Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission

Impact of Financial Incentives on Intimate Partner Violence for Women Living with HIV Initiating Antiretroviral Therapy

Financial incentives have demonstrated effectiveness in improving outcomes for people living with HIV; however, little is known about their impact on intimate partner violence (IPV) in this vulnerable population. A cluster-randomized trial investigating financial incentives and viral suppression was conducted in the Lake Zone of Tanzania (clinicaltrials.gov: NCT0420135). Between May 2021-March 2022, 32 clinics were randomized 1:1 to receive the standard of care (SOC) or to offer 22,500 TZS (~$10 USD) to individuals initiating antiretroviral therapy monthly for up to 6 months, conditional on clinic attendance. An intention-to-treat analysis was conducted to examine the effect of financial incentives on IPV among partnered women at 6 months (n = 494), with prevalence differences (PD) and 95% confidence intervals (CI) estimated using generalized estimating equations. Subgroup analyses were conducted among women partnered at 6 months only and women partnered at both baseline and 6 months. Past 6-month IPV was reported by 241 (48.8%) partnered women. Emotional IPV was the most common form of violence (47.8%), followed by physical (7.5%) and sexual IPV (5.1%). There were no significant differences in past 6-month IPV between arms in the primary (49.6% SOC vs. 48.1% incentive, PD: -0.02, 95% CI: -0.18, 0.15) or subgroup analyses. These findings suggest that small, short-term financial incentives used to improve HIV treatment outcomes do not significantly alter IPV risks, however with the width of the CIs it is not possible to rule out small and moderate-sized effects. Further research among larger samples is needed as financial incentive programs are brought to scale for people living with HIV.

The contribution of intimate partner violence to vertical HIV transmission: a modelling analysis of 46 African countries

BACKGROUND

Addressing gender inequities could be key to the elimination of vertical transmission of HIV. Women experiencing intimate partner violence (IPV) might be at an increased risk of vertical transmission due to their vulnerability to HIV acquisition and barriers to access to and retention in care. Sub-Saharan Africa, where IPV burden is among the highest globally, accounts for most new paediatric HIV infections. We aimed to examine the proportion of excess vertical transmission attributable to IPV in this region.

METHODS

In this modelling analysis, we created a probability tree model of vertical HIV transmission among women aged 15-49 years in 46 African countries. We estimated the proportion of vertical transmission attributable to past-year physical or sexual IPV, or both, as an age-standardised population attributable fraction (PAF) and as excess vertical transmission risk per 1000 births among women experiencing IPV. We incorporated perinatal and postnatal vertical transmission among women who acquired HIV before pregnancy, during pregnancy, and during breastfeeding. Fertility, HIV prevalence, HIV incidence, antiretroviral therapy (ART) uptake, and ART retention varied in the model by women's IPV experience. The model was parameterised using UNAIDS' 2023 Spectrum model data, WHO's Global Database on Violence Against Women, and the peer-reviewed literature. Uncertainty intervals (95% UI) were calculated through 1000 Monte Carlo simulations.

FINDINGS

Across 46 countries 13% (95% UI 6-21) of paediatric HIV infections in 2022 were attributed to IPV, corresponding to over 22 000 paediatric infections. The PAF ranged from 4% (2-7) in Niger to 28% (13-43) in Uganda. The PAF was highest among girls aged 15-19 years (20%, 8-33) and lowest among women aged 45-49 years (6%, 3-9). In southern Africa, where women's HIV prevalence is highest (23%), IPV led to 11 (5-20) additional infections per 1000 births among women affected by IPV.

INTERPRETATION

IPV might be responsible for one in eight paediatric HIV infections in sub-Saharan Africa. Ending IPV could accelerate vertical transmission elimination, especially among young women who bear the highest burden of violence.

FUNDING

Canadian Institutes of Health Research, Canada Research Chair, and Fonds de recherche du Québec-Santé.

TRANSLATIONS

For the French, Georgian and Spanish translations of the abstract see Supplementary Materials section.

"So that's why I found PrEP to be safest way to protect yourself": exploring IPV experiences and impact on HIV prevention among pregnant and postpartum women in Cape Town, South Africa

Intimate partner violence (IPV) occurs at alarmingly high rates towards pregnant women in South Africa. Experiences of emotional, physical, and sexual IPV in pregnancy can adversely impact the health and safety of mother and fetus. Furthermore, IPV is associated with increased risk of HIV, exacerbating the public health impact of violence among pregnant women in this HIV endemic setting. In-depth understanding of cultural and contextual drivers of experiences of IPV is a critical precursor to development of interventions effectively addressing this issue among pregnant women in South Africa. The present study examines factors contributing to IPV among pregnant women to identify potential points of intervention. We conducted twenty in-depth interviews with postpartum women who used oral pre-exposure prophylaxis (PrEP) in pregnancy and reported recent experiences of IPV and/or ongoing alcohol use in a township near Cape Town, South Africa that experiences a heavy burden of both HIV and IPV. Interpretive thematic analysis was used. Several patterns of IPV during pregnancy were identified and violence was frequently described as co-occurring with male partner alcohol use. A majority of women referenced oral PrEP as their preferred method for HIV prevention, highlighting the agency and discretion it provided as beneficial attributes for women experiencing IPV. Fear of judgement from peers for remaining with an abusive partner and a lack of clear community messaging around IPV were identified as barriers to disclosure and support-seeking. Addressing the lack of social support received by women experiencing IPV during pregnancy in South Africa is essential to comprehensive IPV programming.

Intimate partner violence and its associations among HIV-infected MSM with new drug abuse in Jinan, China

BACKGROUND

Intimate Partner Violence (IPV) is prevalent among HIV-infected men who have sex with men (MSM), with well-established risk factors and adverse outcomes. However, there is a lack of comprehensive investigation of both upstream risk factors and downstream adverse outcomes among HIV-infected MSM in a Chinese context. This study aimed to examine IPV and its associations among a Chinese sample of HIV-infected MSM.

METHODS

A cross-sectional study was conducted among 294 HIV-infected MSM in Jinan City from June to December 2020. All data were collected through an online questionnaire, which included IPV, sexual risk behavior, antiretroviral therapy (ART) adherence, depression, anxiety, and suicidal ideation. Chi-square tests and multivariate logistic regressions were performed to examine risk factors and adverse outcomes of IPV.

RESULTS

Of the 294 HIV-infected MSM, 71.1% experienced any IPV, including control (37.1%), threat of public identity (30.6%), emotional violence (25.2%), security threat (18.4%), and physical violence (13.9%). The prevalence of sexual risk behavior, good ART adherence, depression, anxiety, and suicidal ideation was 55.1%, 53.4%, 48.3%, 32.3%, and 65.0%, respectively. Abuse of methamphetamine (METH) (aOR:2.79; 95%CI:1.43 ~ 5.45), capsule 0 or stimulating liquid (aOR:2.68; 95%CI:1.31 ~ 5.47), Magu (aOR:3.16; 95%CI:1.51 ~ 6.60), and other new drugs (aOR:2.87; 95%CI:1.52 ~ 5.43), disclosing HIV infection to partners (aOR:2.03; 95%CI:1.10 ~ 3.78), and gay sexual orientation (aOR = 3.32; 95%CI: 1.82 ~ 6.05) were significantly correlated with the experience of IPV. In addition, IPV was significantly associated with sexual risk behavior (aOR = 2.02; 95%CI:1.16 ~ 3.53), ART adherence (aOR = 2.63; 95%CI:1.46 ~ 4.74), depression (aOR = 3.83; 95%CI:2.09 ~ 7.02), anxiety (aOR = 2.27; 95%CI:1.19 ~ 4.35), and suicidal ideation (aOR = 3.78; 95%CI:2.11 ~ 6.80).

CONCLUSIONS

IPV is prevalent among HIV-infected MSM and is associated with poor behavioral and mental health, highlighting more efforts are needed to address this issue. The finding that new drug abuse, HIV disclosure, and gay sexual orientation are associated with increased risk of IPV provides essential insights for the development of comprehensive and targeted IPV prevention and intervention programs in the future.

In the era of universal test and treat in Uganda, recent intimate partner violence is not associated with subsequent ART use or viral suppression

Intimate partner violence (IPV) has been associated with delays throughout the HIV care continuum. This study explored prospective associations between experiences of past-year IPV and two HIV care outcomes in the context of current universal test and treat guidelines using two consecutive rounds of an ongoing HIV surveillance study conducted in the Rakai region of Uganda. Longitudinal logistic regression models examined associations between IPV, use of antiretroviral therapy (ART) and viral load suppression (VS), adjusting for outcome variables at baseline. To address differences in ART retention by IPV, propensity scores were used to create inverse-probability-of-treatment-and-censoring-weighted (IPTCW) models. At baseline, of 1923 women with HIV (WWH), 34.6%, 26.5%, 13.5% reported past-year verbal, physical and sexual IPV; a lower proportion of persons who experienced physical IPV (79.4%) were VS than those who did not (84.3%; p = 0.01). The proportion VS at baseline also significantly differed by exposure to verbal IPV (p = 0.03). However, in adjusted longitudinal models, IPV was not associated with lower odds of ART use or VS at follow-up. Among WWH in the Rakai region, IPV does not appear to be a barrier to subsequent ART use or VS. However, given the prevalence of IPV in this population, interventions are needed.

