Care and support for people living with HIV/AIDS

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Prevention: daunting challenges aheadWhere more young people are sexually active than are married, there is a greaterlikelihood of HIV infection. Figure 21 shows the difference between the proportion of15–19-year-olds who are married and the proportion who have started having sex inselected countries in Africa, Asia and Latin America. It can be seen that the countrieswith large discrepancies between these two categories are also the ones withhigh rates of HIV in the adult population.Figure 21. Proportion of 15–19-year-old girls married, proportionreporting ever having had sex, and adult HIV prevalence rate,surveys in selected countries, 1996-1998%8070605040marriedever had sexadult HIV prevalence rate3020100Philippines, 1998Indonesia, 1997Bolivia, 1998Senegal, 1997Nicaragua, 1998Kenya, 1998Chad, 1996-97Zambia, 1996Togo, 1998Niger, 1998Cameroon, 1998Mozambique, 1997Source: Demographic and Health Surveys, Macro International, USASex before marriage: the HIV risksClearly, very high proportions of women and men around the world are having sexbefore marriage, often from a very early age. Prevention campaigns that promote nosex until marriage seem to be failing young people in most continents. But so longas people are choosing only one uninfected partner who never has sex with anyoneelse, that is not necessarily a problem. Many people do go on to marry the personthey first have sex with. But the available data suggest that this is by no means thenorm.57
Report on the global HIV/AIDS epidemic – June 2000In a recent study in western Kenya, a third of young married men said they had hadmore than 10 partners before marriage, and the average number of premarital partnersreported was close to 9. Women marry younger and may thus have less opportunityfor premarital partnerships, but married women in rural areas in the Kenyanstudy nevertheless reported having sex with an average of three men before marriage.And it seems that, in many places, these partnerships overlap. In studies ofyoung people’s sexual behaviour in South Africa and Zambia, over half of the sexuallyactive respondents in some areas said they had more than one sex partner currentlyor in the past three months.The number of premarital partners is not the only factor contributing to the risk ofHIV infection. As discussed on pages 46-49, the crucial factors for girls are earlysexual debut – at an age when their biological vulnerability is very high – and sexwith older and more heavily infected men. Studies in African cities where theprevalence of HIV is high tend to confirm that young women are more likely thanyoung men to become infected with HIV during premarital sex. In the Kenyan cityof Kisumu, nearly two-fifths of women who had had premarital partners were HIVpositive,while no infections were found in the women who said they were virginswhen they married. Overall, in the high-prevalence heterosexual epidemics ofeastern and southern Africa, HIV infection rates among young women are farhigher than the rates among the men they are apt to marry – men their own ageand those up to five years older. The inescapable conclusion is that in some badlyaffected countries women are now more likely than men to enter marriage alreadyinfected and may be exposing their new husbands to HIV. In Kisumu, over a quarterof married men aged 20–24 tested HIV-positive, compared with fewer than10% of single men.What about fidelity between regular partners?While some women may be entering marriage infected and putting their husbandsat risk, the reverse still holds true in most countries of the world. Moreover, in mostcases women are far more likely than men to be put at risk of HIV by their partner’sextramarital encounters.Mutual monogamy is a social ideal in many societies and most religions, but a doublestandard tends to relax the rules for men. Men are far more likely than women toreport and indeed to have multiple and casual sex partners, even if women underreportthis activity where it is socially disapproved. In a study of the general populationsof several cities in southern Viet Nam, more than one man in four reported havinghad a casual sex partner in the previous year, compared with 1 woman in 200,and two-fifths of the men did not always use a condom for casual sex. In a qualitativestudy in the Indian state of Gujarat, 33 out of 78 married men interviewed saidthey had had extramarital sex, mostly with unmarried women in their immediatecommunity. The consequences for a spouse who remains faithful to an unfaithfulpartner can be devastating. A review of the case histories of 134 women infected58
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National responses to the epidemic:
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Table of country-specific HIV/AIDS
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