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. Author manuscript; available in PMC: 2023 Aug 25.
Published in final edited form as: Soc Work Public Health. 2015 Mar 9;30(3):272–281. doi: 10.1080/19371918.2014.994726

Intimate Partner Violence and Communication of HIV Diagnosis in Rakai, Uganda

Robert Kairania 1, Ronald H Gray 2, Maria J Wawer 3, Jennifer Wagman 4, Godfrey Kigozi 5, Fred Nalugoda 6, Richard Musoke 7, David Serwadda 8, Nelson K Sewankambo 9, John Semanda 10, Joseph Sembatya 11
PMCID: PMC10452044  NIHMSID: NIHMS1923094  PMID: 25751453

Abstract

Individuals who communicate their HIV diagnosis to sexual partners may be at increased risk of intimate partner violence (IPV). The authors examined past year self-reported IPV associated with communication of HIV diagnosis and other factors, in a sample of 679 sexually active; HIV-positive individuals age 18 to 49, who received HIV results and posttest counselling 12 months or more prior to the survey in Rakai, Uganda, using log-binomial multivariable regression. The rates of verbal and physical abuse among married individuals were significantly higher compared to unmarried persons, respectively. Physical abuse was significantly higher among women compared to men. IPV was not significantly associated with communication of HIV diagnosis. Interventions to prevent IPV among married HIV-positive individuals particularly women, at the community level, are needed.

Keywords: Intimate partner violence, communication of HIV diagnosis, physical abuse, verbal abuse

INTRODUCTION

Intimate partner violence (IPV) is physical, sexual, or psychological/emotional abuse that occurs between two people in a close relationship (Centers for Disease Control and Prevention [CDC], 2011; Ezechi et al., 2009) and includes current and former partners including boyfriend or girlfriend relationships (Coker et al., 2002; Ezechi et al., 2009; Saltzman, Fanslow, McMahon, & Shelley, 2002). IPV is a phenomenon of epidemic proportions prevalent in many communities and cultures. Men and women perpetrate violence against their partners (Gelaye, Lam, Cripe, Sanchez, & Williams, 2010; Muñoz-Rivas, Graña, O’Leary, & González, 2007; Williams, Ghandour, & Kub, 2008). However, globally, rates of reported IPV for men and women range between 5% and 50% (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Heise, Pitanguy, & Germain, 1994; Maman et al., 2003; Population Reports, 1999; Van der Straten et al., 1998). In Uganda, the prevalence of reported IPV for men and women ranges between 14% and 54% (Karamagi, Tumwine, Tylleskar, & Heggenhougen, 2006; M. A. Koenig et al., 2003; Uganda Bureau of Statistics (UBOS) and Macro International Inc., 2007; Zablotska et al., 2009).

In particular, IPV prevalence for men with regard to educational attainment is not affected by one’s level. Men with no education and those with primary or secondary education report similar prevalence rates of IPV in as far as being perpetrators and victims (UBOS and Macro International Inc., 2007). Yet for women, the situation is different. Women with no education are the most perpetrators and victims of IPV compared to those with primary or secondary education (UBOS and Macro International Inc., 2007). IPV numbers may be underestimated as individuals hesitate to report, for fear of social stigma (Agarwal & Panda, 2007).

In general, reported rates of IPV are lower among men compared to women in Uganda (Karamagi et al., 2006; UBOS and Macro International Inc., 2007). Only about 18% of men report having experienced any form of IPV from their partners compared to 33% for women in the past 12 months (UBOS and Macro International Inc., 2007). This means that women are at a greater risk of experiencing all forms of IPV (Flynn & Graham, 2010; Hindin, 2003; Karamagi et al., 2006; Reisenhofer & Seibold, 2007), and the frequency of IPV is more among married women compared to single ones for individuals age 15 to 49 (UBOS and Macro International Inc., 2007).

With regard to HIV infection, average HIV prevalence among individuals age 15 to 49 in Uganda, according to available published data, is about 7.3%, being higher at 8.3% in women compared to 6.1% in men (Uganda Ministry of Health and ICF International, 2012). In Rakai district, according to available data, HIV prevalence is about 11%, with an incidence of 1.2/100 to 1.5/100 person-years (Gray et al., 2003; Kim & Miller, 2009). On the other hand, HIV prevalence is also related to marital status with about 7.4% in current marital relationships compared to about 3% in the never- married persons among individuals age 15 to 49 (Uganda Ministry of Health and ICF International, 2012). Besides, HIV- positive individuals are reported to experience more IPV compared to HIV- negative persons (Maman, Campbell, Sweat, & Gielen, 2000; Van der Straten et al., 1998; World Health Organization [WHO], 2004; Zierler, Witbeck, & Mayer, 1996). In East Africa, there is a reported more than twofold increase in IPV for HIV-positive women compared to HIV-negative women (Emusu et al., 2009; Fonck, Els, Kidula, Ndinya-Achola, & Temmerman, 2005; M. A. Koenig et al., 2003; Maman et al., 2002; Zablotska et al., 2009).