Adverse Impact of Intimate Partner Violence Against HIV-Positive Women During Pregnancy and Post-Partum: Results From a Meta-Analysis of Observational Studies

Objectives: Intimate partner violence (IPV) against pregnant or human immunodeficiency virus (HIV)-positive women have been previously studied. However, data on the impact of IPV on HIV-positive pregnant women have not been systematically synthesized. We performed a meta-analysis to explore this issue and provide evidence regarding IPV prevention and HIV infection control. Method: The PubMed, Web of Science, Cochrane Library, and Embase databases were systematically searched. Studies that quantitatively assessed the association between IPV and its adverse impact on HIV-positive women during pregnancy and post-partum were eligible for inclusion. Pooled odds ratios (ORs) were calculated. Findings: Eight studies were identified to meet our eligibility criteria. The adverse impacts of IPV against HIV-positive pregnant women mainly included nonadherence to maternal antiretroviral treatment during pregnancy, nondisclosure of HIV-positive status to male partners, nonadherence to infant antiretroviral prophylaxis, and antenatal depression. IPV caused a 180% and 145% increase in the odds of antenatal depression and nonadherence to infant antiretroviral prophylaxis, respectively, among HIV-positive women, compared to the odds of their IPV-free counterparts [OR = 2.80, 95% confidence interval (CI): 1.66-4.74; OR = 2.45, 95% CI: 1.40-4.27]. Conclusion: Limited evidence has suggested that IPV against HIV-positive pregnant women caused maternal depression during pregnancy and led to the possible failure of HIV prophylaxis adherence in infants. Interventions to address IPV may ultimately reduce the risk of depression-related adverse birth outcomes and vertical transmission in infants exposed to maternal HIV. Prevention and control against IPV should be developed for HIV-positive pregnant women.

Physical violence during pregnancy in sub-Saharan Africa: why it matters and who are most susceptible?

OBJECTIVE

The study assessed the prevalence of physical violence against pregnant women and its associated factors in sub-Saharan Africa (SSA).

DESIGN

We analysed cross-sectional data of 108971 women in sexual unions from the most recent Demographic and Health Surveys of 26 countries in SSA. The predictors of physical violence were examined using a multilevel binary logistic regression. All the results were presented as adjusted odds ratios (aORs) with their corresponding 95% confidence intervals (CIs).

SETTING

Twenty-six countries in SSA.

PARTICIPANTS

108 971 women who had ever been pregnant.

OUTCOME MEASURE

Physical violence during pregnancy.

RESULTS

Physical violence was identified in 6.0% of pregnant women in SSA. The highest prevalence (14.0%) was reported in South Africa, while Burkina Faso recorded the lowest (2.1%). Women who had primary (aOR=1.26, 95% CI=1.15, 1.38) and secondary education (aOR=1.15, 95% CI=1.01,1.32); those who were cohabiting (aOR=1.21, 95% CI=1.11, 1.32); those who were working (aOR=1.17, 95% CI=1.08, 1.28); and those whose partners had primary (aOR=1.15, 95% CI=1.04, 1.28) and secondary education (aOR=1.14, 95% CI=1.01, 1.28) were more likely to experience physical violence during pregnancy compared with those who had no formal education; those who were married; those who were not working, and those whose partners had no formal education, respectively. Moreover, women whose partners consumed alcohol (aOR=2.37, 95% CI=2.20, 2.56); those who had parity of four or more (aOR=2.06, 95% CI=1.57, 2.72); and those who perceived intimate partner violence (IPV) as a culturally accepted norm (aOR=1.55, 95% CI=1.44, 1.67) had higher odds of experiencing physical violence during pregnancy compared to those whose partners did not consume alcohol, those with parity zero, and those who did not perceive IPV as culturally accepted, respectively. On the contrary, women who were aged 35-39, those who were of the richest wealth index, and those in rural areas had reduced odds of experiencing physical violence during pregnancy.

CONCLUSION

Based on the findings, community leaders are encouraged to liaise with law enforcement agencies to strictly enforce laws on gender-based violence by prosecuting perpetrators of IPV against pregnant women as a deterrent. Also, intensifying education on what constitutes IPV and the potential consequences on the health of pregnant women, their children, and their families will be laudable. Improving the socioeconomic status of women may also help to eliminate IPV perpetration against women at their pregnancy stage.

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.

Intimate Partner Violence and Health Outcomes Among Women Living With HIV/AIDS in Ghana: A Cross-Sectional Study

Intimate partner violence (IPV) is known to have negative health consequences for victims. For women living with HIV/AIDS, whose health may be compromised, exposure to IPV can be devastating. Yet few (if any) studies have explored the health implications of exposure to IPV among HIV-positive women. We begin to fill this gap by examining the effects of various dimensions of IPV (physical, sexual, psychological/emotional, and economic) on the cardiovascular, psychosocial, and sexual reproductive health outcomes of HIV-positive women in Ghana. Data were collected from a cross-section of 538 HIV-positive women aged 18 years and older in the Lower Manya Krobo District in the Eastern Region. We used logit models to explore relationships between IPV and health. The findings indicate high prevalence of IPV in our sample: physical violence (61%), sexual violence (50.9%), emotional/psychological violence (79.6%), and economic violence (66.8%). Generally, participants with experiences of IPV reported cardiovascular health problems, unwanted pregnancies and pregnancy loss, and poor psychosocial health. Our findings suggest the importance of screening for IPV as part of HIV care in Ghana.

Perceived Barriers to HIV Care and Viral Suppression Comparing Newly Diagnosed Women Living with HIV in Rural Uganda with and without a History of Intimate Partner Violence

Intimate partner violence (IPV) is associated with poor HIV care linkage and retention, medication adherence, and viral suppression. However, limited knowledge exists regarding potential mechanisms linking IPV to these outcomes. We aimed to (a) identify the top barriers to accessing HIV care experienced by women living with HIV (WLHIV) who report a history of IPV and have suppressed viral load (VL) versus unsuppressed VL and (b) understand how these barriers influence VL, comparing WLHIV with a history of IPV to WLHIV without a history of IPV. Study data come from newly diagnosed WLHIV in rural Uganda participating in the standard-of-care control arm of a randomized trial (n = 152). Descriptive results ranking mean scores from highest to lowest showed that, among women with a history of IPV, irrespective of viral suppression status, paying for transportation to come to clinic, having to wait at the clinic for long periods of time, and finding a clinic within reasonable travel distance were the top three barriers to accessing HIV care. WLHIV with a history of IPV were significantly more likely to have unsuppressed VL versus suppressed VL if they reported higher levels of difficulty finding a clinic within reasonable travel distance (RRR = 1.7, 95% CI [1.1-2.7]), getting permission to take time off from work (RRR = 1.5, 95% CI [1.0-2.9]), and finding time to come to the clinic for an appointment (RRR = 1.6, 95% CI [1.0-2.6]). The same relationships were not present among WLHIV without a history of IPV, suggesting these barriers and their effect on VL may be uniquely related to IPV. Interventions should address IPV and HIV care continuum outcomes in tandem, targeting barriers to accessing HIV care likely associated with IPV. Additional research is necessary to better understand how IPV relates to HIV care barriers and VL.

Mixed studies review of domestic violence in the lives of women affected by HIV stigma

We conducted a mixed studies review to examine domestic violence and stigma against women affected by HIV. We searched Medline, Web of Science, PsycINFO and EMBASE databases with no starting date limit. Studies that reported on experiences of stigma, discrimination, or domestic violence against women affected by HIV in any country were included. Because the review focused on HIV stigma-related violence, we only included studies that reported violence following an HIV diagnosis or at the time of HIV testing. A total 1056 records were screened; 89 articles were assessed for full text eligibility and 49 studies were selected for evidence synthesis. A convergent approach was used and study findings were analysed thematically. Four broad themes emerged: (1) being affected by HIV increases domestic violence, (2) supportive reactions from partners, (3) HIV stigma is associated with domestic violence, and (4) domestic violence associated with HIV-stigma is gendered. Research gaps identified included the burden of intersectional stigma of domestic violence and HIV, and the mediating role of HIV stigma in domestic violence for women with HIV, highlighting the need for further research in this area to reduce violence against women living with HIV.

Gender, Power, and Health: Measuring and Assessing Sexual Relationship Power Equity Among Young Sub-Saharan African Women and Men, a Systematic Review

Gender inequity, including low sexual relationship power (SRP), is an important determinant of intimate partner violence (IPV) and negative sexual, reproductive, and mental health. Different versions of the Sexual Relationship Power Scale (SRPS) are commonly used within youth studies to examine how gender inequities, including controlling behaviors, in heterosexual relationships impact the lives of young people in sub-Saharan Africa. This review aims to (1) describe definitions and measures of SRP within sub-Saharan African youth studies and (2) review and summarize associations between SRP equity, IPV, and sexual, reproductive, and mental health. After searching Pubmed, Ovid Med, Psych info, Web of Science, Google Scholar, and relevant research forums, 304 papers were identified, of which 29 papers based on 15 distinct studies (published 2004-2019) met our criteria for being youth-specific, conducted in sub-Saharan Africa, and including a quantitative measure of SRP. Details of each SRPS are described, including any adaptations and psychometric properties, as well as associations with IPV, sexual, reproductive, and mental health behaviors and outcomes. Results indicate that there are variations to the SRPS, and a paucity of evidence has detailed the psychometric properties of such measures within sub-Saharan African youth studies. Measures of SRP equity are associated with experiences (among women) and perpetration of (among men) IPV as numerous pathways to HIV risk; however, the evidence remains mixed. In order to address overlapping epidemics of violence against women and HIV, efforts are needed to ensure that measures, including the SRPS, are valid and reliable among highly affected populations.

