Factors Affecting Married, Monogamous Women’s Risk of HIV Infection in India: Traditional Gender Roles and Husbands’ High-Risk Sexual Behaviours

International license. Cite this article : Leslie KAA. Factors Affecting Married, Monogamous Women’s Risk of HIV Infection in India: Traditional Gender Roles and Husbands’ High-Risk Sexual Behaviours. Int J Med Public Health. 2019;9(4):112-7. ABSTRACT The prevalence of HIV in India has been steadily increasing over the last three decades and India is now thought to possess the third largest number of cases out of any country in the world. India is currently experiencing a significant feminization of its HIV epidemic; a large proportion of new HIV infections are observed in women and the majority of all HIV cases in India are contracted by heterosexual transmission. While married, monogamous women were initially considered at low risk for contracting HIV in India, they are now recognized as being a high-risk group, as the prevalence of HIV among women who have ever been married is higher than the national average. Because the vast majority of these women report that unprotected intercourse with their husband is their only risk factor for HIV infection, it can be concluded that they have likely been infected by their husband. This review investigates the principal factors involved in the infection of married, monogamous Indian women with HIV by their husbands, within the context of traditional Indian gender roles and cultural expectations of behaviour. Specifically, this article examines three high-risk sexual behaviour commonly perpetrated by Indian men: extramarital sexual relations, lack of condom use during sex and intimate partner violence. Given the magnitude of the problem of HIV in India and its implications for the spread of HIV throughout the world, the topic of women’s risk of HIV infection in India is clearly of immense public health significance.


INTRODUCTION
The prevalence of HIV in India has been steadily increasing since the first reported cases were observed in commercial sex workers in 1986 period. 1 While there is some discrepancy between current estimates of HIV infections in India, ranging between 2.1 million 2 and 2.5 million, 3 India is judged to possess the third largest number of cases out of any country in the world. 4 Recent surveillance reports have suggested that it will be necessary to control HIV infections in India if infections around the world are to be controlled. 5 India is currently experiencing a significant feminization of its HIV epidemic; 38% of new HIV infections are observed in women, 6 and 84% of all HIV cases in India are contracted by heterosexual transmission. 7 While married, monogamous women were initially considered at low risk for contracting HIV in India, they are now recognized as being a high-risk group, as the prevalence of HIV among women who have ever been married is higher than the national average. 3 This discovery was bewildering at first, seeing as 94% of married HIV-positive women report being monogamous and indicate that heterosexual sex with their husband is their only risk factor for infection. 8 As well, since sexual debut in Indian women occurs predominantly within marriage, 3 98% of In-dian women report having only one lifetime sexual partner. 6 It is therefore now evident that married, monogamous women in India are being infected with HIV by their husbands. Since the rate of HIV transmission among heterosexuals in India is expected to increase by 2% to 3% per year, 9 it is of paramount importance to ask the question: what are the principal factors involved in the infection of monogamous, married women with HIV by their husbands? This question will be addressed by this article, in which it is argued that particular high-risk sexual behaviours committed by many Indian men-extramarital sexual relations, lack of condom use during sex and intimate partner violence-lead to HIV infection in married, monogamous women in India. These behaviours will be examined within the context of traditional Indian gender roles and cultural expectations of behaviour within the home space; culturally relevant prevention strategies targeting these highrisk sexual behaviours will then be explored. and a psychological concept; it is often thought of in a positive light as somewhere warm and secure, an environment in which one is confident of one's identity and history, to which one can withdraw from the chaos of employment and outside life. 10 Importantly, traditional ideologies of the home also encompass the social, economic and sexual relations of its inhabitants, usually consisting of one's spouse and children. 11 Gender roles constitute a fundamental part of the concept of the home space since adults' roles and responsibilities within the home are often dictated by their gender. 12 While gender is a culture-specific construct, meaning that men and women's expected behaviours differ in various cultures, men typically act as the breadwinner of the family and are responsible for making important household decisions, while women are accountable for reproductive and productive actions within the home. 10 Inequalities in power between men and women, resulting from the maintenance of patriarchal relations in the home, mean that men often gain control over significant decisions involving his wife, such as where she is permitted to spend time, how she dresses and when, where and how sex occurs. 13 Over time, the repeated treatment of women in this controlling manner influences the gender roles considered appropriate within the home space and on a broader scale can even become a fundamental feature of a nationality. 10 Such is the case in India, a country possessing a staunchly patriarchal society in which ideas such as the subordination of women are thoroughly entrenched. Throughout the country-regardless of whether one's family is rural or urban, affluent or poor-a double standard is often in effect, allowing men the freedom to pursue their own desires while women are customarily expected to remain virgins until marriage and then dedicate their lives to pleasing their husbands and taking care of the home. 9 Women typically have little social, economic, or political power, whereas men traditionally act as the head of the household. 14 These gender norms pose enormous consequences for the transmission of HIV.

