Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis.

OBJECTIVE: We aimed to estimate the odds of engagement in HIV care and treatment among HIV-positive women reporting intimate partner violence (IPV). DESIGN: We systematically reviewed the literature on the association between IPV and engagement in care. Data sources included searches of electronic databases (PubMed, Web of Science, CINAHL and PsychoInfo), hand searches and citation tracking. METHODS: Two reviewers screened 757 full-text articles, extracted data and independently appraised study quality. Included studies were peer-reviewed and assessed IPV alongside engagement in care outcomes: antiretroviral treatment (ART) use; self-reported ART adherence; viral suppression; retention in HIV care. Odds ratios (ORs) were pooled using random effects meta-analysis. RESULTS: Thirteen cross-sectional studies among HIV-positive women were included. Measurement of IPV varied, with most studies defining a 'case' as any history of physical and/or sexual IPV. Meta-analysis of five studies showed IPV to be significantly associated with lower ART use [OR 0.79, 95% confidence interval (95% CI) 0.64-0.97]. IPV was associated with poorer self-reported ART adherence in six studies (OR 0.48, 95% CI 0.30-0.75) and lower odds of viral load suppression in seven studies (OR 0.64, 95% CI 0.46-0.90). Lack of longitudinal data and measurement considerations should temper interpretation of these results. CONCLUSION: IPV is associated with lower ART use, half the odds of self-reported ART adherence and significantly worsened viral suppression among women. To ensure the health of HIV-positive women, it is essential for clinical programmes to address conditions that impact engagement in care and treatment. IPV is one such condition, and its association with declines in ART use and adherence requires urgent attention

Sexual Relationship Power and Depression among HIV-Infected Women in Rural Uganda

Background: Depression is associated with increased HIV transmission risk, increased morbidity, and higher risk of HIV-related death among HIV-infected women. Low sexual relationship power also contributes to HIV risk, but there is limited understanding of how it relates to mental health among HIV-infected women. Methods: Participants were 270 HIV-infected women from the Uganda AIDS Rural Treatment Outcomes study, a prospective cohort of individuals initiating antiretroviral therapy (ART) in Mbarara, Uganda. Our primary predictor was baseline sexual relationship power as measured by the Sexual Relationship Power Scale (SRPS). The primary outcome was depression severity, measured with the Hopkins Symptom Checklist (HSCL), and a secondary outcome was a functional scale for mental health status (MHS). Adjusted models controlled for socio-demographic factors, CD4 count, alcohol and tobacco use, baseline WHO stage 4 disease, social support, and duration of ART. Results: The mean HSCL score was 1.34 and 23.7% of participants had HSCL scores consistent with probable depression (HSCL>1.75). Compared to participants with low SRPS scores, individuals with both moderate (coefficient b = −0.21; 95%CI, −0.36 to −0.07) and high power (b = −0.21; 95%CI, −0.36 to −0.06) reported decreased depressive symptomology. High SRPS scores halved the likelihood of women meeting criteria for probable depression (adjusted odds ratio = 0.44; 95%CI, 0.20 to 0.93). In lagged models, low SRPS predicted subsequent depression severity, but depression did not predict subsequent changes in SPRS. Results: were similar for MHS, with lagged models showing SRPS predicts subsequent mental health, but not visa versa. Both Decision-Making Dominance and Relationship Control subscales of SRPS were associated with depression symptom severity. Conclusions: HIV-infected women with high sexual relationship power had lower depression and higher mental health status than women with low power. Interventions to improve equity in decision-making and control within dyadic partnerships are critical to prevent HIV transmission and to optimize mental health of HIV-infected women

Pathways From Food Insecurity to Intimate Partner Violence Perpetration Among Peri-Urban Men in South Africa.

