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May 2007, Vol. 13, No. 1HIV and AIDS If present patterns continue, in the next decade more than 100 million girls will be child brides—that is, married before the age of 18—according to Population Council research. “In some cultures, girls are married off at very young ages due to poverty, custom, and in some cases the idea that it provides protection from HIV and other threats. But our research clearly shows that marriage per se, and child marriage especially, cannot be assumed to be a sexual safety zone,” explains Council researcher Judith Bruce. “Girls married at a young age are actually at a higher risk than unmarried girls for HIV infection in some settings.” Delaying marriage, however, does not necessarily improve safety. “Delaying marriage until the mid- to late-twenties may result in a period of risky unprotected sex involving multiple or serial partners,” says Council demographer John Bongaarts. The Council is now looking at the nature of sexual relationships to discover what conditions make them more or less safe. Have women entered into their relationships voluntarily, for example? Are they able to negotiate condom use? “We’re designing programs to try to delay marriage until at least age 18 among girls who have not yet married and to reach married girls and give them more negotiating power within their relationships,” says Bruce. There are a number of factors that increase HIV risk among girls married at a young age in areas with high HIV prevalence. At marriage these girls make a transition from virginity or infrequent sex to a very high frequency of sex. The most common HIV-prevention strategies—abstinence and condom use—are not options for married adolescents, who are under tremendous pressure from family and society to bear children. Girls married young tend to have husbands who are much older than they are. This age gap may further intensify the power imbalance between husbands and wives, discouraging the open communication required to ensure voluntary counseling and testing for HIV, the sharing of test results, and planning for safe sexual relations throughout marriage. Married adolescents are often missed by programs designed to reach married women with information about HIV infection. Married girls also typically have little education and no schooling options, limited control over resources, restricted mobility, and little or no power in their new households. Thus, they face significant challenges in negotiating safe sexual relations. Based on these findings, the Population Council—in collaboration with partners around the world—continues to advocate for the elimination of child marriage and to develop and test programs to delay age at marriage, support married girls, and increase the ability of all girls and women to protect themselves from HIV infection. Clearly, however, having sex with multiple or serial partners also increases HIV risk. In several southern African countries the average interval between age at first sex and age at marriage is about a decade, and HIV infection levels are far higher than anywhere else in the world. High average age at marriage in a population, because it is associated with a longer period of premarital exposure to the risk of infection, apparently contributes to the spread of HIV. This appears to be a key factor in countries with the largest epidemics. “The implications of these results are that sexually active unmarried women and men should make every effort to protect themselves by using condoms and by avoiding multiple partners,” says Bongaarts. Bongaarts analyzed the causes of the large variation in epidemic size among sub-Saharan countries. The countries with the largest HIV epidemics all have late marriage. Bongaarts found that being married is less risky per year of exposure than being sexually active and never married. The elevated risk of infection among never-married sexually active women is likely caused by a higher rate of partner change and higher levels of infectivity among partners of never-married than of married women. These complex findings are actually consistent with one another. Child marriage raises the risk of infection for young girls, because they would otherwise not be at risk, but marriage after the age at first intercourse raises exposure to higher-risk sex, thus contributing to the rapid spread of the virus. The policy implications of the findings are also consistent with one another. In countries with significant AIDS epidemics, the safety of sexual activity cannot be assumed either outside of or within marriage. Outside of marriage, sexually active people should practice abstinence or use male or female condoms to protect themselves. Within marriage, those seeking to avoid pregnancy and HIV infection should use condoms. Sources Clark, Shelley, Judith Bruce, and Annie Dude. 2006. “Protecting young women from HIV/AIDS: The case against child and adolescent marriage,” International Family Planning Perspectives 32(2): 79–88. (offsite PDF) Outside funding See Also
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