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‘People say that we are already dead much as we can still walk’: a qualitative investigation of community… Kim, Jiho; Nanfuka, Mastula; Moore, David; Shafic, Murisho; Nyonyitono, Maureen; Birungi, Josephine; Galenda, Florence; King, Rachel Nov 10, 2016

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RESEARCH ARTICLE Open Access‘People say that we are already dead muchas we can still walk’: a qualitativeinvestigation of community and couples’understanding of HIV serodiscordance inrural UgandaJiho Kim1, Mastula Nanfuka2, David Moore1,3, Murisho Shafic2, Maureen Nyonyitono2, Josephine Birungi2,Florence Galenda2 and Rachel King4*AbstractBackground: Stable, co-habiting HIV serodiscordant couples are a key population in terms of heterosexualtransmission in sub-Saharan Africa. Despite the wide availability of antiretroviral treatment and HIV educationalprograms, heterosexual transmission continues to drive the HIV epidemic in Africa. To investigate some of thefactors involved in transmission or maintenance of serodiscordant status, we designed a study to examineparticipants’ understanding of HIV serodiscordance and the implications this posed for their HIV preventionpractices.Methods: In-depth interviews were conducted with 28 serodiscordant couples enrolled in a treatment-as-prevention study in Jinja, Uganda. Participants were asked questions regarding sexual behaviour, beliefs intreatment and prevention, participants’ and communities’ understanding and context around HIV serodiscordance.Qualitative framework analysis capturing several main themes was carried out by a team of four members, andwas cross-checked for consistency.Results: It was found that most couples had difficulty explaining the phenomenon of serodiscordance and tendedto be confused regarding prevention. Many individuals still held beliefs in pseudoscientific explanations for HIVsusceptibility such as blood type and blood “strength”. The participants’ trust of treatment and medical serviceswere well established. However, the communities’ views of both serodiscordance and treatment were morepessimistic and wrought with mistrust. Stigmatization of serodiscordance and HIV-positive status were reportedfrequently.Conclusions: The results indicate that despite years of treatment and prevention methods being available,stigmatization and mistrust persist in the communities of HIV-affected individuals and may directly contribute tonew cases and seroconversion. We suggest that to optimize the effects of HIV treatment and prevention, cleareducation and support of such methods are sorely needed in sub-Saharan African communities.Keywords: HIV, Sexual health, Serodiscordance, Uganda, Africa* Correspondence: Rach@vtx.ch4Global Health Sciences, University of California San Francisco, San Francisco,California, USAFull list of author information is available at the end of the article© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Kim et al. BMC Infectious Diseases  (2016) 16:665 DOI 10.1186/s12879-016-1998-9BackgroundExpanded access to antiretroviral treatment (ART) hassignificantly reduced HIV-associated mortality and hascontributed to reduced HIV incidence, even in the mosthighly affected region, sub-Saharan Africa. An estimated1.4 million new infections occurred in the region in2014, which account for approximately 70 % of new in-fections worldwide [1]. Most new infections in this re-gion are due to heterosexual transmission, whichdistinguishes the epidemic in this area from most otherregions of the globe where transmission is driven pre-dominantly by transmission between men who have sexwith men (MSM) or people who use injection drugs.Transmission within HIV serodiscordant couples in mar-riage or cohabitation is thought to account for the ma-jority of new infections [2–4]. This major differencenecessitates the need for clear understanding of HIV-serodiscordant relationships and the couples’ under-standing of HIV, serodiscordance, prevention, andtreatment.Much of the research and program effort in HIV pre-vention for serodiscordant couples in Africa thus far hascentred on the correct use of condoms [5–7], microbi-cides [8, 9], the possibility of treatment as prevention(TasP) [10–12], and voluntary counselling and testing(VCT) [13, 14]. Many of these studies were able to es-tablish the effectiveness of such population-basedmethods in reducing HIV incidence [15, 16], but it stillremains clear that all of these interventions aredependent on behaviour and decision-making on part ofthe affected individuals. Thus, it is important to under-stand how individuals involved in a serodiscordant rela-tionship perceive their status and the interventionstaking place in their community.With the publication of the HPTN 052 trial whichdemonstrated a 96 % reduction in HIV transmissionwithin