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THE INTERSECTION OF VIOLENCE AGAINST WOMEN AND HIV/AIDS

Jacquelyn C. Campbell, PhD, RN, FAAN1

Marguerite L. Baty, PhD student, MSN, MPH, RN1

Reem Ghandour, DrPH student, MPA2

Jamila Stockman, PhD Candidate, MPH2

Leilani Francisco, PhD Candidate, MA2

Jennifer Wagman, MHS2

Introduction

Nearly half of the 40 million people living with HIV/AIDS in the world today are women, and women all around the world make up the fastest growing group of persons newly infected with HIV. In sub-Saharan Africa, women represent the majority of those infected and the majority of those dying. A critical aspect of this trend is the intersection of HIV/AIDS and violence against women (VAW), which has been recognized and documented with persuasive and rigorous research (e.g., Dunkle et al. 2004; Gielen et al. 1997; Greenwood et al. 2002; Maman et al. 2000, 2002; Relf 2001; Wingood 2001; Wingood and DiClemente 1997; Wyatt et al. 2002). While VAW can take on many forms including sexual violence that occurs during times of conflict, the scope of this paper primarily is a focus on intimate partner violence and the associated research regarding the overlap with HIV risk. Although men are also victims of violence, women in low- and middle-income countries are most frequently the victims of intimate partner violence (IPV), and therefore, they are most affected by this intersection.

This association between IPV and risk for HIV infection has been the focus of a growing body of evidence that has begun to shed light on the complexities of this intersection. Existing research has demonstrated several important interfaces, which are discussed further in this paper. They include the following: (1) epidemiological studies showing significant overlap in

1

Johns Hopkins University School of Nursing.

2

Johns Hopkins University Bloomberg School of Public Health.



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 APPENDIX C THE INTERSECTION OF VIOLENCE AGAINST WOMEN AND HIV/AIDS Jacquelyn C. Campbell, PhD, RN, FAAN1 Marguerite L. Baty, PhD student, MSN, MPH, RN1 Reem Ghandour, DrPH student, MPA2 Jamila Stockman, PhD Candidate, MPH2 Leilani Francisco, PhD Candidate, MA2 Jennifer Wagman, MHS2 Introduction Nearly half of the 40 million people living with HIV/AIDS in the world today are women, and women all around the world make up the fastest growing group of persons newly infected with HIV. In sub-Saharan Africa, women represent the majority of those infected and the majority of those dying. A critical aspect of this trend is the intersection of HIV/AIDS and violence against women (VAW), which has been recognized and documented with persuasive and rigorous research (e.g., Dunkle et al. 2004; Gielen et al. 1997; Greenwood et al. 2002; Maman et al. 2000, 2002; Relf 2001; Wingood 2001; Wingood and DiClemente 1997; Wyatt et al. 2002). While VAW can take on many forms including sexual violence that occurs during times of conflict, the scope of this paper primarily is a focus on intimate partner violence and the associated research regarding the overlap with HIV risk. Although men are also victims of violence, women in low- and middle-income countries are most frequently the victims of intimate partner violence (IPV), and therefore, they are most affected by this intersection. This association between IPV and risk for HIV infection has been the focus of a growing body of evidence that has begun to shed light on the complexities of this intersection. Existing research has demonstrated several important interfaces, which are discussed further in this paper. They include the following: (1) epidemiological studies showing significant overlap in 1Johns Hopkins University School of Nursing. 2Johns Hopkins University Bloomberg School of Public Health.

