Social-structural determinants of HIV vulnerability in marriage : role of gender norms and power relations, masculinity, social norms and relationship quality

About two-thirds of global HIV infections are in sub-Saharan Africa (SSA), with 46% of new cases being in Eastern and Southern Africa. Despite remarkable progress in controlling the epidemic through scaling up antiretroviral treatment and universal health coverage in Tanzania, the HIV prevalence varies significantly across the regions, ranging from 1.5% to 14.8% and remains substantial among married men and women (5.4% and 5.2%) as compared to non-married men and women (1.2% and 3.3%) respectively. It has been argued that understanding the social-structural factors (social-economic, power relations, norms, political and legal context) of HIV beyond individual risk behaviors (condom use, number of multiple sexual partners), could inform the underlying drivers of, and interventions to reduce HIV vulnerability and health inequities in a long-term.
This thesis aimed to understand the social-structural determinants of HIV vulnerability among married and cohabiting partners in Tanzania. Guided by the World Health Organization, Commission on the Social Determinants of Health framework, this thesis pursued to provide a more in-depth understanding of how socio-structural factors (social norms, marital status, gender power relations and relationship quality) influence dimensions of HIV vulnerability: a) HIV status b) safer sex communication, and c) extramarital affairs.
The study was nested within the community health surveillance cohort entitled “MZIMA” (meaning being healthy), implemented in Ifakara town in south-eastern Tanzania financed by the “Global Fund Round 4”. The overall implementation of this thesis was supported by the Swiss-Tropical and Public Health Institute. In this thesis, a cross sectional sequential explanatory mixed method approach was employed between 2012 and 2015 which combined quantitative and qualitative methods. The quantitative data was part of the MZIMA surveillance cohort study. The qualitative data was primarily collected using in-depth interviews and focus group discussions to explain and explore further the findings of the quantitative study.
The main conclusions, contributions, recommendations are provided based on the three levels of investigations and their interaction with the social-structural factors to potentially influence HIV vulnerability in marriage. The table below provides a summary of the study findings. We highlight potential new evidence, and the key contribution that this thesis adds on to the existing literature.
Findings in the above table are categorized to highlight the fundamental factors (structural, social-cultural) which within the perspective of the WHO-Social Determinants of Health and the scholars of the drivers of the HIV vulnerability are considered responsible for poor health outcomes including HIV vulnerability. In the context of this thesis, the social-structural and socio-cultural aspects shown in the table above present the potential fundamental drivers of HIV vulnerability among married and cohabiting partners in Ifakara town, Tanzania. The fundamental factors, specifically the ‘structural’ aspects within the social determinants of health, are referred to as “upstream” determinants which present important opportunities for improving health, reducing health disparities and increase protection from unhealthy practices. The socio-cultural aspects are considered as interrelated with the “upstream” factors, which influence health outcomes. The World Health Organization refers to the socio-cultural and structural factors together as the “causes of the causes” since they interact, and may indirectly influence the behavioral risk factors by creating conditions that constrain or facilitate healthy practices. In this thesis behavioral factors that are investigated include safer sex communication among married couples and extramarital affairs. Increased knowledge about the social-structural drivers of behaviors linked to the risk of HIV infection aims at guiding appropriate intervention packages for targeting married and cohabiting couples.
The bottom line is that, unlike the biological determinants, the social-structural aspects are amenable for change through structural prevention approaches. It is within this perspective that the interpretation and recommendations provided in this thesis emphasize on the social-structural aspects of HIV vulnerability in marriage.
It is worth pointing out that some of the social-structural ingredients identified in this thesis may also influence HIV vulnerability in non-marital individuals, however, the pace of their influence within marriage may be slightly different since married partners may feel protected based on expectations of mutual monogamy. They have limited independence in their decisions regarding healthy choices and practices, since the marriage potentially obligates them to adhere to the opinion of the partner. Hence they are less likely to use HIV prevention methods such as condoms.
Chapter 5 of this thesis, from the individual responses data base, investigated the social-structural predictors of HIV status among married and cohabiting partners in Ifakara town (findings are presented in the summary table above).
Chapter 6 of this thesis, from the individual responses data base and a qualitative approach, investigated and explored the social-structural aspects that influence extramarital affairs, and the association between extramarital affairs and HIV status among married and cohabiting men and women in Ifakara town (findings are presented in the summary table above).
Chapter 7 of this thesis, from a qualitative design, explored how safer sex communication is practiced in marriage and the social-structural factors that influence safer sex communication between polygamous and monogamous partners in Ifakara town (findings are presented in the summary table above).
What is potentially new evidence from Ifakara town that this thesis provides?
 Married women in Ifakara town who engage in extramarital affairs are significantly more likely to be HIV positive than married men despite higher rates of extramarital affairs among men.
 The social protection groups Village Community Bank (VICOBA) in Ifakara town potentially provide opportunities for men and women to engage in extramarital affairs.
