Examining the context of microbicide acceptability among married women and men in India

Examining the context of microbicide acceptability among

married women and men in India

ELIZABETH E. TOLLEY1, EUGENIA ENG2, REWA KOHLI3,

MARGARET E. BENTLEY2, SANJAY MEHENDALE3, ARWEN BUNCE1 &

LAWRENCE J. SEVERY1

1Family Health International, Durham, NC, USA,

2University of North Carolina, Chapel Hill, NC,

USA, and3National AIDS Research Institute, Pune, India

Abstract

Married women in India are increasingly at risk of HIV, often due to their husbands’ extramaritalsexual behaviour. Topical microbicides may provide protection to women who are unable to negotiatecondom use. During the formative phase of a study to develop measures related to microbicideacceptability, we conducted in-depth interviews with 14 ‘high-risk’ and 16 ‘low-risk’ married womenand 15 husbands. Some participants had recently completed a 2-week microbicide safety trial. Asequence of in-depth interviews with each participant explored the context of microbicideacceptability, including perceptions of couple harmony, vulnerability to HIV, sexual power, andability to control life events. Women’s perceptions of control and sexual power influenced attitudestowards microbicide use. HIV risk was most commonly associated with partner infidelity and easilydetected, according to both men and women, by a lack of marital harmony. Despite this, high-riskwomen denied perceiving HIV risk until confronted with specific evidence of a husband’s positiveHIV or STI diagnosis. This study provides an in-depth examination of HIV risk for Indian marriedwomen, identifying potential determinants of microbicide use, and providing guidance for thedevelopment of psychometric scales to measure couple harmony, HIV risk perception, and sexualpower and control.

Resume

En Inde, les risques lies au VIH sont en augmentation pour les femmes mariees et sont souvent dusaux comportements sexuels extra conjugaux de leurs epoux. Les microbicides topiques pourraientoffrir une protection aux femmes qui ne sont pas en mesure de negocier l’usage du preservatif. Durantla phase initiale d’une etude ayant pour objectif l’elaboration de mesures d’acceptabilite desmicrobicides, nous avons mene des entretiens approfondis avec 14 femmes mariees « a haut risque »,16 autres « a faible risque » et 15 epoux. Certaines de ces personnes venaient de terminer un essai detolerance d’un microbicide d’une duree de deux semaines. Une serie d’entretiens avec chacun(e) desparticipant(e)s a permis d’explorer le contexte de l’acceptabilite des microbicides, comprenant lesperceptions sur l’harmonie du couple, la vulnerabilite au VIH, le pouvoir sexuel et la capacite acontroler les evenements de la vie. Les perceptions des femmes sur le controle et le pouvoir sexuelsont une influence sur les attitudes vis-a-vis de l’usage des microbicides. Les risques lies au VIH sontplus couramment associes a l’infidelite des partenaires et sont facilement reperables, aussi bien selonles hommes que selon les femmes, a travers un manque d’harmonie dans le couple. Malgre cela, lesfemmes « a haut risque » nient percevoir les risques lies au VIH jusqu’a ce qu’elles soient confrontees ades preuves specifiques - serologies positives pour le VIH ou les IST de leurs maris. Cette etude

Correspondence: Elizabeth Tolley, Behavioral and Social Science Research Unit, Family Health International, 2224 East NC

Highway 54, Durham, NC 27713, USA. Email: [email protected]

Culture, Health & Sexuality, July–August 2006; 8(4): 351–369

ISSN 1369-1058 print/ISSN 1464-5351 online # 2006 Taylor & Francis

DOI: 10.1080/13691050600793071

fournit un examen approfondi des risques lies au VIH pour les femmes mariees en Inde. Elle identifieles determinants potentiels de l’usage des microbicides et propose des orientations dans ledeveloppement d’echelles psychometriques permettant de mesurer l’harmonie au sein du couple,les perceptions des risques lies au VIH, et le controle et le pouvoir sexuels.

Resumen

Las mujeres casadas en la India corren cada vez mayores riesgos de contagiarse del VIH, confrecuencia debido al comportamiento sexual extramarital de sus maridos. Los microbicidas topicospodrıan proteger a las mujeres que no pueden negociar el uso del preservativo. Durante la faseformativa de un estudio para introducir medidas relacionadas con la aceptacion de los microbicidas,llevamos a cabo entrevistas exhaustivas con 14 mujeres de alto riesgo y 16 de bajo riesgo y 15 maridos.Algunos participantes acababan de completar un ensayo de seguridad de los microbicidas de dossemanas de duracion. Una serie de entrevistas exhaustivas con cada participante sirvieron paraanalizar si se aceptan los microbicidas, y estudiar ademas las opiniones de la armonıa de la pareja,conocer si eran vulnerables al riesgo de contraer el VIH, la potencia sexual y la capacidad paracontrolar las eventualidades de la vida. Las percepciones de las mujeres en cuanto al control y lapotencia sexual tenıan una influencia en las actitudes hacia el uso de microbicidas. El riesgo decontraer el VIH se relacionaba normalmente con la infidelidad de la pareja y se detectaba facilmente,segun ambos hombres y mujeres, por una falta de armonıa marital. Pese a esto, las mujeres de altoriesgo negaban percibir el riesgo de VIH hasta que se enfrentaban a la realidad de las pruebasdefinitivas de los resultados positivos de sida del marido o del diagnostico de enfermedades detransmision sexual. En este estudio se hace una examen a fondo del riesgo de contraer el VIH enmujeres casadas de la India, se identifican los posibles determinantes para el uso de microbicidas y sedan consejos para el desarrollo de escalas psicometricas que midan la armonıa de la pareja, lapercepcion de riesgo de contraer el VIH y de la potencia y el control sexuales.