A systematic review of the effects of intimate partner violence on HIV-positive pregnant women in sub-Saharan Africa

Background

Intimate partner violence (IPV) affects more than one in three women in sub-Saharan Africa (SSA). It is associated with both pregnancy and HIV, adversely affecting women in this region. This is the first systematic examination of the effects of IPV on HIV-positive (HIV+) pregnant women in SSA.

Methods

A systematic review of the literature on HIV+ pregnant women experiencing IPV in SSA was carried out. Searches were carried out in PubMed, Web of Science and African Journals Online databases. Articles published between January 2010 and June 2020, in English, were included. Data extraction included details on study locations, study design, study participants and the study outcome variables (depression, IPV, medication adherence, postpartum unsafe sex, and HIV disclosure).

Results

Fourteen studies (ten cross-sectional studies, four cohort studies) were included. Results indicate a high prevalence of IPV amongst pregnant women with HIV in SSA (18.0 to 63.1%). The results suggest an association between HIV-positive status and consequences of IPV during pregnancy, particularly mental health effects, such as depression symptoms and suicidal ideation. HIV-related stigma has a key role within the relationship between HIV and IPV during pregnancy. One study described that the presence of IPV reduces adherence to Prevention of Mother-To-Child Transmission (PMTCT) medication. Three studies reported no association between HIV positive status or HIV status disclosure and IPV during pregnancy.

Discussion/conclusions

The systematic review confirms interconnections between IPV and HIV seropositivity amongst pregnant women in SSA. Importantly, stigma, social isolation and poor mental health hinder help-seeking, disclosure, and treatment adherence among HIV+ pregnant women exposed to IPV in SSA. As a result, the potential of community interventions to tackle issues associated with IPV in HIV-positive pregnant women in this area should be explored in research, policy, and practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12619-w.

The relationship between intimate partner violence and HIV outcomes among pregnant women living with HIV in Malawi

Background

Intimate partner violence (IPV) is a global public health concern particularly in pregnancy where IPV can have negative health implications for the mother and child. Data suggest IPV disproportionately affects pregnant women living with HIV (PWLWH) compared to those without HIV. HIV-related outcomes are worse among women experiencing IPV. Despite this knowledge, there is paucity of data concerning PWLWH and IPV in Malawi, where there is a high HIV prevalence (10.6%).

Objectives

We aim to characterize IPV amongst PWLWH in Malawi and describe its relationship to demographic characteristics, psychosocial factors, and HIV-related outcomes.

Methods

This analysis used data from the VITAL Start pilot study, which is a video-based intervention targeting retention and ART adherence amongst PWLWH in Malawi. PWLWH not on ART were recruited at antenatal clinic and given study questionnaires to assess demographics, IPV, and psychosocial factors. Questionnaires were also administered at one-month follow-up to assess outcomes related to HIV. Descriptive statistics and logistic regression models were used to explore the risk factors associated with IPV.

Results

Thirty-nine percent of participants reported ever experiencing IPV from their current partner. The majority (53%) reporting IPV experienced more than one type of violence. IPV was associated with being married (p=0.04) and depression (p<0.0001) in the univariable analysis. For women retained at one-month, IPV was associated with reporting a missed ART dose in the past month but not with adherence measured by pill count.

Conclusions

A large proportion of PWLWH experienced IPV from their current partner and IPV was associated with worse self-reported ART adherence at one-month follow-up. Further evidence is needed to understand how IPV impacts PWLWH throughout postpartum and beyond. Given the detrimental impact on health outcomes among PWLWH in Malawi, additional focus on IPV is essential to identify mechanisms to prevent, screen, and manage IPV among this population.

Prevalence and associated factors of intimate partner violence amongst women attending prevention of mother to child transmission services in Blantyre, Malawi

Background

Intimate partner violence (IPV) during the perinatal period and when one is HIV-positive is a great concern because of the physical and mental impacts it has on health and on adherence to prevention of mother to child transmission (PMTCT) services. However, factors associated with IPV amongst perinatal women on PMTCT services are not adequately explored in Malawi. The aim of this study was to estimate the various types of IPV and the associated factors amongst HIV-positive pregnant and postnatal women in selected health centres in Blantyre district.

Methods

In this cross-sectional study, we recruited 200 HIV-positive women from antenatal, postnatal and antiretroviral therapy (ART) clinics from four selected primary care facilities of Blantyre district. Data were collected between March and May 2018.

Results

A total of 50% of the participants reported to have experienced either physical, psychological or sexual violence from their partner in the last 12 months. The multivariate logistic regression model showed that feelings about safety of the relationship and depression were the only factors that were consistently associated with IPV in the last 12 months (p = 0.001, Pseudo R² = 0.20).

Conclusion

The presence of depression and safety concerns amongst our study participants calls for serious prioritisation of psychological interventions and risk assessment in the management of HIV-positive perinatal mothers who report IPV cases.

Designing a couple-based relationship strengthening and health enhancing intervention for pregnant women living with HIV and their male partners in Zambia: Interview findings from the target community

INTRODUCTION

Interpersonal support can promote positive outcomes among people living with HIV. In order to develop an acceptable psychoeducational couples-based intervention aimed at strengthening the relationship context and improving HIV outcomes before and after pregnancy, we conducted qualitative interviews with pregnant women living with HIV and their male partners.

METHODS

We interviewed a convenience clinic-based sample of pregnant women living with HIV (n = 30) and male partners (n = 18) in Lusaka, Zambia. Interviews included pile sorting relationship topics in order of perceived priority. Interviews also focused on family health concerns. Interviews were audio-recorded, translated, transcribed, and thematically analyzed. Pile sorting data was analyzed using descriptive statistics.

RESULTS

All female participants were living with HIV; 61% of the male partners interviewed were additionally living with HIV. The most prioritized relationship topic among both genders was communication between couples. Honesty and respect were important relationship topics but prioritized differently based on gender. Female participants considered emotional and instrumental support from male partners critical for their physical and mental health; men did not prioritize support. Intimate partner violence was discussed often by both genders. Family health priorities included good nutrition during pregnancy, preventing infant HIV infection, safe infant feeding, sexual health, and men's alcohol use.

CONCLUSIONS

A major contribution of this study is a better understanding of the dyad-level factors pregnant women living with HIV and their male partners perceive to be the most important for a healthy, well-functioning relationship. This study additionally identified gaps in antenatal health education and the specific family health issues most prioritized by pregnant women living with HIV and their male partners. The findings of this study will inform the development of an acceptable couples-based intervention with greater likelihood of efficacy in strengthening the relationship context and promoting family health during and after pregnancies that are affected by HIV.

Intersections of food insecurity, violence, poor mental health and substance use among US women living with and at risk for HIV: Evidence of a syndemic in need of attention

Background

Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States.

Methods

We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women’s Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach.

Results

A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to “feel no pain”. Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence.

Conclusions

Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied “SAVA” (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.

Intimate partner violence is a barrier to antiretroviral therapy adherence among HIV-positive women: Evidence from government facilities in Kenya

INTRODUCTION

Intimate Partner Violence (IPV) is linked to low engagement with HIV management services and adverse clinical outcomes, including poor ART adherence. In sub-Saharan Africa, studies on pregnant/postpartum women and transactional sex workers have produced divergent evidence regarding IPV's association with poor ART adherence. We investigate this association among a broad group of women.

METHODS

We sampled 408 HIV-positive women receiving free ART from different types of HIV clinics at government health facilities, assessing for IPV exposure by a current partner, ART adherence rate, and other factors that affect ART adherence (e.g. education, disclosure). ART adherence rates were measured using the Visual Analogue Scale (VAS); responses were dichotomised at a ≥95% cut-off. Multiple logistic regression models assessed the association between the independent variables and ART adherence.

RESULTS

The participants' mean age was 38.6 (range: 18-69 years). The majority had ever attended school (94%, n = 382), were in monogamous marriages (70%, n = 282), and had disclosed status to partners (94%, n = 380). Overall, 60% (n = 242) reported optimal ART adherence (≥ 95%) in the previous 30 days. The prevalence of IPV by the current partner was 76% (CI95 = 72-80%). Experiencing physical IPV (AOR 0.57, CI95: 0.34-0.94, p = .028), sexual IPV (AOR 0.50, CI95: 0.31-0.82, p = .005), or controlling behaviour (AOR 0.56, CI95: 0.34-0.94, p = .027) reduced the odds of achieving optimal adherence, while a higher education level and having an HIV-positive partner increased the odds.

CONCLUSION

IPV is common and is associated with suboptimal ART adherence rates among a broad group of HIV-positive women. ART programs could consider incorporating basic IPV interventions into regular clinic services to identify, monitor and support exposed women, as they might be at risk of poor ART adherence. Still, there is need for more research on how IPV affects ART adherence.

