Prevalence and factors associated with intimate partner violence after HIV status disclosure among pregnant women with depression in Tanzania

Abstract

Intimate partner violence (IPV) exacts a heavy burden on women, resulting in poor health outcomes. This study had the following aims: 1) estimate the prevalence of IPV post-disclosure of HIV status among pregnant women living with HIV and depression; and 2) evaluate risk and protective factors for IPV post-disclosure. Participants were women accessing PMTCT services at 16 health facilities in Dar es Salaam and screened at the threshold of 9 on the PHQ-9. Generalized linear equations with a log link and standard errors clustered at the facility level were used to calculate associations between predictors and IPV post-disclosure. Among 659 women who were in an intimate relationship, 10.2% had experienced physical violence and 11.6% had reported sexual violence from their partner in the past six months; 327 had disclosed their HIV status to their partners. After disclosure to their partners 279 women (85.3%) experienced IPV. HIV-related stigma was associated with increased risk of IPV following disclosure and appreciative relationships with partners and higher hope were associated with reduced risk of IPV. There is a need to identify and advance approaches to HIV disclosure that prevent IPV. Interventions should be developed based on known risk and protective factors for IPV following HIV disclosure in Tanzania and similar settings.

INTRODUCTION

Intimate partner violence (IPV) is a major public health problem that exacts a heavy burden on women, resulting in poor physical as well as psychological health outcomes. Globally it is estimated that approximately one-third of women experience physical and/or sexual violence in their lifetime, making it the most common form of violence among women, with as many as 38% of all murders of women committed by intimate partners (WHO, 2013). The burden of IPV varies widely and is associated with factors at individual, family, community, and societal levels. Estimates of lifetime prevalence of physical and/or sexual partner violence among women range from 15% to 71% and estimates of one-year prevalence range from 4% to 54% (Kouyoumdjian et al., 2013).

Studies from sub-Saharan Africa have documented that IPV is a critical problem. In Kenya, the Demographic and Health Survey estimated that almost half of women (47%) experienced IPV in their lifetime (Makayoto et al., 2013). Studies in South Africa, Uganda, Kenya, Zimbabwe and Ethiopia have reported estimates of IPV among women ranging from 13% to 45% (Maman et al., 2002). One study from South Africa indicated that IPV was the second highest contributor to the burden of disease after HIV, in which IPV accounted for 62.4% of the total burden among women (Joyner et al., 2011). In Tanzania, the lifetime prevalence of IPV across regions, has ranged from 15% to 60% (Kazaura et al., 2016; National Bureau of Statistics, 2011).

Women living with HIV are at a greater risk of IPV compared to HIV-negative women, with IPV sometimes occurring during or after the disclosure of their status to their partners. A study in Dar es Salaam, Tanzania, found that women living with HIV were nearly twice as likely to have violent partners compared to HIV-negative women (52.2% vs 28.9%) (Maman et al., 2002). Although disclosure of HIV status to intimate partners can help women obtain social support, reduce stigma, and improve antiretroviral therapy (ART) adherence, a significant barrier exists due to fear of negative reactions after disclosure. Anticipation of abandonment or violence from a partner can serve as a significant barrier to HIV status disclosure. A recent systematic review found that following HIV status disclosure to a partner, between 3.5% and 14.6% of women across studies reported experiencing negative reactions, including violence from their intimate partner (Kennedy et al., 2015).

IPV is strongly associated with women’s health outcomes, including a negative impact on mental health outcomes, such as depression, suicidal ideation or attempts, post-traumatic stress disorder (PTSD), and other forms of anxiety (Deborah et al., 2017). Evidence has shown that experiencing IPV is a risk factor for depression (Kabir et al., 2014). Previous studies among women affected by IPV found that 60–90% developed anxiety disorders, including PTSD, and approximately 50% developed mood disorders, such as depression (Zunner et al., 2015). However, in many resource-limited settings such as Tanzania there are a limited number of trained health care personnel to identify women living with HIV who are at risk of IPV and related mental health outcomes. Additionally, there is often little access to referral options for women who experience violence, regardless of their HIV status (Kennedy et al., 2015). IPV can impact transmission of HIV from mother to child, since many women who are in violent relationships fear disclosing their status to their partners which leads to limited access and/or adherence to PMTCT services (Mulrenan et al., 2015). Furthermore, the relationship between IPV and adherence/access to PMTCT services can be mediated by depression, since it can cause significant fatigue and negatively affect self-care (Vranceanu et al., 2008).

Despite all of these challenges, there have not been enough studies on the prevalence and forms of IPV among depressed pregnant women after disclosure of their HIV status to their partners. It is important to address IPV after disclosure of a woman’s HIV status in order to build room for safer disclosure of HIV status among pregnant women living with HIV, particularly among women suffering from depression. Therefore, the aims of this study were to: 1) estimate the prevalence and types of IPV post-disclosure of HIV status among pregnant women living with HIV and depression attending antenatal clinics in Dar es Salaam, Tanzania; and 2) evaluate risk and protective factors for IPV post-disclosure in this vulnerable population.