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0 APPENDIX C prevalence; (2) studies showing IPV as a risk factor for HIV infection among women and men; (3) studies showing both past and current violent victim- ization increasing HIV risk behaviors; (4) studies showing violence or fear of violence from an intimate as an impediment or as a consequence of HIV testing; (5) studies showing partner violence as a risk factor for sexually transmitted infections (STIs), which increases the rate of HIV infection; (6) studies showing the difficulties of negotiating safe sex behavior for abused partners; (7) data suggesting that various adverse health effects related to IPV compromise women’s immune systems in a way that increases their risk of HIV; and (8) data indicating that abusive men are more likely to have other sexual partners unknown to their wives. As critical as it is to address this global epidemic, the issues of IPV and gender inequality remain inadequately addressed by most policy, research, and prevention and intervention initiatives in the United States and glob- ally. The World Health Organization began the call for action in several publications highlighting aspects of the intersection of IPV and HIV (WHO 2000, 2004). More recently, the Institute of Medicine sought to extend this effort through a 2007 Workshop on Violence Prevention in Low- and Middle-Income Countries. As background for this most recent effort, this paper will provide a review of the existent literature, both in the United States and internationally; highlight the areas of new research; and propose directions for initiatives by which the complex interface of HIV and IPV can be addressed. Review Process Search Strategy Pubmed, PsychINFO, and Scopus databases were searched using the following key words: domestic violence, intimate partner violence, relation- ship abuse, physical abuse, sexual abuse, HIV/AIDS, condom use, sexual negotiation, sexual risk reduction, intervention, and prevention. Searches were restricted to those conducted with women during the past decade (1998-2007) and submitted to or published in peer-reviewed journals in English. Inclusion Criteria Studies were eligible for inclusion in the review if they met at least one of following criteria: (1) addressed HIV/AIDS as a risk factor for violence against women; (2) addressed violence against women as a risk factor for HIV/AIDS. All studies also had to present original data (i.e., review articles

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 APPENDIX C and opinion pieces were excluded). Additionally, studies had to focus on heterosexual relationships among populations aged 12 and older. Selection of Articles Articles were excluded if they did not meet the study inclusion criteria, only addressed child abuse, included multiple forms of violence such that results for IPV could not be discerned, or the analyses were not gender specific. Relevant studies were also identified by the authors based on their previous research and knowledge of the topic, and a scan of citations in the selected articles. A total of 82 articles were ultimately selected for full article review. All authors then participated in the review, summarizing and synthesizing the selected articles. Epidemiology of the Problem VAW is defined as IPV (physical and/or sexual assault or threats thereof between married, romantically involved partners or former partners) and sex- ual assault. For the purposes of this paper, we will focus primarily on aspects of IPV (including sexual assault by an intimate) unless otherwise noted. In the United States, approximately 1.3 million women are physically assaulted by an intimate partner compared to 835,000 men (CDC 2006). According to the 2005 United States National Violence Against Women Survey, 64 percent of the women who reported being raped, physically assaulted, or stalked since age 18 were victimized by a current or former husband, cohabitating partner, boyfriend, or date. In addition, one in six women have experienced an attempted or completed rape, defined as a forced or threatened vaginal, oral, and anal penetration, in their lifetime, and many are raped at an early age (CDC 2006). Of the 18 percent of all women surveyed who said they had been the victim of a completed or attempted rape at some time in their life, 22 percent were younger than age 12 when they were first raped, and 32 percent were ages 12 to 17 years (CDC 2006). For a global perspective of VAW, the World Health Organi- sation conducted a multicountry study on women’s health and domestic violence. In the majority of settings, over 75 percent of women physically or sexually abused since the age of 15 years reported abuse by a partner (Garcia-Moreno et al. 2005). Lifetime prevalence estimates of physical vio- lence by partners ranged from 13 percent in Japan city to 61 percent in Peru province, with African countries such as Namibia and Tanzania report- ing estimates of 31 and 47 percent, respectively. The range of reported lifetime prevalence of sexual violence by partners was between 6 percent (city sites in Japan, Serbia, and Montenegro) and 59 percent (Ethiopia province). Namibia and Tanzania had lifetime sexual violence estimates of

