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Early Marriage and HIV/AIDS

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.

Special articles

Early Marriage and HIV/AIDS

Risk Factors among Young Women in India

Athe country’s 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 husband’scharacteristics, 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 wife…it 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

Sex with a Sex with a Non-romantic Per Cent Reporting Condom Use in Romantic Partner or Same Sex Partner Multiple Pre-marital Pre-Marital or Spouse before Partners Relations

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Urban Male

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Urban Female

Economic and Political WeeklyApril 7, 20071294states of Gujarat and West Bengal, observe that between 9 and14per cent of married young women reported forced sexualexperiencesperpetrated by their husband [Santhya et al 2006;Visaria 2000]. Findings from qualitative studies also reflect aconsistent picture of forced early sexual experiences andhighlightthe sexual vulnerability of newly married – usuallyadolescent – women irrespective of whether data are derivedfromretrospective information from older women on their ex-periences as newly married adolescents or from youngwomenthemselves. for example, one study in West Bengal reportsthat girls married at or below the age of 15 were found to beespecially vulnerable to forced sex in marriage [Ouattara, Senand Thomson 1998].Surveys conducted among men in India that shed light on men’sreports of forced sex perpetrated on their wives underscore thelikelihood that women under-report such experiences. A studyof 6,600 married men aged 15-65 years in Uttar Pradesh, inquiredfrom men whether they had ever had sex with their wives“evenif she was not willing” and whether they had ever “physicallyforced” their wives to have sex. Findings suggest that one-third(33 per cent) of younger men (aged 30 or younger) and one-fourth (26 per cent) of older men (31+ years) reported havingnon-consensual sex (with or without physical force) with theirwives at some time in their married life [Martin et al 1999]. Froma study in three states, Punjab, Rajasthan and Tamil Nadu, whilethe exact wording/framing/phrasing of questions was not avail-able, as many as 67 per cent of young men (aged 15-24) comparedto 43 per cent of older men (aged 36-50) reported forcing sexon their wives in the 12 months preceding investigation [Duvvury,Nayak and Allendorf 2002].While direct evidence of a link between forced sex and HIVor related risk behaviours in India is not available, there isevidence from other settings that confirms such an association.For example, in a study in Dar es Salaam, Tanzania, the oddsof reporting violence was 10 times higher among young (under30) HIV+ women than among HIV- women of the same ages[Maman et al 2002]. Another study in Rakai, Tanzania, has notedthat young women who reported coerced first intercourse (notnecessarily within the context of marriage) were significantly lesslikely than those who did not to be currently using moderncontraceptives or to have used condoms at last intercourse andto have used them consistently during the preceding six months[Koenig et al 2004]. Likewise, in a qualitative study of youthin Dar es Salaam, young men reported a strong associationbetween forced sex and sexual infidelity or multiple concurrentsexual partners [Lary et al 2004].Factors Underlying RisksLack of Awareness of HIV and ofSafe Sex PracticesLack of awareness has often been cited as a significant im-pediment to safe sex practices. Indeed, the Reproductive andChild Health Survey 2002-04 reports that 50 per cent of marriedyoung women aged 15-24 compared to 56 per cent of those aged25-34 were aware of HIV/AIDS [IIPS 2006].Qualitative data support this finding of lack of awareness andwidespread misconceptions among young women. In-depthinterviews with HIV positive women reveal the extent of thesemisconceptions: “I did not know anything about HIV. I thoughtthat he [husband] was affected by evil spirits so I took him tothe temple” (Widow, Age 26, completed Class 6, married atage21, no children, reported in Kousalya 2006).“At that time, I did not know what HIV was. I thought thatifyou got it, you would become ‘skin and bones’ and die…. Aftergoing home, I asked my husband, ‘How does one get HIV?’”