In response to the discovery that people living with HIV who achieve viral suppression with antiretroviral treatment (ART) are less infectious, HIV treatment and care outcomes have become the focus of much research and intervention.1 Experiencing violence from a sexual partner has been shown to inhibit women's engagement with HIV care and treatment in the United States, Canada, and South Africa.2–8 In a recent systematic review of studies conducted mostly in the United States and Canada, Hatcher et al9 found that experiencing intimate partner violence was associated with lower levels of ART use and adherence and a lower odds of viral suppression. In addition to direct associations between violence and HIV treatment and care outcomes, Malow et al10 reported partner conflict as having an indirect relationship with ART adherence because of the direct association between partner conflict and depression among people living with HIV in Haiti.
Globally, female sex workers (FSWs) have a 13.5-fold greater odds of being HIV infected than adult women overall.11 Factors including partnership dynamics, sex work environment, and social status can place FSWs at increased risk for violence.12–16 Violence is, in turn, associated with individual HIV-related risk behaviors among FSWs including inconsistent condom use and having a partner who uses injection drugs and has concurrent sexual partners.14,17 In a systematic review of violence among FSWs, lifetime prevalence of sexual and/or physical workplace violence (including violence perpetrated by clients, police, managers, and others in the workplace) ranged from 45% to 75% and in the last year from 32% to 55%.13 Violence also occurs within stable and/or intimate partnerships among FSWs.17–21 In some settings, violence from an intimate partner has been found to be more prevalent than from clients; eg, among FSWs in China, Hong et al20 reported higher levels of lifetime violence from stable partners (58%) than clients (45%).
Despite the importance of violence for HIV care and treatment outcomes and the burden of violence among FSWs, no research has examined the association between violence and HIV care and treatment outcomes among FSWs living with HIV. We aim to fill that gap by determining the prevalence of violence from a sexual partner among a cohort of FSWs living with HIV in the Dominican Republic (DR) and assessing the associations between violence and key HIV care and treatment outcomes.
The study was conducted in Santo Domingo, the capital city of the DR. The HIV epidemic in the DR is concentrated among FSWs, men who have sex with men, transgender women, and individuals who use drugs.22 HIV prevalence among FSWs is estimated to be 4.4%, which is 6 times the overall national adult HIV prevalence estimate of 0.7%.23,24 Sex work is not illegal in the DR, yet significant stigma and discrimination related to this occupation exists.25 A diverse and dynamic range of modalities of sex work exists in the DR in both venues (ie, bars, discos) and nonvenue settings (ie, street, cell phone).26 The DR has a long history of effective community-led, primary HIV prevention efforts among FSWs.27 Yet, the needs of FSWs living with HIV have received limited attention in both research and programming. We used baseline survey data collected from a cohort of 268 women enrolled in Abriendo Puertas (Opening Doors), a multilevel intervention to promote engagement in care and preventative behaviors among FSWs living with HIV in the DR.25
Participants were recruited from November 2013 to February 2014 in Santo Domingo through a nonrandom, hybrid sampling approach led by peer navigators, who were all current/former sex workers with experience doing HIV outreach, prevention, and support for people living with HIV.25 Eligibility criteria for the women were being at least 18 years old, exchanging sex for money in the last 30 days, and being HIV infected. Peer navigators were associated with the local sex worker organization Movimiento de Mujeres Unidas and the nongovernmental organization Centro de Orientación e Investigación Integral. The navigators approached women they already knew who were living with HIV through their ongoing community work. They also did short presentations about the study in HIV clinics and received referrals from clinic-based peer educators. Subsequent recruitment was done with a snowball approach using referrals by women who were already participating in the study. HIV status was confirmed before enrollment through a single rapid test (Retrocheck Qualpro Diagnostics, Goa, India). More details are included in the Abriendo Puertas baseline findings manuscript.25
Eligible women provided oral informed consent and participated in an interviewer-administered socio-behavioral survey. All data collection occurred in Spanish in the private offices of the HIV Vaccine Research Unit of the Instituto Dermatológico y Cirugía de la Piel Dr. Huberto Bogaert Diaz by trained female Dominican field staff. Participants were reimbursed $10 USD ($400 RD pesos) for their travel to the research site. The Institutional Review Boards of the Johns Hopkins Bloomberg School of Public Health, the University of North Carolina, and the Instituto Dermatológico y Cirugía de la Piel Dr. Huberto Bogaert Diaz approved all study protocols and consent procedures.
The socio-behavioral survey instrument included questions on individual, relational, environmental, and structural factors hypothesized to be related to HIV prevention, treatment behaviors, and outcomes in this population. We define our primary independent (sexual partner violence), dependent variables (eg, retention in care, ART adherence), and control variables in detail below.
Violence From a Sexual Partner
Violence questions were adapted from the WHO Violence Against Women Instrument.28 Participants were asked whether they had a fight or argument with any sexual partner in the last 6 months. Those who answered “yes” were asked about violence from an intimate partner, regular client, and/or new client. Intimate partners were defined as sexual partners who you have had sex with 3 or more time, and who do not pay per sexual act, although they may give you money. Regular clients were defined as those who you have had sex with 3 or more times, who pay for sexual acts. New clients were defined as clients who you have had sex with 1 or 2 times and pay for sexual acts. Given the small number of participants reporting violence from regular clients and new clients, we present our analysis for all clients (both new and regular).
