Intimate partner violence and HIV infection among women: a systematic review and meta-analysis

Violence Against Women in Selected Areas of the United States

OBJECTIVES

We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States.

METHODS

We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence.

RESULTS

Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse.

CONCLUSIONS

Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.

Healing Our Women for Transgender Women: Adaptation, Acceptability, and Pilot Testing

Healing Our Women (HOW) is a group-level HIV risk-reduction intervention developed to address the role of prior sexual victimization in HIV risk and protective behaviors among HIV-positive women of color. This article describes the process of adapting HOW for transgender women of color in New York City in accordance with CDC guidance for the adaptation of efficacious interventions. Twenty-one transgender women were enrolled in a study to evaluate the acceptability and fidelity of the adapted intervention, and to assess HIV knowledge, depressive symptoms, coping, condom use self-efficacy, and condom use via pre- and post-intervention surveys. We found the adapted program to be feasible to implement and acceptable to participants. We also found significant decreases in depressive symptoms and increases in positive coping from pre- to post-intervention, although replication with a larger sample and a control group comparison is needed to determine efficacy with this population.

Targeting the SAVA (Substance Abuse, Violence, and AIDS) Syndemic Among Women and Girls: A Global Review of Epidemiology and Integrated Interventions

OBJECTIVES

Multiple pathways link gender-based violence (GBV) to HIV and other sexually transmitted infections among women and girls who use or inject drugs. The aim of this article is to synthesize global literature that examines associations among the synergistic epidemics of substance abuse, violence, and HIV/AIDS, known as the SAVA syndemic. It also aims to identify a continuum of multilevel integrated interventions that target key SAVA syndemic mechanisms.

METHODS

We conducted a selective search strategy, prioritizing use of meta-analytic epidemiological and intervention studies that address different aspects of the SAVA syndemic among women and girls who use drugs worldwide from 2000 to 2015 using PubMed, MEDLINE, and Google Scholar.

RESULTS

Robust evidence from different countries suggests that GBV significantly increases the risk of HIV and other sexually transmitted infections among women and girls who use drugs. Multiple structural, biological, and behavioral mechanisms link GBV and HIV among women and girls. Emerging research has identified a continuum of brief and extended multilevel GBV prevention and treatment interventions that may be integrated into a continuum of HIV prevention, testing, and treatment interventions to target key SAVA syndemic mechanisms among women and girls who use drugs.

CONCLUSIONS

There remain significant methodological and geographical gaps in epidemiological and intervention research on the SAVA syndemic, particularly in low- and middle-income countries. This global review underscores the need to advance a continuum of multilevel integrated interventions that target salient mechanisms of the SAVA syndemic, especially for adolescent girls, young women, and transgender women who use drugs.

HIV, HCV, and Health-Related Harms Among Women Who Inject Drugs: Implications for Prevention and Treatment

BACKGROUND

Although an estimated 3.5 million women inject drugs globally, women are outnumbered 4 to one by men who inject drugs and are often ignored or overlooked in the development and delivery of prevention and treatment services for this population. This study aimed to identify key comorbidities prevalent among women who inject drugs (WWID), consider factors that contribute to vulnerability of this population, and examine implications for prevention and treatment.

METHODS

The literature was reviewed to examine the specific challenges and needs of WWID. We searched health-related bibliographic databases and grey literature to identify studies conducted among WWID and studies conducted among people who inject drugs (PWID), where results were disaggregated by gender and policies/guidelines/reports relevant to WWID.

RESULTS

WWID face a range of unique, gender-specific, and often additional challenges and barriers. The lack of a targeted focus on WWID by prevention and treatment services and harm-reduction programs increases women's vulnerability to a range of health-related harms, including blood-borne viral and sexually transmitted infections, injection-related injuries, mental health issues, physical and sexual violence, poor sexual and reproductive health, issues in relation to childbearing and child care, and pervasive stigma and discrimination.

CONCLUSIONS

There is a need to improve the collection and reporting of gender-disaggregated data on prevalence of key infections and prevention and treatment service access and program coverage. Women-focussed services and integrating gender equity and human rights into the harm-reduction programming will be a prerequisite if improvements in the health, safety, and well-being of this often invisible and highly vulnerable population are to be achieved.

Exploring risk of experiencing intimate partner violence after HIV infection: a qualitative study among women with HIV attending postnatal services in Swaziland

OBJECTIVE

To explore risks of experiencing intimate partner violence (IPV) after HIV infection among women with HIV in a postnatal care setting in Swaziland.

DESIGN

A qualitative semistructured in-depth interview study, using thematic analysis with deductive and inductive coding, of IPV experiences after HIV infection extracted from service-integration interview transcripts.

