Date Published: June 7, 2018
Publisher: BioMed Central
Author(s): Sally M. Mtenga, Constanze Pfeiffer, Marcel Tanner, Eveline Geubbels, Sonja Merten.
Extramarital sex is a potential driver of human immunodeficiency virus (HIV) transmission for long-term couples in sub-Saharan Africa. It is increasingly recognized that preventing sexual risk behaviours requires an understanding and adjustment of sexual relationship factors beyond the individual level. We investigated the association between extramarital affairs and HIV status, factors associated with extramarital affairs, and created insights in the context and pathways for married men and women in rural Tanzania who engage in extramarital affairs.
A cross-sectional sequential explanatory mixed method design was employed. The WHO-Social determinants of health perspective guided the study. Using logistic regression, we analysed the MZIMA project community surveillance representative sample of 3884 married partners aged 15+ residing in Ifakara town, Tanzania (2012–2013). Multinomial logistic regression analysis established the relative risk ratio (RRR) of different social and economic factors with lifetime (proxy) and recent (12 months prior to survey) extramarital affairs. Logistic regression analysis determined the association between extramarital affairs and HIV status. Semi-structured interviews and focus group discussions explored the quantitative findings, capturing the experiences and norms regarding extramarital affairs.
We found a significant association between lifetime (proxy) extramarital affairs and HIV infection among women only. The RRR of having extramarital affairs (lifetime proxy) was significantly higher among Village Community Bank (VICOBA) members, the re-married, consumers of alcohol, those from southern regions, non-Muslims, and those with older age. In the case of recent extramarital affairs (12 months prior to survey), associations were significant for the same variables except for religion, having an income was also associated with the outcome. Qualitative narratives reflected that, desire to prove manhood (masculinity) supported by societal normative beliefs such as; ‘it is not realistic for a man to stay without extramarital partner’ and religious beliefs; ‘a man shall dominate a woman’ encouraged men’s extramarital affairs. For women, striving for financial autonomy, obligations to pay back debts borrowed from several VICOBA, and limited support from their husbands encouraged their engagement in extramarital affairs. Low relationship quality (conflict and sexual dissatisfaction) were reported to encourage both men and women’s extramarital affairs.
The findings show that the link between extramarital affairs and HIV has a gender dimension in which women are more likely to acquire HIV through extramarital affairs (case of recent extramarital affairs (12 months prior to survey). Future programs seeking to address risk sexual behaviors in Tanzanian marriages can consider context-sensitive interventions which address aspects beyond ‘individual risk’ and women’s financial uncertainties, and include couple’s relationship quality, excessive alcohol behaviors, normative masculinity ideology and societal norms, that encourage women’s economic dependence and men’s engagement in multiple sexual partnerships. Microfinance projects (e.g. VICOBA) could be a platform for gender-transformative approaches, combining economic empowerment and HIV risk protection strategies.
Extramarital sex is a potential driver of increased risk of human immune virus (HIV) transmission among couples in long-term relations in sub-Saharan Africa (SSA). An incidence study among stable couples in SSA estimates that 22.5% (range 11.1–39.8%) of HIV infections are acquired by one of the partners from sources external to the couple , with multiple partnerships having contributed to HIV transmission both during early and advanced stages of the HIV epidemic . Absence of contextually adapted information to address extramarital affairs in marriage, together with an underestimation of the potential risk of this behavior among married partners  are likely to have undermined the effectiveness of proven HIV interventions in the region.
The study findings suggest that extramarital affairs in Ifakara marriages are socially constructed through multiple complex contextual (social-cultural) determinants and pathways. Hence, we think that extramarital affairs should not merely be regarded as ‘risky behavior’ or be linked to economic factors alone, but it is important to appreciate the multiple social-cultural factors that contributes to the behaviour. This observation collaborates with findings from similar studies in Tanzania [4, 12, 13] and outside Tanzania  where multiple factors were found to influence extramarital affairs for men and women.
The study findings suggest that extramarital affairs transcend the notion that it is just a ‘risky behavior’ and that multiple contextual aspects are likely to contribute to the behavior. The findings suggest that the link between HIV and extramarital affairs has a gender dimension in which women can be more exposed to extramarital affairs and HIV infection based on various gender dynamics including women’s economic hardship, social beliefs and masculinity norms. This view can be support by another research done in the same sample which revealed that, the level of HIV prevalence among women was significantly higher as opposed to that of men .
The study had several limitations. First, the study was cross sectional i.e. exposures and HIV status had been determined at the same time. Second, we did not have data for condom use which could have enabled the association with extramarital affairs. Third, two-thirds of the married or cohabiting respondents in the MZIMA cohort are female, which means that our study sample is not very much representative of the male/female distribution in the study area. Fourth, the variables measuring extramarital affair could have a reporting bias and the proxy for extramarital affair more than 12 months ago may lack accuracy. We assume that the proxy for life-time extramarital affairs are likely to have overestimated the prevalence of extramarital affairs since it was calculated from the average number of multiple sexual partners at age of marriage. This might have included some of the relationships, which happened before marriage. Therefore, the results should be interpreted with caution by accounting for the possible overestimation of the outcome variable. However, the triangulation of data from the mixed method approach suggests quite a good internal validity for most of our quantitative observations. For example, the qualitative data provided various life scenarios that supported the association between VICOBA and extramarital affairs for women. Likewise, most of the narratives pointed to various social construct contributing to men and women’s extramarital behaviors. Most of our findings are further supported by studies from other SSA countries. For example, in our data we observed the association between income, alcohol and extramarital affairs among men and women, which has been also observed in other contexts. However, further research on how sexual behaviors exposes women to HIV infection, and marital relationship quality is needed to gain a better understanding of the epidemic.