JAIDS Journal of Acquired Immune Deficiency Syndromes:
Epidemiology and Social Science
Associations Between Recent Gender-Based Violence and Pregnancy, Sexually Transmitted Infections, Condom Use Practices, and Negotiation of Sexual Practices Among HIV-Positive Women
Lang, Delia L PhD, MPH*†; Salazar, Laura F PhD*†; Wingood, Gina M ScD, MPH*†; DiClemente, Ralph J PhD*†‡§; Mikhail, Isis MD, DrPH∥
From the *Rollins School of Public Health, Emory University, Atlanta, GA; †Emory Center for AIDS Research, Emory University, Atlanta, GA; ‡Division of Infectious Diseases, Epidemiology, and Immunology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; §Department of Medicine (Infectious Diseases), Emory University School of Medicine, Atlanta, GA; and ∥Epidemiology and Genetics Research Program, National Cancer Institute, National Institutes of Health, Bethesda, MD.
Received for publication March 7, 2007; accepted July 6, 2007.
Supported by a grant from the Center for Mental Health Research on AIDS, National Institute of Mental Health (1R01MH54412); a grant from the University of Alabama Center for AIDS Research (AI027767); and a supplement from the National Institute of Drug Abuse.
Correspondence to: Delia L. Lang, PhD, MPH, Emory University, Rollins School of Health, Department of Behavioral Sciences and Health Education, 1520 Clifton Road, #268, Atlanta, GA 30322 (e-mail: firstname.lastname@example.org).
Background: This study sought to document the prevalence of recent gender-based violence (rGBV) among seropositive women and to determine the association between rGBV and pregnancy, sexually transmitted infections (STIs), condom use, and negotiation of sexual practices.
Methods: A total of 304 seropositive women recruited from HIV clinics in the southeastern United States who reported being sexually active in the previous 6 months with 1 partner were included in analyses. Gender-based violence during the previous 3 months, condom use, and negotiation of sexual practices were assessed. Biologic samples for pregnancy and STI testing were collected.
Results: A total of 10.2% of women reported a history of rGBV. rGBV was related to inconsistent condom use practices, pregnancy, and abuse stemming from requests for condom use. No associations were found between rGBV and negotiation of sexual practices and STIs.
Conclusions: The prevalence of rGBV among HIV-positive women emphasizes the need for screening of abuse and highlights the need for the design and implementation of integrated intervention approaches necessary in addressing the needs of this population.
HIV infection is a major public health issue affecting the lives of millions of women. According to the Centers for Disease Control and Prevention (CDC), the number of women living with HIV/AIDS has tripled between 1993 and 2002.1 More precisely, of the current new AIDS cases and HIV infections, women account for 26% and 30% of them, respectively.2 Minority women account for nearly 75% of all new AIDS cases in the United States, with African-American women having the highest death rate attributable to AIDS (13 per 100,000).3 It is increasingly more difficult to discuss HIV and associated risk behaviors among vulnerable female populations without examining their link to other factors placing women at increased risk of HIV infection, such as gender-based violence (GBV).
GBV, specifically physical and sexual victimization of women, continues to affect the lives of many women in the United States. The prevalence of lifetime GBV by a primary sexual partner is estimated to be 21% to 39% among women in the general population and clinical care settings, whereas during the most recent 12-month period, GBV is estimated to range from 2% to 14%.4-6 Among vulnerable populations such as minority women and women from low-income and low-education groups, estimates of lifetime GBV and GBV in the most recent 12-month period have been reported as high as 62% to 68% and 17% to 33%, respectively.7-10 Furthermore, GBV among pregnant women and HIV-positive women has been estimated to range from 8% to 38%.11-15
Research literature has linked GBV to various sexual risk behaviors and negative sexual health outcomes. Experiences of sexual abuse as early as the childhood years have been repeatedly associated with increased sexual risk taking in adulthood, higher rates of sexually transmitted infections (STIs), more sexual partners,16 and unintended pregnancies.17-22 Women reporting experiences of GBV during their adult years report difficulty in negotiating safer sexual practices, higher rates of inconsistent condom use, unwanted pregnancy, and STI and HIV infections.10,23-29 Other research has documented GBV as a risk factor for using alcohol or drugs during intercourse, multiple sexual partners, and first intercourse before the age of 15 years.30,31 Women who have experienced sexual victimization tend to have more gynecologic symptoms and STIs compared with women who have not been sexually victimized.32-35 With regard to HIV-positive women, research has documented that they are more likely to report GBV compared with HIV-negative women,36 whereas other studies have shown an association between physical and sexual violence and STI incidence.15,37 Furthermore, research findings suggest that approximately 30% of HIV-positive women continue to engage in high-risk sexual practices, such as having unprotected intercourse and reporting high prevalence and incidence of STIs.38-44 Unprotected sexual intercourse in this population represents a critical area of inquiry because it may not only place women at risk for further infections and complications but may expose their partners to STIs and HIV.45 Thus, it is important to document the prevalence of women experiencing recent gender-based violence (rGBV) and the prevalent risk behaviors occurring with the partner perpetuating the abuse.