serodiscordant couples [17] associated with earlyuse of ART, HIV treatment in conjunction with propereducation and awareness [18, 19] are now recommendedas best practice for preventing transmission within sero-discorant relationships. Effectiveness of such interven-tions depend heavily on the couples’ attitudes towardsuch interventions and treatment; this has been moredifficult to measure but much misinformation and dis-trust persists in both the serodiscordant populations andtheir surrounding communities [20–22]. Previous quali-tative studies have found beliefs in “stronger blood” [23]and “spirits and supernatural forces” [24] behind the in-fection, all of which may contribute to some of the be-havioural challenges cited above [25] and mayundermine prevention efforts.We carried out a qualitative study to explore the per-ceptions of members of HIV serodiscordant couples interms of their understanding of serodiscordance oreventual seroconversion. Furthermore, we examinedhow this understanding affected and their sexual behav-ior and adherence to ART (for positive participants) inthe context of an observational study of TasP in ruraleast-central Uganda.MethodsAll of the HIV positive participants were clients of TheAIDS Support Organization (TASO) in Jinja, Uganda.TASO is the oldest and largest non-governmental HIVcare and treatment organization in Uganda. TASO pro-vides treatment and support to over 100,000 HIV-affected clients through 11 service centres across thecountry. The ART program at TASO-Jinja began in2004. Jinja is a moderate-sized town (population 90 000)in the eastern region of Uganda, approximately 80 kmeast of the capital, Kampala. Since serodiscordance wasrecognized as an important contributor to the HIV epi-demic in Uganda, TASO has provided opportunities fordiscordant couples to participate in support groups at allTASO centres as part of their routine programming.Thus, all study participants became TASO clients. Aswell, the concept of TasP has been widely reported inthe Ugandan media since the publication of the resultsof the HPTN 052 trial in 2010, but it is not known howwidely this concept has diffused down to the local levelto HIV care and treatment programs. The 2013 WHOguidelines have been largely adopted by Uganda in termsof recommending ART for HIV positive individualswhose regular sexual partners are HIV negative [26].However these guidelines had not yet been formulatedat the time of this study.Study subjects were part of an observational study ofTasP among serodiscordant couples known as the HighlyActive Antiretroviral therapy as Prevention (HAARP)study. The HAARP study compared HIV incidence be-tween HIV negative members of serodiscordant partnerswho were or were not receiving ART during the studyand was conducted from June 2009 to December 2011.The study did not find a benefit from ART in terms ofpreventing HIV seroconversion in the negative partici-pant [27]. As a result of these findings, we enrolled a se-lection of previous study participants in a qualitativesub-study for a series of in-depth interviews beginningin June 2013 and continuing until August 2014.A total of 28 couples, or 57 individuals were recruitedfor the study. At recruitment for this sub-study, one“couple” was involved in a polygamous relationship (onehusband and two wives). All couples were initially sero-discordant upon recruitment into the HAARP study.However, over the course of the HAARP study 14 of theHIV negative participants seroconverted. We specificallyselected these individuals and their partners for thisstudy. We then recruited 14 age (within +/- 5 years) andKim et al. BMC Infectious Diseases  (2016) 16:665 Page 2 of 8gender-matched control HIV positive participants whosepartners did not seroconvert in the study.Beginning in June 2013, trained interviewers carried outfive individual in-depth interviews over 12 months, witheach member of the couple interviewed separately. Inter-views were conducted at the TASO clinic site at Jinja,Uganda. The interviewers were a diverse group of TASOcaregivers, comprised of 1 physician, 2 nurses, and onecounsellor. Participants were compensated with 20 000Ugandan shillings (approximately $8 USD) at each inter-view for transportation costs. All interviews were gender-matched between the participant and the interviewer. In-terviewers asked open-ended questions regarding the cou-ples’ perceptions of serodiscordance, the participants’views of the community’s perception of serodiscordance,the couples’ sexual behaviour, desire to have children,opinions regarding HIV prevention strategies and the rolein which HIV treatment was incorporated into these strat-egies. For those couples where seroconversion occurred,further discussion included their perceptions of why thisoccurred. The interviews were carried out in the preferredlocal language (Luganda or Lusoga) of