Compared with young people who remain HIV negative, recent seroconverters in Rakai, Uganda describe sexual relationships marked by poorer communication, greater suspicion and mistrust, and larger and more transitory sexual networks.
The study highlights the importance of relational approaches to HIV prevention, the researchers comment in the American Journal of Public Health.
As in many other African settings, young women in this rural area of Uganda have a very high risk of acquiring HIV, particularly during their teenage years. Previous quantitative research in young people in Rakai has identified a number of risk factors that raise the risk of HIV infection – multiple partners, concurrent sexual relationships, drinking alcohol, and having sexually transmitted infections. The risk for new infections is strongly shaped by social transitions such as leaving school or a marriage.
For the current study, the researchers adopted an innovative methodology – a case-control study using qualitative life-history interviews. Thirty men and women aged 15 to 24 who had acquired HIV in the previous year were the cases, while thirty people who had remained HIV negative were the controls. Pairs of cases and controls were matched in terms of gender, marital status, age group, and place of residence.
The researchers collected and compared detailed accounts of the participants’ lives in order to explore the contextual factors that help explain why some young people acquired HIV while others had not.
Not all of those living with HIV were aware of their HIV status (some had chosen not to receive results). Moreover, the interviewers had not been informed of the HIV status of their interviewees, which should help reduce bias. In addition, because interviews took place within a year of HIV seroconversion, participants’ recall of recent events is likely to be relatively accurate.
The interviews covered several topics, but the researchers found that only the accounts of sexual relationships were markedly different between the HIV-positive and -negative participants. Both the cases and controls told similar stories of their aspirations, schooling, employment and experiences of pregnancy. Perhaps due to the numerous HIV projects in the area, young people in both groups had relatively good knowledge of HIV prevention.
Compared with HIV-positive cases, HIV-negative controls were more likely to have had fuller discussions of sexual health with their partners. Controls were more likely than cases to have talked about HIV status and testing, to know their partners’ testing history, to have received couples-based HIV testing, and to have discussed family planning methods and the spacing of children. Whereas women living with HIV often found that their partners were unwilling to test for HIV, men living with HIV had often simply not discussed the topic with their partners.
HIV-negative respondents tended to express greater trust in their relationships – they often said they felt assured their main partner did not have other sexual partners. In contrast, many of those who had acquired HIV – particularly women – said that they did not trust their partners or “know their movements” – a common way of talking about sexual activity outside a primary relationship.
The authors note the possibility that distrust towards a partner could arise in reaction to a diagnosis of HIV. But they say that suspicion was reported by several HIV-positive respondents who were not aware of their own HIV status.
Confirming findings from the previous quantitative study, HIV-positive respondents reported more recent and concurrent partners than HIV-negative interviewees. Those living with HIV were more likely to talk about their primary partner having outside partners. Moreover, they were more likely to report shorter-term relationships and partners they did not know so well.
In order to give a fuller picture of how these themes interconnect and play out in people’s lives, the researchers present some case studies, including two women who were paired in the analysis as a case and a control.
Although both had wanted to study nursing, each had been forced to drop out of school due to shortages of money. Both were now in their early twenties, had two children, and were no longer married.
The HIV-negative respondent had run away from home and married at the age of 14. After experiencing serious domestic violence, she managed to leave her husband and earn some money selling food. At the time of the interview, she was in a healthier relationship with a different man. “We are used to each other and we trust each other,” she said. “He is like my husband now.” Because she had “not yet earned enough to support a child,” she and her partner agreed to delay pregnancy and use contraception. They had also received couples-based HIV testing at the beginning of their relationship. Although she did not know whether he had outside partners, she was not suspicious and had not heard rumours of infidelities.
The HIV-positive respondent’s childhood was marked by financial problems, especially after her father died when she was five years old. She was now aged 23 and had recently been told that she had HIV. In the past year she had had two sexual partners, at different times. Both lived about 25 kilometres away, travelled for work and had helped her financially. She did not know the HIV status of either man and had not felt able to disclose her own status.
When she had tried to ask her current partner about HIV testing, he refused to test, accusing her of thinking he was “sick”. Similarly, he refused to use a condom. When asked how many partners this man may have had in the past year, the interviewee sighed audibly and said, “There are many. . . . there are about 15 or 20.” Her partner wanted her to become pregnant but she was anxious about passing HIV on to a child, and had decided to use intrauterine contraception without his knowledge.
“Compared with HIV-negative life history informants, respondents who had seroconverted in the past year described relationships marked by poorer HIV-related communication, greater suspicion and mistrust, and larger and more transitory sexual networks,” the authors say.
They note two possibilities for interventions that could help with these themes. Firstly, interventions that provide HIV counselling and testing to a couple and encourage them to receive their results together. Secondly, programmes to help couples improve their communication skills.
However, the researchers comment on the deeper, structural origins of these problems. “Scarcity of financial and social resources and asymmetrical gendered power dynamics in particular seemed to fuel poorer relationship quality and different types of sexual partners,” they say. “Any couple-based programs must be conducted hand in hand with structural efforts such as educational reform, alleviation of poverty, and reduction of gender inequality, including financial independence of women.”
Higgins JA et al. Importance of Relationship Context in HIV Transmission: Results From a Qualitative Case-Control Study in Rakai, Uganda. American Journal of Public Health, online ahead of print, 2014. (Abstract here.)
