Demographic and Social Factors associated with HIV discordance among HIV- infected couples in Kaduna State Nigeria.

Background: Discordance has always been a bane in the efforts to stop the spread of HIV within the population as it creates a gap through which re-infection occurs. Knowing the demographics associated with discordance will help in the ght against HIV AIDS transmission. Objectives: The study was conducted to assess the demographic and social factors associated with HIV discordance among HIV- infected couples. Methods: A total of 158 couples and 317 individuals were recruited for the survey using a stratied sampling technique. A detailed closed-ended questionnaire was administered to them to collect their demographic and social information. A blood test was also carried out to conrm their HIV status. Results: The majority 161(50.8%) of respondents had secondary education while the least 29(9.1%) of them had tertiary education. Most of the 135(42.6%) knew their HIV status by voluntary testing, and most respondents 255(71%) were Christians while only 92(29%) were Muslims. More women 105(66.04%) were HIV positive, and the HIV discordance prevalence for Kaduna State was 0.2%. Social factors such as education, employment, unprotected sex, extramarital affairs, body marks/tattoo, surgery/operation, tribal marks, and blood transfusion did not affect HIV discordance, p-value (cid:0) 0.05. Other social factors such as remarriage, use of antiretroviral therapy (ART), pre-marital sex, male/female circumcision, and polygamy were found to affect HIV discordance, p-value (cid:0) 0.05. Conclusions: There is a need to draw the attention of HIV- infected couples to these facts to succeed in the global war against HIV AIDS.


Introduction
Discordance among HIV-infected couples is a common phenomenon in sub-Saharan Africa and this has always been a challenge in the struggle for HIV prevention and cure. 1,2 Discordant couples are those where one partner is HIV-infected while the other is not, where a couple is de ned as two persons in an ongoing sexual relationship and each of these persons is referred to as a "partner" in the relationship. 3,4 There are two types of discordance: hard and soft. Hard discordance is when the male partner is HIV positive while soft discordance is when the female partner is HIV positive. 4 In another report, Merenu et al. 5 also mentioned that serodiscordance can be called magnetic or mixed-status. Discordance usually results from initial non-disclosure before marriage or relationship, traditional marriages without premarital counseling and testing, latency in the event of infection before marriage, and accidental infection of a partner during a marriage or sexual relationship. 6 The phenomenon of discordance among HIV-infected couples has remained a mirage and a concept that needs to be unraveled. It has remained so for as long as when the discovery of the mutant alleles of the CCR5 gene came to the fore. 7,8 The mutant allele concept is just one possibility; there could be other reasons such as reduced viraemia or innate resistance. Knowing that majority of HIV-1 infection which occurs in Africa is among individuals in stable sexual partnership, improving our understanding of the correlates of discordance will provide information on the dynamics and risk factors of couple transmission that can assist in the development of interventions to reduce transmission within couple relationships. HIV discordant partnerships can constitute core risk groups for the transmission of HIV infection. 9 Gray et al. 10 also reported that HIV-negative members of discordant partnerships are at extremely high risk of infection, with the annual incidence of 10 to 100 fold higher than that of their HIV concordant negative counterparts.

