HIV prevention awareness and practices among married couples in Malawi

Abstract

In this study we explored the level of awareness and practice on HIV prevention among married couples from selected communities in Malawi.

Methods

We carried out the study from October to December, 2008 in four communities, two each from Chiradzulu and Chikhwawa districts of Malawi. We conducted face-to-face in-depth interviews with 30 couples in each district using a semi-structured interview guide. The interviews lasted approximately 60–90 minutes. The husbands and wives were interviewed separately. The interviews were audio taped using a digital recorder. We wrote field notes during data collection and later reviewed them to provide insights into the data collection process. We computed descriptive statistics from the demographic data using SPSS version 16.0. We analyzed qualitative data using Atlas ti 5.0 computer software. The coded data generated themes and we present the themes in qualitative narration.

Results

The couples' ages ranged from 20 to 53 years, the majority (52%) being in the 20–31year age group. Most of the couples (67%) attained only primary school education and 84% had been married only to the current partner. Most couples (83%) depended upon substance farming and 47% had been married for 3 to 9 years. The number of children per couple ranged from 1 to 10, most couples (83%) having between 1 and 5 children. All couples were aware of HIV prevention methods and talked about them in their marriages. Both wives and husbands initiated the discussions. Mutual fidelity and HIV testing were appropriate for couples to follow the HIV prevention methods. For most couples (54) there was mutual trust between husbands and wives, and members of only a few couples (6) doubted their partners' ability to maintain mutual fidelity. Actual situations of marital infidelity were however detected among 25 couples and often involved the husbands. A few couples (5) had been tested for HIV. All couples did not favor the use of condoms with a marriage partner as an HIV prevention method.

Conclusion

The level of HIV prevention awareness among couples in Malawi is high and almost universal. However, there is low adoption of the HIV prevention methods among the couples because they are perceived to be couple unfriendly due to their incompatibility with the socio-cultural beliefs of the people. There is a need to target couples as units of intervention in the adoption of HIV prevention methods by rural communities.

Introduction

The majority of sexually active adults in Malawi are married. According to the 2004 Malawi Demographic and Health Survey, 67% of the women of the reproductive age and 63% of the men are married¹. Marriage would be protective if both partners were HIV negative at the time of marriage and maintain a monogamous relationship². However, this is not the situation in many marriages. Married couples face a substantial risk of contracting HIV from their partners, presumably through premarital and extramarital sexual behavior³. The major setback to HIV prevention among married couples is that HIV prevention methods emphasize mutual fidelity, abstinence and condom use which are not readily accepted by most married couples⁴.

Abstinence for example is culturally not readily accepted in a marriage setting and mutual fidelity poses a problem for many married couples because of gender inequality, cultural norms, lack of trust and communication barriers⁴. Maintaining fidelity is a challenge especially in communities where traditionally polygamy is accepted³. Acceptability of polygamy has resulted to the husbands being more likely than wives to report extramarital sexual partners and wives being more likely than husbands to suspect that their spouse has been unfaithful³. The use of condoms as an HIV prevention method is culturally viewed as inappropriate for married couples, consequently, condom use among married couples in Malawi is as low as 4%¹.

The current HIV prevention methods have therefore not fully addressed the needs of married couples⁵. The major reason has been the approach used in the implementation of the HIV prevention methods. Men do not actively participate in reproductive health services because these services are combined with antenatal clinics whose main clients are women. Women have been the focus of these services due to the fear that if men are included the women will lose their voices⁶. Focusing on women only has reinforced the belief that women are responsible for safer sex⁷. The problem with this approach is that it ignores the dynamic nature of sexual behavior, which means that HIV risk reduction is not fully controlled by either partner⁸. In a marriage setting, both the partners and the community have a long-term commitment to preserving the relationship⁹. The ideal situation is therefore to target both couples in marriage in order to consider the structural and environmental forces as well as socio-cultural context that shape HIV vulnerability for men and women^10,11,12,13. Couple based approaches have increased adherence of couples to HIV prevention methods in the USA¹⁴, Kenya, Tanzania and Trinidad¹⁵.

