Assessing Women's Risk of HIV/STD in Marriage in India

This project focuses on married women in slum communities in the northeast portion of Bombay (Mumbai) and addresses the call for, HIV prevention and intervention strategies…[for]… married, monogamous Indian women whose self-perception of HIV risk may be low, but whose risk is inextricably linked to the behavior of their husbands (Newman et al. 2001, p. 250). Despite the overwhelming evidence of the marital unit as a significant locale for transmission for women throughout the world, there has been little effort to explore the marital relationship as a focus for intervention in the prevention of HIV and other STDs.

While neither love nor arranged marriages are guarantors of success, the predominance of arranged marriages in the urban slum communities of northeast Mumbai, mean that most wives and husbands come together as virtual strangers. This emotional distance can be exacerbated by the fact that many men migrate from rural areas, leaving wives in the husbands' parental homes, and until they finally settle in Mumbai, seeing them only during periodic visits back to the rural village. For women that either migrate to or are born in the slum communities, the opportunities for increased intimacy with their husbands are limited by the structure and organization of the "joint family" including the presence of husband's parents, children and other family members in extremely limited residential space. A significant number of women report a lifestyle that is highly restricted; women show limited exposure to mass media and report only limited access to friends, relatives or neighbors.

Men's risky sexual behavior may begin prior to marriage with male-to-male sexuality, with female sex workers, or with "love" relationships. If migration separates husbands and wives, married urban migrants living in Mumbai without their wives have higher drug risk scores and higher sex risk scores compared to single men and married men living with wives. Preliminary research has shown that there is a significant association between men with sexual health problems, STI-like symptoms, and a risky lifestyle that included current involvement with CSWs and other extramarital sexuality.

For a subset of husbands and wives, these dynamics create an interrelationship among extramarital sex, marital violence, and forced sex. Preliminary studies have indicated that a majority of women (62.4%) reported that their husbands had forced them to have sex; 20.4% reported forcible sex on the first night of the marriage; 74.9% were forced to perform unwanted sexual acts; and 36.3% reported that their last sex was only as a result of the husband's desire. Over 40% of women reported physical abuse by their husbands, and a strong link was established between unwanted sexuality and marital violence. Women reporting the most severe problems of abuse were more likely to have experienced forced sexual intercourse and to have husbands who had been forceful rather than cooperative during the first wedding night and did not care about the wife's sexual satisfaction.

This picture indicates that a subset of marital relationships in the urban slums of Mumbai carry significant risk for women, as men visit commercial sex workers and conduct extramarital affairs, limit women's mobility, access to services and acquisition of knowledge, practice forcible sex, and are involved in marital violence. The sexual interaction that characterizes these couples may involve both the greater likelihood of the husband having HIV/STD as well as increasing the risk of transmission through tissue tearing as a result of forcible and/or unwanted sex. At the same time, preliminary studies demonstrate that there is also a significant subset of marital relationships in which there is equity, communication, a lack of violence and a satisfying sexuality, establishing positive role models in the urban communities. Identifying both the resilient and undermining elements associated with risk in the marital relationship will be an important part of this research.

Given this background, this project focuses on the following goals:

• Describe sexual risk from the perspective of monogamous, married women in slum communities in Mumbai
• Assess the risk of HIV/STD for married, monogamous women
• Delineate the dynamics of the marital relationship that increase risk and reduce the potential for HIV/STD transmission
• Assess the potential of the husband-wife dyad as a unit for intervention for sexual risk reduction; assess the feasibility and acceptability of the Narrative Intervention Model (based on a narrative therapeutic approach) as a means of providing risk reduction intervention with women and couples
• Determine the feasibility of developing a marital intervention resource network

The results of this two year study will provide the following: (1) Women's and husband-wife dyad's perspectives on the dynamics of risk for HIV/STD transmission within marriage; (2) Information about the feasibility and acceptability of joint husband-wife approaches to risk reduction; (3) The capacity for developing a marital risk reduction resource network among agencies that serve this area of Mumbai. (4) The formative base for the development of risk reduction interventions for married women and couples, that extends the interventions for men in the parent grant. The paucity of knowledge and intervention experience on married couples and HIV/STD suggests that the results of this project can have implications for India, South Asia and on a global basis.

This project is funded by the National Institutes of Mental Health for the grant period September 1, 2002 - August 31, 2004. Stephen L. Schensul is the principal investigator. The co-PIs are Ravi K. Verma, Bonnie K. Nastasi, T.K. Roy, and G. Rama Rao. Learn more about the India projects from a recent article in the UConn Advance, the University of Connecticut's official weekly newspaper.

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