In this study assessing the association between extra-spousal partnerships and HIV among married or cohabiting individuals in Rakai, Uganda, we found that engaging in extra-spousal relationships increased the risk of HIV infection by 67%. Our finding that engaging in extra-spousal partnerships increases the risk of HIV infection by more than two-thirds is consistent with previous findings on this subject. In a study conducted by Mishra and Vinod (2009) using data from 22 nationally representative surveys, HIV prevalence was 3.22 and 2.87 times higher among women and men respectively, who reported extra-marital relations in the past year than those who did not. In another study conducted by Mishra (2009) using national household surveys, women who reported extra-spousal sexual partnerships in Ethiopia had a 12.1% HIV prevalence compared with 1.6% among those who did not. Mishra (2009) reports the same pattern in Zimbabwe (39.2% vs 20.3%) and Cambodia (6.2% vs 0.6%). Collectively, these findings re-affirm previous findings which indicate that engaging in extra-spousal partnerships increases the risk of HIV infection, suggesting a need for interventions targeting prevention of infection among married or cohabiting individuals.
Evidence shows that extra-spousal partnerships are considered among the primary drivers of the HIV epidemic among married and cohabiting individuals (Nabukenya et al., 2020, Mtenga et al., 2018, Mishra and Vinod, 2009). This can be attributed to the sexual concurrency and the overlap between 2 or more sexual partners which makes spouses involved in unprotected extra-spousal sex to act as conduits through which HIV enters marriages (UNAIDS, 2010 ). As documented elsewhere (Kasamba et al., 2011, Beauclair et al., 2015, Ssekamatte et al., 2020, Kwena et al, 2014), this facilitates faster spread of HIV at the sexual network level in two ways; earlier partnerships begun by the index partner are later exposed to any infections transmitted by an additional partner, and the fact that time to secondary transmission is shortened because the infected person does not need to terminate one partnership before starting another. Evidence also indicates that men in extra-spousal relationships rarely use condoms especially with their official partners (Smolak, 2014). It’s therefore not surprising that individuals in our study who engaged in extra-spousal partnerships had a 67% increased risk of being HIV positive. In Rakai, Nabukenya et al. (2020) similarly established that individuals in extra-spousal partnerships were almost twice as likely to be in an HIV infected couple relationship than those in single partner relationships. This therefore indicates the need for HIV prevention interventions targeting married and cohabiting individuals in extra-spousal partnerships as these do not benefit from abstinence, faithfulness and condom use (ABC).
Surprisingly, although a higher proportion of males than females reported engaging in extra-spousal partnerships, we found that males who engaged in extra-spousal partnerships were less likely to be HIV infected than the females. However, our review of literature found studies reporting similar findings. In a study that used national household surveys from 22 African countries, analyses showed a 10.5% difference between women who reported extra-spousal sexual partnerships and those who did not. The study, however, found similar HIV prevalence among men who reported extra-spousal partnerships and those who did not (Mishra, 2009). These findings can be explained by the biological susceptibility to HIV infection through intercourse among females as compared to males. Evidence from a majority of biological based studies conducted in different countries report the risk of acquisition of HIV infection through vaginal sex to be higher among females (Avert, 2020). In addition, vulnerabilities created by cultural, social, and economic inequalities between males and females especially in SSA play a significant role in facilitating HIV acquisition among females. Females face significant barriers in accessing health care including sexual and reproductive health services, and the majority have limited autonomy to demand for HIV preventive measures such as consistent condom use with their partners, who could be engaged in multiple sexual relationships (Avert, 2020, Türmen, 2003, Sia et al., 2016).
Besides extra-spousal partnerships and sex of respondents, our study identified other factors that increased the risk of HIV infection among married or cohabiting individuals. For instance, we found that individuals that engaged in trading or vending as an occupation were more likely to be HIV infected compared with agrarians. This is corroborated by findings from Anarfi et al. (1997) in a study conducted among female traders in Ghana. The high mobility of the traders and venders to different market places and sometimes staying for days before going back home exposes them to extra-spousal relations. In addition, the daily cash inflow could also facilitate extra-spousal sexual encounters especially among men who utilize female sex workers for their sexual needs while away from home. Salia et al. (2020) in a study conducted in southern Mozambique also reported that women traders with low-income levels were more likely to have sexual intercourse in exchange for money, goods or services such as transportation of their merchandise, thus an increased risk of HIV infection. Collectively, our findings and findings from other studies suggest that traders or vendors are at an elevated risk of HIV infection given their working conditions, therefore necessitating a need for interventions tailored towards this group.
