Delineating the dyadic coping process in HIV serodiscordant male couples: a dyadic daily diary study using the common fate model

We-disease appraisal refers to viewing the illness as a shared experience within the relationship [10]. Berg and Upchurch [10] proposed that viewing the illness as “ours” rather than “mine” or “yours” can optimize the couple’s ability to jointly manage illness and lead to better outcomes. To date, most studies have treated we-disease appraisal as a characteristic of the couple, with couples categorized as appraising the illness as the patient’s alone or as shared within a romantic relationship [12]. However, we-disease appraisal may fluctuate daily, especially for an illness such as HIV that involves a difficult daily regimen (e.g., taking ART as prescribed). We-disease appraisal could fluctuate day-to-day as partners are perceived as more or less in collaborative ways. Furthermore, we-disease appraisal may fluctuate for some individuals but operate as an individual difference variable for others [13]. Only a few studies have examined both within-person (WP) and between-person (BP) levels of we-disease appraisal [13, 14].

The systemic transactional model [9, 15] posits that dyadic coping behaviors are expressed through supportive responses to a partner’s stress (supportive dyadic coping), the transfer of one’s responsibilities to the partner (delegated dyadic coping), and joint efforts to manage stress (common dyadic coping, common dyadic coping). Common dyadic coping has been reported to be more effective for couples coping with chronic illness than other dyadic coping strategies [16‐18]. In a meta-analysis on couples facing cancer, common dyadic coping was a stronger predictor of relationship satisfaction (r = 0.42) than other dyadic coping behaviors (r = 0.17 to 0.34) [19]. This aligns with the systemic transactional model [9, 15], which anticipates common dyadic coping in situations where the stressor impacts both partners similarly and simultaneously, creating a “we-stress” situation. Serious medical conditions typically represent a shared experience of demands, as both partners are affected by the illness, creating a sense of a “we-disease” [20]. Therefore, common dyadic coping may be particularly crucial when a male couple is coping with HIV, a situation shared by both partners [4, 21].

Two prominent frameworks for analyzing dyadic data are the actor–partner interdependence model (APIM) [22] and common fate model (CFM) [23]. While both frameworks address dyadic data analysis, they differ in their theoretical foundations, analytical approaches, and variable considerations.

The APIM emphasizes interpersonal effects, examining how an individual’s characteristics affect both their own outcomes (actor effects) and their partner’s outcomes (partner effects), making it valuable for studying support exchanges in the patient–caregiver dyad through self-referential measures [24‐26].

Contrastingly, the CFM conceptualizes the dyad as a collective unit, focusing on the individual’s and their partner’s shared experiences that simultaneously affect both of them, in addition to emphasizing relationship-level constructs [27, 28].

The present study employs the CFM for three compelling reasons. First, we-disease appraisal and common dyadic coping are inherently dyad-level constructs, co-constructed and agreed upon by both partners. Second, these constructs manifest as single latent variables that generate responses from both partners. Third, while APIM-based daily diary studies are abundant, no research has employed the CFM to examine how daily shared experiences affect both partners’ relational and individual well-being. To date, only one cross-sectional study of serodiscordant couples has adopted the CFM to assess the dyadic coping process [18]. While research has indicated that dyadic coping processes may fluctuate daily [13, 29, 30], no studies have investigated the shared experience of such fluctuations. Furthermore, existing dyadic daily diary research on dyadic coping has focused exclusively on couples managing noncommunicable conditions like cancer, chronic pain, and diabetes. The dyadic coping process among HIV serodiscordant couples presents unique challenges that distinguish it from the process for other chronic illnesses where one partner primarily assumes a caregiving role.

