In this study “maintaining the relationship” was the emergent core category grounded in the data. This was couples’ main concern in the context of long-term HIV discordant relationship. “Struggling to maintain the relationship” was the basic social process used to deal with HIV discordant relationship which is a forward movement through integrating with its own contexts and conditions. Some finding indicates that in addition to other factors HIV/AIDS bring changes in couple’s life/marriage [16
] Another study that has been done in Brazil also indicated that the HIV diagnosis had changed participants sexual trend, according to the women’s responses: they were afraid of infecting their partners, they had many new sources of stress which had made them lose their sexual appetite, or they felt less sensual within themselves [17
This study showed that couples were not tested with a primary intention of knowing their HIV sero-status. Most of them were tested alone by certain coincidence due to some enforcing conditions like sickness, pregnancy and a plan to go abroad. As a result, the overall struggling process to sustain the relationship that couples established start after they enter into the “transition” i.e., knowing that they have HIV discordant serostatus.
A study conducted in Addis Ababa indicated, couples were not able to be tested for HIV together due to unavailability and/or unwillingness of partners [18
]. Moreover, couples voluntary counselling and testing also didn’t get attention in HIV prevention activities in sub-Saharan African countries including Ethiopia [19
]. Thus, entering accidentally into a different dimension of relationship becomes a condition that can bring some changes in couple’s perspectives and life since they were not ready for it. The change as observed in different studies as well as in our study, indicate shifts in the desire to have a child and sexual practices [17
While couples are passing through the process of the central phenomenon which is maintaining the relationship using selected strategies, these were determined by other intervening conditions such as relatives interferences, people’s judgment due to the perspective they have towards HIV, PLHIV and discordant couples, and information influence. Some authors reported that HIV/AIDS brings changes in a couple’s life [16
] and specifically, a study done in Brazil indicated that the HIV diagnosis had changed participants sexual trend and appetite due to concern of infecting their partners. [17
We have seen the role of relatives on couples desire on having children comparing with the finding from Uganda that indicates pressure from relatives to reproduce were one of the reasons why the couples’ desire to have children in such relationship [20
]. Moreover, another cross-sectional study finding from the same country also support this fact that relatives influence was the major factor for couple’s desire to have a child [22
]. Our study limited in producing data in relation to the amount of relative’s pressure on serodiscordant couples to have a child. This may be attributed to the selective disclosure preferred by most or as a result of the existing stigma.
Despite the intervening conditions, couple’s living circumstances were playing a significant role in affecting their decisions and certain outcomes in the process of maintaining their relationship. Our study suggested that context of couple’s living circumstances such as the way couples define their relationship, spending longer time together, being an index case or HIV negative, being a parent, ageing and gender play their own roles in shaping couples actions/interactions/strategies in the process of maintaining their relationship. These properties of couple’s context were interlinked with one another.
A study from Northern Thailand showed that time spent in partnership has been identified as one of the context which is valued by couples to maintain their relationship as discordant couples [23
]. Therefore, this is one of couples’ contexts which affect their decision towards certain actions. Moreover, being an index case or being HIV positive or negative, being parent especially for having children in common, age and gender were another context of couple’s life that shape their desire and preferences in a certain way to some extent.
Therefore, individuals who take into consideration all the conditions and context in regard to their relationship will engage with certain kinds of actions/interactions/strategies that have significant role to play in maintaining their relationship. Some studies from different countries showed similar evidence on couples’ decisions towards a particular strategy or experiencing certain outcomes in their relationships [20
Our findings further indicate that couples use “accepting the fact” as a strategy which is taking HIV test result as normal phenomena. A study done on vulnerability in Brazil among discordant couples showed that there is a naturalization of HIV/AIDS infection among the studied individuals. According to this finding couples were engaged in risky behaviour due to their belief towards the diseases [28
Another strategy used among couples to maintain their relationships was avoiding disclosing their status completely or selective disclosure to closer family members. This was related to a belief that people around them will stigmatize them or induce other forms of social pressure. Couples in discordant serostatus in our study also believed that this strategy has helped them to maintain their relationship. This finding was supported by other studies where people who disclosed their status faced stigma. Individuals have their own specific criteria for deciding to whom to disclose which were based on their calculation of risks and benefits of disclosure [29
In this study spouses were seen to put their health status at risk to comfort their partners by performing unprotected sex with their HIV positive partners or bearing a child. This was with an intention of sustaining their relationship. This is supported by the study from Uganda which found out that because of fear of losing partners, spouses were engaged in certain actions like unprotected sex and conception to secure their relationship [20
Through this struggle process to maintain their relationship, couples face some outcomes as a result of their actions/interactions/strategies. One of the outcomes that emerged as a category was “a double burden” that both of the partners were facing with different extent of pressure. This was expressed by the fact that HIV positive individuals were facing different kinds of psychological pressure as a result of their serostatus. Having an already established relationship with an HIV negative partner introduced a huge fear towards transmission of the virus to the uninfected partner on the one hand and a concern about dissolution of the marriage especially among those who had common children.
Other studies also indicated that people with HIV suffer grossly form mixed feelings towards maintaining their relationship and protecting the uninfected partner from the infection. The change in sexual trend and fertility, were indicative of the fact that HIV positive people are facing psychological pressure to deal with the conditions existing around them [16
On the other hand, HIV negative partners also have their own concerns that impose a psychological burden. One thing that differ their pressure was their serostatus. They don’t have a psychological burden in terms of the virus having a concern of survival like that of HIV positive one. But, they also experience some kinds of pressure that is related with fear of being infected compounded with losing partner or dissolution of a family in general.
In addition to the double burden, shifting of interest was observed among couples which is resulted from the overall process of maintaining their relationship. According to the findings, couples’ interest or desires somehow changed or shifted from before entering into such transition to new relationship experiences. Interest like having a child and sexual desires were somehow changed with taking into account their intervening conditions and context.
Various studies indicated the shift of interest that was observed on individuals who live in a discordant relationship in terms of change in their practice like that of sexual and child desire. Thus couples prioritize their interest more for maintaining their relationship rather than being concerned much for other practices (19–21, 44, 45, 54).
Moreover, selective disclosure of their HIV status to other people throughout the process of maintaining the relationship resulted with less social pressure on couples or individuals who live in a discordant relationship, especially if they have children such strategy were taken as important in order to avoid the unnecessary pressure that might be imposed on children due to their parents’ HIV serostatus.