Local Pathways of “Serodiscordant Couples”: Unpacking a Global HIV Population Category in Papua New Guinea

ABSTRACT

HIV prevention programs focus on global “key populations” and more localized “priority populations” to ensure effective targeting of interventions. These HIV population categories have been subject to considerable scholarly scrutiny, particularly key populations, with less attention given to critically unpacking priority populations at local levels, for example “serodiscordant couples” (one partner has HIV, but not the other). We examine this population in the context of Papua New Guinea to consider how local configurations, relational pathways, and lived realities of serodiscordant relationships strain the boundaries of this population category and raise intriguing questions about its intersection with contemporary biomedical agendas.

KEYWORDS:

• Biomedical technologies
• HIV population categories
• local configurations
• Papua New Guinea
• relationality
• serodiscordance

HIV prevention programs focus on so called “key” and other “priority” populations to ensure effective targeting of interventions. Based on epidemiological mappings and categorizations of HIV distribution and risk, “key populations” are considered particularly vulnerable to HIV due to a confluence of social, legal, and structural marginalization, as well as essential partners in an effective response to the epidemic. According to UNAIDS (2022) and the World Health Organization (2016), the most significant key populations globally are gay men and other “men who have sex with men,” sex workers, transgender people, people who inject drugs, and people in prison. In 2021, it was estimated that while key populations account for less than 5% of the global population, they and their sexual partners comprised 70% of all new HIV infections that year (UNAIDS 2022).

While key populations are considered important everywhere, “priority populations” vary from one country to another and refer to groups that are identified as vulnerable to HIV in locally specific contexts, for example young girls, Indigenous peoples, people with disabilities, and mine workers. The term also refers to people in relationships where the risk of HIV transmission may be high and who are therefore considered a priority for access to preventative biotechnologies, such as HIV treatment-as-prevention (TasP) and pre-exposure prophylaxis (PrEP).¹ They include sexual partners of key populations, pregnant women with HIV, and, our focus in this article: “serodiscordant couples” (UNAIDS 2022). Derived from the medical term “serodiscordance,” which means differing (discordant) blood (sero), the category serodiscordant couples is widely used in epidemiology and public health to describe a sexual relationship between an HIV-positive person and an HIV-negative person.

In Papua New Guinea (PNG), where our research took place, the definition of key populations has narrowed from earlier versions that defined almost everyone as a key population, including truck drivers, heavy drinkers, people who inject drugs, and mobile men with money (e.g., miners and others working away from home). It is now well accepted that key populations disproportionally affected by HIV in PNG include female sex workers, men who have sex with men, and transgender women (Kelly-Hanku, Willie, et al. 2018). However, there is no mention of “priority populations” in the most recent PNG National HIV strategy, with serodiscordant couples mentioned only once in relation to adapting biomedical prevention technologies, such as PrEP, to the PNG context (NACS 2018). Although seemingly common in PNG (Kelly et al. 2011), serodiscordant relationships have generally received scant consideration by researchers and policy-makers, and local data on HIV infections occurring within serodiscordant couples or polygynous unions are unavailable (Kelly-Hanku 2016; Persson et al. 2019).

The usefulness and validity of HIV population categories have been subject to considerable scholarly scrutiny (Aggleton et al. 2014; Boellstorff 2011; Kaplan et al. 2016; Lorway and Khan 2014; Ly et al. 2020; Parker 2019; Truong et al. 2016; Wilson and Miyashita 2016). In 2016, a special issue of Global Public Health was dedicated to “the trouble with categories,” exploring their limitations and unforeseen ramifications in different cultural contexts (Parker et al. 2016). As key population categories, MSM and transgender people have been the prime focus of these analyses and debates. Less attention has been given to the critical unpacking of other HIV population categories, including priority populations, such as serodiscordant couples.

This relative scholarly inattention is curious given that serodiscordant couples have long figured prominently in international clinical trials on TasP and PrEP, and in public health research and policy guidelines that emphasize these HIV biotechnologies as a priority for serodiscordant couples globally (Muessig and Cohen 2014; Rodger et al. 2019; WHO 2012: 2015). However, despite this emphasis, there is often little close consideration of the contexts, formations, or compositions of the relationships assigned to what is in effect represented as a distinct HIV population category. We are reminded here of sociologist John Law’s (2004: 25) notion of an ontological singularity animating science – the idea “that the world is shared, common, the same everywhere” – as it strives to inscribe order and intelligibility onto realities that are inherently “multiple, diffuse and non-coherent,” in short, “messy” (Law 2004: 14). The following remark by Beougher et al. (2013: 379) speaks to the gist of our inquiry:

[Sero]discordant couples are unique because partners do not share the same [HIV] serostatus. Yet research overlooks how they became discordant, mistakenly assuming that they have always been that way and, by extension, that being discordant impacts the relationship in a similar manner.

