Elsevier

The Lancet

Volume 363, Issue 9419, 1 May 2004, Pages 1415-1421
The Lancet

Articles
Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa

https://doi.org/10.1016/S0140-6736(04)16098-4Get rights and content

Summary

Background

Gender-based violence and gender inequality are increasingly cited as important determinants of women's HIV risk; yet empirical research on possible connections remains limited. No study on women has yet assessed gender-based violence as a risk factor for HIV after adjustment for women's own high-risk behaviours, although these are known to be associated with experience of violence.

Methods

We did a cross-sectional study of 1366 women presenting for antenatal care at four health centres in Soweto, South Africa, who accepted routine antenatal HIV testing. Private face-to-face interviews were done in local languages and included assessement of sociodemographic characteristics, experience of gender-based violence, the South African adaptation of the Sexual Relationship Power Scale (SRPS), and risk behaviours including multiple, concurrent, and casual male partners, and transactional sex.

Findings

After adjustment for age and current relationship status and women's risk behaviour, intimate partner violence (odds ratio 1·48, 95% CI 1·15–1·89) and high levels of male control in a woman's current relationship as measured by the SRPS (1·52, 1·13–2·04) were associated with HIV seropositivity. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV serostatus.

Interpretation

Women with violent or controlling male partners are at increased risk of HIV infection. We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships, and HIV risk behaviours in men, as well as effective interventions, are urgently needed.

Introduction

In 2002, more than 42 million people were living with HIV/AIDS, almost 70% of whom were in sub-Saharan Africa.1 In this region, 58% of HIV-positive adults are female,1 making African women the group most severely affected by HIV/AIDS worldwide. Thus, for effective prevention and control of the epidemic, deepening our understanding of women's HIV risk is crucial.

Researchers and policy makers have increasingly cited gender-based violence and gender inequality as essential determinants of women's HIV risk, both worldwide 2, 3, 4, 5, 6 and within sub-Saharan Africa.2, 7, 8, 9 An understanding of the size and nature of these associations is necessary for the development of appropriate intervention strategies-yet, to date, the methodology and scope of empirical research on the topic remain limited. Although most women affected by HIV/AIDS are in sub-Saharan Africa, almost all existing research on violence and women's HIV risk comes from the USA. Since the prevalence of HIV in the general population is low in the USA, researchers have usually studied high-risk populations or used self-reported behaviour, or a person's history of sexually transmissible diseases as a proxy indicator of HIV risk.4, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 Although such research has been valuable in elucidating connections between violence and risk behaviour it relies heavily on potentially unreliable assumptions that there is a simple relation between risk behaviour, acquisition of sexually transmissible diseases, and HIV risk.24 Furthermore, findings from research on violence-related risk behaviour in North America cannot necessarily be applied to the distinctly different cultural and social contexts of sub-Saharan Africa.

Only two sub-Saharan African projects have made quantitative assessments of violence and women's HIV risk. A study in Rwanda, of women in stable relationships who were interviewed 2 years into a continuing intervention trial, showed that HIV-positive women were more likely to report a history of physical violence and sexual coercion by their male partners than were women without HIV.8, 25 A study of 245 women attending a voluntary HIV counselling and testing centre in urban Tanzania noted that in women younger than 30 years, HIV-positive women were more likely to report at least one event of physical or sexual violence from their current partner than were HIV-negative women, while in women older than 30 years, HIV status was not associated with violence.8 These studies provide valuable evidence of a connection between intimate partner violence and women's HIV risk, but investigators in both studies assessed whether women were subject to partner violence after the women were aware of their serostatus. Furthermore, the research was limited by a narrow breadth of experiences that were defined as violent and controlling. Neither study controlled for effects of women's risk behaviours,7, 8, 25 although these behaviours might be associated with violence.7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23

A study in South Africa9 noted that women with a history of physical or financial abuse (ie, taking earnings, preventing a woman from earning money, or not providing money for household/children's expenses) were more likely to request that their partners use condoms. Yet irrespective of abuse history, women who described their relationships as “not good” were less likely to request condom use, and investigators postulate that this group includes women with a general experience of gender inequality in their relationships. They suggest that these results point to a complex inter-relationship between partner violence and couples' sexual practices. Furthermore, they posit that other forms of gender inequality in relationships might also affect women's risk of acquiring HIV.9 Therefore, to fully understand associations between HIV, gender-based violence, and gender-based inequality in intimate partnerships, research must capture and compare a range of abusive experiences, and explore connections between violence, inequality, and risk behaviour.

