Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women

doi:10.4236/aid.2013.33031

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Advances in Infectious Diseases, 2013, 3, 210-218

http://dx.doi.org/10.4236/aid.2013.33031 Published Online September 2013 (http://www.scirp.org/journal/aid)

Marital Status and HIV Prevalence in Nigeria:

Implications for Effective Prevention

Programmes for Women*

Samson B. Adebayo1,2#, Richard I. Olukolade3#, Omokhudu Idogho1, Jennifer Anyanti1,

Augustine Ankomah1,4

1The Society for Family Health, Abuja, Nigeria; 2National Agency for Food and Drug Administration and Control, Abuja, Nigeria;

3Association for Reproductive and Family Health, Abuja, Nigeria; 4Department of Population, Family and Reproductive Health,

School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana.

Email: #[email protected]

Received May 31st, 2013; revised June 31st, 2013; accepted July 31st, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Objective: Until recently, HIV prevalence has been based on estimates from antenatal sentinel surveys which have

been found to overestimate HIV prevalence among the general population. Multiple studies have shown women to be

disproportionately affected by HIV and AIDS epidemic. Design: Data for this study were based on the first Nigerian

population household-based HIV biomarker survey of 2007, which used a multi-stage probability sampling technique.

Methods: Respondents were selected through probability sampling (male age 15 - 64 years and female 15 - 49 years).

This paper, therefore, examined the correlates of marital status and HIV prevalence among women in Nigeria. Results:

A descriptive analysis of the data showed that HIV prevalence of women that were formerly married: divorced, sepa-

rated or widowed were more than double that of those who were currently married/cohabiting with a sexual partner; and

more than three times those that were never married. Bivariate and multivariate levels of analysis were explored in this

paper. At bivariate level, findings showed a significant difference in HIV prevalence among women according to their

marital status (p < 0.0001), educational attainment (p = 0.004) and geo-political zones (p = 0.003). Respondents that

were formerly married were 5.6 times as likely to be infected with HIV compared with those who had never married

(OR = 5.6, p < 0.0001) while HIV prevalence increased with higher educational attainment. Conclusion: In view of

these findings, HIV programmers should design interventions that will improv e economic empowerment as well as so-

cial security for women that were formerly married. In addition, gender mainstreaming in the ongoing HIV and AIDS

preventive efforts should be strengthened and scaled-up.

Keywords: Early Marriage; Sexual Initiation; HIV Prevalence; Marital Status; Formerly Married

1. Introduction

The Human Immunodeficiency Virus (HIV) and Ac-

quired Immunodeficiency Syndrome (AIDS) have been a

major problem in many parts of the world. AIDS was

first recognized as a distinct syndrome in 1981 [1]. In

Nigeria, about 3.3 million people are infected with HIV

with an estimated 220,000 AIDS related deaths [2]. The

2010 National HIV Sero-prevalence sentinel survey

conducted among pregnant women attending antenatal

clinics in Nigeria put HIV prevalence at 4.1% [3]. The

pervading knowledge that women are burden-bearers

cannot be said to be untrue, as from the natural and bio-

logical point of view, women bear the weight of child

birth and the survival of the child greatly depends on the

care of the mother. In the same manner, the impact of

HIV and AIDS on a global level, but especially in sub

Saharan Africa, does not exclude women. This is because

HIV is the leading cause of death and disease among

women of reproductive age (15 - 49 years) worldwide

[4].

Women have constituted approximately half of all

adults living with HIV globally and are more likely to

*Conflict of Interest: The authors have no conflicts of interest to de-

clare.

#Corresponding author. become infected than men. It is estimated that for every

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women 211

10 men infected, 13 women will be infected. Of the sev-

eral factors implicated in the unequal prevalence of the

disease among women in Africa are economic depend-

ence, feminisation of poverty, unequal distribution of

sexual power (sexual violence and coercion), including

limited educational opportunities [5]. Sub-Saharan Africa

remains the region hardest hit by the HIV epidemic [2].

As is the case in most of sub-Saharan Africa, women

greatly surpass men in the number of people living with

HIV and AIDS, and in many areas, women double the

number of men with the virus [6].