Husbands' Extramarital Sexual Relations
A prime example of this is can be observed with extramarital sexual relations. Unlike the vast majority of Indian women, who have only one lifetime sexual partner 7 and would face severe punishment if they were thought to be unfaithful to their husband, 6 it is a common occurrence for Indian men to engage in extramarital sexual activity. In fact, infidelity perpetrated by men is tolerated by society and widely accepted by their wives. 9 The belief that a variety in sexual partners is crucial to a man's masculine nature is deeply established in Indian culture. 13 According to one survey, between 15% and 19% of married Indian men currently have multiple sexual partners. 15 When married men do have sexual relations outside of their marriage, they usually seek out commercial sex workers for this purpose. In a 2006 study conducted in Pune, 80% of married men who were attending a Sexually Transmitted Infection (STI) clinic admitted to ever having sex with a commercial sex worker and 65% did not use a condom during these encounters; this behaviour was correlated with a significantly higher risk of HIV infection than among men who had never paid for sex. 7 In a 2012 study carried out in Lucknow, 43% of HIV-positive men revealed that they had had extramarital sex with commercial sex workers. 16 Interestingly, each of these particular men's wives-who were also HIVpositive-reported that they had remained faithful to their husbands, implying that they had been infected with HIV by their husbands, who in turn had been infected by commercial sex workers. 16 Nevertheless, many women believe that their husbands require sex to relieve stress while traveling for work and condone the use of commercial sex workers to fulfill this need. 9 Recent research has highlighted the disinhibiting effect of alcohol on men's decisions to have extramarital sex with commercial sex workers and to do so without using a condom; this is cited as a primary factor for transmission of HIV. 17 Daily drinking is associated with extramarital sex and higher level drinkers report having higher numbers of non-spousal sexual partners and using less protection with them. 18 In fact, 93% of wives of alcoholics suspect their husbands of having extramarital sexual relationships. 17 In a 2009 study conducted in Chennai, 75% of patrons of an alcohol shop reported having unprotected sex with a non-spousal partner, usually a commercial sex worker, in the prior three months. 15 Notably, men who frequent alcohol shops have an HIV rate more than three times higher than that of the average Indian man. 19 Most worryingly, sales of alcohol increased 8% between 2006 and 2009 and are continuing to grow as it is steadily becoming more socially acceptable to drink alcohol in India; 20 it is therefore feared that as alcohol use increases, so too will the incidence of unprotected sex with commercial sex workers and, consequently, rates of HIV infection. It has also been reported that same-sex sexual practices are relatively common in India; close physical contact between two men is not considered inappropriate in Indian culture and even when this develops into sexual contact, it is not identified as homosexual. 21 In a 2010 sample of 3000 men, the prevalence of same-sex sexual behaviour was 10% among men married to women; 93% of these men reported having multiple male partners each year. 22 However, somewhat paradoxically, because all acts of sodomy were criminalized under Indian Penal Code 377-B up until September 2018 and are still stigmatized, 23 men who have sex with men (MSM) feel pressure to conceal their same-sex activities; they often partake in secretive anal sex practices in secluded parks at night-time and due to the rushed nature of such endeavors, they often fail to use condoms. 9 Because unprotected anal sex carries the greatest risk for HIV transmission, it is unsurprising that more than 13% of MSM in India are HIV-positive. 22 However, between 30% and 60% of MSM are married to a woman, in order to satisfy societal pressures and typically do not disclose their same-sex sexual practices to their wife. 22 In a recent report, 72% of MSM revealed that they had had unprotected sex with their wife in the past year, 22 meaning that many of these women were unwittingly exposed to HIV. In short, it is clear that men's extramarital sexual relations with commercial sex workers and MSM constitute a significant causal factor for HIV infection among men, thus acting as the first step in the pathway leading to monogamous, married women's infection with HIV.

