Marriages in Malawi are characterised by such stark gender inequalities that marriage itself is a risk factor for HIV infection in women, according to qualitative research published last month in Global Public Health. Women with HIV who took part in the research were very aware of patterns of abuse and of their vulnerability due to non-monogamous husbands.

“A deeper understanding of the complex role marriage plays in women’s lives is critical to effective HIV-prevention efforts,” say Lucy Mkandawire-Valhmu and colleagues. “Such understanding allows for interventions and policies that are firmly grounded in the realities of women’s lives.”

In the south-east African nation of Malawi, 12% of adults have HIV, but women are infected at a younger age and in larger numbers than men. Annual average national income is around US$200, and women are substantially poorer than men.

Seventy two women took part in one of twelve focus groups at HIV clinics in southern Malawi (three rural clinics and one urban clinic). Average age was 33, most had some primary school education, half had no current economic activity, and most had been diagnosed with HIV in the past two years. Over half the women were married at the time of the study, but almost all had been married at least once and having been through two or three marriages was common.

Women identified poverty and the desire for companionship as the most important factors that drove them to marry.

“Your thoughts are that the man you are staying with is someone with whom you can work together, support one another. Perhaps you can strengthen one another’s heart.” 

Most women blamed a husband’s non-monogamy for their HIV infections.

“You can agree to do something, to be united, loving, not promiscuous… the way a marriage is supposed to be. But because you cannot tell the heart of another person, you cannot know how he is moving about.”

Women generally reported that they had remained faithful while their husbands may have had girlfriends or taken an additional wife within a polygynous marriage (which is legal in Malawi).

“My husband had a child with me and then he left me… sometimes just beating me up… he finds another woman and then I accept him until he gives me a second pregnancy and after the child is born, he leaves me again and goes to find another woman . . . Until I have given birth to all those children while he was doing all of this so I just strengthened my heart that I should just leave this.”

Women described the cultural norms that put them at risk, including the belief that man and wife should abstain from sex for up to a year after childbirth. Perceiving that men cannot control their sexual appetites, women linked this to unfaithfulness and subsequent HIV infection.

Men’s non-disclosure of their own HIV status was commonly described.

“He was refusing to go to the hospital, just staying at home. His people came to get him. So when he died, after a short while, I noticed that I was unwell. I came here to the hospital and was found with it.”

Other behaviours which women described as nkhaza (domestic abuse or violence) included forced sex (which never involved the use of condoms) and abandonment, often after a wife was diagnosed with HIV, perhaps during pregnancy. During some focus groups, women who had lived with HIV for longer periods advised newly diagnosed women on when – if ever – to disclose their HIV status. Women with physically violent husbands were advised not to disclose.

Both husbands and wives could walk out of a marriage. The end of one relationship could mean the beginning of another, even a risky one, in order to provide for themselves and their children. Women did not always know which husband had infected them.

However, after two or three remarriages, a number of women decided that poverty was preferable to the dangers of marriage, or that they could better concentrate on the wellbeing of their children without a new husband.

“I suffered for a long time. There is nothing for me to benefit from a man. He will only add to my problems. I would rather sit in my house [implies both hunger and loneliness] so that my life should be extended.”

Some women felt that the stress of marriage could counteract life-saving medications and their own health.

“What we have experienced, we cannot repeat it! Even if a man wears trousers, I don’t know what is inside his trousers. The way we have experienced it and the way we have been helped [through ARVs] and then you should go back to the past?”

The authors call for policy and interventions which would improve women’s status and autonomy, including equal access to land, sustainable income-generating activities and microfinance.