While some long standing socio-cultural practices are

reasons for this higher prevalence of HIV among women,

other reasons are evolving with changing patterns of be-

haviour and lifestyle. These reasons include biological

and social risk factors [7]. The social factors consist of

cultural roles and norms, and harmful traditional prac-

tices [8]. Such customs include female genital mutilation,

forced marriage, low female child education, and dis-

crimination against the female gender. Protection of girls

and women from HIV infection should include protecting

them against gender-based violence and promoting eco-

nomic independence from older men [2]. Social norms

that accept extra-marital and pre-marital sexual relation-

ships among men, combined with women’s inability to

negotiate safe sex pr actices with th eir partners make HIV

infection a risk even in women who have only had one

partner in their entire lives [9]. Men tend to dominate

women’s sexuality in Africa’s dramatic context of pov-

erty [10]. Similarly, in many countries and societies,

women and girls are treated as socially inferior [11]. In

all these situations, the inability of women to insist on

condom use is a “trade off” of their inalienable right for

economic advantage.

Biologically, women are two to eight times more

likely than men to contract HIV during vaginal inter-

course [12] and this may be attributed to difference in

anatomical structures of genito-urinary tract which makes

females more susceptible to STIs [13]. Since the majority

of sexually transmitted infections do not give rise to any

symptoms in women, these are less likely to be recog-

nized or treated early enough [9 ]. During unprotected sex,

the virus can also be directly absorbed through the vagi-

nal and cervical mucous membranes. Also, the vaginal

lining in women can sometimes tear and possibly allow

HIV to enter the body during sex [14].

Marital status is reported to be a factor responsible for

the higher HIV prevalence observed among women. In-

dividuals, who are divorced, separated or widowed, tend

to have significantly higher HIV prevalence than their

counterparts who are single, married, or cohabitating;

with divorced or widowed women experiencing espe-

cially higher prevalence [8]. For instance, some studies

have shown that divorced or separated women in Guinea

are more than three times more likely to be infected with

HIV than single women, while widowed women are al-

most seven times more likely to be living with HIV than

their counterparts who are single [15]. Meanwhile in

Tanzania, studies have shown that more than one in four

of widowed women are living with HIV compared with

6% of those who are married or cohabiting and 2% of

those who have never been married [16].

Furthermore, studies in Uganda showed that the risk of

HIV among widowed individuals is almost 5 times

higher than that seen in married individuals, while the

risk of HIV among separated is twice that of married

respondents. This may be because their partners died of

AIDS. Most infections are almost three times higher

among the divorced and separated than the married [15,

17]. Higher prevalence of HIV in many African countries

has been associated with a high rate of marital separation

and widowhood [18].

Although a number of HIV and AIDS prevention and

intervention efforts are ongoing, and literature on pro-

gress made in Nigeria in addressing HIV prevalence is

available, yet more needs to be done. In Nigeria, studies

are yet to fully examine the relationship between for-

merly married women within the general population and

HIV prevalence especially at national level. This may

basically be due to the fact that data to make such infer-

ences are not available until lately.

This paper therefore examines possible correlates of

HIV prevalence among women in the general population

controlling for their marital status. Findings from this

paper will provide HIV programmers and policymakers

with the basis for improving and repositioning strategies

to combat the disease among women especially in view

of higher HIV prevalence among formerly married

women compared with their counterparts who were cur-

rently in a stable relationship or never married. This pa-

per will also review what target groups would need to be

addressed as key populations at risk of HIV.

2. Data and Methods

2.1. Survey Method

The data us ed for this stud y were obtain ed from the 2007

National HIV & AIDS and Reproductive Health Survey

(NARHS) in Nigeria. The primary objective of the

NARHS survey is to provide quantitative data for moni-

toring current levels of sexual and reproductive health

indicators in Nigeria, as well as the impact of reproduc-

tive health interventions. The 2007 wave was the third

round of the survey in the country with earlier rounds

conducted in 2003 and 2005. The 2007 wave was the

only one that included a serological component to deter-

mine the national HIV prevalence level among the gen-

eral population. In essence, the 2007 wave was the first

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women

212

survey in Nigeria that provided population-based esti-

mates of HIV prevalence in Nigeria. Survey participants

were selected across the 36 states and the Federal Capital

Territory (FCT) of Nigeria through a multi-stage prob-

ability cluster sampling techn iqu e at three levels.

Eligible respondents were female aged 15 - 49 years

and male aged 15 - 64 years. Selection was based on the

sampling frame of enumeration areas which is main-

tained by the Nigerian National Population Commission

(NPC). List of localities was provided by NPC and strati-

fied into major or big towns, medium towns and rural

according to the 2006 Population Census. Localities

where the surveys were conducted were selected from

this list comprising of a mixture of the three main cate-

gories with more of rural localities according to the 2006

Nigeria population distribution.