the participants, re-corded, and then transcribed and translated into English.We report here on the first of the five interviews.Three trained analysts coded translated transcriptsusing NVivo software for data management. We usedfor thematic coding and framework analysis as the pri-mary analytic strategy. Framework analysis uses fouranalytic stages: familiarization (reading multiple times),identification of themes (developing the codebook),indexing and charting that involves arranging summariesof the data into a database according to theme, sub-theme, category and interpretation [28]. Thus, afterreading three transcripts, the analysis team memberscollaboratively developed a codebook of themes basedon the interview topics as well as those emerging fromthe data. Three more transcripts were then reviewed toinclude additional topic areas and themes. This processwas repeated until the codebook reached a stage whereno new themes or topic areas emerged. All transcriptswere then coded using the final version of the codebookbefore themes were summarized across respondents.Analysis focused on identifying the dominant themesand the range of explanations for sexual behavior, moti-vations for preventive behaviour, treatment and compari-sons across participants. Interactive discussions wereheld with the analysis team to validate data interpreta-tions and resolve any interpretation discrepancies.The analysis team regularly compared coding to en-sure inter-rater consistency. NVivo Software Version 10(QSR International, Victoria, Australia) was used for allcoding and qualitative analysis.All interviews were conducted and recorded with theparticipants’ written informed consent. The studyreceived approval from the Research Ethics Board of theUniversity of British Columbia in Vancouver, Canadaand the Science and Ethics Committee of the UgandaVirus Research Institute and the Uganda NationalCouncil for Science and Technology in Uganda.ResultsInitial DemographicsAll clients consented to the qualitative interview process.A total of 57 individuals (28 male and 29 female) com-prising 28 partnerships were enrolled into the study. Ofthe 28 couples, in 22 the male member was the initiallyseropositive partner. The average age of all individualsinvolved was 42 years, with a standard deviation of9.2 years.Relationships and HIV riskDuring the qualitative interviews it was reported that atotal of 16 (57 %) of the partnerships involved polygam-ous relationships; which differed from the information atrecruitment where it was reported that only one couplewas polygamous. The distinction between wife andextramarital relationships is sometimes difficult to dis-cern in Ugandan communities, where co-wives often livein separate compounds and may even be sometimes un-aware of each other’s existence. Indeed, some womennoted that they only became aware of the presence ofanother wife in the relationship with the diagnosis ofHIV. Most HIV-positive men cited that they stoppedextramarital affairs with their HIV diagnosis. An inter-esting reason stated for this was the possibility of HIV“mixing”. As commented:‘If you have sex outside marriage you can get anotherkind of HIV […] when they mix, the one that youhave wakes up’ (Female, initially negative butseroconverted; 26 years old)Only one woman reported having extramarital rela-tionships. While many individuals mentioned previousrelationships and marriages, men were often more openabout their histories and any concurrent relationshipsthey may have had at the time of the interview.Another question asked of the couples regarding theirsexual relationship was the adjustment of the frequencyof sexual intercourse as a means of prevention. A major-ity of couples reduced the frequency after a positivediagnosis, and this follows some of the education theywere subject to upon knowing their discordant status.Many participants reported having sex about once everyweek after reduction. Although abstinence is often men-tioned as an option for serodiscordant couples, none ofthe couples said that they were abstaining. The longestduration that a couple went without sexual intercourseKim et al. BMC Infectious Diseases  (2016) 16:665 Page 3 of 8was approximately two months. One reason for rejectingabstinence centred on the importance of sexual inter-course as a means of maintaining the marriage bond, ascited by an HIV-positive male:‘But the problem is that when you decide to stophaving sex, then your wife will not stay home […] shewould say, “My husband no longer has energy to havesex, let me leave.’ (Male, initially seropositive inlasting serodiscordance; 40 years old)This concept of having sex to maintain the marriagefor fear of losing the partner or the partner searching forother sexual partners was commonly reported amongmale participants. A major reason cited by female partic-ipants was that husbands would often suspect them ofbeing unfaithful if abstinence was mentioned as an op-tion. Only a small number of couples cited attempt toconceive as a reason for avoiding abstinence.Condom use and supplyCondoms were the dominant method of HIV preventionreported by the couples in this study. Other methodsmentioned included female condoms and withdrawal be-fore climax. Some couples reported some difficultieswith first learning how to use condoms, but these prob-lems were rectified soon afterwards. Preference for usingcondoms varied significantly by gender and by serodis-cordant status. Many males expressed their distaste forusing condoms, saying that they “squeeze too much”, de-creased pleasure, and cause itching and pain. Somewomen also expressed discontent at the use of condoms,commonly citing “burning pain” in the genital areas withtheir use. Many seroconcordant couples had troublesusing condoms consistently especially before seroconver-sion, mainly on part of at least one partner refusing touse them. Proper use was cited to be more difficult be-fore seroconversion.The hardest or most difficult thing was usingcondoms at the time […] we are afraid of talkingabout condoms and that is why I found it even hardto use them since I didn’t know how to use themproperly […] some condoms were too slippery and gooff […] I think it was in 2011 after I had attended thestudy on how to use condoms [that I started usingthem properly]. (Male, initially seronegative butseroconverted; 50 years old)An interesting finding was that the couples whoremained serodiscordant more commonly reported thatthey came to a mutual agreement on condom-use,while the couples where seroconversion occured usuallyleft the decision to one member or chose not to usecondoms at all. This indifference to condom use wasoften reported as being present even before seroconver-sion occured in these couples, although the non-adherence to condom use became more pronouncedafter seroconversion occurred.Condom supply was adequate, and very few couplesrecalled situations when they wanted to have sex butno condoms were available. As mentioned, the mainissue with condom-use was with agreement betweencouple members and consistent usage.Perceptions about discordanceWhen asked of their own opinions about serodiscordantstatus, many individuals cited confusion and disbelief.Almost all individuals said that upon initial discovery ofdiscordance, they did not believe the test results. Partici-pants had multiple explanations for discordance. A com-mon explanation given was mistrust of the testingprocess; the phrase “testing machines were faulty” was arecurrent perception mentioned by many participants.Individuals said that the machines could have been mal-functioning, “could not be seeing the virus”, or that thetesting personnel were lying to them.Another common explanation for discordance was thepossibility of resistant or strong blood types, exemplifiedby the frequent mention of the blood group O. One ex-ample, cited by a HIV-positive female shows the per-ceived differences in blood type, classified as “strong”and “light”:‘The blood is different. You might have strong bloodyet your spouse has weak blood. There is blood typeA and O […] the strong one is the one of O. The oneof A is lighter.’ (Female, seropositive in couple whereseroconversion occurred; 30 years old)Blood type was commonly mentioned alongside thepossibility of blood being able to hide the virus from de-tection. The couples where seroconversion occurred ap-peared to report this belief more frequently, as theybelieved that the virus had been in their blood all alongand that seroconversion was inevitable. Other explana-tions for discordance included “will of god” and high fre-quency of HIV testing, where participants saw the highfrequency of testing directly contributing to the pro-longed state of serodiscordance and prevention of sero-conversion. Some individuals had no explanation at allfor discordance, and expressed much confusion at theirsituation.When asked about any advantage to being serodiscor-dant, a majority of couples said that the seronegativepartner could continue caring for the family and chil-dren. The belief that the seropositive member would nothave long to live or would not be able to lead a healthyKim et al. BMC Infectious Diseases  (2016) 16:665 Page 4 of 8life was widespread, despite the extensive rollout of ARTin Uganda and the fact that many of the HIV positiveparticipants had been living with the virus for over fiveyears. This belief also contributed to some couples strin-gently using condoms to prevent transmission.The few individuals who believed that discordance waspossible and present were often previous participants inserodiscordant couples group offered by the TASO pro-gram in Jinja. This understanding did not come quicklyor easily for these individuals, as