Faithfulness without sexual exclusivity: gendered interpretations of faithfulness in rural south-western Uganda, and implications for HIV prevention programmes

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  • 1 MRC/UVRI and LSHTM Uganda Research Unit, , Uganda
  • | 2 Guttmacher Institute,1, USA
  • | 3 MRC/UVRI and LSHTM Uganda Research Unit, , Uganda
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This article explores gendered meanings of both faithfulness and sexual exclusivity within intimate long-term relationships, and the implications for HIV prevention messaging. In 2011–12, in-depth interviews were conducted with a random sample of 50 men and women (52 per cent women) in long-term relationships in rural Uganda. Confirming prior research, we found that a double standard exists for sexual exclusivity, where men define faithfulness to mean strict sexual exclusivity by their wife, but women defined it as being for both partners. However, both men and women defined fidelity to imply continued support. Fidelity was perceived to be intact if a man continued to provide material support, despite not being sexually exclusive. These findings highlight the limitations of HIV prevention strategies that emphasise faithfulness, where faithfulness is not synonymous with sexual exclusivity.

Abstract

This article explores gendered meanings of both faithfulness and sexual exclusivity within intimate long-term relationships, and the implications for HIV prevention messaging. In 2011–12, in-depth interviews were conducted with a random sample of 50 men and women (52 per cent women) in long-term relationships in rural Uganda. Confirming prior research, we found that a double standard exists for sexual exclusivity, where men define faithfulness to mean strict sexual exclusivity by their wife, but women defined it as being for both partners. However, both men and women defined fidelity to imply continued support. Fidelity was perceived to be intact if a man continued to provide material support, despite not being sexually exclusive. These findings highlight the limitations of HIV prevention strategies that emphasise faithfulness, where faithfulness is not synonymous with sexual exclusivity.

Introduction

Long-term intimate relationships, both through cohabitation and formal marriage, are commonly considered protective against HIV infection as it is assumed that both partners enter the union while they are HIV negative and remain sexually exclusive. For many years, ‘Be faithful’ was the central HIV protection strategy for HIV negative married couples in the ‘ABC strategy’ of abstinence, being faithful to one’s partner and condom use (Parikh, 2007). However, this approach has remained ineffective at curbing the spread of HIV. The prevalence of HIV among married and cohabiting couples is substantial in sub-Saharan Africa and close to two thirds of new HIV infections occur in stable married/cohabiting couples (Chemaitelly et al, 2014; Nabukenya et al, 2020). Against this background, married and cohabiting heterosexual couples constitute an important HIV prevention target population (Wabwire-Mangen et al, 2009; Beyeza-Kashesya et al, 2010). Studies in Uganda and elsewhere have reported that the greatest need for HIV prevention exists among individuals with multiple casual or long-term intimate relationships (Halperin and Epstein, 2004; Chemaitelly et al, 2014; Nalugoda et al, 2014; Ruark et al, 2018), and married or cohabiting couples have been found to have a high risk of HIV infection (Parikh 2007; Nalugoda et al, 2014).

In sub-Saharan Africa, the primary reason why men and women in long-term intimate relationships are at high risk of HIV infection is the widespread social and cultural acceptance of extra-marital partnerships (McGrath et al, 1993; Kajubi et al, 2011; Green et al, 2013; Mbonye et al, 2021). Extra-marital relationships in sub-Saharan Africa are reported to be higher among men than women (Stephenson, 2010); however, the reported prevalence of extra-marital relationships varies: for example such relationships were reported by 1.3 per cent of women and 13 per cent of men in Malawi, and 10–25 per cent of men and less than 10 per cent of women in Kenya and Uganda (Bishai et al, 2009; Clark, 2010; Kasamba et al, 2011; Maher et al, 2011; Conroy, 2014; Kwena et al, 2014a; 2014b).

Individuals in long-term intimate relationships who engage in extra-marital relationships not only increase their risk of HIV acquisition but also the risk of transmitting HIV to their marital partners. This is more so in the absence of, and/or low condom use or inconsistent condom use (Clark, 2010; Cordero Coma, 2013). Extra-marital relationships are believed to be the basis of the disproportionate levels of HIV infection in intimate relationships in sub-Saharan Africa (Halperin and Epstein, 2004; Mah and Halperin, 2010; Mah and Shelton, 2011).

Despite the widespread acknowledgement that extra-marital partnerships play a key role in HIV transmission, work to understand what fidelity means within the context of marital relationships is limited. Prior work has documented a clear double standard with regard to fidelity, where men are permitted, and sometimes even expected, to have extra-marital partners but women are strictly prohibited from doing so themselves (Delius and Glaser, 2004; Hunter, 2005; Doyle, 2013). This double standard regarding expectations of fidelity is seen to stem from gendered economic inequalities and patriarchal social structures (Hunter, 2005; Reniers and Tfaily, 2012), shaped by local norms of masculinity (Nyanzi et al, 2009; Siu et al, 2013).

