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Table 2 Summary of published literature on GBV as a barrier to women’s uptake of HIV prevention and treatment services and behaviors

From: Gender-based violence and engagement in biomedical HIV prevention, care and treatment: a scoping review

Author Country Population Sample size
(women)
Design Findings
HIV TESTING
Quantitative
Turan et al. (2011) [27] Kenya Pregnant women (≥18 years) attending ANC clinics 1525 Cross-sectional Anticipated stigma from one’s partner upon testing positive for HIV was significantly associated with increased odds of refusing to test for HIV. The measure of anticipated stigma from one’s partner was based on the combined score from two items; anticipating break-up of marriage or relationship and physical violence from a partner.
Nelson et al. (2016) [28] Zambia Women (15–49 years) 5014 Cross-sectional In the unadjusted analysis, IPV was significantly associated with increased odds of consenting to HIV testing. A stratified analysis showed that there was a significant association between IPV and consent to test for HIV in rural areas but not in urban areas. However, in the multivariable analysis, there was no significant relationship between IPV and consent to test for HIV.
Satyanarayana (2009) [29] India Women (18–50 years) 100 Cross-sectional This study found no significant differences between women who consented to test for HIV and those who did not in terms of their exposure to violence.
Pearlman (2005) [30] U.S. Pregnant and post-partum women (≤ 3 months after delivery) enrolled in in a federally funded nutrition program for women, infants and children (WIC) 433 Cross-sectional Experiencing IPV in the past 12 months was associated with reduced probability of receiving a prenatal HIV test.
Tucker (2003) [31] U.S. Women (18–55 years) sheltered and low-income housed 898 Cross-sectional Women who had ever experienced sexual violence since they were 18 were significantly more likely to have ever tested for HIV.
Nikolova et al. (2015) [32] Kenya Heterosexual couples (men and women N = 2862) 1431 Cross-sectional Experiences of sexual violence were not significantly associated with ever having tested for HIV among women.
Mohammed et al. (2017) [33] Ethiopia Heterosexual couples (men and women N = 420) 210 Cross-sectional Women who reported ever experiencing physical violence from their partner were significantly less likely to have tested for HIV.
Etudo et al. (2016) [34] U.S. HIV-negative adult women (≥18 years) 79 Cross-sectional Women who experienced emotional, physical, and/or sexual violence were less likely to test for HIV in the past year, report a longer time since their last HIV test, and reported more barriers to HIV testing, compared to women who had not experienced violence.
Rountree et al. (2016) [35] U.S. Adult women (≥18 years) 18,917 Cross-sectional Women who experienced IPV in their lifetime reported higher rates of HIV testing compared to women who had never experienced IPV.
Nasrullah et al. (2013) [36] U.S. Non-pregnant adult women (≥18 years) 29,209 Cross-sectional Women who experienced threatened violence, attempted violence, or unwanted/forced sex were significantly more likely to have ever been tested for HIV compared to women with no IPV history. However, nearly half of the women who experienced IPV had never tested for HIV.
Brown et al. (2013) [37] U.S. Adult women (≥18 years) 30,182 Cross-sectional Survivors of IPV were twice as likely to have had a HIV test, compared to women who had not experienced IPV.
Decker et al. (2005) [38] U.S. Female students in 9th and 12th grade 1641 Cross-sectional Girls who experienced both physical and sexual dating violence were three times more likely to have been tested for HIV or an STI, compared to girls who had never experienced violence.
Loeliger et al. (2016) [39] Malaysia Adult women who use drugs (≥18 years) 103 Cross-sectional Experiences of adulthood IPV was associated with not testing for HIV.
McCall-Hosenfeld (2013) [40] U.S. Women (18–45 years) 1420 Longitudinal IPV in the past 12 months was significantly associated with increased odds of receiving a test for sexually transmitted infections including HIV in the past two years.
Conroy (2015) [41] Malawi Heterosexual couples (men and women N = 932) 466 Longitudinal Physical and sexual violence was not significantly associated with HIV testing among women.
Kiarie et al. (2006) [42] Kenya Pregnant adult women (≥18 years) who had not yet tested 1638 Longitudinal Previous domestic violence was not associated with a reduced uptake of HIV-1 counseling and testing, or PMTCT.
Qualitative
Naju et al. (2012) [43] Tanzania Adult married men and women (≥18 years), PLHIV, healthcare providers, HTC counselors and community leaders (N = 91) 48 Qualitative IDIs and Focus group discussions (FGDs) Women described barriers to couples testing include fears of being beaten if a partner tests positive.
Mixed methods
Washio (2017) [44] U.S. Young women (18–29 years) enrolled in WIC 80 Quantitative (cross-sectional) and Qualitative FGDs In the quantitative analysis, any lifetime experience of IPV was not significantly associated with testing for HIV in the past 6 months. Focus group participants said that fear of a negative reaction from an abusive partner when asking them to get tested or talking about their HIV status was a barrier to accessing HIV testing. They also discussed how mental or emotional abuse may make it difficult for women to go to get tested for HIV.
