Prevalence and trajectories of intimate partner violence among South African women during pregnancy and the postpartum period

Intimate partner violence (IPV) is a significant public health problem in South Africa. However, there has been limited research on IPV during pregnancy and the postpartum period, despite significant negative consequences. A better understanding of the prevalence and trajectories of IPV for women in South Africa during pregnancy and the postpartum period will inform IPV prevention interventions. Study 1 used data from the South Africa HIV antenatal post-test support study (SAHAPS) to describe the prevalence and rates of physical, sexual and psychological IPV at pregnancy, at four months postpartum and at nine months postpartum. More than 1 in 5 women experienced some form of IPV at least once during pregnancy. Psychological IPV was the most common type of IPV experienced in both pregnancy and the postpartum period. Study 2 used SAHAPS data to address two aims. First, random coefficients growth curve modeling was used to describe mean trajectories of physical and psychological IPV as well as individual variability around the mean during pregnancy and the postpartum period. This method was also used to examine whether relationship characteristics (relationship power, relationship stress and partner social support) and women's history of pre-pregnancy IPV would act together to increase risk for IPV during pregnancy and the postpartum period. The mean trajectory for both types of IPV was flat which means that, on average, there was not significant change in levels of IPV over pregnancy and the postpartum period. However, there was significant individual variability in trajectories of IPV over the study period. The association between pre-pregnancy IPV and IPV during pregnancy and the postpartum period was buffered by higher relationship power. Additionally, higher relationship stress increased women's risk of psychological IPV during pregnancy and the postpartum period, regardless of pre-pregnancy IPV. Partner social support did not change women's risk of IPV. The high prevalence of IPV during pregnancy and the postpartum period highlight the need for screening and intervention during and following pregnancy. While screening alone is not efficacious at reducing IPV, screening in conjunction with an intervention may reduce risk of IPV during this time.Doctor of Philosoph

Diagnosis and disclosure of HIV status: Implications for women’s risk of physical partner violence in the postpartum period

This study prospectively examined whether HIV leads to elevated risk for intimate partner violence (IPV) for women, and how this risk varies depending on HIV status disclosure to a partner

Defining Male Support During and After Pregnancy From the Perspective of HIV-Positive and HIV-Negative Women in Durban, South Africa

Greater male support during pregnancy and in the postpartum period may improve health outcomes for mothers and children. To develop effective strategies to engage men we need to first understand the ways that men are currently engaged and the barriers to their greater involvement. We conducted in-depth interviews in isiZulu with 30 HIV-positive women and 16 HIV-negative women who received prenatal care from a public clinic in Durban, South Africa. Interviews were audiotaped, transcribed, translated, and coded for analysis. While less than a quarter of women reported that their partners accompanied them to the clinic, they described receiving other material and psychosocial support from partners. More HIV-positive women reported that their partners were not involved or not supportive, and in some cases direct threats and experiences with violence caused them to fear partner involvement. We need to broaden the lens through which we consider male support during pregnancy and in the postpartum period, and acknowledge that male involvement may not always be in the best interest of women. Engaging supportive partners outside of the clinic setting and incorporating other important social network members are important next steps in the effort to increase support for women

Effectiveness of Interventions Promoting HIV Serostatus Disclosure to Sexual Partners: A Systematic Review

Disclosure of HIV serostatus to sexual partners is mandated within certain states in the United States and other countries. Despite these laws implemented and public health efforts to increase disclosure, rates of disclosure to sexual partners among people living with HIV (PLWH) remain low, suggesting the need for interventions to assist PLWH with the disclosure process. We conducted a systematic review of studies testing whether HIV serostatus disclosure interventions increase disclosure to sexual partners. We searched six electronic databases and screened 484 records. Five studies published between 2005 and 2012 met inclusion criteria and were included in this review. Results showed that three of the HIV serostatus disclosure-related intervention studies were efficacious in promoting disclosure to sexual partners. Although all three studies were conducted in the United States the intervention content and measurements of disclosure across the studies varied, so broad conclusions are not possible. The findings suggest that more rigorous HIV serostatus disclosure-related intervention trials targeting different populations in the United States and abroad are needed to facilitate disclosure to sexual partners

