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

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

Reference:

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.

Important Quotation:

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 liaisons1.

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. 

Marital sex continues to pose a particular risk for women 5.

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.

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

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.

~Sexual immorality and social acceptability of infidelity~

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.

~Economic security and facilitating sexual networking~

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.

Marriage and Gender in Iganga

Although marriage remains an important marker of adulthood and a social expectation, many younger people delay marriage for various economic and social reasons, such as education

In this patrilineal system, the exchange of bridewealth traditionally transfers rights over a girl or woman’s sexuality (and labor) from her father to her new husband. After marriage, any unauthorized sexual access to one’s wife was traditionally considered a theft committed against her husband by her lover; to a large extent, this holds true today. Conversely, a man’s extramarital liaisons are not considered punishable offenses (although, perhaps, socially objectionable) if carried out with a woman over whom no man (i.e., a father or husband) claims rights. 22 This difference between the rights of men and women is an important historical trajectory from which to understand men’s infidelity today.

In earlier ethnographic literature, the Basoga were described as being highly polygynous, which was particularly the case for wealthier men whose land holdings allowed for and required more dependant.

Over the last 50 years, monetization, Christianization, and formal education have altered the expectations and realities of marriage and family life.25

Premarital workshops and retreats for young singles are regular events of these churches, but there is some debate regarding the ability of these movements to alter sexual behaviors, and some view these churches as hypocritical.

Methods

I gathered data between January and June 2004 with 5 Ugandan research assistants—3 men and 2 women. I also drew on my previous ethnographic research, conducted during different periods since 1996, on changing forms of sexual relationships and sexuality among adults and young people in Uganda. The primary data for this article were obtained from 72 marital life histories conducted with husbands and wives from 34 marital unions28 (Table 1▶). To enhance the generalizability of the small sample size, the research team used systematic ethnographic sampling based on previous research findings29 and recruited participants who would provide the greatest diversity along 3 axes: duration of marriage, current socioeconomic status, and mobility and migration patterns.

Results

SOCIAL MEANINGS AND THE ORGANIZATION OF EXTRAMARITAL RELATIONSHIPS

When I asked one participant how AIDS had changed marriage in Uganda, she replied, “Whenever your husband comes to sleep with you, you feel worried that he is going to infect you with AIDS.” Her immediate association of men’s extramarital sex with women’s vulnerability to HIV infection was a common sentiment among women, indicating widespread knowledge about HIV risk from a partner’s sexual behaviors and histories.

Local understandings of “being faithful” and “risk” differ in significant ways from public health concepts. A man can be “faithful” as long as he continues providing economic support and maintains a respectful public reputation by keeping knowledge of extramarital relations away from people in the home and in the family’s social networks. 

Men’s extramarital relationships fall into 3 general categories: (1) longer-term relationships that may eventually evolve into secondary households; (2) short-term or 1-time opportunistic encounters near a man’s residential area, frequently in the same town; and (3) relationships occurring while the man is away from home, often because of work.

The changing social acceptability and patterns of infidelity clearly emerged in our interviews with men and women. 

Today, however, infidelity cases that emerge publicly have various social consequences, ranging from marital conflicts to public embarrassment to media coverage if prominent people are involved. Consequently, men want their sexual improprieties to remain secret.

Another significant change we found was a shift away from formal polygyny—a process that involved agreement among the husband, the existing wife or wives, and the kin of a new wife—toward the establishment of informal second households, often established without the knowledge of the existing wife or the new wife’s family.

CONDITIONS OF MARRIAGE AS A FACTOR IN MEN’S EXTRAMARITAL LIAISONS

Men’s perceptions of their marriage play an important, yet overlooked, role in their extramarital sexual activities. 

When participants were asked to explain how their relationship with their spouse differed from that of their parents, a noticeable shift from authoritarian husbands toward joint decisionmaking, cooperation, and communication between spouses was evident. This shift in power has been occasioned by gender equality campaigns and changing economic needs that require the attention of both husband and wife. Although wives generally see this shift as positive, some husbands are more ambivalent.

We also found that expectations of modern lifestyles and luxuries require economic means that many men are not able to acquire, yet wealth remains an important part of masculine identity. 

For this man and others, the trend toward marital communication has, ironically, opened the way for wives to express their grievances and dissatisfaction. Hence, taking extramarital lovers allows some men temporary solace from household economic pressures and their wives’ complaints.

SOCIAL AND ECONOMIC CONTEXTS OF MEN’S EXTRAMARITAL ACTIVITIES

Residents of Iganga recognize that poverty drives women into transactional relationships (i.e., sex for money),31 but they more frequently comment that the growing supply of unmarried, unemployed females poses a greater threat to marriage. The pool of unmarried young women appears to be increasing because of several demographic and economic phenomena: (1) the economic inability of younger men to formally marry and establish permanent residences; (2) a sizable population of young people who have come of age as HIV orphans, leaving many young women without parental economic or social support; and (3) a decline in fathers’ cultural rights over daughters, resulting from fathers’ inabilities to economically provide for older offspring and, as a result, frustrated adolescent daughters securing their own finances. Hence, whereas young men delay marriage to try to secure economic resources, relationships with older or wealthier men provide young women an opportunity for social stability and economic support.