Keywords: HIV, risk perception, sexual power, couples, psychometric scale development

Introduction

In India, more than five million people are estimated to be living with HIV, with

approximately 38% being women (UNAIDS/WHO Working Group on Global HIV/AIDS

and STI Surveillance 2004). Several studies have documented elevated rates of sexually

transmitted infections (STIs) and HIV among married, non-sex worker populations of

women in parts of India (Gangakhedkar et al. 1997, Vishwanath, Talwar, Prasad, Coyaji,

Elias and de Zoysa 2000, Ray 2004). Others suggest that married women’s risk arises in

large part from their inability to discuss or negotiate condom use with husbands engaged in

extramarital relations (Newmann et al. 2000, Bhattacharya 2004, Pallikadavath, Garda,

Apte, Freedman and Stones 2005).

The need for women-initiated HIV prevention methods has led to the development of

topical microbicides. These are vaginally-inserted gels, foams, or films that inhibit entry of

HIV into susceptible cells, or create a mucosal environment that inactivates the virus

(D’Cruz and Uckun 2004). As different formulations enter clinical trials (Kresge 2003), it

is hoped that at least one of these products will demonstrate effectiveness. First generation

microbicides are likely to be less effective than condoms which are approximately 95%

effective when used consistently and correctly (Warner and Hatcher 1998). Nevertheless,

microbicides may offer a viable option for married women, if found to be more acceptable

or easier to initiate than condoms.

To date, microbicide acceptability research has been limited. Products are still in

development, and consequently most studies have examined acceptability of hypothetical

or proxy products (Darroch and Frost 1999, Hammett et al. 2000). In clinical trials, where

actual product use could be examined, acceptability has focused on product attributes, for

352 E. E. Tolley et al.

example, ease of use and fear of side effects (van de Wijgert et al. 1999, Bentley et al. 2000).

One four-country phase I clinical trial, however, concluded that HIV risk perception was

among the most important determining factors (Bentley et al. 2004). Research on

determinants of condom use for HIV protection suggests that aspects of the sexual

relationship and feelings of efficacy will also influence a couple’s ability to adopt risk

reduction methods (Catania, Coates and Kegeles 1994). Few studies have attempted to

examine these broader constructs within the framework of microbicide acceptability. Such

understanding will be essential if microbicides are to be introduced in a manner that makes

them a viable option for populations at risk.

This paper presents findings from the formative phase of a study to develop measures for

factors that may predict microbicide acceptability among women in India. The purpose of

the formative phase was to explore the context of women’s personal characteristics, their

marital relationships, and environments that might enhance or limit microbicide

acceptability. The intent was to provide evidence addressing earlier theoretical attempts

to extend the understanding of microbicide acceptability (Severy, Tolley, Woodsong and

Guest 2005). We examined the relevance of a priori and emergent constructs, generated

hypotheses about the relationships between constructs and microbicide use, and identified

the ways such constructs might fit the Indian context.

Methodology

Fourteen ‘high-risk’ and sixteen ‘low-risk’ married women were recruited from an urban,

low-income population in Pune, India. Women were considered high-risk if they

acknowledged any of the following: having an HIV-positive husband, if they or their

husband had a history of STIs, or if they or their husband had multiple sex partners. Low-

risk women did not acknowledge any of these risks. Women were 18 to 45 years old,

married, and HIV-negative or of unknown status. They were recruited by a network of

healthcare and community-based organization staff supporting clinical trials operated by

the National AIDS Research Institute (NARI). Eight women had completed a phase I

microbicide safety trial. All women in the formative study were asked whether they would

be willing for their husband to be contacted. If so, he was provided with information, and

asked whether he would participate in an interview. Women participated in the study

whether or not their husband did.

Individuals were interviewed separately two or three times by same-sex interviewers. By

conducting multiple interviews, greater rapport with participants was developed before

broaching sensitive topics. This approach permitted interviewers to check contradictory

information and address gaps from earlier sessions. Data collection and analysis followed a

‘local theory’ approach whereby initial questions were driven by researchers’ theoretical

perspectives, but further exploration was responsive to participants’ descriptions of their

lives and relationships (Schensul, Schensul and LeCompte 1999).

Data collection and analysis occurred concurrently, enabling identification of areas for

deeper investigation. Analysis steps included an iterative process of reading, coding, data

display, and reduction (Ulin, Robinson and Tolley 2005). After developing a set of codes

identifying major themes in the transcripts, a detailed memo was constructed for each

major theme. Each thematic memo identified sub-themes. Memos noted hypotheses as

well as unanswered questions related to the theme.

As the relationship between different themes became clearer, second level coding

included development of a hierarchical tree that specified relationships between larger

themes, as well as their sub-themes. Excel matrices were developed to examine differences

The context of microbicide acceptability 353

in thematic content between risk and gender groups. Qualitative data were sometimes

transformed into numbers, in the same way that open-ended questions are coded in a

structured interview, to better examine group differences. Simple statistics were computed

to examine differences between women and men, and between high- and low-risk

participants. This study was reviewed and approved by Family Health International’s

Protection of Human Subject’s Committee and by the NARI’s Ethical Committee.

Results

Findings emerged from our analysis of 106 verbatim transcripts of in-depth interviews with

30 married women and 15 husbands. Of these, eight women and five husbands had

participated in a recent microbicide trial. Participants were provided with fictional names.