LINKAGE TO & ENGAGEMENT IN CARE AND TREATMENT
Quantitative
Blank et al. (2015) [45] U.S. Women of color living with HIV 587 Cross-sectional Experiences of IPV were not significantly associated with retention in HIV care or viral suppression.
Blackstock (2015) [46] U.S. Women of color living with HIV 748 Cross-sectional Experiences of IPV were not significantly associated with engagement in HIV care.
Dale et al. (2014) [47] U.S. WLHIV 138 Cross-sectional There was no significant main effect of current abuse, history of abuse, or multiple abuses on ART adherence, CD4+ cell count, or HIV viral load. However, among WLHIV who reported experiences of sexual abuse or multiple abuses, resilience was associated with increased odds of ART adherence.
Hatcher et al. (2012) [48] Kenya WLHIV (≥18 years) 483 Cross-sectional Women who anticipated a violent response from their partner were less likely to link to care.
Hampanda et al. (2016) [49] Zambia Pregnant and post-partum WLHIV (≥18 years) 320 Cross-sectional IPV was associated with decreased odds of PMTCT adherence during and after pregnancy.
Sullivan et al. (2015) [50] U.S. Women of color living with HIV 563 Cross-sectional Explored the effect of substance abuse, violence and HIV/AIDS (SAVA syndemic) on viral load. SAVA scores included measures of substance abuse, binge drinking, IPV, poor mental health and sexual risk taking. The study demonstrated that higher SAVA scores were significantly associated with reduced odds of viral suppression.
Trimble et al. (2013) [51] U.S. WLHIV receiving care at a HIV clinic 272 Cross-sectional IPV was associated with reduced ART adherence. IPV was also associated with more detectable viral loads.
Siemieniuk et al. (2013) [52] Canada WLHIV (≥18 years) receiving care at a HIV clinic 339 Cross-sectional IPV was associated with decreased use of ART, and increased interruptions in HIV care longer than one year.
Schafer et al. (2012) [53] U.S. PLHIV (women and men) (≥18 years) receiving care at a HIV clinic (Total N = 251) 64 Cross-sectional Found no significant relationship between experiences of IPV and no show rates to HIV clinic appointments among women.
Illangasekare et al. (2012) [54] U.S. WLHIV (≥18 years) 196 Cross-sectional Experiences of IPV were not significantly associated with current ART use, CD4 cell count or HIV-1 RNA levels.
Rose et al. (2010) [55] U.S. African American WLHIV (≥18 years) receiving care at a HIV clinic 40 Cross-sectional Women who experienced IPV had lower CD4 counts and increased HIV viral load. Medication adherence mediated the relationship between IPV and low CD4 count and high viral load.
Lopez et al. (2010) [56] U.S. Adult HIV seroconcordant and serodiscordant couples 190 Cross-sectional ART adherence was negatively associated with experiences of violence among women.
Espino et al. (2015) [57] U.S. African American WLHIV (≥18 years) 102 Cross-sectional Women with a history of violence were less likely to be virally suppressed.
Kidman et al. (2018) [58] South Africa Perinatally infected female youth living with HIV (13–24 years) 129 Cross-sectional Experiences of violence in the past year was associated with poor ART adherence. However, neither lifetime or past year IPV was associated with viral load.
Kacanek et al. (2016) [59] U.S. Perinatally infected male and female youth living with HIV (8–15 years) (Total N = 268) 142 Cross-sectional Among girls, indirect violence exposure (i.e. witnessing violence) was not significantly associated with unsuppressed viral load.
Cohen et al. (2004) [60] U.S. WLHIV (≥18 years) 1219 Longitudinal Women who experienced any physical or sexual abuse were significantly more likely to be non-ART users after three month follow up.
Mendoza et al. (2017) [61] Dominican Republic Female sex workers living with HIV 268 Cross-sectional Violence from an intimate partner in the past six months was associated with not currently being on ART and missing an ART dose in the last four days. Violence from a client in the past six months was associated with never having received HIV care and ever-interrupting ART.
Lyons et al. (2017) [62] Cote D’Ivoire Adult female sex workers living with HIV (≥18 years) 466 Cross-sectional Physical and sexual violence were not significantly associated with HIV testing, or ART adherence.
Machtinger et al. (2012) [63] U.S. Adult women and transgender women living with HIV (≥18 years) 113 Cross-sectional Participants who reported recent trauma had over four-times the odds of ART failure, compared to those without recent trauma.
Kalokhe et al. (2012) [64] U.S. Inpatient adult male and female crack cocaine users living with HIV (N = 343) 173 Cross-sectional IPV was associated with significantly lower current ART use among females.
Wechsberg et al. (2017) [65] South Africa Adult substance using black African women 641 Cross-sectional Women who reported experiencing physical violence in the past year were significantly more likely to be newly diagnosed with HIV. Experiences of physical or sexual assault in the past year were not significantly associated with ART use.
Qualitative
Mepham et al. (2011) [66] South Africa Pregnant WLHIV (≥18 years) 43 Qualitative IDIs Women revealed that threats of violence and actual experiences of IPV were a barrier to PMTCT adherence.
