscordant couples access supportive services.

5.5 Restrictive code of Ethics and lack of Professional support Counsellors further face ethical constraints in their quest toprovide effective counselling to couples. As shown in RCT inKenya, Trinidad and Tanzania among 4000 respondents, thoughdisclosure was found to be the most effective way of reducingsexual risk behavior, counsellors reported facing ethicaldilemmas that prevented them from ensuring that disclosure wascarried out as soon as possible to ensure the safety of thenegative (Best, 2002). In their work, counsellors have to livewith the feeling of inadequacy. Their states of powerlessness todisclose on behalf of partners who delay bring frustrations,stress and sometimes depression knowing they cannot protect thenegative partner (Odhiambo, 2007).

5.6 Non-integrated Reproductive Health and TB ServicesWith no time and understaffed, counsellors would manage theirclients well if the services are well integrated in one place

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(Bruyn et al 2006). Services such as TB family planning, PMTCT,condoms, STI and TB screening and treatment and Fertilityservices are important services for serodiscordant couples (WHO,2008; (Bruyn et al 2006; Vernazza et al, 2006,). But these are soset apart with different administration and information on theseservices is non-existent making it difficult effective referraldifficult for counsellors. Counsellors use their most valued timetrying to locate these services. Most of the time counsellorreferrals are disregarded or not given the attention they deserveby other health workers.

5.7 Inadequate health care policies for serodiscordancecounsellingTo better address the problem of serodiscordance there is needfor better policies and guidelines to ensure provision ofresources for support, treatment, education and advocacyprogrammes (Gbikpi, 2000). In Zambia, HIV/AIDS control programsworking with serodiscordant couples operate in an environmentthat has insufficient guidelines and policies that do notacknowledge serodiscordance as an important driver of theepidemic and insufficient attention in policies of HIVprevention.These incidences show difficult situations in couple counsellingexperienced by counsellors. Their training does not cover many ofthese important issues.Therefore, though Couple counselling has been promoted as an

effectiveway of reducing infections in married couples in Zambia and hasbeen estimated to reduce 60% of HIV infections taking place inserodiscordant couples (Dunkle, 2008) this is not possible aslong as comprehensive training is not affected and responsivepolicies not put in place. Some of these challenges account forthe low VCT uptake among married couples in Zambia. In Lusakaurban, only one out of ten who passed through KARA counsellingand Training Trust agreed to take an HIV test in 1997 (Kara,1997).

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CHAPTER 7 SUMMARY AND RECOMMENDATIONSThis study discussed the findings of the literature review on the

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transmission dynamics of HIV in Serodiscordant couples and howthis contributes to increase in the risk of infection to thenegative partner and further discussed challenges faced byserodiscordant couples, challenges of Health workers and HIV/AIDScontrol programs in trying to help serodiscordant couples dealwith their situation were also discussed.

It is evident from the review that serodiscordance is one of thedrivers of HIV epidemic in Zambia and it presents a growingpublic health problem that needs urgent effective and specificintervention.The literature review revealed that the prevalence ofserodiscordance in Zambia does not differ from other countries inthe SSA region. Though it is not clear how much serodiscordanceis a problem in Zambia, the prevalence ranges between 4 and 7% asshown by many other SSA countries that carried out populationsurveys and have the same characteristics as Zambia.

It has further been found that the risk of infection ofinfections to the negative partner in serodiscordant couples isaffected by different factors within the transmission dynamics ofHIV. The level of risk depends on four main transmission dynamicsnamely; stage of infection of the positive partner, presence ofSTDs, frequency of coital acts and other risk factors thatinclude dry sex, non condom use, gender and violence, method ofsex practice, sex under the influence of drugs/alcohol, use oflibido enhancers, sex during menstruation, young age, lack ofmale circumcision and stigma and discrimination.

Thirdly the review found that serodiscordant couples differ insituations and thus can be classified according to thesesituations. There are about seven types or stages ofserodiscordant couples discussed in this thesis and these arealso different according to whether it is a male positive partneror it is a female positive partner and they are namely;

unaware couple where both spouses have no idea about theirserostatus,

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couple with one symptomatic spouse but unaware, couple with aware positive partner and unaware negative

partner, aware couple with both partners aware of their

serodiscordant status, aware couple with both partners aware of their status as

serodiscordant aware couple with positive partner on treatment and aware couple with chronically ill positive partner couple.

Each of these types experience unique and sometimes overlappingchallenges. What is most outstanding is that they all experienceanxieties, stress and fear and concern about their situationexcept for the unaware couples. Some of the outstandingchallenges are disclosing, maintaining intimacy, uncertaintyabout illness progression, fulfilling reproductive health needs,managing effects of treatment, gender violence, and stigma anddiscrimination from work, friends, and family and health workers.

