World Journal of AIDS, 2011, 1, 185-191
doi:10.4236/wja.2011.14027 Published Online December 2011 (
Copyright © 2011 SciRes. WJA
Human Immunodeficiency Virus Prevention
among HIV-Serodiscordant Couples in Burkina
Faso: Biomedical Issues, Bioethical and Cultural
Jacques Simpore1,2*, Eveline Compaore3, Joseph Sawadogo1 , Florencia Djigma1,2, Djeneba Ouermi1,2,
Marina Martinetto1, Virginio Pietra1, Fernando Fabó4, Henk A. M. J. ten Have5, Alberto García4
1Centre de Recherche Biomoléculaire Pietro Annigoni, Saint Camille-CERBA/LABIOGENE, Ouagadougou, Burkina Faso; 2Université
de Ouagadougou, Ouagadougou, Burkina Faso; 3University of Nottingham, Nottingham, United Kingdom; 4Università Regina Apo-
stolorum, Roma, Italia; 5Duquesne University, Pittsburgh, USA.
E-mail: *
Received September 2nd, 2011; revised October 9th, 2011; accepted October 27th, 2011.
Context: In Burkina Faso, there are young HIV-serodiscordant partners who want to get married and wish to pro-
create. Objectives: The purpose of this research was: 1) to assess the sexual behaviour of young people in Burkina
Faso, 2) to estimate their knowledge about the modes of HIV transmission, 3) to appreciate the cultural reasons of
the desire to procreate among HIV serodiscordant couples and 4) to draw some bioethical lessons. Methods: From
April to September 2009, the survey on HIV and reproductive health in Burkina Faso carried out with 815 young
people. Among them, 407 were females and 408 males (average age: 23.59 ± 2.99). They have voluntarily agreed to
answer a questionnaire which gave the following results. Results: This study shows that young people in Burkina
Faso had their first sexual intercourse at 18.99 ± 2.76 years, 23.68% (193/815) were afraid to be tested for HIV,
30.92% (252/815) have not yet been tested for HIV-serostatus and 39.75% (324/815) of them have never heard of
HIV vertical transmission. Despite the fact that 36.81% (300/815) are HIV negative, th ey would be willing to marry
the beloved HIV positive person and amongst them, 28.34% (231/815) want a child even with an HIV positive person
beloved. Conclu s io n: So far, there is no effective vaccine against HIV. However, it is clear that Highly Active
Anti-Retroviral Therapy (HAART) associated with ethical and cultural good options can contribute to reduce the
spread of HIV in Sub-Saharan Africa.
Keywords: AIDS, HIV-Serodiscordant Couple, PMTCT, Procreation, Tradition, Burkina Faso
1. Introduction
Nowadays, 33 million people are leaving with HIV/
AIDS in the world [1]. From 1981 to today, AIDS killed
25 million people, caused more than 15 million orphans
in Africa and few million widows who are rotting in pov-
erty [2]. In Burkina Faso, 2.5% of people aged between
15 and 24 years, 2.3% of pregnant women and 16.0% of
sex workers are infected by HIV [3]. While tremendous
strides have been made in improving access to HIV
treatment, the epidemic continues to outpace the re-
sponse [4]. In living memory, no other infectious disease
has caused as much physical suffering, much moral mis-
ery and comparable death of young people as AIDS did.
With the advent of this new pathology which mainly
ravages people who are of an age to procreate, grand-
parents find themselves taking the roles of fathers and
mothers, for the children of their children who become
orphans. If an adequate strategy of prevention is not im-
plemented, if a judicious research of medicine is not car-
ried out and efficient vaccines against HIV are not found,
many generations of boys and girls, in the prime of life,
will undeniably disappear in Sub-Saharan Africa, in
Southeast Asia and in Latin America.
