Abstract
Introduction
Women living with HIV (WLHIV) in conflict zones are at high risk of sexual and physical violence due to instability, stigma and proximity to military personnel. Given sustained ongoing conflict, this study evaluated the relationship between displacement and gender-based violence (GBV), including experiences of sexual violence, abuse by healthcare workers and reproductive coercion among WLHIV in Ukraine. These forms of violence are conceptualised as severe forms of enacted stigma that are downstream outcomes of social, cultural and political norms, as well as social and structural stigmas related to misogyny and HIV.
Methods
Data were collected in Ukraine in 2020 as part of the People Living with HIV Stigma Index 2.0, led by 100% Life, the largest organisation for people living with HIV in Eastern Europe/Central Asia. WLHIV were recruited throughout Ukraine through limited chain referral and venue-based sampling. All participants completed a sociobehavioural questionnaire. Self-reported outcomes included sexual violence, violence in healthcare settings and reproductive coercion related to pregnancy, sterilisation and contraception. Displaced participants comprised WLHIV who were asylum seekers/refugees or internally displaced. Log binomial regression models estimated adjusted prevalence ratios (aPR) and 95% CIs for associations between displacement and GBV outcomes.
Results
A total of 1062 cisgender WLHIV completed the questionnaire, among whom 144 (13.6%) were displaced. Displaced WLHIV had higher proportions of lifetime experience using drugs (66.7% vs 22.0%, p=<0.01), selling sex (28.5% vs 12.2%, p=<0.01) and facing HIV-related stigma/discrimination (47.9% vs 34.4%, p=<0.01). Displaced WLHIV were significantly more likely to have experienced sexual violence (aPR: 2.74, 95% CI: 1.67 to 4.51), violence in healthcare (aPR: 2.57, 95% CI: 1.49 to 4.43), pregnancy coercion (aPR: 2.60, 95% CI: 1.41 to 4.78), sterilisation coercion (aPR: 4.26, 95% CI: 1.17 to 15.43) and contraception coercion (aPR: 2.48, 95% CI: 1.00 to 6.15) compared with non-displaced WLHIV.
Conclusion
As the war in Ukraine continues, humanitarian and health systems can use these findings to guide integration of GBV referrals and scale-up of trauma-informed care and antiexploitation training into Ukrainian programming. Moreover, additional surveillance methods, including community-led monitoring, can support routine documentation of experiences of coercion and abuse in healthcare settings. Broadly, transformative approaches are needed to tackle structural causes of gender inequality, HIV and violence.
Keywords: HIV, Global Health, Cross-sectional survey, Health systems, Gender-Based Violence
WHAT IS ALREADY KNOWN ON THIS TOPIC
Women living with HIV experience high rates of gender-based violence resulting from unbalanced power structures, comprising sexual violence, intimate partner violence, rape as a crime of war, coercion and physical, mental, verbal and financial abuse.
In conflict-affected settings such as Ukraine, experiences of sexual violence and other gender-based violence are common and can have long-lasting impacts on physical and mental health. However, there is still a lack of evidence documenting experiences of violence among women living with HIV in Ukraine, including among women who have been displaced as a result of conflict.
WHAT THIS STUDY ADDS
This study adds to an existing body of literature quantifying the burden of HIV stigma and sexual violence among women living with HIV in Ukraine and is among the first to explicitly examine the relationship between displacement and gender-based violence among women living with HIV.
This study is one of the first to quantify experiences of reproductive coercion among women living with HIV, which has been infrequently measured and documented relative to other forms of gender-based violence.
WHAT ARE THE POLICY AND RESEARCH IMPLICATIONS
Trauma-informed humanitarian aid for internally displaced women in Ukraine and refugees across neighbouring European countries can be scaled up and integrated with HIV, maternal health and family planning services.
As the study of reproductive coercion in clinical settings advances, inclusion of environmental and upstream factors in quantitative and qualitative research can better illustrate the systems where coercive practices occur for women living with HIV.
Introduction
The last decade in Ukraine has seen an escalation of conflict that has resulted in the displacement of nearly 5 million people, the majority of whom are women and children.1,3 While the 2022 Russian invasion sharply increased the number of asylum seekers and displaced people in Ukraine, between 2014 and 2020, 1.7 million people were internally displaced following the annexation of Crimea and conflicts in Donetsk and Luhansk.4,6 Disruptions to basic infrastructure followed, including the destruction of healthcare supply chains and a reduction in per capita healthcare resources that have limited access to critical health services.7 Alongside these disruptions in resources and services, widespread changes to the distribution and burden of disease in Ukraine have also been reported, including cancer, cardiovascular disease and other chronic conditions.4 Among those displaced, more than 86 000 individuals are estimated to be living with HIV.7
In Ukraine, the burden of HIV is the second highest in Eastern Europe.8 Prior to 2022, 69% of the 260 000 people living with HIV in Ukraine were aware of their status, of whom 82% were receiving antiretroviral treatment (ART).9 HIV transmission in Ukraine has historically occurred amidst a confluence of social epidemics including drug use, poverty and stigma.8 10 11 Structural violence and HIV criminalisation laws in Ukraine have also fuelled the epidemic, although these laws have been disproportionately enforced among women.12 Women living with HIV (WLHIV) are also vulnerable to other forms of violence and abuse, which have been shown to impact ART outcomes, mental health and engagement in formal health systems.13 14
Women with HIV globally face violence across various settings, including home, work and in healthcare. This violence is typically gendered and born of unbalanced power structures and comprises sexual violence, intimate partner violence, rape as a crime of war, coercion and physical, mental, verbal and financial abuse.15 These factors both indirectly and directly create barriers to healthcare, including screening and counselling for gender-based violence (GBV).16,18 Reproductive coercion by healthcare providers is also defined as GBV and includes abusive and discriminatory practices that are designed to force reproductive decisions. These practices include withholding informed consent, forced and coerced sterilisation and abortion and refusals to provide services or counselling.19 WLHIV have reported reproductive coercion in clinical settings across the world.20,27 A global survey on reproductive coercion found that nearly a third of women face discrimination by their healthcare providers due to their HIV status.27 Sterilisation is globally recognised as a modern human rights violation against WLHIV,28 but other types of coercion tied to childbirth, contraception and pregnancy decision-making have not received the same attention.21 23 27 However, few studies have assessed reproductive coercion among WLHIV in Ukraine.