While the context and factors that shape extra-marital partnerships are well documented, research to date has not interrogated what being faithful means to men and women in long-term intimate relationships, and how individuals prioritise sexual exclusivity against other attributes of their marital partnership. Understanding the meaning of faithfulness and sexual exclusivity in the context of these relationships is essential towards designing effective HIV and other sexually transmitted infection prevention strategies. The aim of this study was to examine gender differences in how faithfulness is conceptualised and the implications this has for HIV prevention messaging and programming for married and co-habiting couples.

Methods

Study setting and design

This was a qualitative cross-sectional study nested in the larger General Population Cohort (GPC), a demographic surveillance site in Kalungu district, established in 1989 to study the population dynamics of the HIV epidemic in rural south-western Uganda (Asiki et al, 2013; Riha et al, 2014). Annually, the GPC study team maps the study area and then conducts a census. Biannually the team collects data through an individual survey with consenting residents of the 25 neighbouring villages in the study area.

The majority of people in the area are Baganda, one of the dominant ethnic groups resident in central and southern Uganda. Among the Baganda, a man’s biological children belong to his clan (Roscoe, [1911] 1965: 128). A clan comprises a group of related (patri)lineages. However far away an individual and immediate family have moved, a man and his children are bound to the clan, and as members of his clan children may inherit their father’s land and property (Nahemow, 1979). Clans are exogamous, which means that the wife in a marriage belongs to a different clan from her husband and their children. While legally married women have land rights protected by law, giving them the right to security of occupancy on the family land (Naybor, 2015), in Baganda culture women share their lineage and clan with their father and brothers, not with their husband and their own children. These women retain a link, therefore, to their natal lineage and home, and some rights to their natal family’s land. If a husband dies or the marriage ends, a woman can often only remain in her husband’s home and on his land if his relatives agree, usually in the role of custodian of her children’s property (Nannyonga-Tamusuza, 2009). While fertility is important for both women and men, a woman who fails to have children or has repeated miscarriages may be sent away by her husband or find him taking a new wife in the hope of having children with her (Seeley, 2012). The Baganda norms and customs regarding land inheritance continue to be followed in the study area.

Data collection

Between August 2011 and April 2012, a sex, age and religion stratified random sample of 50 individuals (24 men and 26 women) who had reported being in an intimate relationship were selected from GPC census data collected in 2008/2009 and were still resident in the area in 2011. In the GPC dataset, a ‘long-term intimate relationship’ was defined to mean a sexual relationship that had lasted for the previous two years. However, for this present study we selected from participants within the GPC dataset who had reported being in an intimate relationship for four years prior to this study onset. Long-term intimate relationship in this study was defined to mean both marriage and cohabiting intimate relationships that had lasted for four years or more. Only one individual from each couple was selected for this study, which minimised anticipated response bias if respondents knew that their partners were also going to be interviewed.

In-depth interviews were conducted by two experienced interviewers in Luganda, a widely spoken and understood local language in the study area. The in-depth interviews took a lifecourse approach to allow the respondents to tell the story of their adult life and also to build trust between the interviewer and the respondents. In addition, the lifecourse approach was considered the most appropriate to investigate how fidelity and other relationship attributes shape relationship formation, and how these factors sustain relationships over time. Interviews lasted 1–1.5 hours and were audio recorded, but the interviewers also took field notes. In the course of telling the story of their marriage/marriages, respondents were asked about their understanding of the concept ‘faithfulness’, the ideal qualities for a long-term intimate partner, partner communication, and what men and women did to sustain their long-term intimate relationships. The audio recordings were transcribed, and together with the field notes used to write the interview transcripts.

Data analysis

Lifecourse analysis was conducted, focusing on the conceptualisation of faithfulness and what trade-offs men and women made to sustain their relationships. The concept of lifecourse can be defined as ‘the age-structured pathways across settings from birth to death’ (Elder, 1981: 509). A lifecourse perspective, unlike a life-cycle approach, looks at nonlinear patterns of change, focusing on the transitions between different stages such as marriage, employment and parenthood, which an individual may leave and then return to during their lives because they remarry or have another child. Our lifecourse analysis focused on the connections between the historical and socioeconomic contexts of the study participants and the sequence of socially defined events and relationship roles the participants enacted over time (Bengtson and Allen, 1993). Two team members conducted the first level of manual data analysis by carefully reading through each interview transcript to identify common relationship characteristics, which provided the broad codes used in the analysis for this article. The second level of analysis used these codes across the data set to identify and categorise the recurrent themes in the transcripts and develop thematic frameworks setting out the patterns in terms of the similarities and differences by sex/gender, age and life history trajectory.

In the results, the term ‘monogamy’ is used to refer to a sexually exclusive intimate formal (married) or informal (cohabitating) relationship, while the term ‘extra-marital relationship’ refers to intimate relationships outside an established, long-term formal or informal relationship.

Ethical considerations

Ethical clearance of both the larger GPC and this qualitative study was granted by the Uganda Virus Research Institute Research Ethics Committee while the Uganda National Council for Science and Technology granted the overall study approval. Study participants went through an informed consent process and were also compensated for their time.