Sexual Relations with Wives at Home
However, even if a man is infected with HIV, it is not necessarily inevitable that his wife will become infected as well. Numerous studies conducted around the world have revealed that when serodiscordant heterosexual couples use condoms regularly and consistently, the transmission of HIV from one spouse to the other is reduced by 87%. 9 In a 2006 prospective study administered in the Indian state of Maharashtra, the incidence rate of HIV among originally uninfected members of a serodiscordant couple who used condoms consistently with their partner over a one-year period was almost 6 times lower than that among comparable individuals who did not use condoms consistently with their HIV-positive partner. 24 Unfortunately, there are many significant challenges associated with the prevention of HIV transmission from husband to wife in India, many of which are linked to deep-rooted gender roles and cultural expectations of behaviour. Firstly, in Indian culture, the topic of sex is shrouded in secrecy; it is inappropriate to discuss sex, even between spouses. 3 This culture of silence compels women to remain ignorant about sex and conduct themselves in a passive manner during sexual relations in order to be perceived as "good" and "pure" by their husband. 13 Therefore, it is extremely difficult for a wife to broach the topic of sex or sexually transmitted diseases with her husband. Secondly, the use of condoms among married couples in India is very low; only 7% of Indians surveyed in 2011 reported using a condom with their spouse. 3 This may be due to a number of factors related to traditional gender roles, considering that the atmosphere of the typical Indian home space is heavily patriarchal and the husband is usually in control of all sexual activity. For instance, it is an expectation that married women in India provide their husbands with unprotected sex; 17 sex is considered a duty rather than a choice. 9 To defy this unspoken commandment by attempting to negotiate safer sex would be a very risky endeavor. In fact, if a woman even suggests that her husband use condoms when they have sex, in order to protect herself from whatever infections that he may have, he may accuse her of infidelity 9 or even leave her-which would likely prove disastrous, considering that most women are economically dependent on their husbands. 16 As well, because procreation constitutes a fundamental aspect of marriage in India, many women feel a tremendous amount of pressure to conceive a child immediately, in order to prove their fertility, and so voluntarily forego all forms of contraception. 13 Childlessness in India can be just as upsetting and stigmatizing as an HIV diagnosis and so many women prefer to risk becoming infected with HIV in the hopes of becoming pregnant. 17 This has important implications for mother-to-child transmission of HIV-whereby the virus is transmitted from the mother to her child through pregnancy, labour, delivery, or breastfeeding-which appears to be increasing rapidly in India. 25 Condoms are also often associated with commercial sex workers in India and therefore possess the negative reputation of being contraceptive devices used during "illicit" sexual relations. 9 Because married Indian women do not believe that using condoms with their husbands is consistent with female virtue, they are unlikely to be inclined to encourage their husbands to use them. 9 Even men who are aware of their HIV-positive status and have been instructed by health care providers to use condoms with their sexual partners may still fail to do so consistently. A 2006 study conducted in five Indian states found that one third of men living with HIV reported irregular condom use with their partners, citing reasons such as being afraid of raising their wife's suspicions by suddenly starting to use condoms, which could lead to the disclosure of their HIV status and cause their wife to leave the marriage; experiencing diminished sexual pleasure and spontaneity if a condom was used; feeling no need to use condoms with their wife because they believed their wife had likely already contracted HIV from them; and fearing bringing "shame and disgrace" to their family if knowledge about their HIV status became widespread. 26 Notably, because Indian society is collectivistic, meaning that its members highly value interdependence and social cohesion, some researchers argue that there is a greater potential for shame following HIV disclosure in Indian culture than in more individualistic cultures. 27 Finally, because Indian women are expected to remain in the home and perform all of their daily work there, they are usually not permitted to obtain an education. 16 Therefore, their awareness of such issues as HIV transmission is often inadequate for them to protect themselves and they do not perceive all of the risks associated with unprotected sex with their husbands. 14 According to a 2011 nationally representative survey, 28% of married women had never heard of AIDS; 3 the level of education attained by a woman has been found to be very strongly related to her quantity of HIV/AIDS knowledge. 28 Clearly, traditional Indian culture and gender roles present significant obstacles to negotiating safer sex to prevent the transmission of HIV from men to their wives.