A structured questionnaire which was pre-tested was

administered to the respondents. Research personnel

were trained with the aim of acquainting them with the

survey instruments. Questions were adapted from UN-

AIDS general population HIV & AIDS indicator and the

Demographic and Health Survey questionnaires. Due to

the language complexity in Nigeria (with over 250 lan-

guages), questionnaire was designed primarily in English

Language. Translations of keywords into local languages

were done at a central level training to enhance uniform-

ity and standardisation of questionnaire administration.

Enumerators, including HIV & AIDS counsellors/testers

were versed both in English and the local languages of

the communities where they worked. For ethical appro-

priateness, the survey instruments and materials received

the approval of the Federal and State Ministries of Health

in Nigeria before implementation through the Nigerian

Institute of Medical Research. Consent of the respon-

dents was obtained individually and they were ade-

quately informed of the survey objectives upon which an

individual has the right to participate or otherwise with-

out any fear of intimidation. A total of 11,822 respon-

dents were selected for the survey but only 11,521 re-

sponded to the questionnaire.

An HIV pre-test (to all selected eligible respondents)

and post-test (only for those that obliged HIV testing)

counselling was offered, while results of the test was

provided orally but referrals to facilities for further con-

firmation and possible placement on treatment for those

that were positive. At the end of data co llection exercise,

the HIV test results were further confirmed on the dried

blood samples collected from respondents, in a well-eq-

uipped laboratory by an external consultant.

2.2. Data

Overall, 5360 women were interviewed in the 2007

NARHS. Of these, only 4195 agreed to be tested after the

HIV pre-test counselling. Therefore, all analyses in this

paper were based on the 4195 female respondents that

answered the behavioural questionnaire and accepted

HIV testing. Marital status was grouped into “Never mar-

ried, Currently married/cohabiting, and formerly mar-

ried (i.e. separated, divorced and widowed)”. In general,

the mean age of the respondents was 27.8 years with a

standard deviation (SD) of 9.34. Mean ages according to

the marital status are 19.8 years (SD = 4.90) for never

married, 30.5 years (SD = 8.61) for currently mar-

ried/cohabiting, and 35.9 years (SD = 9.33) for formerly

married. Table 1 presents the distribution of the respon-

dents according to marital status and selected character-

istics.

2.2.1. Depend ent Variable

The outcome variable of interest in this study is the result

of the HIV test conducted among respondents who were

interviewed and volunteered to be tested. For the purp ose

of this analysis, response indicating positive HIV test

was scored “1” and “0” otherwise.

2.2.2. Independent Variables

The key independent variables in this paper are: “marital

status”, “location of residence”, “geo-political zones”,

“age”, “tribe”, “age at first sex”, “experience of sexually

transmitted infections (STIs)”, “multiple partnering”,

“transactional sex i.e. sex in exchange for gifts/favour”,

religion, “k nowledge of HIV p revention ”, “knowledge of

HIV transmission”, and “education”. Marital status with

never married as reference category. Place of residence:

urban and rural (reference category). Others include

educational attainment: Qur’anic/primary, secondary,

higher, and no formal education (reference category).

Nigeria is divided into six geo-political zones: North

West, North East, South West, South East, South South

and North Central (the North Central zone was used as

the reference). Respondents’ age was grouped into four

categories; 15 - 19 years, 20 - 24 years, 25 - 34 years,

and 35 - 49 years (reference). Tribe was put into: Hau sa,

Igbo, Yoruba, and others (reference). Religion was clas-

sified into three; Christianity, Islam and others (refer-

ence).

Background characteristics (demographic variables)

and other correlates of HIV prevalence which are impor-

tant predictors were adjusted for in multiple logistic re-

gression models. These include location, marital status,

education, geo-political zones, respondents’ age, tribe,

religion, knowledge about modes of transmission and

prevention of HIV and AIDS, and sexual behavioural

indicators such as age at sexual debut, multiple sexual

partnering; sex in exchange for gifts, favour or money,

and self-report of sexually transmitted infections in the

las 12 months. t

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women

213

Table 1. Descriptive information about the respondents according to demographic characteristics.