GBV has been reported by displaced women across humanitarian crises and has been linked to serious physical injuries, sexually transmitted infections, fistulas and chronic pain, unwanted pregnancies and suicide.29 30 There are few studies of GBV in Ukraine to date, but in other contexts of complex humanitarian emergency, more than one in five displaced women report sexual violence.531,33 While displacement has been associated with an increase in GBV for women, including violence related to military operations,5 31 34 this relationship has not been explicitly studied among women living with HIV.5 35 Moreover, there is a substantial gap in epidemiological data documenting different types of violence including reproductive coercion among WLHIV more broadly. These forms of violence are conceptualised as severe forms of enacted stigma that are downstream outcomes of social, cultural and political norms, as well as social and structural stigmas related to misogyny and HIV. When enacted, these stigmas can manifest at the individual level into discrimination, prejudice and stereotyping, and manifestation into violence is among the most severe in terms of impact to health and well-being.36 Understanding the burden of violence and elucidating the mechanisms through which stigma against HIV and against women impacts reproductive autonomy is valuable to this understudied population. In response to these gaps, this analysis examines and quantifies the relationship between displacement and GBV, including sexual violence, abuse by healthcare workers and reproductive coercion among women living with HIV in Ukraine.
Methods
Study setting and procedures
Data were collected in Ukraine from June to August 2020 using a quantitative cross-sectional questionnaire implemented as part of the People Living with HIV (PLHIV) Stigma Index 2.0. The PLHIV Stigma Index 2.0 is a standardised tool that documents the impact of stigma and discrimination on the lives of people living with HIV globally. The International Partnership is a collaboration between the Global Network of People Living with HIV (GNP+), the International Community of Women Living with HIV (ICW) and UNAIDS, with technical support provided by Johns Hopkins University. The second iteration of the tool was developed in 2018 to include additional focus on intersectionality and the experiences of key populations37 and was validated through three studies in Cameroon, Senegal and Uganda.38
The methodology and implementation of the PLHIV Stigma Index 2.0 have been previously described.38 Briefly, recruitment for the PLHIV Stigma Index 2.0 in Ukraine included two types of sampling: limited chain-referral sampling and venue-based sampling.39 Limited chain-referral sampling, where participants send up to three invitations or ‘seeds’ out to their personal network, comprised about 5% of participant recruitment. Venue-based sampling across both healthcare facilities and HIV-service non-governmental organisations (NGOs) comprised the other 95% of participant recruitment, although not all sampled participants were consistently engaged in HIV care and treatment. Recruitment quotas were implemented to ensure sufficient representation within the sample among PLHIV who were not taking ART, and data collection was led by the Ukrainian NGO, 100% Life, in 16 oblasts or regions, including the city of Kyiv. Some safety precautions taken by PLHIV Stigma Index 2.0 studies during the height of the COVID-19 pandemic included personal protective equipment usage, social distancing and health surveys. These precautions supported inperson data collection.
Patient and public involvement
The PLHIV Stigma Index 2.0 upholds the principles of Community-Based Participatory Research, whereby both the conceptualisation and implementation of the PLHIV Stigma Index 2.0 are led by PLHIV for PLHIV. PLHIV were involved in every step of the previously detailed study methodology design, recruitment, interview and survey analysis process.39 These data are used to track HIV-related stigma and discrimination globally, with the goal of informing both direct programme and advocacy decisions at local and national levels.
Approval for the PLHIV Stigma Index 2.0 in Ukraine was obtained from the Professional Ethics Commission at the State Institute of Family and Youth Policy, with the Johns Hopkins School of Public Health institutional review board providing approval for secondary data analysis. All analyses were completed using Stata V.17.40
Study population
Participants in the study were ages 18 and older, confirmed that they were aware of their HIV status for 12 or more months and provided written informed consent. The questionnaire assessed demographics, past disclosure of HIV status, experiences of stigma and discrimination, internalised stigma and resilience, interactions with healthcare services, human rights and affecting change and stigma and discrimination experienced for reasons other than HIV status such as sexual identity, gender identity, drug use and sex work. All participants included in this secondary analysis identified as women and were assigned female sex at birth.