Hatcher et al. (2014) [14] South Africa Pregnant WLHIV (≥18 years), pregnant abused women, healthcare providers, district health managers (Total N = 38) 18 Qualitative IDIs and FGDs Experiences with IPV limited women’s ability to adhere to PMTCT because taking the medication or accessing HIV services might unintentionally alert male partners to women’s HIV status.
Zunner (2015) [67] Kenya WLHIV, Health care providers, Community health workers and community advisory board (Total N = 61) 25 Qualitative IDIs and FGDs Emotional distress from experiences of violence was described as a cause of HIV treatment default through various avenues including loss of appetite and weight loss, which interferes with ART adherence, as well as feelings of hopelessness, which participants said caused women to intentionally stop ART. Women also stated that the emotional distress from violence caused their health to deteriorate, including decreasing CD4 counts, even if they were fully adherent to ARTs.
Hatcher et al. (2016) [68] South Africa Pregnant and postpartum WLHIV (≥18 years) 32 Qualitative IDIs Experiences with IPV led some women to feel depressed, which caused them to unintentionally or intentionally miss PMTCT doses. Women who intentionally missed medication used it as a form of “passive suicidality” to escape IPV.
Conroy et al. (2017) [69] South Africa Heterosexual couples with at least one partner living with HIV (Total N = 24) 12 Qualitative IDIs Findings illuminate how relationship conflict, including violence, can result in forgetfulness to take ART pills among women.
Lichtenstein et al. (2006) [70] U.S. WLHIV (≥18 years) attending a public health clinic 64 Qualitative IDIs and FGDs Women who experience violence were unwilling to keep their appointments if they were afraid of their partners, feeling depressed, feeling “too worn down,” or if they were embarrassed by their abuse. Some women reported that their partners prevented them from seeking care, keep appointments, or take their ARTs.
Watt et al. (2017) [71] South Africa WLHIV with a history of sexual assault 15 Qualitative IDIs Women reported how the sexual assault they experienced led to a delay in initially linking to HIV care. Women described how they were emotionally unable to accept their HIV diagnosis after experiencing sexual assault, causing them to delay linking to HIV care. Women also reported how experiences of sexual assault limited their engagement in HIV care and treatment. Specifically, participants described how taking antiretroviral therapy sometimes brought up memories of their sexual trauma history, especially if they acquired HIV through sexual assault.
Kosia et al. (2016) [72] Tanzania WLHIV with a history of GBV 35 Qualitative IDIs Participants described how their male partners verbally abused them, prevented them from attending their HIV care appointments, and threw away their antiretroviral medication. Women reported that such actions prevented them from staying engaged in HIV care and adhering to their antiretroviral therapy.
Maeri et al. (2016) [73] Kenya & Uganda Community members, care providers and community leaders from 8 communities (Total N = 194) 112 Qualitative IDIs WLHIV anticipated violent reactions from their partners upon disclosure of their sero-status. As a result, these women avoided disclosing their status to their partners. Non-disclosure was reported as a major barrier in the uptake of HIV care and treatment. For example, some women forgot to take their antiretroviral medication because they hid it outside the home so their husbands would not suspect them of being HIV-positive. Some women reported experiencing physical abuse from their partners upon disclosing their HIV-positive status. Violent reactions typically occurred in the context of sero-discordance.
Mixed Methods
Orza et al. (2017) [74] Bolivia, Cameroon, Nepal, Tunisa WLHIV 197 Quantitative (cross-sectional) and qualitative open-ended survey responses Fear and experiences of violence prevented women from disclosing their HIV status, which participants said led to anxiety, missing HIV care services, and lower adherence. Women also described facing discrimination and violation of their rights to health from health care providers both in the context of HIV care and treatment and labor and delivery.
Wilson et al. (2016) [75] Kenya Female sex workers (FSW) living with HIV (≥18 years) 195 Quantitative (longitudinal) and qualitative IDIs and FGDs Longitudinal quantitative data analysis revealed that IPV was associated with significantly lower risk of detectable viral load. In the qualitative findings, women did not suggest that experiences with IPV limited their ability to engage in HIV care, initiate and adhere to ART. Women employed different strategies to ensure experiences with violence did not interfere with their engagement in care. Such strategies included not disclosing their HIV status to their partner, and seeking support from their friends or HIV support groups after an episode of IPV to ensure they continued taking their medication.
PRE-EXPOSURE PROPHYLAXIS (PrEP)
Mixed methods
Roberts et al. (2016) [76] Uganda HIV-negative adult women (≥18 years) in sero-discordant relationships 1785 Quantitative (longitudinal) and Qualitative In-depth interviews (IDIs) In the longitudinal quantitative analysis, women who reported experiencing IPV in the past three months had increased risk of low adherence to PrEP, measured by pill count and plasma tenofovir. Verbal, economic and physical IPV were associated with low adherence to PrEP. In the qualitative interviews, women reported that IPV caused them to forget their pills, that their partners threw away their pills, and that they would leave their pills behind if they fled the house during a violent episode.