Among this sample of HIV-positive women receiving care in an inner city clinic, nearly 27% percent reported experiencing IPV in the past year, while only 1.4% of women in the general population report experiencing physical or sexual IPV in the past year (Breiding et al., 2008
). This high prevalence among HIV-positive women is consistent with existing literature on the intersection between HIV and IPV, which suggests that populations at risk for HIV are often the same that are at risk for experiencing violence in their intimate relationships (Gielen et al., 2007
The relationship between IPV and depressive symptoms that was found among this sample is consistent with the literature on the association between IPV and psychiatric disorders. In this sample, women who reported mild depressive symptoms were over 3 times more likely to report experiencing IPV in their relationships, and women who reported severe depressive symptoms were over 5 times more likely to report experiencing IPV. Other literature indicates that psychiatric disorders are particularly prevalent among women with both HIV and IPV. One study indicated that women who were both HIV-positive and had ever experienced IPV as an adult were 7 times more likely to report having a problem with depression, 5 times more likely to report having a problem with anxiety and 12.5 times more likely to report having ever attempted suicide, as compared to their HIV-negative counterparts who never experienced IPV (Gielen, McDonnell, O’Campo, & Burke, 2005
). Such adverse mental health sequelae has been shown to be associated with increased morbidity among HIV-positive women, and faster progression to AIDS, as well as with decreased CD4 counts and immune functioning (Boarts, Sledjeski, Bogart, & Delahanty, 2006
; Ickovics et al., 2001
; Sledjeski, Delahanty, & Bogart, 2005
A novel finding from this analysis is the association between missed gynecological appointments and IPV. In the bivariate analysis, a higher proportion of women who missed gynecological appointments reported experiencing IPV compared to women who did not miss any appointments. The regression analysis indicated that women who missed any gynecological appointments were more likely to have experienced IPV, although when controlling for other factors, this increased odds was only borderline significant. However, this suggests that missed gynecological appointments could be an important indication that women are experiencing IPV, and could serve as a critical marker for providers who might not otherwise learn of the violence their patients are experiencing. Some existing research does suggest that partners can interfere with women’s health care visits and medical treatment, particularly for those who are HIV-positive (Lichtenstein, 2006
). One study examining women outpatients found that those who experienced physical abuse in the past year were 7.5 times more likely to report that their partners prevented them from seeing a healthcare provider or interfered with their health care, compared to women who did not experience abuse (McCloskey et al., 2007
). However, our findings indicate that women who are experiencing IPV are specifically more likely to miss gynecological appointments, but not primary care appointments. One possible explanation for this finding is that gynecological exams are more invasive and women who are experiencing violence in their relationships might be particularly uncomfortable with an invasive exam. Qualitative findings indicate that fear of a pelvic exam or feeling violated by a pelvic exam are among several reasons why women might miss their gynecological exam (Tello et al., 2010
). These reasons might be particularly relevant for women who have experienced trauma and violence, especially if they have experienced sexual violence by their intimate partner. While we did not explicitly assess for sexual violence, one of the screening questions used to measure violence (“Have you been hit, kicked, punched, or otherwise hurt by someone you were in a relationship with in the past year?”) could have captured women who have been sexually abused (i.e., “otherwise hurt”). Additionally, research on a similar population of HIV positive women indicates that 20% experience both physical and sexual IPV (Burke, Thieman, Gielen, O’Campo, & McDonnell, 2005
), suggesting that a similar percentage of women in our sample that reported physical IPV have also experienced sexual violence.
Neither ART prescription, CD4 count, nor HIV-1 RNA were significantly associated to IPV, indicating that women in this clinical sample who experienced IPV are being prescribed ART treatment and responding to treatment at comparable rates with their counterparts who did not experience violence in the past year. Although previous literature suggests that the experience of IPV is associated with inconsistent medication use (Jones et al., 2010
; Lopez et al., 2010
), and that lower CD4 counts are associated with lower rates of abuse (Gruskin et al., 2002
), we suspect that these comparable rates of ART prescription, CD4 counts, HIV-1 RNA levels (as a proxy for ART adherence and use) are due to the fact that this sample of women is
more clinically engaged than the general population of HIV-positive women. In this sample, women completed an average of 4.9 primary care appointments a year, which did not differ by IPV status, and an average of 2.3 gynecological appointments, suggesting that they are receiving consistent clinical care. Therefore, even women who experienced IPV were not less likely to be prescribed ART and their consistent disease management resulted in viral loads comparable to their counterparts who did not experience IPV.