SETTING

Swaziland.

PARTICIPANTS

19 women with HIV, aged 18-44, were purposively sampled for an in-depth interview about their experiences of services, HIV and IPV from a quantitative postnatal cohort participating in an evaluation of HIV and reproductive health services integration in Swaziland.

RESULTS

Results indicated that women were at risk of experiencing IPV after HIV infection, with 9 of 19 disclosing experiences of physical violence and/or coercive control post-HIV. IPV was initiated through two key pathways: (1) acute interpersonal triggers (eg, status disclosure, mother-to-child transmission of HIV) and (2) chronic normative tensions (eg, fertility intentions, initiating contraceptives).

CONCLUSIONS

The results highlight a need to mitigate the risk of IPV for women with HIV in shorter and longer terms in Swaziland. While broader changes are needed to resolve gender disparities, practical steps can be institutionalised within health facilities to reduce, or avoid increasing, IPV pathways for women with HIV. These might include mutual disclosure between partners, greater engagement of Swazi males with HIV services, and promoting positive masculinities that support and protect women.

TRIAL REGISTRATION NUMBER

NCT01694862.

Sexual violence, condom negotiation, and condom use in the context of sex work: results from two West African countries

BACKGROUND

Female sex workers (FSWs) are vulnerable to violence within and beyond the workplace. Violence is associated with increased burden of HIV, possibly explained through physiologic or behavioral causal pathways. These analyses sought to determine the relationship between lifetime sexual violence with unprotected, condomless vaginal intercourse (UVI) among FSWs in West Africa.

METHODS

FSWs (aged ≥18 years) were recruited into a cross-sectional study through respondent-driven sampling in two West African countries, Togo and Burkina Faso. A total of 1380 participants were enrolled from January to July 2013, and completed a sociobehavioral questionnaire and HIV testing. Measures included sex work history, lifetime experiences of violence victimization, sexual practices, and UVI (past month). Crude and adjusted robust log binomial regression was conducted to estimate prevalence ratios (PrR) as a measure of association between UVI with clients and the primary exposure, forced sex.

RESULTS

Self-reported lifetime physical abuse (47.3%), forced sex (33.0%), and any violence (57.9%) were common. Almost one-quarter (23.9%) reported recent UVI with clients. History of forced sex was independently associated with recent UVI with clients [vs. none, adjusted PrR: 1.49; 95% confidence interval (CI): 1.18 to 1.88], with evidence of partial mediation by difficult condom negotiation with regular (aPrR: 1.83; 95% CI: 1.43 to 2.34) and new clients (aPrR: 1.60; 95% CI: 1.13 to 2.29).

DISCUSSION

These data demonstrate the significant relationship between sexual violence experienced by FSWs and unprotected sex with clients. Comprehensive interventions reducing vulnerabilities to violence combined with improved condom negotiation are needed to address the complex influences of condom use during sex work as a means of ultimately lowering HIV acquisition and transmission.

Current and recent drug use intensifies sexual and structural HIV risk outcomes among female sex workers in the Russian Federation

BACKGROUND

Female sex workers (FSW) and people who inject drugs (PWID) are at high risk for HIV infection, with FSW-PWID at even greater risk. HIV-related research often focuses on the primary mode of transmission - sexual or parenteral transmission for FSW and PWID, respectively - with less known on how sex work and injection drug use (IDU) are collectively associated with the risk environment experienced by sex workers. We investigated this relationship among FSW in three Russian cities.

METHODS

In 2011, FSWs (N=754) in Tomsk, Krasnoyarsk, and Kazan were recruited via respondent-driven sampling and completed a survey and rapid HIV screening. Multivariable models evaluated the role of injection history (classified as active: last 6 months, former: prior to last 6 months, and never) with a set of sexual and structural HIV risk outcomes.

RESULTS

IDU was common: 11% actively injected drugs and 11% were former injectors. HIV infection was most prevalent among active injectors (AOR: 6.7; 95% CI: 2.4-18.9) and former injectors (AOR:4.5; 95%CI: 1.7-11.6), compared to non-injectors. Some 6-8% of non-injecting FSWs reported recent physical or sexual client violence and 23% police extortion. Compared to these non-injectors, active injecting was associated with unprotected anal sex (AOR: 2.8, 95%CI: 1.2-6.4), client violence (AOR: 7.3, 95%CI: 2.1-24.7), and police extortion (AOR: 3.0 95%CI: 1.5-5.9%). Self-reported sexual and structural risk outcomes were also more prevalent among active compared to former injectors; however, few differences existed between former and non-injectors.