Measures
The primary exposure in this analysis was identifying as part of a displaced population, comprising all women who self-identified as currently or ever belonging to the following: refugees or asylum seekers or internally displaced persons. In the main analysis, participants who identified as one or more of these populations were dichotomised as belonging to a displaced population (yes/no).
There were five primary outcomes in this analysis, each representing different forms of GBV, including past experiences of sexual violence, violence in healthcare, pregnancy coercion, sterilisation coercion and contraception coercion. All variables were dichotomised as ‘yes/no’, with ‘yes’ reflecting experiences that occurred both within the last 12 months and prior to it. The framing of the measures as violence instead of stigma in this study was determined by the International Partnership of the PLHIV Stigma Index 2.0 and was intended to highlight the severity of such enacted stigmas such as sexual violence, physical violence, verbal abuse, mistreatment by healthcare providers and coercion in the context of sexual and reproductive healthcare services.
Sexual violence was assessed by the question ‘I was forced to have sex when I did not want to’. The responses ‘Yes, within the last 12 months’ and ‘Yes, but not within the last 12 months’ were collapsed as ‘Yes’, reflecting any past or recent experience of sexual violence. Participants who responded ‘No’ and ‘Not applicable’ were similarly collapsed as ‘No’.
Violence in healthcare was assessed by the following questions: ‘In the past 12 months, when seeking HIV specific healthcare, have you experienced any of the following from health facility staff working in the place you receive your HIV care?’ and ‘In the past 12 months, when seeking care for non-HIV related health needs, have you experienced any of the following treatment by health facility staff?’ A participant was considered to have experienced violence in healthcare if she answered ‘Yes’ to either of the following prompts to those questions: ‘Verbal abuse because of your HIV status’ or ‘Physical abuse because of your HIV status’. Additional options of ‘No’ and ‘Not applicable’ were collapsed into one answer considered ‘No’.
A participant was considered to have experienced pregnancy coercion if she responded ‘Yes’ to the following prompt to the question ‘In the last 12 months, has a healthcare professional done any of the following, solely because of your HIV status?’: ‘Advised you not to mother a child’. In addition, a participant was considered to have experienced pregnancy coercion if she responded, ‘Yes, within the last 12 months’ or ‘Yes, but not within the last 12 months’, to any of the following prompts to the question ‘Has a healthcare professional done any of the following, solely because of your HIV status?’: ‘Advised you to terminate a pregnancy’, ‘Pressured you to use a particular method of giving birth/delivery option’, ‘Pressured you to use a particular infant feeding practice’ or ‘Pressured you to take HIV treatment during pregnancy’. The other answer option to both questions was ‘No’.
A participant was considered to have experienced sterilisation coercion if she responded ‘Yes’ to either of the following prompts to the question ‘In the last 12 months, has a healthcare professional done any of the following, solely because of your HIV status?’: ‘Pressured or incentivised you to get sterilised’ or ‘Sterilised you without your knowledge or consent’. The other answer option to this question was ‘No’.
A participant was considered to have experienced contraception coercion if she responded ‘Yes’ to either of the following prompts to the question ‘In the last 12 months, has a healthcare professional done any of the following, solely because of your HIV status?’: ‘Denied your contraception/family planning services’ or ‘Told you that you had to use (a specific method of) contraception in order to get your HIV (antiretroviral) treatment’. In addition, a participant was considered to have experienced contraception coercion if she responded ‘Yes, within the last 12 months’ or ‘Yes, but not within the last 12 months’ to the following prompt to the question ‘Has a healthcare professional done any of the following, solely because of your HIV status?’: ‘Pressured you to use a specific type of contraceptive method’. The other answer option to both questions was ‘No’.
A participant was considered to have experienced HIV-related stigma or discrimination if she responded ‘Yes, within the last 12 months’ or ‘Yes, but not within the last 12 months’ to any of the following questions: ‘Have you ever been excluded from social gatherings or activities (eg, weddings, funerals, parties, clubs) because of your HIV status?’, ‘Have you ever been excluded from religious activities or places of worship because of your HIV status?’, ‘Have you ever been excluded from family activities because of your HIV status?’, ‘Have you ever been aware of family members making discriminatory remarks or gossiping about you because of your HIV status?’, ‘Have you ever been aware of other people (other than family members) making discriminatory remarks or gossiping about you because of your HIV status?’, ‘Has someone ever verbally harassed you (eg, yelled, scolded, or was otherwise verbally abusive) because of your HIV status?’, ‘Has someone ever blackmailed you because of your HIV status?’, ‘Has someone ever physically harassed or hurt you (eg, pushed, hit, or was otherwise physically abusive) because of your HIV status?’, ‘Have you ever been refused employment or lost a source of income or job because of your HIV status?’, ‘Has your job description or the nature of your job ever been changed, or have you ever been denied a promotion, because of your HIV status?’ and ‘Has your wife/husband, partner(s) or child(ren) ever experienced discrimination because of your HIV status?’ Additional options of ‘No’ and ‘Not applicable’ were collapsed into one answer considered ‘No’.