Objective

The aim of this study was to explore the level of awareness and practice among couples in Malawi on HIV prevention methods.

Methods

Design

We used a cross sectional design employing qualitative data analysis tools to gain in-depth understanding of husbands' and wives' levels of awareness on HIV prevention and their actual practices.

Study Population and Size

We conducted the study in southern Malawi, in Chiradzulu and Chikhwawa districts from October to December, 2008. Two communities were selected from each district in a way that one was near to the district headquarters, representing a town setting and another in an area remote from the town, representing a rural setting. We used a purposeful sampling to enrol participants for the study. Initially, the sample size was 30 couples per district based on the number of couples in each community but data saturation was reached when the sample size reached 15 couples per district. The final sample size was therefore 60 participants (30 couples).

Inclusion and exclusion criteria

To be recruited for the study, participants had to be;

1. traditionally or legally married for 3 or more years;

2. living together with the spouse;

3. in a monogamous married relationship;

4. at the home district for either husband or wife;

5. at least 18 years old;

6. a wife of childbearing age (i.e., less than 45 years old);

7. at least with a child;

8. able to speak Chichewa; and

9. willing (both spouses) to participate in the study.

Spouses that were not legally married, separated or divorced were excluded from the study. In addition, couples below 18 years and those with wives of above 45 years or those without children and did not consent to the study were also excluded from the study.

Data Collection and Analysis

We used a semi-structured interview guide to collect data. The first part of the interview contained close ended questions that collected demographic variables of age, length of marriage, tribe or ethnic group, education level, socioeconomic status, marriage lineage tradition, and number of children. The second part of the interview guide had open-ended questions that collected qualitative data. The questions were translated into vernacular language. The questions focused on the level of HIV awareness, communication and prevention methods among couples. The instrument was pilot tested with different communities in the two districts to assess the clarity of the questions and feasibility of the collected data.

We collected through face-to-face in-depth interviews which lasted approximately 60–90 minutes. The husbands and wives were interviewed separately to facilitate discussion of sensitive topics. In addition, the female principal investigator interviewed the wives, while the male research assistant interviewed the husbands. The husband and wife were not able to see or hear each other during individual interviews. The interviews were conducted at an agreed public and private place. The discussions were audio taped using a digital recorder. Field notes were written during data collection and later reviewed to provide insights into the data collection process. The participants were assured of confidentiality and all the data were locked in the researcher's office.

Descriptive statistics were computed for the demographic data using SPSS version 16.0. Qualitative data were analyzed using Atlas.ti 5.0 Computer Software. The qualitative data management and analysis followed the following steps; (1) organizing and preparing data for analysis; (2) reading through all data; (3) detailed analysis with a coding process; (4) using coding process to generate themes for analysis; (5) advancing how themes will be presented in a qualitative narration; and⁶ interpretation of the data¹⁶.

Ethical Consideration

The study was approved by the internal review boards of the University of Illinois at Chicago in the USA and the Research and Ethics Committee of the University of Malawi's College of Medicine. Permission to access the communities at district level was sought from the District Commissioners. District Health Officers from both districts were informed of the study and permission was sought to use community health workers from each district hospital to assist the investigator with identification of potential participants from the communities. The chiefs granted permission for researchers to access the homes of potential participants.

Results

Participant Characteristics

In Chiradzulu district eight couples came from Mwanje community that was close to the district township and seven couples from Njagaja, a rural area. Similarly in Chikhwawa, eight couples came from Mbenderana 1 and seven from Moses, representing township and rural communities respectively. The participants had been in the village for over two years. The age composition of the participants is shown in Table 1.

Table 1.

Age composition of the study participants from Mwanje and Njagaja in Chiradzulu district and, Mbendera 1 and Moses villages in Chikhwawa district.