Despite HIV pandemic and its morbidity, we noticed
that in Sub-Saharan Africa and particularly in Burkina
Faso, many “HIV-serodiscordant” young people are in-
Human Immunodeficiency Virus Prevention among HIV-Serodiscordant Couples in Burkina Faso:
Biomedical Issues, Bioethical and Cultural Challenges
creasingly claiming the possibility to start a family. In
addition, many HIV-serodiscordant partners wish to pro-
create. This strong need of these couples, also called
“HIV-serodifferent”, probably results from multifaceted
On the one hand, the increase in the number of HIV
positives in the world and therefore the probability of
meeting a HIV positive partner is very high; from the
culture of some African societies, which are pronatalist
and cannot allow a young girl or a young boy to live un-
married, whatever her or his physical condition is.
On the other hand, from therapeutic progresses in the
treatment of HIV positives with multi antiretroviral
therapies; from new technologies in reproductive biology
which avoid the risks of infection through artificial in-
semination [5]; and from the fact that under the Highly
Active Anti-Retroviral Therapy (HAART), some AIDS
patients return to their professional activities, which they
thought lost forever, develop projects and think with
great hope about the future. Indeed, thanks to the ad-
vancement of medicine, AIDS could become, in a near
future, even in Sub-Saharan Africa, just a simple chronic
affection [6,7].
The present study, the objective of which is the pre-
vention of the transmission of HIV, intends: 1) to assess
the sexual behaviour of young people in Burkina Faso, 2)
to estimate their knowledge about the modes of HIV
transmission, 3) to appreciate the cultural reasons of the
desire to procreate among HIV serodiscordant couples
and 4) to draw some bioethical lessons.
2. Method
From April to September 2009, we have carried out a
survey with 815 people from 18 to 32 years old who have
been casually selected in public places in the city of
Ouagadougou: at the markets, on the streets and at the
university. These people were in average 23.59 ± 2.99
years old. Among them 407 were females and 408 males.
They voluntarily accepted to answer our questionnaire
about: grade level, age of first sexual intercourse, know-
ledge concerning prevention and transmission of HIV,
desire to marry and to have children with HIV positive
Ethical aspects: The Ethics Committee of the Centre
de Recherche Biomoléculaire Pietro ANNIGONI, CERBA
and that of the Centre Médical Saint Camille approved
the protocol of the study and all the young people who
took part to this research have orally given their informed
Data analysis: Statistical analyses were done with
Epi-Info version 6 and SPSS version 12. The value of p
0.05 is considered significant.
3. Results
Table 1 shows the classification of frequencies of the
815 individuals of the sample study according to their
age and gender. We obtain statistically significant dif-
ferences of frequencies in the classification of males and
females from 18 to 20 years old (p < 0.001) and from 24
to 26 years old (p = 0.004). There is also a statistically
significant difference between the average age of females
(22.93 ± 3.04) and of males (23.89 ± 2.92) p < 0.001.
Table 2 shows that with regard to illiteracy (p = 0.676),
the success in secondary school junior certificate (SSC)
and in the leaving certificate (LC) (p = 0.098) and the
attendance of university faculties (p = 0.383), there are
no statistically significant differences between the two
sexes. However, as regards those who hold a primary
Table 1. Classification of age groups by gender.
Age groups Years Average age Total Number Female Male p FM
18 to 20 19.4 ± 0.8 99
25.25% <0.001
21 to 23 22.1 ± 0.8 376
48.40% 0.536
24 to 26 24.8 ± 0.6 252
59.13% 0.004
27 to 29 27.6 ± 0.7 59
61.02% 0.099
30 to 32 31.4 ± 0.8 29
55.17% 0.588
Total 815
50.06% 0.972
Average age 23.59 ± 2.99 22.93 ± 3.04 23.89 ± 2.92 <0.001
X2: 18 20 years. p < 0.001; X2: 20 26 years. p = 0.004.
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Human Immunodeficiency Virus Prevention among HIV-Serodiscordant Couples in Burkina Faso: 187
Biomedical Issues, Bioethical and Cultural Challenges
Table 2. Level of education and knowl e dge about HIV by gender.
Level of education
Total Female Male p
Illiteracy 202/815 (24.79%) 98/202 48.51% 104/202 51.49% 0.676
PSC 187/815 (22.94%) 114/187 60.96% 73/187 39.04% 0.002
SSC-LC 172/815 (21.10%) 75/172 43.60% 97/172 56.40% 0.098
University 254/815 (31.17%) 120/254 47.24% 134/254 52.76% 0.383
Total 815 407 49.94% 408 50.06% 0.972
PSC = Primary School Certificate; SSC-LC = Secondary School junior Certificate-Leaving Certificate.
school certificate (PSC), there is a surprising statistically
significant difference between the two sexes (p = 0.002).