Effects of a Home-Based Intervention on HIV Prevention Health Behaviors in Pregnant/Postpartum Kenyan Women: Estimating Moderating Effects of Depressive Symptoms

We estimated effects of maternal depressive symptoms, utilizing the Patient Health Questionnaire-8 (PHQ-8), on women's HIV prevention behaviors in Migori County, Kenya. Pregnant women ≥ 18 years old, with gestational age of < 37 weeks, were randomized into standard care or three home visits (2 during pregnancy, 1 postpartum) promoting couple HIV testing and counseling (CHTC) and HIV prevention. Of 105 female participants, 37 (35.24%) reported depressive symptoms and 50 (47.62%) were HIV-positive. Three Poisson regressions with robust variance (univariable, multivariable, and multivariable with depressive symptoms/study arm interaction) were modeled for three outcomes: CHTC, infant HIV testing, health-seeking postpartum. In multivariable analysis with interaction, a moderating trend for the interaction between depressive symptoms and individual health-seeking was observed (p-value = 0.067). Women scoring ≤ 9 (n = 68) on the PHQ-8 and participating in home visits were 1.76 times more likely to participate in individual health-seeking compared to participants in standard care (ARR 1.76, 95% CI 1.17-2.66).

The syndemic effects of mental ill health, household hunger, and intimate partner violence on adherence to antiretroviral therapy among pregnant women living with HIV in Yaoundé, Cameroon

Background

This research advances understanding of interrelationships among three barriers to adherence to antiretroviral therapy (ART) among pregnant women living with HIV (WLWH) in Cameroon: probable common mental disorders (CMD), intimate partner violence (IPV), and hunger.

Methods

The sample included 220 pregnant WLWH in Cameroon. Multivariable modified Poisson regression was conducted to assess the relationship between IPV, hunger, and CMD on ART adherence.

Results

Almost half (44%) of participants recently missed/mistimed an ART dose. Probable CMD was associated with greater risk of missed/mistimed ART dose (aRR 1.5 [95% CI 1.1, 1.9]). Hunger was associated with greater risk of missed/mistimed ART dose among those who reported IPV (aRR 1.9 [95% CI 1.2, 2.8]), but not among those who did not (aRR 0.8 [95% CI 0.2, 2.3]).

Conclusion

Suboptimal ART adherence, CMD, and IPV were common among pregnant WLWH in Cameroon. Pregnant WLWH experiencing IPV and hunger may be especially vulnerable to suboptimal ART adherence.

Infant HIV diagnosis and turn-around time for testing in Malawi, 2015

Background

For HIV-exposed infants in Malawi, there are missed opportunities at each step of the testing and treatment cascade.

Objective

This study assessed factors associated with HIV positivity among infants in Malawi and turn-around times for infant HIV testing.

Methods

HIV testing data for infants aged 0–18 months from 2012 to 2015 were extracted from the Malawi HIV laboratory information management system and analysed using logistic regression. Turn-around time was defined as time between collection of samples to results dispatch from the laboratory.

Results

A total of 106 997 tests were included in the analyses. A subset of 76 006 observations with complete dates were included in the turn-around time analysis. Overall positivity was 4.2%. Factors associated with positivity were increasing age (infants aged 3–6 months: adjusted odds ratio [aOR] = 2.24; infants aged 6–9 months: aOR = 3.42; infants aged > 9 months: aOR = 4.24), female sex (aOR = 1.08) and whether the mother was alive and not on antiretroviral therapy at time of the infant’s test (aOR = 1.57). Provision of HIV prophylaxis to the infant after birth (aOR = 0.38) was found to be protective against HIV positivity. The median turn-around time was 24 days (increased from 19 to 34 days between 2012 and 2015).

Conclusion

Infant HIV positivity has decreased in Malawi, whereas turn-around time has increased. Factors associated with positivity include increasing age, female sex, and whether the mother was alive and not on antiretroviral therapy at the time of the infant’s test.

Reproductive Coercion among Intimate Partner Violence Survivors in Nairobi

Reproductive coercion (RC), or partner interference in reproductive decisions, limits women's autonomy. Little is known about RC behaviors and measurement in low- and middle-income countries (LMICs). In this mixed-methods study, we examined the transferability of the US-developed RC Scale to the Kenyan context. Through community-based sampling, recent intimate partner violence (IPV) survivors were recruited from Nairobi's informal settlements. We conducted quantitative analyses (n = 327) to assess the transferability of RC measures via exploratory factor analysis and used descriptive statistics to examine prevalence and continuous metrics. We conducted in-depth interviews (IDIs; n = 30) to contextualize results. Psychometric analyses indicated a two-factor solution comprising pregnancy coercion and condom manipulation (alpha = 0.86). Eighty-two percent of IPV survivors reported experiencing RC (pregnancy coercion = 76.6 percent; condom manipulation = 59.5 percent). IDIs highlighted women's multiple, severe RC experiences; experiences described in IDIs were largely consistent with quantitative findings. We found the RC Scale was transferable to this LMIC context, where IPV survivors face prevalent, severe RC and would benefit from linkage to woman-centered support services.

Women's preferences, expectations, and experiences with male partner support throughout prevention of mother to child transmission of HIV services: a mixed-methods study

Male involvement in prevention of mother to child transmission of HIV (PMTCT) care improves maternal and child outcomes. We conducted a mixed-methods study at two Kenyan government hospitals. We quantitatively assessed women's expectations and preferences for male partner involvement in PMTCT and male partner attendance at PMTCT appointments. Qualitative interviews with women during the postpartum period assessed types of support women received from their male partners. At enrollment, most participants wanted (75%) and expected (69%) male partners to attend appointments; yet, only 9% had a male partner attend any appointments. Most women agreed that their partner would: support them financially (81%), help follow doctor's guidance (61%), support a hospital-based delivery (85%), and want to receive text messages (68%). Expectations and preferences varied by women's characteristics, most notably experiences with mistreatment, disclosure status, and knowledge of male partner's HIV status. In qualitative interviews, instrumental (financial) support was the most frequently discussed type of support. Male partners also provided informational support by reminding women of medication or appointments. Women reported a variety of ways in which their male partners supported them through PMTCT; however, there was a gap between women's expectation for male partner attendance and the level of male attendance achieved.

Reproductive aspirations, contraception use and dual protection among adolescent girls and young women: the effect of motherhood and HIV status

INTRODUCTION

There is a growing interest in adolescent motherhood and HIV among policymakers and programme implementers. To better shape services and health outcomes, we need evidence on reproductive aspirations and contraception use in this high-risk group, including the effect of motherhood and HIV status. We report data from a large survey of adolescent girls and young women conducted in a mixed rural-urban district in South Africa.

METHODS

Quantitative interviews were conducted with 1712 adolescent girls and young women (ages 10 to 24): 336 adolescent mothers living with HIV (AMLHIV), 454 nulliparous adolescent girls living with HIV (ALHIV), 744 HIV-negative adolescent mothers (control adolescent mothers) and 178 HIV-negative nulliparous adolescent girls (nulliparous controls) in 2018 to 2019. Standardized questionnaires included socio-demographic measures, reproductive health and contraception experiences. Reproductive aspirations were measured as the number of children participants wanted to have. Dual protection was computed as use of both hormonal and barrier contraception or abstinence. Multivariate logistic regression and marginal effects models in STATA 15 were used to test associations between HIV status, adolescent motherhood and outcomes of reproductive aspirations, contraception use and dual protection, controlling for covariates.

RESULTS AND DISCUSSION

Nearly 95% of first pregnancies were unintended. Over two-thirds of all participants wanted two or more children. Hormonal contraception, condom use and dual protection were low across all groups. In multivariate regression modelling, ALHIV were less likely to report hormonal contraception use (aOR 0.55 95% CI 0.43 to 0.70 p ≤ 0.001). In marginal effects modelling, adolescent mothers - independent of HIV status - were least likely to report condom use at last sex. Despite higher probabilities of using hormonal contraception, rates of dual protection were low: 17.1% among control adolescent mothers and 12.4% among AMLHIV. Adolescent mothers had the highest probabilities of not using any contraceptive method: 29.0% among control mothers and 23.5% among AMLHIV.

CONCLUSIONS

Among adolescent girls and young women in HIV-endemic communities, reproductive aspirations and contraceptive practices affect HIV risk and infection. Tailored adolescent-responsive health services could help young women plan their pregnancies for when they are healthy and well-supported, and help interrupt the cycle of HIV transmission by supporting them to practice dual protection.

Prevalence and factors associated with intimate partner violence after HIV status disclosure among pregnant women with depression in Tanzania

Intimate partner violence (IPV) exacts a heavy burden on women, resulting in poor health outcomes. This study had the following aims: (1) estimate the prevalence of IPV post-disclosure of HIV status among pregnant women living with HIV and depression; and (2) evaluate risk and protective factors for IPV post-disclosure. Participants were women accessing PMTCT services at 16 health facilities in Dar es Salaam and screened at the threshold of 9 on the PHQ-9. Generalized linear equations with a log link and standard errors clustered at the facility level were used to calculate associations between predictors and IPV post-disclosure. Among 659 women who were in an intimate relationship, 10.2% had experienced physical violence and 11.6% had reported sexual violence from their partner in the past six months; 327 had disclosed their HIV status to their partners. After disclosure to their partners 279 women (85.3%) experienced IPV. HIV-related stigma was associated with increased risk of IPV following disclosure and appreciative relationships with partners and higher hope were associated with reduced risk of IPV. There is a need to identify and advance approaches to HIV disclosure that prevent IPV. Interventions should be developed based on known risk and protective factors for IPV following HIV disclosure in Tanzania and similar settings.