Their quotes are followed by participant identification number. Table 1 presents socio-

demographic information regarding the women and their husbands.

Low-risk women were several years older and more educated than high-risk women.

There was a smaller age gap between low-risk women and their husbands, as compared to

high-risk couples.

Risk reduction behaviours

Most women described their first experiences with condom use as contraceptive, rather

than for disease prevention. As Table 2 indicates, only women and men in the high-risk

group mentioned they had used condoms to protect themselves from disease, often after

receiving counselling. In a few cases, women’s first, and sometimes only, experience with

condoms had been during participation in research. While four out of six high-risk men

described using condoms consistently, only one third of other participants reported the

same.

Groups differed concerning their interest in microbicide use. Ten of 14 high-risk women

had strong interest in microbicide use if they were found protective against HIV. Two

others suggested use after they had conceived a child. In contrast, only two low-risk women

responded positively, and five women indicated they would consider use should they ever

feel at risk. Nine rejected use outright. Capturing the sentiments of other low-risk women,

Neelam a 35 year-old woman said:

Until now I don’t feel any need. In the future I will not need it either. I trust my husband and I am

good … the question of using it will not arise (037).

Table 1. Socio-demographic Characteristics of Women Participants by Risk Group

Low risk women (Total n516) High risk women (Total n514)

% who said husband could be contacted 63 50

Own age (in mean years) 33.3 26.7

Husband’s age (in mean years) 38.6 33.9

Years married 16.3 10.6

Years of education 8.4 (n515) 6.5 (n514)

Total children (total boys) 2.6 (1.3) 2.1 (1.0)


HIV risk perception

In sum, perceptions of risk influenced whether participants considered using condoms or

microbicides for disease prevention. But what led them to perceive risk in the first place and

at what point were they willing to take action?

Beliefs. Women and their partners suggested that HIV was most often transmitted sexually.

More than half also described non-sexual means of HIV transmission, commonly, the

possibility of getting HIV through dirty needles or exposure to infected blood. In their

opinion, protective behaviours included condom use; remaining faithful to one’s spouse;

ensuring that doctors use clean needles; and, less frequently, not sharing food, drink, or

clothing with HIV-positive persons. When asked what kind of precautions a person could

take to avoid AIDS, Rajesh a 42-year-old man stated:

I do not have sex outside and if I want to have sex outside then I use condoms. And when I go to

the doctor’s, we use a new syringe (029).

Severity. A third of participants discussed HIV/AIDS severity. Over half stated that there is

no cure for HIV, and AIDS means death. However, six individuals, representing five of six

HIV-discordant couples in the study, focused on treating AIDS. They emphasized

information received from healthcare providers. When asked what he felt after learning

about his HIV diagnosis, Rajit, a 30-year-old man, replied:

I was frightened thinking that it has no remedies, that the only remedy is death … gradually I came

to know that if we follow the instructions given by the doctor we can recover. So I followed every

instruction … like not having sex with outside women, not drinking alcohol, not having tobacco

and cigarettes (016).

Susceptibility. Participants in the high-risk group were much more likely to perceive

personal vulnerability to HIV. In ten of the 14 high-risk cases, women recognized their

partner’s behaviour as one source of susceptibility. When asked whether she ever worried

Table 2. Reported Condom and Microbicide Use among Women and Men, by Risk Group

Low risk Participants

(Total n525)

High risk Participants

(Total n520)

Women (n516)

%

Men (n59)

%

Women (n514)

%

Men (n56)

%

Condom Use Behavior:

Ever used condoms 56 78 86 100

Reasons for condom use:* (n59) (n57) (n512)

Family planning 67 57 50 50

Disease prevention 0 0 67 67

In Research only 33 43 9 0

Described Consistent Condom Use: 37 (n58) 29 (n57) 33 (n512) 67

Would consider using a microbicide, if

it became available:

31 37 (n58) 82 83

Described Consistent Microbicide Use

in Clinical Trial

40 (n55) n/a 100 (n53) n/a

*Multiple reasons possible.


about getting HIV, Priti, a 40-year-old woman with a history of reproductive tract

infection, responded:

Yes I feel worried … My husband is a drunkard; there are women with him … such thoughts come

in my mind—that if that woman is bad and he has sexual intercourse with her, then I can also have

this disease (020).

Few high-risk women perceived any risk until they were confronted with evidence of their

partner’s behaviour. When asked whether she would have used a microbicide before she

knew about her husband having HIV, one high-risk woman replied:

No, I would not have thought of using it, because he did not have HIV … No women will think of

using it (015; Shoba, 32 years old).

Among five of six high-risk women whose husbands were HIV-positive, evidence came

when they confronted their husband after learning his HIV diagnosis. Several of these men

knew their status 6 months to a year before their wives found out. As 32-year-old Shoba put

it:

When the report came, it showed that he has HIV … I only asked him then how it happened …

because of a syringe or blade or because of some bad behaviour … Then, he told me the truth …

‘You will not feel shocked, no … I had gone there [to a sex worker] once or twice … I did not feel

that I would get such a disease, because many people go there … it did not happen to them, so how

did it happen to me?’ (015).

For others, the recurrence of reproductive tract infections brought them into a clinic where

they were, sometimes, informed that they had a sexually transmitted infection. In all but

three cases, the healthcare system was involved in risk identification and most couples who

used condoms for disease prevention had been counselled to do so.