INTRODUCTION: Although poverty is sometimes seen as a driver of intimate partner violence victimization, less is known about how it intersects with men's violence perpetration. Food insecurity is a sensitive marker of poverty that may have unique mechanisms leading to men's intimate partner violence perpetration given its association with gender roles and men "providing for the family." METHODS: Using cluster-based sampling, the team conducted an audio-assisted questionnaire in 2016 among men living in a peri-urban settlement near Johannesburg, South Africa. The aim was to examine the relationship between men's food insecurity and their use of past-year intimate partner violence, and to explore the pathways linking these two conditions. RESULTS: Among 2,006 currently partnered men, nearly half (48.4%) perpetrated intimate partner violence and more than half (61.4%) were food insecure. Food insecurity was associated with doubled odds of intimate partner violence (OR=2.15, 95% CI=1.73, 2.66). This association persisted after controlling for sociodemographics, relationship characteristics, and neighborhood clustering. In a structural equation model, food insecurity retained a direct relationship with men's violence perpetration and worked through indirect pathways of mental health and relationship quality. CONCLUSIONS: Addressing men's perpetration of intimate partner violence may require examination of broader structural challenges, such as food insecurity. Future interventions should consider livelihood strategies alongside relationship and mental health approaches

When nurses are also patients: Intimate partner violence and the health system as an enabler of women\u27s health and agency in Johannesburg

While violence against women is a recognised global health problem, women’s agency in marginalised settings is poorly understood, particularly in relation to health systems. We explored agency as a practical and theoretical construct through qualitative research among 20 nurses with direct or indirect experiences of intimate partner violence (IPV) in Johannesburg. Interviews conducted from August 2013 to March 2014 generated rich descriptions from respondents in five health facilities. Nurses’ self-reported IPV matched national prevalence of 24–31%. Findings revealed the way in which agency is enacted by nurses, allowing them the economic means to leave abusive partnerships, yet disabling them from agency and health promotion in their workplace. At the same time, nurses expanded agentic possibilities for patients by enabling a national response to IPV within South African health clinics – one that is largely undocumented. We posit that nurses can serve as important agentic actors in public health systems in low- and middle-income country settings by assisting patients to address IPV, even in the absence of targeted training and guidelines. To ensure the health and well-being of women experiencing IPV, nurses should be supported by the health sector to respond skilfully to patients and to safely process their own experiences of violence

Intimate partner violence and forced migration during pregnancy: Structural constraints to women's agency

Little is known about migration during pregnancy related to intimate partner violence (IPV). In this paper, we examine issues of agency in relation to pregnant women\u2019s migrations in a high HIV prevalence area of Kenya. We qualitatively explored forced migration among pregnant women, using data from in-depth interviews, focus groups and IPV screening forms. To quantitatively examine migration during pregnancy, we analysed data from a prospective study of 614 pregnant women. The qualitative data revealed that women had varied responses to violence in pregnancy, with some being able to leave the marital home voluntarily as a strategy to escape violence. Others were \u2018sent packing\u2019 from their marital homes when they dared to exercise autonomy, in some cases related to HIV status. Quantitative analyses revealed that pregnant women who migrated were more educated, less likely to be living with a partner and had fewer children than other women. Migration among pregnant women in Kenya illustrates the complexity of understanding women\u2019s agency in the context of IPV. The findings indicate that there is not a dichotomy between \u2018victim\u2019 and \u2018agent\u2019, but rather a complex dynamic between and within pregnant women, who may sequentially or simultaneously experience aspects of victimhood and/or agentic response

Economic empowerment and intimate partner violence: a secondary data analysis of the cross-sectional Demographic Health Surveys in Sub-Saharan Africa.