According to Table 3, males state having had their
first sexual intercourse (18.94 ± 3.00 years) earlier than
females (19.04 ± 2.50). However, there is no statistically
significant difference between the two sexes regarding
the stated dates of the first sexual intercourses (p =
Table 4 shows that the group of females has done
more HIV test than males, 75.68% versus 62.50 (p <
0.001); that they know more about Preventing Mother-to-
Child Transmission (PMTCT) of HIV than their hus-
bands 63.88% versus 56.62% (p = 0.034); that with re-
spect to marriage, they would be disposed to get married
to an HIV positive 43.24% versus 30.39% (p < 0.001)
and would be predisposed to beget a child with the be-
loved HIV positive man 33.16% versus 23.39% (p =
Table 5 presents the knowledge of the modes of HIV
transmissions according to the level of study. In this in-
vestigation, 47.03% (95/202) of those who are illiterate;
44.77% (77/172) of those who have been to primary/
secondary school (SSC-LC) and 50.00% (127/254) of
those who have been to University, did not fully answer
the questions, showing thus that they do not clearly know
the ways of HIV transmission: sexual transmissions,
through parental and vertical transmissions. In addition,
3.46% (7/202) of illiterate people think that mosquito
bites transmit HIV. In this table, only 35.34% (288/815)
of young people of the survey think that AIDS preven-
tion through condoms is the most trustworthy method,
whereas some people think that fidelity for couples
(32.88%) and abstinence for unmarried individuals
(31.78%) are the best ways to avoid HIV/AIDS infection.
4. Discussion
The analyses and interpretations of the collected data
1) A link between ignorance of HIV transmission, tra-
ditional culture, sexual promiscuity and propagation of
HIV/AIDS among young people in Burkina Faso: This
study shows that the spread of the retroviral infection is
caused by the ignorance of the mechanism of HIV trans-
mission and juvenile sexual promiscuity. From the sur-
vey with the 815 young people (407 girls and 408 boys)
aged between 18 and 32 years (average age: 23.59 ± 2.99)
in Burkina Faso about HIV/AIDS and procreation, it fol-
lows that from now, we know that 30.9% (252/815) of
these young people never did their HIV test; 39.8% (324/
815) never heard about “Preventing Mother-to-Child
Transmission (PMTCT) of HIV” (Table 4). However,
since 2002, there is a program developed by WHO and
the Ministry of Health of Burkina Faso for PMTCT [8].
The group of young people who know better of HIV ver-
tical transmission is not that of the illiterate (35.64%),
nor university graduates (26.38%) or SSC-LC group
(20.93%) but the middle educated class: young people
who are closer to the popular mass with no more than the
primary school certificate (PSC) (46.52%) (Table 5). It
is more likely that the girls who are more than 20 years
old and do not continue their studies at university have
already had their marital experiences and therefore are
able to go to health services which address PMTCT. It
can be underlined that young people of our study had
their first sexual intercourses when they were 18.99 ±
2.76 years old: at 19.04 ± 2.50 for girls against 18.93 ±
3.00 for boys (p = 0.605). In contrast, individuals who
have had sex before 17 years old had their first sexual
intercourses at 15.55 ± 1.69 years. In this perspective,
according to GUIELLA et al., 2006, the sexual life of the
Burkinabe starts, for the majority of them, during ado-
lescence, because 27% of girls and 22% of boys between
12 and 19 years of age, in their lives, had sexual inter-
courses [9,10]. Indeed, during our study, some boys were
very proud to say that they had their first intercourses
when they were 8 or at 11. According to GUIELLA and
collaborators (2006), the proportion of sexually active
young people would increase rapidly with age and would
Copyright © 2011 SciRes. WJA
Human Immunodeficiency Virus Prevention among HIV-Serodiscordant Couples in Burkina Faso:
Biomedical Issues, Bioethical and Cultural Challenges
Table 3. Classification by gender and age at first sexual intercourse.