Only one low-risk woman, and none of the men, admitted feeling vulnerable due to their

partner’s ‘outside’ sexual behaviour. While half of low-risk women and partners

acknowledged that they could get HIV through non-sexual means, most added that

doctors were unlikely to use infected needles. Several low-risk men suggested that they

could not determine their risk of getting the disease, given its rapid spread. A few described

specific scenarios that made them feel at risk:

Yes, I do feel (afraid), because we work in a slum. We have to deal with blood … Suppose some

child has (HIV) and he had some injury. If we have cuts on our hands and we come in contact with

that blood … it may happen (012; Swarna, 40 years old).

Stigma and denial. Some participants suggested that people with AIDS were treated with

suspicion. Despite acknowledgement of multiple modes of HIV transmission, HIV-positive

people were assumed to have behaved ‘indecently’. Gauri a 21-year-old woman whose

husband was HIV-positive, suggested that:

Earlier, (people) didn’t behave properly with him … They felt my husband was an AIDS patient

because he had some extra-marital affairs (004).

One HIV-infected man talked about being taunted and wanting to die quickly, to avoid

people branding him as a harami rickshawalla (dirty or sinful taxi driver) (007; Suresh, aged

34). HIV-related stigma may lead some to deny or ignore their risk, relying instead on fate.


When NARI doctors asked one woman with a history of STDs about her partner’s

behaviour, she responded:

It is not like that … he shows cassettes with AIDS information to children. Then, why would he

have any outside sexual relations? (044; Jhoti, 30 years old).

Despite earlier confessions, five of the six discordant couples attempted to find alternatives

to infidelity as an explanation of their partner’s HIV infection. Several also seemed to

question whether they really had HIV and whether the disease was truly incurable.

Couple harmony

Data suggested that women’s HIV risk perception was linked to concern for partner

infidelity, which was influenced by assessments of marital relationship. Locally constructed

aspects of couple harmony included partner provision of support, lack of conflict and

alcohol use, decision-making patterns, sexual faithfulness, sexual pleasure, and commit-

ment. Table 3 depicts differences between these attributes as reported by women and their

husbands.

Table 3. Attributes of Couple Harmony Reported by Women and Men in Low and High risk Cohorts

Low Risk (Total n525) High Risk (Total n520)

Women (n516) % Men (n59) % Women (n514) % Men (n56) %

Affirms partner emotionally

supportive:

63 75 (n58) 14 60 (n55)

Affirms partner provides for

material needs:

63 88 (n58) 29 100 (n55)

Conflict:

Grumbling 88 78 64 67

Shouting 13 11 64 67

Physical force 19 11 50 0

Threats of divorce, other 13 0 43 0

Sexual force 25 0 50 0

Husband Uses Alcohol*: 25 – 50 –

Decision-making patterns:

Wife no role 19 44 36 0

Wife some role 56 33 43 67

Wife major role 25 22 21 33

Affirms confidence in partner’s

faithfulness:

69 100 29 67 (n53)

Reasons for sex:

Pleasure 44 67 36 100

Bonding 38 44 14 33

Procreation 56 33 43 0

Keep husband faithful 63 (n515) 44 57 (n513) 67

Sex can be pleasurable: 73 89 31 100

No desire for sex: 20 11 38 0

Sex repugnant: 7 0 31 0

Asserts own commitment to

marriage:

25 33 62 0

*Husband’s own admissions about alcohol use not included.


Support from partner. Two-thirds of low-risk women and three-quarters of husbands

reported that their spouses were supportive of them emotionally or materially. Women

emphasized signs of affection and understanding, using a pet name, giving a light kiss

before work, or listening to them. As Meena, aged 34, put it:

I talk with him very sweetly and he also does the same … if we have any tension, he makes me

understand that ‘we both are there for each other …’ (013).

Material support included providing for the family financially or bringing home household

supplies. Several low-risk women suggested that their husbands helped out with household

or job-related chores. Such signs of support were held as proof that a spouse was not

involved sexually outside of the marriage.

High-risk women desired the same partner support described above. Yet, only three

women affirmed that their husbands cared for their emotional needs, and less than one

third affirmed any material support. Most high-risk women described relationships with

partners who were absent emotionally, physically or both. Sunita, a 24-year-old married

woman, explained:

I felt that he should fulfil my wishes … he has never fulfilled any of my wishes and now, after these

12 years of marriage, I do not feel anything (009).

Such behaviours could lead a woman to suspect her husband of infidelity. As Gayatri, a 30-

year-old high-risk woman, explained:

He used to be irritated at home; he used to quarrel. He used to come at 2 or 2:30 am … I used to

ask him where he had been … he used to tell me, ‘I went there, such and such thing happened to

me’ … I used to understand where he had been … (043).

Men in both risk categories described receiving high levels of support from their wives. Men

emphasized a wife’s proper behaviour, her trust and obedience. All but one man described

the ways their wives cared for their physical needs. Ganesh, a 35-year-old HIV-positive

man, listed his expectations:

She should behave properly in the house. She shouldn’t have sexual relations with anyone else. She

should just take care of the house, the children, the mother-in-law and sister-in-law … She has not

had any (sexual) affairs and she does the housework properly (019).

Lack of conflict and alcohol use. For half of participants, lack of conflict and a husband’s lack

of alcohol use were important aspects of couple harmony. Nevertheless, the vast majority of

participants reported some quarrelling with their spouses. Low-risk women and their

partners often described the use of tactics like silence or humour to prevent conflict from

escalating. Ahmed, a 30-year-old low-risk husband, commented:

If I talk 25 percent, she talks 75 percent—with anger, scolding, with authority. At that time I

normally keep quiet and just listen … (018).