Potential confounders for these analyses were selected a priori after reviewing literature on GBV, HIV-related violence and displacement in other contexts. This research informed directed acyclic graphs that identified a minimally sufficient set of confounders for multivariable models for each separate violence outcome.41 42 Age was one of these confounders and was the only variable assessed continuously. Education was treated as a categorical ordinal variable with responses including ‘None’, ‘Primary’, ‘Secondary’, ‘Trade School’ or ‘University’. Number of children living in home was treated as a categorical ordinal variable with responses including ‘0’, ‘1’, ‘2’ and ‘3+’. Currently in an intimate relationship was dichotomised as ‘yes/no’. The assessment of effect measure modification included an additional term for drug use and the associated product term between drug use and displacement. Drug use was assessed by the question ‘Have you ever injected or habitually used drugs such as heroin, cocaine or methamphetamines?’, and dichotomised as ‘yes/no’.
Primary analysis
Characteristics of study participants were described using proportions for categorical variables and medians with IQRs for continuous variables.
We estimated the association of belonging to a displaced population with each of the five GBV outcomes, including sexual violence, violence in healthcare, pregnancy coercion, sterilisation coercion and contraception coercion. We first fit an unadjusted log binomial model for each outcome, specifying displacement as the exposure, to estimate prevalence ratios (PRs) and 95% CIs. Each model was then adjusted for a set of preselected confounders to estimate adjusted PRs (aPRs) and 95% CIs. A final set of confounders for the sexual violence model included age, education and current intimate relationship. A final set of confounders for the violence in healthcare model and all three reproductive coercion models included age, education and number of children. We assessed potential multicollinearity within each model using a correlation matrix with Pearson’s correlation coefficients and found that no variables were highly collinear, considering a threshold of 0.6.43
Sensitivity analysis
To understand potential heterogeneity of experience between refugees/asylum seekers and internally displaced people, we conducted a sensitivity analysis. Existing evidence suggests that internally displaced people experience worse health outcomes compared with other conflict-affected populations, and the relationship between displacement and GBV in internally displaced participants may be stronger than among those identifying as refugees/asylum seekers.44 In this analysis, women who identified as refugees/asylum seekers were excluded from the sample, and main analyses were repeated. At the time of data collection, few participants identified as refugees/asylum seekers, and thus we were unable to repeat this analysis and explicitly assess the relationship between refugee status and GBV outcomes. The breakdown of displaced women identifying as a refugee/asylum seeker, internally displaced person or both is found in online supplemental file 1.
Effect measure modification with drug use
Women who use drugs are a key population in the HIV epidemic in Ukraine and the broader Eastern European region, and the relationship between displacement and GBV may vary based on drug use. To understand potential differences between displacement and violence in the presence or absence of drug use, we assessed potential effect measure modification. We included a term for drug use and its associated product term with displacement and refit all models. We conducted Wald tests (alpha=0.05) and also examined stratum-specific estimates of the association of displacement and GBV outcomes for each level of drug use.
Results
A total of 2201 individuals participated in the PLHIV Stigma Index 2.0 in Ukraine. 1135 participants who identified as cisgender men, transgender men, transgender women or non-binary people were not included in these analyses. Of the 1066 cisgender women, four women did not answer the question about displacement and were therefore excluded from this analysis. Among the 1062 cisgender women with complete data, the median age was 39 years (IQR 34–46 years) (table 1). Of these women, 38.2% (n=406) had completed a secondary education, followed by 34.4% (n=365) who completed trade school, 20.3% (n=216) completed a university education and 7.1% (n=75) reported up to a primary school education. Of these women, 36.3% reported any lifetime experience of HIV-related stigma or discrimination (n=385). The frequency of participants ever using drugs was 28.1% (n=298), the frequency of ever selling sex was 14.4% (n=153) and 18.8% (n=200) of participants had ever belonged to an HIV network. Participants knew their HIV status for a median of 7 years (IQR 3–12 years) and 80.5% (n=855) had ever been on ART. Missingness was very low in this analysis—1.1% sexual violence, 3.9% pregnancy coercion, 1.2% sterilisation coercion and 3.1% contraception coercion, with no missing data regarding healthcare violence or any confounding variable.
Table 1. Demographics and characteristics of 1062 women living with HIV in Ukraine, overall and by displacement status.