BACKGROUND: Intimate partner violence (IPV) has been recognized as a defining human rights, development and public health issue of our time. Economic empowerment is one of the most promising interventions to reduce IPV in sub-Saharan Africa, yet the evidence around economic factors that are key to ensure a reduction in IPV are still mixed. Furthermore, there is a lack of clarity on what kinds of economic empowerment works for which population group. This paper seeks a more nuanced understanding, by investigating whether the associations between indicators of economic empowerment and physical and/or sexual IPV are similar between the general population of women and among urban versus rural and young, or middle aged women versus older women. METHODS: Using couples data from 25 DHS surveys across 15 countries (n = 70,993 women and men aged 15 and above at time of survey), we analyse how household wealth, men's and women's education and employment status, decision making on women's income, differences in education and employment of women and their partners and women's cash income are associated with physical and/or sexual IPV. We also provide sub-analyses for both urban and rural areas and for women aged, 15 to 24 25 to 34 and 35 to 49. RESULTS: Across all surveys, 20% of women reported physical and/or sexual IPV in the last 12 months. On the one hand, our findings reinforced certain well-established patterns between women's economic empowerment and IPV, with women's and men's higher levels of education and increased household wealth  associated with a decrease in IPV, and women's employment, especially if only the woman worked, and women earning more than her partner associated with an increase in IPV. Most patterns did not differ across urban and rural settings and age groups, but notable differences emerged regarding household wealth, women's and men's employment in the last 12 months and relative employment and education. CONCLUSIONS: Factors relating to women's economic empowerment are  vital in understanding and addressing IPV. Our analysis indicate however that future interventions need to consider the differing needs of urban and rural areas as well as be targeted to different age groups

Predictors of linkage to care following community-based HIV counseling and testing in rural Kenya

Despite innovations in HIV counseling and testing (HCT), important gaps remain in understanding linkage to care. We followed a cohort diagnosed with HIV through a community-based HCT campaign that trained persons living with HIV/AIDS (PLHA) as navigators. Individual, interpersonal, and institutional predictors of linkage were assessed using survival analysis of self-reported time to enrollment. Of 483 persons consenting to follow-up, 305 (63.2%) enrolled in HIV care within 3 months. Proportions linking to care were similar across sexes, barring a sub-sample of men aged 18–25 years who were highly unlikely to enroll. Men were more likely to enroll if they had disclosed to their spouse, and women if they had disclosed to family. Women who anticipated violence or relationship breakup were less likely to link to care. Enrolment rates were significantly higher among participants receiving a PLHA visit, suggesting that a navigator approach may improve linkage from community-based HCT campaigns.Vestergaard Frandse

Sexual violence and antiretroviral adherence among women of reproductive age in African population-based surveys: the moderating role of the perinatal phase

INTRODUCTION: Women face challenges in antiretroviral therapy (ART) adherence and achieving viral suppression despite progress in the expansion of HIV treatment. Evidence suggests that violence against women (VAW) is an important determinant of poor ART adherence in women living with HIV (WLH). In our study, we examine the association of sexual VAW and ART adherence among WLH and assess whether this association varies by whether women are pregnant/breastfeeding or not. METHODS: A pooled analysis was conducted among WLH from Population-Based HIV Impact Assessment cross-sectional surveys (2015-2018) from nine sub-Saharan African countries. Logistic regression was used to examine the association between lifetime sexual violence and suboptimal ART adherence (≥1 missed day in the past 30 days) among reproductive age WLH on ART, and to assess whether there was any evidence for interaction by pregnancy/breastfeeding status, after adjusting for key confounders. RESULTS: A total of 5038 WLH on ART were included. Among all included women, the prevalence of sexual violence was 15.2% (95% confidence interval [CI]: 13.3%-17.1%) and the prevalence of suboptimal ART adherence was 19.8% (95% CI: 18.1%-21.5%). Among only pregnant and breastfeeding women, the prevalence of sexual violence was 13.1% (95% CI: 9.5%-16.8%) and the prevalence of suboptimal ART adherence was 20.1% (95% CI: 15.7%-24.5%). Among all included women, there was evidence for an association between sexual violence and suboptimal ART adherence (adjusted odds ratio [aOR]: 1.69, 95% CI: 1.25-2.28). There was evidence that the association between sexual violence and ART adherence varied by pregnant/breastfeeding status (p = 0.004). Pregnant and breastfeeding women with a history of sexual violence had higher odds of suboptimal ART adherence (aOR: 4.11, 95% CI: 2.13-7.92) compared to pregnant and breastfeeding women without a history of sexual violence, while among non-pregnant and non-breastfeeding women, this association was attenuated (aOR: 1.39, 95% CI: 1.00-1.93). CONCLUSIONS: Sexual violence is associated with women's suboptimal ART adherence in sub-Saharan Africa, with a greater effect among pregnant and breastfeeding WLH. To improve women's HIV outcomes and to achieve the elimination of vertical transmission of HIV, violence prevention efforts within maternity services and HIV care and treatment should be a policy priority