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2 APPENDIX C 17 and 31 percent, respectively. Japan city consistently reported the low- est prevalence of all forms of violence, whereas the provinces of Bangla- desh, Ethiopia, Peru, Tanzania, and Namibia reported the highest estimates (Garcia-Moreno et al. 2005). Lifetime prevalence estimates of forced sex by an intimate partner varied from 4 percent in Serbia and Montenegro to 46 percent in Bangladesh and Ethiopia provinces (Garcia-Moreno et al. 2005). The high rates of forced sex is particularly alarming in light of the HIV/AIDS epidemic and the difficulty that women often face with protect- ing themselves from HIV infection. Concurrently, the number of women with HIV infection and AIDS has increased steadily worldwide. By the end of 2005, according to the World Health Organisation, 17.5 million women worldwide were infected with HIV. Similarly, the Centers for Disease Control and Prevention estimated that between 2000 through 2004, the number of AIDS cases in the United States increased 10 percent among females and 7 percent among males. In the United States, women account for more than 25 percent of all new HIV/AIDS diagnoses (CDC 2004). HIV disproportionately affects African American and Hispanic women. Together they represent less than 25 per- cent of all U.S. women, yet they account for more than 79 percent of AIDS cases in women (NIH NIAID 2006). Sub-Saharan Africa remains the worst affected region in the world by the HIV epidemic on women. Women, ages 15 to 49 years, account for the majority (59 percent) of those estimated to be living with HIV/AIDS in the region (UNAIDS 2006). The impact on women is even more pronounced in some countries within the region. In Kenya, for example, 56 percent of all people living with HIV/AIDS are women; in Tanzania, it is 49 percent (WHO 2006). Young women, ages 15 to 24 years, are especially vulnerable because they comprise 76 percent of all young people estimated to be living with HIV/AIDS in sub-Saharan Africa. In some countries within the region, infection rates are up to 6 times higher among young women compared to men (CDC 2004). The impact on young women is exacerbated by the fact that the population of sub-Saharan Africa is quite young relative to other regions in the world, with 44 percent of the population below the age of 15 (compared to 29 percent globally) (UNAIDS 2006). Overlapping Prevalence of HIV and IPV Studies conducted in the United States, Europe, Asia, and sub-Saharan Africa found prevalence of lifetime experience of IPV to be as high as 67 percent among women who were HIV seropositive or at risk of HIV (Cohen et al. 2000; Chandrasekaran et al. 2007) and current exposure to be as high as 64 percent (Gielen et al. 2000). However, estimates of the prevalence of

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 APPENDIX C IPV among HIV-positive women vary by the definition of IPV and study population in question. Of the emerging research that addresses the intersection of IPV and HIV, 18 studies specifically focused on the overlapping prevalence in the United States (Bogart et al. 2005; Burke et al. 2005; Cohen et al. 2000; El- Bassel et al. 2005, 2007; Gielen et al. 2000; Henny et al. 2007; McDonnell et al. 2003, 2005; Molitor et al. 2000; Newcomb and Carmona 2004; Whetten et al. 2006) Tanzania, South Africa, Kenya (Brown et al. 2006; Dunkle et al. 2004; Fonck et al. 2005; Jewkes et al. 2006a; Maman et al. 2002), and Ukraine in Europe (Dude 2007). Studies Comparing HIV-Positive and HIV-Negative Women Results from studies examining the overlapping prevalence of HIV and violence using HIV-negative women as a comparison group were not consistent among studies conducted within the United States. McDonnell and colleagues (2003, 2005) found rates of emotional abuse by an intimate approximately equal among HIV-seropositive women and their seronega- tive counterparts (55 and 53 percent, respectively), while physical abuse by a partner was experienced less frequently among seropositive women than seronegative (56 vs. 64 percent, respectively). Cohen et al. (2000) found a similar, statistically significant difference between HIV-positive and HIV-negative women experiencing physical or sexual intimate partner violence in the past year (21 vs. 28 percent, respectively). On the other hand, El-Bassel et al. (2007) and Burke et al. (2005) did not find significant differences between HIV-positive and HIV-negative groups with regard to physical and sexual intimate partner violence. More consistent results in the opposite direction have been found in international studies. Four of five sub-Saharan African studies (Dunkle et al. 2004; Fonck et al. 2005; Jewkes et al. 2006a; Maman et al. 2002) have showed that HIV-positive women report more lifetime partner violence compared to HIV-negative women, with the greatest difference reported in Tanzania (52 vs. 29 percent, respectively). Differences in definitions and measurement may help explain the discrepancies in results with past year and multiple types of abuse more often measured in the U.S. studies, while in Africa, lifetime IPV was more often measured using fewer ques- tions about a narrow range of types of violence. Overall, less research has been conducted (to date) on the links between violence and HIV in Africa, although the greater prevalence of HIV among African women results in greater effect sizes when differences are found.