| N (%), median (IQR) | Non-displaced persons (n=918) | Displaced persons (n=144) | Total (n=1062) | P value* |
|---|---|---|---|---|
| Demographics | ||||
| Age | 38 (33–45) | 43 (38–49) | 39 (34–46) | <0.01 |
| Years HIV status has been known | 6 (3-11) | 12 (7–17) | 7 (3-12) | <0.01 |
| Number of children living in household | ||||
| No children | 475 (51.7%) | 91 (63.2%) | 566 (53.3%) | 0.04 |
| 1–2 children | 392 (42.7%) | 48 (33.3%) | 440 (41.4%) | |
| 3+ children | 51 (5.6%) | 5 (3.5%) | 56 (5.3%) | |
| Education | ||||
| None/primary | 57 (6.2%) | 18 (12.5%) | 75 (7.1%) | <0.01 |
| Secondary | 336 (36.6%) | 70 (48.6%) | 406 (38.2%) | |
| University | 209 (22.8%) | 7 (4.9%) | 216 (20.3%) | |
| Trade School | 316 (34.4%) | 49 (34.0%) | 365 (34.4%) | |
| How often able to meet basic needs recently† | ||||
| Able to meet needs | 354 (38.6%) | 43 (29.9%) | 397 (37.4%) | <0.01 |
| Sometimes able to meet needs | 429 (46.7%) | 53 (36.8%) | 482 (45.4%) | |
| Mostly unable to meet needs | 135 (14.7%) | 48 (33.3%) | 183 (17.2%) | |
| Currently in an intimate relationship | 571 (62.2%) | 76 (52.8%) | 647 (60.9%) | 0.03 |
| Ever sold sex | 112 (12.2%) | 41 (28.5%) | 153 (14.4%) | <0.01 |
| Ever used drugs | 202 (22.0%) | 96 (66.7%) | 298 (28.1%) | <0.01 |
| Clinical Outcomes | ||||
| Recent mental health condition† | 157 (17.1%) | 29 (20.1%) | 186 (17.5%) | 0.37 |
| Recent opportunistic infection† | 59 (6.4%) | 10 (6.9%) | 69 (6.5%) | 0.82 |
| Recent diagnosis with STI† | 44 (4.8%) | 8 (5.6%) | 52 (4.9%) | 0.69 |
| HIV-Related Experiences | ||||
| Experience of HIV-related stigma or discrimination | 316 (34.4%) | 69 (47.9%) | 385 (36.3%) | <0.01 |
| Belongs to an HIV network | 176 (19.2%) | 24 (16.7%) | 200 (18.8%) | 0.48 |
| Ever been on antiretroviral treatment | 733 (79.9%) | 122 (84.7%) | 855 (80.5%) | 0.17 |
| Gender-Based Violence | ||||
| Experienced sexual violence | 53 (5.8%) | 20 (14.1%) | 73 (7.0%) | <0.01 |
| Recent violence in healthcare† | 50 (5.5%) | 19 (13.2%) | 69 (6.5%) | <0.01 |
| Pregnancy coercion | 35 (4.0%) | 13 (9.1%) | 48 (4.7%) | <0.01 |
| Sterilisation coercion | 9 (1.0%) | 5 (3.5%) | 14 (1.3%) | 0.02 |
| Contraception coercion | 15 (1.7%) | 7 (4.9%) | 22 (2.1%) | 0.01 |
p values were calculated using t-tests for continuous variables and χ2 tests for categorical variables.
Recent is defined as occurring within the previous 12 months.
Out of 1062 total cisgender women in this analysis, 144 identified or had ever identified as displaced (13.6%). Of these displaced participants, 88.9% (n=128) were only internally displaced, 6.9% (n=10) were only a refugee/asylum seeker and 4.2% (n=6) were both internally displaced and a refugee/asylum seeker. Of these same participants, 14.1% (n=20) had experienced sexual violence and 13.2% (n=19) had experienced violence in healthcare settings. Of the three types of reproductive coercion, 9.1% (n=13) had experienced pregnancy coercion, 3.5% (n=5) had experienced sterilisation coercion and 4.9% (n=7) had experienced contraception coercion (table 1).
On average, a higher proportion of displaced women had sold sex compared with non-displaced women (28.5% vs 12.2%, p=<0.01). Additionally, a higher proportion of displaced women had used drugs compared with non-displaced women (66.7% vs 22.0%, p=<0.01). Experiences of HIV-related stigma or discrimination were also more common among displaced women (47.9% vs 34.4%, p=<0.01). Finally, a higher proportion of displaced women were unable to meet basic needs most of the time compared with non-displaced women (33.3% vs 14.7%, p=<0.01) (table 1).
Primary analysis
As compared with non-displaced women, displaced women experienced significantly higher prevalence of sexual violence (PR: 2.41, 95% CI: 1.49 to 3.91), violence in healthcare (PR: 2.42, 95% CI: 1.47 to 3.99), pregnancy coercion (PR: 2.28, 95% CI: 1.24 to 4.20), sterilisation coercion (PR: 3.49, 95% CI: 1.19 to 10.28) and contraception coercion (PR: 2.92, 95% CI: 1.21 to 7.03) in unadjusted analysis. These associations remained unchanged when adjusted for potential confounders (sexual violence aPR: 2.74, 95% CI: 1.67 to 4.51) (violence in healthcare aPR: 2.57, 95% CI: 1.49 to 4.43) (pregnancy coercion aPR: 2.60, 95% CI: 1.41 to 4.78) (sterilisation coercion aPR: 4.26, 95% CI: 1.17 to 15.43) (contraception coercion aPR: 2.48, 95% CI: 1.00 to 6.15) (table 2).
