The Interconnected Dynamics of Partnership and HIV: A Qualitative Exploration of Experiences from Heterosexual Individuals Newly Diagnosed With HIV

Recent studies have focused on the role of intimate partnership on HIV care outcomes among men who have sex with men in the United States (US) and heterosexual couples in some African studies, leaving a gap in the recent US-based literature on the role of having an intimate partner on HIV care outcomes among heterosexual couples. Therefore, the objective of this study was to explore the lived experiences of heterosexual individuals newly diagnosed with HIV regarding the role of partnership on HIV care. Methods This phenomenological study conducted one time, virtual, in-depth interviews with six heterosexual individuals newly diagnosed with HIV ≥ 2017. The data analysis followed Moustakas approach to identify themes and sub-themes. in support


Abstract Background
Recent studies have focused on the role of intimate partnership on HIV care outcomes among men who have sex with men in the United States (US) and heterosexual couples in some African studies, leaving a gap in the recent US-based literature on the role of having an intimate partner on HIV care outcomes among heterosexual couples. Therefore, the objective of this study was to explore the lived experiences of heterosexual individuals newly diagnosed with HIV regarding the role of partnership on HIV care.

Methods
This phenomenological study conducted one time, virtual, in-depth interviews with six heterosexual individuals newly diagnosed with HIV ≥2017. The data analysis followed Moustakas approach to identify themes and sub-themes.

Results
The participants were predominantly female and African American with median age of 46 years. Four themes identifying association between partnership and HIV care included role of HIV on partnership, under which impact of HIV on partnership and presumed reaction if partner was diagnosed with HIV were identi ed; Impact of partnership on HIV identi ed perception on dealing with HIV diagnosis without a partner and role of family vs. partner in HIV care as sub-themes; forms of support from partner in HIV care identi ed partner support around the time of HIV diagnosis and linkage to HIV care and around retention in care; and perceptions on the types of partner-based clinic services, which identi ed areas such as couples therapy, assistance with partner communication on sensitive topics such as HIV disclosure, and HIV education of the partner. The ndings showed that partnership played a vital role in HIV care among partnered individuals; and the importance of a partner in HIV care was acknowledged by unpartnered participants. Various support practices by partners around HIV diagnosis and retention in care were identi ed. Quality of partnership played a bigger role in HIV care than presence of partnership.

Conclusion
The importance of partner-based interventions in improving the HIV care of the person with HIV (PWH) was acknowledged. While demonstrating views of mainly African American women living with HIV in the Southern US, ndings may be transferrable to other heterosexual PWH in other locales.

Background
Following a new HIV diagnosis, attending regular HIV care visits and taking antiretroviral therapy (ART) daily may seem burdensome (1). Missed HIV care visits can lead to loss of ART adherence and inability to achieve viral suppression (2); viral suppression is the goal of HIV treatment as it is associated with prolonged lifespan and improved quality of life (3). In the United States (US), where recent studies show a positive impact of having a partner on HIV-related health outcomes such as linkage to care, retention in care, and viral suppression in men who have sex with men (MSM) (4)(5)(6), studies involving heterosexual person with HIV (PWH) were conducted more than 20 years ago and mostly reported negative impacts of the diagnosis on a relationship (7)(8)(9). Some recent African studies exploring the role of a partner on HIV care outcomes among heterosexual couples have shown partnership to be helpful. However, since the majority of the African study population were married, results are not transferable to unmarried-partnered individuals or to the US populations (10,11).
This mixed evidence on the impact of heterosexual partnership (African vs. US) and a gap in the contemporary evidence in the US highlight the importance of exploring the role of heterosexual partnership on HIV care among newly diagnosed PWH in the US. Therefore, the aim of this study was to capture lived experiences in order to develop a comprehensive understanding of the role of partnership on HIV care among heterosexual PWH newly diagnosed with HIV. This in-depth knowledge can contribute to the design of clinic level interventions that involve partners of the newly diagnosed. The aim of these services would be to help reduce the burden of the new diagnosis and to ease the transition from diagnosis to linkage to care to retention in care for the newly diagnosed individual. The central research question that guided this study was, "How does having a partner impact HIV diagnosis, linkage to HIV care, and HIV retention in care among heterosexual individuals newly diagnosed with HIV?"