Variables Never marriedCurrently married/cohabiting Formerly married Total frequency

HIV Status

Positive

Negative

2.9

97.1

4.0

96.0

10.6

89.4

170

4025

Place of residence

Rural

Urban

56.7

43.3

69.3

30.7

70.3

29.7

2761

1434

Educational attainment

None

Qur’anic

Primary

Secondary

Higher

5.7

1.9

10.9

68.6

12.9

36.5

8.8

24.3

24.1

6.3

42.4

8.1

28.4

18.2

3.0

1182

285

870

1524

334

Geo-political zones

North West

North East

North Central

South West

South East

South South

9.5

11.1

16.5

23.0

20.0

19.9

26.1

15.9

18.4

17.4

8.2

14.0

17.4

14.0

17.9

17.0

15.7

17.9

876

605

745

792

501

665

Ethnicity

Hausa

Igbo

Yoruba

Others

16.1

23.9

22.9

37.1

37.0

10.7

17.4

34.9

21.6

17.4

19.5

41.5

1269

621

799

1506

Religion

Islam

Christian (Catholic and Protestants)

Traditional/No religion/Others

30.4

69.4

0.3

54.5

44.9

0.7

41.1

57.6

1.3

1966

2201

Knowledge of mode of HIV transmission

Correct knowledge of all (i.e. all five)

Otherwise

27.2

72.8

18.6

81.4

15.7

84.3

875

3320

Knowledge of m ode of prevention

Correct knowledge

Otherwise

48.2

51.8

36.4

63.6

33.1

66.9

1658

2537

Exchange sex for a gift

Yes

12.7

87.3

96.5

3.5

6.0

94.0

170

3269

Experienced STI symptoms

Had STI

Did not have STI

12.6

87.4

89.9

10.1

90.7

9.3

452

3743

Age at first sex

First sex below 15 years

15 years and above

Never

Can’t remember

5.1

33.7

59.5

1.7

21.0

71.7

0.3

6.9

22.0

64.8

N/A

13.1

694

2543

715

243

3. Data Analyses and Results

3.1. Descriptive Analysis

Table 1 presents the descriptive information about the

respondents considered in this paper. HIV prevalence

was highest among those who were formerly married

compared with those currently married/cohabitating, and

those who were never married.

Among the formerly married, 6.0% had exchanged sex

for gifts, favour or money, compared with 96.5% of cur-

rently married and 12.7% of never married who had ex-

changed sex for g ift, favour or mone y. In general, 90.7%

of those who were formerly married, 89.9% among cur-

rently married/cohabiting respondents, and 12.6% among

never married reported to have experienced STIs.

3.2. Bivariate Analysis

Bivariate analyses were performed to establish any sig-

nificant relationship between HIV status and its corre-

lates i.e. demographic characteristics and other factors

that are suspected to be associated with HIV status con-

sidered in this paper. In order to assess the degree of as-

sociation between HIV prevalence (status) and the se-

lected variables, Pearson Chi-square (X2) test of associa-

tion between the dependent and independent variables

was used. Results of the bivariate analyses are shown in

Table 2. HIV status was foun d to be significantly associ-

ated with marital status. Findings revealed a significant

and higher HIV prevalence among women who were

formerly married (10.6%), compared with those currently

married (4.0%) and never married (2.9% ) ( p < 0.0 001 ).

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women

214

HIV prevalence varies considerably according to edu-

cational attainment, geographical regions, age and relig-

ion. Respondents with primary education and above are

about twice as likely as those with Qur’anic and no for-

mal education to be infected with HIV (p = 0.004). Con-

sidering the geo-political zones, HIV prevalence was

highest among formerly married women in North Central

zone. Results showed that formerly married women in

age group 20 - 34 have higher HIV prevalence compared

with their counterparts in other age groups (p < 0.0001).

HIV prevalence was highest among those practising

Christianity (Protestants and Catholics combined) (p <

Table 2. Percentage distributions of the level of HIV prevalence according to selected characteristics. p-values are based on

Pearson chi-square (X2).