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 APPENDIX C Studies Among HIV-Positive Women Of the U.S. studies that focused on violence among HIV-positive women only, the prevalence of IPV in the past 6 months ranged from 18.1 to 19.8 percent (Bogart et al. 2005; Henny et al. 2007), while lifetime exposure to IPV (physical) ranged from 62 to 68 percent and adult sexual abuse ranged from 32 to 46 percent (Geilen et al. 2000; Henny et al. 2007). Addition- ally, prevalence of child sexual abuse among HIV-positive women was 31 percent (Whetten et al. 2006), and Gielen et al. (2000) found a prevalence of 13 percent for combined intimate partner and other perpetrator physical and sexual abuse after receiving an HIV diagnosis. Studies with Abused Women Only three studies assessed the prevalence of HIV among abused and nonabused women (Dude 2007; Molitor et al. 2000; Wingood et al. 2000a,b). Molitor et al. (2000) found that women with a history of forced sex were less likely to have been tested than nonabused women but if tested were more likely to self-report HIV infection. Other studies have studied prevalence of other STIs or STIs in general among abused versus nonabused women. Wingood and colleagues found that women who had experienced both physical and sexual violence, compared to women who reported sexual abuse alone, were more likely to have had a recent STI and to have been threatened when negotiating condom use (Wingood et al. 2000a). Similarly, Dude (2007) reported that Ukrainian women who have been physically abused by a sexual partner, whether recently or less recently, were significantly more likely to report having had an STI. Abused women have been found to be more likely to self-report STIs than nonabused women in a number of U.S. controlled investigations (e.g., Champion et al. 2004; Coker et al. 2002; Laughon et al. 2007; Martin et al. 1999). Studies with Adolescents In the United States, adolescent girls account for a growing number of new cases of HIV and AIDS. In 2003, adolescent girls (13-19 years) accounted for 50 percent of HIV cases (CDC 2004) and AIDS diagno- ses among women and adolescent girls rose from 8 percent in 1995 to 27 percent in 2004 (CDC 2005). Evidence suggests that the majority of adolescents in this age group are dating (Wolfe and Feiring, 2000) and unfortunately, a significant number of these young relationships include partner-perpetrated violence (Foshee et al. 1996; Fredland et al. 2005; Wekerle and Wolfe 1999). Research investigations into prevalence estimates of partner violence have noted that between 6 and 46 percent of adolescents