We build on our previous work here, which has challenged the ways serodiscordance is conceptualized as homogenous and intelligible across time and contexts (e.g., Kelly-Hanku 2016; Persson 2013; Persson and Hughes 2016). Our explorations rest firmly on the premise that serodiscordance, like any phenomenon, is brought into being by different personal and social circumstances, and is shaped by cultural practices and meanings. Using this perspective as our point of departure, we ground it in the empirical context of PNG. Through the lens of anthropological and other scholarly work, we examine the local intricacies that can be easily obscured by the generic HIV category “serodiscordant couples” and by the emphasis on biomedical solutions. In line with global guidelines, PNG has identified serodiscordant couples as one of several populations for whom HIV treatment should be prioritized (NACS 2018), and has recently commenced a PrEP pilot program. At a time when PNG is struggling to achieve UNAIDS (2020) targets to greatly reduce new HIV infections through biomedical interventions (Kelly-Hanku, Redman-MacLaren et al. 2020; WHO 2021), unpacking this population category to gain much needed insights into its “messy” realities is a timely task. By doing so, we hope to lay the groundwork for greater recognition of the motley inceptions and constellations of mixed-status relationships in this Pacific Island nation, and hopefully beyond.

HIV population categories

In The Order of Things: An Archaeology of Human Sciences, philosopher Michel Foucault (1970) argued that, throughout western history, humans have sought to bring order and certainty to the empirical world through different classificatory systems. These systems of grouping and labeling have provided the epistemological ground, or episteme, that defines the temporal and cultural conditions of possibility for knowledge and its production. Since the start of the HIV epidemic, population categories have emerged, evolved, and changed in an attempt to track the spread of the virus and to identify and respond to affected communities. Starting with the “4 H’s” (homosexuals, heroin users, Haitians and hemophiliacs) in the early 1980s, this process has largely been driven by epidemiological data. However, critical debates among affected communities and scholars, and the formation of new practices and biosocialities among targeted populations, have effectively challenged reigning categories as potentially exclusionary, counterproductive, misleading, or stigmatizing (Lorway and Khan 2014; Moyer 2019; Parker 2019).

A common critique is that the pervasive use of generic HIV population categories by epidemiologists, health agencies, policy-makers, and funders bypass the mélange of sexual cultures, identities, and relationships submerged within those groupings. Critics argue that this “taming of complexity” (Schramm and Beaudevin 2019: 280), can impede HIV workers from reaching and attending to people and communities at risk who inhabit lives beyond and betwixt the imaginary bounds of designated categories (Parker 2019; Wilson and Miyashita 2016). Kaplan et al. (2016: 828) ask in relation to the “transwomen” category, “What realities, narratives, bodies, sexualities, and practices are implied and prioritized by this category? Which ones are excluded or erased?” The question could be asked of any contemporary HIV category, including “serodiscordant couples.” In short, the argument is that “broad-brush” categories end up “obscuring the porous margins of these classifications, the important diversities that exist within categories, and the intersections between them” (Parker et al. 2016: 820).

Nonetheless, HIV categories are powerful tools widely applied both locally and globally to guide and optimize programs and interventions. HIV categories also mean money. As Moyer (2019: 318) observes, in an era of increasingly “data-driven responses and ‘value for money’ discourses,” there is much at stake: human lives, but also resources. Internationally funded HIV prevention programs rely on epidemiological categories as a “selling point” to attract donors, aggregating individuals assumed to be at risk of HIV into “definable, calculable and governable subpopulations” (Lorway and Khan 2014: 56). This makes categories useful also to local governments and communities who benefit from global funding to support their HIV response. As organizations, civil society, affected individuals, and other stakeholders leverage HIV categories as a transactional mechanism to secure resources, “categories become sites of meaning and value production,” with the capacity to generate new local identities and links between people with enabling and constraining effects alike (Biruk 2019: 191). Hence, some anthropologists resist the critique of HIV categories as a mode of governance that “only serve[s] to conceal social complexity” (Moyer and Nguyen 2019:ii), instead highlighting their productive potentialities in the specific contexts in which they are mobilized (Biruk 2019; Lorway and Khan 2014; Moyer 2019; Schramm and Beaudevin 2019).

Our intention here is to “unpack ‘the local’” (Moyer and Nguyen 2019:ii), and to uncover real-life relationships enfolded into the epidemiological category of “serodiscordant couples,” a task that has not yet received adequate empirically-based scholarly attention, particularly in the Pacific. Only a few studies have pursued insights into how these relationships came to be. For example, there is a difference between those who are already serodiscordant when they meet and those who become so after the start of the relationship, and these two contrasting infection histories can have a pivotal impact on relational dynamics and on HIV prevention practices as a qualitative study of gay couples in San Francisco found (Beougher et al. 2013). Hughes and Truong (2017) coined the terms “sero-cognisant” and “sero-discovering” to describe these two pathways to serodiscordance and the different challenges and needs they presented for heterosexual couples in Brazil.