HIV status disclosure to families for social support in South Africa (NIMH Project Accept/HPTN 043)

Literature on HIV status disclosure among persons living with HIV/AIDS (PLWHA) is dominated by research on the rates, barriers and consequences of disclosure to sexual partners because of the assumed preventive health benefits of partner disclosure. Disclosure of HIV status can lead to an increase in social support and other positive psychosocial outcomes for PLWHA, but disclosure can also be associated with negative social outcomes including stigma, discrimination and violence. The purpose of this article is to describe the HIV status disclosure narratives of PLWHA living in South Africa. Thirty in-depth interviews were conducted with 13 PLWHA (11 women, 2 men) over a three year time period. We explored disclosure narratives of the PLWHA through questions about who they chose to disclose to, how they disclosed to these individuals, and how these individuals reacted. Narratives focused on disclosure to family members and contained relatively little discussion of disclosure to sexual partners. Participants often disclosed first to one trusted family member, and news of the diagnosis remained with this person for a long period of time, prior to sharing with others. This family member helped the PLWHA cope with the news of their diagnosis and prepared them to disclose to others. Disclosure to one’s partner was motivated primarily by a desire to encourage partners to test for HIV. Two participants described overtly negative reactions from a partner upon disclosure, and none of the PLWHA in this sample described very supportive relationships with their partners after disclosure. The critical role that family members played in the narratives of these PLWHA emphasizes the need for a greater focus on disclosure to families for social support in HIV counseling protocols

Social support among HIV-positive and HIV-negative adolescents in Umlazi, South Africa: changes in family and partner relationships during pregnancy and the postpartum period

Abstract Background Pregnancy is common among adolescents in South Africa, yet the social experiences of adolescents during the pregnancy and postpartum period remain understudied in this context. We aimed to explore how adolescent women’s discovery and disclosure of both their pregnancy and HIV status affected their relationships with family members and sexual partners, with a particular focus on whether and how support changed throughout this time period. Methods We conducted in-depth semi-structured interviews with 15 HIV-positive and HIV-negative adolescent women who were either pregnant or had delivered in the last 18 months from one urban clinic in Umlazi, South Africa. Interviews were audiotaped, transcribed, translated, and coded for analysis. Results Young women described stress and instability in their relationships with family and partners during pregnancy and the postpartum period, though prior to and during HIV-status disclosure women generally experienced less stress than in disclosing their pregnancy to family members and partners. After a destabilizing period immediately following pregnancy disclosure, families became and remained the primary source of material and emotional support for the young women. Women discussed heightened closeness with their partners during pregnancy, but few women had close relationships with their partners postpartum. Support experiences did not differ by HIV status. Conclusion Programs should be aware of the relative importance of pregnancy-related concerns over HIV-related concerns in this population of young women. Engaging family members is critical in ensuring social support for this population of young pregnant women, and in encouraging timely initiation of antenatal care

Fertility Intent and Contraceptive Decision-Making Among HIV Positive and Negative Antenatal Clinic Attendees in Durban, South Africa

We explored contraceptive decision-making among South African antenatal clinic attendees, fertility intent post-HIV diagnosis, and women’s experiences at government health facilities. Data are from in-depth interviews with HIV negative and HIV positive women. We interviewed women in Zulu; interviews were recorded, transcribed and translated. We conducted qualitative analyses of interviews. Women were the dominant decision-makers about contraceptive use, whether they involved their partners or not. A majority of women obtained a contraceptive method at a government facility; however, several women were unable to attain sterilizations. Women were presented with limited contraceptive options and were not always able to access services

Associations Between Intimate Partner Violence and Emotional Distress Among Pregnant Women in Durban, South Africa