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 APPENDIX C have experienced some form of IPV (Ackard et al. 2003; CDC 2006; Coker et al. 2000; Foshee et al. 1996; Glass et al. 2003; Spencer and Bryant 2000; Valois et al. 1999; Watson et al. 2001). In a recent review, Teitelman and colleagues explored the relationship between the experience of IPV victim- ization among heterosexually active adolescent girls, condom use, and the implications for HIV prevention (Teitelman et al. in press). Using gender and power theories to evaluate existing research, the authors conclude that physical and verbal IPV by male intimate partners is associated with con- dom nonuse and therefore an increased risk of HIV infection among their adolescent partners. The review highlights the need for additional research to better understand the direction of causality and the context of both abuse among teen partners and HIV risk behavior. IPV and HIV: Mutual Risk Factors Prevalence studies have called attention to the overlap in HIV and IPV in women’s lives and have demonstrated that women in abusive rela- tionships are at a compounded risk for HIV infection. Further research has examined several mechanisms that may explain how exposure to IPV increases a woman’s risk of STIs. Due to the multifaceted, complex nature of the two issues, exact causal relationships have been difficult to ascertain. Maman and colleagues hypothesized that exposure to IPV can increase women’s risk for HIV infection in three ways: (1) through forced sex with an infected partner, (2) through limited or compromised negotiation of safer sex practices, and (3) through increased sexual risk-taking behav- iors (Maman et al. 2000). These mechanisms may operate in tandem or individually and have particular significance for adolescent girls in sexual relationships with older men (Garcia-Moreno et al. 2005). Biology and Forced Sex Current evidence suggests that women are biologically more vulnerable than men to contracting STIs, including HIV. Research has shown that abuse in a relationship places a woman at a fourfold higher risk for con- tracting STIs, including HIV, than her nonabused counterpart (Campbell and Soeken 1999; Dude 2007; Koenig et al. 2004; Wingood et al. 2000a,b). The apparent female biological susceptibility may be explained partially or completely by the sexually coercive behaviors of abusive partners (Miller et al. 1999; Raj et al. 2004; Wu et al. 2003). Forced sex occurs in approxi- mately 40 to 45 percent of physically violent intimate relationships and increases a woman’s risk for STIs by 2 to 10 times over that of physical abuse alone (Campbell and Soeken 1999; Wingood et al. 2000a). As a result of forced sex, genital injuries, such as vaginal lacerations, facilitate

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 APPENDIX C disease transmission (Liebschutz et al. 2000). Lichtenstein and others found that abusive partners used deliberate HIV infection, lack of disclosure about known serostatus, and forced injection drug use as mechanisms to control and endanger their intimate partners (Lichtenstein 2005; Neundorfer et al. 2005). IPV, Substance Use, and HIV The relationship among violence against women, HIV risk, and sub- stance use is a particularly complex one. Studies in the United States have found that women exposed to abuse during childhood or adulthood are more likely to abuse alcohol and illicit substances, potentially as a cop- ing mechanism (Beadnell et al. 2000; Gilbert et al. 2000; Wingood et al. 2000a). Substance abuse, in turn, has been associated with high risk behaviors for HIV and other STI infection (Collins et al. 2005; El-Bassel 2000). Unfortunately, because many studies of gender-based violence and HIV risk are cross-sectional in design, it is not possible to determine the temporal relationship between factors. For example, exposure (as a witness or victim) to abuse during childhood has been documented as a risk factor for victimization by an intimate partner later in life (Tjaden and Thoennes 2000). Similarly, children who experience maltreatment are at increased risk for a wide range of negative health consequences, including substance abuse (Felitti et al. 1998). Viewed from a lifecourse perspective, the precise relationship between substance use, a known risk factor for sexual risk- taking behavior, and IPV, a known precursor for substance use, is difficult to ascertain. Finally, STI risk, including HIV risk, may also be indirectly exacerbated by the victim’s psychological trauma of violence and abuse leading to impaired decision making, substance abuse, and greater risk taking (Campbell and Lewandowski 1997; Miller et al. 1999). In spite of the role that substance abuse plays in HIV and VAW in the United States, substance abuse is rarely part of the HIV transmission picture in low- and middle-income countries. Sexual Decision Making and IPV IPV also impairs open communication between partners regarding safe sex practices including condom negotiation, monogamy, or HIV status dis- closure. Kalichman and colleagues (1998) found that women with abusive partners were more likely to fear negotiating condom use, believing that her insistence may be seen as implying unfaithfulness or untrustworthiness of either partner. The fear of retributive violence is real among abused women at risk for HIV. Studies have shown that a woman’s fear of her partner’s potentially violent reaction to suggesting condom use hinders her ability

