Demography

, Volume 52, Issue 1, pp 259–280 | Cite as

The Impact of Married Individuals Learning HIV Status in Malawi: Divorce, Number of Sexual Partners, and Condom Use With Spouses

  • Theresa M. Fedor
  • Hans-Peter Kohler
  • Jere R. Behrman
Article

Abstract

This article assesses how married individuals’ knowledge of HIV status gained through HIV testing and counseling (HTC) affects divorce, the number of sexual partners, and the use of condoms within marriage. This study improves upon previous studies on this topic because the randomized incentives affecting the propensity to be tested for HIV permit control for selective testing. Instrumental variable probit and linear models are estimated, using a randomized experiment administered as part of the Malawi Longitudinal Study of Families and Health (MLSFH). The results indicate that knowledge of HIV status (1) does not affect chances of divorce for either HIV-negative or HIV-positive respondents; (2) reduces the number of reported sexual partners among HIV-positive respondents; and (3) increases reported condom use with spouses for both HIV-negative and HIV-positive respondents. These results imply that individuals actively respond to information about their HIV status that they learn during HTC, invoking protective behavior against future risk of HIV/AIDS for themselves and their actual and potential sexual partners. Some limitations of this study are a small sample size for those who are HIV-positive and dependence on self-reported sexual behaviors.

Keywords

Divorce Sexual behavior Malawi HIV testing and counseling (HTC) Information and health 

Notes

Acknowledgments

We also gratefully acknowledge the generous support by the National Institute of Child Health and Development (Grant Nos. R03 HD058976, R21 HD050652, R01 HD044228, R01 HD053781), the National Institute on Aging (Grant No. P30 AG12836), the Boettner Center for Pensions and Retirement Security at the University of Pennsylvania, and the National Institute of Child Health and Development Population Research Infrastructure Program (Grant No. R24 HD-044964), all at the University of Pennsylvania.

Supplementary material

13524_2014_364_MOESM1_ESM.docx (1.8 mb)
Online Resource 1 (DOCX 1836 kb)