Intimate Partner Violence
Another way in which traditional Indian gender roles influence HIV transmission from husbands to wives is through intimate partner violence, which is defined as psychological, physical, or sexual violence directed toward a partner within the home. 29 Intimate partner violence is a widespread and socially accepted phenomenon in India; 30 for example, it is condoned as a means for men to resolve conflicts and maintain control over their wife. 31 As is illustrated in Figure 1, South-East Asia possesses the highest rate of intimate partner violence out of any WHO region worldwide. 32 In India specifically, 56% of young married women taking part in a study in Bangalore report having been hit, kicked or beaten by their husband, 30 and between 19% and 26% of women surveyed across the country describe having experienced forced sex with their husband. 14 Violence is often precipitated when the husband becomes intoxicated with alcohol, 20 his wife refuses sex, 14 or his wife questions him about his behaviours outside the home, particularly his [in]fidelity. 17 These high rates of intimate partner violence, and the apparent widespread societal acceptance of the act, serve as an indication that substantial power inequalities between men and women have become a fundamental feature of the social construction of the typical Indian marriage and home space. The attitude of indifference that authorities often take regarding victims of intimate partner violence in India also helps cement the notion of male superiority in Indian culture. 11 Married Indian women who have experienced both physical and sexual abuse from their husband exhibit a four times greater prevalence of HIV infection than non-abused women. 6 This is thought to occur for three principal reasons: firstly, abusive husbands are more likely to engage in high-risk extramarital sex with commercial sex workers than non-abusive husbands, suggesting that they are more likely to be infected with HIV. 13 Secondly, abusive husbands are more likely to exert higher levels of control over sex and sexual protection with their wives, 6 meaning that women in abusive marriages are especially unlikely to report having used condoms during sex. 3 Finally, forced sex causes physical trauma, such as tearing and lacerations, which makes women far more susceptible to HIV infection. 6 Leaving an abusive relationship may seem like a logical solution; however, gender roles come into play yet again in the case of Indian women. Not only are most women entirely economically dependent on their husbands, 33 they would also have to confront the challenges involved in breaking up their family-including the impact this would have on their children, parents, in-laws and extended family. Since Indian cultural values hold family and the home in high regard, 11 this would be an extremely difficult feat to accomplish. As well, since Indian women traditionally play a submissive role in the home space and a sense of their inferiority to men is constantly instilled into them, 33 it might be difficult for them to muster up enough courage to actually leave their husband. Therefore, intimate partner violence is plainly associated with increased risk of HIV transmission from men to their wives and is executed in a restrictive home environment from which it is difficult for women to escape.