While it is challenging to apply the daily diary approach to HIV serodiscordant male couples, evidence from individual-level studies has demonstrated the value of this methodology for understanding how PLWHs cope with HIV-related stressors (e.g., stigma). The daily diary approach also offers distinct advantages over traditional questionnaires since it allows for capturing real-time variations in stigma experiences, minimizing recall bias, and enhancing ecological validity [31]. Studies have shown that daily experiences of HIV-related stigma predict worsened emotional well-being [32], with social support potentially buffering these negative effects [33]. Since HIV-related stigma can affect both PLWHs and their seronegative partners in daily life, a daily diary design would provide valuable insights into how serodiscordant couples collectively cope with HIV-related challenges.

Serodiscordant male couples in China encounter distinct contextual factors that influence their coping mechanisms. First, the collectivist nature of Chinese culture may contribute to the perpetuation of stigma, as it emphasizes a social pattern characterized by strong interpersonal connections, a sense of belonging to a cohesive in-group, social harmony and conformity [34]. Research has consistently shown that Chinese societies exhibit an exceptionally high level of stigma, particularly in the context of HIV and sex minority [35‐37]. Consequently, serodiscordant male couples frequently struggle to access coping resources beyond their intimate relationships. Second, family dynamics in Chinese culture play a central role, with strong expectations regarding marriage and procreation. As a result, such couples may experience pressure to conform to traditional family roles, complicating their ability to disclose their same-sex relationship and HIV status as they may feel compelled to conceal their relationship from family members, further limiting their access to familial support. Third, in heterosexual relationships, traditional masculinity norms often inhibit emotional expression and open communication. This cultural emphasis can make it challenging for partners to engage in effective dyadic coping strategies, as men may feel pressured to conform to societal expectations of stoicism and emotional restraint. In contrast, same-sex male couples may experience different dynamics in their dyadic coping processes. While they also face societal stigma related to both their sexual orientation and HIV status, the absence of traditional gender roles can create a more egalitarian space for emotional expression and communication [38]. Given these complexities, this study aims to deepen our understanding of the dyadic coping processes among serodiscordant male couples in China.

Drawing from the dyadic coping models [9, 10, 15] and using a dyadic daily diary study design, we aimed to examine the connections between we-disease appraisal and individual outcomes—quality of life, ART adherence, and pre-exposure prophylaxis attitude (PrEP)—as well as relational outcomes like relationship satisfaction among Chinese serodiscordant male couples. As HIV has transitioned from a fatal illness to a manageable chronic condition, prioritizing the quality of life for PLWHs has become increasingly vital. The proposed “fourth 90” treatment goal underscores this focus, extending the continuum-of-care model beyond immune reconstitution and viral suppression [39]. This shift necessitates an emphasis on quality of life in our study. In serodiscordant couples, ART adherence and PrEP attitude are crucial for preventing cross-partner HIV transmission. Therefore, we choose ART adherence and PrEP attitude as individual outcomes. Furthermore, relationship satisfaction is strongly associated with individual health [40] and risk-taking behaviors [41], thus identifying predictors of relationship satisfaction and has important clinical implications not only for relational health, but also for individual health. We also assess the mediating role of common dyadic coping in these associations. Figure 1 shows our hypothetical models.

We used dyadic multilevel structural equation modeling to fit the common fate mediation model at both levels [27, 54] and used Monte Carlo method procedures for the confidence intervals of the indirect effect when managing nested data [55]. For more, we provided statistical details for mediation analyses in Appendix. In the present study, we modeled we-disease appraisal, common dyadic coping, and relationship satisfaction as common fate constructs, with quality of life, ART adherence, and PrEP attitude as noncommon fate constructs. Missing data were handled with full information maximum likelihood estimation. Analyses control for age, ethnicity, education level, sex orientation, personal monthly income, relationship length, self-reported viral load, CD4 + cell counts, and years since HIV diagnosis. All analyses were conducted using Mplus version 8.