References

  1. Alderman, H., Behrman, J. R., Kohler, H.-P., Maluccio, J. A., & Watkins, S. (2001). Attrition in longitudinal household survey data: some tests for three developing-country samples. Demographic Research, 5(article 4), 79–124. doi: 10.4054/DemRes.2001.5.4 CrossRefGoogle Scholar
  2. Anglewicz, P. (2012). Migration, marital change, and HIV infection in Malawi. Demography, 49, 239–265.CrossRefGoogle Scholar
  3. Anglewicz, P., Adams, J., Obare, F., Kohler, H.-P., & Watkins, S. (2009). The Malawi Diffusion and Ideational Change Project 2004–06: Data collection, data quality, and analysis of attrition. Demographic Research, 20(article 21), 503–540. doi: 10.4054/DemRes.2009.20.21 CrossRefGoogle Scholar
  4. Anglewicz, P., & Clark, S. (2013). The effect of marriage and HIV risks on condom use acceptability in rural Malawi. Social Science & Medicine, 97, 29–40.CrossRefGoogle Scholar
  5. Anglewicz, P., & Kohler, H.-P. (2009). Overestimating HIV infection: The construction and accuracy of subjective probabilities of HIV infection in rural Malawi. Demographic Research, 20(article 6), 65–96. doi: 10.4054/DemRes.2009.20.6 CrossRefGoogle Scholar
  6. Angrist, J. D., & Pischke, J. (2009). Mostly harmless econometrics: An empiricist’s companion. Princeton, NJ: Princeton University Press.Google Scholar
  7. Arthur, G., Nduba, V., Forsythe, S., Mutemi, R., Odhiambo, J., & Gilks, C. (2007). Behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya. Sexually Transmitted Infections, 83, 541–546.CrossRefGoogle Scholar
  8. Bakari, J. P., McKenna, S., Myrick, A., Mwinga, K., Bhat, G. J., & Allen, S. (2000). Rapid voluntary testing and counseling for HIV: Acceptability and feasibility in Zambian antenatal care clinics. Prevention and Treatment of HIV Infection in Infants and Children, 918, 64–76.Google Scholar
  9. Baranov, V., Bennett, D., & Kohler, H.-P. (2012). The indirect impact of antiretroviral therapy (PSC Working Paper Series, PSC 12-08). Philadelphia, PA: Population Studies Center, University of Pennsylvania. Retrieved from http://Repository.Upenn.Edu/Psc_working_papers/39 PSC 12-08
  10. Becketti, S., Gould, W., Lillard, L., & Welch, F. (1988). The Panel Study of Income Dynamics after fourteen years: An evaluation. Journal of Labor Economics, 6, 472–492.CrossRefGoogle Scholar
  11. Bellan, S. E., Fiorella, K. J., Melesse, D. Y., Getz, W. M., Williams, B. G., & Dushoff, J. (2013). Extra-couple HIV transmission in sub-Saharan Africa: A mathematical modelling study of survey data. Lancet, 381, 1561–1569.CrossRefGoogle Scholar
  12. Boileau, C., Clark, S., Bignami-Van Assche, S., Poulin, M., Reniers, G., Watkins, S., . . . Heymann, S. (2009). Sexual and marital trajectories and HIV infection among ever-married women in rural Malawi. Sexually Transmitted Infections, 85, i27–i33.Google Scholar
  13. Burton, J., Darbes, L. A., & Operario, D. (2010). Couples-focused behavioral interventions for prevention of HIV: Systematic review of the state of evidence. AIDS and Behavior, 14, 1–10.CrossRefGoogle Scholar
  14. Chemaitelly, H., Awad, S. F., Shelton, J. D., & Abu-Raddad, L. J. (2014). Sources of HIV incidence among stable couples in sub-Saharan Africa. Journal of the International AIDS Society, 17, 18765. doi: 10.7448/IAS.17.1.18765 CrossRefGoogle Scholar
  15. Conroy, A. A. (2014). “It means there is doubt in the house”: Perceptions and experiences of HIV testing in rural Malawi. Culture, Health, and Sexuality, 16, 397–411.CrossRefGoogle Scholar
  16. Cremin, I., Nyamukapa, C., Sherr, L., Hallett, T. B., Chawira, G., Cauchemez, S., . . . Gregson, S. (2010). Patterns of self-reported behaviour change associated with receiving voluntary counselling and testing in a longitudinal study from Manicaland, Zimbabwe. AIDS and Behavior, 14, 708–715.Google Scholar
  17. Deaton, A. (2010). Instruments, randomization, and learning about development. Journal of Economic Literature, 48, 424–455.CrossRefGoogle Scholar
  18. Delavande, A., & Kohler, H.-P. (2012). The impact of HIV testing on subjective expectations and risky behavior in Malawi. Demography, 49, 1011–1036.CrossRefGoogle Scholar
  19. Denison, J. A., O’Reilly, K. R., Schmid, G. P., Kennedy, C. E., & Sweat, M. D. (2008). HIV voluntary counseling and testing and behavioral risk reduction in developing countries: A meta-analysis, 1990–2005. AIDS and Behavior, 12, 363–373.CrossRefGoogle Scholar
  20. De Paula, A., Shapira, G., & Todd, P. E. (2014). How beliefs about HIV status affect risky behaviors: Evidence from Malawi. Journal of Applied Econometrics, 29, 944–964.CrossRefGoogle Scholar