We also found that engaging in fishing as an occupation also increased the likelihood of HIV infection among married or cohabiting individuals. Fishing communities have been identified as areas of high HIV prevalence (Smolak, 2014, Kagaayi et al., 2019) and, as our study indicates, residing in a high HIV prevalence area can increase the risk of HIV infection. Similar findings have been reported by Kaiser et al. (2011) where proportions of couples infected with HIV were highest in areas with the highest HIV prevalence in Kenya. Frequent mobility, transactional and commercial sex, multiple sexual partners, high consumption of alcohol, poor health infrastructure, and limited access to health services are some of the documented factors shaping the HIV epidemic in this key population (Musumari et al., 2021). These findings suggest that married or cohabiting individuals in fishing communities have a higher likelihood of HIV acquisition calling for a need to promote HIV preventive measures such as condom use, PEP, among other.
Building on prior findings on this subject, we found that remarriage significantly increased the risk of being HIV positive, where individuals who reported extra-spousal partnerships, and in their second and third or higher marital order, were more than twice and thrice respectively, more likely to be HIV positive compared with those in the first marital order. These findings concur with those of earlier scholars Nabukenya et al. (2020) in Rakai, Uganda, and De Walque and Kline (2012) in 13 SSA countries of which Uganda was part. Being in a third or higher marital union indicates instability in one’s previous relationships. This instability could have been caused by factors such as infidelity and HIV status. In addition, Nabukenya et al. (2020) express that individuals form new marital unions after the loss of a partner or after separation from a partner due to HIV infection but rarely do they test for HIV before forming the next union, which exposes them to the likelihood of infection. Remarried individuals are also likely to engage in behaviors typically associated with married couples, such as regular intercourse with infrequent condom use. Such behaviors, coupled with extra-spousal sexual intercourse increase the likelihood of HIV infection to the unfaithful partner who then becomes a channel for HIV spread to the HIV-negative partner. These findings imply that remarriage is substantial risk factor for HIV infection and interventions targeting remarried or individuals forming new unions are critical.
Finally, we found that individuals who reported a marital duration of six or more years were 47% less likely to be HIV infected compared to those who reported 1–3 years. These findings are collaborated by another study conducted in 13 sub-Saharan Africa countries using nationally representative datasets where longer marital durations were protective of HIV infection (De Walque and Kline, 2012). It’s probable that a long duration symbolizes stability and trust in one’s current relationship which prevents separations and remarriages. Remarriage, as earlier established in this study and other (Nabukenya et al., 2020, De Walque and Kline, 2012, Żaba et al., 2009), increases likelihood of being HIV infected.
Strengths and limitations
This study had several limitations that are worth noting. Firstly, as with most self-reported behavior studies, the assessment of extra-spousal partnerships is prone to recall bias as well as under-reporting and exaggerations. However, as Nnko et al. (2004) reported, under-reporting of extra-spousal partnerships is more common among single than married women, and exaggerations are more common among single than married men. Although under-reporting and exaggerations cannot be completely eliminated, this observation suggests that what was reported by respondents in this study is close to reality. Secondly, being a cross-sectional study, we cannot determine the direction of causality. We cannot establish if the individuals were already HIV positive before they started engaging in extra-spousal partnerships or whether they got infected while on the sexual network. However, our findings still remain relevant given that cross-sectional data has previously been used to establish risk of HIV infection that comes with concurrent sexual partnerships (Mishra and Vinod, 2009). Thirdly, although we used data for married or cohabiting individuals, we were not able to link spouses into couples and It’s probable that the relationship between extra-spousal partnerships and HIV infection would have been stronger had we analyzed linked spousal data. Nonetheless, couples are made up of individuals and we believe individual data can be used to assess the association and give reliable findings. Furthermore, data were collected in Rakai district, an area where HIV was first discovered in Uganda in 1982 and several interventions targeting HIV prevention have been implemented in the area. It could be argued that Information saturation due to several interventions has possibly led to tolerance where people no longer fear the infection and have fallen back to their high-risk sexual behaviors. Despite this, our study still brought out the risk involved in engaging in extra-spousal partnerships as it is in other districts and regions in the world. Therefore, our findings still remain valid and generalizable across districts in Uganda and elsewhere. Lastly, we failed to adjust for consistent condom use in our model. This was because only about 1.5% of the respondents reported consistent condom use across all partners. Although consistent condom use among casual partners increases to about 6%, the absolute number of individuals reporting consistent condom use with casual partners was too low to allow for meaningful stratified analysis let alone multi-level regressions.
The above-mentioned limitations notwithstanding, our study strengths lay in the fact that our data adjusts for differing HIV prevalence levels including low, medium and high HIV prevalence communities in the RCCS enumeration area. This mimics the reality in the world today and therefore our findings remain generalizable for different regions of the country and beyond and can inform the design of strata-specific HIV prevention interventions for married individuals. Our study contributes to current research on extra-spousal partnerships and HIV infection by establishing the extent to which such relationships can lead to infection.