The scarce evidence indicating a relationship between violent deaths (i.e. deaths related to homicide or suicide) and HIV is only derived from studies performed in industrialized countries [1,2]. Yet, no studies have documented a higher HIV seroprevalence among violent deaths' victims in Africa. Indeed, in contexts in which stigma related to HIV infection is widespread and access to antiretroviral drugs is limited, a positive HIV status may serve as a psychosocial trigger for suicide. Some studies have also established an association between intimate partner violence (potentially leading to homicide) and HIV infection [3,4]. We report here the results of a study performed in Pointe-Noire, Republic of Congo, where post-mortem HIV serology was systematically performed .
From June 30 to 18 October 2001, all adult deaths occurring in Pointe-Noire and referred to the unique morgue of the city were investigated. Causes of death were obtained by interviewing the accompanying persons and examining the bodies. HIV serology was performed on blood samples obtained by intracardiac puncture. The prevalence of HIV in violent deaths, considered as ‘cases’, was compared with that in accidental deaths, considered as ‘controls’. Age was categorized into three groups (<25, 25–39 and ≥40 years). A logistic regression model was used to adjust for age and sex. Ethical clearance was obtained from the Ministry of Health of Congo.
During the study period, 1309 adult deaths were registered at the morgue, among which 19 were violent deaths, including 14 homicides and five suicides. Among them, none presented signs or symptoms of AIDS. Table 1 provides the HIV prevalence rates among violent and accidental deaths. HIV prevalence among violent deaths was 37%, which is significantly higher than the 10% among the accidental deaths (P = 0.021). The adjusted odds ratio for HIV infection was 5.9 (P = 0.03).
Our study is the first to provide strong evidence of a relationship between violent death and HIV in an African country. Although the numbers are small, our results are based on indisputable data on both the cause of death and HIV. The HIV prevalence among accidental deaths was, as expected in a healthy population, of the same order of magnitude as the prevalence in the general population, about 6% at the time of the study . Conversely, the prevalence among suicide and homicide victims was much higher, at 37%.
In the international literature, there is no convincing evidence of a connection between violent death and HIV. In a study performed in New York City in 1991–1993, before access to antiretrovirals, HIV was associated with a two-fold increase in suicide risk . However, most HIV-infected individuals in this study also had other risk factors for suicide, such as substance abuse and alcoholism, which would support the existence of an indirect association. In another study in Baltimore, HIV-positive women were found to be 4.5-fold more likely to have ever attempted suicide than a sample of demographically similar HIV-negative women .
Among the four HIV-positive homicides in our sample, three were women who had been slaughtered by family members. This is consistent with the finding of a study in Tanzania, which showed that HIV-positive women were more than twice as likely to report violence with their current partner than were HIV-negative women . A review of 35 studies in the USA indicates that HIV-positive women appear to experience intimate partner violence at rates comparable to HIV-negative women from the same underlying populations but their abuse seems to be more frequent and more severe . It is difficult to tell, however, whether intimate partner violence can be seen as a cause or consequence of sexual risk taking. In the context of heterosexual transmission, men who perpetrate violence have been shown to engage in more risky sex behaviours and therefore are more likely to expose their partners to HIV . But physical violence could also be a consequence of HIV disclosure within the family, or the outcome of stigmatization exercised outside the family against HIV-positive women or men. Although the causal pathway is difficult to ascertain, our findings suggest that the prevention of domestic violence and the fight against stigmatization should be essential parts of HIV prevention programmes in Africa.
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