Discordance: In Sickness And In Health

Currently the prevalence rate of HIV/AIDS in Nigeria is 5.6% and NACA claims that 6.1million Nigerians are living with HIV. 


In my opinion, these figures are conservative as I believe we have glitches in our bio-statistics in these parts. That, however, is for another day.


An issue that is gradually assuming significant proportion however is HIV discordance. Discordance simply means there is an incompatibility between a man and his wife i.e the presence of the HIV in one member of a couple. Put simply, the man is positive and the wife is negative or vice versa.


Ongoing research on the cause of HIV discordance has not been  successful enough in describing the pathogenesis. What I can affirm is that it exists and I see it everyday.


The discordant rate is on the increase and I believe we need give the issue the much deserved attention. A study done in UCH Ibadan puts discordance rate in the Prevention-Of-Mother-To-Child-Transmission Clinic (PMTCT) as high as 45%. That's startling! It means of every 10 women who attend that clinic, 4 have sero-negative spouses. 


Unfortunately, unfaithfulness is the reason most adduced for the trend. Even though it may be a factor, it really cannot completely explain the problem. Factors implicated in discordance include the anatomical structure of the genitals of men and women, circumcision of males and level of sexual experience prior to marriage. Of course there are the other means of transmission such as intravenous drug abuse, vertical transmission, needle and other sharp infected pricks and blood transfusion.


It is scientifically proven that the females are more susceptible to getting the virus via unprotected intercourse by virtue of the anatomy of the external genitalia. The vagina presents a wider surface area and secretes more fluids thus the transmission rate is twice as high from a man to a woman than from a woman to a man. What this means is that, a 'lucky' man could have intercourse with an infected woman twice before getting the virus while a woman could have intercourse just once with an infected man and become infected. It thus leaves the probability that a negative wife could -by chance- not transmit the virus to the husband. This however is not a hard and fast rule. It is totally 'by chance'. Its science. Did I hear someone say its a man's world?


Male circumcision is also a factor as it has been documented scientifically that circumcision reduces transmission rates. Some reports say it reduces transmission by as much as 60%. Little wonder, the male Zimbabwean legislators recently submitted themselves for mass circumcision. Unfortunately, this only holds for the males. Again, did someone say its a man's world?


Another argument is the level of the female's sexual experience before marriage. From the foregoing about anatomical susceptibility, a woman who has had multiple sexual partners in the past would be particularly at risk. 


I spoke to a client recently who is currently on antiretroviral therapy. She refuses to disclose her status to her husband. She has probably been on medication for at least a year now with the husband not even having the slightest idea. Yet, they live together, they eat together and they sleep together. More worrisome is the fact that in a bid to keep her secret a secret, she allows him to have unprotected intercourse liberally just so he doesn't suspect anything. Her fear is that the man will send her packing the day he finds out she's positive and he presumably is negative. The contention will be how to explain the discordance without tagging her 'promiscuous and wayward'. 


So she is faced with two evils. Which is the lesser one? Does she come out clean with hubby and risk losing her home? Or does she continue the mendacious modus operandi and continue to expose her 'beloved' hubby to the virus? 


Ethically, its not my business. My primary allegiance lies with my patient. I have tried unsuccessfully to convince her to tell her hubby, she will not hear of it. She says she 'loves' him too much for him to leave her and she argues she might not survive the heartache if he did leave her. Then again, her hubby could be my friend, who I met socially or even a childhood buddy. This work no easy o! 


It then begs the question, what is the place of marital vows? They both swore before God to be together, in sickness and in health. She currently jeopardizes the life of her beloved husband while the husband also has not assured her he'll remain with her 'in sickness'. There must be something in his demeanor that makes her so certain he'll leave her. But then again, is it possible that she's just paranoid?


She's not alone. Several other discordant women and men continue to hide their statuses from their spouses. I know several. Some close acquaintances, some professionally. Call them cowardly, call them selfish but they are only being self preservative as any other human will be.


We should talk about the causes of discordance. It is clear from the foregoing that promiscuity is not the sole reason why a couple could be discordant. She may have been transfused poorly screened blood or even blood that had the virus in the latent period (window period). Surely, she's not to blame for that! He may have been inadvertently cut by the barber's public non-sterilized clipper. Who knows, its all by chance. He may even be a Doctor who was exposed occupationally. He may have had needle pricks with HIV infected blood. She may have gone for an innocuous tattoo or even just abused drugs intravenously as a teenager. Stupid, yes but have we not all done stupid things? Thankfully, we have information now. Who knows if there was no such luxury at the time?.


Overall, I believe stigmatization is at the center of the problem. Culturally, we still have serious acceptance issues. We stigmatize almost subconsciously. Maybe the trend will change when we begin to relate equally and respectfully with PLWHA.


In the mean time, get tested and know your status. Unlike before, these days, what you don't know can kill you.






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