Variables HIV prevalence p-value

Place of residence

Rural

Urban

3.7

4.7 0.142

Marital status

Currently married/cohabiting

Formerly married

Never married

4.0

10.6

2.9

<0.0001

Educational attainment

None

Qur’anic

Primary

Secondary

Higher

2.6

2.1

5.5

4.5

5.1

0.004

Geo-political zones

North West

North East

North Central

South West

South East

South South

2.3

4.6

6.3

4.0

3.8

3.5

0.003

Age categorized

15 to 19

20 to 24

25 to 34

35 to 49

1.4

4.4

6.0

3.4

<0.0001

Tribe

Hausa

Igbo

Yoruba

Others

3.4

4.3

3.6

4.7

0.303

Religion

Islam

Christian (Catholic and Protestants)

Traditional/No religion/Others

2.6

5.3

4.2

<0.0001

Knowledge of mode of HIV transmission

Correct knowledge

Otherwise

3.9

4.5 0.495

Knowledge of mode of prevention

Correct knowledge

Otherwise

3.4

5.0 0.011

Sexual behaviour in the last 12 months

Multiple sexual partners

Did not

13.5

4.4 <0.0001

Exchange sex for a gift

Yes

5.9

4.6 0.423

Experienced STI symptoms

Had STI

Did not have STI

6.5

3.7 0.004

Age at first sex

First sex below 15 years

15 years and above

Never

Can’t remember

3.3

5.0

1.3

4.1

<0.0001

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women 215

0.0001) compared with those practising Islam or no re-

ligion. Knowledge of modes of prevention and modes of

transmission was positively associated with HIV infec-

tion. Prevalence was higher among those with incorrect

knowledge than those with correct knowledge. This as-

sociation is only significant for modes of prevention (p =

0.011). Respondents that had experienced STIs in the last

three months are almost twice as likely to be HIV posi-

tive compared with those who have never experienced

STIs (6.5 vs. 3.7) (p = 0.004).

Practising multiple sexual partnering showed a signi-

ficantly positive association with HIV status. Respon-

dents with multiple sexual partners in the last 12 months

are over 3 times more likely to be HIV positive com-

pared with those with at most one sexual partner (p <

0.0001).

3.3. Multivariate Analysis

Multiple logistic regression was used to assess possible

association between HIV status and marital status while

controlling for other factors. First, a simple logistic re-

gression of the dependence of HIV status on marital

status was fitted. This was aimed at investigating the

relationship between HIV status and marital status.

Hosmer and Lemeshow statistic [19] was used as a test

of goodness-of-fit for model checking. While respon-

dents who were currently married or cohabiting with

sexual partners were 40% (OR = 1.402, CI: 0.949, 2.073,

p = 0.09) more likely to be HIV infected, those who were

formerly married were over three times (OR = 4.014, CI:

2.347, 6.867, p < 0.0001) more likely to be HIV infected

(results not shown). In addition to marital status; demo-

graphic variables were controlled for in a multiple logis-

tic regression model at a further stage. This was aimed at

assessing the net-effect of association between HIV

status in the presence of demographic variables. Table 3

presents findings from the three models reported in this

paper. Findings showed significant association with

marital status. Respondents who were currently married

or cohabiting with sexu al partn ers are 80% more likely to

be HIV infected compared with those never married (OR

= 1.80, C.I.:1.19, 2.88). However, respondents who were

formerly married are 5.6 times more likely to be HIV

infected (OR = 5.6, CI: 3.09, 10.28).

Education and religion are found to be significantly

related to HIV status (p < 0.05). While respondents with

higher education level are 1.4 times more likely to be

HIV infected than those with no formal education (OR =

2.4, C.I: 1.21, 4.83), those with Qur’anic or Primary

education are 100% more likely to be HIV infected than

their counterparts with no formal education (OR = 2.0,

C.I.: 1.25, 3.24). Considerable regional variation exists in

HIV prevalence. All regions are less likely to be HIV

infected compared with the North Central region.

Model 2 controls for knowledge about modes of pre-

vention and transmissions in addition to the demographic

variables controlled for in model 1. The significant asso-

ciation between HIV status and knowledge that was seen

in bivariate analysis disappears with the inclusion of

other variables. The implication is that, some of the

demographic variables can explain this association seen

at bivariate level. In model 3 after sexual behaviour in-

dicators were controlled for in addition to Model 2, edu-

cation was found to be significantly asso ciated with HIV

status. Those with Qur’anic or primary education are

more than 100% more likely to be HIV infected than

those with no formal education (OR = 2.11, C.I: 1.29,

3.431). Those with secondary education are 1.51 times

more likely to be HIV infected th an those with no formal

education (OR = 2.51, C.I: 1.47, 4.30) . Thos e with high er

education are 1.41 times more likely to be HIV positive

than respondents without formal education (OR = 2.41,

C.I.18, 4.91). Also, multiple sexual partnering is signifi-

cantly related to HIV status. Respondents with multiple

sexual partners are 2.87 times more likely to be HIV

positive.