Average age Total Female Male p Female Male
X < 17 years 15.55 ± 1.69 211
(51.66%) 0.628
17 to 22 years 19.36 ± 1.07 448
(47.95%) 0.365
X > 22 years 23.32 ± 1.51 116
(56.03%) 0.190
Total 18.99 ± 2.76 815
(50.06%) 0.972
First sexual intercourse year 19.04 ± 2.50 18.94 ± 3.00 0.605
Table 4. Knowledge about HIV/AIDS.
407 Female 408 Male p
Answers: Yes or No NO YES* NO YES FY*MY
Fear for the test 307
22.79% 0.551
HIV Test 99
62.50% <0.001
Results of HIV Test 357
4.66% <0.001
Know about PMTCT 147
56.62% 0.034
Fiancé with HIV+ 231
30.39% <0.001
HIV Procreation 272
23.53% 0.002
FY = Female yes; MY = Male yes.
Table 5. Knowledge of HIV/AIDS prevention and transmission.
HIV AFC prevention Mode of HIV transmission
Abstinence Fidelity Condom Sex Sex-Mtct Sex-Mtct-Pa Mosquitoes
Illiteracy 202 65/202
PSC 187
SSC-LC 172 62/172
University 254 72/254
Total 815
AFC = Abstinence, Fidelity, Condom; PSC = Primary School Certificate; SSC-LC = Secondary School junior Certificate-Leaving Certificate; Mtct = Mother-
to-child-transmission; Pa = HIV Parental Transmission.
significantly increase with 14 years old youths. The au-
thor found in his study that more than 7% of girls of 20
to 24 years old stated having had their first sexual inter-
courses before 15 years of age; 62% before 18 years and
83% before 20 years of age[10]. Whereas with boys of
the same age group, there are 2.5% who declared having
had sexual intercourses before 15 years of age; 32% be-
fore 18 years and 57% before 20 years of age [11,12].
Poverty and the social status of adolescent boys, and
more so for adolescent girls, can expose them to very
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Human Immunodeficiency Virus Prevention among HIV-Serodiscordant Couples in Burkina Faso: 189
Biomedical Issues, Bioethical and Cultural Challenges
unequal or even constrained sexual relationships. There-
fore, these early and frequent sexual intercourses before
marriage could account for the high prevalence of HIV
infection in Burkina Faso [13].
AIDS epidemic spreads through the weak bonds of so-
cieties. It develops where some backward sexual customs
are maintained; where access to information, to preven-
tion, economic autonomy and respect of human rights are
not guaranteed for all. In Burkina Faso, a lot of tradi-
tional practices favored the propagation of HIV. Among
the causes of HIV infection, we can mention polygamy,
forced marriage, levirate and sororate marriage. Indeed,
these three traditions are socio-cultural realities that are
still practiced in some ethnic groups in Burkina Faso.
One can find, in villages and in big cities, men who get
married to many women (two, three, even four or six,
according to their social rank and their economic capa-
bilities). Therefore, one can find young girls of 17 years
old who become the sixth or eighth spouse of a 70 years
old rich man or chieftain. According to the traditional
law of the Moose, a gerontocratic patrilineal ethnic group
in Burkina Faso, it is the head of lineage (head of family,
bùud-kasma) or of a segment of lineage, who decides
marital unions. Marriage is after all a covenant between
two lineages. In this perspective, “marital relationships
result from social and political strategies, the making
and implementation of which are not opened to the par-
ticipation of young men and young women” [14].
Thus, social pressure is often so strong in these socie-
ties that it does not leave a place to individual freedom
and compels young people to dangerous options, such as
getting married, no matter what, despite one’s serious
pathology or accepting principles of levirate, taking as
wife the spouse of a brother who died from AIDS.
Paradoxically, according to Bernard Taverne, the
Moose traditional law is fundamentally unequal in its
distribution of rights and duties according to gender. It
makes a very clear sexual distinction regarding fidelity
between husband and wife: the wife has the duty to
strictly remain faithful, in comparison to her man who
has the right to extramarital sexual intercourses. Besides,
the wife has the duty to tolerate extramarital intercourses
of her spouse [15]. From this perspective, the duty of
women to be faithful is strongly related to the principles
of patrilinearity and of “lineage fertilization” which are
the foundations of the social structure of the Moose [16].
