► The Challenges Of Serodiscordant Relationships, By Mark Cichocki, R.N.

One Positive...One Negative...It Can Work.

From the beginning of the HIV epidemic, relationships made up of one positive partner and one negative partner have been fraught with challenges. This couple type, known as serodiscordant, is a challenge both for the couple themselves as well as their providers, counselors, and loved ones. Serodiscordant relationships often are riddled with stress, anxiety, fear and concern.

Stress in the Serodiscordant Relationships
One would be safe in saying that there is stress in the serodiscordant relationship. In fact, scientific studies have proven that relationship stress increases dramatically after one partner becomes HIV positive. A study conducted at the University of Medicine and Dentistry of New Jersey found that psychological distress along with drug and alcohol abuse were commonly found in serodiscordant relationships. Where does the stress in serodiscordant relationships come from?

Transmission vs. Caregiving – In couples where both partners are HIV negative, the concern of both partners is the same: to stay HIV negative. However, in couples that have one partner negative and one partner positive, different issues are at hand. The positive partner is concerned about transmitting the virus to the negative partner. The negative partner commonly devotes his or her attention to their positive partner's health, becoming the caregiver in the relationship. This difference in perspective and direction causes emotional conflicts ultimately increasing the stress within the relationship.

How Did That Happen? – If one partner becomes positive while in a relationship, the first burning question the other partner will have is “How did that happen?" If the new infection is the result of unprotected sex outside the relationship or a consequence of sharing needles while injecting drugs, chances are the negative partner had no idea either behavior was going on. The stress caused by the new HIV infection is compounded by feelings of anger, betrayal, and sadness as the reality of their partner's infidelity and drug use sets in.

Overly Cautious – In any serodiscordant relationship, there is concern at the prospect of spreading the HIV infection to the negative partner. Sexually, the couple may become overly cautious and at the worst, stop any sexual or intimate contact in fear of spreading the infection. While it’s not the most important part a relationship, sexual intimacy is a key component of any loving relationship. Without intimacy, feelings of frustration, longing, and resentment surface and in turn, the relationship suffers.

Survivor’s Guilt – Guilt can be a powerful and destructive emotion. Most often, survivor’s guilt is a product of situations such as car accidents in which one person survives while many others die. The survivor feels guilty for having lived. In a serodiscordant relationship, the negative partner can feel guilty for being negative. The guilt increases if the positive partner becomes sick due to their HIV. In extreme cases of guilt, the negative partner wishes they too were infected, feeling their infection would relieve the guilt and other stressors present in the relationship.

The Desire to Have Children – Most loving couples will consider having a family at one time or another. In serodiscordant relationships, this decision can be a stressful one. There is the typical stress all couples feel when deciding to start a family but there are additional concerns of HIV transmission to the negative partner and the unborn child.

Stress itself can be a barrier to a successful relationship. But certain circumstances that arise in serodiscordant relationships that are particularly difficult.

Barriers and How to Overcome Them

Barriers to a Successful Serodiscordant Relationship
Ninety percent of the issues that strain a serodiscordant relationship are the same ones affecting any relationship. However, it's the other 10 percent that is the most challenging. What are some of the issues facing serodiscordant couples?

Money / Employment – Money problems are common in relationships. But, the cause of the money problems in serodiscordant relationships is unique. The cost of HIV care and medications can be significant. The positive partner may be unable to work because of illness. Such situations cause significant stress, anxiety, and resentment between the two partners. And to add to the stress, the positive partner may feel guilty because he is unable to contribute to the household finances.

To Disclose or Not to Disclose – Disclosure becomes a problem when one partner wants to disclose to more people than the other partner. In this situation, one rule that applies to every couple:

Except in circumstances of medical emergency or necessity, when and to whom disclosure is made is the decision of the positive partner.
If the positive partner says no to disclosure, then the negative partner must abide by his or her wishes without question.

Sharing Medical Information – Some positive people want their partner with them at every doctor's visit. Other positive people prefer not to share medical information or discus their medical condition. Negative partners sometimes have a hard time understanding this feeling. The negative partner needs to know the positive partner is medically okay. Fear of the unknown can be powerful. Being left out of the medical aspect of their partner’s life spawns fear and doubt, two emotions that can undermine any relationship.

Difference of Sexual Comfort and Desire – In a serodiscordant relationship, there will be differences surrounding sex. How much risk is each partner willing to take? What type of safer sex practices will be used? In what sexual activities is each partner willing to participate? A good rule of thumb is that if either partner does not want to engage in an activity or take a risk with unsafe sex, then that partner has the final say. Regardless, differences in sexual drive and risk taking can become divisive in a serodiscordant relationship.

Fear of the Future – As is true with any chronic illness, there is some fear related to the prospect of deteriorating future health. The negative partner dwells on questions like when will the positive partner get sick; how long will he live? Fortunately, advances in HIV care has resulted in more promising futures for those infected. As life spans continue to improve, couples will become more optimistic about what their future holds.

Dealing With the Struggles – Making it Work
For as many barriers and issues that exist in serodiscordant relationships, they can and do flourish. The fact of the matter is not unlike any relationship, it takes work and commitment from both partners. Psychologist Robert Remien of the HIV Center for Clinical and Behavioral Studies in New York City has done extensive research on the issues facing serodiscordant couples. He reminds us all that there are ways to work through the rough spots and enjoy the good ones. Here are a few ideas:

Never stop talking to one another about the relationship issues you face. Share your feelings, regardless of how sensitive or painful it may be. While the pain is short term, the benefits from openly discussing issues will have lasting effects on the relationship.