4. Discussions and Conclusions

This study examines possible determinants o f HIV infec-

tion among women age 15 - 49 years in Nigeria. Of spe-

cial interest in this paper is the very high HIV prevalence

among formerly married women. At the preliminary

analyses, marital status was explored as a proximate cor-

relate of HIV prevalence. To further understand other

correlates of HIV infection among this group, attempts

were made to control for demographic variables, knowl-

edge and sexual behaviours of the respondents. The aim

is to provide more insight into the issue of HIV preva-

lence among the female group, with a view to providing

more information for policy makers and stakeholders

interested in the health and quality of life for women in

Nigeria and by extension, in the sub Saharan region.

Findings revealed disproportionate HIV prevalence

across differential marital levels with formerly married

women worst affected. This finding could be attributed to

reasons such as lack of economic independence, lack of

formal education, low knowledge about HIV transmis-

sion and prevention which could result into poor or in-

ability to negotiate safe sex.

In this part of the world, widows are defenceless with

no provision for social security on the part of government.

On the other hand, the society often stigmatizes divorced

women. This double barrelled tragedy has its conse-

quences on women. In addition, in the Nigerian context,

and similarly in other part of Africa, women who were

once married readily draw the attention of other interested

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women

216

Table 3. Estimates of adjusted odds ratios for HIV prevalence from multiple logistic regression.

Model 1 Model 2 Model 3

95% Conf Int. 95% Conf Int. 95% Conf Int.

Characteristics OR

Lower UpperOR LowerUpper OR Lower Upper

Marital Status

Never married (ref) 1.00 1.00 1.00

Currently married/cohabiting 1.8** 1.19 2.88 1.8** 1.19 2.88 1.38 0.81 2.34

Formerly married 5.6*** 3.09 10.28 5.60*** 3.11 10.37 4.10*** 2.15 8.08

Locality

Rural (ref) 1.00 1.00

Urban 1.24 0.87 1.77 1.23 0.87 1.76 1.21 0.84 1.76

Age

35 to 49 years (ref) 1.00 1 .00 1. 00

15 to 19 years 0.53 0.18 1.51 0.54 0.19 1.56 0.51 0.67 3.95

20 to 24 years 1.52 0.86 2.68 1.53 0.87 2.71 1.51 0.83 2.73

25 to 34 years 0.63 0.29 1.37 0.63 0.29 1.37 0.58 0.26 1.28

Education

None 1.00 1.00 1.00

Qur’anic/Primary 2.00** 1.25 3.24 1.90** 1.21 3.16 2.11** 1.29 3.431

Secondary 2.30** 1.38 3.89 2.20** 1.30 3.73 2.51** 1.47 4.30

Higher 2.40* 1.21 4.83 2.20* 1.10 4.54 2.41* 1.18 4.91

Religion

Islam & Others (ref) 1.00 1.00 1.00

Christianity 2.40*** 1.59 3.85 2.40*** 1.56 3.80 2.19** 1.38 3.46

Tribe

Other tribes (ref) 1.00 1.00 1.00

Hausa 1.18 0.71 1.96 1.17 0.71 1.95 1.11 0.66 1.86

Igbo 0.89 0.40 1.99 0.89 0.40 1.99 0.97 0.43 2.21

Yoruba 0.57 0.27 1.14 0.56 0.27 1.15 0.55 0.25 1.20

Geo-political zone

North central (ref) 1.00 1.00 1.00

North West 0.40* 0.23 0.83 0.40* 0.24 0.86 0.47* 0.24 0.93

North East 0.90 0.52 1.52 0.89 0.52 1.53 0.96 0.55 1.69

South East 0.40 0.16 0.95 0.39 0.16 0.97 0.34 0.13 0.88

South South 0.30*** 0.18 0.52 0.30*** 0.18 0.52 0.29*** 0.16 0.51

South West 0.70 0.35 1.42 0.69 0.34 1.40 0.67 0.31 1.42

Knowledge of modes of HIV prevention

Have no knowledge (ref)

1.00 1.00

Have knowledge

1.19 0.83 1.66 1.17 0.83 1.67

Knowledge of HIV transmission

Have no knowledge (ref)

