The Effect of Marriage and HIV status on Condom Use in Rural Malawi

As the HIV/AIDS epidemic spreads to the general population, a large and increasing proportion of HIV transmissions occur within marriage. Condom use within marriage could, therefore, be an important prevention strategy in sub-Saharan Africa, but there is considerable debate about whether married couples would be willing to use condoms. This paper contributes to this debate by identifying key factors that affect the acceptability of condom use within married for men and women in rural Malawi using three waves of longitudinal data from Malawi Diffusion and Ideational Change Project (MDICP). Specifically, we focus on the effect of (1) first marriage, and (2) HIV status on condom use acceptability within marriage. Using fixed-effects regression to control for unobserved characteristics that may affect condom use acceptability, marriage, and HIV status, we find that getting married leads to lower acceptability of condom use; and that perceived HIV status, rather than actual HIV status, affects the acceptability of condom use within marriage. 1 Post-Doctoral Researcher, Population Studies Center, University of Pennsylvania, philipaz@sas.upenn. edu 2 Associate Professor, Canada Research Chair in Youth, Gender and Global Health, McGill University, shelley.clark@mcgill.ca 2 Introduction As the HIV/AIDS epidemic spreads to the general population, a large and increasing proportion of HIV transmissions occur within marriage. Empirical evidence from countries throughout subSaharan Africa shows that many married individuals are at high risk of HIV infection from their spouses: according to a recent study in urban Zambia and Rwanda, between 55.1% and 92.7% of new heterosexually-acquired HIV infections take place within serodiscordant married or cohabiting (Dunkle 2008). Furthermore, age patterns of HIV incidence imply increasing risk of HIV infection within marriage (Zaba et al 2008). Discordant couples (i.e. couples where only one partner is infected with HIV) represent the majority of HIV-infected couples in sub-Saharan Africa, (de Walque, 2007). Although HIV positive individuals are more likely to experience marital dissolution (either via divorce or the death of a spouse) than the HIV negative (Floyd et al. 2008 for Malawi; Gregory et al. 2007 for Tanzania; Lopman et al. 2009 for Zimbabwe; Porter et al. 2004 for Uganda), male divorcees and widowers are likely to remarry after marital dissolution regardless of their HIV status (Gregory 2007, Ntozi 1997, Reniers 2003). Individuals in high prevalence settings of sub-Saharan Africa appear to be aware of the risk of HIV infection presented by their spouse. Evidence from rural Malawi shows that many are worried about HIV infection from a husband or wife: rural Malawians are more likely to overestimate their spouse’s likelihood of HIV infection than to underestimate (Anglewicz et al 2008), and some are divorcing spouses who they believe are a potential source of HIV infection (Reniers 2008, Watkins 2004). In addition, unmarried men and women in Malawi state that “being HIV-negative” is the single most important characteristic of a potential future spouse (Clark et al 2009). Still, the fact that it is more likely for couples to be HIV sero-discordant than concordant HIV positive in many sub-Saharan African countries implies that either these strategies are not effective or widespread, or that remarriage for HIV positive is not uncommon. As a result of the widespread risk of HIV infection within marriage, condom use within marriage is an important strategy in preventing the spread of HIV/AIDS. Despite this, condom use does not appear to be a widely-accepted strategy to prevent HIV infection. While survey data throughout sub-Saharan Africa indicates that individuals are well aware of the threat of HIV