The child is the property of the lineage of the husband,
whereas the wife who is considered within the lineage as
a stranger, would be the receiver of a vital principle
transmitted through agnatic bond by the ancestors,
through the father: the “Sigré” [17]. Thus, female marital
fidelity is fundamental in order to control fertilization
and the extension of the family (“bùudu”) of the husband.
Transgression of the law of marital fidelity by the wife is
considered as a serious act which should be punished not
only by the husband’s family, but also by his ancestors.
2) Marriage between HIV serodifferent persons and
the problematic of HIV transmission: In this research,
36.80% (300/815) of young people, although they are
HIV negative would accept to get married to the beloved
HIV positive person. There is statistically speaking a
significant difference between the two sexes: 43.24% of
girls and 30.39% of boys would accept marriage in the
case of serodifference (p < 0.001) (Table 4). This obser-
vation could be explained by the fact that, as our study
shows it, some young people still ignore the modes of
HIV infection and think that AIDS is a disease caused by
mosquito bites or by sorcerers [18].
3) Culture and HIV serodifferent partners need for a
child: In this investigation, 28.34% (231/815) of young
people would accept to have a child with a HIV positive
spouse: in the case of serodifference, 33.16% of girls
against 23.53% of boys would accept to have a child in
their couple (p = 0.002) (See Table 4). Despite the fact
that girls know more of the principles of Mother-to-Child
Transmission (63.88%) than boys (56.62%) (p = 0.034),
they would accept more freely, because of cultural rea-
sons, to get married, even with a HIV positive spouse, in
order to be fulfilled as women through procreation. In-
deed, in Burkina Faso, many cultural principles make
young girls and young boys get married, no matter what,
in order to have children.
In some cultures, a single woman, free, without a
husband and a child cannot be allowed. Every woman
should get married and procreate. A girl without a hus-
band is considered to be either a child or an easy woman
who is open to any proposal. If she does not find her ful-
fillment as a mother, she would be viewed as a sterile
woman, with all the contempt that this involves.
A boy should get married at a certain age, otherwise he
could never be part of the group of adults and deserve
having funerals after his death. As a single man, he will
be considered to be like a child. These facts would ex-
plain in part that there is a strong need to get married no
matter what, and then have progenitors. In this perspec-
tive, a married man, if he is not sexually active and if he
is not able to have a child, cannot avoid having affairs
with another woman outside the conjugal family to try
his chance. It is difficult to make such a person under-
stand the dangers of sexual promiscuity. That man, who
experiences a kind of social shame because he did not
procreate, finds necessary to try his chance with many
women, even with strangers. In these situations, it be-
comes very difficult to stop the propagation of AIDS
Copyright © 2011 SciRes. WJA
Human Immunodeficiency Virus Prevention among HIV-Serodiscordant Couples in Burkina Faso:
Biomedical Issues, Bioethical and Cultural Challenges
because of that obsession for procreation, and the blatant
ignorance of the modes of transmission of HIV [19].
Everything being considered, generally speaking, we
see that the need for a child in serodifferent couples
clearly exists today in African societies where the dif-
ferent tribes or ethnics have a pronatalist culture.
In Africa, more than half of HIV positive persons have
access to anti-retroviral medicines. Therefore, patients
who are not under ARV treatment, and who see them-
selves losing their forces, develop an instinct for procrea-
tion and put into contribution their remaining energy to
perpetuate their name through the life they will bring
about in the child.
There is no doubt that there are multiple dangers of
infections which threaten HIV serodifferent couples. The
fundamental question which follows from that is this:
how do we make these individuals who are infected by
the virus understand the highly dangerous problematic of
the sexual infection and the vertical transmission of
With respect to procreation, certain scholars are for
non protected sexual intercourses in HIV serodiscordant
couples who have the chance to be under ARV treatment
and whose “viremy” cannot be detected. According to
doctor VERNAZZA, a specialist on HIV sexual trans-
mission, the risk of transmission in that context during
non protected sexual intercourse is “very low”, around
one out of one million sexual intercourses [20].
