To our knowledge, this is the first study to examine the associations between HIV risk behaviours and experiencing IPV among a random sample of predominantly low income, ethnic minority women receiving care at an urban ED. Consistent with rates found in other studies,1,15,16,17
the findings show that a substantial number of female patients in the ED reported experiencing sexual, physical and/or injurious IPV both in the past 6 months and over their lifetime. These IPV rates underscore the severity of the problem among female patients in the ED, in particular the high rates (15%) of severe sexual coercion (rape). Women who are sexually abused clearly are at high risk for HIV transmission because safe sex and use of condoms are not practised during forced sex. The finding that the majority of the sample was sexually active, but that less than one‐fifth always used condoms also highlights these women's significant risk for HIV/STI transmission. Consistent with the findings of other studies in ED settings, HIV seropositivity was high in our sample of women.14,22,23
Several HIV risk behaviours were significantly associated with experiencing IPV, including: having had sex with a HIV‐positive partner or an IDU, having had sex with more than one partner and injection drug use. Dovetailing with several previous studies,5,10,25,35,36
this study found that women seen in an inner city ED who have had sex with a HIV positive partner or an IDU have an increased likelihood of experiencing IPV. Recent research findings have indicated that the relationship stress created over a partner's injection drug use or HIV status may escalate into IPV.29,30
Moreover, the significant relationship between having multiple sexual relationships and experiencing IPV, a finding which is consistent with previous studies,7,10,12
suggests that a partner's perception of a woman's additional sexual affairs may trigger IPV, or, conversely, that a woman's experience of IPV may lead her to engage in outside relationships. Finally, the significant relationship between a woman's IDU and experiencing any type of IPV and any severe IPV is consistent with previous studies that propose that gender‐based inequalities often pervade the practice of injecting drugs.1,4,5,37,38
According to our research, women are forced to use and in some cases inject drugs with their male partner for several reasons: (1) to obtain financial support from him for household expenses, (2) to obtain protection against other drug users in her social network, (3) out of fear of losing the relationship and (4) for other financial and social dependencies.4,5
This finding could also indicate that psychological distress and physical pain from IPV may lead women to inject drugs as a means to cope with IPV.
This study is limited by the following factors:
1. The non‐response rate in this study limits the generaliseability of the study findings. For example, the exclusion of women who were admitted because of psychiatric emergencies, which has been found to be associated with a range of mental health problems may underestimate the rate of IPV.39,40,41
2. The cross‐sectional design of this study prohibits drawing conclusions about the causal relationships between HIV risks and IPV.
3. Research shows that IPV is associated with a number of health problems not adjusted for in the analysis.
4. Collecting sensitive, person‐identifiable data and paying study participants may potentially bias results.
5. The study would have been strengthened by the use of a validated scale for socioeconomic status, rather than the use of education, employment and homelessness as markers of socioeconomic status.
Despite these limitations, the study findings underscore that IPV is a health‐related risk factor that needs to be addressed as a public health problem by health professionals, in particular ED staff. Furthermore, our findings build on what are known clinical indicators of IPV (eg, multiple injuries, drunkenness, depression and post‐traumatic stress disorder (PTSD))42
by identifying HIV risk behaviours as potential “abuse indicators” that should prompt inquiry into abuse, particularly when consultation time with patients is limited. While some researchers argue that there is insufficient empirical evidence to show that identification of abused women contributes to either reduction of IPV or improvement in quality of life,43,44
today, many professional associations in the US and England45,46,47,48,49,50
recommend routine inquiry for IPV for all patients who visit EDs and other healthcare settings—a recommendation also supported by epidemiological data.51,52,53,54,55
Research has also recognised a number of challenges that include time constraints, professional discomfort with raising the topic, the patient's fear of disclosure, staff attitudes toward women who experience IPV, lack of staff training on the topic and lack of evidence on effective IPV interventions that can be used to help women. These challenges, while significant, should not obviate the goal of routine inquiry for IPV, but should lead to identifying effective ways to safely conduct inquiry, and to develop more effective interventions to address IPV.50,56,57,58,59
HIV testing and IPV routine inquiry for women in ED settings, in particular for women who disclose IPV or report HIV risk behaviours or positive HIV serostatus, would offer an important window of opportunity to initiate treatment and referral for services for women affected by these overlapping epidemics.