Specifically, the objective of the current study is to examine the prevalence of rGBV among seropositive women and to extend prior research by determining the association between rGBV and biologically confirmed pregnancy and STIs, condom use practices, and negotiation of safer sexual practices within the context of an abusive relationship. In the present study, we define rGBV as any physical or sexual abuse experienced in the previous 3 months.
This study is a substudy of a larger randomized clinical trial designed to evaluate the efficacy of an intervention to reduce HIV transmission risk behaviors and STIs and enhance HIV-preventive psychosocial and structural factors among women living with HIV.46 From September 1997 through December 2000, project staff recruited participants from 7 of the largest clinics and health departments providing medical care to women living with HIV/AIDS in Georgia and Alabama. Participants were recruited from 5 clinics in Alabama and 2 clinics in Georgia. Participants' HIV/AIDS status was confirmed through the clinic where they received care and through chart abstraction data.
After receiving care from their HIV/AIDS clinic providers, women were screened and assessed for eligibility. Of the women screened, 415 (266 from Alabama and 149 from Georgia) met eligibility criteria. Women were eligible if they were between the ages of 18 and 50 years, sought medical care for HIV/AIDS at a study recruitment site, were sexually active in the previous 6 months, and provided written informed consent. Of the eligible women, 391 (94.2%) were enrolled and subsequently completed baseline assessments. Of those completing baseline assessments, 366 (93.6%) were randomized to study conditions. The Institutional Review Boards at the University of Alabama at Birmingham and Emory University approved the study protocol. Results and further description of the randomized trial can be found in a prior publication.46
Participants completed face-to-face interviews by trained female interviewers. The interview assessed sociodemographic characteristics, sexual behavior patterns, and psychosocial characteristics. Additionally, participants were asked to provide a vaginal swab specimen that was assayed for STIs (Chlamydia, Gonorrhea, and Trichomoniasis) and a urine sample that was analyzed for drug use and pregnancy.
Recent Gender-Based Violence
rGBV was assessed by combining 2 questions used to assess abuse by a primary sexual partner10: (1) “In the past 3 months, have you been physically abused by your main partner? This means have you ever been pushed, had something thrown at you, been shoved, grabbed, kicked, slapped, hit, or beat up?” and (2) “In the past 3 months, have you been sexually abused by your main partner? This means have you ever been forced to have sex or do something sexually that you didn't want to?” Responses to both questions were summed, and participants were categorized into 2 groups: (1) women who responded negatively to both questions and (2) women who responded affirmatively to either question or to both questions.
Condom Use Practices
Several condom use variables were computed from self-reported data. Frequency of unprotected vaginal intercourse was calculated by subtracting the number of times participants reported having vaginal intercourse from the number of times participants reported using condoms during vaginal intercourse in the 30 days preceding the assessment. Proportion of condom use was calculated by dividing the number of times participants reported using a condom during vaginal intercourse by the total number of vaginal intercourse episodes in the 30 days before assessment. Inconsistent condom use was calculated by dichotomizing the proportion of condom use variable into 2 groups: those who reported 100% condom use versus all other participants reporting less than consistent condom use in the 30 days before assessment. Finally, never use of condoms was calculated by dichotomizing the proportion of condom use variable into 2 groups: those who reported using condoms 0% of the time versus all other participants reporting some condom use during the 30 days before assessment. Inconsistent condom use during the past 6 months was obtained through the question: “In the past 6 months, when you had vaginal sex with a spouse/steady partner how frequently did you use condoms?” Participant responses ranged from never (0) to always (4). The variable used in subsequent analyses was dichotomized into those who indicated they always used a condom versus those who indicated any of the other categories (never, sometimes, about half of the time, or most of the time). Finally, participant responses to a single item inquiring about their condom use the last time they had intercourse were also used.
Negotiation Practices and Consequences
Negotiation of safer sexual practices comprised 2 separate single item questions: (1) “Have you ever asked your partner to use a condom (yes/no)?” and (2) “Have you ever refused to have sex because your partner didn't want to use a condom (yes/no)?” Consequences of negotiation practices comprised 2 separate single item questions: (1) “When you asked your partner to use condoms, how often did he actually threaten to hit you (never/sometimes)?” and (2) “When you asked your partner to use condoms, how often did he actually hit you (never/sometimes)?”
