Marriage as a risk factor for HIV: Learning from the experiences of HIV-infected women in Malawi

Abstract

The gender inequalities that characterise intimate partner relationships in Malawi, a country with one of the highest HIV prevalence rates in the world, arguably place marriage as an important risk factor for HIV infection among women, yet few studies detail the complex interactions of marriage and risk. In order to develop HIV-prevention interventions that have lasting impacts in such communities, we need a deeper understanding of the intricacies of women's lives, how and why they are involved in marital relationships, and the implications of these relationships for HIV transmission or prevention. This article describes how women understand marriage's effects on their lives and their HIV risks. Drawing from focus group discussions with 72 women attending antiretroviral clinics in Malawi, we explore why women enter marriage, what women's experiences are within marriage and how they leave spouses for other relationships. Based on their narratives, we describe women's lives after separation, abandonment or widowhood, and report their reflections on marriage after being married two or three times. We then review women's narratives in light of published work on HIV, and provide recommendations that would minimise the risks of HIV attendant on marriage.

Cultural practices, gender inequality and inconsistent condom use increase vulnerability to HIV infection: narratives from married and cohabiting women in rural communities in Mpumalanga province, South Africa

“…While women in general continue to bear the brunt of the HIV epidemic, married older women, who were not regarded as vulnerable to HIV in past decades, are currently regarded as the largest HIV risk group. In most societies in SSA, HIV infection rates among married women are significantly higher than among single women, and over 80% of new HIV infections in women in SSA are estimated to occur in marriage or long-term relationships through heterosexual transmission [4,5]. This phenomenon could be attributed to the fact that condom use may be more acceptable to younger individuals than to their older counterparts; married individuals tend to be older than unmarried individuals [6].…”

“…This may explain the high prevalence of HIV among people aged 50 years and above. The risk of HIV in marriage and in stable or cohabiting relationships is due to an increased frequency of sex and low condom use [4]. In patriarchal societies, suggesting condom use or refusing unprotected sex in a marriage or cohabiting relationship is seen as questioning male authority [8].…”

“…Bride price involves payment in the form of cattle or money from the groom to the bride’s father and his family, and is part of the formal marriage in many African cultures [11]. This translates into a power imbalance in sexual interactions and increases the woman’s vulnerability to HIV, as negotiation for safer sex or refusal may result in violence [4,12]…”

“…Women living in rural areas are marginalized and disempowered, and face geographical barriers in terms of accessing HIV knowledge and services [13]. In rural communities, the deeply entrenched beliefs about the role and position of women in society [3,4,11] place marriage as an important risk factor for HIV infection among women [4]. The perceived entitlement to sex that is ascribed to men by society and male dominance contribute to forced sex in marriage and increase the risk of HIV infection for women [14].…”

“…However, in SSA, HIV prevention strategies continue to centre on young unmarried individuals despite increasing rates among married and cohabiting women [1,4,5]. The high prevalence of HIV infection among adolescents and young women in past decades resulted in HIV interventions resources dedicated to preventing HIV among adolescents and youth in urban settings.…”