As shown in Table 3 Model 1 and Fig. 2 Panel a, regarding WP level, on days when couples reported higher we-disease appraisal, they reported higher common dyadic coping (b = 4.78, SE = 1.15, p < 0.001). Furthermore, on days when common dyadic coping was higher, the couples reported higher quality of life (PLWHs: b = 0.07, SE = 0.03, p = 0.03; partners: b = 0.10, SE = 0.04, p = 0.008). However, neither direct effect of we-disease appraisal was significant for the PLWHs’ quality of life (b = 0.37, SE = 0.33, p = 0.25) or partners’ quality of life (b =  − 0.02, SE = 0.41, p = 0.95). Common dyadic coping significantly mediated the associations (PLWHs: est = 0.33, SE = 0.16, 95% CI [0.03, 0.68]; partners: est = 0.49, SE = 0.24, 95% CI [0.14, 0.99]), indicating that for every one-point increase in daily we-disease appraisal (on a 7-point Likert scale), the quality of life for PLWHs is expected to improve by 0.33 points. Similarly, for each one-point rise in daily we-disease appraisal, partners are expected to experience a 0.49-point increase in their quality of life, when considering only the indirect influence of common dyadic coping.

Regarding BP level, when the average we-disease appraisal was higher, couples reported higher common dyadic coping (b = 2.08, SE = 0.60, p = 0.001). However, no significant association existed between common dyadic coping and PLWHs’ quality of life (b = 0.01, SE = 0.04, p = 0.80) or partners’ quality of life (b = 0.02, SE = 0.05, p = 0.59). Regarding direct effects, we-disease appraisal was associated with higher quality of life at a trend level for PLWHs and significant level for partners (PLWHs: b = 0.23, SE = 0.14, p = 0.09; partners: b = 0.45, SE = 0.17, p = 0.006). Common dyadic coping did not mediate the association between we-disease appraisal and both partners’ quality of life (PLWHs: est = 0.02, SE = 0.08, 95% CI [− 0.12, 0.15]; partners: est = 0.05, SE = 0.09, 95% CI [− 0.14, 0.25]), indicating that, on average, for each one-point increase in we-disease appraisal (on a 7-point Likert scale), the quality of life for PLWHs is expected to increase by only 0.02 points. Similarly, partners are expected to experience an increase of 0.05 points in their quality of life for each one-point rise in we-disease appraisal, when only considering the indirect influence of common dyadic coping.

Regarding post-diary quality of life (Table 3, Model 2; Fig. 2 Panel b), common dyadic coping cannot predict both partners’ post-diary quality of life (PLWHs: b = 0.65, SE = 0.56, p = 0.25; Partners: b = 0.48, SE = 0.76, p = 0.52, Table 3 Panel B). However, we-disease appraisal significantly predicted both partners’ post-diary quality of life (PLWHs: b = 3.84, SE = 1.83, p = 0.04; Partners: b = 6.20, SE = 2.79, p = 0.03). Moreover, we failed to find the mediating effect of common dyadic coping (PLWHs: est = 1.35, SE = 1.20, 95% CI [− 0.98, 4.00]; Partners: est = 1.01, SE = 1.51, 95% CI [− 2.52, 3.91]), indicating that, on average, for every one-point increase in we-disease appraisal during the daily diary (on a 7-point Likert scale), the quality of life for PLWHs is expected to improve by 1.35 points in the follow-up assessment. Similarly, partners are predicted to experience a 1.01-point increase in their quality of life in the follow-up assessment for each one-point rise in we-disease appraisal during the daily diary, considering only the indirect influence of common dyadic coping.

As shown in Table 3, Model 4 and Fig. 2 Panel c, our analyses did not find significant associations between we-disease appraisal and ART adherence (b =  − 0.27, SE = 0.38, p = 0.48), common dyadic coping and ART adherence (b = 0.03, SE = 0.10, p = 0.80) or evidence of the mediating effect of common dyadic coping (est = 0.06, SE = 0.22, 95% CI [− 0.39, 0.50]), indicating that for every one-point increase in we-disease appraisal, on average, during the daily diary (on a 7-point Likert scale), ART adherence is expected to only increase by 0.06 points in the follow-up assessment, considering only the indirect influence of common dyadic coping. Moreover, as shown in Table 3, Model 5 and Fig. 2 Panel d, common dyadic coping did not predict the PrEP attitude (b = 0.11, SE = 0.15, p = 0.45) or mediate between we-disease appraisal and PrEP attitude (est = 0.24, SE = 0.28, 95% CI [− 0.48, 0.74]), implying that for every one-point increase in we-disease appraisal, on average, during the daily diary (on a 7-point Likert scale), PrEP attitude is expected to increase by 0.24 points in the follow-up assessment, considering only the indirect influence of common dyadic coping. However, we-disease appraisal significantly predicted PrEP attitude (b = 1.17, SE = 0.56, p = 0.04).

