Paper: The Political Economy of Marriage and HIV: The ABC Approach, “Safe” Infidelity, and Managing Moral Risk in Uganda

Parikh, S. A. (2007). The political economy of marriage and HIV: the ABC approach,“safe” infidelity, and managing moral risk in Uganda. American journal of public health, 97(7), 1198-1208. 

Abstract

Research has shown that married women’s greatest risk for HIV infection is their husbands’ extramarital sexual activities. Using 6 months of ethnographic research in southeastern Uganda, I examined how the social and economic contexts surrounding men’s extramarital sexuality and the dynamics of marriage put men and women at risk for HIV infection.

I found that Uganda’s HIV prevention messages may be inadvertently contributing to increased difficulty in acknowledging HIV risk and to newer forms of sexual secrecy and that structural determinants, including persistent poverty, intersect with gender inequalities to shape marital risk. After examining a community effort to regulate men’s sexuality, I suggest that HIV prevention strategies should focus more on endogenous forms of risk reduction while simultaneously addressing structural factors that facilitate opportunities for men’s extramarital sex.

Evidence from around the world shows that sexual intercourse within marriage or with a permanent partner puts many women at risk for HIV infection, most commonly from their husbands’ or partners’ extramarital liaisons.1 Women who are economically and socially dependent on their husbands or lovers have difficulty negotiating condom use and inquiring about their partners’ extramarital liaisons,2 both key components of the widely promoted ABC approach—abstinence, be faithful, and condom use. Moreover, structural factors such as labor migration involving separation of spouses, masculine sexual privilege, expectations of female sexual passivity, and domestic violence exacerbate women’s HIV vulnerability.3

Although Uganda appears to have experienced declining national HIV prevalence rates and population surveys report an overall reduction in the number of people’s sexual partners,4 marital sex continues to pose a particular risk for women.5 I examined the social and economic contexts of men’s extramarital sex in southeastern Uganda with the aim of contributing to discussions of risk reduction for HIV infection within marriage.

As a risk group for HIV, married women demonstrate the limitations of traditional public health models that focus primarily on an individual’s risky behaviors without fully accounting for secondary risk associated with a partner’s behaviors and the social and economic contexts that influence an individual’s sexual decisionmaking.6 To understand marital HIV risk, it is important to move from discussions of risky behaviors toward an analysis of how risky situations shape opportunities for men’s extramarital sex, which makes both men and women vulnerable to infection.

Using 6 months of ethnographic research in Iganga District of southeastern Uganda, I examine 2 aspects of the wider context that facilitates or enables men’s extramarital sex. First, HIV prevention messages may be inadvertently contributing to an increased difficulty of acknowledgment of marital HIV risk by men. The widespread circulation of social, moral, and public health messages about HIV/AIDS promulgated by the Ugandan government, donor agencies, religious institutions, and a wide range of nongovernmental organizations has reconfigured the social landscape of HIV risk. In the context of highly visible medico-moral HIV prevention messages to “be faithful” and popular culture and religious discourses promoting monogamous marriages,7 increased secrecy and discretion about extramarital relationships allow husbands (as well as their wives) to manage their public reputations and maintain the appearance of being modern and moral. This does not mean that secrecy and discretion are new forms of reputation management in Uganda. Rather, recent notions of sexual immorality have altered the social acceptability of infidelity, heightening men’s personal motivation for sexual secrecy to avoid public scorn and domestic conflict. Risk, in this sense, is more about the social risk of getting caught in sexual scandals and less about the biomedical risk of catching a sexually transmitted infection.

Second, the combination of persistent poverty faced by many families in Uganda and the large number of young adults orphaned from the first decades of the HIV epidemic has left a distorted economic demographic in which fewer people (most often men) have sufficient economic means and many young adults lack access to resources. Young men often do menial temporary work, engage in small-scale farming on their parents’ land, and delay marriage. This economic situation interacts with gender inequality in ways that make the uncertainty of source of income, living situation, livelihood, and everyday life worse for young women. For instance, historically, most Ugandan women have limited rights to their parents’ property, and many lack the means to obtain advanced education or training. Relationships with wealthier (frequently married) men provide young women temporary social and economic security, facilitating sexual networking (situation in which a cluster of people have had sexual contact with the same person or people and hence are potentially exposed to illnesses from their partners’ other partners) and increasing HIV risk for young women, husbands, and wives.