(Widow, age 27, completed Class 5, married at age 20,twochildren,reported in Kanniappan, Jeyapaul and Kalyanwala 2007).Several studies in India [George 2002; George and Jaswal 1995;Haberland, McGrory and Santhya 2001; Jejeebhoy 2000; Khanet al 1996; Ouattara, Sen and Thomson 1998] and other devel-oping countries have documented that young girls are often keptuninformed about sexual matters until they are married [Goldstein1994; Khan, Townsend and D’Costa 2002; Puri, Cleland andMatthews 2003]. Indeed, parental attitudes ensure that youngfemales remain poorly informed about sexual matters; parentstypically (mis)-perceive that deliberate withholding or obfuscat-ing of information are protective strategies [Mehra, Savithri andCoutinho 2002a]. As mothers observed, for example, “Why givethem so much information at this stage? They will learn whenthey need to... [after marriage]” [Delhi slum, Mehra, Savithri andCoutinho 2002b].Low Self-perception of RiskRelated to lack of awareness are married young women’sperceptions of self-risk and vulnerability to HIV and otherreproductive health risks. Evidence suggests that even youth whoare aware of the risks associated with unprotected sex do notalways perceive themselves to be at risk, even when they adoptunsafe sex practices. For example, preliminary findings from astudy among married young women and men in Andhra Pradeshand Madhya Pradesh report that only 5 per cent of young womenperceived themselves at risk of contracting sexually transmittedinfections. Perception of risk was low among even those whoreported extra-marital sexual experiences; only 19 per cent ofthose who reported extra-marital sexual experiences perceivedthemselves to be at risk, even though an additional 27 per centreported that they did not know whether they were at risk or not[Santhya et al 2007]. Moreover, married young women may notperceive themselves to be at risk because they may be monoga-mous and not have multiple partners and because they may nottake into consideration (or even know of) the pre- and extra-marital sexual experiences of their husbands. For example, a studyof 122 women attending a tertiary HIV care centre in Tamil Nadu(115 women were monogamously married to an HIV infectedhusbands, mean age 27, mean age at marriage 19), showed that97 did not perceive themselves to be at risk of STI/HIV but 73wereHIV+ and 31 had one or more STIs [Narayan et al 2000]. Inyetanother study among 350 married women in Mumbai, only 12percent women perceived themselves at risk of getting infected.Thosewho did not perceive themselves at risk cited reasons suggestiveof low self-perception of risk: that they were in a monogamousrelationship, that they were not members of a high-risk groupsuch as sex workers and that they trusted that their husbands didnot have other partners [Chatterjee and Hosain 2006].Studies of HIV+ women corroborate low self-perception ofrisk. For example, in in-depth interviews with women in Namakkal,Tamil Nadu [Kanniappan, Jeyapaul and Kalyanwala 2007]narratives highlight that even women who were aware of HIVdid not perceive themselves to be at risk: “Yes, I knew about
Economic and Political WeeklyApril 7, 20071295HIV through books, TV and newspaper. My husband and I hada love-marriage. I had total trust in my husband when I marriedhim. ……He had HIV even before we married. But he kept itasecret from me. Now it has been three and a half years sinceIknow….. When my child tested positive, I asked my husbandwhyhe married me in spite of knowing that he was positive. But hejust remained silent and did not answer me”(28 years, 12 yearsof schooling pass, married at 23, 1 child, currently pregnant).Lack of AccessLack of access, in practice, to information, services, suppliesand providers poses yet another obstacle to married young women.For example, the reproductive and child health programme takeslittle cognisance of the special constraints faced by andconsequentneeds of married young women. The outreach ofhealthand family welfare workers under the Reproductive and ChildHealth Programme tends to neglect married adolescent girls andyoung women until they have proven their fertility; there is alsoatendency to overlook the fact that newly married women maynothave the mobility, decision-making ability or access to resourcesintheir marital homes to seek information, counselling or care ontheir own and therefore require more concerted provider contactswithin the home than older women [IIPS and ORC Macro2000].While provider perceptions about youth needs have rarely beenexplored, preliminary findings from an ongoing study among 326healthcare providers and Integrated Child Development Services(ICDS) staff in the public sector of two states – Andhra Pradeshin which marriage age is low and HIV prevalence is high andMadhya Pradesh in which both marriage age and HIV prevalenceare low –indicate that there is a lack of recognition of the specialhealth service needs of married young women and men. One intwo stakeholders reported that married young women are no morelikely to be in need of sexual and reproductive health servicesthan married adult women aged 25 and above. Likewise, some63 