Effects of Depression, Stigma and Intimate Partner Violence on Postpartum Women's Adherence and Engagement in HIV Care in Kenya

We explored the association between HIV-related stigma and experiences of intimate partner violence (IPV) and depression with viral load suppression, and medication and visit adherence in postpartum women receiving lifelong antiretroviral therapy (ART) (N = 200). We administered a cross-sectional survey to 200 women with HIV at 12 months postpartum who were enrolled in the MOTIVATE trial. The MOTIVATE study is a cluster-randomized trial evaluating the impact of community mentor mothers and text messaging on PMTCT outcomes in southwestern Kenya. Simple and multivariable logistic regression analysis was performed in STATA. Women who experienced stigma or IPV were more likely to miss clinic visits (internalized stigma aOR 1.30 95%CI 1.03-1.64; anticipated stigma aOR 1.20 95%CI 1.04-1.42; IPV aOR 15.71 95%CI 1.47-167.80), report difficulty taking ART drugs (internalized stigma aOR 1.32 95%CI 1.10-1.58; anticipated stigma aOR 1.14 95%CI 1.01-1.30) and not taking medication as prescribed (IPV aOR 2.00 95%CI 1.05-3.74). Depression was additionally associated with decreased odds of viral load suppression (aOR 0.16 95%CI 0.04-0.76). There is need to develop tailored psychosocial interventions within PMTCT programs that appropriately address mental health, stigma, and violence.

Psychological and Physical Intimate Partner Violence and Maternal Depressive Symptoms during the Pre- and Post-Partum Period among Women Living with HIV in rural South Africa

PURPOSE

Women in South Africa also have high rates of depression and intimate partner violence, and they often co-occur. Women living with HIV who experience IPV are particularly likely to experience elevated levels of depressive symptoms and such symptoms are more likely to persist. Although the association between IPV and depression has been examined extensively, the role of depression on IPV has not. Therefore, this study examined the bidirectional association between intimate partner violence (IPV) and depression in South Africa (SA).

METHOD

Participants were N=699 pregnant women with HIV in rural SA who completed measures of depressive symptoms and IPV at baseline (M=17.52±5.77 weeks of pregnancy), 32 weeks antenatally, and 6- and 12-months postnatally.

RESULTS

Depressive symptoms were linked to increased psychological IPV from baseline to 32-weeks, and from 32-weeks to 6-months. However, from 6-months to 12-months, depressive symptoms were associated with decreased psychological IPV. Psychological IPV was linked to depressive symptoms from baseline to 32-weeks. Depressive symptoms were associated with physical IPV from 32-weeks to 6-months, and 6-months to 12-months. Physical IPV was associated with increased depressive symptoms from baseline to 32-weeks, and from 32-weeks to 6-months.

CONCLUSIONS

Findings merit replication, as there may be measurement differences of psychological IPV in SA. However, targeting depressive symptoms and IPV concurrently in prevention and intervention programs may help optimize maternal and child outcomes in the context of prevention of mother-to-child transmission of HIV.

Characterizing Sociostructural Associations With New HIV Diagnoses Among Female Sex Workers in Cameroon

BACKGROUND

Female sex workers (FSW) are disproportionately affected by HIV in Cameroon, with an estimated 23.6% HIV prevalence. Given the unavailability of HIV incidence data, to better understand associations with acquiring HIV we assessed the prevalence and associations with new HIV diagnoses among FSW in Cameroon.

METHODS

In 2016, FSW were recruited through respondent-driven sampling from 5 cities for a biobehavioral survey. Participants self-reporting living with HIV or with an indeterminate test status were excluded from analysis. New diagnoses were defined as testing HIV-positive when participants self-reported HIV-negative or unknown status. A multivariable modified Poisson regression model was developed to assess determinants of new HIV diagnosis (referent group: HIV-negative) using key covariates; adjusted prevalence ratios (aPR) are reported if statistically significant (P < 0.05).

RESULTS

Overall 2255 FSW were recruited. Excluding participants who self-reported living with HIV (n = 297) and indeterminate test results (n = 7), 260/1951 (13.3%) FSW were newly diagnosed with HIV. Variables significantly associated with new HIV diagnosis were: no secondary/higher education [aPR: 1.56, 95% confidence interval (CI): 1.12 to 2.15], 5+ dependents compared with none (aPR: 2.11, 95% CI: 1.01 to 4.40), 5+ years involved in sex work compared with <1 year (aPR: 2.84, 95% CI: 1.26 to 6.42), history of incarceration (aPR: 2.13, 95% CI: 1.13 to 3.99), and low social capital (aPR: 1.53, 95% CI: 1.12 to 2.10). Higher monthly income (>250,000 FCFA vs. <50,000 FCFA) was associated with lower prevalence of new HIV diagnosis (aPR: 0.22, 95% CI: 0.05 to 0.86).

CONCLUSIONS

There are significant sociostructural factors that seem to potentiate risk of HIV infection and delay diagnosis among FSW in Cameroon. Initiatives to build social capital and integrate services such as pre-exposure prophylaxis and HIV self-testing into HIV programs may reduce new infections and decrease time to diagnosis and treatment.

Maternal Factors Associated With Infant Neurodevelopment in HIV-Exposed Uninfected Infants

Background

This study evaluated maternal factors associated with infant neurodevelopmental outcomes among HIV-exposed uninfected (HEU) infants in rural South Africa. This study followed pregnant women living with HIV pre- and postpartum and evaluated sociodemographic factors, use of antiretrovirals (ARVs), and mental health factors as predictors of HEU infant developmental outcomes (cognitive, receptive, and expressive communication, fine and gross motor skills).

Methods

Participants were 80 mother–infant dyads. Mothers were assessed during pregnancy, and HEU infant development was assessed at a mean (SD) of 13.36 (1.89) months of age.

Results

Women were an average (SD) of 28.9 (5.2) years of age, and infants were on average 13.4 (1.9) months old. An analysis of covariance indicated that infants whose mothers had ARV detected in dry blood spots at 32 weeks of pregnancy had lower functioning scores in the cognitive domain than those with undetected ARV (n = 14; M, 15.3 vs 17.2; P = .048). Antenatal physical intimate partner violence was also associated with delayed cognitive functioning (F (1, 74), 4.96; P = .029).

Conclusions

This study found risks for delayed infant cognitive development to be associated with the use of ARV during pregnancy and intimate partner violence, although findings merit replication due to the low sample size. Given the growing number of HEU infants, the necessity to better understand the potential toxicity of ARV exposure in utero is apparent. Similarly, the need for preventing intimate partner violence and screening for, and managing, developmental delays among these infants is increasing.

Gender-based violence and engagement in biomedical HIV prevention, care and treatment: a scoping review

BACKGROUND

While gender-based violence (GBV) has been shown to increase women's risk of HIV acquisition, the role of GBV in the HIV testing to care continuum is less clear. Clarifying how GBV may act as a barrier to accessing HIV services, treatment and care - such as anti-retroviral treatment (ART) or pre-exposure prophylaxis (PrEP) - will not only provide insights into how to best meet individual women's HIV care needs, but also inform public health oriented HIV epidemic control strategies.

METHODS

Through a comprehensive scoping review, we synthesized and analyzed existing evidence regarding the influence of GBV on engagement in PrEP and the HIV care continuum among women living with HIV, including members of key populations (female sex workers, transgender women and women who use drugs). We explored PubMed, Scopus and Web of Science for peer-reviewed studies published in 2003-2017. Of the 279 sources identified, a subset of 51 sources met the criteria and were included in the scoping review.

RESULTS

Studies were identified from 17 countries. The majority of studies utilized quantitative cross-sectional designs (n = 33), with the rest using longitudinal (n = 4), qualitative (n = 10) or mixed methods (n = 4) designs. Taken together, findings suggest that GBV impedes women's uptake of HIV testing, care, and treatment, yet this can vary across different geographic and epidemic settings. Substantial gaps in the literature do still exist, including studies on the impact of GBV on engagement in PrEP, and research among key populations.

CONCLUSIONS

This scoping review contributes to our knowledge regarding the role GBV plays in women's engagement in PrEP and the HIV care continuum. Findings reveal the need for more longitudinal research to provide insights into the causal pathways linking GBV and HIV care and treatment outcomes. Research is also needed to illuminate the impact of GBV on PrEP use and adherence as well as the impact of GBV on engagement along the HIV care continuum among key populations. It is critical that programs and research keep pace with these findings in order to reduce the global burden of GBV and HIV among women.

Evidence of perpetration of intimate partner violence among HIV-positive couples: a systematic scoping review protocol

BACKGROUND

Human immunodeficiency virus (HIV) infection and intimate partner violence (IPV) remain highly sensitive areas that have issues to do with stigmatization in many African countries. Despite the fact that there are several studies on the prevention of HIV, the prevalence of HIV in many African countries is still high. Literature shows that prevention of intimate partner violence is key in the spread of HIV infection. This study will focus on evidence of experiences of HIV positive couples with intimate partner violence and the types of violence experienced. This scoping review will map information about intimate partner violence in low- and middle-income countries as well as other countries with intimate partner violence. There is the need to review these studies on HIV positive couples with intimate partner violence to establish gaps and identify where primary research is necessary. The purpose of this study will be to explore evidence of experiences of HIV-positive couples with IPV and the types of violence experiences by HIV-positive couples.