Marital relations within the high-risk cohort evinced serious conflict. Two-thirds of high-

risk women said their partners would shout at or verbally abuse them. Half of high-risk

women reported being beaten by their husbands. Some reports being moderate, a husband


might give his wife one or two slaps for questioning his whereabouts. Others endured

routine violence. Priti, married at the age of 13, said:

When I got married, I was not mature … He used to beat me everyday, because I could not become

pregnant. If my husband did not beat me in the morning, then he used to beat me at night, and if

not night, then in the morning (020).

Four women had sustained permanent physical damage from their partner. Half of high-

risk women described being forced to have sex. Shoba, aged 32, said:

Even if I say no, he will do it (sex) forcefully … he has lots of strength. I cannot do anything (015).

Sometimes the threat of divorce or physical harm was sufficient to gain a wife’s compliance.

Accounts of marital conflict often included alcohol use. And, while only one-quarter of

low-risk women reported that their husbands ever drank alcohol, half of high-risk women

did.

Decision-making. Seven women described playing an important role in household

decisions. Three of the four low-risk women in this group shared decision-making in

which they were able to request or veto the purchase of ‘big-ticket’ items, from electrical

goods to land, as well as the small day-to-day purchases. Their husbands independ-

ently corroborated their wife’s involvement in such decisions. Prakash, aged 42 years,

explained:

We built this house through her job, taking out loans and paying instalments from our salaries …

This decision, to purchase land and to build a home on it, was my wife’s advice … purchased in my

wife’s name. We have that much understanding (014).

However, one low-risk and two high-risk women suggested they controlled most household

decision-making, because their husbands were unable or unwilling to do so, due to chronic

alcohol use or debilitation from HIV. More often, women and men described separate

realms of decision-making, in which women made smaller, day-to-day, decisions, while

ultimate authority remained with the husband. Sunita, a 24-year-old, said:

I alone look after my children’s food, clothing … I do not like to depend on others. We both are

working. He also gives me 100–200 rupees daily. I manage everything in that (amount) … if

medicines or anything else are needed, I manage on my own … Now he gives all his salary to me,

but I do not like to spend money on unnecessary things (009).

Women in the high-risk group were the most likely to have no say in household

decision-making, even when they contribute financially to the household. Jhoti, aged 30

years, said:

When he sold our car I had a lot of tension, because I had sold my jewellery to buy that car. And he

didn’t tell me in advance (044).

Interestingly, high-risk men tended to value their wives’ contributions to decision-making

more highly than the wives did themselves.

Sexual faithfulness and sexual pleasure. Although both men and women expected their

spouses to remain faithful in marriage, the consequences of infidelity fell mainly on women.


Even the appearance of infidelity could bring grave consequences to a married woman.

Satya, a 28-year-old low-risk man, said:

If we do not live faithfully … then our relationship can break and she will go to her mother’s house

… I will get married again; she will regret it … I am a male. I can marry again. But she is a female

(034).

Many participants appeared to tolerate men’s infidelity if not legitimate it. Vimla, a 28-

year-old young woman, explained:

It (faithfulness) is very important. But nowadays most men are not like that … Many of them have

sexual relations outside. Women are responsible for that. If he gets all he wishes from his wife, then

he will not go outside (005).

Some women worried about being physically separated from their husbands, and this was

especially common around the prenatal period. One woman described her feelings of

insecurity this way:

When I got married and was pregnant with my first child, I went to my mother’s place for 2 months

for delivery. During that time he said, ‘if you do not come back soon, I will do anything’ (011;

Padma, 35 years old).

The majority of low-risk women and almost all men indicated they had complete faith in

their partner’s fidelity. Women’s confidence stemmed, in part, from their efforts to sexually

satisfy their husbands. Leena, aged 31, said:

I tell him we will do it (sex). I have fear that he should not go to anybody else. I give him lots of

happiness, so why will he go to somebody else? (030).

A few women suggested that their husbands also cared for their wife’s sexual satisfaction by

taking time for sex, ensuring that it was mutually satisfying. They emphasized the

importance that sex had in bonding their relationship. However, more women viewed sex

as important only in terms of reproduction and keeping a husband from straying. For them,

sex was satisfying to the extent that their husbands did not impose it. According to

Shakuntala, a 25-year-old woman:

(a woman) should fulfil all her husband’s wishes … if we said no to sex, they get angry. My

husband never does that, he asks my desire also. Only then we have sex … he never forces me. He

understands (028).

While none of the low-risk partners admitted to having had sex with a woman other than

his wife, all of the high-risk partners eventually did so. The accounts they provided and

what they told their wives often differed. One HIV-positive man was 100% sure he got HIV

from outside contacts. His wife said:

My husband has specifically and clearly told me that ‘You might think that I got this disease

because I have some affairs outside but, trust me; I never made such a mistake till now’. So, we

don’t know the exact reason why he got HIV (004; Gauri, 21 years old).

Two high-risk men maintained that they had only had sex with one other woman, usually

described as a love relationship, before marriage. However, four of six high-risk partners

described routinely visiting sex workers, or having multiple relationships both before and


during marriage. Some suggested that men had sex because it was pleasurable or helped

relieve them of tension. Suresh, a 34-year-old HIV-positive man, said:

A person should have it (sex). The motor can’t run without it. Everything seems wonderful then

(007).

Few high-risk women described sex as pleasurable, rather, something to endure. Married

for 8 years, Vimla mused:

Now I no longer have any feelings. I have lost all my sexual desires. We just have sex when he wants

to have it (005).