Table 2. Unadjusted and adjusted prevalence ratios and 95% CIs for the association of displacement and various types of gender-based violence among 1062 women living with HIV in Ukraine.
| Outcomes* | Unadjusted | 95% CI | Adjusted | 95% CI |
|---|---|---|---|---|
| Sexual violence† | 2.41 | 1.49 to 3.91 | 2.74 | 1.67 to 4.51 |
| Recent violence in healthcare‡ § | 2.42 | 1.47 to 3.99 | 2.57 | 1.49 to 4.43 |
| Pregnancy coercion‡ | 2.28 | 1.24 to 4.20 | 2.60 | 1.41 to 4.78 |
| Sterilisation coercion‡ | 3.49 | 1.19 to 10.28 | 4.26 | 1.17 to 15.43 |
| Contraception coercion‡ | 2.92 | 1.21 to 7.03 | 2.48 | 1.00 to 6.15 |
Primary exposure for every model is being internally displaced or a refugee/asylum seeker versus not (referent).
Adjusted for age, education and current relationship.
Adjusted for age, education and number of children in home.
Recent is defined as occurring within the previous 12 months.
Sensitivity analysis
In sensitivity analysis that excluded women identifying as only refugees/asylum seekers (n=10), effect estimates comparing GBV outcomes by displacement status remained generally unchanged (table 3).
Table 3. Unadjusted and adjusted prevalence ratios and 95% CIs for the association of internal displacement and various types of gender-based violence among women living with HIV in Ukraine.
| Outcomes* | Unadjusted | 95% CI | Adjusted | 95% CI |
|---|---|---|---|---|
| Sexual Violence† | 2.53 | 1.55 to 4.13 | 2.89 | 1.72 to 4.83 |
| Recent Violence in Healthcareठ| 1.86 | 1.06 to 3.24 | 1.94 | 1.09 to 3.47 |
| Pregnancy Coercion‡ | 2.61 | 1.42 to 4.80 | 3.09 | 1.67 to 5.71 |
| Sterilisation Coercion‡ | 3.99 | 1.36 to 11.73 | 5.22 | 1.31 to 20.80 |
| Contraception Coercion‡ | 3.34 | 1.39 to 8.04 | 2.88 | 1.15 to 7.18 |
Primary exposure for every model is being internally displaced versus not (referent).
Adjusted for age, education and current relationship.
Adjusted for age, education and number of children in home.
Recent is defined as occurring within the previous 12 months.
Effect measure modification with drug use
In analyses that explored potential effect measure modification by drug use, associations between displacement and GBV outcomes varied. Among women who did not report a history of habitual drug use, displacement was strongly associated with violence in healthcare (PR: 4.99, 95% CI: 2.46 to 10.12), pregnancy coercion (PR: 3.17, 95% CI: 1.09 to 9.18) and contraception coercion (PR: 4.02, 95% CI: 1.14 to 14.13) (table 4). No such associations were detected among women who reported habitually using drugs such as heroin, cocaine or methamphetamines; however, precision was limited. Of the Wald tests calculated for each of the GBV outcomes, two were significant (sexual violence 17.45, p=<0.01) (violence in healthcare, 7.90, p=<0.01) (table 4).
Table 4. Adjusted PRs and 95% CIs for the association of displacement* and various types of gender-based violence among women living with HIV in Ukraine, stratified by drug use.
| Adjusted PR | 95% CI | Wald test statistic | P value | |
|---|---|---|---|---|
| Sexual violence† | 17.45 | <0.01 | ||
| Lifetime drug use | ||||
| Displaced person | 1.69 | 0.95 to 3.03 | ||
| Non-displaced person | Ref. | Ref. | ||
| No lifetime drug use | ||||
| Displaced person | 2.71 | 0.82 to 8.99 | ||
| Non-displaced person | Ref. | Ref. | ||
| Recent violence in healthcare‡ § | 7.90 | <0.01 | ||
| Lifetime drug use | ||||
| Displaced person | 0.91 | 0.40 to 2.04 | ||
| Non-displaced person | Ref. | Ref. | ||
| No lifetime drug use | ||||
| Displaced person | 4.99 | 2.46 to 10.12 | ||
| Non-displaced person | Ref. | Ref. | ||
| Pregnancy coercion‡ | 1.21 | 0.27 | ||
| Lifetime drug use | ||||
| Displaced person | 1.71 | 0.68 to 4.33 | ||
| Non-displaced person | Ref. | Ref. | ||
| No lifetime drug use | ||||
| Displaced person | 3.17 | 1.09 to 9.18 | ||
| Non-displaced person | Ref. | Ref. | ||
| Sterilisation coercion‡ | 2.06 | 0.15 | ||
| Lifetime drug use | ||||
| Displaced person | 2.56 | 0.58 to 11.26 | ||
| Non-displaced person | Ref. | Ref. | ||
| No lifetime drug use | ||||
| Displaced person | 4.21 | 0.45 to 38.96 | ||
| Non-displaced person | Ref. | Ref. | ||
| Contraception coercion‡ | 0.58 | 0.44 | ||
| Lifetime drug use | ||||
| Displaced person | 1.49 | 0.40 to 5.50 | ||
| Non-displaced person | Ref. | Ref. | ||
| No lifetime drug use | ||||
| Displaced person | 4.02 | 1.14 to 14.13 | ||
| Non-displaced person | Ref. | Ref. |
Primary exposure for every model is being internally displaced or a refugee/asylum seeker versus not (referent).
Adjusted for age, education and current relationship.
Adjusted for age, education and number of children in home.
Recent is defined as occurring within the previous 12 months.