METHODS

This scoping review will involve electronic databases, which will include academic search premier, CINAHL, PsycARTICLES (EBSCO), PsycINFO (EBSCO), ScienceDirect, PubMed, MEDLINE (EBSCO) and Google Scholar. The study will be conducted in two stages: the first stage will map out the studies descriptively while the second stage will map the additional inclusion criteria of quality assessment. Two independent reviewers will undertake the data extraction. Relevant outcomes of the studies will be analyzed thematically using NVivo computer software.

RESULTS

Results on the evidence of the experiences of HIV-positive couples with partner violence will be coded independently by the authors. Thereafter, the authors will critically cross-examine the relationship of the research questions to the emerging themes from the selected articles.

CONCLUSION

The authors hope to find studies on intimate partner violence among HIV-positive couples to establish gaps where primary research will be necessary.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017062190.

Perspectives on HIV partner notification, partner HIV self-testing and partner home-based HIV testing by pregnant and postpartum women in antenatal settings: a qualitative analysis in Malawi and Zambia

INTRODUCTION

HIV testing male partners of pregnant and postpartum women can lead to improved health outcomes for women, partners and infants. However, in sub-Saharan Africa, few male partners get HIV tested during their partner's pregnancy in spite of several promising approaches to increase partner testing uptake. We assessed stakeholders' views and preferences of partner notification, home-based testing and secondary distribution of self-test kits to understand whether offering choices for partner HIV testing may increase acceptability.

METHODS

Interviewers conducted semi-structured interviews with HIV-negative (N = 39) and HIV-positive (N = 41) pregnant/postpartum women, male partners of HIV-negative (N = 14) and HIV-positive (N = 14) pregnant/postpartum women, healthcare workers (N = 19) and policymakers (N = 16) in Malawi and Zambia. Interviews covered views of each partner testing approach and preferred approaches; healthcare workers were also asked about perceptions of a choice-based approach. Interviews were transcribed, translated and analysed to compare perspectives across country and participant types.

RESULTS

Most participants within each stakeholder group considered all three partner testing strategies acceptable. Relationship conflict was discussed as a potential adverse consequence for each approach. For partner notification, additional barriers included women losing letters, being fearful to give partners letters, being unable to read and men refusing to come to the clinic. For home-based testing, additional barriers included lack of privacy or confidentiality and fear of experiencing community-level HIV stigma. For HIV self-test kits, additional barriers included lack of counselling, false results and poor linkage to care. Preferred male partner testing options varied. Participants preferred partner notification due to their respect for clinical authority, home-based testing due to their desire to prioritize convenience and clinical authority, and self-test kits due to their desire to prioritize confidentiality. Less than half of couples interviewed selected the same preferred male partner testing option as their partner. Most healthcare workers felt the choice-based approach would be acceptable and feasible, but noted implementation challenges in personnel, resources or space.

CONCLUSIONS

Most stakeholders considered different approaches to partner HIV testing to be acceptable, but concerns were raised about each. A choice-based approach may allow women to select their preferred method of partner testing; however, implementation challenges need to be addressed.

Women's experience of intimate partner violence and uptake of Antenatal Care in Sofala, Mozambique

Intimate partner violence (IPV) is associated with negative physical and mental health outcomes. Although maternal health services, especially antenatal care (ANC), can act as a link to IPV resources, women experiencing IPV likely have reduced uptake of ANC due to social and emotional barriers. Poor ANC uptake can also further exacerbate adverse pregnancy outcomes. However, there is limited research examining the association between IPV and ANC within the context of Mozambique. Using data from a study conducted to assess the impact of membership in savings groups on maternal health service utilization in Mozambique (N = 205), we investigated the association between IPV and uptake of ANC. Pearson chi-square and logistic regression were employed to examine the association between IPV and ANC service utilization. The mean age of the participants was 33.4 years (SD = 11.88). Overall, 47.3%, 83.4%, and 51.7% of the participants reported experiencing IPV, receiving at least one ANC, and four or more ANC, respectively. Women who reported experience of IPV had lower odds of receiving both at least one (AOR 0.31 [95% CI:0.12-0.82]) and four or more ANC (AOR 0.50 [95% CI: 0.27-0.92]). Women who reported experience of IPV also had lower odds of receiving ANC from skilled personnel (AOR 0.32 [95% CI: 0.10-0.90]). Experience of IPV showed significant association with reduced ANC service utilization among women in the study area. Further study is needed to assess whether the negative association between IPV and ANC service utilization is also a causal relationship, the evidence which will then help guide a comprehensive intervention effort to improve maternal health services use.

"If He's Abusing You . . . the Baby Is Going to Be Affected": HIV-Positive Pregnant Women's Experiences of Intimate Partner Violence

Pregnancy represents a time of increased risk for intimate partner violence (IPV), and an HIV diagnosis further increases the vulnerability of this at-risk group. This study explores experiences of recent IPV using qualitative interviews with N = 12 HIV-positive pregnant women recruited from a clinical setting in South Africa, a location with a high global prevalence of IPV and HIV. Partner dynamics around IPV resulted in HIV shame and stigma and adversely affected engagement in HIV care and HIV treatment behaviors. The results highlight the challenges women face in navigating disclosure of both IPV and HIV, accessing necessary support, and engaging in both HIV-related and pregnancy-related care in the context of an abusive relationship.

Female Sex Workers' Experiences Selling Sex during Pregnancy and Post-Delivery in South Africa

Nearly 75 percent of female sex workers (FSWs) in Port Elizabeth, South Africa are mothers, many of whom engage in sex work during pregnancy or after delivery. We conducted in-depth interviews with 22 postpartum and 8 pregnant FSWs in Port Elizabeth. Interview guides were used to probe women's experiences, challenges, and concerns about selling sex during pregnancy and post-delivery in a high-HIV-prevalence context. Interviews were transcribed, translated, and coded using thematic analysis. FSWs experienced and feared violence by clients during pregnancy, highlighting the need for safe work environments. Further, FSWs expressed concerns about HIV acquisition and vertical transmission during the perinatal period. Physical challenges related to pregnancy affected women's ability to work. Returning to work post-delivery presented barriers to initiating and practicing exclusive breastfeeding. As a result, many FSWs practiced mixed feeding. Interventions, tailored to respond to FSW's challenges and experiences, may offer improved health outcomes in this context.

Women's autonomy and utilisation of maternal healthcare services in 31 Sub-Saharan African countries: results from the demographic and health surveys, 2010-2016

OBJECTIVES

To examine the association between women's autonomy and the utilisation of maternal healthcare services across 31 Sub-Saharan African countries.

DESIGN, SETTING AND PARTICIPANTS

We analysed the Demographic and Health Survey (DHS) (2010-2016) data collected from married women aged 15-49 years. We used four DHS measures related to women's autonomy: attitude towards domestic violence, attitude towards sexual violence, decision making on spending of household income made by the women solely or jointly with husbands and decision making on major household purchases made by the women solely or jointly with husbands. We used multiple logistic regression analyses to examine the association between women's autonomy and the utilisation of maternal healthcare services adjusted for five potential confounders: place of residence, age at birth of the last child, household wealth, educational attainment and working status. Adjusted ORs (aORs) and 95% CI were used to produce the forest plots.

OUTCOME MEASURES

The primary outcome measures were the utilisation of ≥4 antenatal care visits and delivery by skilled birth attendants (SBA).

RESULTS

Pooled results for all 31 countries (194 883 women) combined showed weak statistically significant associations between all four measures of women's autonomy and utilisation of maternal healthcare services (aORs ranged from 1.07 to 1.15). The strongest associations were in the Southern African region. For example, the aOR for women who made decisions on household income solely or jointly with husbands in relation to the use of SBAs in the Southern African region was 1.44 (95% CI 1.21 to 1.70). Paradoxically, there were three countries where women with higher autonomy on some measures were less likely to use maternal healthcare services. For example, the aOR in Senegal for women who made decisions on major household purchases solely or jointly with husbands in relation to the use of SBAs (aOR=0.74 95% CI 0.59 to 0.94).

CONCLUSION

Our results revealed a weak relationship between women's autonomy and the utilisation of maternal healthcare services. More research is needed to understand why these associations are not stronger.

Pre- and postnatal exposure to intimate partner violence among South African HIV-infected mothers and infant developmental functioning at 12 months of age

In rural South Africa, pregnant HIV-infected women report high rates of psychological (55%) and physical (20%) intimate partner violence (IPV). IPV increases the risk of infant developmental delays. Such delays may have negative socioemotional and cognitive outcomes throughout the lifespan. This paper assesses the relationship between IPV and infant development in rural South Africa. The present investigation was a cross-sectional add-on follow-up designed retrospectively. A randomly selected sub-sample of mothers from the main randomized controlled trial (n = 72) were asked to participate with their infants at 12 months of age; all women invited agreed to participate. Women were 18.35 ± 5.47 weeks pregnant; demographics, HIV disclosure status, and pre- and postnatal IPV measured via the Conflict Tactics Scale during pregnancy at baseline and 12 months post-partum were assessed. Infant HIV serostatus and developmental functioning at 12 months of age were assessed. Women were a mean age of 29 ± 2 years. One third had completed at least 12 years of education and had a monthly income of ~ US$76. At 12 months post-partum, 6% of infants tested HIV seropositive. Postnatal physical IPV was associated with delays in cognitive and receptive language development p < 0.05, but only in unadjusted analyses. This study identified an association between early IPV exposure and infant cognitive and receptive communication delays. Given the small sample size, findings support replication. Longitudinal studies are needed to confirm temporal order and identify appropriate timing for interventions in HIV-exposed infants.