Some high-risk women went so far as to describe sex as abhorrent. As Shoba, aged 32,

explained:

… if he cannot sleep, then the whole night he will keep on touching me here and there,

everywhere—even when I do not have the desire … I feel disgusted. If he does it with love then I

will not feel this way. But since he does not do it properly, I have started to hate him (015).

A few women described sex as painful. These women often had a history of reproductive

tract infections. Still, they described having to submit regardless of pain.

Commitment. One third of participants said commitment to stay in the marriage was also

indicative of couple harmony. One woman (Pushpa, 21 years old) especially expressed the

opinion that: ‘When we get married once, it is for a whole life. We took an oath …’ (035).

Here, commitment was associated with adjustment, being willing to overlook a partner’s

mistakes in order to ‘keep the family from breaking’. However, participants indicated that

such commitment was expected from women much more than from men. ‘If my wife is

living with me until my death, I will say it is a successful marriage’ (16; Rajit, 30 years old,

sign painter).

Interestingly, high-risk women were much more likely than low-risk women to discuss

their commitment to marriage. They based their decisions to remain with their husband,

despite his illness, alcohol use or beatings out of a sense of duty, personal dignity or the

honour of their parents and family members.

I stayed with him when he was healthy, bearing all of his torture. Now that he has become sick, it is

not good to leave him … to understand and stay with a sick person is not easy. It is our duty (001;

Asha, 29 years old).

Power and control

Women considered their ability to control events, and their sexual power within the

marriage, when sensing risk and making decisions about risk reduction methods. Table 4

summarizes women’s descriptions of indicators of power and control.

Personal characteristics. Education and other personal characteristics like temperament or

religious practice seemed to influence both consideration and consistent use of

microbicides. Educated people think about the benefits and disadvantages of using the

gel, because they ‘know the importance of this gel … They know what HIV is … no one can

save himself after getting AIDS’ ((029); Rajesh, 42 years old). Illiterate people would have


to be convinced to use it by doctors: ‘A literate woman can insert it easily, but for an

illiterate woman it may be difficult’ ((004); Gauri, 21 years old). Several participants

suggested that patience, maturity, and control would be necessary to use a microbicide

consistently. Prakash, the 42-year-old husband of a low-risk woman who participated in

microbicide trials said:

Yes, she can stop me (to insert the gel) and I also can stop for some time. We have that much

maturity because we are not newly married. We got married twenty years back … (014).

Perceived control over life events. Women described themselves as having varying levels of

control. Self-perceptions of control appeared tied to women’s freedom to travel, access to

work or money, and ability to make decisions. Perceived control also appeared related to

women’s consideration of microbicide use.

Ten of 16 low-risk women, but only one high-risk woman, portrayed themselves as

having or sharing control with their husbands. Most were working or volunteering outside

their homes, had freedom to move about in their communities, and were involved in

financial decisions. More than half had attained a secondary education. These women gave

the impression that they could express their desires, and expected husbands and others to

consider them. Having pursued a college education after marriage, Padma, 35 years old,

declared:

I am not like them (other women) because I have studied social studies. I have my own personality,

and it is not like it should always happen the way the husband wants. She should also make her

own decisions … and he also knows this (011).

Lalitha, a 43-year-old woman, describes her experience participating in a women’s savings

group:

I felt good mixing with other women during monthly meetings. I felt that I also can talk with other

women, I can get new information and it also gave me chance to go out of the house (039).

Manisha, 30 years old, stated:

Table 4. Indicators Developed from Women’s Descriptions of Power and Control, by Risk Group

Low risk Women

(Total n516)

High risk Women

(Total n514)

Mean years of education 8.4 (n515) 6.5 (n513)

Beliefs about own level of control %:

In control 62 7

Self-sacrificing 19 57

Helpless 19 36

Working outside the home %:

63 50

Freedom of movement %: (n59)

Unrestricted 56 33

Somewhat to highly restricted 44 67

Communication %:

Has expressed own desire for sex 44 36

Can say ‘‘No’’ to sex 63 36


I have got confidence from this group, and in short I have become independent. Previously I was

not able to speak confidently, but now I can (041).

About half of high-risk and a quarter of low-risk women appeared to defer to husbands and

others for most decisions. Although the majority of these women were working and claimed

some freedom of movement or involvement in financial decisions, they described their roles

as self-sacrificing. They routinely suppressed their desires and needs to the benefit of

others. They tolerated demands of other family members, and suppressed anger and

questions about their partner’s behaviours to maintain the peace. As Nirmala, a 21-year-old

woman, explained: ‘I felt like crying after knowing about his illness … but I couldn’t show

that. I kept quiet and then again I start my work’ (006). Shoba, 32 years old with an HIV-

infected partner, declared: ‘I decided that I will stay properly and convert bad conditions to

good’ (015). These women seem caught between action and accepting their fate. As Jhoti,

30 years old, wondered:

How to fight financial problems … how to fulfil the dreams I have for my children? But I didn’t lose

my courage … I have decided to make my children good citizens … I feel bad, but when I see my

children I feel good, because after all we live for our children and whatever happens is written in

our fate. Everything happens the way god decides (044).

Eight women described themselves as having no control over life’s events. None of them

worked. Ravindra, 35-years-old, a high-risk husband, explained:

I go on my own to buy groceries or pay my daughters’ school fees. I don’t ask my wife, because I

don’t generally like my wife going outside (042).

