Spousal agreement is important for couples with HIV because of shared risk for health outcomes. Although high spousal agreement (concordance) is expected on most issues because of close daily contact and common living conditions, studies have shown discrepancies between husbands' and wives' reports on several family issues. Understanding spousal concordance on HIV-related issues offers opportunity to develop interventions that promote better health for both partners. This study assessed the extent of spousal agreement on reproductive decision making, self-management, and health promotion; and determined how spouses’ responses reflect their partner’s attitude and preferences on such issues. Mixed method was used to collect qualitative and quantitative data from 25 purposively selected, consenting couples living with HIV and attending two HIV Counselling & Testing clinics in Cross River State, Nigeria. Husband-wife pairs were interviewed separately and concordance was calculated. Ethical clearance was obtained from relevant gatekeepers as well as informed consent from participants. Significant male domination in reproductive decision making was identified. Concordance was poor for decision making power of the wife on sexual/reproductive issues (24%, kappa 0.16), changes in sexual relations (28%, kappa 0.22); communicating sexual and fertility issues with spouse (28%, kappa 0.24), and mutual support (35% (kappa 0.40); while strong concordance existed for starting medication & adherence to ART (72%, kappa 0.60), health promotion (85%, kappa 0.80) and self-management (89%, kappa 0.81). Spousal agreement is therefore poor for sex-related matters but good for health promotion and self-management. Partner agreement on HIV-related issues contributes to a fuller understanding of decision making among spouses. Knowledge of this by health providers is critical for effective counselling and interventions for couples with HIV.