Intimate partner violence increases a woman’s risk of acquiring HIV

A recent study suggests that intimate partner violence (IPV) increases the risk of HIV beyond what is expected for women living in sub-Saharan Africa who have male partners living with HIV. Women aged 15-24 had a 3% increase in risk when they had a partner living with HIV who perpetrated IPV, compared to women whose partner just had HIV.  Men who perpetrate IPV were also shown to have higher rates of HIV. In Sub-Saharan Africa, one in three women between 15-49 report IPV at some point in their lifetime. Thus, the importance of tackling IPV to decrease HIV must not be underestimated.

The study conducted by Salome Kuchukhidze of McGill University and colleagues which pooled data from several sub-Saharan countries was published in PLOS Global Public Health. Increased alcohol use, acceptance of IPV and stereotypes of male dominance contributed to violence against women. Perpetrators of IPV were more likely to engage in behaviours associated with an increase in HIV risk, which may be part of the reason why they had higher HIV rates.

The researchers analysed data from 27 different countries between 2000 and 2020. The data was all taken from nationally representative household surveys which were all anonymised. There were 111,659 heterosexual couples that were reported to be married or co-habiting, aged over 15 years old. Of these couples, 79,325 had data on HIV available. IPV was detected by the female partner reporting sexual or physical violence within the last year in the survey, and the perpetrator was assumed to be her current partner. A separate analysis to assess if IPV increased the risk of HIV included only women aged 15-24 years old, to decrease the chance of pre-existing HIV before their current partner. Women aged 15-24 also have the highest risk of IPV and greatest incidence of HIV, making it the best group to estimate the additional risk of HIV in the context of IPV.

Overall, 21% women reported IPV. Unsurprisingly, women who were younger, poorly educated, less likely to have a say in household decisions and less wealthy were more likely to report IPV. Women earning more than their partner were more likely to experience IPV, which may be due to the challenge this poses to gender stereotypes, leaving the male partner feeling threatened. These women may be more likely to refuse sex and negotiate condom use which would reduce their HIV risk but may increase their IPV risk.

After adjustments for other factors, men who perpetrated IPV were 9% more likely to be living with HIV than those that didn’t. These men were slightly more likely to report paying for sex and having multiple partners in the previous year, which may contribute to the increased rates of HIV. Men who had more accepting attitudes towards IPV and who drank more alcohol were also more likely to be perpetrators. The researchers suggested that underlying attitudes around dominance over women could be driving higher rates of HIV in perpetrators of IPV due to these attitudes, leading to behaviours that increase the risk of HIV.

When looking at women aged 15-24, the risk of HIV was 26.6% higher when their partner was living with HIV and 0.4% higher if they reported IPV. Combining these values, one might expect that the risk of HIV would be 27% greater for women who had a partner living with HIV and experienced IPV. However, women who reported IPV and had a partner with HIV were found to have a 30.1% increased risk of HIV, showing a joint effect of IPV with HIV which increased the risk of HIV by a further 3.1%. This may be explained by the finding that men living with HIV who perpetrated IPV were less likely to be on ART and virally suppressed compared to men who didn’t perpetrate IPV, although the sample size was too small to be conclusive on this point. However, other studies have shown higher rates of unsuppressed viral loads for men living with HIV who commit IPV compared to men who do not commit IPV. Other factors that the researchers suggest could increase the risk of HIV for those experiencing IPV were the effects of IPV on mental health and sexual behaviours which could increase risk factors for HIV acquisition like substance misuse, transactional sex and coerced anal sex.

Important limitations to this study are that the timings of IPV perpetration and HIV acquisition are not available, making it impossible to be sure about whether IPV or HIV came first. It is also important to note that IPV and sexual behaviours may have been underreported due to their sensitive nature. However, neither of these limitations diminish the importance of trying to tackle IPV when trying to decrease HIV transmission.

Given that this study was conducted over 27 different countries, the cultural and structural practices underlying the high rate of IPV are varied and complex. Efforts to decrease violence against women and girls must be tailored and specific. Further research to assess the causality of the increase in HIV amongst women subjected to IPV must be undertaken, which will inform efforts to reduce both IPV and HIV. “The impacts of violence and HIV are profound and have long-lasting effects on the well-being of millions of women and girls globally,” the researchers note. “Actions to eliminate violence and end AIDS must be accelerated.”