Age group	Number of participants	Percentage
20–31	31	52
32–40	22	37
42–50	5	8
52–53	2	3

The majority of the participants were of the younger age group and most of them were between 20 and 40 years of age (Table 1). The participants that were over 45 years were husbands.

The length of stay in the village ranged from 2 to 53 years. There was equal proportion (33%) of the participants in the length of stay categories of 2–20, 21–40 and 41–53 years. The education levels of the participants are shown in Table 2.

Table 2.

Education levels of the study participants from Mwanje and Njagaja in Chiradzulu district and, Mbendera 1 and Moses villages in Chikhwawa district.

Education level	Number	Percentage
No education	6	10
Adult literacy	1	2
Primary Education	40	67
Secondary Education	13	21

Most of the participants had attended primary school education. The combined proportion of participants who were literate was 91% (Table 2). The proportion of the participants with adequate food throughout the year was 50%.

The majority (83%) was of low socioeconomic status and depended on subsistence farming and small businesses for their income. For the remaining 17%, the husbands were on salaried jobs. The employed participants were either primary school teachers, brick layers, messengers, office assistants, watchmen or grocery assistants. The employment enabled 80% of the participants to provide support to their relatives, 90% to own radios, 53% to own bicycles, and 30% to have iron sheet roofed houses.

The predominant tribe in Chiradzulu was Lomwe (84%). The Yaos comprised 12% and the others (Ngoni and Chewa) were 4% of the participants. In Chikhwawa, 66% of the participants were Man'ganja. The Senas comprised 16% and the remaining 18% comprised the other tribes. The majority of the participants (82%) from both districts had been married once, that is, only to the spouse they were living with during the time of the study. The matrilineal system was predominant in the two districts and was practiced by 60% of the participants. The majority of the participants (83%) had 1–5 children in their families and the remaining 17% had high number of children that is, between 6 and 10. Most of the couples (47%) had been married for 3 to 9 years and there were equal proportions of couples that had been married for 10 to 15 year (23%) and 16–20 years (23%). The proportion of couples (7%) that had been married for 21–23 years was low.

HIV prevention

The participants described HIV prevention strategies in their marriage relationships. Their descriptions were placed into the categories of HIV prevention awareness, HIV communication and HIV prevention methods.

HIV prevention awareness

All couples knew that HIV in a married relationship was contracted mainly through extramarital sexual relations. In addition, the participants were aware that either the husband or wife could be involved in extramarital sexual relations. However, both the women and men reported that men were more likely to indulge in extramarital relationships than women. One of the men narrated as follows; “This is common to men and not women, you go out and sleep with other women and you come back and sleep with your wife. If you contract the infection you can easily transmit it to your wife.”

Apart from extramarital sexual relationships, all participants mentioned that HIV could also be transmitted through exchange of razor blades, needles, safety pins, and toothbrushes. One woman narrated how HIV could be transmitted through use of safety pins as follows; “Supposing you use an HIV infected needle to remove a thorn and the infected blood on the needle touches yours, you will contract AIDS.” The sources of information for all the participants were the radio, hospital, and village meetings held by different organizations. For the village meetings, some non-governmental organizations, the church and civil society and drama groups visited the villages and hold rallies where the messages about the spread of HIV were delivered. The teachers (three of the participants) in addition to these sources also mentioned books and newspapers as sources of information. The Church was also an important source of information regarding the spread of HIV for four of the participants.