Such delineations of relational pathways contribute to a “more conceptual nuance in our understanding of ‘serodiscordance,’” thus strengthening the capacity to respond effectively to people in such relationships (Hughes and Truong 2017: 888). As we show, the more we delve into stories of how serodiscordant relationships come into being, the more varied and jumbled these pathways appear. Likewise, the more we unpack local configurations of these relationships, the more they strain “serodiscordant couples” as a distinct population category, which raises questions around biomedical technologies as a global solution, but also the ways HIV biomedicine might work to shape and define this category.

Settings and method

PNG has the highest burden of HIV in the Pacific region, with an estimated prevalence of more than 1% among the adult population aged 15–49 years (UNAIDS 2023). HIV treatment was introduced in 2006 and is now nominally available across the country, though stock-outs are a recurring problem (NACS 2018). The contemporary global agenda of TasP has been formally implemented with the introduction of “test and treat.” However, HIV viral load testing, which is critical to TasP, is not yet readily available at point-of-care, though attempts to scale up are currently under way (Gare et al. 2022). And, as mentioned earlier, PrEP is at a pilot stage.

We draw on interviews conducted in Port Moresby and Mount Hagen, two high-burden areas in PNG, as part of a qualitative study of serodiscordant couples and polygynous partners. An “arms-length” recruitment approach was used whereby key informants working in the HIV sector informed potential participants about the study. All participants identified as being in a relationship with someone with a different HIV status (we did not verify serodiscordance through testing). The study included three waves of face-to-face interviews between 2017 and 2019. Ninety-six people participated in one or more interviews (28 became lost to follow-up during the course of the study and new participants were recruited), representing a total of 59 serodiscordant relationships, of which 13 were polygynous. They included 58 women (including seven transwomen) and 38 men. Of these, 59 were HIV-positive (39 women, 13 men, seven transwomen) and 37 were HIV-negative (13 women, 24 men). The length of relationships ranged from a few months to 15 years and longer. The majority participated in the study together with their partner/s (but were interviewed separately), while 21 participated without their partner/s. All participants with HIV were on HIV treatment. The study received ethics approval from the relevant institutions in PNG and Australia (see acknowledgments). Informed written consent was gained from all participants.

Interviews were conducted in Tok Pisin or English by AM and RNT, two cis-gendered, experienced Papua New Guinean social researchers, using semi-structured interview schedules, which had been piloted and refined to explore various relational aspects of serodiscordance, some detailed in recent publications (Mitchell et al. 2021; Persson et al. 2020, 2021). Interviews were audio-recorded, transcribed, translated into English and de-identified, including replacing personal names with pseudonyms. A coding framework was co-developed by the Australian/PNG research team through multiple readings of select transcripts and agreement on optimal codes to capture key themes. First level coding was completed by EM, while the analysis for this article was conducted by AP and followed the principles of inductive thematic analysis (Braun and Clarke 2006). The analysis and draft manuscripts were workshopped by the team, drawing on each author’s area of expertise.

Pathways to serodiscordance

The first juncture of any pathway to a serodiscordant relationship is an HIV infection. In this study, stories of HIV acquisition were notably gendered. Women typically reported acquiring HIV from previous husbands who were polygamous or who had engaged in extramarital sex, while five women reported being infected through sexual violence by someone other than their current spouse. Men typically reported acquiring HIV from having had multiple sex partners prior to or during their current relationship. In a handful of stories, two participants believed they had acquired HIV from a family curse, one woman believed she had been infected by the HIV testing needle itself, while a few claimed they did not know.

Of the 59 men and women with diagnosed HIV, 34 knew about their HIV status before entering into their current relationship. The remaining participants had been infected or diagnosed during their current union. Of those, only four had unequivocally acquired HIV from their current partner, though several women suspected it, but had no evidence. Resonant with the two basic pathways to serodiscordant partnerships described by Hughes and Truong (2017), our findings included sero-cognizance and sero-discovery, but splintered further into more complicated relational pathways that do not readily align with serodiscordant couples as a singular HIV category.

Knowledge and discovery

Less than half the couples had knowingly entered into their relationship or marriage, with both partners being aware of their serodiscordance. In many cases, the partner with HIV had disclosed upfront at the start of the union, and the HIV-negative partner accepted the situation for a range of practical and emotional reasons. For example, in 48-year-old Erick’s case, his need for a wife to help with his four teenagers, together with Selina’s honesty and courage to disclose, drove his decision to accept her into his life. However, disclosure is not always a private moment between partners, which is how it is often described in the Anglo-European HIV literature; it can be a relational event beyond the couple in societies where people, including couples, are constituted in relationship to others, as exemplified by descriptors such as “dividual” and “collectivist” cultures (e.g., Strathern 1988). We found that it was common for other people (friends, family, community members) to have intervened at an early stage and revealed the information to the HIV-negative partner, despite it being unlawful to do so in PNG (HAMP 2003). This was the case for Jude, aged 35, who met his future wife at a workshop:

I went and when I saw her, I fell in love with her … My friends told me then, that she’s infected, but I didn’t care. I said, “that’s alright; whether she’s infected or not, I’m willing to live with her, and how we go about supporting each other is our business” … I accepted her status and agreed to live with her and face whatever may come. So, I attended some training about HIV, which gave me the knowledge about [HIV] prevention.