As shown in Table 3, Model 5 and Fig. 2 Panel e, regarding WP level, when couples reported higher we-disease appraisal, they reported higher common dyadic coping (b = 4.90, SE = 1.21, p < 0.001, Table 3 Panel E). Furthermore, when common dyadic coping was more prevalent, couples reported higher relationship satisfaction (b = 0.11, SE = 0.03, p < 0.001). Regarding the direct effect, on days in which we-disease appraisal was higher, couples reported higher relationship satisfaction (b = 0.54, SE = 0.28, p = 0.05). Our analyses also showed that common dyadic coping acted as a mediator in this association (est = 0.52, SE = 0.17, 95% CI [0.21, 0.86]), indicating that for every one-point increase in daily we-disease appraisal (on a 7-point Likert scale), couples’ relationship satisfaction is expected to improve by 0.52 points, when considering only the indirect influence of common dyadic coping.

Regarding BP level, when the average we-disease appraisal was higher, couples reported higher common dyadic coping (b = 1.92, SE = 0.57, p = 0.001). However, common dyadic coping was not related to relationship satisfaction (b = 0.04, SE = 0.03, p = 0.29). Regarding the direct effect, when the average we-disease appraisal was higher, couples reported higher relationship satisfaction (b = 0.37, SE = 0.12, p = 0.001). We found no evidence of the mediating effect of common dyadic coping (est = 0.07, SE = 0.06, 95% CI [− 0.06, 0.18]), indicating that for every one-point increase in average we-disease appraisal (on a 7-point Likert scale), couples’ relationship satisfaction is expected to only increase by 0.07 points on average, when considering only the indirect influence of common dyadic coping.

As shown in Table 3, Model 6 and Fig. 2 Panel f, regarding post-diary relationship satisfaction, there was a positive association between we-disease appraisal and post-diary relationship satisfaction (b = 1.06, SE = 0.44, p = 0.02). However, we found no significant association between common dyadic coping and post-diary relationship satisfaction (b = 0.15, SE = 0.13, p = 0.23) and no evidence of the mediating effect of common dyadic coping (est = 0.31, SE = 0.26, 95% CI [− 0.23, 0.85]), implying that for every one-point increase in we-disease appraisal in average during the daily diary (on a 7-point Likert scale), their relationship satisfaction is expected to improve by 0.31 points in the follow-up assessment, when considering only the indirect influence of common dyadic coping.

This initial study sought to understand WP variability in the dyadic coping process using CFM in Chinese serodiscordant male couples. The absence of obvious differences in PLWHs and their partners rate of we-disease appraisal and common dyadic coping suggests a more egalitarian dynamic within serodiscordant same-sex relationships, which replicated our earlier cross-sectional findings using the same measurement [18]. Our findings also support earlier reports of WP variability in the dyadic coping process [13; 25] by showing that the BP differences in we-disease appraisal and common dyadic coping exceeded the WP variations. This disparity suggests that the coping journey for couples managing HIV is prolonged, where day-to-day fluctuations are infrequent if no urgent stressors emerge. An alternative explanation for these findings is that these couples had established relatively stable dyadic coping mechanisms by the time of the study, given that the PLWHs had been diagnosed with HIV and had maintained relationships with their partners for several years. Although dyadic coping processes among serodiscordant couples are relatively stable, other data analyses with diabetes samples found that greater variability in we-disease appraisal in spouses is associated with less secure attachments and poorer diabetes outcomes [56]. Future work is required to understand whether variability in the dyadic coping process is associated with characteristics of the PLWHs, the partners, the relationship, or HIV and its associated daily stressors. For example, precious studies in couples in which one person had type one diabetes showed that greater variability in we-disease appraisal in spouses is related to less secure attachment [56].