  21. Desgrees-du-Lou, A., & Orne-Gliemann, J. (2008). Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa. Reproductive Health Matters, 16, 151–161.CrossRefGoogle Scholar
  22. De Walque, D. (2007). Sero-discordant couples in five African countries: Implications for prevention strategies. Population and Development Review, 33, 501–523.CrossRefGoogle Scholar
  23. Dunkle, K. L., Stephenson, R., Karita, E., Chomba, E., Kayitenkore, K., Vwalika, C., & Allen, S. (2008). New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: An analysis of survey and clinical data. Lancet, 371, 2183–2191.CrossRefGoogle Scholar
  24. Easterly, W. (2009). Can the West save Africa? Journal of Economic Literature, 47, 373–447.CrossRefGoogle Scholar
  25. Eriksson, K., & Sovero, V. (2013). Knowledge of HIV-Negative status and household decision-making: Experimental evidence from Malawi. Unpublished manuscript, California Polytechnic State University and Wake Forest University.Google Scholar
  26. Fitzgerald, J., Gottschalk, P., & Moffitt, R. (1998). An analysis of sample attrition in panel data: The Michigan panel study of income dynamics. Journal of Human Resources, 33, 251–299.CrossRefGoogle Scholar
  27. Fonner, V. A., Denison, J., Kennedy, C. E., O’Reilly, K., & Sweat, M. (2012). Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries. The Cochrane Database of Systematic Reviews, 9. doi: 10.1002/14651858.CD001224.pub4
  28. Gong, E. (2014). HIV testing and risky sexual behaviour. The Economic Journal. Advance online publication. doi: 10.1111/ecoj.12125
  29. Gregson, S., Zhuwau, T., Anderson, R. M., & Chandiwana, S. K. (1998). Is there evidence for behavior change in response to AIDS in rural Zimbabwe? Social Science & Medicine, 46, 321–330.CrossRefGoogle Scholar
  30. Grinstead, O. A., Gregorich, S. E., Choi, K., & Coates, T. (2001). Positive and negative life events after counselling and testing: The voluntary HIV-1 counselling and testing efficacy study. AIDS, 15, 1045–1052.CrossRefGoogle Scholar
  31. Heckman, J. J., & Urzua, S. (2009). Comparing IV with structural models: What simple IV can and cannot identify (NBER Working Paper No. 14706). Cambridge, MA: National Bureau of Economic Research.Google Scholar
  32. Helleringer, S., Kohler, H., Kalilani-Phiri, L., Mkandawire, J., & Armbruster, B. (2011). The reliability of sexual partnership histories: Implications for the measurement of partnership concurrency during surveys. AIDS, 25, 503–511.CrossRefGoogle Scholar
  33. Imbens, G. W. (2010). Better LATE than nothing: Some comments on Deaton (2009) and Heckman and Urzua (2009). Journal of Economic Literature, 48, 399–423.CrossRefGoogle Scholar
  34. Kabiru, C. W., Luke, N., Izugbara, C. O., & Zulu, E. M. (2010). The correlates of HIV testing and impacts on sexual behavior: Evidence from a life history study of young people in Kisumu, Kenya. BMC Public Health, 10, 412–423.CrossRefGoogle Scholar
  35. Kohler, H.-P., Watkins, S. C., Behrman, J. R., Anglewicz, P., Kohler, I. V., Thornton, R. L., . . . Mwapasa, V. (2014). Cohort profile: The Malawi Longitudinal Study of Families and Health (MLSFH). International Journal of Epidemiology. Advance online publication. doi: 10.1093/ije/dyu049
  36. Kranzer, K., McGrath, N., Saul, J., Crampin, A. C., Jahn, A., Malema, S., & Glynn, J. R. (2008). Individual, household and community factors associated with HIV test refusal in rural Malawi. Tropical Medicine & International Health, 13, 1341–1350.CrossRefGoogle Scholar
  37. Macro International, Inc. (2008). HIV prevalence estimates from the Demographic and Health Surveys. Calverton, MD: Macro International, Inc.. Retrieved from http://www.measuredhs.com/pubs/pdf/OD51/OD51.pdf Google Scholar
  38. Matambo, R., Dauya, E., Mutswanga, J., Makanza, E., Chandiwana, S., Mason, P. R., & Corbett, E. L. (2006). Voluntary counseling and testing by nurse counselors: What is the role of routine repeated testing after a negative result? Clinical Infectious Diseases, 42, 569–571.CrossRefGoogle Scholar
  39. Matovu, J. K. (2010). Preventing HIV transmission in married and cohabiting HIV-discordant couples in sub-Saharan Africa through combination prevention. Current HIV Research, 8, 430–440.CrossRefGoogle Scholar
  40. Matovu, J. K. B., Gray, R. H., Makumbi, F., Wawer, M. J., Serwadda, D., Kigozi, G., & Nalugoda, F. (2005). Voluntary HIV counseling and testing acceptance, sexual risk behavior and HIV incidence in Rakai, Uganda. AIDS, 19, 503–511.CrossRefGoogle Scholar
  41. McCallum, E. B., & Peterson, Z. D. (2012). Investigating the impact of inquiry mode on self-reported sexual behavior: Theoretical considerations and review of the literature. Journal of Sex Research, 49, 212–226.CrossRefGoogle Scholar