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7 APPENDIX C to negotiate safe sexual health practices, which is a critical component to enhancing women’s health, particularly in the area of HIV prevention (e.g., Champion et al. 2004; Davila 2002; Davila and Brackley 1999). Addition- ally, this fear of violence can influence whether a woman utilizes voluntary counseling and testing services (Karamagi et al. 2006). Communication about sexual and reproductive health is also impacted by cultural norms. In the United States, Davila and colleagues found that males were the primary decision makers regarding safe sexual practices, particularly among married women who reported less ability to negotiate condom use than single/dating women (Davila 2002; Davila and Brackley 1999). Similarly, several studies have demonstrated the impact of relation- ship status and power on sexual health practices. In South Africa, Pettifor et al. (2004) found that low relationship power is significantly associated with inconsistent condom use among women. In the same region, Dunkle and colleagues (2004) found that pregnant women with low relationship power are at a twofold risk for never using a condom as compared to those women who feel they have high levels of power in the relationship. Further, a history or diagnosis of an STI may be an initiating factor for partner violence (Gielen et al. 2000; Koenig et al. 2002; Medley et al. 2004; Zierler et al. 2000). Studies by Maman et al. (2002) and Kiarie and colleagues (2006) found that this fear was substantiated, as HIV-positive women were up to two times more likely to experience immediate violence after disclosure than HIV-negative women. Fear of violence from an inti- mate partner may also serve as a barrier to HIV-positive women seeking and obtaining needed health care (Lichtenstein 2005). Male Behavior, IPV, and HIV Several studies conducted in international settings have found that male perpetrators of intimate partner violence engage in behavior that puts their partners at greater risk for HIV. As discussed earlier, studies have found that among women, there is an association between being a victim of IPV and having STIs, which puts women at greater risk for HIV. In addition, recent studies have established that among women, there is an association between being a victim of IPV and having a confirmed HIV-positive status. These studies have emphasized the need to conduct research on the specific HIV risk behaviors engaged in by male abusers. Most research to date has utilized self-report by women regarding their partner’s behavior within their relationship. In these studies measuring the victims’ perceptions of their partners’ HIV risk behaviors, abused women report more high-risk behaviors among their partners than nonabused women (Garcia-Moreno et al. 2005).This adds a level of complexity to the woman’s risk for HIV infection within the context of intimate relationships.

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 APPENDIX C Yet few studies explore the HIV risk behaviors among perpetrators versus nonperpetrators, as reported by men themselves. Five recent studies have addressed this gap. Although they are limited by their cross-sectional designs, limited measurement of violent behaviors, and potential under- reporting of sensitive behaviors, they consistently reflect an association between male engagement in HIV risk behavior and perpetration of IPV. The first study by Abrahams et al. (2005) was conducted in three Cape Town municipalities and explored risk factors for male sexual intimate partner violence perpetration. Data were collected from 1,368 randomly selected males. The study found an association between the perpetration of sexual violence and two HIV risk behaviors, including problematic alcohol use and having more than one current partner (adjusted OR = 2.87, 95 percent CI 2.08–2.96). A second study by Dunkle et al. (2006), conducted in rural South Africa, explored the associations between HIV risk behaviors and the per- petration of IPV. Data were collected from 1,275 males in 70 communities as part of a baseline assessment for a randomized controlled trial of the Stepping Stones HIV prevention program. The study found that perpetra- tors of violence are significantly more likely to engage in HIV risk behav- iors, such as casual partners, transactional sex, use of drugs and alcohol, and non-IPV sexual assault, than nonperpetrators. The level of risk behav- ior was correlated with level of violence severity. Also in sub-Saharan Africa, Andersson and colleagues (2007) explored the relationship between male perpetration of physical violence and the HIV risk behavior of having multiple partners. The sample consisted of 8,767 men (and 11,872 women) from Botswana, Lesotho, Swaziland, Malawi, Mozambique, Namibia, Zambia, and Zimbabwe. Men who had multiple partners were two times more likely to also be perpetrators of violence, except in Mozambique. The fourth study by Silverman et al. (2007) explored the association between violence against women and sexual risk behaviors among men in Bangladesh. The sample consisted of 3,096 married men, who participated in the MEASURE Demographic Health Survey. Violent behaviors included physical and/or sexual violence, while HIV risk behaviors included having premarital and extramarital sex partners, having STI symptoms or an STI diagnosis in the past year, and failing to disclose their infection status to their wives. Perpetrators of physical and sexual violence were 1.8 times more likely to report both premarital and extramarital partners than their nonabusing counterparts. Those using physical violence were 1.68 times more likely to report STI symptoms or diagnosis than nonperpetrators. Per- petrators of physical violence who had an STI diagnosis were somewhat less likely to disclose their infection status to their wives (OR = 1.58, 95 percent CI 0.93–2.70) than infected men not perpetrating physical violence.