Our analyses suggest that we-disease appraisal and common dyadic coping can be modeled as common fate variables at the WP level and BP level. Notably, the results indicate that both constructs at the BP level account for a greater variance, as evidenced by larger standardized factor scores for both partners compared to the WP level. Extending our previous cross-sectional study among serodiscordant couples using the common fate medication model [18], the present study highlighted that daily fluctuations in the dyadic coping process are intricately interlocked within couples. Our findings align with those of previous studies that have documented daily fluctuations in dyadic coping among couples managing type 1 diabetes [13] and type two diabetes [14]. We extend these findings by demonstrating that both partners’ responses tend to co-fluctuate, suggesting a truly dyadic process. Future work is needed to assess whether such co-fluctuation can be generalized to other dyadic constructs (e.g., co-rumination).

While we-disease appraisal and common dyadic coping were linked at WP level and BP level, their associations with various outcomes differed. In general, daily we-disease appraisal was associated with relationship satisfaction. Conversely, average we-disease appraisal demonstrated a broader range of associations (better quality of life for partners during the diary period, better post-diary quality of life for both partners, more positive PrEP attitude among partners, greater relationship satisfaction both during the diary period and afterward). Moreover, daily common dyadic coping was associated with better quality of life for partners and greater relationship satisfaction during the diary period. Conversely, we failed to identify any significant associations for common dyadic coping at BP level. A shared appraisal may be related to these outcomes because individuals feel they are part of a team in managing HIV [18], or because both partners include each other’s stress as part of their own future goals [10] or because a we-disease appraisal may reduce secondary stress appraisals regarding possible coping resources [57]. In contrast, common dyadic coping consists of tangible actions, which may serve as an observable signal to couple members that they are working as a team to manage HIV in daily life, thereby leading to more immediate effects during the diary period.

Common dyadic coping mediated the associations between we-disease appraisal and quality of life and relationship satisfaction at WP level. This dynamic relationship suggests an immediate and interconnected link between these variables from day to day. However, the mediation effects observed at the WP level were not replicated at the BP level. This discrepancy indicates that a couple’s traits or characteristics associated with common dyadic coping may not consistently predict the levels or changes in outcomes when comparing different dyads [58]. Stable dyad and contextual factors cannot explain the findings, as dyads show higher quality of life and relationship satisfaction on days when they have more common dyadic coping. Despite the absence of the mediating role of common dyadic coping at the BP level, BP differences in we-disease remain highly predictive of most outcomes, suggesting other possible mediating pathways may exist. For example, two qualitative dyadic studies consistently showed that disengaged avoidance occurred when couples appraised the stressor as an individual stress affecting each of them individually rather than as a couple [38; 59]. However, common negative coping was not included in the measure used in the present study. Therefore, future studies are required to expand the present study by considering the positive and negative aspects of common dyadic coping. While common dyadic coping represents a joint effort, with both partners working together to manage stress, other forms of dyadic coping, particularly supportive dyadic coping (where one partner assists the other), may also occur in couples’ daily lives. Daily diary studies examining partner support as a unidirectional form of dyadic coping have yielded mixed findings among PLWHs. Some studies have found that perceived emotional support helps to buffer the negative impact of stigma on emotional well-being, although this effect is limited to specific periods and contexts, particularly during heightened stress, such as occurred during the early COVID-19 pandemic [33]. Other studies have shown that only provided support (not received support) buffers the negative effect of HIV-related stress, but this buffering effect is only present among those in intimate relationships, while single participants often experience detrimental effects [60]. Importantly, these studies have primarily collected data from PLWHs alone, without considering their partners’ perspectives. Since partner support represents a transactional process requiring balance and reciprocity (as suggested by equity theory), future research should adopt dyadic approaches to better understand support exchange processes between both partners in serodiscordant couples.