There were stories of families and whole communities interceding to determine whether a marriage between serodiscordant partners was acceptable, a consideration generally entangled in concerns around potential compensation demands from the HIV-negative spouse’s family in the case of HIV transmission, especially if a brideprice had been paid. Compensation claims are a customary (but changing) practice in PNG to settle disputes and losses, including marital breakdown, injury, or desertion (Pupu and Wiessner 2018). Rita and Damien are one example. Damien, aged 22, grew up in the same compound as 32-year-old Rita. He said he “felt sorry for this woman” and often tried to help her. “I saw her being sick and it was not good, so I talked to the community, especially her brothers and her people. I said, ‘I will take care of this woman.’” When he proposed marriage, Rita involved the community to make sure Damien openly acknowledged that he knew she was HIV-positive, so that he would not be able to demand compensation should he become infected (cf. Wardlow 2017). “She told the entire leaders in our compound and she made it public and we talked in public … I said that if anything happens to me, my people won’t say anything to the woman’s people.”

In about half of the couples, serodiscordance was discovered after the relationship began, sometimes years after the partners had married. Many had entered into marriage not knowing their HIV status, with one partner subsequently testing HIV-positive, most commonly after having fallen ill or as a result of routine antenatal screening when pregnant. While most women had acquired HIV prior to their current marriage, men were often infected during their marriage due to extramarital sex, like 42-year-old Goliath who said he “contracted HIV because of my mischievous womanizing.” He was diagnosed 14 years after he married Delailah who brought him to hospital when he became sick. “I described his sick[ness] to the doctors and they said, ‘sister, your husband is HIV-positive.’” Although angry, 38-year-old Delailah decided to stay with her husband, on the condition that he committed himself to God, a righteous life and monogamy, to which he agreed. This kind of redemptive transformation following a diagnosis was a recurring story, especially among the men, highlighting the powerful fabric of Christian faith in PNG society, particularly as part of the response to, and living with, HIV (Kelly-Hanku et al. 2014, 2018).

A child falling ill was another circumstance that led to the discovery of HIV. Cherry, aged 42, was pregnant with her fourth child when her 3-month-old baby became unwell: “I only found out about my status when the baby was sick and we came to the hospital. We were admitted at the pediatric ward and just after a week, the baby died.” Her husband Hosea, aged 40, explained that Cherry initially blamed him for having infected her and their unborn baby because of his track record of having multiple sex partners prior to their marriage. But he tested negative. They were both uncertain how Cherry acquired HIV, and described their situation “as something that was created by God in order for us to be close to each other.” When couples discovered their serodiscordance during marriage, they often incorporated biomedical explanations into culturally resonant frameworks in this way, including beliefs in God’s will or family curses (Kelly-Hanku et al. 2014; Persson et al. 2021).

Disclosure dilemmas

Some of the reasons why serodiscordance was discovered only after the couple met were more complicated. One pathway to serodiscordance hovered awkwardly in the interstices between sero-cognizance and sero-discovery: namely when knowledge of an HIV diagnosis was withheld either before entering into a relationship or during it. Belated disclosure was common, as were denials of an HIV-positive diagnosis. In over a third of the serodiscordant unions represented in the study, the partner with HIV did not disclose until after marriage, sometimes several years later, or delayed disclosing when diagnosed during the marriage. A blend of scenarios brought the issue to the fore. Pregnancy motivated several participants to disclose, like 34-year-old Mona who disclosed to her husband Leo when she was pregnant with their second child: “I realized that it’s not good for me to keep this secret any longer.” Xavier, aged 35, also knew his HIV status, but said that, for the first year of his marriage to his second wife Daisy, “I did not tell her.” He used her pregnancy as pretext to get tested together and thereby reveal his HIV status. This is how Daisy, aged 20, explained it:

When I was pregnant with my first daughter he forced me to go and do blood testing and I refused. But he insisted because he was scared I might pass the infection to our daughter. So we went and did the testing and they said I was (HIV-)negative and he was positive … that was when I found out that he has this sickness.

Besides pregnancy, other scenarios that prompted disclosure included the discovery of HIV medication, the intervention by family, friends, or health workers, and subterfuge, all of which converged in the story of Brown and Nora, both in their early 30s. As Nora tells the story, Brown was a compulsive womanizer with several wives and sex partners, “so one of them must have infected [him].” When his family noticed that he was looking sick, they urged him to get tested, which he did. But he did not tell Nora his test turned out positive. When she found his medication, she became suspicious and, together with health workers, found a way to ambush him into having a test.