Prevention Strategies
If the risk of HIV infection of married women in India is to be reduced, culturally sensitive and relevant strategies targeting extramarital sex, lack of condom use, intimate partner violence and gender inequity will need to be developed and put into practice across the country.

Extramarital Sex
As previously mentioned, a substantial proportion of married Indian men engage in extramarital sexual activity, often with commercial sex workers and occasionally with other men; this increases the risk of these men becoming infected with HIV, which then consequently increases the likelihood that they will infect their wives. However, according to the results of a handful of studies, it appears that it is possible to decrease the prevalence of extramarital sexual relations in India, mainly by focusing on educating men about HIV and AIDS, highlighting the fact that the risk of becoming infected with HIV and other STIs climbs with increased numbers of sexual partners and promoting monogamy. For example, in a 4-year longitudinal study of men attending STI clinics in Pune, one-on-one counseling focusing on abstinence and condom use was provided to men before being tested for HIV; the men who tested negative for HIV were then offered on-going HIV prevention counseling every three months for four years. 34 At the beginning of the study, 63% of men had had sex with a commercial sex worker in the previous three months; however, at the 6-month follow-up visit, the proportion of men describing recent sex with a commercial sex worker had decreased to 16%, a figure that remained stable until after 24 months, when a modest increase to 23% was observed. 34 As well, the proportion of men who reported being monogamous increased from 61% at the beginning of the study to 89% after 6 months; 84% of these men described being monogamous after 24 months. 34 It is likely that a similar approach, emphasizing the fact that unprotected anal sex carries the highest risk of HIV transmission, would also prove useful for decreasing same-sex sexual practices among married men. However, it would be extremely important to be sensitive to the special issues that the MSM community faces in India, such as the stigma surrounding these practices and many men's fear of disclosure of their participation in them. 21 As well, efforts to curb extramarital sexual relations may also benefit from addressing and refuting widespread, but erroneous, cultural beliefs concerning sex, such as the previously mentioned idea that men require a variety of sexual partners to maintain their masculinity. 13

Lack of Condom Use
To increase the use of condoms by married men in order to reduce the likelihood of HIV transmission from husband to wife, health education will again play an essential role. In the same longitudinal study conducted in Pune mentioned above, 89% of the men who received regular HIV prevention counseling for 6 months reported knowing that condoms could prevent sexual transmission of HIV, in stark contrast to only 45% of the men at the beginning of the study. 34 As well, out of the men who continued to visit commercial sex workers throughout the study, 58% of men reported using condoms during these encounters at 12 months of follow-up, compared with only 30% who reported doing so at the beginning of the study; the rate of condom use with other female partners, including wives, continued to be low, but increased from 5% at baseline to 13% at 6 months, a rate that was maintained throughout the 24 months of follow-up. 34 It seems likely that a combination of education about HIV/AIDS, including methods to reduce the sexual transmission of HIV and the promotion of voluntary HIV testing will increase condom use. More than two thirds of people living with HIV and receiving Antiretroviral Treatment (ART) in five Indian states reported consistent use of condoms with their spouses, a rate much higher than the national average, which suggests that men who are HIV positive and unaware of their status may be especially likely to forego condoms and expose their partners to the virus. 26 Being diagnosed with HIV and receiving comprehensive counseling from healthcare providers may also instill in men a sense of personal responsibility to prevent the spread of HIV to others, which could then lead to increased condom use. However, even among people who are motivated to use condoms, there are still many challenges to overcome. Interviews conducted with 250 sexually active men and women in Mumbai suggest that condoms would be used more consistently and by a greater number of people if they were made more widely available, made of higher quality and were sold at lower costs and if there were increased privacy at stores that sold condoms. 35 The social stigma surrounding condom use should be addressed directly in widespread, culturally sensitive public health campaigns, perhaps by hiring influential local leaders to be featured in advertisements, extolling the numerous health benefits of condom use. One method of increasing condom use that has so far received relatively little attention in research is the empowerment of women in the context of marriage, specifically by teaching them condom negotiation skills and increasing their knowledge of HIV/AIDS. The onus should not be completely on men to prevent transmission of HIV; rather, women should also be aware of the ways in which HIV is transmitted and the protective effects of condom use and learn how to discuss such matters openly with their husband. As well, since men's alcohol abuse is correlated with higher numbers of extramarital sexual partners and lower rates of condom use during these encounters, alcohol dependence treatment should be made more accessible to men in order to decrease the incidence of HIV infection. Finally, it is important to address common misconceptions concerning condoms and HIV/AIDS. For example, many men who are diagnosed with HIV believe that there is no point in using condoms with their wife because she is likely already infected; healthcare providers should inform these men that it is still important to use condoms to protect both oneself and others from STIs and from reinfection with more aggressive or treatment-resistant strains of HIV. 26