Results

Social demographic information

The mean age of respondents was 39 years, with men being older on average than women (43 years vs. 36 years). Over 75 per cent of the women and 50 per cent of the men had only primary education, 24 per cent of the sample had secondary level education, while only 8 per cent had attained tertiary education. Nationally, 60 per cent of the population have only primary education, although the percentage of people with primary education has been steadily increasing over the past 20 years (CEIC Data). Approximately 70 per cent of the respondents were Christians (who constitute about 84 per cent of Uganda’s national population). The rest were Muslims, who comprise less than 14 per cent of the national population (Central Intelligence Agency Africa).  All were in a long-term relationship at the time of study, with the time in that relationship ranging from four to 45 years. More than half of the respondents earned an income through small-scale farming, which was supplemented with small businesses such as food vending, local brewing, brick making, tailoring, electrical wiring and carpentry. Other reported sources of income included operating a boda boda (motorcycle taxi), working in other peoples’ gardens, rental property, singing at local celebrations/events and teaching (Table 1).

Table 1:

Sociodemographic information on study participants

VariableMaleFemaleTotal
Sex24 (48%)26 (52%)50 (100%)
Age, mean (range)43 (20–70)36 (21–67)39 (20–70)
Religion
Catholic141327 (54%)
Anglican246 (12%)
Muslim8917 (34%)
Ethnicity
Ganda171633 (66%)
Rwandese4711 (22%)
Others336 (12%)
Education level
Nil022 (4%)
Primary122032 (66%)
Secondary9312 (24%)
Tertiary314 (8%)
Duration of the long-term relationship in years, mean (range)6 (4–43)8 (7–45)7 (4–45)
Number of children in a long-term relationship, mean (range)4 (0–6)3 (0–5)3.5 (0–6)
Income sources
Small-scale farming131844 (88%)
Small-scale businesses7613 (26%)
Local brewing6410 (20%)
Food vending033 (6%)
Brick making404 (8%)
Tailoring123 (6%)
Electrical wiring101 (2%)
Carpentry303 (6%)
Labouring235 (10%)
Motorcycle taxi101 (2%)
Singing at local events and teaching101 (2%)

Note: Percentage total under income sources are higher than 100% because participants reported more than one income source.

Faithfulness and extra-marital relationships

Our data revealed that all male participants defined faithfulness to mean exclusive conjugal rights for them and freedom to have extra-marital partners for themselves, if they so wished, but not for their partner. “She is decent, not a prostitute [meaning not promiscuous]. She keeps herself for me because I have never heard of rumours that she was seen with another partner” (male aged 43 years).

Twenty men further explained that they did not believe that they could compromise over the faithfulness of their partners. To the men, suspected or confirmed infidelity was a basis for temporary separation, punishment or relationship dissolution. Talking of a past relationship, one man observed:

‘When I got to know that she had another partner I didn’t take long to abandon the relationship. My friend who was the go-between started telling me that she was in a relationship with another boy. I first told her about it but she denied, saying it was rumours. I started spying to find out the truth. One time, I caught them red-handed.’ (male aged 39 years)

While being unwilling to compromise over the fidelity of their partners, more than a third (10/24) of the men reported being in extra-marital relationships themselves. “Si Malaya [she is not a prostitute/promiscuous], and when I produced a child out of the wedlock, she did not overreact” (male aged 51 years).

While the women in the study defined faithfulness to mean having exclusive conjugal rights with only one intimate partner, more than half (17/26) of the women reported that although their current intimate partnerships were sexually exclusive/faithful (monogamous) originally, the relationship had evolved to include other women.

‘In the beginning, he was not promiscuous. After having the third baby with him, he became so promiscuous. Life continued like that and after some time, he fell sick. When we went to the clinic, the health workers bled us. We were counselled and told that he was sick [infected with HIV] and I was not.’ (female aged 52 years)

In addition, nine women reported agreeing to an intimate relationship with men who were being unfaithful to their current intimate partners. However, after some time the same men became unfaithful to their new partners as well. “He showed me his bad behaviour of womanising [unfaithfulness] from the start. He came to me when he already had his wife. He pestered and pestered me for a [intimate] relationship through offering gifts. I did not take long to conceive when I accepted” (female aged 49 years).

Nevertheless, there were seven women who reported that they would never agree to an intimate relationship with a man they knew would never be faithful to them. “I wanted a partner who is not [sexually] promiscuous and one who could treat me well. I wanted a man for myself alone. I could not compromise on that” (female aged 28 years).

It was unclear whether such women would be able to adhere to their resolve, as they grew older. Twenty-one women reported an inability to dissolve an intimate relationship where sexual exclusivity was not observed. This was more so with older women who had had children in the long-term relationships.

“He was a promiscuous person. While we stayed on one island, he was moving out with a certain girl, in fact he impregnated her. Even when we shifted to another island he would cross and meet her. He had several other girls around the island, and he used to get a lot of money after selling the fish and he would not return home but rather spend all the money on women and booze. I tried to escape from him but failed because I had had children with him already.” (female aged 39 years)

However, there were three women who had not had children in a relationship who reported their determination to dissolve a relationship with an unfaithful partner. “When I met him with another sexual partner besides his wife that I used to know, I easily ended the relationship; after all we had not had children together.” (female aged 31 years).