In the context of communication of HIV diagnosis to sexual partners and IPV, empirically documented evidence is conflicting. Some studies report that communication of HIV diagnosis to sexual partners is associated with increased social and financial support, sympathy, acceptance, less anxiety, fewer symptoms of depression and kindness, and less or no IPV (Keogh, Allen, Almedal, & Temahagili, 1994; King et al., 2008; Maman et al., 2003; WHO, 2003). Conclusions from other studies have, on the other hand, generally indicated that persons who communicate their HIV diagnosis to sexual partners are at a more increased risk of IPV (Emusu et al., 2009; Gielen, Faden, O’Campo, & Eke, 1997; Gielen, McDonnell, Burke, & O’Campo, 2000; Maman, Mbwambo, Hogan, Kilonzo, & Sweat, 2001; Rothenberg & Paskey, 1995).

Consequently, stigma, abandonment, depression, anxiety-related problems, post-traumatic stress disorders, antisocial behaviors, and repeated suicidal thoughts and behaviors have been acknowledged as implications of the HIV diagnosis communication–IPV nexus (Bergen, 1996; Coker et al., 2002; Diop-Sidibe, Campbell, & Becker, 2006; Gielen et al., 2000; Roberts, Klein, & Fisher, 2003; WHO, 2003;Ystgaard, Hestetun, Loeb, & Mehlum, 2004; Zierler et al., 2000) in the community (Agarwal & Panda, 2007; CDC, 2011; Population Reports, 1999). These negative outcomes stemming from the IPV–HIV diagnosis communication connection increase health and social care costs and demands on the scanty resources in families and communities (Little & Kantor, 2002; Tomison, 2000) particularly in sub-Saharan African situations (Maman et al., 2001; WHO, 2003).

Communication of HIV diagnosis (disclosure of HIV status) to sexual partners and reduction of IPV (gender-based violence) are two core behavioral interventions targeted by the Ugandan Government for HIV sero-positive persons in the national HIV prevention strategy 2011 to 2015 (Uganda AIDS Commission, 2011). However, data assessing the association of IPV with communication of HIV diagnosis, marital status, age, and gender and education level in sexually active HIV-positive individuals who already know their HIV infection status in a community-based setting are limited. To address these gaps, we examined the association of past year experiences of IPV with communication of HIV diagnosis, gender, marital status, age, and education level in an HIV positive sample in Rakai district, Uganda.

METHOD

Participants and Procedures

Participants for this study were retrospectively identified from the 2007 to 2008 survey of an ongoing Rakai Community Cohort Study (RCCS) using unique alphanumeric computer generated identification numbers (unique identifiers). The details of RCCS have been reported elsewhere (Nakigozi et al., 2011; Reynolds et al., 2011). However, in brief, RCCS is a prospective rural population-based cohort, which collects annual surveillance data to document HIV and sexually transmitted diseases (STDs) prevalence and incidence, and associated risk factors from approximately 14,000 men and women, age 15 to 49, residing in 50 communities in rural Rakai District, found in southwestern Uganda about 160 kilometers from Kampala capital city. We retrospectively identified an eligible sample of 679 (female = 454, male = 225) heterosexual individuals age 18 to 49 who were HIV infected, sexually active, and reported to be in a sexual relationship, with the same sexual partner (s), within a time frame of at least 12 months. Also, eligible participants had individually received HIV results and posttest counselling from the Rakai Health Sciences Programme (RHSP) counselling department, where they learned their HIV infection status, at least 12 months preceding the survey.

Participants were invited to a central hub in the participants’ respective villages and/or trading centers where same-sex interviewers conducted a one-to-one private and confidential interview, to obtain survey data on sociodemographic characteristics such as age, education level, and marital status; and communication of HIV diagnosis to one’s sexual partner, and experience of IPV. On the other hand, participants were not asked about sexual victimization. Also, participants were not asked about the order of occurrence of IPV and HIV diagnosis communication.

Communication of HIV diagnosis was defined as having taken place if participants reported that they had informed sexual partner(s) about their HIV infection status. IPV was defined as verbal/emotional abuse if research participants reported that they were verbally abused, shouted at, or barked at by their sexual partners in the past 12 months. And IPV was defined as physical abuse if participants reported that they were pushed, slapped, kicked, punched with a fist or with something that could hurt them, or were forcefully held on the ground by their sexual partners in the past 12 months preceding the survey.

Ethical Considerations

Participants were informed of study procedures, benefits, and risks and provided written informed consent for interviews. Participants were also referred to the RHSP’s HIV care and treatment program, funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and were offered free condoms. The study was approved by the Uganda National Council of Science and Technology, the Science and Ethics Committee of the Uganda Virus Research Institute, Entebbe, Uganda and the Committee for Human Research at the Johns Hopkins University, Bloomberg School of Public Health Baltimore, USA.