I stole one of [his] medicines and took it to [the HIV clinic] … [They] asked for him to come for blood test, which he refused. Then one of our girls got sick … So they admitted us to [the] ward … Once we were inside the small office, I told him directly; “you often trick me many times, so now we will do blood tests.” When I said that, he said; “no!” I said “why not? The child is sick” … Then out of his own guilt he admitted. He cried in there and said, “It’s alright.” So we did our test and Brown tested positive; for me they said negative.

One man and five women (including four transwomen) had not disclosed their HIV-positive status to their partner. Hence, they alone knew that their relationship was serodiscordant. Potential loss of financial support was a major concern expressed by the transwomen, a stigmatized and highly vulnerable population in PNG (Kelly-Hanku et al. 2020). Research that specifically explores HIV disclosure among serodiscordant couples in PNG is scarce, but findings from other countries show that non-disclosure is relatively common in such partnerships and is typically underpinned by HIV-related stigma and fears of rejection or violence (e.g., Bhatia et al. 2017; Colombini et al. 2016). This was the case for 32-year-old Regina who said she was terrified her husband “would kill me” if he found out, a far from unfounded fear, given that violence against women is endemic and often condoned in PNG, most acutely in marriages (Eves 2021; Human Rights Watch 2015), and often in relation to HIV (Lepani 2016). While there was no shortage of loving and supportive relationships (Mitchell et al. 2021), we also heard stories of women whose husbands had assaulted them when they disclosed, with some experiencing continued partner abuse because of their HIV status. This nexus between gender violence and HIV is not isolated to PNG and has been described as “twin epidemics” more broadly (Global Coalition on Women and AIDS 2005).²

Deception, secrecy and proxy testing

There were also several stories of spouses (mostly men) refusing to get tested or lying about their HIV test results and their serostatus, insisting they were HIV-negative when confronted by their partner. Echoing several women, 29-year-old Alice was convinced that she had acquired HIV from her polygynous husband. After they married, she became sick and was brought by her family to hospital where she was diagnosed: “I have been blaming him for putting me in this situation, because as far as I know, I was healthy during my marriage with my previous partner.” Despite what she described as some tell-tale “signs,” her husband denied having HIV when she challenged him. Alice, however, remained suspicious and believed he was lying, because “he normally hides everything from me.” Regina, who had not disclosed her HIV-positive status to her husband for fear of violence, similarly suspected that her polygynous husband had HIV. She tried to encourage him to get tested together as a way to bring the matter to a head, but he refused. And so, they lived together in serostatus uncertainty:

I don’t know about his status, but somehow we met and [are] living like this. I want to tell him in some ways, when he wants to sleep with me, that he should use condoms, but he insists on sleeping without it. He is accusing me, saying, “are you a promiscuous woman, encouraging me to use condom?” … In my thoughts, I say, “you have married many women and you are also a man who [sleeps] around, so I don’t know.” [your HIV status]

Pathways to serodiscordance were edged with secrecy in more ways than one, from non-disclosure and deception within relationships, to self-protection from the outside world. The majority of couples kept their serodiscordance hidden to shield themselves from community gossip and censure, or interventionist attempts by family to break up the marriage or demand compensation. This comment by 31-year-old Becky was typical: “I’ve always kept his status secret, in case [my relatives] might think that he has transmitted [HIV] to me, and they would demand, ‘you compensate our daughter,’ or something like that.” In addition, the transwomen tended to keep their relationship with their HIV-negative cis-male partners largely out of the public gaze, not because of serodiscordance, but to avoid stigma and discrimination as non-heterosexual sex is illegal in PNG and marriage for gender-diverse people is not customary or legally sanctioned (Kelly-Hanku et al. 2020).

Another intricate pathway to serodiscordance has previously been referred to as testing by proxy (Morrill and Noland 2006); a phenomenon found in PNG, as well as in the US, Kenya, and elsewhere (Camlin et al. 2016; Kelly et al. 2013). It is based on the belief that only one partner (typically the woman) needs to test to reveal the couple’s serostatus on the assumption that the untested partner’s serostatus will be the same. There were several stories of proxy testing, including that of 25-year-old Sara whose husband lied about his HIV status, pressuring her to get tested to prove that he was HIV-negative. Only much later did he finally own up when Sara was pregnant with their third child. For 36-year-old Grace, proxy testing unfolded differently. Ten years into her marriage, her husband Xavier, who had a history of infidelity, became extremely sick and bedridden.

I insisted that we had to see a doctor … But he was scared to follow me to the clinic as he must have known that he had contracted the HIV virus already … [He] said that “I don’t want to see the doctor” … So, one day I went to the clinic to see the doctor by myself … [I] told the staff on duty that I want to do a blood test … I said that “my husband is very sick and I advised him that it’s better if we come to the clinic to see the doctor, but he refused, so I came.” [They said] “It’s good that you came, because your results have shown that you have the HIV virus in your body.”