Intimate Partner Violence
In order to reduce the widespread tolerance and occurrence of Intimate Partner Violence (IPV) in India, which is positively correlated with HIV prevalence, it is likely that interventions at a societal level will need to take place. A nationally representative survey conducted in India determined that acceptance of physical, sexual and psychological violence at the community level leads to tolerance at an individual level; in other words, when women are surrounded by people who condone such abuse, they will endure it silently, without seeking help or even recognizing it as a problem. 31 This has proven to be the case even for women who have achieved a relatively high level of education, which had originally been thought to reduce a woman's risk of intimate partner violence. 31 Therefore, before one can hope to reduce or eliminate IPV in India, attitudes towards abuse at the wider community level must be changed, perhaps by extensive ad campaigns to raise public awareness of and stimulate discussion surrounding the unacceptability of abuse, or by interventions led by community organizations. This may then empower individual women to refuse to passively tolerate such treatment and end the cycle of abuse.
It has also been suggested that healthcare professionals should routinely screen women who seek abuse-related care for intimate partner violence, as these professionals may be the primary contact for victims of violence and are in an excellent position to both recognize abuse and provide referrals to helpful resources. 36 In a 2013 observational study conducted at an Indian orthopedic trauma center, women who presented with fracture-related injuries were given questionnaires addressing physical, sexual and emotional abuse to assess whether they had experienced intimate partner violence; since 30% of these women scored positive on these questionnaires, it was determined that screening for IPV at Indian trauma hospitals would be feasible and effective. 36 It is assumed that women who are recognized as survivors of intimate partner violence and are provided with resources and support will be more likely to leave an abusive relationship, which would then reduce their risk of physical, psychological and sexual harm, including HIV infection. However, only screening women for IPV who present with physical injuries would fail to identify women who solely experience psychological or sexual abuse at the hands of their partner; all three types of violence are correlated with increased risk of HIV infection and need to be recognized and investigated in order to provide support to women experiencing such abuse.

Gender Inequity
While the aforementioned prevention strategies target specific high-risk behaviour, it is possible that the most powerful tool of all to indirectly combat HIV transmission from husband to wife is the promotion of gender equity. The importance of gender equity is recognized by the awardwinning non-profit organization Equal Community Foundation, 37 based in Pune and Kolkata, which asserts that since gender-based violence and discrimination is a society-wide problem, it requires a society-wide solution. The organization aims to give as many men and boys in India as possible the "opportunity to reflect on and practice gender equitable behaviour" through intensive workshops, with a focus on younger individuals so that they can be raised to develop gender sensitive attitudes and behaviour from a young age. 37 In these workshops, young men are partnered with mentors and coached through a process of personal behavioural change towards women, study the important roles that women play in their lives, engage in dialogue about gender equity and participate in ongoing events focused on gender equity. As of 2019, over 8800 young men have enrolled in the organization's Action for Equality Programme, 38 and on average, 61% of women who live with the graduates of this programme have reported a reduction in experience of violence and discrimination at the hands of the graduates. 37 The results of this programme are promising; if the major tenets of the workshops are able to be administered on a significantly wider-ideally nation-wide-scale, perhaps by partnering with government-run primary schools, it is possible that an entire generation of Indian men could grow up to value and practice gender equitable behaviour. This would hopefully reduce intimate partner violence, increase communication and respect between husbands and wives, reduce extramarital sexual relations and, ultimately, reduce both the rate of HIV infection among men and the transmission of HIV from men to their wives.