Consider seeking professional counseling whenever you feel it will be helpful. Whether it is individual counseling, couples counseling, or both, it can be beneficial to have an impartial, trained eye help you through the tough times.

Keep issues in perspective. While your HIV status is a significant difference between the two of you, it should not define your relationship. It is only one of many characteristics that define you as a couple and as individuals.

Take care of one another. All relationships need the partners to find ways to care for one another, treat one another with respect, and show the loving emotions that brought you together in the first place.

Remember that you love one another. There is a reason you are together in the first place. Never be afraid to remind one another now and again. Small little reminders of the feelings you have for one another can do wonders for a stressful time in the relationship.

Be realistic about your situation. Don’t fool yourself into thinking your difference in HIV status will not impact the relationship. There will be times that one partner or the other will feel like they can’t take the stress any longer. Don’t fake it…if you are unhappy say so.

Stay safe, and create guidelines. Plan to discover new ways of eroticizing your lovemaking. Make it fun. Laugh more, and don't be so serious. Share fears and feelings about certain modes of sex play.

Sources:

Kennedy, CA. "Psychological distress, drug and alcohol use as correlates of condom use in HIV-serodiscordant heterosexual couples"; Department of Preventative Medicine and Community Health; University of Medicine and Dentistry of New Jersey; 7 Nov 1993 (11) Pg 1493-1499.

Medellin, JM. "Mixed HIV Status Couples"; Body Positive Vol XVII, No. 2 1 Jul 2004.

Safadiah, M. "When Only One of You Doesn’t Test Poz", Body Positive Jan/Feb 2002.

Smith, R. "Couples" The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic. Fitzroy Dearborn Publishers 1998.

Trisdale, S. "One Positive, One Negative: Both Happy" Positive Words 2002.

Stress in the Serodiscordant Relationships
As I mentioned in an earlier mail in the ‘depression’ topic that the stress of HIV was present in the initial stages of my partner getting infected. On the other hand, it lessened as time passed and now raises its head only when the topic of money or sex gets involved. Long term plans I have never been good with making anyway – but now they become imperative. But then what do we plan for? Sickness? Death? At the moment, I don’t like thinking about them but I have to. God!

Transmission vs. Caregiving
True. The roles have reversed completely and initially it was very difficult to manage – but we eventually found out a way – if we wanted to stay together we just had to.

How Did That Happen?
When it happened, frankly, I never thought about the hows and the wherefores. Because at the time we already had too much on our plate. Later on I would think about it…but infidelity never came to mind. It still doesn’t.

Overly Cautious
THIS I can relate to completely. It is being overcautious when it comes to sex. Now in matters of sex we have completely drifted apart – we just don’t seem to want to indulge. Because the moment we do – a 100 different thoughts come barging into my mind. It is all great while the sex lasts, but the moment we come back to earth, reality hits us like a bolt. Or at least me, since I get paranoid.

Survivor’s Guilt
I remember feeling this. When he was tested positive, I was shell-shocked. I didn’t even look at the report which said that I was negative. I couldn’t be bothered. Through the months that followed, I kept asking him if he felt alienated. Don’t you see? It’s like first we have to deal with being gay – and we come to terms with it. We know that the straight world won’t ever understand what it is like being gay – so we make our own world. And within our own world when we turn positive it is like being alienated from there as well. And all I would think of is whether he would be able to share things with me and feel that I loved him as much after he turned positive. It was a terrible feeling.

Money / Employment
We keep thinking about this. None of the insurances take care of this infection and it is overburdening at times. Especially when the viral load tests are to be taken. The money spent there is enormous and it eats into everything we do for that particular month. Saving would help but then the families would want to know where all that money seems to go.

To Disclose or Not to Disclose
The first time we told a friend. Then another. Two of our best friends. One was supportive and the other just refused to talk to us. He just dropped us like we were breathing out HIV viruses by the millions. After that I decided that we would not disclose his status to anyone else. He keeps telling me to mention it to some of our close friends. But I will not. Once bitten and always shy! The world is a cruel place and haven’t we had enough already by just being gay. He doesn't need to be treated as a pariah from the community as well.

Sharing Medical Information
This has never happened with us. I have been with him on most of his doctor’s visits – not being there is something which happens when it is a routine procedure.

Difference of Sexual Comfort and Desire
We have almost stopped having sex. And if once in a blue moon there is a surge of sexual need, we do not indulge in anal sex at all.

Fear of the Future
One thing that I have begun to notice is that I have stopped thinking of the future. I never think of things as being certain. I feel that anything anywhere may just change and shock you so why bother preparing and planning. I am living a day-to-day existence. Which is bad, I know, but at the moment, I can give you a thousand arguments as to why I feel this way.

Professional counselling: can anyone give us names of good counsellors?

Thanks, Parth, for writing in with this piece. I have gone through the many many topics on magnetic couples on thebody.org as well…but many times they leave me more unnerved then I was before reading them. My partner is someone who doesn’t think much. He has a realistic view towards life but I am the one who is overly cautious. I think about things a great deal more.

Sometimes it feels like I want advice on so many things, but don’t know who to talk to. Feel claustrophobic and just feel like life is such a bloody pain. First we had to deal with being gay and just when we come to terms with it and say **** off to those who are not willing to understand, we are faced with this challenge. I hope to God He gives us the strength to say **** off to those who are not willing to understand once again. I hope it is soon.

wud like 2 b a frnd as we both r sailing in d same boat