Sample and Recruitment
This study consisted of one-time, virtual, semi-structured interviews. A criterion sampling method for selecting participants was used (12). The inclusion criteria were individuals diagnosed with HIV since January 1, 2017; identifying as heterosexual; and identifying as partnered at the time of diagnosis. The recruitment was carried out through yer distribution at six sites in Alabama including, University of Alabama at Birmingham (UAB) 1917 Clinic, Birmingham; UAB Family Clinic, Birmingham; Birmingham AIDS Outreach, Birmingham; Health Services Center, Anniston; Unity Wellness Center, Opelika; and Thrive Alabama, Huntsville. Flyers containing study's information were posted in the sites' waiting and examination rooms. Interested participants contacting the PI went through a screening process before scheduling an interview.

In-depth Interviews
The interviews were conducted by two researchers via an online platform (HIPAA-compliant Zoom application) following an interview guide and were recorded using digital recorders. A verbal consent of the interviewee was also recorded. Each interviewee was reimbursed with a $30 gift card. Audio recordings of interviews were transcribed and checked for any personal identifying information before analysis. Participants were assigned pseudonyms for analysis and reporting purposes. All study activities were approved by the UAB Institutional Review Board.

Study Design and Analytic Approach
As the purpose of this study was to explore the lived-experiences of the newly diagnosed individuals on the role of having a partner in their HIV care and to generate an in-depth description of the phenomenon, a Phenomenological design was applied (12). The recommended number of interviews for a phenomenological study design is between six to ten. Keeping this in mind, six interviews were conducted for this study. The average time spent on each interview was 63 minutes.
The data analysis followed Moustakas approach (13). After gaining familiarity with the transcript's content, signi cant statements were identi ed, studied, and clustered into themes. Quotes that contradicted the commonly identi ed theme(s) were also identi ed and reported (12). After achieving thematic saturation, a detailed, "thick" description of "what" the individuals experienced and "how" the experiences happened was prepared. Coding was done individually by two researchers. After resolving discrepancies, an inter-coder agreement rate of 90-95% was attained. The process of data organization, management, and coding was carried out using NVivo 12 (14).

Results
The participants comprised of ve women and one man, 67% were African American, and the median age was 46 years ( Table 1). The interviews were conducted between October 2020 to August 2021. The small sample size was primarily due to the COVID-19 pandemic, which impacted the opportunity for potential participants to learn about and participate in the study. Table 2 outlines the four themes, their subthemes, codes, and illustrative quotes, that were derived from the interviews. The rst theme, role of HIV on partnership, explored the impact HIV disease had on the partner/partnership. Three topics, deliberate HIV transmission by partner, impact of HIV diagnosis on partnership, and presumed reaction if partner was diagnosed with HIV (reverse scenario) emerged under this theme. The second theme, impact of partnership on HIV, described the experiences from a different angle and explored the role played by the partner around the PWH's HIV. Under this theme, three concepts were identi ed: importance of a partner in HIV, perceptions on dealing with HIV diagnosis without a partner, and role of family vs. partner in HIV care. Building on the impact of partnership on HIV, the third theme, forms of support from partner in HIV care, described the ways in which a partner provided support to the PWH during different phases of the HIV care continuum. Two areas, partner support around the time of HIV diagnosis and linkage to HIV care and partner support on retention in care, were uncovered under this theme. The fourth theme, perception on the types of partner-based clinic services, identi ed participants' thoughts on the type of services at the clinic that can involve the partner of the PWH. Three areas, couples' therapy, assistance with partner communication on sensitive topics, and HIV education of the partner, were identi ed under this theme. Each theme supported by quotes from participants are discussed in detail below using participants' pseudonyms.

