These historical, legal, and cultural influences, while understandable, have lead to a collective denial of the continuing and widespread occurrence of child marriage. Of the 331 million girls currently aged 10-19 who live in the countries of the developing world excluding China, 163 million will be married by their twentieth birthday, if present trends continue. Over the next ten years, more than 100 million girls in those countries will be married before their eighteenth birthday.

Why are married adolescent girls at risk?

Crossing the threshold into marriage greatly intensifies sexual exposure via unprotected sex, which is often with an older partner who, by virtue of his age, has an elevated risk of being HIV-positive. This dramatic rise in the frequency of unprotected sex is driven by not only the implication of infidelity or distrust associated with certain forms of contraception, such as condoms, but often also by a strong desire to become pregnant. The increase in the numbers of young females infected with HIV has led some policymakers and researchers to conclude that large age differences in sexual partners leave adolescent girls at particular risk of infection. Not only are husbands, on average, older than boyfriends, they are also more likely to be infected. A concern about large age gaps between sexual partners is increasingly present in national AIDS policies; yet these policies often fail to acknowledge the role of marriage in creating and entrenching such large age differences.

Finally, in most countries married girls report marriage as lonely, cutting them off from friends and family, restricting social and geographic mobility, and limiting access to information, schooling, and community participation. Social isolation is a loss in its own right and is increasingly identified as a predisposing factor for HIV risk as it undermines the benefits of ‘social cohesion'. Social contact and networks are becoming widely recognized as vital to transmitting information and supporting behaviour change. Similarly, media and schools are increasingly enlisted to convey HIV prevention messages and support HIV programmes.

Being young and married doubly affects adolescent girls' access to much-needed sexual and reproductive health services and information:

Adolescent services – Married girls often have received no schooling or are early school leavers and consequently may not receive the benefits of family life education. Girls in general, and certainly married girls, are either not served or less well served in youth centres than males. Married girls have distinctive patterns of social mobility and more limited social networks than unmarried girls, placing them arguably outside the reach of conventional peer-to-peer programmes. Finally, youth-friendly health services, meant to be a major means of improving adolescent reproductive health, to date still give scant attention to marriage preparation and often explicitly exclude antenatal, delivery, and postpartum care as key services.

Adult services – adolescent girls may be inadequately served by antenatal and postpartum programmes such as safe motherhood initiatives. Moreover, many of the services offered, such as contraception and sterilisation, are not sought by recently married young women.

Ideas for improvement

Secular and religious leaders must play an important role in successful efforts to combat HIV transmission within marriage. A key policy decision that leaders need to make is whether delaying marriage to at least age 18 and calling attention to the risks of HIV transmission within marriage will be explicit elements in the HIV-prevention policy. Provided there is political will, other specific policy measures for mitigating the risks of contracting and spreading HIV via marriage can be identified and implemented. Some of these are:

• Developing community-based initiatives that redefine acceptable ages of marriage and offer incentives to parents and girls to delay marriage to legal age
• Introducing information about couple communication, voluntary counselling and testing, condoms, sexual health, safer marriage, and childbearing to newly engaged couples during the pre-marriage negotiation and adaptation process (pre-marriage ceremonies, celebrations, customs, and registrations)
• Fostering more intimate and trusting relationships between new spouses during the first year of marriage and decreasing the imminent pressure for pregnancy
• Refining maternal health and adolescent sexual and reproductive health services to bring married adolescents into the circle.