Moreover, our findings were echoed by another study utilizing the APIM in a daily diary design, which demonstrates significant associations between daily shared illness appraisals and various relational and individual outcomes in couples managing diabetes [13]. This cited study further identified significant moderating effects of shared illness among certain outcomes, indicating that collaborative coping is beneficial only when the illness is perceived as a shared experience. Therefore, future research should examine daily dyadic interdependence as both a common fate and a partner influence, as well as the role of we-disease appraisal, which may function as either a starting point or a buffering factor in the dyadic coping process. Such investigations could significantly contribute to theoretical advancements in this field.

Most of the research in this area has focused on the common dyadic coping strategies adopted by both partners rather than whether individuals view the illness as our-disease or my/your disease [61]. Our findings show that how an illness is appraised on a daily basis might shape the dyadic coping process. The benefits of a we-disease appraisal are especially important in the context of China as collectivist culture and traditional family dynamics may prevent such couples for seeking support outside their relationship. Both partners may benefit if they are able to share their illness within relationship by forming co-constructing the meaning of the illness and increasing co-involvement in HIV management. Although no clinical trials have specifically targeted the dyadic coping process in HIV settings, some couple-based interventions have shown promising effects on various outcomes—such as both partners’ disease appraisal, collaboration, and efficacy—among couples dealing with other chronic illnesses [62‐64]. Moreover, dyadic coping-focused intervention may be effective with just one session [62], indicating that these interventions could be highly cost-effective in clinical settings. Our findings offer additional insights, suggesting that future intervention trials should place greater emphasis on co-fluctuation within the daily dyadic coping process as a shared experience.

While our study offers valuable insights, its limitations must be acknowledged. Despite our use of daily measurements to capture variable fluctuations, our study was constrained to PLWHs diagnosed for several years. Future investigations could focus on long-term WP changes by employing a measurement burst design, enabling the exploration of WP processes at various time intervals from new diagnosis to later stages. As our study used a daily diary approach, the measurement of some constructs was simplified to a single item, representing a significant limitation in the depth of assessment. However, considering the burden of daily diary study, we measured same construct using different measures during the diary and post-diary, which may limit the comparability of findings. Moreover, the present study only assessed PrEP attitudes rather than usage patterns and barriers to adoption, which may have limited our understanding of the complete PrEP uptake process among serodiscordant couples. Future studies should aim to incorporate both quantitative behavioral measures of PrEP usage and qualitative assessments of the barriers encountered during implementation. For example, researchers could assess other psychosocial factors such as accessibility, stigma, low perceived risk, and individual motivations, which may influence PrEP adoption and adherence. Another key limitation of this study is that the 2-month follow-up period may not have allowed us to fully capture the long-term evolution of couples’ coping strategies and relationship dynamics, particularly given the chronic nature of HIV management. Future studies should thus consider implementing longer follow-up periods (e.g., 6–12 months) to examine the temporal stability of dyadic coping patterns and their impact on outcomes among serodiscordant couples. Additionally, incorporating multiple follow-up assessments would help track the trajectory of adjustment processes over time. Furthermore, estimating these daily processes can inform macro-level changes that occur more slowly—over months, years, or even decades—and are considered more distal outcomes within a dynamic system [65].

In summary, this study demonstrates that we-disease appraisal and common dyadic coping are differentially associated with individual and dyadic outcomes in serodiscordant male couples. Furthermore, evidence suggests a potential mediating role of common dyadic coping, particularly for daily quality of life and daily relationship satisfaction. These findings have significant implications for developing targeted interventions for couples navigating HIV-related challenges. Specifically, interventions that promote co-fluctuation in daily dyadic coping processes and establish stable dyadic coping patterns may enhance both partners’ adjustment to HIV.