PR, prevalence ratio.
Discussion
This study aimed to establish and quantify the relationship between displacement and GBV among women living with HIV in Ukraine. The analysis built on research exploring non-HIV related forms of GBV among displaced women in both Ukraine and other areas of humanitarian crisis. We found that experiences of displacement in our study population were common, mirroring international reporting by the United Nations Refugee Agency, Human Rights Watch and others both preceding and during the current conflict with Russia.1 6 Displacement was associated with sexual violence, comprising occurrence of rape and coerced sex that have become endemic in conflict and humanitarian settings.30 45 46 Women who were displaced were also more likely to have experienced reproductive coercion and violence in healthcare, which reflects broad abuse by providers that can decrease quality of care and discourage women from engaging with formal health systems.25
The high proportion of women living with HIV reporting lifetime displacement in this study reflects critically high and increasing rates of displacement within the ongoing conflict in Ukraine.47 Historically, women in conflict zones are often unable to meet their most basic needs. International organisations have recently highlighted that safe shelter, access to food and water and trauma-related healthcare are urgently needed to address immediate health risks of displaced populations in Ukraine. Data collected by the NGO, Positive Women, which led relief efforts across four oblasts in Ukraine in 2022 and 2023, documented that 83% of displaced women reported needing food, hygiene products and baby items.48 Additionally, nearly half of all women in this same population reported limited or non-existent access to critical healthcare services, including HIV services.48 National humanitarian responses often deprioritise sexual and reproductive healthcare in favour of other urgent needs until conflict has stabilised and rebuilding commences, and data on such healthcare interventions are limited.49 50 For women living with HIV, this can compromise continuity of care and outcomes throughout the treatment cascade, which are synergistic with their overall health and well-being.51 52
Women who were displaced in this study experienced a high proportion of GBV, including sexual violence, violence in healthcare settings and reproductive coercion, consistent with other reports, both from Ukraine and settings with similarly complex humanitarian healthcare needs.5 30 31 45 However, there are limited data on the frequency of GBV and associated risk factors for women in Ukraine during the period between the annexation of Crimea and the Russian invasion in February 2022.32 33 Several studies conducted in Ukraine analysed intake data from women seeking GBV services, finding that displacement status and age impact the type of GBV experienced.32 33 Displaced women were found to have an increased risk of GBV generally and sexual violence specifically compared with non-displaced women.33 Among WLHIV, sexual violence has been connected to increased risks for depression, greater depression symptom severity and lower quality of life.14 A recent study in Ukraine found that 25% of WLHIV who were in treatment for opioid addiction had experienced sexual violence by police officers, demonstrating the compounding risk of violence for WLHIV who use drugs.53 Another study conducted among WLHIV in Kyiv assessed intersectional stigma related to HIV status and drug use, finding that both internalised and enacted intersectional stigma were predictors of low HIV care engagement.54 A community-led survey conducted in 2016 found that 51% of WLHIV in Ukraine have no support after experiencing violence.35 For conflict-displaced women, unfamiliar systems away from established community may be a barrier to accessing support networks after experiencing violence and potentially amplify feelings of isolation or traumatisation.
Women living with HIV engage with a variety of healthcare services, and experiences of reproductive coercion and abuse threaten their access to quality care. Reproductive coercion and verbal and physical abuse are conceptualised in the PLHIV Stigma Index 2.0 and assessed in this analysis as severe and discriminatory forms of enacted HIV-related stigma. To date, the body of work on reproductive coercion has primarily consisted of qualitative studies, institutional reporting and legal filings by human rights organisations. In these studies, women have reported pressure from clinics to use condoms instead of other contraceptive methods, prioritising the dual prevention of both HIV transmission and pregnancy over the reproductive autonomy of women.24 The findings in this analysis add to this knowledge base on reproductive coercion and abuse and establish new implications for the reproductive health of displaced WLHIV. Condoms cannot be covertly used like IUDs and injectable alternatives, and the well-known connection to HIV prevention in many settings can ‘out’ women to male partners who may not know they are living with HIV. When male partners refuse to use condoms or respond to requests for the use of condoms with abuse or violence, the sexual and reproductive autonomies of WLHIV are acutely threatened. Literature and reporting across humanitarian contexts have also shown that displaced women surviving forced sex are at high risk for unintended pregnancy.46 49 Preventable pregnancy-related deaths also increase in crisis settings, along with rates of unsafe abortion.46 Neighbouring countries such as Poland, which hosts 60% of the 6.5 million total Ukrainian refugees, have more restrictive abortion laws, which could exacerbate the risk of unsafe abortion.1 Emergency contraception could help address loss of autonomy and prevent unplanned pregnancy, but remains inaccessible for many displaced Ukrainian women living with HIV as it requires a prescription.55 Humanitarian aid both in Ukraine and across Europe will require robust family planning and maternal healthcare services to address these compounding threats to the health of displaced women. These services could be integrated with women-centred clinical ART visits and other common touchpoints for displaced WLHIV.52
A key strength of this study is the PLHIV Stigma Index 2.0 standardised structure—this research is designed by and for networks of people living with HIV, with research operations, data collection and descriptive analysis in Ukraine led by people living with HIV.39 Community-based participatory research is vital for equitable research on access to care, intersectional stigma and human rights violations of WLHIV. The reproductive coercion indicators reported in this analysis were developed for the standardised survey tool in partnership with women’s HIV networks. Additionally, data collection predates the Russian invasion, which marked the beginning of accelerated rates of displacement and instability. As such, findings may serve as a benchmark for future analyses that explore the role of displacement and GBV in Ukraine. Notably, the PLHIV Stigma Index 2.0 is designed as a serial data collection tool, and a second implementation could facilitate comparisons as the conflict continues.
