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

Kidman, Rachel, PhD*; Violari, Avy, MD

JAIDS Journal of Acquired Immune Deficiency Syndromes: January 1, 2018 - Volume 77 - Issue 1 - p 64–71
doi: 10.1097/QAI.0000000000001569
Prevention Research

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.

*Program in Public Health and Department of Family, Population and Preventative Medicine, Stony Brook University, Health Sciences Center, Stony Brook, NY; and

Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Correspondence to: Rachel Kidman, PhD, Program in Public Health and Department of Family, Population and Preventative Medicine, Stony Brook University, Health Sciences Center, Level 3, Stony Brook, NY 11794 (e-mail:

This research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under Award Number R21HD083032 and supported by the South African Medical Research Council. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the South African Medical Research Council.

The authors have no conflicts of interest to disclose.

Received May 26, 2017

Accepted September 20, 2017

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Globally, almost one-third of ever-partnered women will experience physical and/or sexual intimate partner violence (IPV) over their lifetime.1 IPV has a negative impact on health, including injury, substance abuse, depression, unwanted pregnancy, sexually transmitted diseases, and homicide.2 Importantly, IPV is linked to HIV risk both through direct transmission and through an indirect effect on subsequent high-risk sexual behavior.3–5 In a recent longitudinal study of young South African women, for example, those who experienced IPV were one and a half times more likely to acquire HIV.6

Why then might we want to study IPV among those already infected with HIV, including youth perinatal HIV-infected with HIV (PHIV)? One reason is that youth perinatally-infected with HIV may experience a disproportionate burden of IPV. In part, this may be because HIV disclosure can trigger violent reactions from romantic partners (represented by pathway 2a in Fig. 1).7–9 There may also be secondary pathways between HIV and IPV that are mediated by childhood adversity (pathway 1). Research shows that HIV-infected children disproportionately experience physical and sexual abuse10,11 and are more likely to live with an ill parent and/or experience parental death. There is evidence, though not from this population, that such childhood adversities can lead to greater IPV victimization during adolescence.12



There is a second important reason to study IPV among this group: IPV may facilitate onward HIV transmission among PHIV youth. A causal relationship between IPV and sexual risk taking is well documented (pathway 3),13–15 although again such literature has not been extended specifically to PHIV. Such risk taking is often fuelled, at least in part, by heightened levels of depression and substance abuse among victims.2,16,17 Fear also plays a prominent role. Victims fear a violent reaction if they decline sex or suggest using a condom.18 For HIV-positive victims, there is also a fear of inadvertently disclosing their HIV status by insisting on condom use.19 Thus, victims are less able to negotiate condom use, sexual initiation, and sexual exclusivity.4,13,15

HIV disclosure can be one way to encourage safer sexual practices, but IPV complicates this mechanism. As mentioned above, disclosure can trigger violence. Moreover, violence or the threat of violence can discourage disclosure (pathway 2b).8,20–22 This means sexual partners are unable to make informed choices and may not take precautions to prevent transmission.

Finally, IPV may heighten risk of onward transmission by interfering with HIV treatment necessary for viral suppression (pathway 4).23 Among adults, there is ample evidence that IPV impedes adherence to lifesaving antiretroviral therapy (ART): a recent meta-analysis found women experiencing IPV were about half as likely to be adherent or achieve viral suppression.24 Youth already demonstrate poor adherence as compared with other age groups.25 If adherence is lower still among those experiencing IPV, this could have meaningful implications for both disease progression and HIV transmission.

Approximately 4 million youth aged 15–24 years are now living with HIV globally.26 A substantial proportion acquired HIV from their mothers (40% among 15- to 19-year-olds).27 The widespread introduction of ART over the past decade has contributed to the survival and rapid growth of this population. As PHIV become sexually active, however, the potential for onward transmission becomes an increasing concern.28 Understanding the role of IPV in this process is an important step toward effective intervention. This is particularly critical in South Africa, where epidemics of HIV and violence coexist.29 Approximately 7% of adolescents aged 15–24 years live with HIV.30 Many more are in violent relationships: 23% of girls and young women (aged 15–26 years) in the Eastern Cape and 37% of those (aged 15–19 years) in Johannesburg reported past-year IPV.6,31

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This exploratory study was undertaken to examine the prevalence, predictors, and health impact of IPV among a sample of PHIV youth in South Africa. We hypothesized that IPV would be common among perinatal HIV-infected youth and would adversely impact clinical, behavioral, and mental health outcomes associated with onward HIV transmission.