Economic/material provision and relationships

Both male and female respondents defined faithfulness in terms of the economic and/or material support given and received. Most of the men (18/24) additionally defined faithfulness for themselves to include reliability and commitment to offering economic or material support to their female partners. “I am faithful to my partners because I have never stopped looking after them. I buy them soap, sugar, sauce, clothing and pay medical bills and school fees” (male aged 47 years).

Almost all women (23/26) defined faithfulness as stability in economic or material support. Even when they knew that their partner had other relationships they acknowledged that they were still receiving support: “…even when he has fathered children with other women, he is still faithful because he still cares for us” (female aged 39 years).

Furthermore, most of the women (18/26) reported that they compromised on their desires for fidelity to maintain access to material or financial support from their partners. In addition, the women explained that possessions like land, houses, businesses and money indicated the man’s capacity to provide material/financial support. “He buys me household use items like soap, sugar, sauce, pays medical bills and education of the children … also gives me money for taking care of my hair and cosmetics despite having other partners” (female aged 36 years).

Just over half of the women reported maintaining their intimate relationships even when the man openly engaged in extra-marital relationships, as long as he continued to provide material and/or financial support. Monetary or material faithfulness was considered more important in their relationships than sexual fidelity. “He still buys me clothes and gives me money for my hair and cosmetics though I know he has other intimate partners. That is a sign that he still loves me” (female aged 34 years).

Interestingly, there were six women who reported prioritising care for their children and relatives over the partner’s fidelity. These women explained that they considered their intimate relationships as a form of insurance in order to cover care-related costs for their relatives. “My partner owns a kibanja [a piece of land], coffee and houses for rent. Where I lived, there was no food, sugar and money. He started offering my relatives free food and that has kept me in our marriage” (female aged 38 years).

Similarly, nine women also reported staying with partners who had been unfaithful, even when they were no longer providing material or financial support, in order to secure their children’s future property. Some male partners cut off material and financial support, including resorting to selling off the couple’s property, as a strategy to dissolve the relationship.

‘My partner has other sexual partners and had started selling off the family land. I feared for the [couple’s] children’s future. Where will they be staying and burying the dead? I vowed to myself to stop him from selling any more land. I have ended up staying in this relationship that way.’ (female aged 52 years)

Such women resolutely stayed in the relationship as a strategy to safeguard access to property that would become their children’s future land.

Desire for children as a driver of extra-marital relationships

Eighteen men and 21 women reported that an inability to bear children was a key factor that led partners, especially men, into extra-marital relationships. The female respondents explained that a woman’s failure to conceive was a basis for the men to engage in infidelity while still demanding sexual exclusivity from his partner. Both men and women further reported that an inability to have children was a justifiable reason for the relationship dissolution, and that having children kept them together in the relationship. Furthermore, the men explained that a partner’s delayed conception or complete failure to bear children was a strong motivation for them to try to produce children with other intimate partners. Fertility desires justified the men’s unfaithfulness, while women’s willingness to entertain men’s unfaithfulness on these grounds helped to sustain long-term intimate relationships for them. “Men become very promiscuous when you take long to conceive. That delay becomes his basis to have affairs with other women” (female aged 47 years).

However, there were a few exceptions where delayed conception or having no children did not lead to relationship dissolution, although this did not rule out infidelity. “My partner has not rejected me despite not owning any child with him” (female aged 40 years).

In addition, some men suggested that having many children from different women provided some security; some of the children may be successful in the future and then be able to support them when they were old. “I never wanted to produce all my children from one woman. What if they all become fools? One can produce a child out of the wedlock and turns out to be a consolation” (male aged 51 years).

The majority of the men explained that having children with different qualities (including intelligence) could only happen through having extra-marital relations with different women.

Female forbearance

Almost all men (21/24) reported that their female partners exhibited patience and tolerance as well as being submissive, which accorded them the freedom to acquire extra-marital relationships while enjoying the exclusive conjugal rights of their female partners. “A woman who produces your children, will always be patient with you even when you are unable to provide all her needs all the time” (male aged 43 years).

Most of the men (21/24) further added that their female partners continued observing strict faithfulness even when the men became openly unfaithful or stopped financial or material support for their partners. “She is patient, tolerant and appreciative in that even when you give her something very little she appreciates. She keeps her calm even when she hears village rumours about a new partner. She is calm in all her ways” (male aged 51 years).

Some of the men explained that this illustrated their wives tolerance, submissiveness and determination to sustain the intimate relationship.

Discussion

In this study, we found that men and women in a south-western Ugandan setting conceptualised the term ‘faithfulness’ differently. The male conceptualisation was that faithfulness meant freedom to acquire other sexual partners with strict observance of sexual exclusivity by the female partners. In contrast, the female conceptualisation of faithfulness meant sexual exclusivity for both partners. Nevertheless, there was an intersection of both male and female conceptualisation of the term ‘faithfulness’. The intersection was that faithfulness included continued observation of the economic and material support obligation by a male sexual partner. Women were willing to compromise on their desires for sexual exclusivity if economic and material support was still being maintained. This in turn puts them at potential risk of HIV infection, in an area with a generalised HIV epidemic (Agol et al, 2014; Siu et al, 2014; Fleming et al, 2016). In contrast, men seemed to have both the power and means to pursue extra-marital partners/relationships, and may in fact feel pressurised to do so based on the importance of childbearing, the perceived benefits to multi-partner childbearing and the intricate link between childbearing and meanings of manhood. The variation between men and women’s conceptualisation of faithfulness highlights that this seems to be rooted in cultural practices, beliefs and the socialisation of men and women (Agol et al, 2014). Merely promoting faithfulness as an HIV prevention strategy, without addressing the underlying social and cultural factors that shape this practice, is therefore likely to be ineffective (Chirwa et al, 2011).