Pregnancy was determined based on urine samples, whereas presence of STIs was based on assays from 2 vaginal swabs. One swab was evaluated for Neisseria gonorrhoeae and Chlamydia trachomatis using the Abbott LCxProbe System (Abbott Laboratories, Abbott Park, IL).47 The second swab was evaluated for Trichomonas vaginalis using the InPouch TV test (BioMed Diagnostics Inc., Santa Clara, CA).48 Assays were conducted at the Division of Infectious Diseases ST Research Laboratory at the University of Alabama at Birmingham and at the Molecular Diagnostics Laboratory at Emory University. Women identified with an STD were provided directly observable single-dose STD treatment, received appropriate risk reduction counseling per CDC recommendations, and were encouraged to refer their sex partner for treatment.
Participants who were positive for Chlamydia, gonorrhea, and/or trichomoniasis were categorized as “STI-positive” in subsequent analyses.
First, descriptive analyses were conducted to obtain means, standard deviations, and percentages for relevant sociodemographic variables. Additionally, bivariate analyses consisting of χ2 and independent samples t tests were performed to examine the associations between a history of rGBV and sociodemographic variables and to identify potential covariates. Finally, logistic regression models and analysis of covariance (ANCOVA) were conducted to explore whether a history of rGBV predicted condom use behaviors with the current partner, negotiation of safer sexual practices, pregnancy status, and STIs, while controlling for covariates related to rGBV.
Analyses were conducted with baseline data obtained from the 304 participants who were randomized to the study conditions and who indicated that they had been sexually active with a single male partner in the past 6 months. In this sample, a total of 31 women (10.2%) reported having experienced rGBV by their primary sexual partner in the previous 3 months. Of these, 9.9% reported experiences of physical abuse, whereas 1.3% reported sexual abuse. A total of 15.8% tested positive for an STI. Based on our data, we are unable to determine the temporal order of the STI infections relative to the rGBV. Descriptive statistics and differences in sociodemographic characteristics between the 2 groups are presented in (Table 1). Of these, marital status and current employment were empirically related to rGBV at a P < 0.20 level, and are therefore included as covariates in subsequent logistic regression and ANCOVA analyses.
Adjusted odds ratios from logistic regression models are presented in Table 2. Analyses revealed that women with a history of rGBV were more likely to report (1) inconsistent condom use in the past 30 days and 6 months, (2) no condom use during the last sexual intercourse, and (3) never having used condoms during the past 30 days compared with women with no history of rGBV. Similarly, adjusted means from ANCOVA models are presented in Table 3. Women with a history of rGBV were more likely to report a higher frequency of unprotected sexual encounters in the past 30 days and a lesser proportion of condom use in the past 30 days compared with women with no history of rGBV. No significant results were found between a history of rGBV and negotiation of safer sexual practices (asking to use a condom and refusing unprotected sex); however, rGBV was related to threats of abuse and actual abuse resulting from condom use requests. Results regarding pregnancy status indicate that women who experienced rGBV were 5 times more likely to be pregnant than women who did not report rGBV (P = 0.024). Finally, a history of abuse was not significantly related to STIs.
More than 10% of HIV-positive women in this sample reported experiences of physical and/or sexual violence by their primary sexual partner in the past 3 months. There is no prior documentation of rGBV prevalence among HIV-positive women within the 3 months before assessment; thus, there is no referent in the literature for this population. The current findings are supported by prior research reporting a 17% prevalence of rGBV within the same time frame among young African-American women.10 Additionally, the current study was based on women reporting a single steady sexual partner for the past 6 months and experiences of rGBV during the past 3 months. Thus, the women reporting rGBV in this sample were victimized by the partner with whom they shared a relationship at the time of assessment-the same partner with whom they engaged in risky sexual behaviors.
A main finding of this study shows a strong association between having an abusive primary sexual partner and inconsistent condom use, never using a condom, and a higher number and proportion of unprotected sex acts, corroborating prior research.10 These findings are particularly concerning in light of the heightened risk for seroconversion or reinfection of the women's partners and reinfection for the women themselves. Of further concern are the increased pregnancy rates and the possibility of mother-to-child transmission of HIV in the absence of adequate and timely care. In fact, our results revealed significant differences with regard to pregnancy status. Specifically, women reporting rGBV were more likely to be pregnant compared with their counterparts. Although we did not assess whether or not women intentionally became pregnant, this finding is important in that HIV-positive women from low-socio-economic backgrounds often have insufficient access to health care resources,49 and may therefore lack the necessary medical attention to ensure proper treatment and medication adherence for the protection of their own health and that of the unborn fetus.
Prior studies have documented a link between GBV and poor negotiation of sexual practices,23,24,27 which may be contributing to the significantly lower rates of condom use among women with rGBV experience. In our study, however, no association was found between rGBV and asking the partner to use a condom or refusing unprotected sex. This null finding may be a function of how these constructs were measured rather than a lack of true association. Both negotiation items were assessed in a dichotomous manner, which may have limited their variability, thus not fully capturing the extent to which women negotiate sexual practices with their partner. Future studies with larger samples of HIV-positive women and with measures that assess frequency of negotiation practices should investigate whether experiencing victimization by the main sexual partner does, in fact, contribute to an impaired ability to negotiate sexual practices.