Last but not the least, this review established that in trying tohelp serodiscordant couples deal with their situations, healthworkers and HIV control programmes encounter difficulties thatmake their work ineffective. Counsellors lack of appropriate andcultural sensitive training. They face situations whereindividual partners in a couple seek counselling as opposed tocouples coming for counselling together and thereby have extrawork to ensure disclosure takes place. They experience loss ofcouple contact before disclosure takes place and stress over howthey could protect the negative partner from infection. Eventhough they assess danger to a spouse after disclosure they areunable to prevent violence and abuse after counselling. They haveno way of forcing or making sure disclosure takes place whenpartners do not feel like disclosing. In addition, they operatein ill equipped health care services, restrictive professionalcode of ethics and environment that lacks professionalinstruments to protect them. They are made to work in nonintegrated reproductive health services and TB programmes makingaccess difficult for their financially needy couples. They work

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in an environment with inadequate health care policies andguidelines that insufficiently acknowledge serodiscordance as adriver of the epidemic and policies that give less attention toHIV prevention in serodiscordant couples.

RECOMMENDATIONS

POLICYReformulate HIV and AIDS policy to include the importance ofreducing increasing HIV infections in serodiscordant couples andmarried couples and integrate HIV prevention strategies in theNational HIV and AIDS programmes.

Policy on HIV and AIDS prevention must reflect the need to maketreatment of STDs more anonymous with anonymous disclosure ofcontacts.

Enforce the policy on making ART more universally accessible asthis will redress some of the problems of adherence and reducerisk of HIV transmissions in couples.

Get political and traditional leaders engaged in talking openlyabout issues related to HIV and in particular Serodiscordance andconcurrency. These important phenomena need to be brought in theopen and reinforced by using political leaders in getting an ideaof what people see as HIV risk factors.

PRACTICEPlan and implement specific programmes for specific types ofserodiscordant couples in order to be effective

There is need to strengthen education, information and promotionon condom use in married couples in Zambia.

Programmes must involve traditional leaders, practitioners anddoctors in trying to do away with some of the negative traditions

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that increase risk of infections and in developing appropriatecouple counselling techniques that will be more acceptable.Because marriage is so attached to culture and tradition, thereis need to involve traditional healers and leaders in programmestargeting married couples.

Provide social safety net to mitigate the impact of HIV onserodiscordant families especially for women with chronically illbreadwinners to reduce risk of infection from outside therelationship for the surviving partner.

In coming up with programmes on couple counselling, culturalcontexts must be put in mind to reflect the peoples way of lifethan other cultures that are not relevant to the Zambiansituation if they have to be effective and relevant.

HIV and AIDS awareness programmes for PMTCT must ensure targetboth men and women as a way of ensuring men also to appreciatethe need for behavior change in prevention of HIV in theirmarriages.

Incorporating mental health programmes in supportive counsellingfor serodiscordant couples to help them in deal with theirdepression, stress and anxieties.

Need to encourage formation of a strong and reliable continuum ofcare in communities that will include legal services, home basedcare, PMTCT, VCT, social safety nets and other general healthservices. This will help reduce stigma and discrimination andsocial isolation of the couples and PLWH generally.

Need training of couple counsellors in specific skills neededfor dealing with serodiscordant couples.

To be able to make counselling accessible to all, schools mayhave to be used as HIV and AIDS programme centres in Zambia. Thisis because after every 5km there is a school and many people in

34

the rural areas will be able to access them.

Reproductive health services need to be integrated and closecollaboration mechanisms established for instance with TBservices, GBV agencies, Legal services, Social safety nets,workplace programs, media agencies etc. This will make referralmanageable and also make access easy. It will ensure evaluationand monitoring of different programmes easy and ensure betterimproved service for couples

More funding must be provided for programmes targeting couples inZambia.

RESEARCHIntegrate serodiscordance into DHS and HIV surveillance system.There is need to seriously think about carrying out a populationbased survey/ studies that include serodiscordance in order toestablish the extent of the problem of serodiscordance in Zambia

Need for a study in the behavioral issues and dynamics ofserodiscordant relationships to help understand this risk groupsbehavioral dynamics and how these contribute to risk of infectionto the negative partner.

Baseline survey/ study on the introduction of couple counsellingspecific centres/programmes.

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APPENDICES

Map of Zambia

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FIGURE ON STAGES OF INFECTIONTo illustrate the levels of the virus in the blood and semen ofan HIV positive person according to their stage of infection andthe numbers of coital acts needed to transmit HIV at each stageof infection, the figure below by Hayes and White (2006) is used.In this figure, the Yellow bar is showing the highest viral loadin the male semen and blood at each stage of infection, while thered bar is showing the viral load after an intervention to reduceviral replication in the semen/blood at each stage of infection.The dotted line shows the lowest viral load in the semen/bloodbut still infectious. Figure B is showing the viral load at each stage of infection ifand when STDs are present in the positive partner at any stage ofinfection.

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