The link between intimate partner violence and HIV

Prevention in Focus PiF 2019 Fall

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There is a close link between intimate partner violence (IPV) and HIV. IPV can increase risk of HIV by limiting a person’s ability to negotiate safer sex and safer drug use and because the short- and long-term effects from IPV may lead people to engage in higher risk behaviours. IPV is common among people living with HIV, in part because IPV and HIV disproportionately affect some of the same populations. People living with HIV may experience more severe or more prolonged IPV than people who are HIV-negative and experiencing IPV. People living with HIV may be particularly vulnerable to IPV when they disclose their HIV status to their partner. Intimate partner violence can lead to poorer HIV care outcomes. HIV service providers can play a role in helping to prevent or respond to IPV. Likewise, those working with people who experience IPV can play a role in helping to prevent HIV and encouraging testing and treatment.

Intimate partner violence (IPV) is domestic violence caused by a spouse, common-law partner, or dating partner within an intimate relationship. It includes physical violence such as punching or kicking, sexual violence such as rape or the use of manipulation to pressure someone into sex, and emotional and verbal abuse, such as financial abuse and belittling, threatening, and controlling behaviour. The negative effects of IPV are wide-ranging and long lasting, including impacts on mental health, physical health, and well-being.1 This article focuses on the elements of IPV that relate directly to HIV.

Intimate partner violence (IPV) in Canada

In 2016, over 90,000 incidents of IPV were reported to police in Canada, involving about 0.3% of the Canadian population. Of people who reported IPV to the police, 79% were women, and 80% of people accused were male.2 The number of people who reported IPV to the police is probably a small percentage of all people who experienced it. This is because the vast majority of people who experience IPV do not report it to the police (Statistics Canada, 2016). Men are particularly unlikely to report IPV to police.3

The 2014 General Social Survey on Canadians’ Safety may give a better picture of IPV in Canada.3 The survey randomly sampled Canadians who were 15 or older and asked them about spousal violence. The survey found that 4% of Canadians with a current or former spouse experienced physical or sexual IPV and 14% reported emotional or financial IPV in the past five years. Men and women reported similar rates of IPV overall. However, severe physical violence and sexual violence were more common among women. Women were more likely than men to sustain physical injuries and to experience long-term PTSD-like effects as a result of spousal violence. The survey found that Indigenous women and people who identify as lesbian, bisexual, or gay were disproportionately affected by physical or sexual IPV.

HIV risk among people who experience IPV

Intimate partner violence involves one person exerting control over another person. The result is that people experiencing IPV often lose control over various aspects of their lives. This lack of control can affect many parts of their lives including the person’s ability to negotiate safer sex (e.g., the use of condoms or pre-exposure prophylaxis [PrEP]) or safer drug use. Although people of all genders and sexual orientations can experience IPV, women and gay, bisexual and other men who have sex with men (gbMSM) who experience IPV may be at higher risk for HIV than heterosexual men.

Women experience sexual violence at much higher rates than men,3 and gbMSM also experience high rates of sexual violence.4 Sexual violence can lead directly to HIV risk in a variety of ways. Condoms are not often used in sexual assault,5 and the physical trauma of rape can make the risk for HIV transmission higher than it is during consensual sex.6 Besides rape and sexual assault, sexual violence can include control over sexual health decisions. There are situations when sex is consensual but one partner coerces the other partner into not using condoms or other prevention methods. This coercion has direct implications for sexual health.7 A systematic review found that IPV was associated with inconsistent condom use or partners refusing to use condoms.7 Similarly, gbMSM experiencing IPV often feel pressured to have sex without condoms.8 The prevalence of HIV is high among gbMSM;9 therefore, unprotected sex among gbMSM can pose a particularly high risk for HIV.

For women who inject drugs (including those who use drugs to cope with their experiences of IPV), IPV is associated with sharing drug use equipment because of power imbalances in their relationships.10 Male partners are often the ones to buy drugs, to have injection equipment, and to have the capacity to inject themselves while women are more likely to rely on their male partners to inject drugs for them. With control over drugs and equipment, men may pressure their partners to share injection equipment, sometimes with a threat of violence if they refuse.10 When injecting with a male partner, women may use a needle after their partner has used it (called being “second on the needle”).10

Intimate partner violence may also lead to risk for HIV after the person is no longer in the abusive relationship. A large-scale study in the United States found that both men and women who had experienced IPV were more than twice as likely to report HIV risk factors (e.g., injection drug use, or having been treated for a sexually transmitted infection) compared with those who had not experienced IPV.11 One possible explanation for this is that many people who have experienced IPV experience psychological trauma that makes them less likely to advocate for safer sex.12

Intimate partner violence among people living with HIV

Prevalence of IPV among people living with HIV

A review of 31 American studies looked at IPV rates in women and gbMSM living with HIV.13 The studies found that over their lifetime, 26%–62% of women experienced physical violence, 22%–44% experienced sexual violence, and 55% experienced emotional violence. The studies also found that 15%–39% of gbMSM experienced physical violence, 8%–33% experienced sexual violence, and 22%–73% experienced emotional violence in their lifetime. Results vary from study to study, but they highlight the fact that IPV is common among women and gbMSM living with HIV.13

A regional HIV care clinic in Calgary has looked at IPV among people living with HIV in southern Alberta. Healthcare providers at the Southern Alberta Clinic screened all patients living with HIV for IPV. Of the 853 people who were screened, 23% had experienced IPV, and of those who had experienced IPV, 23% had experienced it in their current relationship. A higher proportion of women (36%), Indigenous people (46%), and people with a history of injection drug use (32%) reported that they had experienced IPV.14 Emotional IPV was the most common form of abuse, followed by physical and sexual abuse. The clinic later released IPV screening data on 687 gbMSM living with HIV. They found that 22% had experienced IPV, and of these, 15% had experienced IPV in their current relationship. They noted that Indigenous gbMSM were more likely to have experienced IPV than other gbMSM.15 In both studies, most people who experienced IPV experienced more than one form of violence.14,15

A cohort study in Ontario looked at IPV in over 2,300 people living with HIV.16 In that study, 29% of participants reported ever experiencing IPV. A higher proportion of women (46%) than men (25%) reported IPV. People who identified as gay men or reported their sexual orientation as “other/unknown” experienced IPV at higher rates than people who identified as heterosexual.

