HIV Risk Among Currently Married Couples in Rural Malawi: What Do Spouses Know About Each Other?

According to this ten-page paper, published by Springer Netherlands, in countries with generalised HIV/AIDS epidemics, married couples have a shared risk of acquiring HIV/AIDS. Yet very little research has adopted a couple-level perspective to investigate perceived risk of HIV infection. This paper compares population-based data from 768 married monogamous couples in the 2004 Malawi Diffusion and Ideational Change Project (MDICP) to compare respondents' perceptions about their spouses' HIV status to their spouses' actual HIV status. The researchers found that individuals tend to overestimate their spouse's as well as their own risk of having HIV. Husbands were generally more accurate in assessing their own risk of HIV infection than that of their wives, but wives were more accurate in assessing the HIV status of their spouses.

The report states that despite the clear importance in relation to HIV prevention, little is known about spouses' perceptions and knowledge of the risks they may pose to each other. The study found that of the 72 women who reported that there was a high likelihood that their husband had HIV, 89% were HIV-negative and therefore inaccurate in their assessment. Similarly, of the 31 men who reported that there was a high likelihood their wife had HIV, 91% of their wives were HIV-negative. Respondents were even more likely to overestimate their own HIV risk: Among men and women who reported a high likelihood that they themselves were HIV-positive, 95% of women and 96% of men were not actually infected. Overall, respondents were thus more accurate in assessing their spouse's likelihood of HIV infection than their own. Both female and male respondents reporting that they did not know the likelihood of their spouses having HIV were about as likely to have an HIV-positive spouse as respondents who reported a high likelihood that their spouse was HIV-positive.

While husbands seem to believe that their wives' extramarital relationships will significantly increase the probability that their wives are HIV-infected, they do not perceive their wives' behaviours as a significant factor in assessing their own risk. Thus, for women, characteristics and behaviours of their husbands are significantly associated both with self-assessed HIV status and perceptions about the HIV status of their spouse, whereas women's own characteristics are not significantly associated with women's assessment of their own or their spouses' risk. According to the authors, these findings are thus an important contribution to previous research emphasising the perceived vulnerability of wives to HIV infection via their husbands' sexual behaviour.

The findings indicate that married men and women see their own and their spouses' risks as linked, but also as dominated by husbands' characteristics and behaviours. Since husbands' behaviours may be unknown and uncontrollable from the perspective of their wives, they may engender a particularly high level of anxiety and worry about contracting HIV among wives. Indeed, according to the MDICP data, a larger percentage of women than men are worried about HIV infection. The observed gender differences in assessing the HIV risk of one's spouse have important implications for developing effective HIV/AIDS prevention interventions. In particular, since both husbands and wives perceive their HIV risks as tightly intertwined, couple counselling and testing may be viewed as highly acceptable and effective. Given that both husbands and wives tend to substantially overestimate the probability that they or their spouses are infected, knowing their own and their spouses' HIV status may come as a relief for many married couples.

For the large majority of couples who are HIV-negative, couple testing and counselling can provide what the authors characterise as an excellent opportunity to discuss and develop appropriate strategies to jointly avoid HIV. In particular, findings that both men and women identify men's extramarital sexual partnerships as a primary source of perceived risk both for themselves and their spouses suggest that greater encouragement of male sexual fidelity through couples' counselling, media outreach, and community groups would greatly reduce both men's and women's sense of vulnerability.

The researchers suggest that it is reasonable to believe that in the absence of testing facilities, subjective assessments are likely to drive behaviour. If so, then for many Malawians their sexual behaviours are being guided by faulty assumptions. Given that access to voluntary counselling and testing (VCT) has increased in sub-Saharan Africa since 2004, the authors conclude that it would be useful to examine how the accuracy of individual and spousal perceived HIV risk changes after receiving an HIV test result, as well as the relationships between perceived risk, risk behaviour, and HIV testing.