Linking gender, extramarital affairs, and HIV: a mixed methods study on contextual determinants of extramarital affairs in rural Tanzania

Detail description about how the variables were measured is published elsewhere [24] except for Village Community Bank (VICOBA) membership. Village Community Banks (VICOBA) were initiated in Tanzania as an informal structure to support savings and profit among low income community members. More women than men participate in a VICOBA. VICOBA have evolved and now include people of higher economic status. This variable was included in the study based on the assumption that a VICOBA is an income-securing structure, and members of VICOBA are therefore less likely to be involved in extramarital affairs. VICOBA membership was measured by requesting participants to report on whether they were members of a microfinance program in their community. Participants who reported that they were a member of a VICOBA were assigned a ‘Yes’.

We examined the demographic (sex; age; income; education; ethnicity), social-structural (being part of a Village Community Bank, a ‘VICOBA’; performing any income generating activity), marital characteristics (being re-married or not), health care utilization (VCT access) and lifestyle (alcohol consumption) as correlates of extramarital relationship prevalence. VICOBA membership was measured by requesting participants to report on whether they were members of a microfinance program in their community. Except being part of a VICOBA, these variables were selected based on a review of previous literature [25, 26], the WHO-CSDH framework [27], and on the insights from previous qualitative research.

The study had two outcome variables: HIV status as main, and extramarital affairs as intermediate outcome. First, we establish associations of extramarital affairs with HIV infection stratified by sex of the respondent; second, associations of the independent variables with extramarital affairs were determined. Due to the sensitive nature of the topic, participants were not directly asked whether they engaged in extramarital affairs. The variable ‘extramarital affairs’ was constructed based on marital status and the number of sexual partners (a) in the 12 months prior to the survey, and (b) over the lifetime. As all participants in this study were in a monogamous marriage, participants with more than one sexual partner in the past 12 months were coded as having had extramarital affairs in the 12 months prior to the survey. Because the number of persons who reported extramarital affairs in the last 12 months was low, and with the given HIV incidence less than 1 new HIV infection would be expected in this group, associations of extramarital affairs in the MZIMA sample could not be measured with this variable. Therefore, a variable for extramarital affairs over the course of a person’s marriage was estimated. The overall number of partners of a respondent was available for the respondents, as well as their age at marriage. Based on these variables we estimated the occurrence of lifetime extramarital affairs based on the median age at marriage and the number of partners. At the age of 25 years half of the men were married, whereas among women half of the women were married already at the age of 19. In our sample men who were 25 years old had in average 4.4 partners, while women of age 19 years had 2.8 partners. Since the Tanzanian HIV/AIDS and Malaria Indicator Survey (THMIS) 2011–2012 report shows that men reported more partners than women, this led to the assumption that a woman marries her second partner, whereas a man gets married in average to the fourth partner. Men with less than 5 partners and women with less than 3 partners were considered as not having had extramarital affairs (= 0), whereas it was assumed that if men had 5 or more and women 3 or more partners some of these relationships happened within their marriage (= 1). Therefore, ever having had extramarital affairs is referred here and after as ‘estimated’ or ‘proxy’ lifetime extramarital affairs. For this analysis, extramarital affairs were defined as a trichotomous variable comprising of the values corresponding to the following: 0 = no extramarital affair; 1 = lifetime extramarital affair (proxy based on number of lifetime partners) but not in 12 months prior to survey; 2 = extramarital affairs in 12 months prior to survey.

Characteristics of survey respondents are summarized in Table 1. There were 3884 married and cohabiting participants of which the majorities (35.2%) were between the ages of 25–34 years, females accounted for 66.4%. Eighty-eight percent of participants had attained the formal education, 92% among males and 84% among females. Sixty-four percent of females and 90% of male respondents performed an income generating activity. More than half of participants (61%) were Christians and 38% were Muslims. Seventeen percent of participants were not living with the person they had married first. About 10% of men and 2.2% women had engaged in extramarital affairs in the 12 months prior to the survey, with percentages for lifetime extramarital affairs (proxy) being estimated to be 45.5 for men and 43.8% for women.

Table 2 shows the association between extramarital affairs and HIV infection. Women with estimated lifetime extramarital affairs were more likely to be HIV positive than those who had not had extramarital affairs (OR = 1.55, 95% CI 1.113–2.13). Women who were remarried were also more likely to be HIV positive (OR = 1.50, 95% CI 1.04–2.18). We did not find any statistical significant association between extramarital affairs and HIV among men. We looked at the association between age and HIV but did not find a significant association.

Table 3 presents the results of the multinomial logistic regression analysis. The majority of the independent predictors of the proxy lifetime extramarital affairs were consistent with those in recent (12 months prior to survey) extramarital affairs. The relative risk ratio (RRR) of having extramarital affairs versus non-extramarital affairs in the proxy-lifetime significantly decreased as age increased (RRR: 0.98 95% CI 0.98–0.99), was higher among men (RRR: 1.27; 95% CI 1.06–1.52), among members of a Village Community Bank (VICOBA) (RRR: 1.35; 95% CI 1.08–1.69), among consumers of alcohol (RRR: 1.54; 95% CI 1.29–1.82), among those who re-married (RRR: 2.50; 95% CI 2.07–3.02) and were lower among those of catholic religion (RRR: 0.82; 95% CI 0.71–0.95), and other Christian religion (RRR: 0.52; 95% CI 0.39–0.70) if compared to the Muslim population.