Some women were not only prevented from working, but also from visiting family

members, or chatting with neighbours. Leena, a 31-year-old low-risk woman, was

prevented from visiting her sisters living in the same town:

He tells me, ‘Why go? It’s me who provides everything’. If I have any problems or troubles, why go

and tell them to somebody else? They will not do anything … So I do not talk to anybody … So I

only tell (my problems) to him (030).

Pushpa, a 21-year-old woman, talked about the isolation she had felt since getting married:

I cannot talk to anyone … When people belong to us, then we have right to talk to them.

Otherwise, even if we talk to our husband, then they get angry. He can not bear anger. So I don’t

say anything (035).

The consequences of such restrictions include limiting women’s ability to check on

husbands’ behaviours outside the home, or obtaining information, or making decisions that

might affect family health. Women in control saw little reason for a microbicide. However,

they were supportive of a woman’s right to use a microbicide should she need one. Some

felt they could make their husbands understand that microbicide use would benefit both of

them. Many other women, however, particularly those with low levels of control, felt only

the husband could make the decision to use a microbicide:

I should have my husband’s permission, then I will be more able to use that … she should take

permission from other people living in the house, because if she faces any problem due to

(microbicide use) they will ask ‘Have you ever asked us?’ (005; Vimla, 28 years old).


Sexual power. Consistent microbicide use appeared linked to women’s power to negotiate

within the sexual arena, including their ability to control sexual timing, to communicate

about sexual issues, or use the method clandestinely. Most women denied their husband sex

from time to time. High-risk womenweremore likely to describe scenarios in which husbands

refused to listen to them. When one woman pleaded to avoid sex due to pain, her husband

responded: ‘Let it pain. I do not go out, so don’t I needmywife?’ (024; Radhika, 28 years old).

Contemplating consistent microbicide use, another woman explained:

if he forces me to have sex one day and doesn’t give me sufficient time to use the gel I can’t do

anything … Men’s power is different from women’s power … if it occurs to him to have sexual

intercourse with the gel, I will definitely use it (026; Miriam, 34 years old).

Sexual communication seemed to be a male domain. Only a few women suggested they

could express their own desire for sex. Women felt ashamed discussing sexual matters;

others said they had no desire for sex. Most often the frequency of men’s sexual advances

satisfied women’s needs. Ashok, a 40-year-old low-risk husband, stated:

Normally, women don’t speak out. They don’t say ‘Yes’ or ‘No’ … a man should understand

(010).

Asha, a 29-year-old high-risk woman, said:

A woman can suppress her needs if her husband doesn’t want to have the sex. She cannot demand

it because, after all, it depends upon the man (001).

Most women believed they should negotiate microbicide use with their partners, rather

than use it clandestinely. Over half imagined scenarios in which they could talk to their

husbands about microbicides. However, high and low-risk women viewed the commu-

nication process in different ways. Women with risky partners believed they could easily

demand microbicide use. Husbands would have to submit. Asha, 29 years old, whose

husband was recently diagnosed with HIV emphasized that:

A woman can ask (to use it), if she has to protect herself … a woman can tell her husband that

‘Since you don’t use condoms, I will use this (microbicide)’ (001).

Sunita, 24 years old, a woman from the low-risk group imagined requesting a husband’s

permission this way:

I will tell him that ‘it is useful for both of us. Then what is harm to use it and it has to be

kept in vagina. So would you like it?’ And, I think he also will be ready if it is useful for both

(009).

Others anticipated difficulty negotiating microbicide use. Several imagined they might

invoke a doctor’s advice to facilitate microbicide use. Radhika, a 28-year-old high-risk

woman with a history of reproductive tract infections, believed that a direct request to use a

microbicide would lead to accusations and distrust:

… will tell them that the doctor has asked me to apply … (microbicides) … If we do not tell him

and apply it, and if he sees that we have used something then he will ask who has asked you to

apply that (024).


Half of women and several husbands imagined scenarios in which ‘other’ women used

microbicides clandestinely. Dinesh, a 39-year-old low-risk man, speculated:

If she suspects that he is doing something outside, and if you tell her about this (gel), she will get

the idea that she has to use that … She will not tell her husband that ‘Because you are going out, I

will get this disease’. She will not talk like this, because the husband will say, ‘You have

doubts about me’ and … So, she will not say anything like that, but if she wants to use she will use

it (038).

Lakshmi, a 24-year-old high-risk woman, stated:

I do not feel that all men are trustworthy. If the husband is understanding … she can use it with his

consent and if he is not … she can use without his permission … If this gel comes on the market,

how many women can buy it, think of using it … it is good that women can keep it secretly, and if

her husband goes outside then she can use it for her own protection (047).

Attitudes towards condoms and microbicides. Most low-risk participants did not consider use

of either product for disease prevention. High-risk participants had mixed attitudes. Two

women with HIV-positive husbands felt they could avoid HIV since they were using

condoms. Three others felt tense or scared during sex because ‘if the condom tears, then

the virus will go inside of me and I will also get this disease’ (015; Shoba, 32 years old).

Several high-risk women suggested they would use microbicides if the gel prevented HIV

transmission while enabling them to get pregnant. Several others preferred avoiding sex

rather than using either condoms or the gel.

The majority of participants reported they would worry about the gel before using it for

the first time. Women were most concerned about the gel causing itching, or wounds in the

vagina. Sunita, a 24-year-old high-risk woman, stated: ‘If there is an itching or burning

sensation when used regularly, then I will not like to use it at every sex’ (009). Several

partners of microbicide users also worried about their own safety. Prakash, 42 years old,

reported: ‘I thought I might have a problem while urinating, or I might get boils or scars’

(014). One low-risk and all three high-risk microbicide trial participants reported some

minor itching or discharge.