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Study Design and Participants

This study collected data from 250 youth recruited from the Paediatric Wellness Clinic, part of the Paediatric HIV Research Unit in Soweto, South Africa. To be eligible, participants had to (1) have documented HIV infection before age 10; (2) be aware of their HIV diagnosis; (3) be age 13–24 years; and (4) be able to read English. Participants were excluded for acute psychiatric illness and cognitive impairment. Surveys were preprogrammed in English on tablet computers. Each participant completed the survey themselves in a private conference room at the clinic. Nurses conducted a chart review to abstract clinical data. The current analyses focus on the 129 female adolescents with complete data on IPV (this excludes 7 female participants); male participants were not asked about IPV. The study had ethical approval from both Stony Brook University in the United States and the University of the Witwatersrand in South Africa.

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Intimate Partner Violence

Questions were adapted from the World Health Organization (WHO) Violence Against Women Instrument.32 Female participants were asked if their current boyfriend, husband, or any other partner ever slapped them or threw something that could hurt; pushed or shoved them; hit them with his fist or something else; kicked, dragged, or beat them; choked or burnt them on purpose; or threatened to use or actually used a gun, knife, or other weapon against them. Participants reporting any of the above were classified as having experienced lifetime physical IPV; those reporting that it occurred within the past 12 months were additionally classified as having experienced past-year physical IPV. Two more questions focused on sexual IPV and were classified the same way: whether their current boyfriend, husband, or any other partner ever physically forced them to have sexual intercourse when they didn't want to; and whether they ever have sexual intercourse because they were afraid of what their partner might do. Finally, combined measures of physical and/or sexual IPV were created for each time frame.

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Childhood Adversity

Participants completed the Adverse Childhood Experience—International Questionnaire (ACE-IQ).33 The ACE-IQ covers 13 domains, including abuse, neglect, household dysfunction, parental death, bullying, and exposure to violence outside the home. For each of the 13 domains, we assigned “1” if any question was answered affirmatively.34 The cumulative score was also categorized into lower (0–3), higher (4–7), and very high (8–13) adversity.

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Sexual Risk

Participants were asked whether they had ever had sex. If so, they were asked additional questions about past-year experiences adapted from measures in the South Africa Demographic and Health Survey, previously used among youth.35 These were used create a dichotomous variable representing high-risk sexual behavior, coded “1” if the participant reported having concurrent partners (2 or more in the same month), having 3 or more partners in the past year, or not using a condom with their most recent partner. These are all behaviors previously shown to increase HIV risk in African settings,36,37 and thus, engagement in any one of these could potentially jeopardize health. Sexually inexperienced participants, or those not reporting the above risk behaviors in the past year, were coded as zero. Participants also self-reported on whether they currently were or had ever been pregnant. Finally, participants were asked if they currently had a boyfriend or girlfriend.

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HIV Disclosure

Several questions asked about disclosure to family, peers, boyfriends/girlfriends, and sexual partners. In this study, we report separately on HIV status disclosure to a boyfriend/girlfriend and to the most recent sexual partner; in each case this was coded 1 if they had disclosed that they were HIV-positive and zero otherwise. Participants were also asked to report on reasons for nondisclosure by selecting options from a predetermined list.

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Mental Health

Depression was assessed using the Beck Depression Inventory (analyzed using a preestablished cut-point of 20 for moderate-to-severe depression).38 Problematic substance use was captured with the adolescent self-administered version of the CRAFFT Screening Questionnaire for alcohol and substance abuse.39

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Adherence and Viral Load

Participants who reported currently taking ART were asked about adherence; these questions were adapted from WHO tools.40 Participants were considered to have poor adherence if they reported skipping at least 1 pill in the past week. Viral suppression, abstracted from medical records, was defined as having a viral load of less than 200 copies/mL on their most recent laboratory report.41 Sensitivity analyses were done at other cut points (eg, 400; 20 copies/mL) and results did not change.

