Moving beyond ‘risk’ and ‘difference’: understanding the dynamics of serodiscordant relationships

HIV Australia | Vol. 12 No. 1 | March 2014

By Asha Persson and Jeanne Ellard

ASHA PERSSON and JEANNE ELLARD shed light on the experiences of serodiscordant couples.

Relationships between partners with mixed HIV status (serodiscordance) exist wherever the epidemic exists, and are seen as a major context in which HIV transmission occurs in many parts of the world. As a result, ‘risk’ has become a key focus in prevention research on serodiscordant relationships.

Much of this research is informed by an assumption that serodiscordant partners always perceive and experience their respective serostatus in terms of their ‘difference’ from one another, a difference that they recognise as a distinctive sexual ‘risk’, which they are deemed to manage competently or not.

But even though surveys and trials investigating sexual behaviour and HIV transmission among serodiscordant couples have burgeoned in recent years, they shed little light on how couples themselves perceive their relationship and sexual practices, or whether HIV ‘risk’ might be understood in ways that differ from that of epidemiologists, prevention experts, or social scientists.

The notion that serodiscordant relationships are inevitably defined by ‘difference’ and ‘risk’ is challenged by a small but growing body of studies from different parts of the world that show how serodiscordance can encompass a range of local meanings and practices that far exceed any simple or unitary definition.¹

To understand the dynamics of serodiscordance, there is a need to move beyond the idea of ‘risk’ as an objective fact, and instead examine what HIV ‘risk’ actually means in different cultures and contexts, and how serodiscordance is shaped in many and varied ways by gender, sexuality, medicine, relationship priorities, competing logics, community attitudes, and the dynamics of local epidemics.

It is within these contexts that perceptions and negotiations of HIV risk arise and, therefore, where couples’ sexual practices need to be situated and understood.

Such insights are timely as the international HIV community grapple with emerging scientific data on the preventative effects of antiretroviral treatment, which are challenging and changing long-held understandings about HIV transmission risk.

How might the global push for treatment as prevention (TasP) give rise to new forms of intimacy and prevention among couples in different cultural settings?

NSW provides a good case study, with TasP being a central component of its new HIV Strategy² and Ending HIV campaign.³

In partnership with several research centres and community HIV organisations, the Centre for Social Research in Health (UNSW) is currently conducting a qualitative study in NSW on the social, sexual, emotional and medical management of HIV among serodiscordant couples in a changing epidemic: YouMe&HIV.⁴

Preliminary findings from this study suggest that, for many of the 29 participants interviewed so far, HIV treatment is central to serodiscordant relationships; because it enables a sense of sexual safety, and thereby, a sense of possibility.

There just seems to be this movement towards it now, which is awesome, you know, it’s great. So it’s just … opened my eyes to a whole new world, really. And I guess I’ve been living in a fairly limited view of how all this had to work for me and now I just feel freer … I can actually love who I love, rather than be limited to, you know, “Are you positive or not?” Yeah, that’s big.

– HIV-positive gay man

I can speak as a positive person, the fear of infecting someone else is just overwhelming, especially somebody you love. And so, you know … [TasP] would help you to be able to relax and enjoy your sex life, enjoy your relationship with your partner. It’s one less thing to worry about.

– HIV-positive heterosexual woman

Nearly all HIV-positive partners interviewed so far are on effective treatment, and both positive and negative partners are overwhelmingly positive about the mounting research and growing global consensus on HIV treatments as a prevention tool.

Yet there are a range of perspectives on HIV risk, as suggested by three themes emerging in the interviews: TasP provides ‘an extra layer of protection’ alongside ongoing commitment to condom use, as it is not safe enough on its own:

I think the treatments should commence sooner rather than later … [The possibility of unprotected sex because of TasP] flew through my mind once and I thought “no, the last thing I’d ever want to do is have something go wrong and him get HIV”. I couldn’t do that to him. I love him too much. And that was the end of that argument. I’m not willing to risk it. And condoms are the best method of prevention still today.

– HIV-positive gay man

Growing recognition of TasP provides ‘welcome relief, reassurance or validation’ for those who already practise unprotected sex:

[Unprotected sex] was very scary at first but, you know, it’s something that has to be negotiated as a couple … But now having seen the release of the [NSW HIV Strategy⁵] and understanding that this is, you know, a common consensus … that this is a positive move to take a step further to stopping HIV … it’s taken that uncomfortableness away, that fear away … I think that I can safely say that my partner and I believe that safe sex now … is having an undetectable viral load on its own.

–HIV-positive heterosexual woman

For those who dislike condoms or experience latex-sensitivity, TasP provides ‘permission to consider unprotected sex’:

And then that study [HPTN 052⁶] came out … So then we were like relieved, really, and able to kind of go ahead [and have unprotected sex] … And make a decision … I could sit there and go, “These are the facts. If he has his medication every day, which, by evidence, he’s doing that every day, I’m willing to take the risk because I know he’s doing everything he possibly can to keep me safe.

– HIV-negative trans man

For many participants, the notions of ‘risk’ and ‘difference’ are at the heart of what they see as significant stigma around serodiscordant relationships and the so called ‘sero-divide’ in affected communities. However, many negative partners emphasise that there is safety in ‘knowing what you’re dealing with’:

I’m safer with [partner] because I know it and I can face it head on, and do something about it rather than thinking that someone is negative and being at total risk. So there is that. So it’s a really good attribute that, you know, it’s there. Face it!

– HIV-negative gay man

While many couples simply ‘get on with it’, a serodiscordant relationship is by no means without its challenges, as participants make clear.

A number of issues and decisions can be at stake, including sexual safety, monogamy or open relationships, reproduction, treatment, testing, and disclosure to others. But preliminary findings suggest that the emotional work and honest communication that might be required by couples to tackle those challenges can bring about considerable closeness and solidarity in the relationship.

It’s a really conscious relationship in terms of communication, feelings, care, nurture, protection. It’s just all that stuff. It’s really, yeah, I guess [serodiscordance]’s been the platform for all of that stuff to really come to the fore.

– HIV-positive gay man

Although HIV figures in diverse and sometimes complex ways among the couples in the study, their relationships are not necessarily defined by ‘risk’ and ‘difference’, as is often assumed.

The picture of serodiscordant relationships emerging in the study is one of considerable emotional intimacy, and of both partners’ deep commitment to care for each other’s wellbeing.

At the same time, it is clear that serodiscordance is managed in very different ways and shaped by varied circumstances among the couples.

This will be explored in detail during the study to increase understanding about the needs and experiences of these couples and to ‘put them on the map’.

If you’d like more information or to participate in a confidential interview, contact Asha on (02) 9385 6414 or a.persson@unsw.edu.au, or visit: http://csrh.org/youmeandhiv

References

1 Persson, A. (2012). Notes on the concepts of ‘serodiscordance’ and ‘risk’ in couples with mixed HIV status. Global Public Health, 8(2), 209–220.

2 NSW Health, New South Wales Ministry of Health. (2012). NSW HIV Strategy 2012–2015: A new era. NSW Ministry of Health, Sydney. Retrieved from: http://www.health.nsw.gov.au/publications/Publications/nsw-hiv-strategy-2012-15.pdf

3 http://endinghiv.org.au

4 http://csrh.org/youmeandhiv/

5 NSW Health, (2012), op. cit.

6 HIV Prevention Trials Network. HPTN 052. (2012). A Randomized Trial to Evaluate the Effectiveness of Antiretroviral Therapy Plus HIV Primary Care versus HIV Primary Care Alone to Prevent the Sexual Transmission of HIV-1 in Serodiscordant Couples. Retrieved from: www.hptn.org