they said that it tookextensive education and counselling to convince them ofthe reality of discordance. Frequent testing and consist-ent negative results for the seronegative member alsoconsiderably helped for these individuals to believe intheir discordant status.Community Discordance BeliefsIndividuals were also asked about their perceptions ofdiscordance in the community. Many couples said thatcommunity members did not believe in the possibility ofdiscordance, often dismissing it outright. The most com-mon reaction that individuals encountered upon tellingcommunity members was that they were lying; as statedby a HIV-negative female:‘The villagers say it is a lie […] the person is yourspouse so how possible is it for one to have HIV andthe other doesn’t? […] unless someone has attendedthe sensitizations, then they would understand that itis possible.’ (Female, seronegative in couple whichremained serodiscordant; 39 years old)Participants expressed a perceived lack of education tobe a primary driving factor behind the beliefs propagatedin the community. Beliefs similar to the ones held by theindividuals were also mentioned, including the existenceof resistant/strong blood and faulty/lying testing pro-cesses. Some seronegative individuals were advised toleave their seropositive partner by friends and villagersupon finding their discordant partners; none of themseem to have taken this advice.Stigma regarding HIV status and discordance was stillapparent in the communities; several individuals werenot able to talk about communities’ perceptions of dis-cordance as they decided not to tell anyone about theirdiscordant status. Stigma, rumours, and gossip werecited as common reasons for choosing not to disclose.The equivalence of an HIV diagnosis to a death sentencewas commonly seen from community members, as wasexpressed by an HIV-positive male:‘People say that we are already dead much as we canstill walk.’ (Male, seropositive in couple whereseroconconversion occurred; 42 years old)While many opinions were not as extreme, overall theattitude of villagers and communities regarding discord-ance were rife with distrust, and the degree of misinfor-mation was reported to be even more severe than thosereported by the study participants.Antiretroviral TreatmentAll seropositive individuals were receiving ART prior tothe interview, even though some of them had not yetinitiated treatment during the course of the mainHAARP study. Individuals generally showed a positiveattitude to the use of ART, citing that many of them ex-perienced a drastic increase in quality of life and healthstatus with the start of ART treatment. Some individualsexperienced side effects at the beginning of their treat-ment, but these eventually resolved within a few months.When asked about the impact of ART on their sex lives,most of the couples said that there were no noticeablechanges in their sex lives; the remaining few said their li-bido decreased with the start of ART. However, they saidthat the reduction in frequency of intercourse may haveplayed a role in the perceived decrease in libido.The community’s perceptions of ART as reported bythe study participants were more negative. Most individ-uals said that community members were distrustful ofART. Although some said that the community wasthankful for the presence of ART and for the number ofpeople who had recovered and were in good health. Oneindividual, an HIV-positive male said:‘When I first began taking [ART] people used to sayall sorts of bad things about [it] and that it was meantfor cows and other animals’ (Male, seropositive incouple where seroconversion occurred; 52 years old)Another individual, reported that among members ofher community ART indicated impending death:‘[…] people think that when you start taking ART,you are just nearing your grave and it is given topeople so that they die slowly’ (Female, initially HIVnegative, but seroconverted during study; 50 years old)This opinion was reinforced by the imagery of “spadesand hoes” accompanying ART. Spades and hoes are bur-ial tools in Uganda, and some participants noted thatthe ART boxes had pictures of these tools. The associ-ation of the spades and hoes and ART meant that a per-son taking them was close to death, and someindividuals were actively dissuaded from taking themedicine.When asked about the possibility of ART failure, opin-ions were divided; while some believed it could happen(and saw real instances of it happening), some had neverKim et al. BMC Infectious Diseases  (2016) 16:665 Page 5 of 8thought about the possibility or were unable to under-stand the concept of treatment failure. Opinions werevaried on the impact of ART on transmissibility of HIV;as expressed by the following individuals:I personally think that [ART] increased the chances ofcontracting HIV. This is because it had been barely anhour after I had taken ART and what I think is thatthe HIV got very angry and increased its severity inattack. [My husband] therefore ended up getting it.