We did a cross-sectional survey of 1366 women attending antenatal clinics in Soweto, South Africa, in which we explored the following questions. Is past experience of intimate partner violence, child sexual assault, forced first intercourse, adult sexual assault by non-partners, or current involvement with a controlling partner associated with newly diagnosed HIV infection? Are experiences of violence and control associated with increases in self-reported HIV risk behaviour-specifically, number of male partners, non-primary male partners, transactional sex, non-use of condoms, and substance use? Most importantly, are observed associations between violence and control and HIV serostatus sustained after adjustment for the effects of violence-associated risk behaviour?

Section snippets

Methods

We interviewed women seeking antenatal care at four clinics in Soweto, South Africa, between November, 2001, and April, 2002. All women were offered routine antenatal voluntary counselling and testing for HIV; women aged 16 years or more and who elected to have an HIV test were eligible for our study. A team of six South African female fieldworkers trained in gender-based violence and HIV/AIDS issues visited the clinics in a systematic rotation and screened women who had received HIV pretest

Statistical analysis

Data were double entered into EpiInfo 6·04d and transferred to SAS 8·02 for analysis. We first considered associations between sociodemographic variables and HIV, then associations between violence and HIV, between violence and risk behaviour, and between risk behaviour and HIV. In considering associations between violence and risk behaviours, we used dummy variable adjustment in multivariate logistic regression models to account for the effect of non-random variation between interviewers.

Derived variables

No agreed standard yet exists for measuring severity of intimate partner violence. Because type of violence (physical only, sexual only, or both) and frequency of abuse are conceptually important as potential determinants of HIV risk, we first assessed both of these dimensions with respect to women's HIV risk (table 1). Both dimensions were highly intercorrelated and both proved to be empirically associated with HIV serostatus. We therefore constructed a summary measure which classified women

Role of the funding source

The sponsors of this study had no role in the study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit for publication.

Results

3982 pregnant women attended study clinics during the field work period. Of these, 1790 (45%) were screened for eligibility, and 1467 (82%) were eligible. Of the 323 ineligible women, 274 (85%) had declined or delayed HIV testing.28 1395 (95%) eligible participants agreed to join the study and of these, 1366 (98%) had traceable HIV test results. Participants ranged in age from 16 to 44 years and were from 6 to 41 weeks pregnant; 458 (33·5%) tested HIV-positive on the date of the interview.

Discussion

We assessed associations between newly diagnosed HIV infection and experience of intimate partner violence, male control in relationships, child sexual assault, forced first intercourse, and adult sexual assault by a non-partner in women seeking antenatal care in Soweto, South Africa. The experience of being physically and sexually assaulted by a male intimate partner, or experiencing one of these a few times or more, was associated with increased risk of HIV infection. The association between

References (42)

  • C Garcia-Moreno et al.

    Violence against women: its importance for HIV/AIDS

    AIDS

    (2000)
  • S Zierler et al.

    Reframing women's risk: social inequalities and HIV infection

    Annu Rev Public Health

    (1997)
  • S Maman et al.

    HIV-positive women report more lifetime partner violence: findings from a voluntary counselling and testing clinic in Dares Salaam, Tanzania

    Am J Public Health

    (2002)
  • van der StratenA et al.

    Sexual coercion, physical violence, and HIV infection among women in steady relationships in Kigali, Rwanda

    AIDS Behav

    (1998)
  • K-H Choi et al.

    Sexual harassment, sexual coercion, and HIV risk among US adults 18–49 years

    AIDS Behav

    (1998)
  • N El-Bassel et al.

    Partner violence and sexual HIV-risk behaviors among women in an inner-city emergency department

    Violence Vict

    (1998)
  • N El-Bassel et al.

    Drug abuse and partner violence among women in methadone treatment

    J Fam Viol

    (2000)
  • AC Gielen et al.

    Intimate partner violence, HIV status and sexual risk reduction

    AIDS Behav

    (2002)
  • L Gilbert et al.

    Partner violence and sexual HIV risk behaviors among women in methadone treatment

    AIDS Behav

    (2000)
  • H He et al.

    Violence and HIV sexual risk behaviors among female sex partners of male drug users

    Women Health

    (1998)
  • SC Kalichman et al.

    Sexual coercion, domestic violence, and negotiating condom use among low-income African-American women

    J Women Health

    (1998)
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