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 APPENDIX C A final study conducted by Lary et al. (2004) explored the associations between HIV and violence among young people in Dar es Salaam, Tanzania. Data reflecting HIV risk behaviors among male abusers were gathered via qualitative semistructured interviews with 40 young men between the ages of 16 and 24. Men who reported using violence against their partners also often reported sexual infidelity. These recent data as well as evidence from the WHO Multi-Country Study of Violence Against Women (Garcia-Moreno et al. 2005) provide evidence that men who perpetrate violence against their intimate partners are also more likely to engage in HIV risk behaviors than men who do not perpetrate intimate partner violence. This is of particular note given that data on such behaviors among male abusers is available from the perspec- tive of the female survivors, as well as from the male abusers themselves. Compromised Immunofunction Among Abused Women Women who experience IPV suffer a wide and well-documented range of adverse health consequences, including increased prevalence of stress, depres- sion, and chronic anxiety (Campbell 2002; Golding 1999; Pico-Alfonso et al. 2004, 2006; Woods et al. 2000). A few recent U.S.-based studies have explored the impact of violence victimization on immune system functioning in women. Significant associations have been found between intimate part- ner abuse and altered red blood cell and decreased T-cell function (Brokaw 2002; Constantino et al. 2000). Further research has revealed associations between violence and hypothalamic-pituitary-adrenal axis functioning, such that women in abusive relationships had greater occurrence of altered levels of cortisol and dehydroepiandrosterone (Griffin et al. 2005; Pico-Alfonso et al. 2004; Seedat et al. 2003) compared to nonabused women. Other stud- ies have found that partner violence alters neuropsychological functioning (Stein et al. 2002) and negatively impacts immune responses related to HSV- 1 infection (Garcia-Linares et al. 2004). Woods et al. (2000) explored the interrelationship of IPV, psychopathology, and immune system functioning to determine if posttraumatic stress disorder (PTSD) symptoms mediate the effect of violence on cytokine levels. Their findings indicate that cytokine values were higher among women who were abused and experiencing PTSD, suggesting mediation and a partial explanation for comorbidities of mental and physical health symptoms in victims of violence. A similar body of existent literature demonstrates a strong relationship between stress and other psychosocial factors with disease progression in HIV-infected persons. Specifically, HIV-infected people have been found to suffer from adverse mental health sequalae (including stress and depression) which, in turn, have been associated with increased morbidity (Ickovics et al. 2001) and faster progression to AIDS (Kimerling et al. 1999; Leserman

