Weaponizing HIV: Qualitative interviews with pregnant Zambian women depicting a unique typology of HIV-specific intimate partner violence

Dear Editor,

The bidirectional relationship between HIV and intimate partner violence (IPV) among women has been well established in the literature where is IPV is a risk factor for HIV and women living with HIV (WLWH) are at increased risk of IPV [1-4]. Further, IPV is associated with sub-optimal engagement in HIV care and treatment adherence among WLWH. In Zambia, a southern African country with the seventh highest HIV prevalence globally, 14 % of adult women are living with HIV and 47 % of women report IPV [2,5]. Our prior work indicates that among postpartum WLWH, the IPV prevalence is even higher (60 %). Even with robust evidence on the intersection of HIV and IPV, little is known about how a woman’s HIV status can be a targeted tool of IPV. This letter seeks to fill that research gap by reporting our evidence that male partners are weaponizing a woman’s HIV-positive status through abuse, thereby describing a unique typology of HIV-specific IPV among WLWH in Zambia.

In 2019, we conducted semi-structured qualitative interviews with a convenience sample of 30 pregnant WLWH attending antenatal care at a large district hospital in Lusaka. The aim of the parent study (K99MH116735; PI: Hampanda) was to explore relationship dynamics within Zambian couples and the acceptability of couples-based approaches to promote engagement in HIV care during and after pregnancy. Interviews were conducted by a local qualitative researcher in the local languages, translated and transcribed, and thematically coded in Atlas.ti using constant comparison.

Our population of WLWH had a mean age of 30.9 years ± standard deviation (SD) 6 years, they were predominantly married (90 %), had been in the current relationship at least three years (70 %), had a mean parity of 2.7 ± SD 1.8. 86 % of the sample had completed primary education but only 23 % had completed secondary education. 96 % of participants had electricity in their home and 90 % reported disclosing their HIV-positive status to the male partner.

Of this cohort of WLWH, two-thirds (n = 20) reported experiencing any IPV, and 23 % (n = 7) reported that they experienced IPV that was specifically HIV-driven. 100 % (n = 7) of those reported the IPV was emotional/verbal, with two women also reporting physical abuse and two reporting economic abuse.

Table 1 presents illustrative quotes from WLWH describing the HIV-specific IPV they experienced. The quotes regarding emotional and psychological abuse primarily centered around partners degrading women’s sense of self-worth because they were living with HIV. This came in the form of accusations of women’s infidelity or promiscuity. Women also discussed IPV tactics, including isolation and men’s refusal to talk to them or sleep in the same room after finding out their HIV status. Economic abuse was also reported in the form of denying access to resources to buy food during pregnancy.

Table 1.

Quotes from Zambian women living with HIV regarding experiencing intimate partner violence in pregnancy, specific to their HIV status.

Description of Participant	Illustrative Quote
30-year-old woman who experienced physical and emotional IPV due to her HIV status	"… I told him [that I tested HIV positive at antenatal care] but his reaction towards me was not good. I got scared … [the reason he was beating me was] he brought the issue of my being HIV positive, that I am a prostitute … he thought that I brought the disease [into the relationship] … he does use words that are so hateful to me … what he says makes me sad."
24-year-old woman who experienced physical, emotional, and economic abuse due to her HIV status	"he refused [to come] when I told him we should go to the hospital {for couple HIV testing] … He just slapped and beat me … [when I told him my status] he was upset, he said I am the one who brought him this virus and he even beat me just there … the main reason I left is because of getting beaten because I was [HIV] positive … All along he was a bit difficult but after he found out I was positive, then everything changed and things became difficult … he was saying that [HIV] was from my prostitution … Now we don’t even talk to each other It is hard especially since I found out I was positive … I am suffering a lot especially on the food part because he does not buy me food to eat. I do not even know if my baby will survive … … even eating now I eat from the neighbors.
38-year-old woman who experienced emotional abuse in the form of isolation due to her HIV status	" we went to the clinic and got tested [together] and we found out we were both positive … That was the only discussion we had about it [HIV] even after we went home he was just quiet up to today. There is no communication at all between us … The issue of sleeping in separate bedrooms started when I found out that I was pregnant and at the same HIV positive … That’s when he started behaving like that."

Our study was limited by the fact that we did not design the interview guide with questions about HIV-specific IPV, and accordingly our results are exploratory and hypothesis generating. The interviews may also have been vulnerable to social desirability and recall bias. Strengths of the analysis are its contribution to understanding how women’s HIV status is weaponized against them. Our results suggest that while more research on this specific topic is needed, we have identified a unique typology of HIV-specific IPV that significantly hinders the mental and physical health of WLWH around the time of pregnancy in Zambia, and potentially other, similar settings. Dissemination of these findings to HIV and IPV programs will enhance their ability to understand and support WLWH experiencing IPV.