Thirty-year-old Paulina Adekola is HIV-negative, while her husband, Luke Segelu, 39, is HIV-positive. This condition is called discordance. Paulina and Luke are discordant couple.
They are now 12 years into their marriage, but six years after they were married, Paulina started falling sick regularly. He had a persistent cough and developed Tuberculosis. He was diagnosed with HIV, which made him to be depressed. His major problem was how to tell his wife.
However, one day, he picked courage and told his wife that he had been infected. But months after, Paulina also took up the test. She was negative. After six months, she went for another confirmatory test, which also turned out negative.
Henry, a 25 year-old graduate lives a fast life. He is involved in the use of hard drugs. Often, he resorts to sex trade to feed this habit. Some of his clients are men who offer him free drugs and alcohol.
Many Nigerian couples are like Paulina and Luke, proving that discordance is real, although there are many theories for its cause. What’s more, cases of men having sex with men, sex trade and use of hard drug, all expose to contracting HIV.
HIV discordance is related to a combination of factors that include genetics, HIV type, the extent to which the infection has progressed in the positive partner, presence of other sexually transmitted diseases, use of antiretroviral drugs, as well as tears (scratches) that occur during sex.
Now, game-changing approaches such as medicine to prevent HIV if used before sex is giving people the power to protect themselves from HIV and, for people living with HIV, the power to thrive.
That is because of a pill called Truvada that combines two anti-HIV drugs can prevent the virus from spreading through the body.
The World Health Organisation(WHO) recommends that people at high risk of exposure take it every day to lower their chances of infection — an approach known as pre-exposure prophylaxis, or PrEP.
There is overwhelming evidence that PrEP, when taken consistently by those deemed at high risk of contracting HIV, can help to dramatically reduce the risk of acquiring the virus.
These high risk groups include gay and bisexual men, discordant couples, commercial sex workers, people who inject drugs, and ‘individuals who engage in anal sex on a prolonged and regular basis’. They are a key contributors to the HIV burden.
In Nigeria, men who have sex with men are the only group in Nigeria with which HIV prevalence is still rising.
Project manager, Oyo State Agency for the Control of AIDS (OYSACA), Dr Olukayode Ogunkunle, said pre-exposure prophylaxis is very important in the fight to achieving zero HIV new cases in Nigeria.
“It is key, especially with men having sex with men. The prevalence of HIV in this group is above 10 per cent. It is fueling HIV spread because they are also having sex with females,”he added.
Dr Ogunkunle said a partner that is HIV negative can use Truvada, an antiretroviral therapy (ART) to reduce their chances of contracting HIV even if the other partners is HIV positive.
“Anybody that feels that he is not sure of the partner can use it but basically, it is for discordant couples. It is supposed to be taken daily to prevent contracting HIV,” he added.
Under the Nigerian government guidelines, the HIV-negative partners should be offered PrEP. But in most cases, they are only offered HIV counselling, testing, and condoms.
According to Dr Ogunkunle, “The Federal Government is yet to put all people living with HIV on treatment, so talking of PrEP is something that the government cannot afford for now. But if the person whose partner is HIV positive decided to, with a prescription, they can get it over the counter.”
The US Food and Drug Administration ratified usage of Truvada drug as PrEP in 2012. Since then, PrEP was embraced in many countries, including USA, UK, France, China, and South Africa among others.
More importantly, WHO recently recommended its adoption as one of the strategies to combat new HIV infections among population groups vulnerable to HIV.
Dr Ogunkunle said PrEP comes useful in reducing new cases HIV infections, adding, “Individuals can get prescription for PrEP in hospitals in Oyo state that render ARV services and then buy from the pharmacy shop.”
The expert declared that PrEP, like every other drug, could have its side effects, but “where the partners with HIV is on ARVs and the viral load is undetectable, you do not need to protect yourself with PrEP.
“Also, if government achieve 100 per cent of people living with HIV is on ARV drugs, then we do not need PrEP either. But in a resource constraint environment, providing PrEP freely for everyone that might need it may be difficult.”
According to the 2018 National HIV/AIDS Indicator and Impact Survey (NAIIS) released in March, Nigeria had the fourth highest HIV prevalence behind South Africa, India and Mozambique.
The survey, which provides a clearer understanding of Nigeria’s HIV epidemic, indicated that the South-South zone of the country has the highest HIV prevalence at 3.1 per cent among adults aged 15 to 49 years.
HIV prevalence is also high in the North Central zone (2.0 per cent) and the South East zone (1.9 per cent). HIV prevalence is lower in the South-West zone (1.1 per cent), the North East Zone (1.1 per cent) and the North-West zone (0.6 per cent).
From 2010 to 2017, the country almost tripled the number of people living with HIV that have access to antiretroviral therapy, up from 360, 000 people in 2010 to more than one million in 2018.
Despite this, more than half of people living with HIV still do not have suppressed viral loads and increasing the chance of onward HIV transmission to others.
World Health Organisation say many HIV transmissions in serodiscordant couples occur when the HIV-infected partner has a high CD4 and is not on antiretroviral therapy (ART).
The research also showed that a significant proportion of transmissions in couples were not genetically linked, indicating the infections were acquired through sex with someone other than the HIV infected regular partner.
PrEP is not readily available to the general public in Nigeria; however some serodiscordant couples have been able to access the drug through demonstration projects.
In 2016, 242 people were on PrEP in Nigeria. It was in a study to inform a nation-wide scale-up of PrEP as part of a comprehensive HIV-prevention package.
What is more, heterosexual sero-discordant couples were reluctant to the use of condoms consistently in addition to PrEP – because of the perception that PrEP alone was enough to protect them from HIV based on the Nigeria PrEP demonstration project.
There major motivations for PrEP use were to stay alive, stay negative, protect unborn children from acquiring HIV, and prevent sexual partners from acquiring HIV.
Most couples expressed shock; fear and surprise when they learnt about their sero-discordant status. Negative partners reported a decline and change in sexual activities. Joint couple interviews revealed inconsistent condom use.
Condom use among newly diagnosed serodiscordant couples is motivated by concerns about infection. However, it appears that this declines with time as they become comfortable with the use of PrEP.
Moreso, PrEP is not something for a lifetime but for periods in a person’s life when they are at risk of HIV – unsure of their partner’s HIV status. Poor adherence compromises the efficacy of PrEP and may also foster drug resistance.