June 2001, Vol. 7, No. 2

Women's Health
Study Investigates Links Between HIV and Partner Violence

Encouraging clients to inform partners of their test results is an important component of HIV voluntary counseling and testing programs. Yet many clients do not disclose test results to their partners. Studies have found that many women fear their partners will react violently and that indeed HIV-infected women are at increased risk for partner violence. Researchers with the Population Council’s Horizons program and Muhimbili University College of Health Sciences explored the links between HIV infection, the disclosure of test results, and partner violence among women attending the Muhimbili Health Information Center, a voluntary counseling and testing clinic in Dar es Salaam, Tanzania.

Around the world, the Horizons program conducts operations research to prevent the spread of HIV and other sexually transmitted infections. Horizons researchers also study ways to improve the health and well-being of people living with or affected by HIV/AIDS. The Population Council directs Horizons, under a cooperative agreement with the United States Agency for International Development, in partnership with five other organizations: the International Center for Research on Women, the International HIV/AIDS Alliance, the Program for Appropriate Technology in Health, Tulane University, and the University of Alabama at Birmingham.

The researchers studying HIV and partner violence first collected qualitative data from 62 people—women, men, and couples—who were clients at the Muhimbili Health Information Center. In the second phase, researchers enrolled 340 women after pretest counseling and prior to collection of test results; 245 of these women were followed and interviewed three months after enrollment and testing. 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.

The study, conducted in 1999, found that many women lack the autonomy to make decisions about HIV testing. Men and women participating in the first part of the study frequently referred to the need for women, in contrast to men, to “seek permission” from their partners prior to testing.

And, while HIV-positive women are more likely now than in the past to tell their partners of their test results, they are still significantly less likely to do so than are HIV-negative women. During a study of voluntary counseling and testing conducted at the Muhimbili Health Information Center in the mid-1990s, only 27 percent of HIV-positive women disclosed their test results to a partner within six months of being tested. In the 1999 study, 64 percent of HIV-positive women shared test results with a partner within three months of testing, compared with nearly 80 percent of HIV-negative women. Overall, the major reason for nondisclosure—cited by 52 percent of women, regardless of serostatus, who did not reveal their test results—is fear of their partner’s reaction, principally fear of abuse or abandonment.

The problem of partner violence
Partner violence is a serious problem among many of the clinic’s female clients. More than one-fourth of women interviewed agreed with the statement, “Violence is a major problem in my life.” Study participants, both male and female, 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.

“I punished with a cane and three or four slaps. Small punishments like these are normal,” explained a 45-year-old male informant.

When asked about lifetime violence by an intimate partner, 39 percent of women had had at least one physically abusive partner and 17 percent had had at least one sexually abusive partner. (Women were asked about number of partners who have hit, slapped, kicked, pushed, shoved, or otherwise physically hurt them, and who forced them into sexual activity against their will.) 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 in the three-month period prior to testing.

A small proportion of women who informed their partners of their test results reported a negative reaction. Most women said that partners showed support and understanding when told of the test results. However, the proportion of women who reported this positive reaction was significantly greater among HIV-negative women than among HIV-positive women (82 percent vs. 49 percent).

Twelve women reported one or more negative responses by a partner after disclosing their test results. These included being physically assaulted (one HIV-negative woman and two HIV-positive women) and being told to leave the house or being abandoned (one HIV-negative woman and three HIV-positive women). Given the amount of violence experienced by women in this study, there is considerable and justifiable fear of a partner’s violent reaction. The study revealed little evidence, however, that the act of disclosing HIV test results frequently leads to physical abuse and abandonment.

Being an HIV-positive woman is strongly associated with experiencing partner violence. Without adjusting for other variables, HIV-positive women were 2.7 times more likely than HIV-negative women to have experienced a violent episode by a current partner. Young HIV-positive women (18–29 years) were ten times more likely than young HIV-negative women to report partner violence, controlling for sociodemographic variables. As compelling as this evidence is, the study was constrained by the limitations of cross-sectional surveys and cannot thoroughly illuminate the link between partner violence and HIV infection.

“We need to do more research among younger HIV-positive women to learn about their relationships and the violence that occurs in those relationships,” says Jessie Mbwambo of Muhimbili University College of Health Sciences, a principal investigator for the study.

Program and policy recommendations
The researchers offered several recommendations based on their findings. Communication between couples about HIV/AIDS and HIV testing should be encouraged when promoting voluntary counseling and testing. Moreover, “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,” says Suzanne Maman of Johns Hopkins University, another principal investigator for the study. 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.

Policymakers should encourage community-based efforts to address issues related to violence within sexual relationships. 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 well-being of their intimate partners needs to be the foundation of efforts to prevent both violence and HIV transmission. Implementing programs that focus on conflict resolution is crucial.

Finally, investigators should conduct further research on HIV and violence; the findings from this study highlight many gaps in knowledge on this topic. Researchers should assess the feasibility of engaging people chosen by women—such as counselors, friends, or religious leaders—to help women disclose their test results. Social scientists need to identify the links between partner violence and HIV infection. And investigators should evaluate community-based interventions that attempt to change harmful attitudes about sexuality and violence.

Sources
Maman, Suzanne, Jessie Mbwambo, Margaret Hogan, Gad Kilonzo, Michael Sweat, and Ellen Weiss. 2001. “HIV and partner violence: Implications for HIV voluntary counseling and testing programs in Dar es Salaam, Tanzania,” Horizons Project Report. Washington, DC: Population Council. (PDF)

Outside funding
United States Agency for International Development

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