Statistical Analysis

In this analysis, we first compared communication of HIV diagnosis to sexual partners with demographic characteristics (gender, age, education level, and marital status) using the chi-squared test. Then, IPV in relation to communication of HIV diagnosis was examined using the log-binomial multivariable regression model. Given the design of the study and the dichotomous nature of IPV (Lee, Tan, & Chia, 2009); the log-binomial multivariable regression model to estimate adjusted prevalence risk ratios (APRR) and the 95% confidence intervals (CI) associated with communication of HIV diagnosis to one’s sexual partner was preferred (Lee, 1995; Lee & Chia, 1993; Stromberg, 1994; Zocchetti, Consonni, & Bertazzi, 1995). Possible confounding variables (gender, marital status, age, and education level) were included in the multivariable regression models. Statistical analyses were performed using Stata software version 11.0 (StataCorp, 2009).

RESULTS

This study retrospectively identified a total of 679 eligible HIV-infected heterosexual individuals. However, with regard to comparing HIV diagnosis communication to sexual partners with demographic characteristics, 620 records were found to have complete data. And as shown in Table 1, though not statistically significant, communication of HIV diagnosis was more frequent among men (42.6%) compared to women (35.3%, p = .08). However, with regard to marital status, married individuals (44.1%) were significantly more likely to communicate their HIV diagnosis to sexual partners than unmarried persons (28.0%, p , .001). Age and education level were not significantly associated with communication of HIV diagnosis.

TABLE 1.

HIV Diagnosis Communication by Participant Characteristics (N = 620)

Communicated HIV Diagnosis to Sexual Partner
Characteristic Yes (%) No (%) p Value
Gender
Female 147/416 (35.3) 269/416 (64.7)
Male 87/204 (42.6) 117/204 (57.4) 0.08
Age
18–34 139/380 (36.6) 241/380 (63.4)
35–49 95/240 (39.6) 145/240 (60.4) 0.45
Education level
Primary/lower 178/467 (38.1) 289/467 (61.9)
Postprimary 56/153 (36.6) 97/153 (63.4) 0.74
Married/cohabiting (n = 572)
Yes 172/390 (44.1) 218/390 (55.9)
No 51/182 (28.0) 131/182 (72.0) < .001
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Table 2 shows the rates of verbal abuse. Married individuals were more likely to report verbal abuse (emotional violence) than unmarried persons in the adjusted model (APPR = 2.3 (95% CI [1.5, 3.4]). Communication of HIV diagnosis was not significantly associated with verbal abuse. There were also no significant associations with regard to verbal abuse and age, education level or gender.

Table 2.

Crude and Adjusted Prevalence Risk Ratios (PRR) of Verbal Abuse by Participant Characteristics and Communication of HIV diagnosis (N = 679)

Verbal Abuse
Characteristic Proportion (%) Crude PRR 95% CI Adjusted PRR 95% CI p Value
Gender
Male 65/225 (28.9) 1.0 (reference) 1.0 (reference)
Female 108/454 (23.8) 0.8 [0.6, 1.1] 1.0 [0.7, 1.3] 0.93
Age
18–34 107/413 (25.9) 1.0 (reference) 1.0 (reference)
35–49 66/266 (24.8) 1.0 (0.8, 1.4) 1.1 (0.8, 1.5) 0.55
Education level
Primary or lower 132/516 (25.6) 1.0 (reference) 1.0 (reference)
Post primary 41/163 (25.2) 1.0 [0.7, 1.3] 0.9 [0.7, 1.3] 0.75
Married or cohabiting (n = 629)
No 28/191 (14.7) 1.0 (reference) 1.0 (reference)
Yes 137/438 (31.3) 2.1 [1.5, 3.1] 2.3 [1.5, 3.4] < .001
Communicated HIV diagnosis
Yes 56/234 (23.9) 1.0 (reference) 1.0 (reference)
No 94/386 (24.4) 1.0 [0.7, 1.3] 0.9 [0.7, 1.2] 0.35
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CI = confidence interval.

As shown in Table 3, married individuals were significantly more likely than unmarried persons to report physical abuse (APRR = 1.7, 95% CI [1.0, 2.6]); and women were significantly more likely than men to report physical abuse in the adjusted model (APRR = 2.0, 95% CI [1.2, 3.2]). Communication of HIV diagnosis was not significantly associated with physical abuse even though individuals who communicated their HIV diagnosis reported more physical abuse (32.5%) compared to those who did not communicate their HIV status to sexual partners (14.0%). Age and education level were not significantly associated with physical abuse.

TABLE 3.