1.00 1.00

Have knowledge

1.05 0.71 1.54 0.99 0.66 1.49

Age at first sex

Never had sex & below age 15 (ref) 1.00

Above 15 years 1.15 0.70 1.89

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women 217

Continued

Can’t remember 1.21 0.54 2.70

Experience of sexually transmitted infections

Had no STI (ref) 1.00

Had STI 1.29 0.82 2.02

Multiple Partnering

Had no multiple sexual partners (ref) 1.00

Had multiple sexual partners 2.87** 1.46 6.02

Transactional sex

Never received gift/money for sex (ref) 1.00

Ever received gift/money for sex 0.99 0.49 1.99

*p < 0.05; **p < 0.01; ***p < 0.0001.

male partners who may promise to relieve the ir e cono mic

burden, but in disguise, only want to establish a sexual

relationship. The low ability of a large proportion of Ni-

gerian women to negotiate safer sex and offer an alterna-

tive safe method, such as use of the female condom, are

likely to have also contributed to the heightened probable

causes of the findings of this study.

The harsh economic condition that culminated into

high rate of unemployment irrespective of the educa-

tional status, and high cost of living, may also likely be

responsible fo r this problem. Th e erosion of moral v alues

in the society cannot be undermined. The high tendency

of linking people who were formerly married with be-

haviour that is considered improper and immoral may

have also prevent many women in this category from

seeking HIV Counselling and Testing (HCT). In this pa-

per, most independent variables considered were signifi-

cantly associated with HIV prevalence at bivariate level.

These relationships were further established at the mul-

tivariate level. This provided evidence that special inter-

vention strategies are necessary to stem this tide. Find-

ings revealed geographical variations in HIV prevalence

across geo-political zones. Highest prevalence was ob-

served in the North Central. To gain better insight into

the geographical variations of HIV prevalence, an analy-

sis at a highly disaggregated level of states will be u seful

for policy formulation. This is consequent on the fact that

information may be masked at the geopolitical level

since each geo-political zone comprises of six to seven

states. This will provide policy makers with adequate

tools for enhancing effective HIV & AIDS preventive

interventions. From the fitted logistic models, it became

apparent that multiple sexual partnering was a key de-

terminant of HIV infection among women with a higher

proportion of formerly married females engaged in mul-

tiple sexual partnering.

A key insightful finding from this study suggests that

gender mainstreaming in the on-going preventive efforts

should be strengthened and scaled-up, to particularly

target formerly married women. Findings further rein-

force the need for economic empowerment, social secu-

rity and welfare relief packages for women in this cate-

gory. HIV programming and policies that focuses on

formerly married women will continue to reduce the in-

cidence and prevalence of HIV and AIDS amongst this

group and at large, among women in general.

5. Limitations of the Study

The data used for this paper were obtained from a single

round of a national survey. This means that trend cannot

yet be ascertained. In order to further assess the vulner-

ability of formerly married women to contracting HIV

and AIDS, data at more time points will be desirable. As

in any cross-sectional study, causal relationships cannot

be established. Therefore, one cannot be certain whether

some of the factors precede or post-date HIV infection,

given the asymptomatic nature of HIV. Furthermore,

information on sexual behaviour was based on self-re-

ported responses by the respondents.

6. Acknowledgements

The authors would like to thank the Federal Ministry of

Health of Nigeria for granting us the permission to use

the 2007 NARHS data sets. The grants from DFID and

USAID to implement this survey are gratefully ac-

knowledged. Appreciation goes to colleagues at the Re-

search and Evaluation Division of the Society for Family

Health Nigeria for reading the first draft of this paper.

Their comments have led to substantial improvement of

this manuscript.

The work was carried out in a collaborative effort. AA,

JA, and SBA designed the survey, wrote the survey

protocol and supervised data collection. SBA and RIO

Marital Status and HIV Prevalence in Nigeria: Implications for Effective Prevention Programmes for Women

218

carried out the data analyses. All authors read and ap-

proved the final manuscriptt.

7. Conflicts of Inte rest and Sources of

Funding

None of the authors declared any conflict of interest. The

2007 National HIV & AIDS and Reproductive Health

Survey Plus from where data for this paper was gener-

ated, was funded by the United States Agency for Inter-

national Development (USAID) and the British Depart-

ment for International Development with the support of

the Federal Government of Nigeria.

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