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From the Encyclopedia of AIDS

Couples

Raymond A. Smith

http://www.thebody.com/encyclo/couples.html

A couple is composed of two persons in a committed sexual or romantic relationship, usually over a significant period of time. Couples may be opposite-sex or same-sex, married or unmarried, monogamous or nonmonogamous, and cohabitating or living apart and may or may not have children.

In terms of HIV/AIDS, couples may be either HIV seroconcordant, with both members being either sero-positive or seronegative, or HIV serodiscordant, with the partners having different serostatuses. For most couples, HIV/AIDS raises two paramount concerns: the risk of HIV transmission and the likelihood of illness of one or both partners.

Couples in which both partners believe themselves to be HIV-negative have it as their challenge to remain that way. Statistically, most couples worldwide are seroconcordant-seronegative, especially in populations and regions that do not have a high level of HIV seroprevalence. These couples may be the least likely to practice safer sex consistently with each other, particularly if they have agreed to be sexually monogamous or if they want children. Such couples may feel little incentive to put up with the more unpleasant demands of safer sex and, indeed, may find that issues involved with avoiding the exchange of bodily fluids damages the quality of their sexual and personal lives. Shared HIV-negative status may also encourage a couple to remain together rather than face the risk of infection from partners of unknown status.

If both partners who believe themselves to be in a seroconcordant-seronegative relationship are indeed HIV-negative and remain so over time, then HIV/AIDS poses little direct risk to them. However, some people do not know their actual serostatus but simply presume themselves to be uninfected based on their personal histories or prior HIV test results. A lack of knowledge about HIV transmission and psychological denial may lead some people to underestimate their likelihood of infection.

One member of the couple may become infected by sexual activity outside the relationship or by other routes, such as injecting drug use, blood transfusions, or occupational exposure. A member of a couple who becomes infected during the course of a relationship may unknowingly pass HIV along to his or her partner. Even if one-half of the couple knows him- or herself to be infected, he or she may find it difficult to suggest condom use, because this would be tantamount to admitting to sexual infidelity or unsafe drug use. Even couples with explicit agreements to discuss any risky behavior outside their relationship may find it difficult to do so in practice.

Couples in which both partners are seropositive face a different set of concerns. Such couples occur most frequently in certain risk groups, such as gay men and injecting drug users, or in geographic regions with high HIV seroprevalence. For these couples, transmission may seem to be a less pressing concern. However, such couples run the risk of reinfection, in which one partner infects the other with a different and potentially more virulent strain of HIV, some currently unknown cofactor that might worsen their condition, or a sexually transmitted disease.

Nonetheless, couples in which both partners are HIV-positive may be tempted to ignore safer-sex practices and/or to share needles freely out of a sense that such activity poses little additional risk. Indeed, shared seropositivity may be a source of comfort and solidarity for some couples, although this may be less the case if one partner was the agent of infection for the other.

Pregnancy, either accidental or intentional, is of particular concern for seroconcordant-seropositive heterosexual couples, given the risks of maternal transmission and premature death of the parents. Couples who already have children must take care to make provisions for these children, who may themselves be infected and who run a high risk of being orphaned.

Seroconcordant-seropositive couples face a high degree of uncertainty about the future, because both members must contend with the likelihood of future illness. Yet, the two partners may be at very different stages of disease progression; rather than growing sick and dying together, one partner may still be asymptomatic while the other has already progressed to AIDS. In these cases, the partner who is well may be faced with caregiving, either while healthy or while in declining health. The couple may need to deal with changes in mutual dependence, debilitating opportunistic infections, sexual dysfunction, cognitive impairment, anticipatory grief over the death of the sicker partner, and concern about the future health of the healthier partner.

Meanwhile, psychological and practical support is often less available for well caregivers than for their sick partners. In relationships that are not sanctioned by law, the well partner may also have to contend with difficulties regarding spousal insurance coverage, medical decision making, legal guardianship, inheritance, and unwelcome involvement by parents and other biological relatives.

Serodiscordant couples raise the thorniest set of issues, because they must face major concerns about both transmission and caregiving. Although many HIV-negative individuals might not choose to become involved with someone who is HIV-positive, the seroprevalence rates in some communities are so high that such couplings are almost unavoidable. In other cases, partners may already be committed to one another before their serodiscordant status is discovered or discussed.

Out of concern about transmission, some serodiscordant couples become overly cautious and all but cease sexual relations. Others may become fatalistic about the inevitability of transmission and take unwise risks. Even if the partners find a level of sexual interaction with which they are both comfortable, accidental slipups and condom breaks do occur. Thus, the prospect of infection is always present, causing the infected partner to worry about transmitting the virus, and the uninfected partner may experience "survivor guilt" to the point of wishing to become infected.

Serodiscordant heterosexual couples who wish to have children must be concerned about sexual transmission between partners and about maternal transmission in the womb if the woman is the infected partner. Although a number of technologies have been explored to remove HIV from semen, attempting a pregnancy remains risky for serodiscordant couples.

As a seropositive partner becomes ill, another set of issues arise around caregiving. Although the basic concerns are the same for serodiscordant couples as for seroconcordant-seropositive couples, the divide between the two serodiscordant partners can be greater, as the two do not share the same HIV status. "Survivor guilt" may become even more acute at this stage, impairing the ability of the seronegative partner to protect him- or herself as well as the seropositive partner. Alternatively, some seronegative partners may decide that they are unable or unwilling to help their partner deal with severe illness and abandon the partner to care for him- or herself. In a few cases, the well partner may even be called upon to assist with the suicide of the sick partner.

Related Entries:

Bereavement; Caregiving; Children; Families; Family Policy; Gender Roles; Homophobia; Maternal Transmission; Monogamy

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