The same ethnographic methods that revealed unexpected sources of risk, however, also pointed toward new ideas for community-based prevention. There are locally developed, male-initiated techniques for discouraging extramarital relationships and strengthening the marital bond. This endogenous response emerged among members of the Household Development Program of the Uganda Taxi Owners and Drivers’ Association (UTODA) in Iganga. The transportation industry, including taxi and long-distance operations, has long been recognized as being at high risk for HIV infection. UTODA’s technique of sexual regulation builds on members’ commonly stated goals of economic and affective well-being of their households. By emphasizing alternative notions of masculinity characterized by marital responsibilities, affective bonds, and public interaction between spouses, UTODA’s program attempts to increase partner cooperation and communication and reduce marital HIV risk.

This study is part of a larger 5-country comparative project researching marital HIV risk, in which the same research design and protocol were implemented in all countries.8 All findings and discussions in this article refer solely to the Uganda study.

The other 4 investigators and research sites are Jennifer Hirsch, Mexico; Harriet Phinney, Vietnam; Daniel Smith, Nigeria; and Holly Wardlow, Papua New Guinea. The project is entitled “Love, Marriage, and HIV: A Multi-Sited Study of Gender and HIV Risk.”

Important quotation:

An unexpected finding of our research was that HIV prevention discourses have increased the moral stigma of extramarital sex, inadvertently heightening people’s motivation for sexual secrecy and personal denial that an extramarital liaison puts one at risk for HIV.

CONCLUSION

Ironically, Uganda’s 2 decades of massive HIV prevention efforts have worked to reconfigure landscapes of social morality in ways that present new obstacles to HIV prevention. The widespread circulation of social, religious, and public health messages that present infidelity and polygyny as risky, immoral, backward, and dishonorable have had the unintended effect of creating new motivations and avenues for sexual secrecy. Although almost all men and women in this study recognized the health risks of extramarital liaisons, the risk of getting a bad public reputation by being caught in an illicit relationship presented more immediate cause for concern than the distant, unforeseen effects of contracting HIV. To minimize risks to reputations, individuals employed strategies such as secrecy and discretion to manage sexual relationships that were deemed socially immoral.

There also has been a gradual transformation from formal polygyny, in which households of co-wives were somewhat interconnected, to a pattern of informal secondary households that often remain autonomous and hidden from each other. Whereas in the past women in polygynous unions ideally owed fidelity to their husbands, women of informal or secondary households have no reason not to have multiple male partners. In fact, we found that some had other male partners to provide additional economic and affective support, thus intensifying HIV risk for all sexual partners. Furthermore, we found that longer-term liaisons might put people at risk because condom use tends to decline when relationships are based on emotional attachment and intimacy.

Although men commonly joke with their friends about multiple lovers as a marker of masculinity (“A man with 1 wife is his own co-wife,” goes a saying; “When the wife is sick he has to cook and clean”) or employ the assistance of a friend in carrying out sexual liaisons, most men today prefer to keep lovers and extramarital trysts away from wider social and kin networks for fear of social consequences such as gossip or complaints from wives. The increased moral stigmatization surrounding infidelity, combined with the high value placed on monogamous marriage, may influence respondents’ willingness to report extramarital sexual activity. This might partly explain why men’s reporting of extramarital sexual partners seems suspiciously low in large-scale surveys in which men were asked during rapid questionnaires about partner reduction and the number of nonmarital partners over the last 12 months.32 Although there may be overall partner reduction in Uganda, our data from participant observation and life histories concur with other community-based research studies that report a much higher occurrence of and variability in extramarital sexuality than are captured in rapid surveys.33