CONCLUSIONS

FSW experience sexual, structural, and HIV risk outcomes and these risks are amplified for actively injecting FSWs. FSW who stopped injecting drugs demonstrated risk profiles closer to those of sex workers who had no history of injection. HIV prevention programs and outreach can provide opportunities to include harm reduction interventions and linkage to treatment for FSW to move FSWs towards lower risk environments.

The Lived Experience of Domestic Violence in Iranian HIV-Infected Women

Domestic violence is one of the most prevalent problems linked to HIV. Domestic violence in HIV-infected women has not been sufficiently explored, particularly in developing countries including Iran. This study aimed to explore the lived experience of domestic violence in Iranian HIV-infected women. A qualitative approach was used to conduct the study. Data were collected through semi-structured, in-depth interviews with ten HIV-infected women and were analyzed using content analysis. During the data analysis, four main themes emerged including, "regretful past", "disappointing future", "loneliness", and "no other option", which refer to the condition that the participants experienced in their lives due to challenges that mainly stem from the experience of HIV-related domestic violence. HIV infection can be a risk factor for domestic violence. Health care providers need to address domestic violence during the assessment of HIV-infected women and make appropriate referrals for abused women.

Assisted partner notification services to augment HIV testing and linkage to care in Kenya: study protocol for a cluster randomized trial

Background

HIV case-finding and linkage to care are critical for control of HIV transmission. In Kenya, >50% of seropositive individuals are unaware of their status. Assisted partner notification is a public health strategy that provides HIV testing to individuals with sexual exposure to HIV and are at risk of infection and disease. This parallel, cluster-randomized controlled trial will evaluate the effectiveness, cost-effectiveness, and feasibility of implementing HIV assisted partner notification services at HIV testing sites (clusters) in Kenya.

Methods/design

Eighteen sites were selected among health facilities in Kenya with well-established, high-volume HIV testing programs, to reflect diverse communities and health-care settings. Restricted randomization was used to balance site characteristics between study arms (n = 9 per arm). Sixty individuals testing HIV positive (‘index partners’) will be enrolled per site (inclusion criteria: ≥18 years, positive HIV test at a study site, willing to disclose sexual partners, and never enrolled for HIV care; exclusion criteria: pregnancy or high risk of intimate partner violence). Index partners provide names and contact information for all sexual partners in the past 3 years. At intervention sites, study staff immediately contact sexual partners to notify them of exposure, offer HIV testing, and link to care if HIV seropositive. At control sites, passive partner referral is performed according to national guidelines, and assisted partner notification is delayed by 6 weeks. Primary outcomes, assessed 6 weeks after index partner enrollment and analyzed at the cluster level, are the number of partners accepting HIV testing and number of HIV infections diagnosed and linked to care per index partner. Secondary outcomes are the incremental cost-effectiveness of partner notification and the costs of identifying >1 partner per index case. Participants are closely monitored for adverse outcomes, particularly intimate partner violence. The study is unblinded due to practical limitations.

Discussion

This rigorously designed trial will inform policy decisions regarding implementation of HIV partner notification services in Kenya, with possible application to other parts of sub-Saharan Africa. Examination of effectiveness and cost-effectiveness in diverse settings will enable targeted application and define best practices.

Trial registration

ClinicalTrials.gov NCT01616420.

Identifying and intervening with substance-using women exposed to intimate partner violence: phenomenology, comorbidities, and integrated approaches within primary care and other agency settings

Substance use and/or disorders (SUDs) have been identified as a significant correlate of intimate partner violence (IPV) exposure and present complex issues that intersect with the topography of IPV, attendant mental health, and physical co-morbidities and may pose barriers to primary care- and other agency-based screening and intervention efforts. Despite substantial research indicating significantly higher rates of all types and severity of IPV victimization among women with SUDs and bidirectional associations between partner or self-use of drugs or alcohol and IPV victimization, effective screening, brief interventions, coordinated systems of care, and treatment approaches to address these co-occurring problems remain very limited. We integrated select research examining the intersection of IPV victimization and SUDs and several comorbidities that have significant public health impact and provided recommendations for scaling up targeted interventions to redress these co-occurring problems among women in primary, emergency, and other care settings.

Addressing gender inequality and intimate partner violence as critical barriers to an effective HIV response in sub-Saharan Africa

Introduction

In Africa, women and girls represent 57% of people living with HIV, with gender inequality and violence being an important structural determinant of their vulnerability. This commentary draws out lessons for a more effective combination response to the HIV epidemic from three papers recently published in JIAS.