Community-Based Regulation of Male Sexuality

MORAL STIGMA AND REPUTATION MANAGEMENT STRATEGIES

A Ugandan HIV prevention poster depicting faithfulness as the route to morality and marital happiness.

Note. In this poster, infidelity is equated with immorality, and married people seduced by potential lovers are represented as weak, immoral, and backward.

A popular HIV prevention poster from the 1990s that distinguishes good “safe” people from immoral “unsafe” people at risk of drowning.

Note. The title reads, “Do not drown in the AIDS flood; always be on board.” Although the message might lead some people to change their risky behavior, it could induce others to deny it.

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.

1. Women and HIV/AIDS: Confronting the Crisis—A Joint Report (Geneva: Joint United Nations Programme on HIV/AIDS [UNAIDS], 2004), available at: http://www.unfpa.org/hiv/women/docs/women_aids.pdf (accessed September 14, 2006); The Promise of Equality: Gender Equity, Reproductive Health and the Millennium Development Goals (New York, NY: United Nations Population Fund [UNFPA], 2005), available at: http://www.unfpa.org/upload/lib_pub_file/493_filename_en_swp05.pdf (accessed August 28, 2006); A. O’Leary, “Women at Risk for HIV From a Primary Partner: Balancing Risk and Intimacy,” Annual Review of Sex Research 11 (2000): 191–234; R. R. Gangakhedkar and M. E. Bentley, “Spread of HIV Infection in Married Monogamous Women in India,” Journal of the American Medical Association 278 (1997): 2090–2092; K. Mayer, S. Newmann, S. Solomon, et al., “Marriage, Monogamy and HIV: A Profile of HIV-Infected Women in South India,” International Journal of STD & AIDS 11 (2004): 250–253. [Ref list]

3. Hirsch J., J. Higgins, M. Bentley, and C. Nathanson, “The Social Constructions of Sexuality: Marital Infidelity and Sexually Transmitted Disease–HIV Risk in a Mexican Migrant Community,” American Journal of Public Health 92 (2002): 1227–1237; M. Lyons, “Mobile Populations and HIV/AIDS in East Africa,” in HIV & AIDS in Africa: Beyond Epidemiology, ed. E. Kalipeni, S. Craddock, J.R. Oppong, and J. Gosh (Malden, Mass: Blackwell Press, 2004), 175–190; C. Campbell, “Migrancy, Masculine Identities and AIDS: The Psychosocial Context of HIV Transmission on the South African Gold Mines,” Social Science and Medicine 45 (1997): 273–281; G.M. Wingood and R.J. DiClemente, “The Effects of an Abusive Primary Partner on the Condom Use and Sexual Negotiation Practices of African-American Women,” American Journal of Public Health 87 (1997): 1016–1018; K. Dunkle, R. Jewkes, H. Brown, G. Gray, J. McIntryre, and S. Harlow, “Gender-Based Violence, Relationship Power, and Risk of HIV Infection in Women Attending Antenatal Clinics in South Africa,” Lancet 363 (2004): 1415–1421; L.L. Heise, A. Raikes, C. Watss, and A.B. Zwi, “Violence Against Women: A Neglected Public Health Issue in Less Developed Countries,” Social Science and Medicine 39 (1994): 1165–1179; P. Gordon and K. Crehan, Dying of Sadness: Gender, Sexual Violence and the HIV Epidemic (New York: United Nations Development Programme, Social Development and Poverty Elimination Division [SEPED], 2000), available at: http://www.undp.org/hiv/publications/gender/violencee.htm (accessed August 28, 2006). [Google Scholar] [Ref list]

5. Carpenter L., A. Kamali, A. Ruberantwari, S. Malamba, and J. Whitworth, “Rates of HIV-1 Transmission Within Marriage in Rural Uganda in Relation to the HIV Sero-Status of the Partners,” AIDS 13 (1999): 1083–1089; A. Kamali, L. Carpenter, J. Whitworth, R. Pool, A. Ruberantwari, and A. Ojwiya, “Seven-Year Trends in HIV-1 Infection Rates, and Changes in Sexual Behaviour, Among Adults in Rural Uganda,” AIDS 14 (2000): 427–434; J.W. McGrath, C.B Rwabukwali, D.A. Schumann, et al., “Anthropology and AIDS: The Cultural Context of Sexual Risk Behavior Among Urban Baganda Women in Kampala, Uganda,” Social Science and Medicine 36 (1993): 429–439.