Communicating about HIV Prevention

The majority (27 couples) discussed HIV prevention in their marriages. For those who did not, two couples did not give reasons but one couple explained that there was no need to discuss the issue since they got information from the radio. A total of 28 husbands and 27 wives explained that wives initiate communication on HIV prevention. The women (19 wives) explained that they found an opportune time to talk about HIV when they were chatting with their husbands. The women frequently initiated the communication by asking the husbands how they should protect each other from HIV. Others suggested to the husbands to go for an HIV test, after they learnt about the test at the hospital during under five or antenatal clinic visits. Other women spoke about HIV and initiated the communication when advising their husbands against extramarital sexual relations. Some women inquired from their husbands if they were having extramarital sexual affairs. A wife from Chikhwawa shared: “There was a time when I became very sick and I asked my husband if he had been indulging in extramarital sexual relationship with other women. He denied ever having sex with other women. I however doubted him and asked him again but he denied. I thought that possibly my illness was due to HIV and that he was the one who infected me. After he denied any extramarital sexual relationships, we went to a government hospital where we were tested. We were told that we were not HIV-positive.

Fourteen participants (six husbands and eight wives) described situations in which communication was initiated by the husband. The husbands initiated the communication when they were chatting with their wives in the evenings before going to bed. Some men were prompted by HIV messages in the radio, some had received some education on HIV prevention and some by just seeing people suffering from HIV or those involved in risky sexual behavior for contacting HIV. The communication was initiated in the form of cautioning the wife about risky sexual behaviors and the dangers of HIV. The husbands and wives described reasons for discussing HIV prevention in their marriages. Fourteen participants (six husbands and eight wives) explained that the love, respect, and trust that existed in the family helped them to listen to and understand one another, as narrated by one of the husbands “I take my wife as my mother and because of love, I listen to what she says and she too listens to me, hence we listen to each other.”

The concern about death and leaving children as orphans prompted some of the couples to discuss HIV prevention. One of the men had this to say: “we need to take care so that we should look after our children; they should grow healthy because if one of us dies then our children will also be in problems.” The couples that communicated HIV prevention reported that they openly discuss the issue with their spouses. However, a few couples did not openly communicate with their husbands as narrated by two women (one from each district). One of the women explained that her husband did not show interest in discussing HIV prevention. The other woman explained that the husband accused her of having extramarital affairs when she initiated communication on HIV prevention. Under these situations the wives failed to influence their husbands to discuss HIV prevention.

HIV Prevention Methods

Maintaining Fidelity

Fifty-four participants (28 husband and 26 wives) mentioned that they maintained mutual fidelity in their marriages. The husbands and wives explained that they encouraged and advised each other to be faithful to one another. Some mentioned that they advised each other to “be responsible for one another;” “to trust one another;” “act like one body;” or “to protect themselves.” Based on the descriptions, the husbands and wives discussed this topic and agreed with one another to maintain fidelity. This was the method they felt was best for married couples.

Eight participants (five husbands and three wives) reported that they had never had extramarital sexual relations since marriage and were certain that their partners were also maintaining fidelity. Here is what one husband shared: “I believe women are the same and I do not see a reason for going out with other women. My wife satisfies my sexual desire and vice versa.” The husbands and wives explained that there was nothing that made them suspect that their partners were having extramarital relations. Forty participants (22 husbands and 18 wives) reported that they would terminate the marriage relationship if their partners had extramarital relationships. This indicated that maintaining fidelity was strongly expected in the marriage relationships.

Despite the reports that husbands and wives depended on maintaining fidelity in their marriages, seven wives mentioned that they doubted the fidelity of their husbands. The wives explained that “A man is never satisfied with one woman.” Therefore, they felt husbands were likely to have extramarital affairs. One wife shared: Yes, I cannot know what he does whenever he is out and comes home at 1:00 am. He tells me that he was watching soccer on TV, but I cannot be sure whether he was alone or with other women. I just tell him that whatever he does will one day be revealed.”

Despite the norm of marital fidelity, 25 participants (15 wives and 10 husbands) discussed situations of their partners having extramarital sexual relations. Husbands and wives differed in the way that they reported the situations. The husbands reported in a way that avoided giving the impression that they had extramarital affairs. For example, four husbands reported that their wives had received rumors that they were having extramarital affairs yet this was not true. Two husbands reported that they had actually been involved in extramarital sexual relations which their wives later discovered. One of the husbands mentioned that he usually got involved in extramarital affairs when he was away from home but he used a condom. The issues were resolved by advising the husband to change and warning them that their behavior would lead to contracting AIDS and leaving their children as orphans. The husbands or close relatives apologized on behalf of the husband. Concern about children's welfare was the main reason that made the wives accept the apology and forgive their husbands as narrated by one woman: “(laughter) because I have children. He apologized and his relatives also apologized and advised that I should forgive him. So I forgave him.”