For each partner type, participants were asked if they had experienced any of the following 7 violence tactics in the last 6 months: (1) pushed, held by force, slapped; (2) twisted arm, pulled hair, threw something at her; (3) kicked, threw against wall, punched, or hit with something that could hurt her; (4) burned her on purpose; (5) choked used a knife or weapon; (6) used force like punched, held against wall or floor, threatened with weapon to get sex; and (7) threatened to force her to have sex. For each partner type, participants were considered to have experienced violence if they answered “yes” to any of the 7 questions.
HIV Care and Treatment Outcomes
We assessed 5 HIV care and treatment outcomes. We measured retention in HIV care by asking participants if they had received HIV care in the last 6 months. To assess treatment, we asked if they had ever taken ART, whether they were currently taking ART, if they had ever stopped ART. For adherence, we assessed whether they had missed any ART in the last 4 days per an established AIDS Clinical Trials Group (ACTG) measure.29
Variables included to control for potential confounding included socio-demographics (age, civil status, education, number of children, and city of residence), sex work characteristics (years in sex work and average price per date), and substance use (alcohol and drug use).
We used descriptive statistics including frequency distributions, medians, and ranges to characterize the study sample. We first examined bivariate relationships between violence by any sexual partner and the 5 HIV care and treatment outcomes. We then examined bivariate associations between our outcomes and violence by intimate partners and clients. Subsequently, we looked at these same relationships in a multivariate logistic regression. The multivariate model controlled for relevant socio-demographic, sex work, and substance-use characteristics identified in the literature; we checked for collinearity of the variables before inclusion. We conducted the analyses using SAS version 9.3.
Demographic characteristics are described in Table 1. The median age of participants was 36 years (range, 18–61), and 217 (81.0%) were in an intimate partnership. Over two-thirds of participants had no secondary education. Almost all women had at least 1 child with a median of 3 children. Approximately one-fifth of women lived in other cities or rural areas but came to Santo Domingo for their HIV care.
Participants worked in a range of sex work settings including the street, establishments, and independently via cell phone (Table 1). Most had been in sex work for many years (median 15 years, range less than 1 year to 45 years). Although there was a wide range in the price that the women charged per client date (5–100 USD), the median charge was 20 USD. Alcohol use was common among the sample; over one-third of the women reported alcohol use more than once a week in the last 30 days. Nearly one-quarter of women reported ever having used drugs (marijuana, cocaine, and crack).
Although the majority of women in our sample were currently or had ever been engaged in HIV care, 40 (14.9%) had not received any HIV-related care in the last 6 months, our measure of retention (Table 1). Among those who were ever on ART (n = 228), only 16 (7.6%) reported not currently being on treatment. However, over one-third reported having ever interrupted treatment. Over a quarter had missed a dose of ART in the last 4 days.
Nearly one-fifth of women (n = 49, 18.3%) reported having experienced violence from any sexual partner within the last 6 months. When broken down by partner type, 33 (12.3%) women experienced violence from an intimate partner and 23 (8.3%) from a client. Prevalence of violence was similar for regular clients (n = 15, 5.6%) and new clients (n = 13, 4.9%). A small proportion (2.6%) reported experiencing violence from both a client (new or regular) and an intimate partner.
In bivariate analysis (Table 2), FSWs who experienced violence from any sexual partner in the last 6 months were more likely than those who had not to have not received HIV care in the last 6 months [odds ratio (OR): 2.97, 95% confidence interval (CI): 1.41 to 6.24]. If they had ever been on ART, women who experienced violence were significantly more likely than women who did not experience violence to not currently be on ART (OR: 3.16, 95% CI: 1.07 to 9.31). They were also more likely to have interrupted ART (OR: 3.20, 95% CI: 1.54 to 6.66) and to have missed a dose of ART in last the 4 days (OR: 3.48, 95% CI: 1.66 to 7.30). We found variation in these associations by partner type. Having experienced violence from an intimate partner was significantly associated with not having received HIV care in the last 6 months (OR: 2.97, 95% CI: 1.29 to 6.85), not currently being on ART (OR: 3.96, 95% CI: 1.25 to 12.54), and having missing a dose of ART in the last 4 days (OR: 3.69, 95% CI: 1.57 to 8.69). In contrast, having experienced violence from a client was significantly associated with not having received HIV care in the last 6 months (OR: 3.55, 95% CI: 1.39 to 9.04) and having interrupted ART (OR: 5.46, 95% CI: 1.67 to 17.80).
In the multivariate models (Table 2), violence from any sexual partner remained significantly associated with not having received HIV-related care in the last 6 months, having interrupted ART, and having missed a dose of ART in the last 4 days, controlling for socio-demographic factors, sex work dynamics, and substance use. Violence from an intimate partner remained significantly associated with not being on ART and having missed an ART dose in the last 4 days. And, violence from a client remained significantly associated with not having received HIV-related care in the last 6 months and interrupting ART.
