The Implications of Early Marriage for HIV/AIDS Policy

This brief intends to address the marginalisation of married adolescents in adolescent HIV/AIDS policies and programmes and to give greater attention to the role that early marriage plays in potentially exposing girls and young women to severe reproductive health risks, including HIV. "Protecting these young women may not only serve to help prevent the disease from spreading from ‘high-risk’ groups to the general population in their own generation, but also to the next generation by reducing mother-to-child-transmission among this most intensive childbearing group." It is based on a background paper prepared for the World Health Organization (WHO)/United Nations Population Fund (UNFPA)/Population Council Technical Consultation on Married Adolescents, held in Geneva, Switzerland, December 9-12 2003.

The document describes the issues and risks of early marriage and gives guiding information for country-specific risk assessments, along with case studies. It describes possible prevention efforts in a framework that begins with pre-marriage options, and includes the marriage transition, the first year of marriage, and the first birth. Prevention efforts involving communication might include training of secular and religious leaders for support of delaying marriage to at least 18 years of age and calling attention to HIV transmission risks within marriage. Other specific policy measures for mitigating the risks of contracting and spreading HIV via marriage include:

1. Evaluating the legal basis for eliminating under age/child marriages.
   
2. Developing community-based initiatives that redefine acceptable ages of marriage and offer incentives to parents and girls to delay marriage to legal age - for example, linking schooling to working for wages and looking to the literature on efforts to reduce the extensiveness and degree of female genital cutting (FGC), including combining the following: accurate information dissemination; social mobilisation of parents, elders, and other leaders in the community; retraining of practitioners of genital cutting; and - in some instances - legal action against purveyors of FGC or parents - and, where these efforts are already in place, possibly building on some of these structures.
   
3. Emphasising the importance of safe, age-appropriate spouses - Since older spouses seem to pose a greater risk of HIV transmission, policies designed to minimise or eliminate the practice of brideprice or other economic exchanges at the time of marriage may help to diminish age differences between spouses.
   
4.  Using evidence to challenge the common image of the irresponsible and dangerous, sexually active, unmarried adolescent contrasted with presumably safe, mutually monogamous sexual relations within marriage.
   
5. Using social process (pre-marriage ceremonies, celebrations, customs, and registrations) to seek a series of entry points for promoting information about couple communication, voluntary counselling and testing, condoms, sexual health, safer marriage, and childbearing - including ensuring healthy, disease-free children - to newly engaged couples.
   
6. Characterising the first year of marriage as a “health zone” on the part of public health professionals, including:
   • Fostering greater intimacy and information exchange between partners.
     
   • Increasing the acceptability of delaying childbearing for at least one year while determining HIV status of the partners.
     
   • Destigmatising condoms and protection from sexually transmitted infections (STIs)/HIV within marriage by reshaping the image of condoms to represent not distrust or infidelity but rather respecting a partner’s health, protecting one’s own health, and preserving future fertility.
     
7. Refining maternal health and adolescent sexual and reproductive health services to bring married adolescents into the circle of care.
   
8. Intervening during the first pregnancy to create awareness of HIV and enhancing safety within marriage through services at first birth. 

The authors conclude that married adolescent girls are outside the conventionally defined research interests, policy diagnosis, and basic interventions (family life education, youth centres, peer education, and youth-friendly health services) that have underpinned adolescent reproductive health programming and many HIV/AIDS prevention activities. This population segment would benefit from promoting later marriage and information on and empowerment to discuss condom use within marriage. "Denying the risks of marriage and holding interventions at bay outside the private sphere of marriage will not protect those inside it from the increasing threat of HIV."