Similar social and cultural factors upholding the norm of male infidelity have been found in other contexts. In South Africa and Uganda, having extra-marital partners or multiple sexual partners was found to be a status symbol on which masculinity, attributes of intelligence and success were measured (Varga, 1997; Parikh, 2007; Siu et al, 2014). Peer pressure has also been reported to play a role. In Malawi, men were more likely to have extra-marital partners if others in their social network were already doing so (Clark, 2010; Chirwa et al, 2011). Other studies have reported that migrant and wealthier men were more likely to have extra-marital relationships (Boerma et al, 2002; Mishra et al, 2008; Kwena et al, 2014a; 2014b; Agnarson et al, 2015).

Our study also established that fertility desires, including a desire for children from multiple partners, were used to justify men’s extra-marital partnerships and women’s acceptance of their partners not being sexually exclusive. The commonly reported explanation was that fathering many children from different women worked as a fall-back position in an event that children from a particular mother were not intelligent. A study in Rakai district, a place close to our study area with similar population dynamics to our study site, found that being formally married and having children were prized masculine attributes (Mathur et al, 2016). Barriers to achieving these goals led young men to apply other strategies to achieve an idealised masculinity, such as having unprotected sex with multiple partners. Studies elsewhere have reported that one of the drivers of men’s desire for children was ensuring lineage continuity and prosperity (Beyeza-Kashesya et al, 2009; 2010; Nattabi et al, 2009). However, it is through the pursuit of obtaining these masculine ideals that men and women are put at increased risk of HIV infection.

We found that women were willing to compromise on their desires for sexual exclusivity if their partners maintained material and financial support; in fact, faithfulness was sometimes defined as material and financial fidelity, rather than sexual exclusivity. The prioritisation of economic fidelity was linked to the desire to safeguard their children’s future resources like land and inheritance. Men were willing to maintain this economic and material support as long as their female partners remained sexually exclusive with them. The Baganda (the main tribe in our study area) patrilineal norms favour men at the expense of women through the customary land tenure system. Women do have access to land use through their fathers, brothers and husbands. However, there are differences in land ownership and access within and outside the customary land tenure system among women due to age, marital status, household composition, residence and social status, which vary across the lifecourse (Asiimwe, 2001; Joireman, 2008; Doss et al, 2012; 2014; Kabahinda, 2017; Rutakumwa et al, 2017). In some cases, women were left with few options when their husbands decided to sell off part or the entire family land and marital home.

Overall, the concept of faithfulness to promote HIV prevention is faced with operational limitations. This stems from the different ways in which faithfulness is conceptualised between men and women and how these preferences are shaped by their different economic realities. A study from the Democratic Republic of the Congo reported that it was hard to practise faithfulness in an environment where women and their parents were poor and unable to provide for growing children (Kanda and Mash, 2018). Studies from Botswana and Uganda also reported that faithfulness as an HIV prevention message was a lower priority compared with more technological and biomedical preventive measures, presumably due to the challenges to practise it given the high prevalence of extra-marital relations (Halperin and Epstein, 2004; Green et al, 2006; 2013; Hearst et al, 2012; Kanda and Mash, 2018). Our findings underscore that HIV prevention approaches cannot simply rest on stated norms of sexual behaviour, but instead must also address the social and economic conditions that underpin both men and women’s sexual decision making.

A key strength of our study was the use of the lifecourse technique in both data collection and analysis, which helped us to minimise the social desirability bias which could have resulted if we had only asked about relationships and marriage; our respondents told the stories of their marriages as a part of their life story narratives. Another study strength was the recruitment of only one partner out of the couple, which helped to prevent respondents portraying their views and those of their partners positively during the interview. In our study, we used local social science interviewers with over 15 years’ data collection experience who were able to encourage the respondents to speak freely and frankly.

Our study had several limitations, including the reliance on cross-sectional data. Faithfulness changes over the course of relationships and may be shaped by changing social norms and generational shifts (Parikh 2007; Bantebya et al, 2014; Seeley 2015), which is difficult to gauge through data collected over a limited period of time. However, the application of the lifecourse technique in interviewing and data analysis helped to generate detailed understanding of what sustains long-term relationships, and that this may be fluid and change not only across time within relationships but also in wider society.

Conclusion

The men’s advantaged economic position in society and their belief in the privileges that come with local norms of masculinity, coupled with the women’s less advantaged economic position, form the foundation for a double standard in the gendered meaning of faithfulness. For men, faithfulness can exist without sexual exclusivity, while that exclusivity is prized by women. Understanding that faithfulness may be hard to achieve in marriage, and the compromises made by women in order to maintain faithful economic and material relations within an intimate relationship, is an important finding of this study. Such information could be helpful in designing more effective HIV prevention policies and messages by using such terms carefully, mindful of local definitions.

