ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846

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Early Marriage and HIV/AIDS

Available programmatic sexual and reproductive health initiatives have focused disproportionately on the unmarried and on premarital sexual activity. Married young people have received little attention as a vulnerable group with distinct needs because marriage is assumed to be safe and because married adolescents and young people are assumed to face none of the stigma that their unmarried counterparts experience in accessing sexual and reproductive health services. Emerging evidence highlights that neither of these assumptions are tenable. Within the sub-population of young people, married young women constitute a group with distinct risks of human immunodeficiency virus and face a host of obstacles in making informed sexual and reproductive health decisions.

Athe countrys population are young people aged 1024 years [Registrar General, India 2001]. Compared to Economic and Political WeeklyApril 7, 20071292been undertaken among special populations: in one study among1,020 women attending sexually transmitted diseases (STD)clinics who denied a history of sex work in Pune, Maharashtra,15 per cent of adolescent women and 21 per cent of 20-30 yearold, were found to be HIV positive [Mehta et al 2006]. An earlierstudy among married women attending STD clinics in Pune alsoshowed that after controlling for socio-economic and husbandscharacteristics, adolescent girls (and those aged 20-29 years) wereconsiderably more likely to be HIV-positive than were oldermarried women [Gangakhedkar et al 1997].Other studies have documented the percentage of womendiagnosed with HIV who are young. These are reported in panelBof Table 1. For example, analysis of sentinel surveillance datafrom one state in India, Andhra Pradesh suggests that 13 per centof women at antenatal clinic sites found to be HIV positive wereunder 20 years of age and another 80 per cent were 20-29 yearsof age [APSACS 2002]. Findings from a number of hospital-based, retrospective studies conducted among HIV positive womenalso show that a substantial proportion of infected women wereyoung women whose only HIV risk factor was sex with theirspouse. for example, a multi-site study to test the feasibility ofadministering AZT to 687 infected women reports that 80 percent of women were below 25 years of age (www.nacoonline.org2006). Yet another study of infected women in Tamil Nadureports that 40 per cent of the positive women were 18-25 year-olds [Newmann et al 2000].Narratives of HIV positive women reiterate the link of marriageand infection, as the experience below, from a positive youngwomanin a Tamil Nadu study [Kousalya 2006] suggests: I got pregnanttwo months after my marriage. We were all very happy wewent for a check-up to a private hospital. They tested my bloodand said, We cannot do the check-up; go to Chennai. We wentto Erode and got tested there. There they told my husband thatboth of us had HIV (Widow, age 27, completed Class 5, marriedat age 20, two children). I think he knew that he had this disease[HIV] when he married me he should have been truthful andtold me about this. I would have been happy that he had spokenthe truth. Till he died he did not tell me anything (Widow, age27,completed Class 5, married at 19, no surviving children).Proximate DeterminantsThere are three factors that make young married womenvulnerable to risky sex and HIV: exposure to regular sex withinmarriage, exposure to unprotected sex within marriage and riskthey face of engaging in risky sexual relations.Exposure to Regular Sex within MarriageMarriage occurs overwhelmingly in adolescence for youngwomen but not young men. The large majority of women in Indiamarry by age 18 the 2005-2006 National Family Health Surveyreports that 45 per cent of all women aged 20-24 were marriedby age 18; in contrast, relatively fewer men aged 20-29 29per cent were married by age 21 [IIPS 2007]. Notwithstandingimpressive changes in educational attainment, marriage in ado-lescence will undoubtedly continue to characterise large propor-tions of girls in these settings over the next decade [UNICEF2005; IIPS and ORC Macro 2000].In settings such as India where marriage marks sexual initiationfor girls, but not necessarily for boys, early marriage may exposeadolescent girls to the risk of acquiring STIs or HIV. Evidencethat compares the married and unmarried is unavailable fromIndia but research from other settings Kenya and Zambia forexample finds that married adolescent girls have higher ratesof HIV infection than do sexually active unmarried girls. A keyexplanatory factor is that married adolescent girls have sex morefrequently than the unmarried [Bruce and Clark 2004; Clark2004]. While this assertion has been somewhat questioned onthe basis of ecological relationships deriving from Demographicand Health Survey (DHS) data from over 30 countries in sub-Saharan Africa, it does not question the link in settings in whichyoung girls marry before the age at which they would otherwisebecome sexually active indeed it agrees that in this case, girlsare exposed to an elevated risk of infection that would not occurin the absence of early marriage [Bongaarts 2006]. In India,moreover, once married, girls face enormous pressures to initiatechildbearing as swiftly as possible. Hence, while they are far morelikely than the unmarried to experience regular sexual relationsbecause of the pressure to prove their capacity to reproduce, thisplaces them at higher risk than unmarried sexually active womenof sexually transmitted infections [National Research Counciland Institute of Medicine 2005; Miller and Lester 2003].Exposure to Unprotected Sex within MarriageSexual activity within marriage among the young is unlikelyto be protected for a number of reasons. Because of the pressureto prove their fertility, married young women are probably lesslikely to use condoms than are unmarried sexually active ado-lescents or married adult women. Evidence from the NationalFamily Health Survey (1998-99) shows that only 3 per cent ofmarried adolescents was currently using condoms compared to10 per cent of 25-34 year old women [IIPS and ORC Macro 2000].Also, condom use is likely to be infrequent among married youngpeople because of misconceptions about condom use withinmarriage. Evidence from a study among young people in Punesuggests that only 42 per cent and 23 per cent of young malesand females, respectively, believed that condoms do not slip anddisappear inside a woman. Moreover, a sizeable proportion ofyoung males (17 per cent) and females (41 per cent) felt thatcondom is not a suitable method for married couples [Alexanderet al 2006a]. Similar perceptions were reported in yet anotherstudy conducted among young men in Mumbai [Verma et al2006]: Why should I use condoms during sexual relations withmy own wifeit is not needed(IDI, young man, Mumbai).Similarly, preliminary findings from a study conducted amongover 4,000 married young women and men in rural settings inAndhra Pradesh and Madhya Pradesh show that amongthosewhowere aware of condoms, one-third of young men andwomen reported that only sex workers and unfaithful peopleshould use condoms. Indeed, only a little over 50 per cent ofyoung menand over 40 per cent of young women believed thatcondoms are not only for sex workers or unfaithful people[Santhya et al 2007].Sexual Risk TakingSeveral factors suggest that women who marry in adolescenceare vulnerable to sexually transmitted infection and HIV.Pre-marital and extra-marital sexual risk behaviours: First andforemost, young women and men enter marriage with vastly 82.3 44.3 26.5 34.9 69 50.7 23.3 44.1 100 3.6 6.1 4.1 93 11.8 4.8 19.1 0 20 40 60 80 100 120

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