Comment: The Link between HIV Infection and Marriage

The Fidelity Fallacy: The Link between HIV Infection and Marriage

With 80 percent of HIV cases worldwide transmitted by sexual contact, promoting marriage and sexual fidelity would seem to make sense as a way to limit the spread of AIDS. Yet this politically popular approach to public health among conservative policymakers in the United States promotes the false assumption that within marriage, sex is always safe-and consequently puts unknowing men and women at increased risk of infection. This fidelity fallacy holds enormous implications for the effectiveness of our government's global AIDS prevention program, where almost $400 million was spent last year in 15 focus countries for the President's Emergency Plan for AIDS Relief, or PEPFAR.

In most societies, cultures, and religions, the institution of marriage marks an important transition from childhood to adulthood and plays an essential role in social organization. In addition to the many social and economic factors that lead (or force) people into marriage, ideals and judgments about fidelity are pervasive throughout society and often prioritize marriage and marital fidelity. Laws often penalize extramarital sex, economic and health policies encourage fidelity, religious leaders frequently condemn infidelity as immoral, and in the general population there is often disapproval of extramarital sex-despite the frequency with which people fall below the ideal of marital monogamy.

A recent study (http://www.mailman.hs.columbia.edu/sms/cgsh/lmhiv1.html) funded by the National Institutes of Health and published by the American Journal of Public Health found that while sexual fidelity is often an ideal, what fidelity means to individuals may vary and is not seen by all married people in all cultures as necessary to achieving a satisfactory marriage. In fact, many men across cultures consider extramarital sex as an important component to social acceptance, a condition for achieving successful masculinity, and a reality that coexists with migrant labor practices. This study underscores the need to fix dangerous deficiencies within U.S. global AIDS policy, and particularly the programs that do not address these realities.

Recent findings from the multi-site study in Mexico, Nigeria, Uganda, Vietnam, and Papua New Guinea indicate that for most women around the world, marital sex represents their greatest risk for HIV infection. Responding to the well-documented epidemiological evidence that men's extramarital sex is a major element of HIV risk for married women, researchers found that prevention messages that associate infidelity with immorality simply are not compatible with different cultural views on marriage.

Specifically, the NIH-funded study shows that keeping affairs secret and maintaining financial support for a family are important to men. Men show concern for their reputation as being responsible and preserving their wives' dignity by keeping their affairs secret rather than actually abstaining from extramarital sex. What made them "moral" men was their continued financial support for their families and an emotional commitment to their wives.

These findings demonstrate that conservative public health programs that promote the narrow "AB" (Abstain-until-marriage and Be-faithful-in-marriage) and the "ABC" (Abstain, Be faithful, use Condoms) prevention programs are incompatible with the diverse experiences and moral reasoning of men. It also shows the misleading-and potentially counterproductive-effect that the moralizing "ABC" approach has on actual prevention.

Indeed, "ABC" programs may be helping to fuel the spread of AIDS because the approach stigmatizes those who use condoms or those who ask their marriage partners to use condoms. In "ABC" programs, abstaining or being faithful in marriage are presented as the most moral choices, with condoms as a last resort-only to be used if you are sexually immoral because you failed to choose "A" or "B" or are part of an "at-risk" population. As a result, women are discouraged from asking their husbands to use condoms, because asking them to do so is tantamount to accusing them of infidelity and implicates them as being immoral. Stigmatizing condoms also discourages men from using condoms in extramarital sex, because their use demeans those extramarital relations.

This is why current U.S. global AIDS funding today is so misguided. In direct conflict with these recent empirical research findings, 56 percent of U.S. global AIDS funding for prevention of sexual transmission of HIV is spent on programs that promote the narrow "AB" approach. The assumption behind this approach is that regardless of the social and economic context, abstinence and mutual fidelity are choices that individuals readily can make. It also assumes a universal morality that men and women in all cultures value abstinence and fidelity as morally good.

Neither of these assumptions is true in practice. Nor are these practices the only way to stop the sexual transmission of HIV. Public health programs cannot reduce married women's HIV risk simply by exhorting men to be faithful. Based on their scientific findings, researchers recommend a harm-reduction approach to marital risk of HIV in U.S. global AIDS policy and programming. Their recommendations include:

Avoid moralistic approaches to extramarital sex, which exacerbate the stigma of HIV.
Associate condom use with masculinity by building on men's existing sense of responsibility to their families.
Recognize the impact of economic migration by including workplace education on HIV risk and providing family housing in migration sites where possible.
Educate men where they are most likely to engage in extramarital sex, such as bars and brothels.
There is no silver bullet that will stop the spread of HIV, so it is no surprise that the United States' one-size-fits-all "ABC" approach is insufficient. While it is useful and important to create the conditions necessary for individuals to be able to choose fidelity, the morality of saving lives must take precedence.

In order to make real progress on HIV prevention, policy makers in Washington must be able to put aside their own moral judgments and face the complexities and realities of an imperfect world. There is an urgent need today for creative, comprehensive, community-based efforts that address interconnected factors of gender inequality, masculine ideals, migrant labor, and leisure time activities to reduce the risk of HIV infection-not only for married women, but for all women and men.

Serra Sippel is Acting Executive Director of the Center for Health and Gender Equity. Analysis, information and resources about restrictions to U.S. global AIDS funding can be found at www.pepfarwatch.org.

Online at: http://www.americanprogress.org/issues/2007/08/fidelity.html

Serra Sippel
Acting Executive Director
Center for Health and Gender Equity (CHANGE)
6930 Carroll Avenue, Suite 910
Takoma Park, MD 20912
USA
Tel: 1.301.270.1182
Fax: 1.301.270.2052
www.genderhealth.org
www.pepfarwatch.org
www.preventionnow.net