On the basis of my findings, I recommend 3 marital HIV risk reduction strategies that emphasize the need to address structures that provide opportunities for extramarital liaisons. First, whereas women in this study acknowledged their own risk for HIV infection, men tended to downplay their own vulnerability. The emphasis of many HIV prevention campaigns regarding girls, women, and commercial sex workers has allowed men to deny their own susceptibility and perhaps their own responsibility in the spread of HIV. Given men’s historical role in transmitting HIV to wives, younger women, and other sexual partners, it is crucial that campaigns highlighting women’s vulnerability be accompanied by programs that address men’s risk behaviors and the economic, social, and demographic conditions that facilitate these behaviors. We found that men’s participation in extramarital sex is frequently structured around work-related mobility and commercialized leisure activities that involve alcohol consumption; collaborations with key players from occupations and leisure places could therefore provide ideal opportunities for developing risk-reduction strategies. These programs could strengthen alternative social activities or notions of masculinity that are currently available in arenas that encourage men not to engage in extramarital liaisons. The UTODA sexual regulation program offers insight into how sexual and marital well-being can be positively integrated into people’s larger projects of household and individual development. Risk-reduction strategies that build on a community’s resources, understandings, and needs have a greater chance of being sustainable and effective than ones that impose external concepts, assumptions, and priorities.

Second, although many women and some men in our study expressed anxiety about their own HIV status and that of their spouse, most participants had never been tested for HIV. Fear of receiving an HIV-positive test result and uncertainty about the location of testing sites were cited as primary reasons for not getting tested. Anxiety over HIV status was worsened by silence within marriage about sexual histories and possible HIV risks. Notably, hardly anyone felt they had had a productive marital dialog—as opposed to accusations and arguments—about possible HIV risks in marriage, including past and current sexual partners. Yet the expressed desire among men and women for better marital communication suggests ideal opportunities for improving voluntary counseling and testing services for married people. In addition, in this study I found that although people knew the biomedical basics about HIV transmission and had firsthand knowledge of the later stages of AIDS-related illness and suffering, many people did not know how to live comfortably with HIV and how to gain access to medical care, which might also inhibit people’s desire to get tested. My preliminary research with HIV-positive groups suggests that increasing people’s knowledge about how to live with HIV and how to obtain care and support increases people’s chances of getting tested for HIV and joining prevention programs for people living with HIV/AIDS.

Finally, the current prevention message of “be faithful”—the marital prevention strategy in Uganda’s globally recognized ABC approach—may be inadequate, unsustainable, and potentially counterproductive when only 1 partner is faithful, certain acts of infidelity are not considered socially harmful, and structural factors including mobility, masculine sexual privilege, and social and economic inequalities support extramarital liaisons. Because extramarital liaisons are embedded within wider structures of inequalities that exist not only between men and women but also within society as a whole, our findings support poverty reduction as an integral element of HIV prevention.

Early in the sub-Saharan epidemic, wealthier men were among the first to become infected because their greater resources provided access to greater numbers of sexual partners. In line with more recent studies, however, I suggest that risk is also an element of poverty and economic gender inequality.34 Specifically, I found that, whereas wealthier men are attractive to young women in search of economic stability and modern lifestyles, lack of money might lead poorer men either to delay marriage (thereby increasing the pool of unmarried young women) or to engage in extramarital liaisons as an alternative route to masculinity. Policies and programs that enhance women’s educational and economic opportunities but that neglect younger and poorer men risk doing a grave disservice to the community at large. Poverty is not the only force driving the epidemic; the tremendous gap between the wealthy and the poor that puts all economic sectors at risk is also to blame. Structural determinants that promote men’s extramarital sex are not addressed, and if both husbands and wives are not included in prevention programs, interventions targeting marital HIV risk will be ineffective and unsustainable. Furthermore, in designing HIV prevention strategies, serious attention should be given to endogenous forms of risk reduction that have emerged in response to locally felt needs and that have the aim of changing existing norms that contribute to negative social, economic, and health consequences.