For Professor Patrick YENI, at present, the practice of
non protected sexual intercourses between serodiscordant
couples cannot in any case be recommended in natural
conception, because of the risk of contamination that it
involves [21].
According to professor Lino CICCONE, objectively,
non protected sexual intercourse in a serodiscordant cou-
ple, even for the purpose of procreation, is tantamount to
an attempt to the life of the healthy spouse. For him,
every time a case is sent to court because of HIV trans-
mission in a serodiscordant couple, judges always con-
demn the infected spouse for a homicide/murder at-
tempt21. In the light of these condemnations from courts,
CICCONE states that we cannot severely judge these
types of behaviour as irresponsible. Thus, it is actually a
pity that through a gesture of conjugal love, through a
sentiment full of interpersonal love communion, such as
the practice of “procreation”, an act of murder is com-
mitted which irrevocably leads to the slow physiological
degradation of the beloved person, then to his/her death
[22] from AIDS.
In Sub-Saharan Africa, intra uterine artificial insemi-
nation of treated spermatozoids of HIV positive man and
that of ICSI (Intra Cytoplasmic Injection of Spermato-
zoids) are not yet developed in order to enable HIV sero-
discordant couples to procreate. However, in the case in
which the man is HIV negative and the woman HIV
positive, it would exist self insemination which is easy to
do and does not have any risk for the couple. Nonetheless,
this technique does not eliminate/prevent mother-to-child
HIV transmission.
5. Conclusions
This study demonstrated that many young people in
Burkina Faso have never been tested for HIV. They have
their first sexual intercourse early; they ignore the trans-
mission modes and types of HIV prevention. Many
young people, due to obsolete traditions, without precau-
tion, want to marry the HIV positive person beloved even
desiring to have children with him/her.
In spite of the fact that HIV serodiscordant couples are
aware of the risks related to HIV/AIDS, they remain at-
tached to their aspirations to procreate [23]. The extent of
this pandemic requires therefore of tradition bearers (re-
source persons of ancestral traditions), researchers, health
professionals, public health decision-makers, interna-
tional organizations and religious leaders, to coordinate
their education strategies and their actions. Until now,
there is no zero risk in biomedical sciences. For this rea-
son, the following questions come to my mind: do we
have to give birth to a child even if the child was to be-
come orphan, HIV positive and morbid? In developing
countries, where AIDS is raging, because less that 50%
of the patients have access to antiretroviral medicine: do
we stigmatize and discriminate HIV positive people by
refusing to celebrate their marriage [24]? Can we advise
them to get married but abstain to procreate? Any person
of good will and of common sense cannot avoid these
multiple vital questions about human relations and mari-
tal bonds related to HIV serodiscordant couples or ignore
the concerns regarding assisted medical procreation
(AMP) for HIV serodifferent couples. There is, indeed, a
need for further pluridisciplinary thought to be given to
the issue, in order to avoid leading engaged or serodis-
cordant couples to make a bad choice which, later, will
condemn them or put the lives of other people in danger.
In the current context, any HIV positive person should
live his/her situation with responsibility by being con-
cerned for the good of his/her partner because, for the
moment, the discovery of a vaccine or an efficient treat-
ment seems implausible in a near future. And through
this stressing search for solutions to the pandemic, only
wise and just options, from ethical, cultural and bio-
medical points of view, can enable the human species to
stand together and collectively initiate a new battle to
maintain and protect our common humanity, by devel-
Copyright © 2011 SciRes. WJA
Human Immunodeficiency Virus Prevention among HIV-Serodiscordant Couples in Burkina Faso:
Biomedical Issues, Bioethical and Cultural Challenges
Copyright © 2011 SciRes. WJA
oping in us a more responsible behavior.
6. Acknowledgements
The Authors are deeply grateful to the staff of Saint
Camille laboratory and CERBA. They are grateful to Mr
Armand Natewindé SAWADOGO for the translation of
the manuscript into English and to Dr André Kaboré and
Miss Rebecca COMPAORE for the correction of the
manuscript. The authors declare no competing interest.
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