Ruptures d'union en région rurale au Malawi : attitude des femmes vis-à-vis du divorce et sérodiscordance du VIH des couples

Sub-Saharan Africa is the region of the world where cases of human immunodeficiency virus (HIV) infections are the most numerous. The 2015 Joint United Nations Program on HIV/AIDS (UNAIDS) estimated that 19 million people were infected with the virus. Women are more affected than men because of visible gender inequalities in, among other things, access to and discrimination against financial resources. In societies where marriage is universal, women can use divorce as a strategy to protect from an HIV infected partner who has risky sexual behaviours, thus avoiding an HIV infection. Marital trajectories thus become an important determinant in understanding HIV infections for married women and the challenges associated with HIV infections. However, the relationship between divorce and HIV infections remains inconclusive, partly because of the lack of information on individuals’ past unions to determine the effects of divorce on the risk of HIV infection for couples. In this thesis, we use data from the Malawi Longitudinal Study on Family and Health (MLSFH) project to better understand the effects of marital trajectories of women and men in the context of the HIV epidemic in sub-Saharan Africa. The MLSFH project is a large-scale longitudinal survey on behaviours related to sexual and reproductive health and it collects HIV biomarkers for all participants in three rural areas of Malawi. The project data is relevant to our research as it gives access to participants’ marital history and to socioemographic characteristics over time. Furthermore, all respondents and their spouses were offered HIV tests at one survey wave at least. This thesis contributes to the literature on divorce and HIV infections in sub-Saharan Africa by exploring two main objectives. First, we determine whether women's attitudes toward divorce are related to the subsequent divorce of women in a first marriage. More specifically, we use a longitudinal approach (discrete-time logistic regression) to study the factors associated to divorce. Our interest is to better understand the role of women’s attitudes towards divorce, which reflects their level of perceived autonomy and the social norms associated with divorce. In particular, we use women's attitudes towards divorce in five situations: 1) lack of financial support from the husband to the wife and their children, 2) domestic violence against women, 3) spousal infidelity, 4) the wife’s suspicion of her husband infection with HIV and 5) when a husband does not allow family planning.  The statistical analyses we conducted show that women’s attitudes towards divorce have little predicting power over divorce, except for domestic violence. The likelihood of divorce increases for women who believe that spousal violence is a justifiable reason for divorce. On the other hand, the likelihood of divorce decreases for women with a favourable opinion towards divorce in the event of suspicion of spousal HIV infection. Other marital characteristics are associated with greater likelihood of divorce, including place of residence after marriage (matrilocal, patrilocal and neolocal) and age difference between spouses. Second, we explore the marital trajectories through which married couples become HIV serodiscordant, and their implications for HIV prevention. This is particularly important as the majority of new HIV infections in Malawi occur among heterosexual couples. The MLSFH data are among the few that allow reconstructing the marital histories of both partners in a couple. We use a basic sequential analysis approach to identify the most common trajectories for couples and to highlight the different characteristics of the trajectories. We find that couples who have a greater number of union dissolutions are more likely to be in a HIV serodiscordant union particularly for female positive discordant couples. Other marriage related indicators such as the type of union and residence after marriage and number of sexual partners are also highly relevant in explaining the couple’s HIV status. Our results have important political implications as the UN Member States have committed themselves to the new Sustainable Development Goals. These goals include the promotion of women's rights and the reduction of new HIV infections, two topics emerging from our research. In particular, we wish to draw attention to fight against domestic violence by raising awareness to involve boys and men. Their commitment is needed to address cultural practices where violence is tolerated and to work towards changing attitudes and gender norms. Finally, repeated HIV testing should be recommended in order to detect new infections as quickly as possible and avoid new cases. This recommendation goes for singles as well as couples in which partners engage in unprotected extramarital sex. Addressing violence against women is important to limit their vulnerability and decrease their risk of HIV infection.

Keyphrases: Divorce, Attitudes, Couples, Marriage, Autonomy, HIV, AIDS, Serodiscordant, sub-Saharan Africa