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0 APPENDIX C et al. 1999, 2002). A rapidly growing body of literature indicates the impact of PTSD and depression in HIV biomarkers, including decreased CD4 counts and immune decrements (Boarts et al. 2006; Delahanty et al. 2004; Sledjeski et al. 2005). Despite increasing attention being paid to how stress and immune function relate to IPV and HIV, no known research has investigated the hypotheses that an association exists between abuse and reduced immunity to HIV acquisition or that intimate partner violence might be associated with increased disease progression (reduction of CD4 levels) among HIV- infected women. A striking commonality does exist, however, in the above referenced findings on IPV and immune function and HIV and immune function, namely that the depressive episodes described in both associations have the same effects on the immune system. These findings indicate an important direction for future research on the intersections of IPV and HIV. Research is warranted to examine the impact of violence-related PTSD and comorbid depression on immunity to HIV acquisition and disease progres- sion in HIV-infected women. Conclusions The research reviewed clearly indicates complex but real relationships between two epidemics threatening the health and safety of women in the United States and around the world, particularly among low- and middle- income countries. The increased risk for HIV/AIDS related to violence against women, particularly IPV, works through both male and female behavior, through physiological consequences of violence, and affects both adult women and adolescents. There is now evidence that all three behav- ioral areas proposed by Maman and colleagues (2000) as mechanisms by which the risk is increased: forced sex with an infected partner, limited or compromised negotiation of safer sex practices, and increased sexual risk-taking behaviors (Maman et al. 2000). Another mechanism found to be important is the increase in other STIs that accompany abuse and facilitate HIV transmission. There is beginning to be evidence of a connec- tion between abuse-related immunocompromised states which may have implications for both HIV infection, conversion from HIV to AIDS, or AIDS-related infections such as tuberculosis, also potentially fatal. All of these connections need further investigation of the precise mechanisms of enhanced transmission (e.g., forced anal sex) in order to design effec- tive prevention strategies. Further epidemiological studies are needed, but even more important is the need for studies that combine physiological and qualitative data with self-report so that these complex relationships can be better elucidated. Prospective studies are critical to address issues of causality and time ordering, as almost all studies to date have been

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 APPENDIX C cross-sectional. Also imperative are studies that indicate how women who are being abused can protect themselves from HIV safely, and even more importantly, how to reduce abusive behavior toward women by men (e.g., Jewkes et al. 2006b; Pronyk et al. 2006). Finally, although similar risk factors for HIV and IPV have been identified among women around the world, significant differences exist in the quantity and quality of research conducted to date in various settings. Future efforts should target multiple low- and middle-income countries where the AIDS epidemic is widespread or emerging so that the effects of culture and context on the ways that HIV/AIDS risk is increased by violence against women can be both better explicated and contextually understood. Implications for Prevention Given the evidence related to men’s behavior, efforts to prevent HIV need to focus on the reduction of male use of violence against women as well as reduction of male HIV risk behaviors in intimate partnerships. The need to focus specifically on the reduction of multiple and concurrent part- ners to prevent HIV was one of two major recommendations at a recent meeting on preventing AIDS in high-HIV-prevalence countries in southern Africa convened by the Southern African Development Community and UNAIDS in 2006. After reviewing evidence reflecting the limited success of current HIV efforts and calls for revised HIV prevention strategies, two recommendations were made: one focused on male circumcision, and the second on the reduction of multiple and concurrent partners (Halperin and Epstein 2007). What was missing was a recommendation about reducing violence in intimate partner relationships. Future policy and programmatic efforts must address this area of primary prevention in order to effectively reduce women’s risk of HIV infection. References Abrahams, N. et al. 2005. Sexual violence against intimate partners in Cape Town: Preva- lence and risk factors reported by men. Bulletin of the World Health Organization 82:330-337. Ackard, D. M., D. Neumark-Sztainer, and P. Hannan. 2003. Dating violence among a nation- ally representative sample of adolescent girls and boys: associations with behavioral and mental health. Journal of Gender-Specific Medicine 6(3):39-48. Andersson, N. et al. 2007. Risk factors for domestic physical violence: National cross-sectional household surveys in eight southern African countries. BMC Women’s Health 7:11. Beadnell, B, S. A. Baker, and D. M. Morrison. 2000. HIV/STD risk factors for women with violent male partners. Sex Roles 42(7-8):661-689. Boarts, J. M. et al. 2006. The differential impact of PTSD and depression on HIV disease markers and adherence to HAART in people living with HIV. AIDS and Behavior 10(3):253-261.

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