MATERIALS AND METHODS

Setting

The study was conducted among women accessing PMTCT services at 16 health facilities within three districts of the Dar es Salaam region of Tanzania: Ilala, Kinondoni, and Temeke. Healthcare facilities were eligible for inclusion in this study if they were government-managed clinics in Dar es Salaam that were supported by the study partner, Management and Development for Health (MDH). Within the public sector, PMTCT care is offered within the context of reproductive as well as pediatric care at Reproductive and Child Health (RCH) clinics. All women at RCH clinics are offered a rapid HIV test during their first prenatal visit unless they have been previously tested, with results available on the same day of testing. If they are positive then they are referred for Option B+ PMTCT services, which involve the provision of antiretroviral therapy (ART) regardless of CD4 count (Sariah et al., 2019). PMTCT services are provided until breastfeeding the child is complete. Within the context of these services women are typically not advised if or when to disclose their HIV status. The decision to disclose to partners and other family members is at the discretion of the women.

Study design and population

Baseline data from a cluster randomized controlled trial (RCT) were analyzed (Smith Fawzi et al., 2020). All women attending clinics for PMTCT services from May 25, 2015 to April 29, 2016 were approached to identify those that were eligible to participate. Inclusion criteria were: elevated depressive symptoms comparable with major depression (having a Patient Health Questionnaire-9 (PHQ-9) score of 9 or greater) (Smith Fawzi et al., 2019); 18 years of age or above; pregnancy less than 30 weeks of gestation; receiving PMTCT services at study sites; and planning to attend the same clinic after delivery. Women were enrolled if they were eligible and provided written informed consent. Among those who were eligible 98% participated. Data were collected by trained Swahili-speaking interviewers using structured questionnaires to obtain information on sociodemographic measures, experience with physical or sexual IPV in the past six months, disclosure of HIV status, IPV post-disclosure, and additional measures of social and emotional health. For this analysis, we included all participants who stated they had been in an intimate partner relationship in the six months prior to the interview.

Measures

The primary outcome of interest was IPV after disclosure of HIV status. Disclosure was assessed through a questionnaire that was adapted from a prior study conducted among pregnant women living with HIV in Dar es Salaam. This questionnaire included the woman’s report of her partner’s responses to disclosure of her HIV status, with items reflecting physical and emotional IPV (Antelman et al., 2001). There were six items indicating emotional violence (did not believe me, did not react at all, angry at me for testing, blaming me for becoming infected, left me in the house, told me to leave the house) and one indicating physical violence (physically beat or hit me). If the women reported any of these items she was coded as experiencing IPV post-disclosure.

Intimate partner violence, physical and/or sexual, in the past six months was measured based on items derived from the domestic violence module of the 2011 Tanzania Demographic and Health Survey (TDHS, 2011). The quality of relationship with her intimate partner was also measured by asking the participants whether they appreciated their relationship with their partners, whether they felt like they were appreciated by their partners, and if their partners listened to them. Other variables which were collected as predictors included: age; marital status; education level; employment status; food insecurity; depressive symptoms based on the PHQ-9 (Kroenke et al., 2001); ART non-adherence through self-report of missing all of their ART doses in the past four days (Ivers et al., 2014; Safren et al., 2014); HIV-related stigma based on items derived from the HIV-Stigma Scale developed by Berger et al., (2001), which included items for internalized (e.g. ‘I feel guilty that I am HIV-positive’) as well as externalized stigma (e.g. ‘people have avoided me because I have HIV or suspect that I have HIV’); problems with alcohol, measured using the five-item Rapid Alcohol Problems Screen (RAPS-5) (Cherpitel et al., 1995); social support, assessed using the Duke University-UNC Functional Social Support Questionnaire that has been used in prior studies in Tanzania (Broadhead et al., 1988); self-efficacy, measured with the General Self-Efficacy Scale (Schwarzer et al., 1997); and hope, based on a scale developed by Siril et al., (2017) with individuals living with HIV in Tanzania. The hope scale was developed among men and women living with HIV who were accessing ART. In this population hope was characterized by positive emotions, evidence of better clinical prognosis related to ART, and the normalization of their lives as a result (Siril et al., 2017).