Over a quarter of the women and several husbands believed that lack of privacy and

difficulties with storage would make consistent use difficult. Jayashree, an 18-year-old high-

risk woman, imagined difficulty using the gel consistently, especially with visitors in the

house: ‘… if there are other people in the house then how can I insert it? Once in a while is

OK. It is not possible every time’ (008). Others suggested this is only temporary as once

women become familiar with the routine, she would find a place to store the gel and

applicator and insertion would be less time-consuming.

Discussion

Given the high risk of HIV infection among women, microbicide acceptability research

must better understand the social contexts that surround initial and sustained use (Bentley

et al. 2004, Mantell et al. 2005, Severy et al. 2005). This study attempted to provide an

enriched perspective on how perceptions of HIV risk, couple harmony, perceptions of

control over life events, and sexual power influence both initiation and sustained use of

microbicides.


Based on the study findings, figure 1 hypothesizes the relationships between risk

reduction behaviours and factors of the social context that emerged from this formative

study. We suggest that contextual factors influencing initial consideration and consistent

use of microbicides will differ. That is, participants were not likely to consider using a

microbicide unless they perceived themselves to be at risk of HIV. Both women and

men equated HIV acquisition to partner infidelity, a behaviour that many felt was

common and synonymous with couple disharmony. When women perceived harmonious

relationships, they had little feeling of personal vulnerability to HIV infection. At the

same time, women’s sense of commitment to their marriage led some to ignore their

husband’s behaviour, unless they had received explicit evidence of their husband’s risky

activities.

Not all women who perceived themselves at risk of HIV believed they could use

microbicides. Perception of microbicide effectiveness and perceived control influenced

initial consideration of microbicide use. While some high-risk women indicated they would

consider microbicide use if it were proven effective, others believed that abstinence was the

only way to remain uninfected. Women’s perceived control over their daily lives also

influenced their initial consideration of microbicide use. Women with low perceived control

tended to lack mobility, access to money, and decision-making power, which would make

initiating a microbicide difficult.

Participants felt that once initiated, consistent use of microbicide would depend on

women’s attitudes towards certain product attributes. Women indicated that they would

only know about side effects once they had tried the method, and that recurrent problems

like irritation or wetness might prevent continuation. They indicated that difficulty

Figure 1. Emergent Conceptual Model of Microbicide Acceptability


privately inserting and storing the gel could hinder consistent use. Finally, consistent use

would require women to have sexual power, including the ability to influence the

occurrence and timing of sex and to communicate about microbicide use with a husband or

use it clandestinely.

Implications and conclusion

The conceptual model emerging from this study identifies several contextual factors that

are likely to determine microbicide acceptability. These indicate some of the key

determinants upon which microbicide introduction strategies must intervene to be

successful. For example, given the essential role that ‘evidence’ plays in this population,

interventions will be needed to help people more rapidly assess their risk of HIV. One

approach may be to encourage healthcare providers to discuss with individuals their own

and their partner’s sexual behaviours and be pro-active about HIV and STD testing and

counselling. Research has documented the high levels of sexual and reproductive tract

infections (RTIs) in India (Mehendale et al. 1996) as well as barriers to diagnosis and

treatment (Barua and Kurz 2001, Santhya and Dasvarma 2002) Similarly, we found that

both women and men were loath to discuss such problems with spouses or with doctors.

Additionally, research suggests that not all healthcare providers clearly communicate the

sexual nature of diagnosed RTIs, recommend partner notification and treatment, or discuss

risk reduction methods. However, most participants who used condoms for disease

prevention had been counselled to do so by a healthcare provider. The healthcare setting

should be even more instrumental in assisting individuals to explore options for reducing

their risk of STDs and HIV.

Programmes aimed at changing norms may also be warranted. Uganda’s successful

health communication campaign focused on remaining faithful to one’s partner is a model to

consider (Wilson 2004). For India, messages will need to fit the local context, where a shroud

of secrecy and denial often envelops sexual behaviour (Bhattacharya 2004). Campaigns

might create images of the strong Indian male as someone who adjusts, demonstrates

emotional support, and withstands the temptations of outside sex. Message designers

should carefully consider how to frame health communication campaigns that promote

risk reduction behaviours like condom or, eventually, microbicide use. Should micro-

bicides become largely associated with infidelity, they may not be a viable option for many

women.

As a final note, although the formative research reported here identifies potential

determinants for behavioural change, it does not indicate which determinants, when acted

upon, will be most effective in increasing uptake and use of risk reduction behaviours. The

data in this study provided the raw material from which to develop psychometric scale

items measuring HIV risk perception, couple harmony, and sexual power and control.

Future research is planned to test the relationships specified in this model to determine

which predictors are most strongly associated with use and can be effectively manipulated

by microbicide-based or other HIV risk reduction programmes.

Acknowledgements

This research was made possible through funding from the US Agency for International

Development (USAID). In addition, the authors wish to acknowledge the members of the

research team – Neelima Karandikar, Babita Rajkumari, Himanee Bhat, Swapna Vaidya,

Puroshottam Chandankar, and Rajesh Alone – for the countless hours they spent


interviewing participants and transcribing tapes, as well as the sensitivity and enthusiasm

with which they accomplished their work. Finally, the authors thank the men and women in

Pune who shared their stories with such courage and candor.

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Examining the context of microbicide acceptability among married women and men in India

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