Investigations
When marriage raises AIDS rates

Although many parents in sub-Saharan Africa believe early marriage will shield their adolescent daughters from the region’s HIV/AIDS epidemic, in fact the opposite may be true, according to research by Shelley Clark, assistant professor in the Harris Graduate School of Public Policy Studies.

As a demographer with the nonprofit Population Council before coming to Chicago in 2001, Clark studied adolescent girls in South Africa. Much of the New York–based council’s work had demonstrated that marriage posed disadvantages for sub-Saharan 15- to 19-year-old girls—such as stunted educational opportunities, restricted access to public spaces (it’s considered inappropriate for married women to appear unescorted in public), and limited control over their reproductive health. Even so, Clark, like many other researchers, thought it an “outrageous claim” when a colleague suggested that, in the context of high HIV rates, “early marriage was tantamount to a death sentence for young girls.”

“The presumption that sex within marriage is good and safe, and that it is premarital sex that is bad, risky, and dangerous,” she explains, “runs deep.” Yet she found research on girls in Kisumu, Kenya, and Ndola, Zambia—countries in which, respectively, about 40 percent and 47 percent of sexually active 15- to 19-year-old girls are married—suggesting that her colleague’s claim was valid. The 1997–98 study showed that 32.9 percent of married girls in Kisumu were HIV-positive, compared to 22.3 percent of unmarried girls. In Ndola the ratio was 27.3 percent to 16.5 percent. The likelihood of infection, therefore, was 48 percent higher for married girls in Kisumu and 65 percent higher in Ndola. Those figures “really got me hooked,” Clark says, “since this result was left largely unexplained.”

She began her research, part of a larger Population Council project, to look for an explanation. Using the Kisumu-Ndola study and Demographic and Health Survey data (funded by the U.S. Agency for International Development), she found three main causes. First, marriage effectively ends condom use, both because of the desire for children and because condoms are seen as a sign of distrust. Second, sexual frequency rises dramatically with marriage. And third, the husbands of married girls are generally older and more sexually experienced—and therefore more likely to be infected—than the boyfriends of single girls.

“These girls typically marry a man five to ten years older than themselves,” Clark says. Husbands often are older in part because it takes men years to save for the traditional “bride price” given to a girl’s family. “He will have had more sexual partners, including prior wives, since many of these marriages are polygamous,” Clark says.

Given HIV’s low transmission rate (women have a 0.3 percent chance of infection for every act of unprotected sex with an infected partner, while men have a 0.1 percent chance), Clark says, the risk posed by frequent, unprotected intercourse—far more prevalent among married girls—is a more critical determinant in the likelihood of infection than is the number of one’s sexual partners. This helps to account for the unexpected finding that even single girls with multiple partners are at less risk than their married counterparts.

Ironically, Clark says, “Parents told us they really wanted their daughters to marry early to protect them from HIV.” At the same time “public and private policymakers actively encouraged virginity before marriage and promoted marriage as the best option to avoid disease,” she says. “Most researchers saw premarital sex as the problem and marriage as the solution.”

She hopes her study can convince parents, policymakers, and researchers that marriage does not offer the best protection against contracting a sexually transmitted disease. But in sub-Saharan Africa, where such diseases are pandemic, attitudes about marriage and sex are entrenched. “Unfortunately, many individuals in these countries appear to be fatalistic about contracting HIV,” she says. “We need to develop policies that will raise awareness and change prevailing beliefs in a way that will genuinely address the problem.”

Clark’s next step, in fact, is working with the Population Council and the World Health Organization to “figure out what the policy messages should be for married girls.”

— Amy Braverman