This study also has several limitations. The PLHIV Stigma Index 2.0 recruitment methodology prioritises reaching a diverse group of people living with HIV, especially those representing marginalised communities who are under-represented in research and difficult to reach via traditional healthcare surveillance. The PLHIV Stigma Index 2.0 methodology is not intended to yield findings that are generalisable to all women in Ukraine or the global population of WLHIV. Additionally, the methodology was designed to assess stigma across identities but was not designed to support intersectional stigma analysis, and attributing all experiences of violence to specific types of stigmas is challenging. The GBV outcomes assessed in this analysis include those related to HIV-status or common human rights violations experienced by people living with HIV and are not designed to be an exhaustive examination into all types of GBV. Further, the cross-sectional study design cannot differentiate between displacement periods, experiences of violence and pregnancy. Similarly, the relationships explored in this analysis are potentially bidirectional in nature, limiting statistical management of the causal pathways involved. While associations born of humanitarian research can inform programming and research across conflicts (especially regarding understudied topics), each conflict has unique migration patterns, resource constraints and drivers of violence. Also, WLHIV who are currently displaced or have limited access to HIV-related and reproductive healthcare may have been less likely to participate in the study. Data were collected in select oblasts and may not reflect the overall prevalence of displacement and GBV among WLHIV in Ukraine. Increases in GBV and sexual violence have been reported in both Donetsk and Luhansk within the eastern Donbas region, but Luhansk was not included in our overall sample. The associations between displacement and GBV outcomes may be even stronger for women in these specific regions. Finally, while we did perform a sensitivity analysis, we lacked sufficient sample size to explore the relationship between different types of displacement and GBV outcomes given the limited number of refugee/asylum seekers. The analysis of effect measure modification was similarly limited by small subgroup sample sizes and lack of precision, particularly among participants who reported lifetime drug use. However, future efforts that disentangle the relationship between experiences of drug use, displacement and violence among WLHIV are likely warranted.
Despite these limitations, this is one of the first studies to provide evidence regarding the immense and specific health needs of conflict-displaced women living with HIV in Ukraine. Quantifying the relationship between displacement and GBV outcomes that are intertwined with complex levels of HIV stigma provides a much-needed evidence base for violence and abuse prevention and programmatic interventions for survivors, both in Ukraine and other conflict-affected settings.
Conclusion
As the war in Ukraine continues, humanitarian and health systems can use these findings to guide integration of GBV referrals and scale-up of trauma-informed care and antiexploitation training into existing and emerging programmes in Ukraine. Moreover, additional surveillance methods, particularly support for community-led monitoring, are likely needed to ensure experiences of coercion and abuse in healthcare settings are routinely documented. There is also a clear need for transformative approaches to tackle structural causes of gender inequality, HIV and violence. Access to sexual and reproductive healthcare interventions in the face of the ongoing and systemic threat of violence against women living with HIV is essential for health, dignity and human rights.
Supplementary material
Acknowledgements
We would like to extend our sincere appreciation to the stakeholders who provided critical oversight and were instrumental in the successful implementation of the PLHIV Stigma Index 2.0 in Ukraine. Specifically, we would like to thank the Global Network of People Living with HIV (GNP+), The International Committee of Women Living with HIV (ICW), and the Joint United Nations Programme on HIV/AIDS (UNAIDS). We are incredibly grateful to 100% Life for providing critical technical assistance in ensuring study coordination and implementation, including data collection. Above all, we want to thank the women living with HIV in Ukraine who informed this work by participating in the PLHIV Stigma Index 2.0 survey. We would also like thank this same group of stakeholders, partners, and study participants for their contributions to the oral abstract presenting this work at the IAS 2023 Conference in Brisbane.
Footnotes
Funding: The PLHIV Stigma Index 2.0 in Ukraine was funded by USAID through the framework of the HealthLink Project, award number RFA-121-17-00000. KR was supported through the National Institute of Mental Health (NIMH) under award number K01MH129226. The research presented in this manuscript was also made possible through additional grants from NIMH under award number R01MH110358. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Provenance and peer review: Not commissioned; externally peer reviewed.
Handling editor: Manasee Mishra
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and the primary data collection of the PLHIV Stigma Index 2.0 in Ukraine was approved by the Professional Ethics Commission at the State Institute of Family and Youth Policy, with reference number 137/01. The Johns Hopkins School of Public Health institutional review board provided approval for secondary data analysis. All participants gave informed consent before participating in the study. Participants gave informed consent to participate in the study before taking part.
Data availability free text: Data are available upon reasonable request and are accessible for all authors regardless of affiliation.
Patient and public involvement: Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.
Data availability statement
Data are available upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available upon reasonable request.