Part of the reason for the correlation between IPV and HIV is that IPV and HIV disproportionately affect some of the same populations.17 For example, in Canada, gbMSM and Indigenous people are disproportionately affected by both IPV3 and HIV.9 Also, some aspects of a person’s life, such as drug use and poverty, are associated with higher risk for both HIV and IPV.17

People living with HIV may experience worse or more frequent episodes of IPV than people who do not have HIV.17 Researchers sometimes talk about this in terms of syndemic theory – the idea that multiple stressors happening at the same time (in this case HIV and IPV) can make each other worse than they would be without the other.18,19

HIV-related violence

In many cases, IPV that people with HIV experience is related to their HIV status. An American study looked at physical violence in a nationally representative sample of people living with HIV.20 They found that 21% of women, 12% of gbMSM, and 8% of heterosexual men had experienced physical violence by their partner or someone close to them since their diagnosis. Of those people, nearly 45% had experienced violence that they felt was because of or related to their HIV status.20 People living with HIV may be at particularly high risk for physical violence when they first disclose their status to their partner. In a study of 310 women with HIV,21 29% said that they had ever been afraid to tell someone their status for fear of violence, and 4% had experienced physical violence at the time when they disclosed their status to someone.

Besides physical violence, people living with HIV can experience emotional abuse that is also related to their HIV status.21 There is not a lot of research about the nature of emotional violence among people living with HIV. Emotional violence could include stigmatizing remarks related to the person’s HIV status, disclosing or threatening to disclose the person’s HIV status, or threatening to report the person to legal authorities for not disclosing their status.22 This type of abuse can take a serious toll on self-esteem, and some people living with HIV may feel that they cannot leave an abusive relationship because they worry that they will not be able to find another partner who accepts their HIV status.23

IPV and HIV care outcomes

For people living with HIV, IPV can affect HIV care outcomes. A meta-analysis found that women who experienced IPV were 21% less likely to be on treatment, reported 52% lower adherence to medication, and were 36% less likely to be virally suppressed than women who had not experienced IPV.24

An analysis of data from gbMSM at the Southern Alberta Clinic compared men who had experienced IPV with those who had not.15 Men who had experienced IPV were 1.95 times more likely to have had a clinically significant interruption in care (defined as having an undetectable viral load and leaving care for at least one year, then returning to care with a detectable viral load) and 1.55 times more likely to have had a hospitalization related to HIV.

Programs that deal with both IPV and HIV

Since HIV and IPV are related and affect one another, there is an opportunity for people who work in the HIV and IPV sectors to learn about each other’s work and form partnerships. Some North American programs aim to facilitate referrals and collaboration between the two sectors.

IPV screening at the Southern Alberta Clinic

In 2009, the Southern Alberta Clinic implemented a program to routinely screen all patients living with HIV for violence.25 The program screens for both childhood violence and violence as an adult (current or past). People who have experienced violence are then told about services that they might benefit from including immediate removal from a current dangerous situation, and being referred to a social worker in the clinic to explain the various services available in the community. In addition, healthcare providers at the clinic provide empathy and support for patients who are dealing with or have dealt with IPV.

To get feedback on the program, the clinic interviewed 158 people who had been screened for IPV.25 Almost three-quarters (73%) of the people interviewed thought that IPV should be asked about routinely in healthcare for people living with HIV. Almost everyone who was interviewed (97%) thought that there should be regular follow-up for people who report that they are currently experiencing IPV. This feedback shows that many people living with HIV support IPV screening and follow-up. This screening practice could be implemented at other HIV clinics.

Positively Safe toolkit

In 2014, the National Network to End Domestic Violence in the United States released a toolkit called Positively Safe.26 The toolkit aims to facilitate collaboration between people who work in the HIV and IPV sectors. It includes resources for service providers, such as tips for starting a conversation about HIV with someone who is experiencing IPV, tips for starting a conversation about IPV with someone who is living with HIV, and a template for a memorandum of understanding to establish collaborations between people working in the two fields. It also includes brochures and posters to help educate clients. Some of the information in the toolkit is specific to an American context, but many of the resources could be helpful to people working in Canada.

Working at the intersection of IPV and HIV

Given the close link between IPV and HIV, HIV service providers can play a role in preventing and responding to IPV. Service providers who specialize in IPV can also play a role in preventing HIV and encourage testing and treatment. People working in these two sectors should be aware of each other’s services, so that clients can be referred when needed. People working in these sectors may also wish to form formal partnerships to develop programs or resources that concern both IPV and HIV.

Resources

Women living with HIV and intimate partner violence – HIV & AIDS Legal Clinic Ontario

Positively Safe toolkit – National Network to End Domestic Violence (United States)

 

References

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  23. McDonnell KA, Gielen AC, O’Campo P. Does HIV status make a difference in the experience of lifetime abuse? Descriptions of lifetime abuse and its context among low-income urban women. Journal of Urban Health. 2003 Sep 1;80(3):494-509.
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About the author(s)

Mallory Harrigan is CATIE's specialist, client publications and ordering centre. She has a Master’s degree in community psychology from Wilfrid Laurier University.