Health researchers have uncovered a silent HIV epidemic among spouses, where they are infecting each other, contributing 11 percent of total new infections in the country. This is driven by secrecy, extramarital affairs, lack of pre-marital or pre-relationship testing, and low uptake of prevention tools. Ms Anne Nabukenya and colleagues at Makerere University School of Public Health investigated drivers of infections among couples in Rakai District, one of Uganda’s longest-studied HIV hotspots. She observed that ‘married couples can be at an elevated risk of HIV infection.’
Of the 664 couples studied, 6.4 percent were in HIV-discordant relationships (one partner is HIV-negative and another is HIV-positive) while 5.8 percent were in concordant HIV-positive relationships (in which both partners were HIV-positive). But the 87.8 percent were in concordant HIV-negative relationships (both partners are HIV negative). ‘Of those in HIV-discordant relationships, 52.4 percent had the male partner living with HIV, while 47.6 percent had the female partner living with HIV. Overall, 12.2 percent of couples had at least one partner living with HIV,’ the report reads.
The researchers found that the strongest predictors of HIV infection within marriage are living in a high-prevalence community, having had multiple previous marriages or couple relationships, and engaging in extramarital sex. ‘Individuals who had been in three or more previous couple relationships were almost four times more likely to be infected with HIV than those in the first marital union, while individuals who reported having more than one sexual partner were almost two times more likely to be in an HIV-infected relationship,’ the report reads further.
The 2023/2024 Joint Aids Review Report sheds more light on the matter. For those in marriages or cohabitating couples who were previously all negative, there were 5,300 new HIV infections. This was based on a study on a population of 5.4 million. According to the report, 11 percent of the 37,000 new infections were contributed by marrieds and those in cohabiting relationships.
The report also shows that more than 60 percent of new infections are contributed by females (36 percent never married; 12.2 percent previously married; and 9.8 percent female sex workers). The Rakai study dug deeper, highlighting the danger of remarriage or entering another couple relationship without testing.
Many people enter new unions or couple relationships after separation or widowhood without knowing their status, unknowingly carrying the virus from past relationships into the next relationship.
Low testing among couples
Canon Dr Ruth Senyonyi, the chairperson of the Uganda Aids Commission (UAC) Board, emphasised this concern around low testing among couples. ‘There is low uptake of couple testing, and the couples are not testing together. One goes and tests secretly, finds out they are positive, they come back and keep quiet,’ she said. ‘They start on medication, they don’t tell the partner. They should be going together [for testing], we encourage that,’ she added. Some people may be hesitant to reveal their status for fear of rejection, violence from the other partner, or being accused of infidelity, according to activists and researchers.
Testing positive for HIV doesn’t automatically mean the other partner is also positive, according to researchers. HIV positive partners are less likely to transmit the virus to HIV negative partners if their viral load is suppressed and undetectable, according to scientists. The low viral load can either be achieved naturally by an ‘elite controller’ or, more commonly, due to effective Anti-retroviral drug. The HIV negative partner may also have some natural bodily mechanisms which reduce HIV susceptibility or protect them totally. But this risk of breakthrough infection increases if the viral load of the HIV partner rises, often due to low medication adherence.
This can be prevented if the HIV negative partner uses and adheres to freely available Pre-exposure prophylaxis (PrEP), vaginal ring or condoms during intercourse with the partner. Ms Ritah Atuhaire from Kampala International University, in a separate study conducted in Bushenyi District, western Uganda, among 85 couples, found that unfaithfulness among partners a risk factor for HIV infection in marriage. Their 2023 report shows that 51 percent of the couples have ever had sex outside their relationship, while a few, 14 percent, never had sex outside their relationship.
Even cultural and religious practices are under scrutiny. While some have suggested polygamy could be fuelling the epidemic, the UAC director of planning, Dr Vincent Bagambe, pushed back. ‘It all boils down to the individual and how you are managing your relationship. Even if it is polygamy, you are still talking about a relationship between you and your partner,’ Dr Bagambe explained.
‘We have seen that HIV prevalence among the Muslim couples is not necessarily higher than that of the general population. But it is an area that requires more investigations,’ he added. Compared to Christianity, the Islamic religion has a higher tolerance of polygamy.
National surveys appear to support Dr Bagambe’s caution. In both the 2004/2005 and 2011 sero-behavioural surveys, Muslims consistently recorded the lowest HIV prevalence among major religious groups at five percent in 2004/2005 and 5.7 percent in 2011, compared with rates above seven percent among Protestants and Catholics in the same period.
According to UAC, pregnant women who test negative at their first antenatal visit sometimes seroconvert and test HIV-positive during pregnancy or while breastfeeding, indicating that they contracted infection midway. ‘The source of the infection maybe the spouse or from outside,’ observed Dr Nelson Musoba, the UAC Director General.
He said some of these mothers will also be considered for the long-acting injectable drug for HIV prevention, lenacapavir, after risk assessment, when the government rolls out the drug next year. Discordant couples, where one partner is HIV-positive and the other negative, are another priority group for the injectable drug.
‘If there are two people in a discordant relationship, the HIV negative partner is at risk of acquiring HIV, especially if the viral load from the HIV-positive partner is not controlled,’ Dr Musoba added. In the 2023/2024 Joint Aids Review Report, for those in marriages or cohabitating couples where one was previously HIV-positive and the other negative, there were 67 new infections in a population of 72,565, where the man was the one who was initially infected. While in a population of 236,000 where the female was the one initially positive, there were 117 HIV infections
Statistics from UAC 2025 fact sheet
– Four percent of women aged 15-49 reported having more than one partner.
– 15 percent of women had sex with a person who was neither their husband nor lived with them.
– 23 percent of men aged 15-49 reported having more than one sexual partner
– 34 percent of men reported having sex with a person who was neither their wife nor lived with them.