per cent of stakeholders reported that married young womenare no more likely to be in need of services than their unmarriedcounterparts. Similar views were expressed with respect to sexualand reproductive health needs of married young men as well.For example, 52 per cent of stakeholders reported that marriedyoung men are no more likely to be in need of services thanmarried adult men. Similarly 67 per cent of stakeholders reportedthat married young men are no more likely to be in need of servicesthan their unmarried counterparts [Santhya et al 2007].Access to information is also limited. Although programmeshave been initiated that focus on enhancing awareness, marriedadolescent girls and young women are less likely to be reachedwith HIV/AIDS prevention efforts than are the unmarried. Forexample, most HIV/AIDS prevention programmes in India focuson unmarried students in schools and colleges through the schoolAIDS education programmes and the University Talk AIDSProgramme, and to some extent, on married young men throughthe Village Talk AIDS Programme. The latter programme worksthrough networks of youth organisations, including sports clubs,National Student Service and Nehru Yuvak Kendras, and is, intheory, designed for out-of-school unmarried and married youth.However, since most of these organisations cater largely to youngmen, married girls and young women are not likely to be reached[Santhya and Jejeebhoy 2007].Findings from a survey among newly married young womenand first-time mothers in Gujarat and West Bengal corroboratethis; the findings show that no more than 6 per cent of youngwomen received information on reproductive tract infections/HIV/AIDS from a health worker [Ram et al 2006].Lack of Agency and Unequal Gender NormsPerhaps the most intractable set of factors in patriarchal age-and gender-stratified settings such as India relate to unequalgender norms and power imbalances. These norms and powerimbalances act to increase married young women’s risks of STIsincluding HIV in many ways. First, post-marital agency is typi-cally limited. Married adolescents are particularly vulnerable andunable to exercise choice in their husbands’ homes – as evidentfrom Table 2, married adolescents are far less likely than olderwomen married at 18 or older to report involvement in decisionspertaining to their own lives, access to economic resources orphysical mobility. Studies have also reported their limited in-timacy with their husbands and limited social support moregenerally [UNICEF 2005; Barua and Kurz 2001; Santhya andJejeebhoy 2003; Kulkarni 2003]. All of these no doubt play akey role in exacerbating the SRH vulnerabilities experienced byyoung married women in India.Second, unbalanced gender norms play a considerable role inincreasing the vulnerability of married adolescent and youngwomen to HIV. Double standards that condone and even encour-age premarital relations for males but not for females are wide-spread. Several studies have reported that while pre-marital sexand even social interaction with boys is unacceptable and oftenprohibited for girls, it is far more likely to be condoned for boys[see for example Mehra, Savithri and Coutinho 2002a; 2002b;Abraham 2001]. As a consequence, the behaviour of boys is lessclosely supervised than that of girls and there is far less concernfor their reputation than those of girls [Mehra, Savithri andCoutinho 2002b; Sodhi and Verma 2003]. Gender norms alsoassociate masculinity with toughness and dominance, and femi-ninity with submissiveness, and the notion that it is a woman’sduty to submit to sex with her husband. Moreover, unbalancedgender norms socialise men with a sense of entitlement to sex,evenif forced, with their wives. For example, in a recent study ofmasculinity among young men in Mumbai, large proportions ofyoung men reported gender inegalitarian attitudes. For example,29 per cent agreed with the statement that “a man needs otherwomen,even if things with his wife are fine”; 31 per cent agreed that“thereare times when a woman deserves to be beaten”; 35 per centagreedTable 2: Agency among Married Young Women – Percentage ofWomen Reporting Decision-Making Authority, Mobility andAccess to Resources, by Age, 1998-99, NFHSAges20-24 Year15-19Old WomenMarried at18 or OlderPercentage involved in decision-making concerning:Own healthcare38.749.7Purchase of jewellery39.950.9Visits to parents/natal kin37.448.3Percentage of women reporting freedom of movement:Per cent not needing permission to go to a market13.826.7Per cent not needing permission to visit friends10.219.5Access to resources:Per cent reporting access to money45.661.7Domestic violence:Per cent women reporting experience of wifebeating in last 12 months16.09.0
EPW
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