Placement, support, and retention of health professionals: national, cross-sectional findings from medical and dental community service officers in South Africa

Background: In South Africa, community service following medical training serves as a mechanism for equitable distribution of health professionals and their professional development. Community service officers are required to contribute a year towards serving in a public health facility while receiving supervision and remuneration. Although the South African community service programme has been in effect since 1998, little is known about how placement and practical support occur, or how community service may impact future retention of health professionals. Methods: National, cross-sectional data were collected from community service officers who served during 2009 using a structured self-report questionnaire. A Supervision Satisfaction Scale (SSS) was created by summing scores of five questions rated on a three-point Likert scale (orientation, clinical advising, ongoing mentorship, accessibility of clinic leadership, and handling of community service officers’ concerns). Research endpoints were guided by community service programmatic goals and analysed as dichotomous outcomes. Bivariate and multivariate logistical regressions were conducted using Stata 12. Results: The sample population comprised 685 doctors and dentists (response rate 44%). Rural placement was more likely among unmarried, male, and black practitioners. Rates of self-reported professional development were high (470 out of 539 responses; 87%). Participants with higher scores on the SSS were more likely to report professional development. Although few participants planned to continue work in rural, underserved communities (n = 171 out of 657 responses, 25%), those serving in a rural facility during the community service year had higher intentions of continuing rural work. Those reporting professional development during the community service year were twice as likely to report intentions to remain in rural, underserved communities. Conclusions: Despite challenges in equitable distribution of practitioners, participant satisfaction with the compulsory community service programme appears to be high among those who responded to a 2009 questionnaire. These data offer a starting point for designing programmes and policies that better meet the health needs of the South African population through more appropriate human resource management. An emphasis on professional development and supervision is crucial if South Africa is to build practitioner skills, equitably distribute health professionals, and retain the medical workforce in rural, underserved areas

Depressive symptoms and violence exposure in a population-based sample of adult women in South Africa

Depressive symptoms are a major burden of disease globally and is associated with violence and poverty. However, much of the research linking these conditions is from resource-rich settings and among smaller, clinical samples. Secondary data from a household survey in Gauteng Province of South Africa examines the cross-sectional association between adult women’s elevated depressive symptoms and markers of violence. Using tablet computers, participants self-completed interview modules to screen for depressive symptoms (Patient Health Questionnaire 2-item screener), childhood exposure to physical and sexual abuse (Childhood Trauma Questionnaire 4-item index), as well as past-year exposure to sexual or intimate partner violence (SIPV; WHO Multicountry Study instrument 4-item index). Socio-economic status, food security, education, and income were self-reported. Representative data at the ward level allows for modeling of results using survey commands and mixed-level modeling. Of the 7,276 adult women participating in the household survey, 42.1% reported elevated depressive symptoms. A total of 63.9% reported childhood violence exposure and 5.3% had past-year SIPV. Multi-level modeling suggests that violence is a strong predictor of depressive symptoms. Childhood abuse alone increases the odds of high depressive symptomology, after controlling for individual-level markers of poverty and neighborhood of residence (aOR 1.31, 95%, CI 1.17–1.37). Combined exposure to childhood abuse and past-year SIPV increased odds of reporting elevated depressive symptoms (aOR 2.05, 95%, CI 1.54–2.71). Ward characteristics account for 6% of the variance in depressive symptoms, over and above the contributions of household food security and socio-economic status. Exposure to violence in childhood and past-year SIPV were associated with depressive symptoms among women. These associations persist after controlling for socio-economic markers and latent neighborhood characteristics, which also had significant association with elevated depressive symptoms. These data suggest that efforts to reduce the burden of depressive symptoms may benefit from approaches that prevent violence against women and children