We assessed the prevalence of violence from intimate partners and clients among a cohort of FSWs living with HIV in the DR and examined the association between experiencing violence and HIV care and treatment outcomes. Approximately 1 in 5 women in our sample had experienced violence from a sexual partner in the last 6 months. Given our use of a screener based on the occurrence of an argument as a precipitating event to violence, it is possible that we underestimated the true burden of violence from a sexual partner. Our findings are very similar to those reported from 2 studies with FSWs in the border cities of Mexico, where sex work is quasilegal as it is in the DR, though lower than estimates from other regions.7,15,30 The fact that sex work is not illegal in the DR may provide some protection from violence, though this would need to be studied in more detail and through comparative research. More FSWs reported violence perpetrated by intimate partners than by regular or new clients, a pattern that has been documented elsewhere.
We found that violence perpetrated by a sexual partner is an important correlate of HIV care and treatment outcomes among FSWs living with HIV in the DR. Having experienced any violence from a sexual partner in the past 6 months was significantly associated with not being engaged in HIV care, missing HIV care appointments, interrupting ART treatment, and not adhering to ART. Although this is the first study to examine violence among FSWs living with HIV in this setting, our findings are consistent with the associations identified in studies of violence among women living with HIV in South Africa.3,4 Although our findings are consistent, it is important to continue exploring the experiences of FSWs living with HIV across settings as the context of sex work and HIV care and treatment services could affect key HIV outcomes.
The variability in the patterns of associations for violence experienced by intimate partners compared with clients may reflect differences in the dynamics of these partnerships.31,32 Violence from intimate partners was associated with ART adherence, which may indicate that this form of violence affects women's autonomy and ability to acquire and take their medication. It may also reflect that women with violent intimate partners fear being seen taking treatment, especially if they have not disclosed their status. In contrast, the association between violence from a client and retention in care and interrupting treatment could be the cause and/or effect of greater vulnerability, trauma, and socioeconomic stability, which make it difficult to stay in care and on treatment. These nuanced findings highlight the need for programs to understand and address the specific ways in which violence from intimate partners and clients may impact HIV care and treatment outcomes among FSWs.
Violence prevention is understood to be a key component of community empowerment–based approaches to prevent HIV among FSWs.33 Programs with FSWs in Brazil and India have begun to integrate violence prevention activities into community-led initiatives and document its impact on behavioral prevention outcomes.34–37 Recent research among the general population in Uganda has also shown that integrating partner violence prevention in the context of combination HIV prevention can reduce HIV incidence.38 Mathematical modeling has also shown that violence prevention among FSWs can reduce HIV incidence among FSWs and the general adult population in settings ranging from Kenya to Ukraine.39 The direct associations we found between violence from a sexual partner and HIV care and treatment outcomes have serious implications for “treatment as prevention” programs and highlight the need to integrate sexual partner violence screening, support, and referrals into comprehensive HIV prevention, care and treatment services, and programs.40
This study is among the first to examine the association between violence and HIV care and treatment outcomes among FSWs living with HIV. However, several limitations should be noted. We relied on retrospective, self-reported data, which could be limited by recall and social desirability bias. Our sample was recruited through peer and clinic referrals and may have underrepresented women experiencing violence if they are uniquely isolated. There is no available comparison group of women who were living with HIV but were not sex workers, so it is difficult to tease apart whether these relationships are unique to FSWs or general to women living with HIV in the DR.
One limitation to our violence assessment is that we did not ask the number of partners in each category who had perpetrated violence or the relative intensity or context of violence. Also, the survey items were only asked to women who answered yes to having had an argument or fight with their partners in the past 6 months, which could have resulted in an underestimate of the burden of specific forms of violence. This limited our ability to assess differences in associations between violence and HIV care and treatment outcomes for different types of clients (eg, new clients vs. regular clients). Additionally, we did not measure psychological violence or controlling behaviors, which could also be associated with HIV outcomes.
Additional research, using both qualitative and quantitative methods, is needed to obtain a more holistic understanding of the relationship between violence and HIV care and treatment outcomes among FSWs living with HIV. Qualitative research with women living with HIV points to possible mechanisms of influence between HIV and partner violence including the influence of violence on mental health and, in turn, on motivations and ability to adherence to care and treatment regimens.2 Life histories could be used to examine experiences of violence through the life course and their effect on outcomes later in life. Additionally, longitudinal survey data could be used to assess the temporal sequence between violence and HIV outcomes and to assess for mediators. Finally, such research should measure characteristics of partnerships (eg, intimacy, trust, economic dependence) and experiences of violence for specific partners to be able to link these factors in analyses. Disclosure of HIV status is another key variable that should be examined as a potential moderator of the association between violence and HIV outcomes.
With regard to programming, our findings highlight the importance of integrating appropriate screening for violence into HIV care and treatment services along with support for referrals to support services. Although our study focused on recent violence, it is important to screen for violence throughout the life course because of the possible impact on partnership dynamics and care-seeking behaviors. Our findings also highlight the importance of violence-related screening and support by type of partner to provide appropriate referrals and mitigate the health and safety impact of abuse.
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