Statistical analysis

Data were entered into Microsoft Access then exported to Stata version 14.2 (StataCorp LP, College Station, USA) for analysis. We first calculated descriptive statistics for the sociodemographic and economic characteristics for the population of women who reported being in an intimate partner relationship. We reported proportions for all categorical variables and the mean, standard deviation, and range for all continuous variables. In addition, we calculated the proportion of women who reported any IPV post-disclosure as the proportion who reported any of the negative responses shown in Figure 1. We used generalized linear equations with a log link and standard errors clustered at the facility level in order to calculate the association between each predictor of interest and any IPV post-disclosure. Then, in order to account for confounding by potential sociodemographic characteristics, we conducted multivariable analyses for each predictor of interest adjusting for age and education.

Figure 1. Types of intimate partner violence experienced by women following disclosure (n=327)*.

*n=327 participants that disclosed their HIV status to partners

Ethics statement

The study was reviewed and approved by the institutional review boards of the Harvard Medical School in the U.S. and the National Institute for Medical Research (NIMR) in Tanzania. All respondents were enrolled in the study after they had provided written informed consent.

RESULTS

Among 742 women participating in the larger study, 659 women (88.8%) reported that they were in an intimate relationship in the past 6 months and were thus included in these analyses. The mean age of participants was 29.7 years (SD=5.4; range of 18–43) among whom 140 (21.3%) were not married or living with a partner, while 516 (78.7%) were either married or living with a partner. Over 46% were not employed and approximately 34% reported having difficulty satisfying food needs in the past six months (see Table 1).

Table 1.

Baseline sociodemographic and economic characteristics of pregnant women living with HIV and depression in an intimate relationship in the past six months in Dar es Salaam, Tanzania (n=659)

Sociodemographic characteristic	n (%)*
Age (years)
18–24	113 (17.2%)
25–34	406 (61.6%)
35–43	140 (21.2%)
Marital Status
Not married or living with a partner	140 (21.3%)
Married or living with a partner	516 (78.7%)
Highest level of education attainment
Less than primary school	87 (13.3%)
Primary school	433 (66.1%)
Secondary school	135 (20.6%)
Employment status
Employed/self-employed	354 (53.9%)
Not employed	303 (46.1%)
Main source of water
Improved water source	420 (63.8%)
Other	238 (36.2%)
Difficulty in satisfying food needs in past 6 months
Yes	226 (34.4%)
No	431 (65.6%)
Owes money for purchased food
Yes	184 (28.0%)
No	474 (72.0%)

^*Totals may be less than 659 due to missing data.

Among the 659 women who were in an intimate relationship 67 (10.2%) had experienced physical violence, and 76 (11.6%) had reported sexual violence from their partner in the six months prior to interview. Seventy-six percent of women disclosed their HIV status to anyone outside health facility staff, of whom 67% (n=327) had disclosed their HIV status to their partners. After disclosing their HIV status to their partners 279 women (85.3%) experienced IPV with 85.3% reporting emotional IPV and 3 (0.9%) experiencing physical violence. A large percentage of partners did not believe the woman (54.3%) or did not react at all (33.6%). In addition, 5.2% left the woman in the household and 4.6% told her to leave the home (Figure 1).

Participants with HIV-related stigma had an increased risk of experiencing intimate partner violence following disclosure (RR: 1.05, 95% CI: 1.01, 1.10). In addition, participants with an appreciative relationship with their partners (RR: 0.96, 95% CI: 0.93–1.00) and those with higher hope (RR: 0.89, 95%, CI: 0.79–0.93) had a reduced risk of experiencing IPV. Participants with food insecurity and those with ART non-adherence demonstrated a trend towards an increased risk of experiencing IPV; however, these factors were not statistically significant. Additionally, findings in this study demonstrated that age, education level and marital status were not associated with IPV after disclosure (see Table 2).

Table 2.

Bivariable and multivariable regression models of factors associated with intimate partner violence (IPV) following disclosure of HIV (n=327)

	Bivariable models			Multivariable models^
	n	Risk ratio	95% CI	n	Risk ratio	95% CI
Risk factors
Depressive symptoms	320	1.00	(0.98 – 1.01)	319	1.00	(0.98 – 1.01)
ART non-adherence	310	1.15	(0.93 – 1.35)	321	1.12	(0.93 – 1.35)
HIV-related stigma	279	1.05**	(1.01 – 1.11)	278	1.05**	(1.01 – 1.10)
Problems with alcohol	320	0.99	(0.82 – 1.19)	319	0.98	(0.82 – 1.18)
Food insecurity	321	1.05	(0.92 – 1.19)	320	1.05	(0.92 – 1.20)
Protective factors
Social support	322	0.96	(0.86 – 1.07)	321	0.95	(0.86 – 1.07)
Appreciative relationship with partner	322	0.96**	(0.93 – 1.00)	321	0.96**	(0.93 – 1.00)
Hope	319	0.86***	(0.79 – 0.93)	318	0.89***	(0.79 – 0.93)
Self-efficacy	322	1.00	(0.95 – 1.05)	321	1.00	(0.95 – 1.06)

Notes:

^{^}Multivariable analyses adjusted for age and education.