(Female, Seropositive in couple whereseroconconversion occurred; 35 years old)[ART reduces chances of contracting HIV] becausethe virus becomes dormant […] If you take medicineat the prescribed time for instance at 8:00 am andagain at 8:00 pm it will still be dormant and continuebeing dormant. (Female, Seropositive in couple whichremained serodiscordant; 48 years old)DiscussionThrough in-depth, gender-matched interviews with bothmembers of serodiscordant couples in a rural Ugandancommunity, we were able to elucidate some of their per-ceptions about discordance in relation to their intimaterelationships, ART, and prevention methods. Most par-ticipants had poor understanding of serodiscordance;most did not present scientifically sound reasons for sus-tained serodiscordance. Though many participants be-lieved that this lack of scientifically sound reasoning fordiscordance was a driving force in misperceptions of thecommunity, health education alone may not be sufficientto change strongly held health beliefs. Some of the rea-sons given, such as the existence of immune blood andthe virus in hiding, have been seen in previous qualitativestudies of HIV serodiscordance in Africa [18, 29, 30].Some of these misconceptions may result in stigma andsuboptimal use of prevention methods, which were citedas common reasons for seroconversion [31]. Misconcep-tions were common in regards to ART as well, with manyindividuals citing their or their community’s negativeopinions of ART. Although this mistrust was cited in astudy carried out in Uganda in 2004-05, [18], it is remark-able that after the intense scale-up of ART programs andHIV education over the last decade, mistrust in diagnosisand medication remains widespread and may play a rolein undermining prevention measures.Difficulties were commonly cited with the use of con-doms among these couples, although most peopleencountered these problems only at the initiation ofthese methods. Disagreement in use between partnerswere frequent, which likely reflected complex genderroles and societal factors which determine use.Participants also reported some issues with their comfortin using condoms. Abstinence was not cited as acommon prevention method used and for those who didreport attempting to abstain, this did not last for longperiods of time, which is consistent with findings fromprevious research [32]. A look into the complex factorsdictating a satisfactory sexual relationship revealed thatthe desire for abstinence was often overshadowed by aneed to minimize suspicions of unfaithfulness or a lackof virility. Although Uganda has long promoted abstin-ence as a part of its HIV prevention campaigns, serodis-cordant couples did not seem to seriously consider it asa choice for prevention of HIV transmission.Interestingly, some couples reported that there was adifference in stringent condom-use before and after dis-covering their serodiscordance. This change in sexualbehavior after testing is common in African settings, es-pecially when accompanied by counselling and educa-tion [33, 34]. We also found that the couples whoseroconverted tended to report less consistent condomuse before becoming seroconcordant; although this dif-ference was not found in the quantitative analysis of theparent HAARP study [27].Respondents reported that they believed that the com-munity’s thoughts of HIV and treatment were more nega-tive than those held by the couples. Participants reportedthat the community still perceived discordance to be im-possible, and mistrust of ART was common. The commu-nity’s knowledge and perceptions play a significant role inthe stigmatization of HIV and serodiscordance [35, 36].The reported community view that an HIV infection isthe equivalent of a death sentence, and that ART is givento those nearing their deaths are particularly disturbing.These perceptions likely serve as impediments to theefforts to properly educate serodiscordant couples andHIV positive individuals in sub-Saharan Africa.There are some limitations to the study. The couplesrecruited into this study, as TASO clients have access tocounselling regarding discordance. Participants in thissub-study have all been followed in the HAARP cohortstudy and were thus previously exposed to counsellingabout prevention, medical treatment, and serodiscordantstatus. Accordingly, they likely do not represent mostserodiscordant heterosexual couples in rural African set-tings who have not participated in such programs. How-ever, given that these individuals appear to have manymisperceptions about HIV infection, it is likely thatthese perceptions are even more strongly held by otherserodiscordant couples. Although interviewers weretrained on how to elicit