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Control Variables

Additional questions captured age, relationship to caregiver (dichotomized into parent versus non-parent), and wealth. Wealth was a cumulative measure of whether their household owned a TV, radio, car, cell phone, or computer; this was transformed into wealth quintiles for analyses.

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Analyses focus on 129 female participants; 7 additional female participants were excluded from current analyses because of incomplete data on IPV. We use frequencies to describe the sample characteristics, including IPV prevalence. We run 2 sets of logistic regressions. First, we regress childhood adversity on IPV. Second, we regress IPV on the behavioral and clinical outcomes described above. Models were created separately for past-year and lifetime physical and/or sexual IPV. Neither wealth nor relationship to the caregiver was predictive of health outcomes; age was thus the only control variable retained in the final models. Finally, we reran the outcome models restricting the sample to those participants who are currently partnered. All analyses were performed in Stata v13.0.

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Table 1 presents the sample characteristics. Just over half the participants were in mid-adolescence (age 13–16 years), a quarter in late adolescence (age 17–19 years), and the remainder were age 20–24 years. A parent was reported as the primary caregiver by only about half the participants. Almost two-fifths (37%) met the criteria for depression and 15% for substance abuse problems.



All but 2 were currently on ART (data not in tables), yet just 59% were virally suppressed. Although a substantial number of sexually active youth reported risky behavior, this was offset by the low prevalence of sexual debut (only 36%). This meant that just 16% of the total cohort (sexually active and not) reported high-risk sexual behaviors. Despite such, 10% of the cohort had already been pregnant.

Since learning of their own status, only 42% of participants had told someone else that they were HIV-positive. Many reported currently being in a relationship (59%), but few had ever shared their HIV status with a romantic partner (16% overall; 22% among those with a current partner). Disclosure was higher to sexual partners, but still far from universal: only 47% of those who were sexually active had told their most recent partner that they were HIV-infected. When asked about reasons for nondisclosure, one-third cited fear that their sexual partner might physically hurt them (data not shown in tables).

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Prevalence and Correlates of IPV Among Perinatal HIV-Infected Youth

Overall, one-third of participating PHIV youth reported ever experiencing physical and/or sexual IPV violence in their lifetime (Table 1). Lifetime physical violence (27%) was more common than sexual violence (17%). Almost a fifth of the participants were victimized by their partner in the past year: 18% experienced physical violence and 4% experienced sexual violence. Sexual and/or physical IPV increased with age (eg, past year IPV was 32% among youth aged 20–24 years versus 15%–16% among younger ages).

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Childhood Adversity was Positively Associated With IPV Among Perinatal HIV-Infected Youth

On average, participants reported 7.3 childhood adversities. Most participants reported multiple childhood adversities: 35% reported between 4 and 7 adversities and 55% reported 8 or more adversities. PHIV youth reporting greater adversity also reported greater IPV. Among those with 8 or more childhood adversities, past-year and lifetime physical and/or sexual IPV prevalence was 25% and 44%, respectively. In comparison, only 8% of participants with 3 or fewer adversities reported any IPV.

In age-adjusted models, each additional adversity was associated with approximately a 30% increase in the odds of experiencing lifetime [AOR = 1.37; 95% confidence interval (CI): 1.15 to 1.63; P = 0.000] or past-year physical and/or sexual IPV (AOR = 1.30; 95% CI: 1.06 to 1.60; P = 0.013). If examined categorically, moving from one adversity category to the next was associated with over 3 times the odds of experiencing lifetime physical and/or sexual IPV (odds ratio = 3.07; 95% CI: 1.50 to 6.28; P = 0.002) and twice the odds of past-year physical and/or sexual IPV (AOR = 2.23; 95% CI: 0.96 to 5.18; P = 0.061).