Crude and Adjusted Prevalence Risk Ratios (PRR) of Physical Abuse by Participant Characteristics and Communication of HIV diagnosis (N = 679)

Physical Abuse
Characteristic Proportion (%) Crude PRR 95% CI Adjusted PRR 95% CI p Value
Gender
Male 22/225 (9.8) 1.0. (reference) 1.0 (reference)
Female 80/454 (17.6) 1.8 [1.2, 2.8] 2.0 [1.2, 3.2] 0.01
Age
18–34 69/413 (16.7) 1.0 (reference) 1.0 (reference)
35–49 33/266 (12.4) 1.4 [0.9, 2.0] 1.3 [0.8, 2.0] 0.28
Education level
Primary or lower 83/516 (16.1) 1.0 (reference) .0 (reference)
Postprimary 19/163 (11.7) 0.7 (0.5, 1.2) 0.7 [0.4, 1.1] 0.15
Married or cohabiting (n = 629)
No 22/191 (11.5) 1.0 (reference) 1.0 (reference)
Yes 76/438 (17.4) 1.5 [1.0, 2.4] 1.7 [1.0, 2.6] 0.04
Communicated HIV diagnosis
No 54/386 (14.0) 1.0 (reference) 1.0 (reference)
Yes 76/234 (32.5) 1.1 [0.8, 1.6] 1.1 [0.7, 1.6] 0.71
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CI = confidence interval.

DISCUSSION

We found that communication of HIV diagnosis was significantly higher among married persons than unmarried individuals. The high rate of communication of HIV diagnosis among married individuals is comparable to earlier studies (Bairan et al., 2007; Kimberly, Serovich, & Greene, 1995; Trieu, Modeste, Marshak, Males, & Bratton, 2010) and suggests the importance of the emotional bond and feelings of trust and confidence in married relationships as a factor influencing sharing of an HIV diagnosis with sexual partners. The high rate of communication of HIV diagnosis to sexual partners among married persons also suggests the difficulty in seeking HIV care and treatment and the managing of HIV medications (antiretroviral therapy adherence) and related processes without communication of HIV diagnosis given the proximity of most married relationships. Additionally, this finding adds credence to the growing body of research that shows married individuals as being more likely to share their HIV diagnosis to sexual partners compared to unmarried persons (Ciccarone et al., 2003; Kalichman & Nachimson, 1999; Sullivan, 2009) because married individuals are perceived as understanding, compassionate, trustworthy, and supportive from whom a favorable response is predicted (Kimberly et al., 1995; Semple, Patterson, Shaw, Pedlow, & Grant, 1999; Stein et al., 1998; Sullivan, 2009). Our results are also comparable to findings from an earlier Ugandan study in which positive outcomes such as initiation of condoms use, increased care seeking behaviors for partner and self, relief from worry, and improved motivation to plan for the future among married persons were associated with HIV sero-status disclosure than with unmarried individuals (King et al., 2008).

On the other hand, married participants reported more frequent verbal and physical abuse than unmarried persons. These results are consistent with studies in East Africa and India in which marriage was also associated with IPV (Prabhu et al., 2011; Silverman, Decker, Saggurti, Balaiah, & Raj, 2008; UBOS and Macro International Inc., 2007; Van der Straten et al., 1998) and supports the suggestion that IPV and HIV infection coexist within similar environmental and behavioral risk contexts (L. J. Koenig & Moore, 2000) among married individuals. Besides, this finding may be due to the fact that married individuals spend more time with each other and, thus, have more opportunity to commit acts of emotional and physical abuse. However, this contradicts with suggestions that romanticized marriage is a safe haven and a frequent source of happiness in an often harsh world (Berscheid & Reis, 1998; Marcus & Swett, 2003).

Conversely, neither verbal abuse nor physical abuse was statistically significant with regard to communication of HIV diagnosis to sexual partners. This contrasts earlier findings from studies in sub-Saharan Africa and the United States in which reported IPV was associated with communication of HIV diagnosis (Emusu et al., 2009; Ezechi et al., 2009; Gielen et al., 1997; Gielen et al., 2000; Maman et al., 2001; Medley, Garcia-Moreno, McGill, & Maman, 2004; WHO, 2003; Zierler et al., 2000). Probably, this may be due to the fact that previous studies in which IPV was associated with communication of HIV diagnosis were conducted in specialized urban antenatal clinics, STD clinics, or urban voluntary counselling and HIV testing (VCT) centers. This study is community based and was conducted in a rural setting with an exclusively HIV-positive sample in which violence may be differently associated.

On the other hand, women were more likely than men to report physical abuse. This finding is consistent with earlier analyses from sub-Saharan Africa on gender inequality and IPV among women (Ezechi et al., 2009; Hindin, 2003; Jewkes et al., 2006; Karamagi et al., 2006; M. A. Koenig et al., 2003; Maman et al., 2002; McCloskey, Williams, & Larsen, 2005) and supports arguments by feminist/ sociocultural theorists that aggression is the product of socially sanctioned domination and control of women by men and IPV is used as a form of power and control (Bell & Naugle, 2008; Corvo & deLara, 2010; Corvo & Johnson, 2003; Dutton, 1995; Manfrin-Ledet & Porche, 2003). Also, this finding has important implications regarding women’s discussions about initiation of condoms use, the use of contraception with sexual partners to reduce the number of unintended pregnancies, and subsequently HIV-infected women’s uptake and optimal adherence to prevention of mother-to-child transmission of HIV (PMTCT), support, care and treatment programs. Thus, programs that promote sexual and reproductive health issues among married HIV-infected women need to first assess the risk of IPV.