Intimate partner violence (IPV) during pregnancy has been associated with multiple negative health outcomes for the mother, including emotional distress during pregnancy. However, little is known about IPV during pregnancy and its association with emotional distress among pregnant women in South Africa. The objectives of this study were to determine the prevalence of both emotional distress and IPV during pregnancy, to identify whether different exposures of violence and relational control were associated with emotional distress during pregnancy, and to assess whether social support attenuated the relationship between IPV and emotional distress in pregnancy. Pregnant women enrolled in the South Africa HIV Antenatal and Post-test Support Study (SAHAPS) who completed the baseline survey were included in this cross sectional analysis. We used logistic regression models to explore bivariate and multivariate relationships between the proposed covariates and emotional distress. Nearly a quarter of women reported experiencing some type of IPV during the current pregnancy, with psychological violence being the most prevalent. The odds of emotional distress was 1.41 times (95% CI: 1.26–1.57) higher for each additional episode of psychological violence and 2.01 times (95% CI: 1.16–3.77) higher for each additional episode of sexual violence during pregnancy, adjusting for other covariates. Physical violence was only marginally associated with increased odds of emotional distress (A.O.R.: 1.17, 95% CI: .99–1.38) after adjusting for other covariates. Finally, social support was also marginally significant as a main effect, but did not attenuate the relationship between IPV and emotional distress. The high prevalence of IPV among pregnant women in South Africa and its association with emotional distress during pregnancy suggest that interventions that reduce violence during or prior to pregnancy are needed. Such interventions can positively impact IPV and may also ameliorate poor mental health in pregnancy

The complexity of consent: women's experiences testing for HIV at an antenatal clinic in Durban, South Africa

Informed consent has historically been a cornerstone to ensuring autonomy during HIV testing. However, recent changes to global guidance on HIV testing have led to substantial debate on what policy provisions are necessary to ensure that consent remains meaningful in the context of testing. Despite disproportionate rates of testing during pregnancy, pregnant women's perspectives on the HIV testing process are underrepresented in the testing discourse. This study explores women's experiences with HIV testing and the consent process in a public antenatal clinic in South Africa. Qualitative interviews with 25 women were conducted at the clinic at either an antenatal visit or an infant immunization visit that followed HIV testing. Interviews were transcribed, translated, and coded for analysis. Women were categorized into one of the three groups based on their perceptions of choice in consenting for an HIV test. Matrices were used to allow for cross-category and cross-case comparison. Half of the women described having a clear choice in their decision to test. Others were less clear about their choice. Some women felt they had no choice in testing for HIV. None of the women stated that they were tested without having signed a consent form. We found that half of the women's narratives illustrated direct and indirect ways in which providers coerced them into taking an HIV test while receiving antenatal care. As the new guidance on HIV testing is implemented in different settings, it is critical to monitor women's testing experiences to ensure that a woman's right to make an informed, voluntary choice is not violated. Furthermore, models of testing that allow us to meet broader public health goals while simultaneously respecting women's autonomy are needed

HIV testing for pregnant women: A rights-based analysis of national policies

Ethical and human rights concerns have been expressed regarding the global shift in policies on HIV testing of pregnant women. The main purpose of this research was to conduct a policy analysis using a human rights-based approach of national policies for HIV testing of pregnant women. We collected HIV testing policies from 19 countries including: Cambodia, China, Guyana, Haiti, India, Jamaica, Kenya, Moldova, Papua New Guinea, Russian Federation, South Africa, Sudan, Swaziland, Tanzania, Ukraine, United States, Uzbekistan, Zambia and Zimbabwe. We analysed the HIV testing policies using a standardised framework that focused on government obligations to respect, protect and fulfil. Our results highlight the need for more attention to issues of pregnant women's autonomy in consenting to HIV testing, confidentiality in antenatal care settings and provision of counselling and care services. We conclude with a discussion about potential implications of the current testing policies and provide recommendations for ways that HIV testing policies can more effectively uphold the human rights of pregnant women