Notes

1

The author’s affiliation is included for information purposes only; this work was not conducted under the auspices of the Guttmacher Institute. The views expressed herein are those of the authors and do not necessarily reflect the views of the Guttmacher Institute.

Funding

The MRC/UVRI and LSHTM is jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. JS is a faculty member of THRiVE-2, a DELTAS Africa grant # DEL-15-011 from Wellcome Trust grant # 107742/Z/15/Z and the UK government.

Acknowledgements

We acknowledge the contributions of the MRC/UVRI and LSHTM Uganda Research Unit General Population Cohort study team and Professor Anne Katahoire, Child Health and Development Centre, Makerere University, Kampala. We are particularly grateful to all the study participants for the time and information they shared with us.

Conflict of interest

The authors declare that there is no conflict of interest.

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  • Chirwa, E., Malata, A. and Norr, K. (2011) HIV prevention awareness and practices among married couples in Malawi, Malawi Medical Journal, 23(2): 327. doi: 10.4314/mmj.v23i2.70745

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  • Clark, S. (2010) Extra-marital sexual partnerships and male friendships in rural Malawi, Demogr Res, 22: 128. doi: 10.4054/DemRes.2010.22.1

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  • Conroy, A.A. (2014) Marital infidelity and intimate partner violence in rural Malawi: a dyadic investigation, Archives of Sexual Behaviour, 43(7): 130314. doi: 10.1007/s10508-014-0306-2

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  • Cordero Coma, J. (2013) When the group encourages extramarital sex: difficulties in HIV/AIDS prevention in rural Malawi, Demogr Res, 28(30): 84980. doi: 10.4054/DemRes.2013.28.30

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  • Delius, P. and Glaser, C. (2004) The myths of polygamy: a history of extra-marital and multi-partnership sex in South Africa, South African Historical Journal, 50(1): 84114. doi: 10.1080/02582470409464797

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  • Doss, C., Truong, M., Nabanoga, G. and Namaalwa, J. (2012) Women, marriage and asset inheritance in Uganda, Development Policy Review, 30(5): 597616. doi: 10.1111/j.1467-7679.2012.00590.x

    • Search Google Scholar
    • Export Citation
  • Doss, C., Meinzen-Dick, R. and Bomuhangi, A. (2014) Who owns the land? Perspectives from rural Ugandans and implications for Large-scale land acquisitions, Feminist Economics, 20(1): 76100. doi: 10.1080/13545701.2013.855320

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  • Fleming, P.J., DiClemente, R.J. and Barrington, C. (2016) Masculinity and HIV: dimensions of masculine norms that contribute to men’s HIV-related sexual behaviors, AIDS Behav, 20(4): 78898. doi: 10.1007/s10461-015-1264-y

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    • Search Google Scholar
    • Export Citation
  • Green, E.C., Kajubi, P., Ruark, A., Kamya, S., D’Errico, N. and Hearst, N. (2013) The need to reemphasize behavior change for HIV prevention in Uganda: a qualitative study, Stud Fam Plann, 44(1): 2543. doi: 10.1111/j.1728-4465. 2013.00342.x

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    • Export Citation
  • Halperin, D.T. and Epstein, H. (2004) Concurrent sexual partnerships help to explain Africa’s high HIV prevalence: implications for prevention, The Lancet, 364(9428): 46. doi: 10.1016/S0140-6736(04)16606-3

    • Search Google Scholar
    • Export Citation
  • Hearst, N., Kajubi, P., Hudes, E.S., Maganda, A.K. and Green, E.C. (2012) Prevention messages and AIDS risk behavior in Kampala, Uganda, AIDS Care, 24(1): 8790. doi: 10.1080/09540121.2011.582478

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    • Export Citation
  • Hunter, M. (2005) Cultural politics and masculinities: Multiple‐partners in historical perspective in KwaZulu‐Natal, Culture, Health and Sexuality, 7(3): 20923. doi: 10.1080/13691050412331293458

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  • Joireman, S.F. (2008) The mystery of capital formation in Sub-saharan Africa: women, property rights and customary law, World Development, 36(7): 123346. doi: 10.1016/j.worlddev.2007.06.017

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  • Kabahinda, J. (2017) Culture and women’s land rights on the ground in Uganda, Development in Practice, 27(6): 82838. doi: 10.1080/09614524.2017.1343801

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    • Export Citation
  • Kajubi, P., Green, E.C., Hudes, E.S., Kamya, M.R., Ruark, A.H. and Hearst, N. (2011) Multiple sexual partnerships among poor urban dwellers in Kampala, Uganda, Journal of Acquired Immune Deficiency Syndromes, 57(2): 1536. doi: 10.1097/QAI.0b013e318211b466

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  • Kasamba, I., Sully, E., Weiss, H.A., Baisley, K. and Maher, D. (2011) Extraspousal partnerships in a community in rural Uganda with high HIV prevalence: a Cross-sectional population-based study using linked spousal data, Journal of Acquired Immune Deficiency Syndromes, 58(1): 10814. doi: 10.1097/QAI.0b013e318227af4d

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  • Mah, T.L. and Halperin, D.T. (2010) Concurrent sexual partnerships and the HIV epidemics in Africa: evidence to move forward, AIDS Behav, 14(1): 116, dicussion 34–7. doi: 10.1007/s10461-008-9433-x

    • Search Google Scholar
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    • Export Citation
  • Mbonye, M., Siu, G. and Seeley, J. (2021) Conflicted masculinities: understanding dilemmas and (re)configurations of masculinity among men in Long-term relationships with female sex workers, in Kampala, Uganda, Culture, Health and Sexuality, 126, doi: 10.1080/13691058.2021.1891569.