LIMITATIONS

In this cross-sectional analysis, we could not determine whether reported IPV occurred before or after communication of HIV diagnosis. We were also not able to measure the frequency of IPV in the past year. The past 12 months was a long period and thus, in our view, affected recall memory. In addition, we relied on self-reported data that is prone to social desirability and recall biases. In light of these limitations, we propose a longitudinal study to document the frequency and temporal occurrence of IPV and communication of HIV diagnosis. Also, this study was quantitative in nature. We could not obtain a more holistic view of the world of individuals experiencing IPV. An in-depth exploration of lived experiences of IPV and communication of HIV diagnosis through a qualitative inquiry is needed. Nevertheless, our findings showcase important implications for counselling programs that target married HIV-positive individuals, particularly women.

CONCLUSIONS

In this study, IPV is not significantly associated with communication of an HIV diagnosis. However, verbal and physical forms of IPV are significantly associated with being in a marital relationship. Women are more likely to report physical abuse compared to men. Interventions to prevent IPV among married HIV-positive individuals especially at community level are needed.

FUNDING

This study was funded by the National Institutes of Health (# R01 HD 050180), the Bill and Melinda Gates Foundation (#22006.02) and the Fogarty International Centre (#5D43TW001508). This study was also supported by the Intramural Research Program of the National Institute of Allergy and Infectious Diseases, NIH.

The authors would like to thank the study participants and the data collectors.

Contributor Information

Robert Kairania, Rakai Health Sciences Program, Entebbe, Uganda.

Ronald H. Gray, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA

Maria J. Wawer, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA

Jennifer Wagman, San Diego School of Medicine, University of California, La Jolla, California, USA.

Godfrey Kigozi, Rakai Health Sciences Program, Entebbe, Uganda.

Fred Nalugoda, Rakai Health Sciences Program, Entebbe, Uganda.

Richard Musoke, Rakai Health Sciences Program, Entebbe, Uganda.

David Serwadda, Makerere University School of Public Health, Kampala, Uganda.

Nelson K. Sewankambo, Makerere University College of Health Sciences, Kampala, Uganda

John Semanda, Rakai Health Sciences Program, Entebbe, Uganda.

Joseph Sembatya, Rakai Health Sciences Program, Entebbe, Uganda.