Likewise, the relative risk ratio (RRR) of having recent extramarital affairs (12 months prior to survey) versus non-extramarital affairs, significantly decreased with increasing age (RRR: 0.95; 95% CI 0.94–0.96), was higher among those with stable sources of income (RRR: 2.70; 95% CI 1.64–4.35), among the VICOBA members (RRR: 2.63; 95% CI 1.72–4.0), among the re-married (RRR: 2.41; 95% CI 1.69–3.43) and among those consuming alcohol (RRR: 2.5; 95% CI 1.85–3.33). When calculating predictive margins for men and women separately; we found that most associations with extramarital affairs were similar for men and women. Only a few differences can be noted, in the youngest age-category men were less likely to have had extramarital affairs in contrast to women; women from the southern region, were more likely to have extramarital affairs than men; religion played a role mainly for women.

Twenty-four participants (13 females and 11 males) took part in the IDIs (Table 4). Thirty-eight individuals participated in the focus group discussions (18 males, 21 females) (Table 5). Participants were of age between 18 and 68. All participants were currently married, 44 lived in monogamous marriages and 20 in polygamous ones. Most participants reported to have had 1–7 children and had been married for 10 years or less.

‘Kidumu’ and ‘Mchepuko’ were the local names for extramarital affairs in Ifakara town. In Kiswahili, Kidumu symbolically denote a plastic container, which is used to store local brew, milk and water. Mchepuko is diverging. As such, Kidumu in Ifakara is considered as a backup for sexual desires and economic needs as reflected in the subsequent excerpts.

When the Vignette (refer to the method section) was presented, various participants reported that the extramarital affairs is a common behavior among men and women in the community and that one spouse may initiate the behavior and another spouse may do the same for revenge:

“Extramarital affairs happen much in our community, we see people, husbands and wives, competing in moving out with other partners, one (spouse) may initiate (extramarital affair) and another one may do the same as revenge, I saw one of my friends doing the same”

[IDI, Woman_24 years, Monogamous]

In this section, emerged themes on the determinants of extramarital affairs are presented based on the social-cultural domains as adopted from the WHO-CSDH framework. From the interpretation point of view, most themes were converging. We thus used broader theoretical domains to categorize the key themes.

Men’s extramarital affairs were linked to religious faith, societal norms and masculinity. From the religious perspective, participant’s views reflected that men’s extramarital affairs is justified based on the notion that, religious books endorse men’s dominance over women: “Even the religious books stated that a man should dominate his wife and not otherwise and so he ‘can have extramarital affairs’ [IDI_ Male_ 56 years_Polygamous]. Interestingly, while men’s extramarital affairs could be justified based on religious faith, on the other hand, women’s extramarital practice seems not to be justifiable based on cultural system: “the wife who have extramarital affairs destroys the system of culture” [IDI_ Male_ 56 years_ Polygamous].

Staying without extramarital affairs is believed to be ‘unrealistic to men’. Some participant’s views reflected a notion of masculinity in a self-reflective attitude, where one participant (man) declared that he cannot stay without having extramarital partner since extramarital affairs for men is believed to be a reality: “I cannot stay like this without a woman (extramarital partner), it is not realistic for a man, I cannot lie”. In addition, for men, having fewer or several extramarital partners may depend on the affordability (being good financially):

“I used to have several (extramarital women) but I now have only one ‘kidumu’ (extramarital partner)”, […] since I cannot afford (not having money) many at the moment”

[IDI_Man_26 years_ Monogamous]

Participant’s views also reflected that masculinity norm exemplifies the normalization of men’s extramarital affairs, such that, some ‘repugnant names’ such as ‘prostitute’ associated with having multiple sexual partners are mainly used to refer females and not men:

“A man […] with several women outside marital will never be called a prostitute, because ‘he is a man’, he can even finish all the women in the village but will never be called a prostitute […] but not you (woman)”

[IDI_Female_26 year_Monogamous]

Women and men frequently cited VICOBA as an aspect that drives women to seek extramarital partners. Participants (mostly women) reported that women’s economic hardship, lack of financial support from their husbands and the obligations to pay back debts to several VICOBA encourage women to initiate and continue with extramarital behavior.

One woman explained her experience:

F: How long have you been with this “mchepuko” (extramarital partner)?

P: 3 years

F: Can you please tell me how the relationship started?

P: There is a time that I was supposed to give back the money to VICOBA. But I did not have money, therefore, group members took me to the village chairman. I explained to the village chairman that my husband does not want to assist me in paying the money back to VICOBA (fearing that the woman will be superior in the house), so when I was explaining this to the chairperson there was a man aside who was listening and looking at me. When I was leaving that man followed me and told me that [..] “I will assist you in paying the VICOBA” I said why can’t I have an affair with this man who is ready to help me? Then we started the relationship”

[IDI_Female_35years_Monogamous]

Clarifications which were provided during ‘member check’ validation session with some community members in the study site highlighted that, some women in Ifakara town prefer to engage in several VICOBA (i.e. a woman could be a member of more than two VICOBA). Those women with poor economic background who are members of more than one VICOBA, are likely to encounter difficulties in financing their membership in all the VICOBA groups. This was mentioned as a common scenario that is likely to expose some women to extramarital affairs.