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    • Search Google Scholar
    • Export Citation
  • Chirwa, E., Malata, A. and Norr, K. (2011) HIV prevention awareness and practices among married couples in Malawi, Malawi Medical Journal, 23(2): 327. doi: 10.4314/mmj.v23i2.70745

    • Search Google Scholar
    • Export Citation
  • Clark, S. (2010) Extra-marital sexual partnerships and male friendships in rural Malawi, Demogr Res, 22: 128. doi: 10.4054/DemRes.2010.22.1

    • Search Google Scholar
    • Export Citation
  • Conroy, A.A. (2014) Marital infidelity and intimate partner violence in rural Malawi: a dyadic investigation, Archives of Sexual Behaviour, 43(7): 130314. doi: 10.1007/s10508-014-0306-2

    • Search Google Scholar
    • Export Citation
  • Cordero Coma, J. (2013) When the group encourages extramarital sex: difficulties in HIV/AIDS prevention in rural Malawi, Demogr Res, 28(30): 84980. doi: 10.4054/DemRes.2013.28.30

    • Search Google Scholar
    • Export Citation
  • Delius, P. and Glaser, C. (2004) The myths of polygamy: a history of extra-marital and multi-partnership sex in South Africa, South African Historical Journal, 50(1): 84114. doi: 10.1080/02582470409464797

    • Search Google Scholar
    • Export Citation
  • Doss, C., Truong, M., Nabanoga, G. and Namaalwa, J. (2012) Women, marriage and asset inheritance in Uganda, Development Policy Review, 30(5): 597616. doi: 10.1111/j.1467-7679.2012.00590.x

    • Search Google Scholar
    • Export Citation
  • Doss, C., Meinzen-Dick, R. and Bomuhangi, A. (2014) Who owns the land? Perspectives from rural Ugandans and implications for Large-scale land acquisitions, Feminist Economics, 20(1): 76100. doi: 10.1080/13545701.2013.855320

    • Search Google Scholar
    • Export Citation
  • Doyle, S. (2013) Before HIV. Sexuality, Fertility and Mortaility in East Afirca 1900–1980, Oxford: Oxford University Press.

  • Elder, G.H. (1981) History and the family: the discovery of complexity, Journal of Marriage and the Family, 43: 489519. doi: 10.2307/351752

    • Search Google Scholar
    • Export Citation
  • Fleming, P.J., DiClemente, R.J. and Barrington, C. (2016) Masculinity and HIV: dimensions of masculine norms that contribute to men’s HIV-related sexual behaviors, AIDS Behav, 20(4): 78898. doi: 10.1007/s10461-015-1264-y

    • Search Google Scholar
    • Export Citation
  • Green, E.C., Halperin, D.T., Nantulya, V. and Hogle, J.A. (2006) Uganda’s HIV prevention success: the role of sexual behavior change and the national response, AIDS Behav, 10(4): 33546; discussion 47–50. doi: 10.1007/s10461-006-9073-y

    • Search Google Scholar
    • Export Citation
  • Green, E.C., Kajubi, P., Ruark, A., Kamya, S., D’Errico, N. and Hearst, N. (2013) The need to reemphasize behavior change for HIV prevention in Uganda: a qualitative study, Stud Fam Plann, 44(1): 2543. doi: 10.1111/j.1728-4465. 2013.00342.x

    • Search Google Scholar
    • Export Citation
  • Halperin, D.T. and Epstein, H. (2004) Concurrent sexual partnerships help to explain Africa’s high HIV prevalence: implications for prevention, The Lancet, 364(9428): 46. doi: 10.1016/S0140-6736(04)16606-3

    • Search Google Scholar
    • Export Citation
  • Hearst, N., Kajubi, P., Hudes, E.S., Maganda, A.K. and Green, E.C. (2012) Prevention messages and AIDS risk behavior in Kampala, Uganda, AIDS Care, 24(1): 8790. doi: 10.1080/09540121.2011.582478

    • Search Google Scholar
    • Export Citation
  • Hunter, M. (2005) Cultural politics and masculinities: Multiple‐partners in historical perspective in KwaZulu‐Natal, Culture, Health and Sexuality, 7(3): 20923. doi: 10.1080/13691050412331293458

    • Search Google Scholar
    • Export Citation
  • Joireman, S.F. (2008) The mystery of capital formation in Sub-saharan Africa: women, property rights and customary law, World Development, 36(7): 123346. doi: 10.1016/j.worlddev.2007.06.017