REFERENCES

  1. Agarwal B, & Panda P (2007). Toward freedom from domestic violence: The neglected obvious. Journal of Human Development, 8(3), 359–388. [Google Scholar]
  2. Bairan A, Taylor GAJ, Blake BJ, Akers T, Sowell R, & Mendiola R (2007). A model of HIV disclosure: disclosure and types of social relationships. Journal of the American Academy of Nurse Practitioners, 19(5), 242–250. [DOI] [PubMed] [Google Scholar]
  3. Bell KM, & Naugle AE (2008). Intimate partner violence theoretical considerations: Moving towards a contextual framework. Clinical Psychology Review, 28, 1096–1107. [DOI] [PubMed] [Google Scholar]
  4. Bergen RK (1996). Wife rape: understanding the response of survivors and service providers. Thousand Oaks, CA: Sage. [Google Scholar]
  5. Berscheid E, & Reis HT (1998). Attraction and close relationships. In Gilbert DT, Fiske ST, & Lindzey G (Eds.), The handbook of social psychology (4th ed., Vol. 2) (pp. 193–281). New York, NY: McGraw-Hill. [Google Scholar]
  6. Centers for Disease Control and Prevention. (2011). Understanding intimate partner violence: Fact sheet 2011. Atlanta, GA: CDC, National Center for Injury Prevention and Control, Division of Violence Prevention. Retrieved from: http://www.cdc.gov/ViolencePrevention/pdf/IPV_factsheet-a.pdf [Google Scholar]
  7. Ciccarone DH, Kanouse DE, Collins RL, Miu A, Chen JL, Morton SC, & Stall R (2003). Sex without disclosure of positive HIV sero-status in a U.S. probability sample of persons receiving medical care for HIV infection. American Journal of Public Health, 93(6), 949–954. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Coker AL, Davis KE, Arias I, Desai S, Sanderson M, Brandt HM, & Smith PH (2002). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 23(4), 260–268. [DOI] [PubMed] [Google Scholar]
  9. Corvo K, & deLara E (2010). Towards an integrated theory of relational violence: Is bullying a risk factor for domestic violence? Aggression and Violent Behaviour, 15, 181–190. [Google Scholar]
  10. Corvo K, & Johnson PJ (2003). Vilification of the “batterer”: How blame shapes domestic violence policy and interventions. Aggression and Violent Behaviour, 8(3), 259–281. [Google Scholar]
  11. Diop-Sidibe N, Campbell JC, & Becker A (2006). Domestic violence against women in Egypt—Wife beating and health outcomes. Social Science & Medicine, 62, 1260–1277. [DOI] [PubMed] [Google Scholar]
  12. Dutton D (1995). Male abusiveness in intimate relationships. Clinical Psychology Review, 15, 567–581. [Google Scholar]
  13. Emusu D, Ivankova N, Jolly P, Kirby R, Foushee H, Wabwire-Mangen F, … Ehiri J (2009). Experience of sexual violence among women in HIV discordant unions after voluntary HIV counselling and testing: A qualitative critical incident study in Uganda. AIDS Care, 21(11), 1363–1370. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Ezechi OC, Gab-Okafor C, Onwujekwe DI, Adu RA, Amadi E, & Herbertson E (2009). Intimate partner violence and correlates in pregnant HIV positive Nigerians. Archives of Gynecology and Obstetrics, 280, 745–752. [DOI] [PubMed] [Google Scholar]
  15. Flynn A, & Graham K (2010). “Why did it happen?” A review and conceptual framework for research on perpetrators’ and victims’ explanations for intimate partner violence. Aggression and Violent Behaviour, 15, 239–251. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Fonck K, Els L, Kidula N, Ndinya-Achola J, & Temmerman M (2005). Increased risk of HIV in women experiencing physical partner violence in Nairobi, Kenya. AIDS and Behavior, 9(3), 335–339. [DOI] [PubMed] [Google Scholar]
  17. Garcia-Moreno C, Jansen H, Ellsberg M, Heise L, & Watts CH (2006). Prevalence of intimate partner violence: Findings from the WHO multi-country study on women’s health and domestic violence. Lancet, 368(9543), 1260–1269. [DOI] [PubMed] [Google Scholar]
  18. Gelaye B, Lam N, Cripe SM, Sanchez SE, & Williams MA (2010). Correlates of violent response among Peruvian women abused by an intimate partner. Journal of Interpersonal Violence, 25(1), 136–151. [DOI] [PubMed] [Google Scholar]
  19. Gielen AC, Faden R, O’Campo P, & Eke A (1997). Women’s disclosure of HIV status: Experiences of mistreatment and violence in an urban setting. Women and Health, 25(3), 19–31. [DOI] [PubMed] [Google Scholar]
  20. Gielen AC, McDonnell KA, Burke JG, & O’Campo P (2000). Women’s lives after an HIV-positive diagnosis: Disclosure and violence. Maternal and Child Health Journal, 4(2), 111–120. [DOI] [PubMed] [Google Scholar]
  21. Gray RH, Li X, Wawer MJ, Gange SJ, Serwadda D, Sewankambo NK, … Quinn TC (2003). Stochastic simulation of the impact of antiretroviral therapy and HIV vaccines on HIV transmission, Rakai, Uganda. AIDS, 17, 1941–1951. [DOI] [PubMed] [Google Scholar]
  22. Heise L, Pitanguy J, & Germain A (1994). Violence against women: The hidden health burden. Washington, DC: World Bank. [PubMed] [Google Scholar]
  23. Hindin MJ (2003). Understanding women’s attitudes towards wife beating in Zimbabwe. Bulletin of the World Health Organization, 81, 501–508. [PMC free article] [PubMed] [Google Scholar]
  24. Jewkes R, Dunkle K, Nduna M, Levin J, Jama N, Khuzwayo N, … Duvvury N (2006). Factors associated with HIV sero-status in young rural South African women: Connections between intimate partner violence and HIV. International Journal of Epidemiology, 35, 1461–1468. [DOI] [PubMed] [Google Scholar]