Adapting the Risk Environment Framework to Understand Substance Use, Gender-Based Violence, and HIV Risk Behaviors Among Female Sex Workers in Tanzania

Female sex workers (FSWs) in sub-Saharan Africa are disproportionately affected by HIV and gender-based violence (GBV). Substance use overlaps with these co-occurring epidemics to further increase FSWs' risk for negative health outcomes. We explored the relationship between substance use, GBV, and consistent condom use utilizing baseline data from a cohort of 496 FSWs in Tanzania. Results demonstrate high levels of alcohol use and GBV, and low levels of consistent condom use. Frequent intoxication during sex work was associated with increased odds of recent GBV (aOR 1.64, 95% CI 1.07, 2.49; p value 0.02) and reduced odds of consistent condom use with clients (aOR 0.58, 95% CI 0.37, 0.92; p-value 0.02). We adapt the risk environment framework to contextualize our findings in the social and structural context and to gain insight into intervention approaches to address the intersecting challenges of substance use, GBV, and HIV among FSWs in Tanzania and similar settings.

Interventions that Address Intimate Partner Violence and HIV Among Women: A Systematic Review

Recognizing the high prevalence of human immunodeficiency virus (HIV)-positive women and girls who are either at risk for or suffer from intimate partner violence (IPV) and the overlapping challenges posed by both public health issues, the White House established an Interagency Federal Working Group to address the intersection of both public health issues in 2012. We conducted this systematic review in response to the Working Group's charge to identify and describe interventions that address both IPV and HIV among women. We identified 14 studies that met our inclusion criteria, including seven studies (nine unique intervention arms) that significantly affected at least one outcome related to IPV and HIV. In this article, we examine the characteristics of these studies including core components, intervention populations, and effectiveness data. We highlight opportunities to improve the effectiveness of existing interventions, guide future research about IPV and HIV, and inform prevention programmatic delivery. This knowledge will improve the lives of populations at risk, reduce gender-related health disparities, and ultimately reduce the societal burden of both public health issues.

Intimate partner violence and prevention of mother to child transmission of HIV: Evidence from Kinshasa, Democratic Republic of Congo

Intimate partner violence (IPV) is a risk factor for non-adherence to HIV treatment for women, however the evidence on the impact of IPV on uptake of the prevention of mother to child transmission of HIV (PMTCT) cascade is inconclusive. We examined data from 433 HIV positive pregnant women in Kinshasa, Democratic Republic of Congo, enrolled between April 2013 and August 2014 and followed-up through 6 weeks postpartum. Participants were asked about their IPV experiences in a face-to-face interview at enrollment. Measures of PMTCT cascade included: uptake of clinical appointments and services, viral suppression, and adherence to antiretrovirals (ARV). Approximately half of the sample (51%) had experienced some form of IPV; 35% had experienced emotional abuse, 29% physical abuse, and 19% sexual abuse. There were no statistically significant associations between experiencing any form of IPV and uptake of clinical appointments and services (Adjusted Prevalence Ratio [aPR] = 1.02; 95% [CI]: 0.89–1.17), viral load suppression (aPR = 1.07, 95% CI:0.96–1.19) and ARV adherence (aPR = 1.01, 95% CI: 0.87–1.18). Findings from this study indicate that, among HIV-infected pregnant women enrolled in PMTCT care, experiencing IPV does not reduce adherence to clinic visits and services, adherence to ARV. The high prevalence of IPV in this population suggests that IPV screening and intervention should be included as part of standard care for PMTCT.

Association between maternal HIV disclosure and risk factors for perinatal transmission

OBJECTIVE

To determine whether maternal disclosure of HIV serostatus is associated with uptake of perinatal HIV transmission prevention interventions.

STUDY DESIGN

Retrospective cohort study of women living with HIV enrolled in a perinatal HIV clinic. Women who disclosed their HIV serostatus to sexual partner(s) prior to delivery were compared to non-disclosers. Multivariable logistic regression was performed.

RESULTS

Of 209 women, 71.3% (N = 149) disclosed. Non-disclosers were more likely to attend <10 prenatal visits, demonstrated worse antiretroviral therapy adherence, required more time to achieve virologic suppression, and were less likely to have an undetectable viral load. On multivariable analyses, disclosure status did not remain associated with these factors. However, compared to non-disclosers, disclosers had lower odds of preterm delivery (OR: 0.43, 95% CI: 0.19-0.94) and greater odds of postpartum visit attendance (aOR: 5.10, 95% CI: 1.65-15.72).

CONCLUSIONS

Non-disclosure of HIV status to sexual partner(s) during pregnancy may be a risk factor for preterm birth and poorer postpartum visit attendance.

HIV Positive Diagnosis During Pregnancy Increases Risk of IPV Postpartum Among Women with No History of IPV in Their Relationship

There has been limited study of whether and for whom physical intimate partner violence (IPV) is a consequence of an HIV-positive diagnosis. Per the diathesis stress model, the consequences of HIV infection may be worse for women with a history of IPV. We hypothesize that the positive association between HIV diagnosis in pregnancy and postpartum IPV will be exacerbated for women with a history of IPV. Data come from a prospective cohort study with 1015 participants who completed a baseline antenatal and 9-month postpartum visit. Using logistic regression analyses, we found a statistically significant interaction between HIV diagnosis, history of IPV and postpartum IPV (AOR: 0.40, 95% CI 0.17-0.96). The findings were in the opposite direction as expected: HIV-diagnosis was not associated with IPV for women with a history of IPV (AOR: 2.17, 95% CI 1.06, 4.42). However, HIV-positive women without a history of IPV faced more than two times the risk of incident postpartum IPV than HIV-negative women (AOR: 2.17, 95% CI 1.06, 4.42). Interventions to reduce incident and ongoing IPV during the perinatal period are needed.

Relationship between intimate partner violence and antiretroviral adherence and viral suppression in pregnancy

OBJECTIVE

To determine whether intimate partner violence (IPV) during pregnancy is associated with increased risk of clinical factors that influence maternal to child transmission (MTCT) of HIV.

STUDY DESIGN

Retrospective cohort study of pregnant women living with HIV (WLHIV) who received prenatal care in a multidisciplinary perinatal HIV clinic (2007-2014). All women were assessed for IPV status during pregnancy by a social worker and/or health psychologist. Records were abstracted for obstetric information and factors associated with MTCT of HIV, including antenatal visit attendance, adherence to antiretroviral regimen, time until viral suppression after initiation of antiretroviral medications, HIV RNA at 36 weeks and at delivery, and preterm birth. Women who reported IPV were compared to those who did not using bivariable and multivariable logistic and linear regression analyses.

RESULTS

Of 215 women receiving care during the study period, 91.6% (N = 197) had documentation of IPV history. Of these women, 13.7% (N = 27) reported experiencing IPV during pregnancy. Women who reported IPV were less likely to be completely adherent to antiretroviral doses (38.5% vs. 62.0%, p = 0.039) and required significantly more time to achieve stable virologic suppression (16.0 vs. 8.5 weeks, p = 0.010). Time to achieve suppression remained significant in multivariable models (β 4.68, 95% CI 0.03-9.32).

CONCLUSION

IPV during a pregnancy complicated by HIV appears to be associated with decreased antiretroviral adherence. Pregnant WLHIV who reported IPV exhibited delays in achieving virologic suppression. These women represent a vulnerable population who may require additional support and interventions to reduce the risk of MTCT of HIV.

HIV Status Disclosure Among Postpartum Women in Zambia with Varied Intimate Partner Violence Experiences

HIV-positive pregnant and postpartum women's status disclosure to male sexual partners is associated with improved HIV and maternal and child health outcomes. Yet, status disclosure remains a challenge for many women living with HIV in sub-Saharan Africa, particularly those who are fearful of violence. The objective of the present study is to advance the current understanding of the relationship between intimate partner violence against women and their HIV status disclosure behaviors. We specifically evaluate how the severity, frequency, and type of violence against postpartum HIV-positive women affect status disclosure within married/cohabiting couples. A cross-sectional survey was administered by trained local research assistants to 320 HIV-positive postpartum women attending a large public health center for pediatric immunizations in Lusaka, Zambia. Survey data captured women's self-reports of various forms of intimate partner violence and whether they disclosed their HIV status to the current male partner. Multiple logistic regression models determined the odds of status disclosure by the severity, frequency, and type of violence women experienced. Our findings indicate a negative dose-response relationship between the severity and frequency of intimate partner violence and status disclosure to male partners. Physical violence has a more pronounced affect on status disclosure than sexual or emotional violence. Safe options for women living with HIV who experience intimate partner violence, particularly severe and frequent physical violence, are urgently needed. This includes HIV counselors' ability to evaluate the pros and cons of status disclosure among women and support some women's decisions not to disclose.

Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living with HIV

People living with HIV (PLWH) have distinct needs when it comes to reproductive health, specifically regarding fertility, family planning, and pregnancy, and these needs are often complicated by HIV status. While there is ample research that focuses on reproductive health in PLWH through a quantitative lens, there is a lack of research using qualitative methods, namely, the narrative interview model. We searched PubMed and relevant abstracts to identify 72 articles published from 1997 to 2016 that described a qualitative framework for exploring the behaviors and perceptions regarding family planning, abortion, pregnancy, parenthood, fertility, and forced sterility in PLWH. The inclusion criteria initially showed 147 articles, which were further screened to exclude those that did not address fertility and family planning specifically. Our final sample of articles included articles related to qualitative research on reproductive attitudes, beliefs, and behaviors of PLWH. Several of these articles were mixed-methods analyses, but our focus was on the qualitative portion only. Further qualitative works in this area will not only contribute to gaps quantitative research in the field cannot capture by design, but also inform clinical practice, policy, and interventions through systematic, in-depth evaluation.

Stopping the rise of HIV among adolescents globally

PURPOSE OF REVIEW

Adolescents, in particular those that are most disenfranchised, are increasingly at risk of acquiring HIV and, when acquiring HIV, have worse outcomes than adults. This article reviews the recent approaches to combination prevention aiming to optimize the HIV prevention and HIV treatment continua.

RECENT FINDINGS

There are dramatic sociodemographic differences in the HIV epidemics in low and middle-income countries (young women in sub-Saharan Africa) compared with high-income countries (predominantly gay, bisexual, transgendered youth, especially black and Latino youth). Researchers and clinicians are designing developmentally tailored interventions that anticipate youths' engagement with mobile technologies and build on the common features of evidence-based interventions that predate the use of antiretroviral therapies (ARV) for prevention and treatment.

SUMMARY

Evidence-based HIV prevention and treatment programs that are cost-effective need to be broadly diffused globally. Substantial investments must be made in understanding how to implement programs, which have clinically meaningful impact and continuously monitor intervention quality over time.

Dating Violence Against HIV-Infected Youth in South Africa: Associations With Sexual Risk Behavior, Medication Adherence, and Mental Health

BACKGROUND

As perinatal HIV-infected youth become sexually active, the potential for onward transmission becomes an increasing concern. In other populations, intimate partner violence (IPV) is a risk factor for HIV acquisition. We build on this critical work by studying the role of IPV in facilitating onward transmission among HIV-infected youth-an important step toward effective intervention.

SETTING

Soweto, South Africa.

METHODS

Self-report surveys were completed by 129 perinatal HIV-infected female youth (aged 13-24 years). We calculated the IPV prevalence and used logistic models to capture the association between IPV and health outcomes known to facilitate onward HIV transmission (eg, risky sex, poor medication adherence, depression, and substance abuse).

RESULTS

A fifth of perinatal HIV-infected participants reported physical and/or sexual IPV in the past year; one-third reported lifetime IPV. Childhood adversity was common and positively associated with IPV. Past-year physical and/or sexual IPV was positively correlated with high-risk sex [odds ratio (OR) = 8.96; 95% confidence interval (CI): 2.78 to 28.90], pregnancy (OR = 6.56; 95% CI: 1.91 to 22.54), poor medication adherence to antiretroviral therapy (OR = 5.37; 95% CI: 1.37 to 21.08), depression (OR = 4.25; 95% CI: 1.64 to 11.00), and substance abuse (OR = 4.11; 95% CI: 1.42 to 11.86). Neither past-year nor lifetime IPV was associated with viral load or HIV status disclosure to a partner.

CONCLUSIONS

We find that IPV may increase risk for onward HIV transmission in perinatal HIV-infected youth by both increasing engagement in risky sexual behaviors and lowering medication adherence. HIV clinics should consider integrating primary IPV prevention interventions, instituting routine IPV screening, and collocating services for victims of violence.

Forced sexual intercourse and its association with HIV status among people attending HIV Voluntary Counseling and Testing in a healthcare center in Kinshasa (DRC)

INTRODUCTION

Sexual violence, an HIV determinant, is an integrated behavior in the D.R.Congo. We aimed to analyze the prevalence of forced sexual intercourse (FSI) among people receiving HIV Voluntary Counseling and Testing in a hospital in Kinshasa, and its association with socio-demographics, behaviors and HIV status.

METHODOLOGY

Case-control study (2010-2012). Two-hundred and seventy-four cases with a new HIV+ test and 1,340 controls with an HIV- test were interviewed about HIV-related knowledge, attitudes and behaviors, including FSI.

RESULTS

Thirty-four percent of the participants declared having had FSI (38% of women and 32% of men). Being a woman, aged 25-49 and reporting multiple sexual partners were associated with reporting FSI. For men, being single was protective against FSI; and cohabiting, having a high socioeconomic status, and alcohol consumption increased the odds. For women, being single, divorced/separated and widow was associated with reporting FSI. A significant positive association was found between FSI and an HIV positive test.

CONCLUSION

Among our Congolese population, FSI was strongly associated with HIV infection and it was also associated with alcohol consumption and multiple sexual partnerships, other key HIV determinants. These behaviors need to be identified as potential risk factors of FSI during counseling interventions. Researchers, practitioners and decision-makers should work together to get violence prevention integrated into health, social and educational policies.

The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa - A review

BACKGROUND

The global scale-up of Prevention of mother-to-child transmission (PMTCT) services is credited for a 52% worldwide decline in new HIV infections among children between 2001 and 2012. However, the epidemic continues to challenge maternal and paediatric HIV control efforts in Sub Saharan Africa (SSA), with repercussions on other health services beyond those directly addressing HIV and AIDS. This systematised narrative review describes the effects of PMTCT programs on other health care services and the implications for improving health systems in SSA as reported in the existing articles and scientific literature. The following objectives framed our review:To describe the effects of PMTCT on health care services and systems in SSA and assess whether the PMTCT has strengthened or weakened health systems in SSATo describe the integration of PMTCT and its extent within broader programs and health systems.

METHODS

Articles published in English and French over the period 1st January 2007 (the year of publication of WHO/UNICEF guidelines on global scale-up of the PMTCT) to 31 November 2016 on PMTCT programs in SSA were sought through searches of electronic databases (Medline and Google Scholar). Articles describing the impact (positive and negative effects) of PMTCT on other health care services and those describing its integration in health systems in SSA were eligible for inclusion. We assessed 6223 potential papers, reviewed 225, and included 57.

RESULTS

The majority of selected articles offered arguments for increased health services utilisation, notably of ante-natal care, and some evidence of beneficial synergies between PMTCT programs and other health services especially maternal health care, STI prevention and early childhood immunisation. Positive and negative impact of PMTCT on other health care services and health systems are suggested in thirty-two studies while twenty-five papers recommend more integration and synergies. However, the empirical evidence of impact of PMTCT integration on broader health systems is scarce. Underlying health system challenges such as weak physical and human resource infrastructure and poor working conditions, as well as social and economic barriers to accessing health services, affect both PMTCT and the health services with which PMTCT interacts.

CONCLUSIONS

PMTCT services increase to some extent the availability, accessibility and utilisation of antenatal care and services beyond HIV care. Vertical PMTCT programs work, when well-funded and well-managed, despite poorly functioning health systems. The beneficial synergies between PMTCT and other services are widely suggested, but there is a lack of large-scale evidence of this.

The Role of Relationship Dynamics and Gender Inequalities As Barriers to HIV-Serostatus Disclosure: Qualitative Study among Women and Men Living with HIV in Durban, South Africa

BACKGROUND

This qualitative study investigated gender power inequalities as they contribute to relationship dynamics and HIV-serostatus disclosure among men and women living with HIV in Durban, South Africa. HIV serodiscordance among men and women within stable partnerships contributes to high HIV incidence in southern Africa, yet disclosure rates remain low. Given the emphasis on prevention for HIV-serodiscordant couples, this research supports the urgent need to explore how best to support couples to recognize that they are part of this priority population and to access appropriate prevention and treatment.

METHODS

Thirty-five in-depth individual interviews were conducted with 15 HIV-positive men and 20 HIV-positive women (not couples) receiving care at public-sector clinics near Durban. A structured coding scheme was developed to investigate men's and women's attitudes toward HIV-serostatus disclosure and behaviors of sharing (or not sharing) HIV serostatus with a partner. Narratives were analyzed for barriers and facilitators of disclosure through the lens of sociocultural gender inequality, focusing on reasons for non-disclosure.

RESULTS

Among 35 participants: median age was 33 years (men) and 30 years (women); average years since HIV diagnosis was 1 (men) and 1.5 (women). Four themes related to gender inequality and HIV-serostatus disclosure emerged: (1) Men and women fear disclosing to partners due to concerns about stigma and relationship dissolution, (2) suspicions and mistrust between partners underlies decisions for non-disclosure, (3) unequal, gendered power in relationships causes differential likelihood and safety of disclosure among men and women, and (4) incomplete or implicit disclosure are strategies to navigate disclosure challenges. Findings illustrate HIV-serostatus disclosure as a complex process evolving over time, rather than a one-time event.

CONCLUSION

Partner communication about HIV serostatus is infrequent and complicated, with gender inequalities contributing to fear, mistrust, and partial or implicit disclosure. Relationship dynamics and gender roles shape the environment within which men and women can engage successfully in the HIV-serostatus disclosure process. Integrated interventions to reduce barriers to trustful and effective communication are needed for HIV-affected men and women in partnerships in which seeking couples-based HIV counseling and testing (CHCT) is challenging or unlikely. These data offer insights to support HIV-serostatus disclosure strategies within relationships over time.