Having good income was one of the main aspects reported by participants which facilitate men’s engaging in extramarital affairs. One participant pointed that it is a privilege for a man with income to have several women:

“Us men when we get money we feel privileged to have several women […] it speaks about the status [….]and I tell you any man with high income will not be complete without having several women”

[IDI_Male_63years_Polygamous]

Participants were in the opinion that alcohol consumption encourages extramarital behaviors of men and women through sexual networks in the local brew. It is believed that for men excessive alcohol stimulate their sexual desire and make them bold enough to approach several women at the alcohol venues. It was mentioned that this behavior could also be experienced by women.

Participants thought that exposure to extramarital relations at the local brew could be resulting from failure of men and women to be accompanied by their marital spouses when visiting the local brews. Men and women may not feel comfortable visiting the local brew with their spouses, since this could infringe their freedom to socialize. Women mostly participate in local brewing, while men are the main customers:

F: What happens in the local brew with regards to extramarital affairs?

P: For men alcohol goes down to the penis and they no longer feel shy [when they have consumed excessively]. You know, when you are in the local brew you can get a woman and take her for sex, even women when they are drunk they behave the same (having extramarital affairs)

F: What happen to a woman in the local brew?

P: Women sell the local brew and we (men) buy alcohol for them and other friends

F: Does this apply also for married women?

P: Let me tell you my sister, it is rare here to find married couples going together to the local brew since this will limit their socialization, enjoyment and searching for extramarital partners […]

[IDI_Male_30years_Monogamous]

[IDI_Female_41 years_Monogamous]

Male and female participants raised their concerns that relates to marital sexual dissatisfaction, which could also encourage them to search for extramarital partners. While comparing the quality of sex they receive from their extramarital partners and that which they receive from their husbands, some women complained that they are being denied ‘romancing’ including not being prepared enough for sex by their husbands: “[…], My husband just comes and start making love as if he is entering the farm [..] but the one from outside (extramarital partner) start talking to me for a long time [..]. I just do sex with my husband just because he is my husband […]” [IDI_Woman_26_Monogamous]

Men complained about being denied opportunity to practice as much sex as they would wish by their wives. This aspect was mentioned mainly by men as one of the reasons for them to search for extramarital partners:

“You find that I need sex frequently or I have the speed more than my wife but she refuses to give me whenever I need (sex) and then I need to look for other women […]”

[IDI_Male_30years_Monogamous]

The study findings revealed that being a member of a VICOBA was statistically significantly associated with the relative risk of engaging in extramarital affairs for men and women.

To the best of our knowledge, this finding is new in the respective literature and requires further investigation. But we have tried to discuss the finding in the light of information drawn from the qualitative findings and from the validation sessions conducted in the study community. What we know is that, VICOBA as an informal social protection mechanism in Tanzania is expected to improve men and women’s financial saving capacity and enhance their economic livelihood [32, 33]. How VICOBA exposes women to extramarital practices is an interesting question especially at this era when social protection mechanisms are expected to alleviate women’s poverty and HIV vulnerability [34]. The qualitative findings in this study suggest that women with economic hardship in Ifakara town are likely to have several debts in VICOBA since they are unable to raise enough money to support their membership in VICOBA groups. During the validation sessions of the qualitative data [as described in the analysis section of qualitative study in this paper], participants further clarified that, some women belonged to several VICOBA groups, which in turn brought them in the situation that they couldn’t keep up with paying all the loans. Our findings further revealed that some husbands may refuse to support their wives’ VICOBA membership fearing loss of power and competition in the households even in the context where men would in turn borrow money (received from VICOBA by their women). This may imply that, engaging in extramarital affairs seems to be an acceptable coping strategy for women who are economically dependent on men. A similar study in Tanzania found that women may engage in multiple concurrent sexual partnership to ensure social and financial security for their families, as such they nick-named a concurrent sexual partnership as ‘mafiga matatu’ (three stones used to support fire wood when cooking) [13]. This symbolic meaning of an extramarital affair is similar to that which we found in our study that ‘Kidumu’ was also a local name for an extramarital partner of women in Ifakara town and was considered as a financial back up in case one fails to meet the demands of VICOBA.

In the case of men, the qualitative findings further clarified that, men in a VICOBA usually found opportunities to establish sexual networks with non-marital spouses since it is unlikely that both spouses belong to the same VICOBA group. This finding can be supported by Comas’ observations [35] that men tend to form extramarital relation in dense networks. Although in this study we had fewer men (4% men vs 14% women) reporting belonging to VICOBA, it could be that men have sexual relations with several women in the same VICOBA group.

In the view of the above highlights, it seems that VICOBA groups could be an important platform to foster HIV prevention strategies for married men and women in the study community.