answers in a non-judgementalmanner, some social desirability bias may exist. Partici-pants may have been uncomfortable talking especiallyabout extramarital relationships, which were not oftendisclosed by female participants during the interviews.Much progress has been made in prevention and treat-ment of HIV in sub-Saharan Africa, especially inKim et al. BMC Infectious Diseases  (2016) 16:665 Page 6 of 8heterosexual couples where transmission is most com-mon. However, the phenomenon of serodiscordancecontinues to remain poorly understood by those affectedby it and the communities surrounding them in ruralUgandan settings. After extensive education campaignsand communication about HIV prevention and medica-tion, the efforts do not seem to be penetrating deeplyinto rural regions, at least in terms of some of the morecomplex issues, such as HIV serodiscordance. Fortu-nately, the serodiscordant couples themselves seem to bebetter informed on their situations than others in thecommunity, but these individuals still encounter scepti-cism when discussing their condition. A better under-standing of serodiscordance is fundamental toprevention of heterosexual transmission in sub-SaharanAfrica, and perceptions regarding it should be placed inthe cultural context where participants live.ConclusionsDespite the availability of HIV treatment and educationregarding serodiscordance, affected individuals (serodis-cordant couples) in rural Uganda and their communitiesstill have a poor understanding of the phenomenon andproper prevention methods. Misinformation was moreprevalent in the communities more so than the couplesthemselves. Participants had the most difficulty explain-ing the reasons for serodiscordance. Most participantsrecognized the efficacy and importance of ARTs, butsome community members remained suspicious of thedrugs and treatment. Stigma about a HIV-positive statusand serodiscordance remains widespread. We concludethat understanding of serodiscordance remains poor inrural areas, and this is likely to be the case in many ruralcommunities in sub-Saharan Africa. Improved educationregarding serodiscordance and ART treatment will berequired to address heterosexual transmission and en-suring the maintenance of serodiscordant status in thoseaffected.AbbreviationsART: Antiretroviral treatment; HAARP: Highly Active Antiretroviral therapy asPrevention; HIV: Human immunodeficiency virus; MSM: Men who have sexwith men; TASO: The AIDS Support Organisation; TasP: Treatment asprevention; VCT: Voluntary counselling and testingAcknowledgementsThe authors wish to thank the participants of the HAARP study andmembers of TASO Uganda who were involved in the collection of data andcare for patients.FundingThis work was supported by the Canadian Institutes of Health Research(Grant numbers MOP-8970 and MOP-119369). DM is supported by a ScholarAward from the Michael Smith Foundation for Health Research.Availability of dataThe datasets during and/or analysed during the current study available fromthe corresponding author on reasonable request.Authors’ contributionsRKing, DMoore designed the study; DMoore and JBirungi were responsiblefor the conduct of the study; MNanfuka, MShafik, FGalenda interviewed theparticipants and collected the data; JKim, MNyonyitono, analysed the dataand interpreted the interview transcripts; RK provided training andintellectual guidance for the qualitative analysis process. JK wrote the initialarticle. All authors provided input to and approved the final manuscript.Competing interestsThe authors declare no competing interests.Consent for publicationNot applicable.Ethics approvals and consent to participateAll interviews were conducted and recorded with the participants’ consent.The study received approval from the Research Ethics Board of the Universityof British Columbia in Vancouver, Canada and the Science and EthicsCommittee of the Uganda Virus Research Institute and the Uganda NationalCouncil for Science and Technology in Uganda.Author details1BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada. 2The AIDSSupport Organization, Jinja, Uganda. 3Faculty of Medicine, University ofBritish Columbia, Vancouver, BC, Canada. 4Global Health Sciences, Universityof California San Francisco, San Francisco, California, USA.Received: 10 May 2016 Accepted: 29 October 2016References1. UNAIDS Fact Sheet. 2015. 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"I have an evil child at myhouse": stigma and HIV/AIDS management in a South African community.Am J Public Health. 2005;95(5):808–15.36. Visser MJ, Makin JD, Vandormael A, Sikkema KJ, Forsyth BW. HIV/AIDSstigma in a South African community. AIDS Care. 2009;21(2):197–206.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Kim et al. BMC Infectious Diseases  (2016) 16:665 Page 8 of 8


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