^*p-value < 0.1

^**p-value < 0.05

^***p-value < 0.01

DISCUSSION

The rate of emotional IPV that women living with HIV and depression experience after disclosure was very high (85.3%) compared to physical violence (1.0%). Furthermore, the rate of sexual IPV in the past six months among women who were in an intimate partner relationship was slightly higher (11.6%) than physical violence (10.2%). Shamu et al. (2014), in a study implemented in Harare, Zimbabwe, found that among 259 pregnant women living with HIV who disclosed their HIV status to their partners, 141 (58.3%) experienced negative reactions from their partners, with nearly 41% reporting any kind of abuse. Among women living with HIV attending reproductive health services in Kenya, nearly one-third of the respondents reported experiencing physical and emotional violence from their partners following disclosure (Colombini et al., 2016). Similarly, in antenatal clinic populations in Johannesburg, a study to understand the links between IPV and HIV-related health status of pregnant women found that disclosure leads to violence because it can result in conflict, with women often being blamed for bringing the disease into the relationship (Hatcher et al., 2014). These studies, together with our findings, suggest that HIV status disclosure can be a period of high risk for IPV and should be addressed carefully.

Furthermore, a study that was conducted in Zambia demonstrated an association between the severity of IPV against women living with HIV and the chances of HIV status disclosure to male partners— for each violent event a woman experienced in her current relationship, she had significantly reduced chances of HIV status disclosure to her current male partner. They also found that the most common type of IPV women experienced was emotional IPV (40%), followed by sexual IPV (34%), and physical IPV (32%) (Hampanda et al., 2018). In a study performed among women living with HIV attending clinics in Kisumu, Kenya, all participants perceived that violence against women living with HIV was highly prevalent, whereby the majority of participants (79%) reported that violence against women living with HIV began after they disclosed their HIV status to their male partners (Zunner et al., 2015). In Dar es Salaam, Tanzania, a study amongst women testing for HIV found that women that tested positive were more than twice as likely to report physical and sexual violence with their current partner than those that tested negative (52.2% vs 28.9%); and over one-quarter (27.2%) of the women agreed or strongly agreed that violence was a major problem in their lives (Maman et al., 2002). Findings from these studies demonstrate that intimate partner violence among women living with HIV is something that needs urgent intervention.

Factors associated with IPV following disclosure in the present study included HIV-related stigma, appreciative relationship with partner, and hope. ART non-adherence and food insecurity demonstrated a trend towards an increase in risk, although these results were not significant. Other factors, such as age, education, problems with alcohol, and self-efficacy were not associated with IPV after disclosure of HIV test result among this population of pregnant women living with depression and HIV. Similar findings were observed in South Africa among women living with HIV receiving antenatal services, which found that having more social support and an appreciative relationship were associated with a reduction in women’s IPV victimization (Carpenter et al., 2017). Our findings together with results from South Africa suggest that a point of entry to improve IPV post-disclosure may be to intervene to improve social support, the quality of relationships with partners, and hope. These interventions may require focusing on both the woman and her partner. In contrast, another study in Tanzania found that factors associated with IPV included marital status, age, and education level (Kazaura et al., 2016). These individual-level factors may be more challenging to address from a public health perspective.

This study has several limitations. This study did not explore which approaches participants used to disclose their HIV status to partners and how long it took for the participant to experience IPV after disclosure. This limits our ability to determine if some strategies for disclosure are more effective in limiting IPV. In addition, this study did not assess from which partner the IPV resulted in the past six months. It is possible that the IPV was from former partners whom they were no longer with at the time of disclosure. Similarly, we do not know if this was the first incident of IPV, or if this was one of many incidents within the relationship. Also, the non-significant trend of the association between ART adherence and IPV following disclosure may be related to the fact that all women in this sample had depressive symptoms comparable with moderate-to-severe clinical depression. This lack of variability in depression status may have resulted in an underestimate of this association. On a similar note, there is also limited generalizability of the findings to populations that are not living with HIV and/or not depressed. Finally, this was a cross-sectional analysis, and as such we were not able to determine the temporal relationship and therefore causality for any of the risk and protective factors examined.

Conclusion

In summary, these findings indicate that there is a need to identify and advance approaches to safe HIV disclosure in order to prevent IPV. Several strategies can be pursued to address intimate partner violence, including working with known perpetrators to prevent their continued use of violence, safety planning for women living with HIV who are at risk of experiencing violence, and advancing interventions that focus on safe disclosure. Findings from the present study suggest that reducing HIV-related stigma, promoting the quality of relationships with partners, and hope can play a role in preventing IPV after disclosure of HIV status. Given the significant burden of IPV, interventions should be developed and evaluated based on the given evidence regarding risk and protective factors for IPV following HIV disclosure in Tanzania and similar settings.