SPEAK OUT

HIV and Partner Violence

Implications for HIV Voluntary Counseling and
Testing (VCT) Programs

An important component of HIV voluntary counseling and testing (VCT)
programs is encouraging clients to inform partners of their serostatus. Yet
many clients do not disclose results to partners. Studies have found that a
serious barrier to disclosure for women is fear of a violent reaction by
male partners and that HIV-infected women are at increased risk for partner
violence (Gielen et al. 1997; Rothenberg et al. 1995; Temmerman et al.
1995). Building on previous research, this study explored the links between
HIV infection, serostatus disclosure, and partner violence among women
attending the Muhimbili Health Information Center (MHIC), a VCT clinic in
Dar es Salaam, Tanzania.

Study Methods

The study first collected qualitative data from women, men, and couples
(n=67) who were MHIC clients. In the second phase, researchers enrolled 340
women after pre-test counseling and prior to collection of test results; 245
of these women were followed and interviewed three months after enrollment
and testing[1]. Nearly a third of the sample were HIV-positive, almost half
were married, and 50 percent were between the ages of 18 and 29 years and
had less than seven years of education. The study followed WHO ethical and
safety protocols for conducting research on violence against women.

Key Findings

There are marked differences between women's and men's motivations for
getting an HIV test. Male informants who came to the clinic alone often
sought testing to confirm a suspected HIV-negative serostatus. Some
mentioned the need to have an HIV test to regain a partner's trust after a
suspected infidelity or prove commitment to a partner. Conversely, women
tended to seek HIV testing to verify a suspected HIV-positive serostatus;
their decision to test was often motivated by the sickness or death of
either a child or partner, or by their own health problems, particularly
fertility problems [2].

Many women lack autonomy to make decisions about HIV testing. Male and
female informants frequently referred to the need for women to "seek
permission" from partners prior to testing. Men, on the contrary, generally
made the decision to test on their own without soliciting prior consent.
According to a married, 36-year-old, HIV-negative male:
Let's take an example. She passes, she finds there is a centre of testing
like here... Now she can't test for just good intention. When she goes home
she can't say she went to that certain place. Now if it is a man having mind
to test it is not a problem.

Most women in the study thought about testing for at least a month prior to
actually seeking services.

Disclosure to partners by HIV-positive women has increased over time but is
still significantly less than that for HIV-negative women. During a VCT
study conducted at MHIC in the mid-1990s, only 27 percent of HIV-positive
women who were tested as individuals disclosed their test results to a
partner within six months after being tested (Grinstead, personal
communication, 2000). In this study 64 percent of HIV-positive women who
enrolled as individuals shared test results with a partner within three
months of testing. The researchers hypothesize that this increase in
disclosure rates may be due to increased awareness and acceptability of HIV
in the community, increased communication between couples about HIV and HIV
testing, and greater emphasis on disclosure by counselors during pre- and
post-test counseling.

While the figure for disclosure among HIV-positive women is high, it is
significantly lower than the 83 percent of HIV-negative women in the study
sample who disclosed their test results to a partner. Overall the major
reason for non-disclosure (52 percent) among all women, regardless of HIV
serostatus, is fear of the partner's reaction, principally fear of abuse or
abandonment.

Partner violence is a serious problem among many female VCT clients. More
than a fourth of women interviewed agreed with the statement, "Violence is a
major problem in my life." Male and female informants described violence as
a way to "correct" or "educate" women, and said that violence that does not
leave a physical mark on a woman is justifiable. According to a 45-year-old
male:

I punished by beating with a cane and like three or four slaps. What I know
is small, small punishments like these are normal. It is a must that I
remain firm as father of the family. I am head of the household.

When asked about lifetime violence by an intimate partner, 38.5 percent of
women had had at least one partner who had been physically abusive and 16.7
percent had had at least one partner who had been sexually abusive [3].
Physical violence by a current partner was also commonly reported. Nearly a
third of women had experienced at least one physically violent episode
perpetrated by a current partner, such as slapping, twisting an arm,
grabbing, punching, and kicking, in the three-month period prior to testing.

A small proportion of women who disclosed their serostatus to partners
reported a negative reaction. Most women said that partners showed support
and understanding when told the test results. However, as shown in Figure 1,
the proportion of women who reported this positive reaction is significantly
greater among HIV-negative women compared to HIV-positive women. Regardless
of the women's serostatus, only a small percentage of women's male partners
said they would come for HIV testing.

Twelve women (5 percent) reported one or more negative responses by a
partner after disclosing their test results. This included being blamed for
the results or for getting tested (two HIV-negative women and 8 HIV-positive
women), physically assaulted (one HIV-negative woman and two HIV-positive
women), and/or told to leave the house or abandoned (two HIV-positive women
and one HIV-negative woman). Given the prevalence of violence among women in
this study, there is considerable and justifiable fear of a partner's
violent reaction, but little evidence that serostatus disclosure frequently
leads to physical abuse and abandonment.