Discussion

Hatcher and colleagues present qualitative data from women attending ante-natal clinics in Johannesburg, describing how HIV diagnosis during pregnancy and subsequent partner disclosure are common triggers for violence within relationships. The authors describe the challenges women face in adhering to medication or using services. Kyegombe and colleagues present a secondary analysis of a randomized controlled trial in Uganda of SASA! – a community violence prevention programme. Along with promising community impacts on physical partner violence, significantly lower levels of sexual concurrency, condom use and HIV testing were reported by men in intervention communities. Remme and her colleagues present a systematic review of evidence on the costs and cost-effectiveness of gender-responsive HIV interventions. The review identified an ever-growing evidence base, but a paucity of accompanying economic analyses, making it difficult to assess the costs or value for money of gender-focused programmes.

Conclusions

There is a need to continue to accumulate evidence on the effectiveness and costs of different approaches to addressing gender inequality and violence as part of a combination HIV response. A clearer HIV-specific and broader synergistic vision of financing and programming needs to be developed, to ensure that the potential synergies between HIV-specific and broader gender-focused development investments can be used to best effect to address vulnerability of women and girls to both violence and HIV.

Intimate partner violence and human immunodeficiency virus risk among black and Hispanic women

BACKGROUND

Approximately 80% of new HIV infections among U.S. women are among black/African American and Hispanic women. HIV risk may be associated with intimate partner violence (IPV); data regarding IPV for women in high-HIV prevalence areas are scarce.

PURPOSE

To examine prevalence and correlates of IPV among women.

METHODS

Heterosexual women and their male partners in cities with high HIV prevalence were enrolled. During 2006-2007, participants completed interviews about HIV risk factors and IPV (physical violence or forced sex) experiences. Data were analyzed during 2012-2013 using multivariate logistic regression to identify individual- and partner-level IPV correlates.

RESULTS

Of 1,011 female respondents, 985 (97.4%) provided risk factor and demographic data. Most were non-Hispanic black/African American (82.7%); living at or below poverty (86.7%); and tested HIV-negative (96.8%). IPV-physical violence was reported by 29.1%, and IPV-forced sex by 13.7%. Being married/living with a partner (AOR=1.60, 95% CI=1.06, 2.40); non-injection drug use (AOR=1.74, 95% CI=1.22, 2.48); and ever discussing male partners' number of current sex partners (AOR=1.60, 95% CI=1.15, 2.24) were associated with IPV-physical violence. Women reporting concurrent sex partners (AOR=1.80, 95% CI=1.04, 3.13) and ever discussing number of male partners' past sex partners (AOR=1.85, 95% CI=1.13, 3.05) were associated with IPV-forced sex. Feeling comfortable asking a male partner to use condoms was associated with decreased IPV-physical violence (AOR=0.32, 95% CI=0.16,0.64) and -forced sex (AOR=0.37, 95% CI=0.16, 0.85).

CONCLUSIONS

Prevention interventions that enhance women's skills to decrease HIV and IPV risk are important strategies for decreasing racial/ethnic disparities among women.

Perceptions of the mental health impact of intimate partner violence and health service responses in Malawi

BACKGROUND AND OBJECTIVES

This study explores the perceptions of a wide range of stakeholders in Malawi towards the mental health impact of intimate partner violence (IPV) and the capacity of health services for addressing these.

DESIGN

In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in three areas of Blantyre district, and in two additional districts. A total of 10 FGDs, 1 small group, and 14 IDIs with health care providers; 18 FGDs and 1 small group with male and female, urban and rural community members; 7 IDIs with female survivors; and 26 key informant interviews and 1 small group with government ministry staff, donors, gender-based violence service providers, religious institutions, and police were conducted. A thematic framework analysis method was applied to emerging themes.

RESULTS

The significant mental health impact of IPV was mentioned by all participants and formal care seeking was thought to be impeded by social pressures to resolve conflict, and fear of judgemental attitudes. Providers felt inadequately prepared to handle the psychosocial and mental health consequences of IPV; this was complicated by staff shortages, a lack of clarity on the mandate of the health sector, as well as confusion over the definition and need for 'counselling'. Referral options to other sectors for mental health support were perceived as limited but the restructuring of the Ministry of Health to cover violence prevention, mental health, and alcohol and drug misuse under a single unit provides an opportunity.

CONCLUSION

Despite widespread recognition of the burden of IPV-associated mental health problems in Malawi, there is limited capacity to support affected individuals at community or health sector level. Participants highlighted potential entry points to health services as well as local and national opportunities for interventions that are culturally appropriate and are built on local structures and resilience.