Drug use was not found to be significantly associated with the experience of IPV in the past year, which is inconsistent with current literature. Several studies have indicated that women who used any drugs were more likely to experience physical or sexual IPV as compared to women who used no drugs (Burke et al., 2005
; El-Bassel, Witte, Wada, Gilbert, & Wallace, 2001
; Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997
). We hypothesize that women with active drug use and IPV may not be accessing clinical services consistently. Because our sample was recruited in a clinic waiting room, we did not survey individuals not engaged in clinical care. Women with the most severe drug use may not have been captured in this study. Our setting differs from the previous studies conducted by Burke et al (2005)
El-Bassel et al (2001)
, and Kilpatrick et al (1997)
, which recruited women from a variety of settings, including community centers, shelters, and a general population database. Alternatively, women who had used drugs anytime earlier than within the previous month would not have been included as having used drugs in the past month, but might still be drug abusing or drug addicted. If these women reported being abused, but were classified as having not used drugs, then any possible association between drug use and IPV in this sample might have been attenuated.
These findings have important implications for practitioners who care for HIV-positive women. First, the increased prevalence of experiencing IPV among this clinical sample highlights the importance of screening women for IPV. In order to even begin to refer women to resources and services that could increase her safety, women who are experiencing violence in their intimate relationships must be identified. While many women might be very aware of the IPV they are experiencing, they do not often disclose this to their health care providers voluntarily (Plichta, Duncan, & Plichta, 1996
). Furthermore, only 5–15% of female patients on average disclose about their IPV to their healthcare providers or report being asked about IPV by their practitioners (Rodriguez, Sheldon, Bauer, & Perez-Stable, 2001
). Numerous validated tools exist, including the Partner Violence Screen, that can be used to quickly and accurately in a clinical setting to identify women who are experiencing IPV (Rabin et al., 2009
In addition to being screened for IPV, HIV positive women should also be screened and for depressive symptoms and other psychiatric disorders, which could subsequently serve as a indication of possible IPV. Psychiatric disorders, such as depression, anxiety and PTSD, are associated with increased morbidity and faster progression to AIDS among HIV-infected individuals (Boarts et al., 2006
; Ickovics et al., 2001
; Kimerling et al., 1999
; Leserman et al., 2000
). Therefore, it is of particular importance that HIV-positive women who are experiencing both depressive symptoms and IPV are identified and provided with care and necessary resources to address these issues.
Several limitations of this research must be acknowledged. First, the sample is a convenience sample, is relatively small, and is representative of only a single clinic in an inner-city area that serves predominately urban minority women. Therefore, these findings are not generalizable to all HIV-positive women. However, since some of our findings do concur with existing literature, we do believe that the unique findings could also apply to a larger population of low-income HIV-positive women who are clinically engaged. However, to ascertain generalizability, this finding will need to be confirmed in a larger, more representative sample. Furthermore, because this study is cross sectional, causality between IPV, depressive symptoms and missed appointments could not be determined. It is possible that the experience of IPV leads to increased depressive symptoms, but also possible that depressive symptoms make women increasingly vulnerable to experiencing IPV. The items used to assess drug and alcohol use did not measure prescription drug use or abuse, which could have resulted in the failure to capture some aspects of this sample’s drug use. Lastly, while the Partner Violence Screen has been validated, it does not specifically inquire about sexual abuse or emotional abuse, which are equally important forms of IPV. Therefore, the prevalence of IPV in this sample could be underestimated. Underreporting could have also occurred if the women did not feel comfortable discussing their experiences of IPV in the open waiting room where the interview took place.
Despite these potential limitations, this study makes several important contributions to the literature. It is the first study to examine and identify missed gynecological appointments, as well as depression, as clinical correlates related to intimate partner violence among HIV-positive women. The results suggest that providers who care for HIV-positive women should be aware of the potential of intimate partner violence to exist in the lives of their patients and highlight the critical importance of screening for IPV.