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IPV Correlates With Behavioral Risk Among Perinatal HIV-Infected Youth

IPV was associated with high-risk sex, pregnancy, depression, and substance abuse. Compared to girls who had not experienced past-year IPV, girls with a history of either physical and/or sexual IPV had 9 times the odds of having engaged in high-risk sexual behaviors in the past year (AOR = 8.96; 95% CI: 2.78 to 28.90, Table 2) and almost 7 times the odds of pregnancy (AOR = 6.56; 95% CI: 1.91 to 22.54). Depression and substance abuse were also elevated in those participants reporting past-year physical and/or sexual IPV (AOR = 4.25; 95% CI: 1.64 to 11.00 and AOR = 4.11; 95% CI: 1.42 to 11.86, respectively). Modeling lifetime IPV produced similar results (Table 2). Of note, every participant who reported a pregnancy also reported experiencing lifetime IPV.



Past-year physical and/or sexual IPV also displays a strong relationship with poor medication adherence (odds ratio = 5.37; 95% CI: 1.37 to 21.08). However, this relationship did not reach significance in the lifetime IPV model. Neither past-year nor lifetime IPV was associated with viral load. IPV was likewise unrelated to HIV status disclosure.

The above analyses include all girls and young women in our sample, regardless of partnership status. If IPV is a proxy for being partnered, then this approach may artificially inflate some of the above associations. Thus, we reran the above models restricting the sample to the 59% of participants who reported that they currently had a boyfriend or girlfriend (Table 3). Although results are qualitatively similar, there is reduction in the magnitude of the associations. For example, past-year IPV was associated with almost 6 times the odds of engaging in high-risk sexual behaviors (AOR = 5.55; 95% CI: 1.62 to 19.04) or ever being pregnant (AOR = 5.59; 95% CI: 1.35 to 23.17) in the restricted sample; these are each a bit lower than the ORs found in the full sample (AOR = 8.96 and 6.56, respectively).



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IPV is an established risk factor for HIV acquisition.5 To our knowledge, no previous studies have examined the confluence of IPV and risk of onward transmission among PHIV. We find that PHIV girls and youth contend with unacceptably high levels of violence: one-fifth reported being physically or sexually victimized by their partner in the past year. IPV was much higher still for those girls reporting a heavy burden of childhood adversities, emphasizing the compounding nature of violence and suggesting early intervention is crucial.

Critically, we find that this violence likely serves to perpetuate the cycle of HIV. Girls experiencing IPV were less likely to practice health behaviors that protect against onward transmission or reinfection. Instead, victims were more likely to engage in risky sexual behavior, inconsistently take their HIV medications, and have a substance abuse problem. Moreover, there was a strong association between IPV and pregnancy—another outcome of unprotected sex. In our sample, each young woman who reported a pregnancy also reported experiencing lifetime IPV. Taken together, this suggests that IPV may facilitate onward transmission. Cross-sectional data, however, prohibit inference on the causal link. It is possible that IPV is both a predictor and a product of sexual risk and/or pregnancy or that they have mutual risk factors.

The cross-sectional nature of the data also makes it difficult to interpret the null results around disclosure. Studies in Uganda have found that less than half of perinatal HIV-infected youth tell partners that they are HIV-positive.42,43 We found similarly low rates but did not find a clear relationship between IPV and HIV status disclosure. This may reflect 2 simultaneous but opposing processes: for some youth, disclosure may trigger IPV (a positive association)8; for other youth, a history of IPV may discourage disclosure (a negative association).8,22 Temporal data are needed to tease out any bidirectional relationships.

Another limitation of this exploratory study was its focus on a small, clinic-based sample. In other studies, IPV has been linked to interruptions in HIV care.23 If this is true, PHIV youth with high rates of IPV may be less likely to be captured in our study. This may lead to an underestimation of the prevalence of IPV and/or its association to negative health behaviors. Moreover, almost all participants in our sample were on ART. A US-based study found that IPV influenced viral load only if HIV-positive women were not on ART. There was no impact if women were on ARTs, consistent with our finding.23 The fact that our sample was engaged in care and on ART may partially explain why we did not find a relationship between IPV and viral load.