Limitations of Conceptual Framework
This article was constructed by examining the question, what are the principal factors involved in the infection of monogamous, married women with HIV by their husbands? within the context of traditional Indian gender roles and cultural expectations of behaviour. Specifically, this article investigated three high-risk sexual behaviours commonly perpetrated by Indian men: extramarital sexual relations, lack of condom use during sex and intimate partner violence. However, the framework did not incorporate all of the possible major factors involved in the transmission of HIV from husbands to their monogamous wives in India. For instance, the topic of intravenous drug use, which is a common method of primary HIV infection in northern India, is noticeably absent. As well, the subject of commercial sex workers, which was discussed intermittently in this article, could have included many more details in order to be described comprehensively. For example, this article could have examined the link between intimate partner violence suffered by married commercial sex workers at the hands of both their own husband and other men with whom they engage in sex and the incidence of HIV infection among these women; in addition, strategies to increase commercial sex workers' insistence that all of their customers use condoms would be worthwhile to consider.

Strengths and Weaknesses of Literature
A powerful strength of the literature reviewed in this article is the large proportion of primary studies included, which had been conducted in an impressive range of locations throughout India. Since India is an incredibly culturally diverse country consisting of hundreds of small ethnic groups, each speaking different languages and abiding by different customs, the inclusion of a large number of primary sources incorporating data from rural, urban, rich and poor communities in the North, South, East and West of the nation is essential in order to gain a comprehensive understanding of the current ideologies of the Indian population related to sex and HIV. However, many of these primary studies, specifically the ones relying on self-reports of data, suffer from the cultural stigma associated with HIV 9 and the social taboos concerning speaking about sexuality 3 that are both prevalent throughout India. Individuals tend to dramatically underreport HIV infections and high-risk sexual behaviour and it is for this reason that precise estimates of the burden of HIV in the nation cannot be made. As well, due to widespread societal tolerance of intimate partner violence, women who have experienced such abuse may not recognize it for what it is and will thus underreport its prevalence; on the other hand, women who have been abused by a partner may be too frightened of the potential repercussions to disclose such information, again resulting in underreporting. Finally, literature concentrating on men who have sex with men in India is sorely lacking; the majority of such data mentioned in this article was collected from just one study conducted in 2010. This is likely due to the cultural taboos regarding homosexual sex that exist in India and the difficulty in collecting accurate and extensive data about such a sensitive topic.

CONCLUSION
This article investigated the principal factors involved in the infection of married, monogamous Indian women with HIV by their husbands, within the context of traditional Indian gender roles and culture. Because the vast majority of these women report that unprotected sex with their husband is their only risk factor for HIV infection, it can be concluded that they have been infected by their husband. These men, in turn, were likely infected with HIV as a result of engaging in unprotected extramarital sexual relations and subsequently pass on the virus to their wives during sex due to a lack of condom use and, in many cases, intimate partner violence. The fact that the vast majority of all new HIV cases in India are contracted by heterosexual transmission 7 -which is expected to continue increasing in rate each year 9 -has implications for the spread of HIV throughout the world and emphasizes the considerable significance of this topic. It is imperative that additional research be conducted on the complex relationship that exists between traditional inequitable gender roles, men's high-risk sexual behaviour and the impact that they have on married women, in order to supplement the relative paucity of studies on this topic that have been published to date. Implementing large-scale, culturally appropriate prevention strategies based on such research will likely prove essential in the struggle to curb the spread of HIV in this vulnerable population sector.