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Domestic violence against HIV-positive women and its impact on their health

<p>Sean R. Hosein</p>


September 3, 2013

Several terms are used by researchers who study violence against women committed by men who are their partners. Examples of such terms include the following:

  •     domestic violence
  •     gender-based violence
  •     intimate partner violence (IPV)


The United States Institute of Medicine (IOM) now recommends that healthcare professionals screen and counsel all women for IPV.

Past research in sub-Saharan Africa, India and the U.S. has found that IPV is a risk factor for women acquiring HIV. However, little research has been done to explore the impact of IPV on the health of HIV-positive women.

Now researchers in Calgary, Alberta, have conducted a study to assess the presence of IPV among HIV-positive women as well as its impact on their health. Their findings are distressing­—IPV is common, reported by 40% of HIV-positive women in the region’s major clinic. Furthermore, HIV-positive women who disclosed IPV had worse health and quality of life compared to other HIV-positive women who did not report IPV. Indeed, HIV-positive women who reported IPV were more likely to have been hospitalized even after initiating care for HIV.

The present study has uncovered a high rate of IPV among HIV-positive women and documented a link to increased hospitalization in affected women. Hospital stays arising from any cause, including IPV, are costly for the healthcare system. These factors should encourage policy planners and regional health departments to intensify programs to help prevent IPV and treat women, particularly those with HIV, affected by abuse. By building a trusting relationship with HIV-positive women, healthcare providers can help engage these women into care and improve the women’s overall health and well-being.

Study details

The Alberta research team noted that there are several types of abuse that can be directed at people, including the following:

  •     physical abuse
  •     sexual abuse
  •     emotional abuse
  •     financial abuse
  •     isolation
  •     neglect
  •     intimidation


As part of their study, the research team screened HIV-positive women for these types of abuse during the course of routine clinic visits between May 2009 and Jan 2012. Any woman who disclosed abuse was offered further care with a social worker who had expertise dealing with IPV among HIV-positive people.

Results

Nearly 80% (339 women) of women receiving HIV care in Southern Alberta were screened for abuse during the study. The main findings were as follows:

  •     40% (137) of women reported a history of IPV
  •     among the 137 women who disclosed a history of abuse, 20% reported that abuse occurred in their current relationship
  •     8% (11) of women who experienced abuse disclosed that abuse occurred both in their past and current relationships
  •     22% of the 137 women who reported a history of IPV also disclosed a history of childhood abuse


Common forms of abuse included the following:

  •     emotional
  •     physical
  •     sexual


However, the researchers stated that most women (72%) disclosed that they “experienced multiple types of abuse."

Race and ethnicity

The research team found that Aboriginal and white women reported high rates of IPV as follows:

  •     Aboriginal women – 65%
  •     white women – 61%


In contrast, black women, most of whom were immigrants from sub-Saharan Africa, reported a lower rate of IPV (22%).

IPV, substance use and imprisonment

The researchers found that women who had a history of IPV were significantly more likely to do the following:

  •     use street drugs
  •     use tobacco or have a history of smoking


The research team found that IPV did not predict the “excessive” use of alcohol.

The study was mostly cross-sectional in nature; this is akin to taking a snapshot of a group of people at one time and studying the data captured, rather than conducting a longer and more expensive study that monitors participants for many years. As a result of the nature of the study, the timing of substance use in relation to abuse is not clear. However, it is likely that substance use occurred after IPV as women sought temporary refuge from the psychological burden imposed by abuse.

The researchers found it noteworthy that 19 out of 25 women who had a history of being imprisoned reported IPV.

Mental health

In reviewing the medical records of the women in the study, researchers found that women who experienced IPV had high rates of depression prior to their HIV diagnosis. In general, the intensity of depression was severe and many affected women required prescription medicines to cope.

Women who had IPV also had an increased risk for previously being diagnosed with an anxiety-related disorder. Furthermore, women with IPV were more likely to have attempted to commit suicide before having been diagnosed with HIV.

Quality of life

Women who reported IPV had greatly reduced health-related quality of life.

General health

Women who disclosed IPV were generally diagnosed with HIV relatively early in the course of infection, with CD4+ counts greater than 500 cells. Also, women who disclosed IPV were less likely to use antiretroviral therapy (commonly called ART or HAART); if they did use it, they did so irregularly. Moreover, women who experienced IPV found it difficult to stay engaged with regular clinic visits and other care. Over the long term, such interruptions in care could affect their survival.

Rates of hospitalization were greater for women with IPV than women who did not have IPV.

Key findings

The Alberta study has found a high overall rate—40%—of IPV among HIV-positive women. According to the researchers, it is possible that the actual rate of IPV is even greater: “Many women experiencing IPV do not interpret their experiences as IPV, often minimizing the situation.”

The researchers also found that substance use and a history of smoking were relatively common among women who disclosed IPV. They stated that “helping patients address IPV in a constructive manner may also [reduce the illness and death that can arise from] substance use and smoking.”

Another finding noted by researchers was that women who faced IPV “experience multiple barriers to care, such as the immediate threats to the safety of themselves and their dependents, which in turn requires less imminent threats, such as HIV infection, to fall in priority.”

The researchers stated that many women “may also experience IPV as a consequence of HIV infection and its disclosure [to their partner]. As such, these women may be risking violent repercussions by engaging in care. Our study supports this [idea], as women who experienced IPV found it more difficult to remain engaged in HIV care.”

In this context it is not surprising that many women with IPV had poor health and quality of life, in part due to severe stress and no or intermittent use of ART. So the Alberta team proposes that by “directly addressing IPV, we may support adherence to care and thereby improve [their health and well-being].”

Advice for care teams

Women who disclosed IPV were less likely to be using ART; this may have at least partially accounted for their increased risk for hospitalization. Therefore, the researchers encourage medical and social teams caring for HIV-positive women to help develop safe and trustworthy relationships so that care teams can address IPV and its psychological consequences. As a result, affected women should improve psychologically and be able to take ART exactly as directed, which would lead to them experiencing better health and quality of life. Physicians, nurses, pharmacists and other healthcare providers can begin to help women with IPV by “appropriate referrals to specialized agencies and other health professionals” who are trained and experienced in dealing with IPV.

The Alberta study is a good first step in tackling the horror of IPV among HIV-positive women. Further research is needed to study the long-term outcomes on the health of affected HIV-positive women who have been able to disclose and escape IPV. As well, more effort needs to be made by regional health authorities everywhere to educate and screen all women about IPV.

—Sean R. Hosein

REFERENCES:

    Siemieniuk RA, Krentz HB, Miller P, et al. The clinical implications of high rates of intimate partner violence against HIV-positive women. Journal of Acquired Immune Deficiency Syndromes. 2013 Sep 1;64(1):32-8.
    Siemieniuk RA, Krentz HB, Gill MJ. Intimate partner violence and HIV: a review. Current HIV/AIDS Reports. 2013; in press.



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