Role of Family vs. Partner in HIV Care
Of all the relationships in one's life, all participants reported family and/or partner playing a signi cant role in their HIV care. When asked who played a bigger role, mixed responses were given. Marie noted that her family and partner both played a role in her HIV care. However, she noted that her partner played a greater role; she said, "In my opinion, a signi cant other or a partner has the greatest in uence on me in my HIV treatment". Similarly, Zoey mentioned discussing her HIV health more with her sister than her partner, but stated both, her sister and her partner playing an equally important role.
On the other hand, some participants who were partnered at the time of diagnosis but ended the relationship after discovering the dishonesty from their partner's side, thought family to play a bigger role in their HIV care. While these individuals did not have a partner to in uence their HIV care, they acknowledged the importance of having a partner in dealing with health conditions. Moreover, support from partners was noted as special as partners made a conscious choice to provide support to their partner as compared to family members, who mostly provided support due to having a biological bond.
Marie noted partner accepting a person's health condition(s) and still choosing to remain in the relationship to be valuable. Similarly, Donna said, When you get the opposite sex to help you along your journey, whatever your sickness is, that's very important...When somebody that's not related to you can take all of the load to help you along the way, that's good for you to help you come through whatever it is you're going to through.

Forms of Support from Partner in HIV Care
This theme explored ways in which a partner provided support to the participants. This was divided into support around the time of diagnosis and linkage to HIV care and support with HIV retention in care. The most common types of support identi ed by the participants were emotional support, informational support, and tangible support. Participants also experienced tangible support from their partners. Some participants noted their partners providing transportation to the HIV clinic. In addition to providing transportation, John noted his partner around diagnosis helping with the paperwork needed for linking him to HIV care and making sure he had his HIV medications; he said, "She went and got my [ART] re lls, all the medicine, paperwork, everything".

Partner Support in Retention in Care
This sub-theme explored ways in which the participants experienced support from their partner which impacted their retention in care. This included the partner providing emotional support and tangible support. Emotional support was again the most common type of support experienced by the participants around HIV retention in care. Participants reported partners providing a sense of belonging The feeling that the life of PWH mattered to someone kept PWH motivated to maintain their HIV care. Zoey noted that, even though being un-partnered and dealing with HIV care (in a hypothetical scenario) would not have meant she would have fallen out of care, having someone did provide a "wonderful" feeling. Similarly, Marie noted, "It gives my soul joy to know that somebody cares that I wake up every day, so it motivates me to do better today than I did yesterday".
Some participants mentioned their partners providing appointment reminders. Zoey noted her partner making sure she remembers about her upcoming appointment; she said, "He'll send me a text message as a reminder about what time an appointment is". Similarly, Marie talked about her partner helping her to remember her HIV appointments as "second nature".
As daily medications such as ART are taken around the same time every day, Zoey noted her partner making sure she took her medication at the correct time. Similarly, Marie noted her partner helping with getting her in a routine of taking her ART; she said, He's the one that got me on the schedule with my medication...for two weeks, he sent me a reminder that would go off every mornin' at 6:15. 'Take my meds', so that's what I did for two weeks until I got into the habit of just automatically walkin' to the bottle, gettin' it rst thin' in the morning.
The partner making sure PWH has transportation to the clinic was also noted. Zoey noted her partner ensuring she had available transport to attend her HIV care appointments. Similarly, Marie noted her partner making sure her car has enough fuel for the drive to her HIV appointment; she said, "He has came and pumped my gas 'cause he knows usually when I drive from here to my appointment, it takes so long".

Perception on the Types of Partner-based Clinical Services
Understanding how relationship dynamics play a role in HIV care could be helpful in designing clinicbased services that involve the partner of the PWH. These services can be aimed at improving HIV linkage and retention in care in the newly diagnosed individual. Keeping these potential services in mind, participants were asked their thoughts on potential areas in which these services could focus, that would be bene cial. Participants recommended services such as couple's therapy, a mediator assisting with partner communication on sensitive topics, and HIV education of the partner.