 Norms of masculinity and low relationship quality may lessen the protective effect of economic opportunities (VICOBA) for married women, and might expose them to sexual risk behaviors (extramarital affairs).
 Married women may transact money for “quality sex” and care since they may miss these aspects from their marital husbands.
 Some women in monogamous relations have the agency to initiate safer sex communication to their husbands despite social-structural constraints.
 In polygamous unions, the husband may choose to divorce women if he fails to satisfy them sexually and economically, increasing their economic vulnerability.
 In polygamous unions safer sex communication may be considered inappropriate. Only the younger wives may have the legitimacy to communicate about safer sex with the husband.
What is the main contribution of this thesis?
 This thesis links epidemiology (HIV status), public health prevention strategies (safer sex communication and abstinence from extramarital affairs) and social science theories on the underlying social-structural drivers of HIV infections in marriage. The linking provides insights on the pathways in which agency (married partners) interact to influence low relationship quality, women’s economic hardship, gender norms and power-relations, social norms of marriage, marital status (re-marriage, polygamous) and masculinity and later these social-structural aspects influence various levels of social risk behaviors such as extramarital affairs and safer sex communication.
 Sexuality among women is not homogeneous; some women may actively initiate risk sexual behaviors (extramarital affairs) to meet their sexual satisfaction and others may initiate to meet their economic and social needs.
 Prevailing gender inequality within marriage based on norms of masculinity may not only sustain married women’s social and economic hardship, but might lower their safer sex negotiation power, expose them to extramarital affairs, and in turn elevate their risk of HIV infection.
 Norms of masculinity based on religious and social expectations potentially promotes multiple sexual partners among men. Yet, despite the many tangible benefits (power, authority and control over women) that this behavior gives to men, it has negative social and health consequences for both spouses. It destabilizes the peaceful atmosphere and relationship quality in marriage, constrains discussions on safer sex aspects, and often results in both spouses having extramarital partners.
 Consequently in this thesis, it is not exclusively biological sex that predicted HIV status of married men and women; it was also the socially constructed gender norm (e.g. a woman is not expected to suggest condom use even when she knows that a husband has a disease).
 This thesis recommends a model which may be adopted to understand HIV vulnerability in marriage. The proposed model is found in section 8.6.1 of the main thesis. The model hypothetically shows how multiple social-cultural, economic and legal aspects as structural aspects interact and intersect to influence HIV vulnerability in marriage.
Further research on couples to corroborate these findings is needed as data on the partner’s behavior and HIV status were not available in this study.
To conclude, this thesis accentuates that married or cohabiting couples are a window of addressing social-structural drivers of HIV in Tanzania. Addressing HIV vulnerability in marriage requires multiple approaches which are beyond individual interventions, to address the contextual realities of marriages by challenging the harmful social norms, gender norms, power inequality and norms of masculinity that constraints adoption of safer sex communication, engagement and happy life in marriage. Improving quality of relationship and acknowledging married men and women as active agents of HIV prevention could be a social resource to foster safer sex discussions and practices in marriage.
Some social-structural aspects of HIV vulnerability in marriage such as social norms, gender power relation and masculinity operate across a wide spectrum of human life and in inter-related ways. This may require changes at policy level: changing the current marriage legal act of 1971 in Tanzania which perpetuates gender discriminatory practices and women’s economic hardship by fostering early marriages for girls (15years), and by legalizing men to marry multiple women. Economic empowerment programs should be tailored to address relationship quality in marriage in order to increase their protection effect against risk sexual behaviors particularly among married women. Social protection policies that discourage wife beating and promote the rights of married men and women to communicate freely about their health and sexual needs requires attention. Health system level: the choice of HIV prevention interventions including health promotion messages should be informed by the context specific evidence on the underlying HIV vulnerability in marriage. Social-structural indicators such as those that relates to gender equality could be incorporated within the HIV multi-sectoral strategic framework in Tanzania to allow implementation, monitoring and evaluation of broader contextual interventions. Couple-based counseling services for HIV prevention could emphasize on social risk aspects of HIV vulnerability: i.e relationship quality, marital status (i.e polygamous), gender power relation, social norms of marriage and norms of masculinity. Emphasize on HIV testing prior to re-marriage may increase opportunity for HIV prevention in marriage. The public health messages may also emphasize on similar aspects. At the community level, influential structures i.e religious leaders, local leaders and political leaders can advocate against the harmful social norms, gender inequality and poor relationship quality in marriage that constrain adoption of safer sex practices in marriage. Pre-wedding ceremonies could be used as venues to emphasize about the significance of relationship quality (fighting against sexual dissatisfaction, extramarital affairs and conflict) and safer sex communication in marriage. Establishing community based marital counseling centers would add value to the HIV prevention efforts targeting married partners. On the family level, childhood socialization should embrace the rights of boys and girls to speak freely about their concerns and equal education opportunity. On the theory part, the WHO-CSDH could be improved by adopting the social determinants that reflect African context buy incorporating the relationship quality, norms of masculinity, marital status and social norms as social determinants of health and health inequity.