A final limitation to note is that we could not identify whether participants had ever been partnered. Individuals are only at risk for IPV if they have had a partner, and they are also only at risk for sexual outcomes if they have had a partner. Thus, IPV could be acting as a proxy for sexual risk in our full sample. To examine this possibility, we restricted the sample to those participants who were currently partnered and found similar—though slightly attenuated—associations. The restricted sample, however, excludes girls who may have had a violent partner in the past and ended the relationship (20% of those not in a current relationship reported lifetime IPV). Thus, the true association between IPV and sexual health may lie somewhere in the middle.

These limitations, however, do not take away from finding that IPV is linked to multiple behavioral risks in youth with known HIV infection and could result in onward HIV transmission. Even in an exploratory study, this finding emerges clearly and should serve to stimulate programmatic action and rigorous research.

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Relative to other ages, we have made little progress in lowering HIV incidence among adolescent girls and young women.26 The United Nations General Assembly Declaration of Commitment on HIV/AIDS highlights tackling violence against women as a key prevention strategy. However, their focus is on HIV-negative women. Our findings strongly suggest that this strategy should be broadened to explicitly address IPV among PHIV youth with high potential for onward transmission. Although our findings are more mixed regarding clinical implications, it is possible that reducing IPV would improve adherence and subsequent disease progression.

Our research suggests to 2 main intervention points in the HIV care continuum. First, pediatric HIV providers could integrate services for primary IPV prevention. As hypothesized, PHIV youth had a high burden of childhood adversity, a key driver of later IPV. Pediatric providers are well placed to recognize such and to offer early intervention. Parenting programs, for example, have been shown to reduce child maltreatment and domestic violence.44,45 For those who have already been traumatized, linkage to mental health and substance abuse treatment may help mitigate the impact on later IPV exposure.46 As patients reach adolescence, clinics could offer HIV-specific prevention education coupled with components designed to prevent IPV exposure.47,48 Promising intervention could be adapted for the PHIV audience. For instance, additional components might include how to facilitate safer HIV disclosure and protect against inadvertent disclosure.49

Second, routine screening for IPV among PHIV youth should be a priority. Although WHO guidelines do not recommend universal IPV screening in low- and middle-income countries, they do suggest selective screening when “assessing conditions that may be caused or complicated by intimate partner violence.”50 The guidelines specifically acknowledge the complex issues around HIV, including the impact of IPV on disclosure and risk-reduction strategies, and leave the door open for routine testing among HIV-positive patients. Our findings add to growing body of evidence linking IPV to health outcomes among HIV-positive patients24 and lend related support for routine screening. Research has shown that patients react positively to routine IPV screening in HIV counseling sessions.51 South African nurses likewise report a strong desire and willingness for IPV training.52 Taken together, we believe there is a strong argument for routine screening. Of course, screening is not effective when implemented in isolation; it needs to be followed by engagement in effective intervention.53 In our study, past-year IPV was associated with recent adherence; lifetime IPV was not. This suggests that girls and young women may be resilient to the effects of past IPV when it comes to adherence but are affected by ongoing or recent trauma. Services that help girls and young women exit abusive relationships may yield relatively quick dividends for medication adherence. Services designed to address IPV, mental health, and substance abuse need to be readily available—an admittedly large challenge in settings with limited social services. Collocating services for victims of violence into existing HIV treatment centers may increase availability and uptake. In addition to making referrals,54 HIV health providers can play a supportive role by helping patients devise strategies to optimize health and reduce transmission within the context of known IPV.

Finally, structural interventions that address the broader norms influencing IPV should be a high priority. Individually focused interventions do not address the gendered power dynamics or prevailing social norms in which IPV occurs. Ultimately, any actions directed at PHIV will need to be coupled with broader wider gender-transformative interventions in their community.47,48,55

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perinatal infection; youth; intimate partner violence; sexual risk; adherence

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