Shocked and angry, Grace went home and told Xavier what she had done and what the result was. He finally relented and went and got tested, which confirmed that he had HIV and very low immunity. “I saved his life,” Grace said. “If I had never gone to the clinic to get me tested, he would have died.” Thirty-five-year-old Xavier, who was immediately put on treatment and eventually recovered, said he was “very happy and proud” of his brave, resolute wife. He later went on to marry his second wife Daisy, but, as we saw earlier, he did not disclose his status to her for their first year of marriage, despite his previous dramatic experience with Grace. The three of them subsequently reconciled and went on to build what they described as a harmonious serodiscordant polygynous marriage together. This, however, was not the norm.

Serodiscordant ambiguity

Of the 59 serodiscordant relationships represented in the study, 13 were polygynous, with 24 participants in such a union. Reflecting its highly diverse cultures, PNG has a medley of statutory and legally permitted customary marriage practices, including polygynous marriages (Luluaki 2014; Mek et al. 2018). As we have described elsewhere (Persson et al. 2020), knowledge of serodiscordance was not always distributed evenly in these unions. That is, spouses were often unaware of who in the union was HIV-positive or HIV-negative. Co-wives in particular, who in PNG typically have separate households, often did not know each other’s HIV status, and sometimes did not even know of each other’s existence. Thirty-year old Ruanah, for example, was not aware that her husband Ray was also in a committed 10-year relationship with a transwoman, 36-year-old Annaly, who in turn believed that Ray had long-since divorced Ruanah.

When first interviewed, 25-year-old Martha, who was diagnosed HIV-positive after she married, did not know her husband’s HIV status, nor that of his many wives and, as she put it, “concubines,” highlighting the precariousness of HIV prevention in such an ambiguous environment. “He is frequently marrying young girls, one after the other,” she said about her husband. Martha later found out that her husband had HIV and expressed concern that he kept it hidden from his other wives and sexual partners: “Yes, he brings a lot of different ladies to our house and his behavior is getting worse … In addition to that, he has the HIV virus in him and has been infecting the young girls and ladies.” Not only does this lack of transparency around HIV status destabilize the very definition of “serodiscordance,” but polygynous unions also challenge the heteronormative emphasis on the dyadic “couple” embedded in this HIV category.

Normative assumptions about “the couple” were also destabilized by sex work. One bisexual man and 10 women, including four transwomen, were or had recently been involved in paid sex work, often condomless. For the women, it was a means of subsistence in the highly gendered economy in PNG where women, due to limited opportunities for education and formal employment, are economically disadvantaged and typically dependent on men for economic survival (Mek et al. 2021; UNDP 2023). As Mek et al. (2021) state, the booming resource extraction industry has opened up new opportunities for men to seek wealth, multiple wives, and new sexual relationships, upending traditional gender norms and bringing about a proliferating sexual economy. This has contributed to marital abandonment, frequently absent polygynous husbands, and poverty for many women, including in this study, requiring them to find alternative ways to support themselves and their children, such as exchanging sex for money or goods. In this way, relationships swelled beyond “the couple” to encompass multiple spouses and sexual partners over time – known and unknown, permanent and transitory – blurring and imbricating supposedly distinct HIV categories.

Clearly, the stories presented here show that the “serodiscordant couples” category, scaffolded by the biological “fact” of serodiscordance, becomes far from clear-cut or even ascertainable when sited in real lives shaped by cultural customs, relational dynamics, and social change. Beyond the examples of deception, refusal to test, polygyny, and overlapping risk categories, serodiscordant ambiguity looped like a thread across the study, upending categorical certainty and thus complicating biomedical interventions. Many relationships were simply assumed to be serodiscordant, or lived “as if” in the absence of medical verification. Several self-proclaimed HIV-negative partners had tested only once – often at the start of the relationship or when their partner was diagnosed – and did not feel the need to test again for various reasons: because they believed their HIV status was permanently “fixed,” or that God protected them from becoming infected, or that HIV “belonged” solely to their partner because of their “sins” (Persson et al. 2021).

Although most participants understood the concept of having mixed HIV status, few were familiar with the extralocal descriptor “serodiscordant,” and those who were did not use it when speaking about their relationship. For example, Vagi, a 30-year-old HIV-negative man, rejected “the medical term” when asked to describe his relationship: “Like that, I will not answer it … I will just say that it is all about love.” Like Vagi, the vast majority did not identify as a serodiscordant couple, and were rather indifferent to this term when it was explained to them. Nor did they use any alternative local word to describe mixed-status relationships, instead insisting that the positive partner’s HIV treatment enabled them to “live normally,” just like any “ordinary couple,” based on the cultural meanings and practices of what constitutes normality locally (Persson et al. 2022).

