Can relationship-based approaches improve uptake of HIV-prevention among serodiscordant couples in Tanzania?
Interviews with heterosexual couples in Tanzania suggest that pairs often make decisions about HIV-prevention together and that working with both partners could increase PrEP and ART access.
Research from Kisarawe in Tanzania has found that heterosexual, serodiscordant couples (where one partner has HIV and the other does not) tend to make joint decisions about HIV prevention and treatment.
Although findings show that gender norms can influence the way couples communicate, most made decisions on whether to take PrEP or antiretroviral treatment (ART) together. This suggests that, in some settings, taking a relationship-centred approach to HIV prevention could be more effective than focusing on individuals.
Interviews were conducted with 22 people taking part in a study offering home-based HIV testing for couples. The study enrolled those testing HIV negative onto PrEP, and initiated those testing HIV positive onto ART. Nine people from serodiscordant couples who had taken an HIV test but had not agreed to initiate PrEP or ART were also interviewed. The age of participants ranged from 32 to 71 (with a mean age of 48 years).
Nine of the participants said the male partner made decisions in their couple, while three said the female partner was the decision-maker. But the majority of interviewees said decisions were made jointly, based on feelings of mutual respect, love, and trust.
Due to stigma and discrimination, people who tested HIV positive had typically only told their partner, although some also told a trusted family member. This meant that couples often saw HIV as being a joint issue, rather than an individual one, and so shared decision-making on HIV-related matters.
Participants still reported having difficulties talking about HIV with their partner and linked this to social norms and stigma.
Many interviewees said that they had expected their partner to leave the relationship after finding out about the others’ HIV. This was especially true for women diagnosed with HIV, who as a result were often more worried about disclosing their status to their male partners.
Participants said that love and commitment were driving forces for their PrEP use. They described taking PrEP as an act of ‘symbolic solidarity’, which benefited both members of the couple, as well as their personal health.
Mutual support in couples also encouraged PrEP and ART use. Interviewees living with HIV said that knowing their partner could access PrEP helped alleviate feelings of guilt and worry about transmitting HIV to them. But this was not true for all participants, as two women had stopped PrEP due to their partner’s influence.
About half the couples said they had started using condoms after receiving their HIV test results. Couples that did not want to use condoms saw PrEP as essential to maintaining their relationship.
Those who did not take up the study's offer of PrEP or ART still expressed support for their partner. The main reasons for not doing so were misunderstandings about eligibility, miscommunication with study staff, or partners being absent for PrEP or ART enrolment.
The education and counselling that participants received in the main study, irrespective of PrEP use, was often given as the biggest benefit for participating. Couples said the study had shown them how to manage their different HIV statuses and continue living together. The fact that the main study took place in people’s homes also played a critical role in uptake.
It was less clear how well participants understood that being virally suppressed means that a person cannot transmit HIV. Only one couple referred to this as a motivation to take ART.
It’s important to note that the couples involved in the study may not be representative of the wider population, as those selected were already demonstrating high uptake of HIV-prevention. In the wider population, rates of partner abandonment for people recently diagnosed with HIV remain high, especially among women.
But the results do suggest that jointly engaging a couple and utilising couple communication and mutual support could improve HIV prevention among people in relationships. Providing trained counsellors to help couples talk about HIV, informing couples on the joint implications of different HIV prevention options, and fostering more equal gender norms will be important aspects to focus on to ensure such relationship-based approaches are effective.
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