  42. Mensch, B. S., Hewett, P. C., Gregory, R., & Helleringer, S. (2008). Sexual behavior and STI/HIV status among adolescents in rural Malawi: An evaluation of the effect of interview mode on reporting. Studies in Family Planning, 39, 321–334.CrossRefGoogle Scholar
  43. Mola, O. D., Mercer, M. A., Asghar, R. J., Gimbel-Sherr, K. H., Gimbel-Sherr, S., Micek, M. A., & Gloyd, S. S. (2006). Condom use after voluntary counselling and testing in central Mozambique. Tropical Medicine & International Health, 11, 176–181.CrossRefGoogle Scholar
  44. National Statistical Office (NSO) [Malawi], & ICF Macro. (2011a). Malawi Demographic and Health Survey 2010 [Dataset]. Data extract from MWIR61.DTA and MWHR61FL.DTA. Zomba, Malawi, and Calverton, MD: NSO and ICR Macro [Distributor].Google Scholar
  45. National Statistical Office (NSO) [Malawi], & ICF Macro. (2011b). Malawi Demographic and Health Survey 2010—Final report. Zomba, Malawi, and Calverton, MD: NSO and ICF Macro.Google Scholar
  46. National Statistical Office (NSO) [Malawi], & ORC Macro. (2005). Malawi Demographic and Health Survey 2004 [Dataset]. Data extract from MWIR4DFL.DTA and MWHR4DFL.DTA. Zomba, Malawi, and Calverton, MD: NSO and ORC Macro [Distributor].Google Scholar
  47. Porter, L., Hao, L., Bishai, D., Serwadda, D., Wawer, M. J., Lutalo, T., . . . The Rakai Project Team. (2004). HIV status and union dissolution in sub-Saharan Africa: The case of Rakai, Uganda. Demography, 41, 465–482.Google Scholar
  48. Reniers, G. (2008). Marital strategies for regulating exposure to HIV. Demography, 45, 417–438.CrossRefGoogle Scholar
  49. Reniers, G., Araya, T., Berhane, Y., Davey, G., & Eduard, J. S. (2009). Implications of the HIV testing protocol for refusal bias in seroprevalence surveys. BMC Public Health, 9, 1–9.CrossRefGoogle Scholar
  50. Reniers, G., & Helleringer, S. (2011). Serosorting and the evaluation of HIV testing and counseling for HIV prevention in generalized epidemics. AIDS and Behavior, 15, 1–8.CrossRefGoogle Scholar
  51. Schatz, E. (2005). “Take your mat and go!”: Rural Malawian women’s strategies in the HIV/AIDS era. Culture, Health & Sexuality, 7, 479–492.CrossRefGoogle Scholar
  52. Sherr, L., Lopman, B., Kakowa, M., Dube, S., Chawira, G., Nyamukapa, C., & Gregson, S. (2007). Voluntary counselling and testing: Uptake, impact on sexual behaviour, and HIV incidence in a rural Zimbabwean cohort. AIDS, 21, 851–860.CrossRefGoogle Scholar
  53. Smith, K. P., & Watkins, S. C. (2005). Perceptions of risk and strategies for prevention: Responses to HIV/AIDS in rural Malawi. Social Science & Medicine, 60, 649–660.CrossRefGoogle Scholar
  54. Stoneburner, R. L., & Low-Beer, D. (2004). Population-level HIV declines and behavioral risk avoidance in Uganda. Science, 304, 714–718.CrossRefGoogle Scholar
  55. Tenkorang, E. Y. (2014). Marriage, widowhood, divorce and HIV risks among women in sub-Saharan Africa. International Health, 6, 46–53.CrossRefGoogle Scholar
  56. Thornton, R. L. (2008). The demand for, and impact of, learning HIV status. American Economic Review, 98, 1829–1863.CrossRefGoogle Scholar
  57. Thornton, R. L. (2012). HIV testing, subjective beliefs and economic behavior. Journal of Development Economics, 99, 300–313.CrossRefGoogle Scholar
  58. Trinitapoli, J. (2012). AIDS & religious life in Africa: Rethinking how demographic processes shape religious teachings and authority. Unpublished manuscript, Department of Sociology, Penn State University, State College, PA.Google Scholar
  59. UNAIDS. (2010). Fact sheet: Sub-Saharan Africa. New York, NY: World Health Organization and UNAIDS. Retrieved from http://www.unaids.org/documents/20101123_FS_SSA_em_en.pdf Google Scholar
  60. Wooldridge, J. M. (2002). Econometric analysis of cross section and panel data. Cambridge, MA: MIT Press.Google Scholar
  61. Wooldridge, J. M. (2009). Introductory econometrics: A modern approach (4th ed.). Mason, OH: South-Western Cengate Learning.Google Scholar
  62. World Health Organization (WHO). (2010). Priority interventions: HIV/AIDS prevention, treatment and care in the health sector (Version 2). Geneva, Switzerland. Retrieved from http://www.who.int/hiv/pub/guidelines/9789241500234/en/

Copyright information

© Population Association of America 2015

Authors and Affiliations

  • Theresa M. Fedor
    • 1
  • Hans-Peter Kohler
    • 2
  • Jere R. Behrman
    • 3
  1. 1.University of PennsylvaniaPhiladelphiaUSA
  2. 2.University of PennsylvaniaPhiladelphiaUSA
  3. 3.University of PennsylvaniaPhiladelphiaUSA

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