Men who are coerced into having sex by their long-term female partner have a dramatically increased likelihood of being or believing themselves to be HIV-positive, according to a study conducted in rural Malawi.¹ While the likelihood of HIV infection was also elevated among older men (odds ratio, 1.1 for each additional year of age) and among those who had had concurrent sexual partners in the prior four months (4.9), the strongest association in the study was with having been pressured into having sex (7.2).

Considerable research has documented the high prevalence of sexual violence against women throughout Sub-Saharan Africa and its link to HIV infection, but the few studies to date on sexual coercion among men have mostly focused on men in short-term relationships with older women. To address this issue, the investigators analyzed data from a longitudinal panel study on reproduction and AIDS conducted with a random selection of women and men residing near or in Balaka town in southern Malawi. The sample for the present analysis consisted of 684 men who were interviewed every four months. In the study’s third wave, in 2010, participants completed a module on interpersonal violence. Men were asked whether their partner had ever pressured them into having sex or beaten them, and whether they had had a concurrent sexual partner during the last four months. They also provided demographic information and answered questions about condom use with their main partner and alcohol consumption in the last month.

At wave 3, about eight in 10 men were married or living with their partner (79%), half had been with their current partner for more than four years (46%) and the vast majority had not had an additional partner during the last four months (96%). The men had an average age of 26, and virtually all were the same age as or older than their partner (98%). Most men used condoms inconsistently (90%), and thought that their partner was HIV- negative (95%) and faithful (90%); some 17% had had alcohol in the previous month.

Ten percent of respondents reported they had experienced unwanted sex with their wife or partner, 2% had suffered physical abuse and 3% had either tested positive for HIV or reported that they were infected. In a bivariate analysis, men who had been coerced into having sex were more likely than other men to be married (90% vs. 77%), be older than 24 (75% vs. 60%), have been physically abused (9% vs. 1%), have drunk alcohol in the past month (28% vs. 16%) and believe that their partner had HIV (10% vs. 5%).

In a logistic regression analysis that adjusted for social and demographic characteristics and source of serostatus information (HIV test or self-report), men whose partner had been sexually coercive were far more likely than those who had not experienced such behavior to be HIV-positive (odds ratio, 7.2). Moreover, respondents’ odds of being HIV-positive increased by 10% with each additional year of age (1.1), and men who had had an additional partner during the past four months had almost five times the odds of HIV infection as did those who had remained monogamous (4.9).

Limitations of the study, according to the authors, include the cross-sectional nature of the data and the reliance, in some cases, on men’s reports of their HIV status. Moreover, the data do not indicate whether sexual coercion preceded HIV infection, though the investigators assert that the timing of coerced sex and HIV infection is less important than the "strength of the association" between the two characteristics; they note that if infection preceded coercion, rather than vice versa, the findings would underscore the need for interventions to reduce risky sexual behavior and improve communication among serodiscordant couples. Future work on this understudied topic should include qualitative as well as couples-based studies to give male respondents the opportunity to fully explain their experiences with unwanted sex, the authors conclude.—S. Ramashwar

REFERENCE

1. Conroy AA and Chilungo A, Male victims of sexual violence in rural Malawi: the overlooked association with HIV infection, AIDS Care, 2014, doi: 10.1080/09540121.2014.931562, accessed Aug. 13, 2014.