Couples Therapy
As a majority of the participants sought care from a therapist along with their HIV care, most participants suggested having similar sessions for couples. Donna suggested partner accompany her to her therapy session. Zoey suggested having a joint therapy session (partner and PWH) with a therapist, similar to that already offered to her at her HIV clinic; she said, "I think that would be wonderful if couples could come in and see the psychotherapist or if they had a class or a study or something involving couples".

Assistance with Partner Communication on Sensitive Topics
These suggestions involved the therapist helping with discussing sensitive topics, such as HIV disclosure or mediating communication among the couple on other sensitive topics. John suggested mediating the HIV disclosure to the partner; he stated, The process of telling their signi cant other about their condition or their [HIV] diagnosis…For the person [with HIV] that is having a hard time accepting and disclosing that information to others, I think it could be really helpful. I think it could be a life or death type of saving for some people.
In addition to HIV disclosure, Donna suggested having a therapist to help with communicating topics that the patient may nd di cult or feel hesitant about communicating with their partner alone; she said, Maybe they [partner] would ask your therapist, "can they sit in with a session with you" …they could be dealin' with you and have something bundled up inside and so many things they wanna say, but they don't wanna say it to you 'cause they might not wanna hurt your feelings. While partnership was helpful in HIV care for some participants, it did not play a role in others who mostly had a history of unhealthy partnerships. However, the importance of having a partner in HIV care was highlighted by even those without a partner or those with an unsupportive partner. This speaks to the importance of the quality of partnership rather than the presence of a partnership alone. When focusing on the quality of partnership, a study exploring the factors that play a role in HIV-related joint decision making among heterosexual couples in Kenya, found that relationship-centered motivation led to better HIV care behaviors such as HIV disclosure, improved ART adherence, and HIV appointment adherence(16).
Moreover, although most partnered individuals suggested their partners playing an equally encouraging role along all steps of the HIV care continuum, one individual highlighted a lesser need for a partner to rely on in the later phases of the HIV care continuum, such as retention in care. However, a de nite theme could not be concluded based on this expression by one individual; this area has a potential to be explored in detail in future studies.
Having Most of the support practices noticed in our study are similar to those found in African studies (10,11,18 stressful period for the newly diagnosed individual, another potential reason for the small sample size could be the reduced willingness in PWH to share and relive their di cult experiences around their HIV diagnosis. Moreover, the mode of interviews was changed from in-person to virtual due to the COVID-19 pandemic, which may have discouraged some individuals, especially those with lower technological literacy, from participating. Although the sample size was small, it may be adequate for exploring the central research question this study was based on, as thematic saturation was achieved. Moreover, none of the participants were partnered with the same partner from the time of diagnosis; this limited our ability to explore experiences of long-term partners on HIV care. Furthermore, the experiences described in this study are of PWH who attended the recruitment sites and therefore may not represent experiences of individuals out of care. Lastly, as most participants reported receiving psychotherapy along with their HIV care, there is a possibility that the recommendations made by these individuals on areas for partnerbased services mostly involved a mediator/therapist.

Conclusion
This study found quality of partnership in addition to the presence of a partner to play a vital role in the HIV care continuum. The importance partner-based clinic services highlighted in this study provided support for the potential success of services that can be focused on heterosexual couples in reducing the burden of the new HIV diagnosis for both the diagnosed and their partner, which will ultimately help with The datasets used and/or analysed during the current study are not publicly available due to possible risk of participants' identi cation but are available from the corresponding author on reasonable request.
Ethics approval and Consent to participate: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the University of Alabama at Birmingham on July 26 th , 2019. Verbal informed consent was obtained prior to the interview.

Consent for publication:
Not applicable.

Con icts of interest/Competing interests:
No potential con icting/competing interests were reported by the authors. Emily B. Levitan receives research funding from Amgen and has received consulting fees for a research project funded by Novartis, unrelated to this work. Funding: The research leading to these results received funding from the UAB Department of Epidemiology and grant number P30 AI027767.