There was a traditional way of discovering that the husband was having extramarital sexual relations that three wives from Chikhwawa reported. This was related to the norm of abstaining from sexual relations when the child is born up to 6–12 months of the child age. If the husband was having extramarital sexual relations, then the child or wife would become ill. Two wives reported that their children became ill with diarrhea, fevers, or edema and the elders advised them that it was because the husband was having extramarital sexual affairs. One wife reported that she herself was started feeling general body weakness and the child became ill. In all of the situations, the parents of the husbands or wives took the husband, wife and child to the traditional healers where the husband confessed infidelity, traditional medicine was prepared and the child or mother were healed. Another wife did not report any illness, but the husband confessed that he was having extramarital sexual relations when they wanted to resume sexual relations and traditional medication was given to the husband. In all situations, the wives did not act negatively because they were concerned about the child's well being.

There was only one situation when the husband reported that his wife was involved in extramarital sexual relations. The husband was tipped by friends and later caught her red handed. The husband reported the issue to his close relatives and chief. They told him that they could not resolve the issue but that he needed to go to the court. The husband chose to forgive his wife and defended her by saying that she did not know what she was doing. The issue was resolved and marriage was sustained. Regarding maintaining fidelity, all couples agreed to the words of one of the women, “it is normal for men to go out with other women” but “it is not appropriate that a woman should have multiple partners.”

HIV Testing

Fifty-one participants (27 husbands and 24 wives) mentioned that testing is a way of knowing HIV status and finding ways of prevention. However, actual HIV testing was reported by only five couples (three from Chiradzulu and two from Chikhwawa). They reported that they had both been tested for HIV. The factors that motivated them to go for testing were: spouse illness; wife being told at antenatal clinic; and just wanting to know their HIV status. In all situations except one, the husband and wife agreed to go for HIV amicably as shared by one of the women. “both of us initiated this. It was as if we were thinking along the same lines…both of us have had the test four times. Now we just encourage each other because we are not infected by HIV.” Three of the five couples reported that they were HIV-negative. However, one couple reported that the wife was positive and another reported that both were positive but the husband reported only about his wife's HIV positive status. Both couples mentioned that they used condoms but not consistently and were planning to have more children in the future. One couple was taking ARVs and attended an ART clinic at the district hospital.

Five couples from Chiradzulu reported situations where only one partner was tested. They explained that the partners were planning to go for testing later or the partners were not planning to go for testing because they assumed that if one of the partners was HIV-negative then their status was also the same. In four out of the five situations, the wives tried to persuade their husbands to go for HIV testing, but they were not successful. Eight couples (four from each district) reported that they felt that there was no need for them to go for testing. Some felt that they did not think that they needed to take an HIV test because they were not at risk of getting HIV.

Condom Use

Fifty-seven participants (29 husbands and 28 wives) said they did not use condoms in their marriages. Only two wives from Chiradzulu and one husband from Chikhwawa mentioned that they used condoms as a means of HIV prevention because one or both of them were HIV-positive. Therefore, they had been advised at the hospital to use condoms. However, the partners of the HIV positive wives or husbands did not mention that they used condoms. Almost all participants expressed that condom use was not appropriate in a married relationship because it meant that there was no trust. They said that condoms are meant for extramarital sexual relationships. Other husbands and wives expressed that they did not like condoms because they are not reliable; they are mostly expired and would burst while in use. Despite the negative feelings about condom use in married relationships, four husbands and eight wives mentioned that they would demand condom use if they suspected that their partners were having extramarital sexual relations. A total of 5 wives expressed desire for condom use but had not been successful in persuading their husbands.

