An Intimate Epidemic: HIV and Marriage in Rural Uganda

Abstract

This dissertation examines the relationship between HIV and marriage before and after the introduction of antiretroviral treatment (ART) in rural Uganda.

Chapter one employs 13 years of sero-surveillance data from Masaka and Rakai districts to measure HIV incidence by marital status. I find that, despite having lower incidence rates, the majority of new HIV infections occur among married men and women. To understand how married couples become infected with HIV, I measure the HIV incidence in serodiscordant marriages and marriages with extra-marital partnerships (EMPs). I find that the majority of new HIV cases among married people are attributable to EMPs, despite incidence rates being higher in serodiscordant marriages. The greatest risk in marriage does not come from spouses who are already HIV-positive, but rather from external partners or newly infected spouses.

Chapter two uses mixed methods to investigate the HIV status of couples at marriage formation. Controlling for population composition effects, I find evidence of serosorting, that is, where both HIV-positive and HIV-negative men and women are more likely to marry someone of the same HIV status. Using simulation models, I find little evidence that indirect selection of partners on attributes other than HIV could lead to the observed HIV mixing patterns. I do, however, find qualitative evidence that people directly select partners of the same HIV status.

Chapter three concludes by examining the impact of HIV on marital dissolution and remarriage. Historically, marriages with an HIV-positive partner had higher dissolution rates via both widowhood and divorce, and the remarriage rates of HIV-positive people tended to be lower than those of HIV-negative people. Since the introduction of ART, seroconcordant positive marriages have stabilized and the remarriage rates of HIV-positive men have increased. This suggests that the availability of treatment is having a stabilizing effect on only some types of marriages, and is only improving the remarriage prospects of men, but not women.

These chapters explore three unique aspects of HIV and marriage dynamics: marital formation, intra- and extra-marital HIV transmission, and marital dissolution. They document important changes in the transmission and social repercussions of HIV with the roll-out of ART.