  25. Kalichman SC, & Nachimson D (1999). Self-efficacy and disclosure of HIV-positive serostatus to sex partners. Journal of Health Psychology, 18, 281–287. [DOI] [PubMed] [Google Scholar]
  26. Karamagi CA, Tumwine JK, Tylleskar T, & Heggenhougen K (2006). Intimate partner violence against women in eastern Uganda: Implications for HIV prevention. BMC Public Health, 6, 284–296. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Keogh P, Allen S, Almedal C, & Temahagili B (1994). The social impact of HIV infection on women in Kigali, Rwanda: a prospective study. Social Science & Medicine, 38(8), 1047–1053. [DOI] [PubMed] [Google Scholar]
  28. Kim SJ, & Miller V (2009). Evaluation of impact of adult male circumcision programs on HIV incidence and prevalence: Current research, gaps in knowledge and recommendations for additional research. Washington, DC: Forum for Collaborative HIV Research. [Google Scholar]
  29. Kimberly J, Serovich J, & Greene K (1995). Disclosure of HIV-positive status: Five women’s stories. Family Relations, 44(3), 316–322. [Google Scholar]
  30. King R, Katuntu D, Lifshay J, Packel L, Batamwita R, Nakayiwa S, … Bunnell R (2008). Processes and outcomes of HIV serostatus disclosure to sexual partners among people living with HIV in Uganda. AIDS & Behaviour, 12, 232–243. [DOI] [PubMed] [Google Scholar]
  31. Koenig LJ, & Moore J (2000). Women, violence, and HIV: A critical evaluation with implications for HIV services. Maternal and Child Health Journal, 4(2), 103–109. [DOI] [PubMed] [Google Scholar]
  32. Koenig MA, Lutalo T, Zhao F, Nalugoda F, Wabwire-Mangen F, & Kiwanuka N (2003). Domestic violence in rural Uganda: Evidence from a community-based study. Bulletin of the World Health Organization, 81, 53–60. [PMC free article] [PubMed] [Google Scholar]
  33. Lee J (1995). Estimation of prevalence rate ratios from cross-sectional data: A reply. International Journal of Epidemiology, 24, 1066–1067. [DOI] [PubMed] [Google Scholar]
  34. Lee J, & Chia KS (1993). Estimation of prevalence rate ratios for cross-sectional data: An example in occupational epidemiology. British Journal of industrial Medicine, 50, 861–862. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Lee J, Tan CS, & Chia KS (2009). A practical guide for multivariate analysis of dichotomous outcomes. Annals of Academic Medicine Singapore, 38, 714–719. [PubMed] [Google Scholar]
  36. Little L, & Kantor GK (2002). Using ecological theory to understand intimate partner violence and child maltreatment. Journal of Community Health Nursing, 19(3), 133–145. [DOI] [PubMed] [Google Scholar]
  37. Maman S, Campbell J, Sweat MD, & Gielen AC (2000). The intersections of HIV and violence: Directions for future research and interventions. Social Science & Medicine, 50, 459–478. [DOI] [PubMed] [Google Scholar]
  38. Maman S, Mbwambo J, Hogan N, Kilonzo G, Campbell JC, & Weiss E (2002). HIV-positive women report more lifetime partner violence: Findings from a voluntary counselling and testing clinic in Dar es Salaam, Tanzania. American Journal of Public Health, 92(8), 1331–1337. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Maman S, Mbwambo J, Hogan NM, Kilonzo GP, & Sweat M (2001). Women’s barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counselling and testing. AIDS Care, 13, 595–603. [DOI] [PubMed] [Google Scholar]
  40. Maman S, Mbwambo JK, Hogan NM, Weiss E, Kilonzo GP, & Sweat MD (2003). High rates and positive outcomes of HIV-serostatus disclosure to sexual partners: Reasons for cautious optimism from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. AIDS and Behaviour, 7(4), 372–382. [DOI] [PubMed] [Google Scholar]
  41. Manfrin-Ledet L, & Porche DJ (2003). The state of science: Violence and HIV infection in women. Journal of theAssociation of Nurses in AIDS Care, 14(6), 56–68. [DOI] [PubMed] [Google Scholar]
  42. Marcus RF, & Swett B (2003). Violence in close relationships: The role of emotion. Aggression and Violent Behaviour, 8, 313–327. [Google Scholar]
  43. McCloskey LA, Williams C, & Larsen U (2005). Gender inequality and intimate partner violence among women in Moshi, Tanzania. International Family Planning Perspectives, 31(3), 124–130. [DOI] [PubMed] [Google Scholar]
  44. Medley A, Garcia-Moreno C, McGill S, & Maman S (2004). Rates, barriers and outcomes of HIV sero-status disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes. Bulletin of the World Health Organization, 82(4), 299–307. [PMC free article] [PubMed] [Google Scholar]
  45. Muñoz-Rivas MJ, Graña JL, O’Leary DK, & González PM (2007). Aggression in adolescent dating relationships: Prevalence, justification, and health consequences. Journal of Adolescent Health, 40, 298–304. [DOI] [PubMed] [Google Scholar]
  46. Nakigozi G, Makumbi F, Reynolds S, Galiwango R, Kagaayi J, Nalugoda F, … Wawer MJ (2011). Non-enrollment for free community HIV care: Findings from a population-based study in Rakai, Uganda. AIDS Care, 23(6), 764–770. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Population Reports. (1999). Ending violence against women. Issues in World Health, 27(4), 1–43. [PubMed] [Google Scholar]
