title: Prevalence and social drivers of HIV among married and cohabitating heterosexual adults in south-eastern Tanzania: analysis of adult health community cohort data.
abstract: BACKGROUND
  In sub-Saharan Africa, the prevalence of HIV among married and cohabiting couples is substantial. Information about the underlying social drivers of HIV transmission in couples is critical for the development of structural approaches to HIV prevention, but not readily available. We explored the association between social drivers, practices, and HIV status among stable couples in Ifakara, Tanzania.
  
  
  METHODS
  Using a cross-sectional design, we analyzed data from a sample of 3,988 married or cohabiting individuals, aged 15 years and older from the MZIMA adult health community cohort study of 2013. Sociodemographic factors (sex, income, age, and education), gender norms (perceived acceptability for a wife to ask her partner to use a condom when she knows he is HIV positive), marriage characteristics (being in a monogamous or a polygamous marriage, being remarried), sexual behavior practices (lifetime number of sexual partners and concurrent sexual partners), health system factors (ever used voluntary HIV counseling and testing), and lifestyle patterns (alcohol use) were used to explore the odds of being HIV positive, with 95% confidence intervals.
  
  
  RESULTS
  Prevalence of HIV/AIDS was 6.7% (5.9% males and 7.1% females). Gender norms, that is, perception that a woman is not justified to ask her husband to use a condom even when she knows he has a disease (adjusted odds ratio AOR=1.51, 95% CI 1.06-2.17), marital characteristics, that is, being remarried (AOR=1.49, 95% CI 1.08-2.04), and sexual behavior characteristics, that is, lifetime number of sexual partners (2-4: AOR=1.47, 95% CI 1.02-2.11; 5+: AOR=1.61, 95% CI 1.05-2.47) were the main independent predictors of HIV prevalence.
  
  
  CONCLUSIONS
  Among married or cohabiting individuals, the key social drivers/practices that appeared to make people more vulnerable for HIV are gender norms, marriage characteristics (being remarried), and sexual behavior practices (lifetime number of sexual partners). Married and cohabiting couples are an important target group for HIV prevention efforts in Tanzania. In addition to individual interventions, structural interventions are needed to address the gender norms, remarriage, and sexual practices that shape differential vulnerability to HIV in stable couples.
authors.affiliation: Ifakara Health Institute, Ifakara, Tanzania; smtenga@ihi.or.tz.
authors.forename: Sally M
authors.initials: SM
authors.lastname: Mtenga
authors.affiliation: Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.|Department of Epidemiology & Public Health (EPH), University of Basel, Basel, Switzerland.
authors.forename: Constanze
authors.initials: C
authors.lastname: Pfeiffer
authors.affiliation: Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.|Department of Epidemiology & Public Health (EPH), University of Basel, Basel, Switzerland.
authors.forename: Sonja
authors.initials: S
authors.lastname: Merten
authors.affiliation: Ifakara Health Institute, Ifakara, Tanzania.
authors.forename: Masuma
authors.initials: M
authors.lastname: Mamdani
authors.affiliation: Ifakara Health Institute, Ifakara, Tanzania.
authors.forename: Amon
authors.initials: A
authors.lastname: Exavery
authors.affiliation: Centre for Social Science and Global Health, Amsterdam Institute of Advanced Labour Studies, University of Amsterdam, Amsterdam, The Netherlands.|Department of General Practice AMC, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Joke
authors.initials: J
authors.lastname: Haafkens
authors.affiliation: Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.|Department of Epidemiology & Public Health (EPH), University of Basel, Basel, Switzerland.
authors.forename: Marcel
authors.initials: M
authors.lastname: Tanner
authors.affiliation: Ifakara Health Institute, Ifakara, Tanzania.
authors.forename: Eveline
authors.initials: E
authors.lastname: Geubbels
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D005191:Family Characteristics; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control / Q000635:transmission*; D020010:Heterosexuality; D006801:Humans; D008297:Male; D017533:Marital Status; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors; D012309:Risk-Taking; D012424:Rural Population; D012725:Sexual Behavior / Q000523:psychology; D013636:Tanzania / Q000453:epidemiology; D055815:Young Adult
keywords: HIV; Tanzania; community surveillance data; couples; social drivers