HIV AND DISCORDANCE

Regina* was 27 when I met her. She was expecting her second baby but she was filled with trepidation when she walked into the office. She was eight weeks along and so far everything seemed peachy.

Her medical history went well until we started talking about other pre-existing medical conditions. She was a bit hesitant at first before coming out bluntly and stating that she was HIV positive and had been taking anti-retroviral drugs for the past five years. She looked relieved to have gotten that out of the way.

Knowing that I was going to be seeing her for a long time, I did not delve into too many details. It was more comfortable for her if we took things one step at a time. We went through her drug regimen to ensure everything she took was safe. Her physical examination was very good. She was as fit as a fiddle.

We discussed her care plan and she was quite amiable. She had been around doctors for far too long, she understood the relevance of most of the tests ordered and the need for compliance with her medication, pregnancy supplements, diet and regular follow-up.

Subsequent clinics with Regina were a pleasure. She blossomed in pregnancy and was glowing both within and without. By the third trimester I had met her adorable five year old but never her husband. She always smiled and made fun of him whenever he came up in discussion, saying that he believed he was an African man who did not believe in attending to women’s affairs. However, I did learn that he was HIV negative.

At 38 weeks gestation, Regina underwent a caesarian delivery and was blessed with a healthy baby girl. She opted to breastfeed her exclusively for six months. The little one was put on anti-retroviral medication to prevent mother to child transmission of HIV. They both went home in stable condition.

Her review ten days later was brief and unremarkable. She needed to get back home with the baby before it started raining. At her next visit, six weeks after delivery, I finally met the mysterious husband. Quite the gentleman, he said hello and opted to wait in the reception area with the baby. Regina was all smiles.

She finally opened up about her HIV status, how she was diagnosed at the birth of her first baby.  She went through some terribly dark days that shredded her marriage and she almost lost her son. She hit a rock-bottom that she never knew was possible, both mentally and physically, with long hospital admissions for various illnesses. It took months of medical treatment, psychotherapy and counselling to get her back on her feet. Through all this, her mother was her strongest ally.

During the dark days, her husband repeatedly tested negative for HIV and this was used against her by relatives, serving to widen the rift in their marriage. Being so young and naïve, she did not have the spine to fight for her marriage. However, when she had given up all hope of reclaiming any semblance of family life, her husband showed up on her mother’s doorstep to take his wife and son home.

Long story short, the journey towards healing was well on its way and they had made the decision to stick together despite being a discordant couple. She faithfully attended her comprehensive care clinic and worked hard to maintain her body in peak condition. She ate well, exercised, took her medication, religiously monitored her CD4 counts and her viral loads and kept a positive spirit.

What she never spoke about at her clinics though, was her desire to have another baby. She felt robbed of an important period in her son’s life when he was an infant fully dependent on his mother yet she was not available. She had a gnawing need to walk that path fully and this desire grew year by year. However, being a discordant couple who used condoms for protection, she was scared of asking her caregivers how to go about safely conceiving.

Her husband could see how this was tearing her apart even though she wouldn’t talk about it. To help his wife, he fell back on the African man stereotype. He refused to use condoms with her and did not want to be questioned about it. When she conceived, he resumed condom use without prompting. After the birth of their daughter, he confessed that he would rather get HIV than see her unhappy. He had taken time to complete his tests and was happy to report that his tests showed he was still HIV negative. This explained why Regina was a bit flustered at her first visit. She thought she would be reprimanded for getting pregnant by exposing her partner to the risk of contracting HIV.

This incredible story left me amazed. I couldn’t fathom what deep love would drive a man to take the risk of getting a lifelong disease to grant his wife her one wish in life. But it also exposed a huge gap in knowledge among this special category of patients, the discordant couples. How often do we discuss safe conception options?

For discordant couples, the best option offered is use of intra-uterine insemination. Where the man is the one who is HIV negative, his sperm is collected and used, leaving him unexposed. In the event the man is the one who is HIV positive, then sperm from a HIV-negative donor is recommended.

In the event that intra-uterine insemination is not acceptable, accessible or affordable, then the couple is fully counselled on the prevailing risk of possible infection before the following options are provided. In the case where the HIV positive partner is fully compliant with treatment and their viral load is undetected, they may have unprotected intercourse limited to three days in the cycle when ovulation is anticipated. For those where the viral load is elevated despite being on treatment, the partner must concurrently take pre-exposure prophylaxis medication for the duration of unprotected sex and still limit exposure to three days in the cycle.

Science and research has now turned HIV into a chronic disease rather than a cause of death as it was a few years ago. This means that we must appreciate the fact that those with the disease have a life to live, including wanting to be parents. They must not be denied this chance!