Previous research with HIV-negative women in abusive relationships suggests that negotiating condom use may directly result in abuse or threats of abuse.10,29 We found significant associations between rGBV and threats of abuse and actual abuse as a result of asking partners to use a condom. Specifically, women who experienced rGBV and who asked their partners to use a condom were 8 times more likely to report being threatened with violence and, most notably, were 14 times more likely to be hit. Although this association is consistent with prior studies,10,29 the percentage of HIV-positive women reporting actual abuse when negotiating condom use in this sample of HIV-positive women is much higher (29.8%) than reported in previous studies of HIV-negative women (4% to 5%).29
Finally, although 15.8% of the women in our sample had an STI, we did not find rGBV to be a significant risk factor. Previous studies have reported significant associations between experiences of abuse and STI, although mostly among HIV-negative women.32-35 One explanation is the relatively small sample size, and thus insufficient power to detect significant differences. Based on our data, we were also unable to determine the temporal order of the STI relative to the rGBV. Another explanation is how we measured recent experiences of abuse. We did not measure the frequency or severity of abuse; thus, there may be variability within the group of women who experienced abuse that could potentially affect the relation between abuse and STI outcomes. Alternatively, it may be that HIV status acts as a moderator of the relation. Clearly, more research is needed to capture better the mechanisms through which abuse is affecting STIs.
Several limitations to this study need to be acknowledged. The generalizability of the findings is limited to HIV-positive women meeting the specific criteria for inclusion in the randomized clinical trial from which the data are obtained. With the exception of STIs, pregnancy status, and drug abuse, which were determined through biologic testing, all other data, including history of abuse, were obtained through self-report, including the woman's knowledge at time of assessment regarding her partner's HIV status. As mentioned previously, the severity and frequency of abuse were not assessed. Thus, possible relations between frequency and severity of abuse could not be tested against the outcome variables. Additionally, no data were collected from male sexual partners; thus, no information is available regarding their reports of perpetration of abuse or their STI and HIV status. Finally, analyses in this study are based on cross-sectional data, precluding the ability to make any cause-effect interpretations.
The findings in this study emphasize the need to address the adverse impact of rGBV in the lives of HIV-positive women and their sexual partners. Multiple levels of interventions must be considered in addressing these public health issues. First, intervention efforts targeting HIV-positive women must take into consideration that rGBV is a present reality for this population. Efforts should be first directed toward screening efforts to identify women who are in abusive relationships so that they can receive additional services (eg, advocacy programs for abused women) that go beyond treating their HIV. These services may help to empower them so that they can protect themselves from abusive partners by accessing resources and venues where they can receive the necessary support and protection.50 Only within this context of an external support system can intervention programs hope to be effective in increasing self-efficacy and skills development designed to empower women to obtain the support they need.50 Outside of such a context where women can have a reasonable expectation of safety, skills such as assertiveness and negotiation of sexual practices may aggravate existing abusive circumstances, as was found in the present study when women requested condoms.
Second, these findings emphasize the need to address the perpetrators of rGBV. There are many intervention programs designed to teach anger management and address the underlying attitudes toward GBV. Evaluations of these programs indicated that the results are mixed but may still offer some hope of achieving behavior change and reducing violence.51 Many of these programs are offered through the criminal justice system, where men are typically mandated by the courts to attend the program after an arrest. Thus, if women experiencing abuse do not alert the criminal justice system, it would be an arduous challenge to get the male partners into a psychoeducational batterers' program. Yet, researchers have demonstrated that this population is accessible,44 making it feasible to develop intervention programs designed to teach anger management and emotional regulation in ways that do not result in victimization of the female partner. Further complicating the issue, however, is that these programs would also need to focus on the serodiscordant relationship. Appealing to the perpetrators' need to remain HIV-negative and to protect themselves in their sexual relationships may be an approach worth trying. Nevertheless, the most successful approach would have to involve multisystems in which the police, hospitals, courts, and abused women's advocates work together with perpetrators' programs to address these issues.52
rGBV was prevalent among HIV-positive women seeking services for HIV. HIV-positive women who are in abusive relationships are less likely to use condoms and more likely to be pregnant. Not surprisingly, they are also more likely to experience physical abuse and threats of physical abuse when requesting condoms. Efforts to devise effective sexual risk reduction interventions and to provide treatment in clinical settings, including pre- and postnatal services, must take into account whether the woman is in an abusive relationship. In addition, identifying those women who experience GBV allows for referrals to community-based programs designed specifically for abused women. An integrated approach (ie, medical, clinical, community) will maximize services and help to reduce not only the potential for reinfection but the risk for future GBV.
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