Unpacking serodiscordance

Like all HIV population categories, the definition of “serodiscordant couples” rests on certain criteria of inclusion, specifically two primary binaries: HIV-positivity and HIV-negativity; and a dyadic relationship between intimate partners who are implicitly assumed to both be aware of their serodiscordance. As anthropologists and philosophers, such as Mary Douglas (1966) and Foucault (1970), have long observed, categories and classification systems are enormously functional knowledge tools in many cultures, bringing about order and normative standards and, thus, the ability to systematically code and decode the world and intervene accordingly. But, as Law (2004: 6) argued, categories and standardizations also require, by implication, boundaries, and limits: “Indeed, that is a part of their double-edged power. And they set even firmer limits when they try to orchestrate themselves hegemonically into purported coherence.” How this assumed logic translates and makes sense “in different contexts and to different subjects is often profoundly disparate,” Parker (2019: 271) notes.

The breadth and vicissitudes of human relationships clearly rebel against tidy categorization, as scholars theorizing HIV categories have argued, albeit not in relation to serodiscordant couples. Our findings strained the coherence of this category and its binary assumptions in several ways. In stories of how serodiscordance relationships transpired, the notionally insulated, dyadic “couple” was upended by the common involvement of families and community members in the disclosure of HIV and in decisions around marriage between serodiscordant partners. It was further upended by polygynous unions, with both known and unknown co-wives in different locations, and by overlapping HIV risk categories, which surfaced through accounts of sex work and multiple sex partners alongside the primary serodiscordant relationship. These coexistent webs of sexual connection, whether enduring or transient, also complicated the binary of HIV-positive and HIV-negative, given that knowledge of the HIV status of spouses, co-wives and sexual partners was not necessarily the norm. Different relational dynamics around disclosure and testing meant that serodiscordant ambiguity emerged also in some monogamous, non-polygynous relationships, with neither partner, or one partner alone, being aware of the presence of HIV, thus calling into question the very definition of serodiscordance.

Returning to Biruk’s (2019) earlier point about the potentially productive mobilization of global HIV categories in local contexts, the category “serodiscordant couples” did not noticeably generate new links, meanings, or identities in this study. The very diversity of relational pathways, experiences, and meanings of being in a mixed-status relationship, as illustrated, likely explains why serodiscordance has not gained traction as a coherent identity in PNG. Unlike “gay” or “trans,” serodiscordance is not an identity intimately anchored in gender and sexuality prior to and independent of HIV; another plausible reason for its lack of local purchase. This raises interesting questions around what role biomedical prevention technologies might play in relation to HIV population categories. Globally, these technologies are framed by a discourse that operates to thematize and define nominated recipients as at-risk HIV populations in need of care and resources, thus providing a platform for potential identity production. As the epidemic continues to evolve and biotechnologies, with their attendant discourses, continue to make inroads in PNG, it remains to be seen if serodiscordant couples, positioned as a “priority population” for biomedical interventions, will congeal into a locally meaningful identity.

Biomedicine and public health systems mold how HIV is perceived and lived, not only in terms of access to life-saving treatment, but also clinical monitoring. Viral load testing for people with HIV, which can detect potential infectiousness, has not been widely available in PNG until recently and “is still in its infancy” (Gare et al. 2022: 2), in contrast to high-resource Anglo-European countries where viral load testing is well-established, along with social and sexual narratives around “undetectability” and non-infectiousness. As the test becomes an integrated, normalized part of HIV health care in PNG, it will be interesting to observe how the concept of undetectability might be interpreted and how the meanings and relationality of serodiscordance might unfold and change in response. How will it play out in a context where traditional gender relations and social life are being transformed by an influx of money and modernity, by accelerated mobility, intercultural marriages, and a new sexual economy?

The introduction of PrEP will undoubtedly similarly shape and be shaped by evolving social, economic, and gender relations in PNG in critical ways that make it difficult to predict the impact on serodiscordant relationships. Notably, PrEP requires routine clinical monitoring and frequent testing for HIV by HIV-negative partners. But, as we found, regular partner testing was complicated by refusal, deception, and misconceptions about serodiscordance (see Persson et al. 2021). Our findings also suggest that the prevalence of non-disclosure and serostatus ambiguity in serodiscordant unions is likely to complicate access to PrEP in PNG for those in need. This raises vital questions in relation to future PrEP strategies in the local context. An over-reliance on PrEP as a solution to serodiscordance can erase important diversity by assuming all HIV-negative partners are equally at risk and have equal knowledge of HIV within their relationships. While PrEP should definitely be made available to serodiscordant partners, it must not come at the expense of close attention to significant differences in needs, experiences, and practices. Not all HIV-negative partners need to be on PrEP, because not all serodiscordant couples are at risk, while others might be at risk, but not even be aware that they are, or unable to prove it.

The capacity to understand how serodiscordance is lived, what it means and what it might come to mean in future scenarios is foreclosed if mixed-status relationships are viewed as a singular phenomenon dislodged from cultural ecosystems. Nuanced insights crafted by situated anthropological work often go unnoticed when governments and funders prioritize HIV research that rely on global key population categories that provide attractive and expedient clarity, but does so by aggregating and invisibilizing all those people and partners who dwell in the cracks of classificatory boundaries, thereby hampering not only effective biomedical interventions, but also the ability to recognize and respond to their varying social, sexual, and clinical needs more broadly (Hirsch et al. 2009; Hughes and Truong 2017; Persson et al. 2020).

