Marital sexual behavior and HIV risk across 16 African countries

Research has identified multiple sexual partners as an underlying driver of high HIV infection levels in parts of sub-Saharan Africa. Though polygamy, as a form of multiple partnerships within marriage, likely increases risk for HIV, research on the relationship between polygamy and HIV has resulted in contradictory findings. Few, if any, studies have directly assessed the risk posed by extramarital sexual partnerships, although this is proposed to be a leading source of infection for men. Utilizing a multi-level model of Demographic and Health Surveys for thirteen African countries, this study assessed the relationship between individual HIV infection and formal multiple partnerships (polygamous unions) and informal multiple sexual partnerships (having an extramarital partner) among sexually active, married adults controlling for covariates and national fixed effects. Regional-level variables (% polygamous unions, % extramarital partner past year) were constructed and modelled to test the contextual effect of living in a region with higher levels of formal or informal concurrency. Both having an extramarital partner and being in a polygamous union were positively associated with HIV-infection at the individual-level though the odds of having HIV was higher in regions with more extramarital partnerships, but lower in regions with more polygamy. Across multiple African countries, both formal and informal multiple sexual partnerships within marriage were associated with greater HIV risk at the individual-level, but living in a region with greater polygamy was protective. This finding suggests that at the community level, having more extramarital partnerships increases risk for everyone in the community.