    • Search Google Scholar
    • Export Citation
  • Kabahinda, J. (2017) Culture and women’s land rights on the ground in Uganda, Development in Practice, 27(6): 82838. doi: 10.1080/09614524.2017.1343801

    • Search Google Scholar
    • Export Citation
  • Kajubi, P., Green, E.C., Hudes, E.S., Kamya, M.R., Ruark, A.H. and Hearst, N. (2011) Multiple sexual partnerships among poor urban dwellers in Kampala, Uganda, Journal of Acquired Immune Deficiency Syndromes, 57(2): 1536. doi: 10.1097/QAI.0b013e318211b466

    • Search Google Scholar
    • Export Citation
  • Kanda, L. and Mash, R. (2018) Reasons for inconsistent condom use by young adults in Mahalapye, Botswana, African Journal of Primary Health Care and Family Medicine, 10(1): e1e7. doi: 10.4102/phcfm.v10i1.1492

    • Search Google Scholar
    • Export Citation
  • Kasamba, I., Sully, E., Weiss, H.A., Baisley, K. and Maher, D. (2011) Extraspousal partnerships in a community in rural Uganda with high HIV prevalence: a Cross-sectional population-based study using linked spousal data, Journal of Acquired Immune Deficiency Syndromes, 58(1): 10814. doi: 10.1097/QAI.0b013e318227af4d

    • Search Google Scholar
    • Export Citation
  • Kwena, Z., Mwanzo, I., Bukusi, E., Achiro, L. and Shisanya, C. (2014a) A cross-sectional survey of prevalence and correlates of couple sexual concurrency among married couples in fishing communities along Lake Victoria in Kisumu, Kenya, Sex Transm Infect, 90(2): 13944. doi: 10.1136/sextrans-2013-051168

    • Search Google Scholar
    • Export Citation
  • Kwena, Z., Mwanzo, I., Shisanya, C., Camlin, C., Turan, J., Achiro, L. and Bukusi, E. (2014b) Predictors of extra-marital partnerships among women married to fishermen along Lake Victoria in Kisumu County, Kenya, PLoS One, 9(4): e95298.

    • Search Google Scholar
    • Export Citation
  • Mah, T.L. and Halperin, D.T. (2010) Concurrent sexual partnerships and the HIV epidemics in Africa: evidence to move forward, AIDS Behav, 14(1): 116, dicussion 34–7. doi: 10.1007/s10461-008-9433-x

    • Search Google Scholar
    • Export Citation
  • Mah, T.L. and Shelton, J.D. (2011) Concurrency revisited: increasing and compelling epidemiological evidence, Journal of International AIDS Society, 14: 33. doi: 10.1186/1758-2652-14-33

    • Search Google Scholar
    • Export Citation
  • Maher, D., Waswa, L., Karabarinde, A. and Baisley, K. (2011) Concurrent sexual partnerships and associated factors: a Cross-sectional Population-based survey in a rural community in Africa with a generalised HIV epidemic, BMC Public Health, 11: 651. doi: 10.1186/1471-2458-11-651

    • Search Google Scholar
    • Export Citation
  • Mathur, S., Higgins, J.A., Thummalachetty, N., Rasmussen, M., Kelley, L., Nakyanjo, N., Nalugoda, F. and Santelli, J.S. (2016) Fatherhood, marriage and HIV risk among young men in rural Uganda, Culture, Health and Sexuality, 18(5): 53852. doi: 10.1080/13691058.2015.1091508

    • Search Google Scholar
    • Export Citation
  • Mbonye, M., Siu, G. and Seeley, J. (2021) Conflicted masculinities: understanding dilemmas and (re)configurations of masculinity among men in Long-term relationships with female sex workers, in Kampala, Uganda, Culture, Health and Sexuality, 126, doi: 10.1080/13691058.2021.1891569.

    • Search Google Scholar
    • Export Citation
  • McGrath, J.W., Rwabukwali, C.B., Schumann, D.A., Pearson-Marks, J., Nakayiwa, S., Namande, B., Nakyobe, L. and Mukasa, R. (1993) Anthropology and AIDS: the cultural context of sexual risk behavior among urban Baganda women in Kampala, Uganda, Social Science and Medicine, 36(4): 42939. doi: 10.1016/0277-9536(93)90405-S

    • Search Google Scholar
    • Export Citation
  • Mishra, S., Swain, B.K. and Babu, B.V. (2008) Sexual risk behaviour among migrant tribals living in urban slums of an eastern Indian city: implications on the spread of HIV, Coll Antropol, 32(1): 14.

    • Search Google Scholar
    • Export Citation
  • Nabukenya, A.M., Nambuusi, A. and Matovu, J.K.B. (2020) Risk factors for HIV infection among married couples in Rakai, Uganda: a cross-sectional study, BMC Infectious Diseases, 20(1): 198. doi: 10.1186/s12879-020-4924-0

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  • 1 MRC/UVRI and LSHTM Uganda Research Unit, , Uganda
  • | 2 Guttmacher Institute,1, USA
  • | 3 MRC/UVRI and LSHTM Uganda Research Unit, , Uganda

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