Table 3 shows the HIV incidence stratified by marital status and risk behaviors. Currently married women had a lower HIV incidence than did the never-married and previously married women irrespective of age at sexual debut, age at marriage, number of sexual partners, and alcohol use before sex. The marital status differentials in HIV incidence were less consistent when stratified by condom use and age differentials between partners. Among men, those currently married had a lower HIV incidence than did the previously married for all strata of covariates, and in most cases, never-married men had incidence rates similar to those of currently married men.
The univariate and multivariable analyses are presented in Table 4. Currently married women were at a significantly lower risk of contracting HIV infection compared with the never married (Adj IRR = 0.26, 95% CI: 0.16 to 0.42), but there was no statistically significant difference in the risk of incident HIV between the never-married and previously married women. Among men, there were no statistically significant differences in the risk of incident HIV between the currently married and never married (Adj IRR 0.70, 95% CI: 0.31 to 1.59), but previously married men were at a significantly higher risk of HIV acquisition than were the never-married men (Adj IRR 2.62, 95% CI: 1.13 to 6.13). Multiple sex partners significantly increased HIV risk in both men (Adj IRR = 1.79, 95% CI: 1.20 to 2.65) and women (Adj IRR = 2.30, 95% CI: 1.45 to 3.63). Urban residence was a significant predictor of HIV risk in men (Adj IRR 1.87, 95% CI: 1.20 to 2.92), but not in women (Adj IRR = 1.11, 95% CI: 0.76 to 1.63).
Effect of Entry Into First Marriage and Risk of HIV Infection
HIV prevalence among those women entering into a first marriage was 11.6% (98/848), which was higher than in women who remained unmarried 7.5% (969/12,888, P < 0.001). Similarly, men entering into a first marriage had a higher HIV prevalence 5.6% (82/1472) than did men who remained unmarried, 2.1% (341/16,266, P < 0.001). Newly married women had a lower incidence of contracting HIV infection (1.67/100 py, 13/780.5 py) compared with women who remained unmarried (2.17/100 py, 73/3369.9 py), but this difference was not statistically significant (Adj IRR 0.77, 95% CI: 0.42 to 1.39). The HIV incidence among newly married men (1.59/100 py, 22/1382.7 py) was higher than in men who remained unmarried (1.07/100 py, 51/4779 py), but this was not statistically significant (Adj IRR = 1.22, 95% CI: 0.72 to 2.07).
Effect of Previous Marriage on the Risk of HIV Infection
HIV incidence among women in their first marriage (0.73/100 py, 111/15, 187 py) was lower than in those who reported second- or higher-order marriages (1.38/100 py, 32/2318.7 py, P = 0.002). In men, the incidence was 0.67/100 py (46/6867.4 py) in first-order marriages and 1.06/100 py (57/5383.4 py) in men with ≥2 marriages (P = 0.013). With reference to never married, first marriage was significantly protective against HIV infection occurring in women (Adj IRR = 0.32, 95% CI: 0.23 to 0.45) compared with that in men (Adj IRR = 0.67, 95% CI: 0.39 to 1.17) and in persons in second order or higher (Adj IRR = 0.65, 95% CI: 0.42 to 1.01 in women and Adj IRR = 1.23, 95% CI: 0.69 to 2.21 among men). Irrespective of marital order, the incidence of HIV among married women was lower than in women who remained unmarried (2.16/100 py, 73/3373.8 py). Relative to women who had never married, the risk of HIV acquisition was lower in first marriages (Adj IRR = 0.32, 95% CI: 0.23 to 0.45) and in higher-order female marriages (Adj IRR 0.65, 95% CI: 0.42 to 1.01). However, in men, HIV risk did not differ significantly by marital order when compared with that in the never married.
We found that the incidence of HIV was significantly lower in currently married women relative to that in the never married, and entry into a first marriage did not significantly affect HIV incidence relative to women who remained unmarried. For men, HIV incidence was comparable in the currently married and never-married groups. HIV incidence was the highest for both men and women who had experienced marital dissolution, although the risk for women was attenuated after adjustment for risk behaviors.
These findings are consistent with previous Rakai data that the incidence of HIV is higher among persons who were not currently married,17 but they are in contrast with previous reports suggesting that marriage constitutes a risk for prevalent HIV.3,7–10 However, HIV prevalence is a cumulative measure and cannot account for the differentials in the duration of exposure to the risk of HIV in each marital state. Because the interval between sexual debut and marriage is relatively short in Rakai (∼2.1 years for women and 5.2 years for men), compared with the mean duration of marriage in this population (∼9.0 years for women and 9.4 years for men), cumulative HIV prevalence is invariably lower before marriage than during marriage because of the shorter duration of exposure. Nevertheless, because of the longer duration of marital state, 60.7% of female incident infections and 71.0% of male infections occurred among the currently married. The mechanism whereby marriage may be protective from incident HIV for women is unknown, but it is noteworthy that fewer married women reported ≥2 sex partners in the past year (2.7%), whereas ≥2 partners were frequently reported by the never (8.7%) and previously married women (10.6%). In contracts, among men, multiple partnerships were frequent and comparable among the never, currently, and previously married (43.5%, 44.7%, and 48.6%, respectively, Table 3). Thus, differentials in the number of sex partners by marital status may protect married women, but there were no comparable differentials observed among men.
However, HIV prevalence was higher among men and women who had entered into a first marriage than those remaining unmarried, which possibly reflects previous high-risk behaviors among the newly married before the initiation of observation. However, the incidence of HIV was not significantly different between those entering a first marriage and those who remained unmarried suggesting that entry into marriage per se did not increase risk. Other risk factors for contracting HIV, such as multiple sex partners, alcohol consumption, and urban residence, were consistent with that in previous findings.10,13,18–20 In addition, the finding of a higher HIV incidence among persons in second- or higher-order marriages than those in their first marriages is consistent with the higher incidence observed in persons who experienced marital dissolution before remarriage.
The strategy of Abstinence, Be faithful, and use of condoms may be difficult to practice within marriage, because a woman's status often depends on childbearing, making abstinence, and condom use in marriage culturally inappropriate.7 In many societies, multiple sexual partners are condoned for men, whereas women are expected to remain faithful,21,22 and unprotected sex with extramarital partners is a risk factor for contracting HIV infection.17,23–28 Wide age disparities between spouses (eg, >10-year age difference) could contribute to risk if younger women marry older men who are more likely to be infected, and age disparities could reduce a woman's ability to negotiate safer sex behaviors such as condom use increasing the risk of HIV infection.14,29,30 It is programmatically important to determine subgroups of the population most at risk to target intervention.
These findings have implications for the targeting of HIV prevention initiatives. If as suggested by these and other data,28 HIV incidence is the highest in never-married women and previously married persons of both genders, interventions should be targeted on these subpopulations most at risk of acquisition.
In summary, in this rural Ugandan society, currently married women were at a decreased risk of incident HIV compared with the never-married ones or those who had experienced marital dissolution.
The authors thank the staff of the Rakai Health Sciences Program; the RCCS study participants, the Rakai District Directorate of Health services, and the Director, Uganda Virus Research Institute for supporting this study.
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Keywords:© 2014 by Lippincott Williams & Wilkins
marriage; HIV infection; Uganda