Women's HIV status is strongly associated with partner violence. Without
adjusting for other variables, HIV-positive women were 2.68 times more
likely than HIV-negative women to have experienced a violent episode by a
current partner. Examining the interaction between women's age and HIV
status and controlling for other sociodemographic variables, young
HIV-positive women (18-29 years) were ten times more likely to report
partner violence than young HIV-negative women. Given the limitations of
cross-sectional surveys, this study cannot describe the causal pathways
between violence and HIV infection. However, the strong association between
prior history of violence and HIV infection does support the theory that
violence plays a role in women's risk for HIV infection in this population.

Program and Policy Recommendations

Encourage couple communication about HIV/AIDS and HIV testing when promoting
VCT. This may make it easier for couples to get tested together and for
individual women and men to share test results with sexual partners.

Train HIV counselors to ask questions about partner violence and to
encourage disclosure when appropriate. At the time of this study counselors
did not ask clients about experiences with partner violence. Counselors have
an important role to play in helping clients develop safe disclosure plans,
which include finding out about the role violence plays in their lives.
Therefore counselors need to be trained in how to ask sensitive questions
about violence and to use this information to foster but not force
disclosure among clients. Counselors must also be made aware of existing
services to help women living in violent relationships so that they can make
appropriate referrals when necessary.

Ensure that clients are the ones to make decisions about partner
notification of test results. Given the high prevalence of physical violence
reported among these female VCT clients, involuntary disclosure of women's
test results through a provider-referral system of notification may have
negative consequences for women. Women in violent relationships may face
serious outcomes from involuntary disclosure of their serostatus to
partners. A provider-referral system may also have a negative backlash on
the number of clients who seek VCT services. A better alternative is to have
counselors discuss disclosure plans with clients but to let the client
decide whether to share results with a partner.

Institute community-based efforts to address sexuality and violence. Women
are often at risk for both HIV infection and violence because of the
behavior of their sexual partners. Developing an ethic of respect among men
and women for the health and wellbeing of their intimate partners needs to
be the foundation of both violence prevention and HIV prevention efforts.
Implementing programs that focus on changing negative norms about male and
female sexuality and on conflict resolution is crucial.

Conduct further research on HIV and violence. The findings from this study
highlight the need to:

1.    Assess client-initiated approaches to facilitating serostatus
disclosure, such as the use of a third party (e.g., a counselor, friend,
religious person) chosen by the client to mediate disclosure to a partner.
2.    Identify the pathways through which partner violence increases women's
risk of HIV infection.
3.    Examine the relationship between VCT clients' serostatus, their rate
of serostatus disclosure to partners, and the incidence of negative outcomes
of serostatus disclosure among women and men at other sites.
4.    Evaluate community-based HIV-prevention interventions that address
partner violence to change harmful attitudes and norms about sexuality and
violence.

January, 2001

References

Gielen, A.C., P. O'Campo, R. Faden, and A. Eke. 1997. "Women's disclosure of
HIV status: Experiences of mistreatment and violence in an urban setting,"
Women Health 25(3): 19-31.
Grinstead, O. Personal communication, June 6, 2000.
Rothenberg, K., S. Paskey, M. Reuland, S. Zimmerman, and R. North. 1995.
"Domestic violence and partner notification: Implications for treatment and
counseling of women with HIV," Journal of American Medical Women's
Association, Vol. 50: 87-93.
Temmerman, M., J. Ndinya-Achola, J. Ambani, and P. Piot. 1995. "The right
not to know HIV test results," The Lancet, Vol. 345: 969-970.

Study investigators are Jessie Mbwambo, Margaret Hogan, and Gad Kilonzo of
Muhimbili University College of Health Sciences, Suzanne Maman and Michael
Sweat of Johns Hopkins University School of Public Health, and Ellen Weiss
of Horizons/International Center for Research on Women.

For more information about the study, contact Dr. Maman (smaman@jhsph.edu)
or Dr. Mbwambo (jmbwambo@muchs.ac.tz) or Ms. Weiss (eweiss@pcdc.org). For a
copy of the full report, contact Horizons Publications (horizons@pcdc.org).

1 There were no significant differences between those followed and those
lost to follow-up with regard to HIV status, age, marital status, education,
and violence with a current partner in the last year.

2 Based on MHIC service data, female clients are more likely to be HIV
infected (33 percent) than male clients (15 percent); therefore it is not
surprising that women in the study expressed a more profound sense of
vulnerability to HIV infection than did men.

3 Women were asked about number of partners who have hit, slapped, kicked,
pushed, shoved, or otherwise physically hurt them, and physically forced
them into sexual activity against their will.

Horizons Global Operations Research on HIV/AIDS/STI Prevention and Care is
implemented by the Population Council in collaboration with the
International Center for Research on Women (ICRW), International HIV/AIDS
Alliance, Program for Appropriate Technology in Health (PATH), Tulane
University, and the University of Alabama at Birmingham.

Sherry Hutchinson
shutchinson@pcdc.org
Taken from: http://www.popcouncil.org/horizons/ressum/vct_violence.html