Materials And Methods
Study area/population A total of 158 couples or 317 persons who are either HIV positive or negative from 9 LGAs of the 23 LGAs of Kaduna State, Nigeria were recruited for the study using a strati ed sampling technique. Kaduna State is one of the 19 northern states of Nigeria and has long been seen as the Major capital of the northern region, and now the capital of the North West. It is ranked 4 th by land area and 3 rd by population in Nigeria. The state capital was the former capital city of the British protectorate of the Northern Nigeria region  after Zungeru (1903Zungeru ( -1923 and Lokoja (1897Lokoja ( -1903. It is made up of some major towns which include: Zaria, Kagoro, Kafanchan, Kachia, Zonkwa, Makar , and Birnin Gwari. 11 Kaduna State has coordinates of 10 0 20'N 7 0 45' E of Nigeria. It has a total land area of 46,053 km 2 and a total population of 6,113,503 according to the 2006 population census of Nigeria. 12 Kaduna State has over 1,000 primary healthcare facilities to cater to every resident -even in the most remote village or ward of the state. In addition to these, the government has made efforts to establish General hospitals in each of the 23 LGA headquarters to enhance effective and accessible healthcare for its citizens. These General hospitals have now become treatment centers for HIV anti-retroviral therapy all around the state. A structured questionnaire was administered to capture demographic data (sex, educational quali cation, religion, marital status, and employment status) of respondents; and social factors (discovery of HIV status, unprotected sex, use of ARTs, use of condom, pre/ extramarital affairs, polygamy, male/ female genital mutilation, tattoo/ surgery and tribal marks, blood transfusion) of respondents. Blood samples were also collected from HIV-negative partners to re-screen the clients for their HIV status. This was done in a space of 4months, from July 2020 to November 2020.

Sample collection
The questionnaire was issued to the HIV-positive partners at the treatment center on clinic days after proper enlightenment on the essence of the study. Five milliliters (5ml) of whole blood was aseptically collected from the cephalic vein of the ante-cubital fossa of each HIV-negative donor after signing informed consent at the end of the group information session (GIS). A sterile EDTA container was used to keep the whole blood unclotted and stored in the refrigerator for further analysis.
Test procedure (HIV serology) The test device (cassette) was removed from the foil and placed on a at surface (laboratory worktop). A blood sample (about 20µL) was dropped onto the testing reagent Determine. UNI-GOLD was later used for a con rmatory test. Any sample that yielded discordant results in two tests was resolved using STAT-PAK as the tie-breaker. This followed the national guidelines for a rapid test as outlined by UNAIDS/WHO, 2004 using serial algorithm. 13

Statistical analysis
The data generated in this study were analyzed for statistical signi cance in the association of HIV discordance and demographic social factors using Pearson Chi-square, Fisher's exact test with the aid of statistical package for social sciences (SPSS) version 21. The signi cance level was set at a p-value of ≤ 0.05.

Demography
One of the inclusion criteria in this study was that participants must be couples who have been in stable sexual activities for at least one 1year. For this reason, sex is of no signi cance here-they must be male and female but however, one man had two wives in participation-this is why we had 317 respondents for 158 couples. Similarly, age is of no signi cance here because all participants were adults (18years and above) to participate. Table 1 shows that the majority of 161(50.8%) of respondents, had secondary education followed by 72(22.7%) who had primary education. Those who had no education were 55(17.4%) while those with tertiary education were only 29(9.1%).     Table 3 shows a state discordance prevalence of 0.2% as calculated from a United Nations national report of 2019 which places Kaduna on a state HIV prevalence of 1.1%.

Discussion
The study revealed in Table 1 Table 1 also revealed that more Christians 225(71%) participated in the study than Muslims 92(29%). This result also points to the fact that in treatment centers more Christians were seen participating-even in Muslim-dominated areas. This is because of stigmatization; people moved far away from their localities to access treatment in strange lands where the chances of identi cation were very slim. This agrees with the reports of Earnshaw and Kalichman 15 and Saki et al. 16 Figure 1 shows the distribution of respondents based on their HIV status. The results show that more men 105(66.46%) were HIV negative while more women 105(66.04%) were HIV positive. This really agrees with what we see in the communities-more women are positive than men; and this goes in line with the report of Magaji et al. 17 Biologically, women are two to eight times more likely than men to contract HIV during vaginal intercourse 18,19 and obviously, our results agree with such ndings.
We can also conclude that a large proportion of HIV discordance in Kaduna State is "soft discordance". 20 On the other hand, the results in Figure 1 do not agree with one particular report which found out that more men were HIV positive among discordant couples in Anambra State, Nigeria. 20 The results in Table   2 showed us an array of social factors that were associated with HIV discordance. 21