Discussion

The results show that all couples were aware of how HIV is contracted and how it can be prevented. The level of HIV awareness among the couples in this study was almost universal due to efforts of government, church, the media and other nongovernmental organizations on community sensitization about the dangers and prevention of HIV. Regarding maintaining fidelity as an HIV prevention method, all couples were aware of the method. However, there were challenges regarding actual practice by the couples. Results show that despite couples advising and encouraging each other to be faithful some couples did not maintain fidelity. The results that men were more likely to indulge in extra marital relationships than women agree with the findings of other studies in Malawi. It has been reported that husbands were more likely than wives to report that they had extra-marital sexual partners and wives were more likely than husbands to suspect that their spouses had been unfaithful³. The results that some husbands were actually involved in infidelity are also consistent with the findings of other researchers who reported that husbands are likely to have extramarital affairs¹⁷. Hence, married couples are at risk of HIV primarily because of the current behaviors of their partners².

The results of wife infidelity in this study are in agreement with the findings of other studies that only few women admit to infidelity³. The reason for low reporting of women infidelity is the belief that it is inappropriate for women to have multiple sexual partners. However, in a society that strongly discourages wife infidelity, it was surprising that the husband reported to have caught a wife red-handed and also to have forgiven her. These results may be due to the way that couples perceive their vulnerability to HIV in which a women's own infidelity is not associated with their own or their spouse's assessment of risk³.

There was open communication about HIV prevention among the couples in this study which was initiated by both parties. The communication was initiated because of concerns for a healthy family life, desire to know their HIV status and family planning. The fear for death and leaving children as orphans was a major concern among the couples. The results show that shared decision making was used when husbands and wives discussed to protect each other from HIV. This finding is supported by a study conducted with married women in Malawi¹⁸. The women identified a range of contextually appropriate ways to resist exposure to HIV that included starting discussions with their husbands about the dangers of extramarital partners and convincing them of the risks.

Couples did not favor condom use because of the traditional belief that husbands and wives cannot use these method in a married relationship. This is consistent with results from other studies in Malawi which reported lack of reference to condom use during spousal discussions on strategies to deal with the mutual risk of contracting HIV within marriage^1,4. In addition, the desire for children among the HIV positive couples also discourages the use of condoms. Consequently, condom use among married couples in Malawi is very low¹. There is a need for more discussions with couples to raise the awareness on the importance of protected sex, especially among discordant couples. In this study, results show some participants desired to demand a condom if they were convinced that their spouses were HIV positive or leading high risk behavior for contracting HIV.

In this study, very few couples had been tested for HIV, despite the fact that all the participants mentioned HIV testing and knowing one's status as being useful in the prevention of HIV transmission. These results may be attributed to the fact that the study targeted married couples. Testing is more common among urban residents, single sexually active women and men, and men and women who are no longer married¹. Some married couples may not see the need for HIV testing because of trust in their partners. Lack of testing services in the rural areas may have influenced the results of this study.

Results in this study show that despite high level of awareness among couples in some districts of Malawi and possible reporting bias that leads to overestimation of one's own and spouse's HIV risk³, actual practice regarding HIV prevention is very low. There is still some level of infidelity affecting both patrilineal and matrilineal systems of marriage, low condom use and low HIV testing. There is therefore need to target couples as a unit of HIV prevention in Malawi, in order to break the socio-cultural barriers that prevents the adoption of the HIV prevention methods.

Conclusion

Most couples are aware of HIV prevention methods. There is communication among the couples regarding HIV prevention which is initiated by both husbands and wives. Despite the knowledge, most couples have not adopted the HIV prevention methods. Actual practice shows prevalence of infidelity, low condom usage and low HIV testing among the couples. There is a need to reach out the couples in the rural areas with couple based HIV prevention messages that should aim at removing the socio-cultural barriers that prevent couples from adopting the HIV prevention methods.