Concluding reflections

The serodiscordant couple category is, in practice, a reservoir of heterogeneity, of myriad lives and experiences stitched together. In this study, relationships nominally assigned to this category transgressed its global public health definitions. This “trouble with categories” is unsurprising and has been pointed out by us and others before in relation to HIV categories (Kelly-Hanku 2016; Parker et al. 2016; Persson 2013). But the category of serodiscordant couples have so far remained under-researched, with few empirical studies unpacking this category at a local level. There is no doubt that categories are useful for organizing and targeting HIV prevention programs. But they are essentially “utopian systems” (Law et al. 2013: 178) that are only “meaningful because they are bounded” (Blank 2012: 180). Anything that aims to delineate inclusion also, by extension, excludes. And anything that aims for generalization flattens differences and trades away specificity, leaving people and lives unaccounted for.

Unless we remain attentive to the provisionality of the serodiscordant couple category, its fault lines and fissures, and the multiple ways it spills over its designated boundaries, this category, as with all HIV categories, defeats its own purpose and effectiveness. In view of the UNAIDS (2020) targets to greatly reduce new HIV infections globally by 2025, it is critical that we better understand serodiscordant unions, in all their shapes and constellations, their confluence and overlap with key populations, and their evolving and productive encounters with biomedical technologies. After all, intimate relationships are the primary context in which HIV is both transmitted and lived, in PNG and everywhere.

Author contributions

Lead investigators AKH and AP conceived and designed the study. All authors contributed to development of research tools, materials preparation, and data analysis. AKH, EM, and AM oversaw project management. Data collection was performed by AM and RNT. EM conducted first level coding. AP did the analysis and drafted the manuscript, which was workshopped and revised by the whole author team. All authors read and approved the final manuscript.

Acknowledgments

The study received ethics approval from the PNGIMR Institutional Review Board, the PNG National AIDS Council Secretariat’s Research Advisory Committee, the PNG National Department of Health’s Medical Research Advisory Committee, and the Human Research Ethics Committee at UNSW Sydney, Australia. Informed consent was obtained in writing from all participants in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This project was funded by an Australian Research Council Discovery Project Grant; Understanding global biomedical technologies in local realities: The case of couples with mixed HIV status in Papua New Guinea [grant number DP160103659].

Notes on contributors

Asha Persson

Asha Persson is an Adjunct Senior Lecturer at the Centre for Social Research in Health, UNSW Sydney, where she worked from 2001 to 2020, conducting qualitative, community-based research on cultural and lived aspects of HIV, with focus on hidden or under-researched populations within the Australian epidemic, including heterosexuals, children growing up with HIV, straight-identified men who have sex with men, and couples with mixed HIV status.

Agnes Mek

Agnes Mek is section head of the Social and Behavioural Research Group, Sexual and Reproductive Health Unit at the Papua New Guinea Institute of Medical Research. She is an experienced social researcher with a background in nursing, midwifery, and human resources management. She has a Masters in Communication and Social Change, and uses participatory and mixed qualitative methods to examine HIV, gender, and social change.

Richard Naketrumb

Richard Naketrumb is a highly accomplished social researcher having undertaken qualitative research in the fields of masculinity, sexuality, gender-based violence, HIV, and medical male circumcision.

Elke Mitchell

Elke Mitchell is a senior research fellow at the Kirby Institute at UNSW Sydney. Her research focuses on the cultural and social aspects of sexual, reproductive and maternal health, HIV, and neglected tropical diseases. Her work is concentrated in the Asia-Pacific region, particularly Fiji and Papua New Guinea.

Stephen Bell

Stephen Bell holds associate professor positions in the Centre for Social Research in Health at UNSW Sydney, and the School of Public Health at The University of Queensland. He has published extensively on research pertaining to global health and social development, including the use of community-based, participatory and ethnographic research methodologies with excluded peoples in diverse settings in Africa, SE Asia, Western Pacific and Europe. Stephen has also worked in research and advisory roles with UNAIDS, UNFPA and WHO.

Angela Kelly-Hanku

Angela Kelly-Hanku is a Scientia Associate Professor at the Kirby Institute at UNSW Sydney and holds a joint appointment as Senior Principal Research Fellow and Head, Sexual and Reproductive Health Unit at the Papua New Guinea Institute of Medical Research. Angela undertakes interdisciplinary research on various aspects of the cultural, biological, and personal aspects of sexual, reproductive and maternal health, HIV and tuberculosis.

Notes

1. PrEP is HIV medication taken by HIV-negative partners daily or on a need-to basis to prevent HIV infection.

2. See Lepani (2016) and Macintyre (2012) for a critique of how the twinning of HIV and gender violence by global development and aid agencies can ignore the structural inequality between men and women and its cultural contexts.