  48. Prabhu M, Mchome B, Ostermann J, Itemba D, Njau B, & Thielman N (2011). Prevalence and correlates of intimate partner violence among women attending HIV voluntary counselling and testing in northern Tanzania. International Journal of Gynaecology and Obstetrics, 113, 63–67. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Reisenhofer S, & Seibold C (2007). Emergency department care of women experiencing intimate partner violence: Are we doing all we can? Contemporary Nurse, 24, 3–14. [DOI] [PubMed] [Google Scholar]
  50. Reynolds SJ, Makumbi F, Nakigozi G, Kagaayi J, Gray RH, Wawer MJ … Serwadda D (2011). HIV-1 transmission among HIV-1 discordant couples before and after the introduction of antiretroviral therapy. AIDS, 25, 473–477. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Roberts TA, Klein JD, & Fisher S (2003). Longitudinal effect of intimate partner abuse on high-risk behavior among adolescents. Archives of Pediatrics and Adolescent Medicine, 157(9), 875–981. [DOI] [PubMed] [Google Scholar]
  52. Rothenberg KH, & Paskey SJ (1995). The risk of domestic violence and women with HIV infection: implications for partner notification, public policy, and the law. American Journal of Public Health, 85, 1569–1576. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Saltzman LE, Fanslow JL, McMahon PM, & Shelley GA (2002). Intimate partner violence surveillance: uniform definitions and recommended data elements, version 1.0. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. [Google Scholar]
  54. Semple SJ, Patterson TL, Shaw WS, Pedlow CZ, & Grant I (1999). Disclosure of HIV seropositivity to sexual partners: An application of social cognitive theory. Behaviour Therapy, 30, 223–237. [Google Scholar]
  55. Silverman JG, Decker MR, Saggurti N, Balaiah D, & Raj A (2008). Intimate partner violence and HIV infection among married Indian women. Journal of the American Medical Association, 300(6), 703–710. [DOI] [PubMed] [Google Scholar]
  56. StataCorp. (2009). Stata statistical software: Release 11.0. College Station, TX: StataCorpLP. [Google Scholar]
  57. Stein MD, Freedberg K, Sullivan L, Savetsky J, Levenson S, Hingson R, & Samet JH (1998). Sexual ethics: Disclosure of HIV-positive status to partners. Archives of Internal Medicine, 158, 253–257. [DOI] [PubMed] [Google Scholar]
  58. Stromberg U (1994). Prevalence odds ratio vs. prevalence ratio. Occupational and Environmental Medicine, 51, 143–144. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Sullivan K (2009). Male self-disclosure of HIV infection to sex partners: A Hawaii-based sample. Journal of the Association of Nurses in AIDS Care, 20(6), 442–457. [DOI] [PubMed] [Google Scholar]
  60. Tomison A (2000). Exploring family violence: Links between child maltreatment and domestic violence. Issues in Child Abuse Prevention, 13, 1–23. [Google Scholar]
  61. Trieu SL, Modeste N, Marshak H, Males MA, & Bratton SI (2010). Partner communication and HIV testing among US Chinese college students. American Journal of Health Behaviour, 34(3), 362–373. [DOI] [PubMed] [Google Scholar]
  62. Uganda AIDS Commission. (2011). National HIV Prevention Strategy 2011–2015. Kampala, Uganda: Author. [Google Scholar]
  63. Uganda Bureau of Statistics (UBOS) and Macro International Inc. (2007). Uganda Demographic and Health Survey 2006. Calverton, MD: Author. [Google Scholar]
  64. Uganda Ministry of Health and ICF International. (2012). 2011 Uganda AIDS Indicator Survey: Key findings. Calverton, MD: Author. [Google Scholar]
  65. Van der Straten A, King R, Grinstead O, Vittinghoff E, Serufilira A, & Allen S (1998). Sexual coercion, physical violence, and HIV infection among women in steady relationships in Kigali, Rwanda. AIDS and Behaviour, 2(1), 61–73. [Google Scholar]
  66. Williams J, Ghandour RM, & Kub JE (2008). Female perpetration of violence in heterosexual intimate relationships: Adolescence through adulthood. Trauma, Violence & Abuse, 9(4), 227–249. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. World Health Organisation. (2003). Gender dimensions of HIV status disclosure to sexual partners: Rates, barriers and outcomes–a review paper. Geneva: World Health Organization. [Google Scholar]
  68. World Health Organization. (2004). Violence against women and HIV/AIDS: Critical intersections - Intimate partner violence and HIV/AIDS. Geneva, Switzerland: Author. [Google Scholar]
  69. Ystgaard M, Hestetun I, Loeb M, & Mehlum L (2004). Is there a specific relationship between childhood sexual and physical abuse and repeated suicidal behaviour? Child Abuse and Neglect, 28, 863–875. [DOI] [PubMed] [Google Scholar]
  70. Zablotska IB, Gray RH, Koenig MA, Serwadda D, Nalugoda F, Kigozi G, … Wawer MJ (2009). Alcohol use, intimate partner violence, sexual coercion and HIV among women aged 15–24 in Rakai, Uganda. AIDS and Behaviour, 13, 225–233. [DOI] [PubMed] [Google Scholar]
  71. Zierler S, Cunningham WE, Andersen R, Shapiro MF, Bozzette SA, Nakazono T, … Turner B (2000). Violence victimization after HIV infection in a probability sample of adult patients in primary care. American Journal of Public Health, 90(2), 208–215. [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Zierler S, Witbeck B, & Mayer K (1996). Sexual violence against women living with or at risk for HIV infection. American Journal of Preventive Medicine, 12(5), 304–309. [PubMed] [Google Scholar]
  73. Zocchetti C, Consonni D, & Bertazzi PA (1995). Estimation of prevalence rate ratios from cross-sectional data. International Journal of Epidemiology, 24, 1064–1065. [DOI] [PubMed] [Google Scholar]

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