Associations Between Recent Gender- Based Violence and Pregnancy, Sexually Transmitted Infections, Condom Use Practices, and Negotiation of Sexual Practices Among HIV-Positive Women Delia Lang, PhD, MPH Delia Lang, PhD, MPH Research Assistant Professor Emory University Rollins School of Public Health

BACKGROUND Women & HIV/AIDS The number of women living with HIV/AIDS has tripled between 1993 and 2002 according to CDC data The number of women living with HIV/AIDS has tripled between 1993 and 2002 according to CDC data Women account for 26% of new AIDS cases and 30% of new HIV infections Women account for 26% of new AIDS cases and 30% of new HIV infections Minority women account for 75% of all new AIDS cases in the US Minority women account for 75% of all new AIDS cases in the US

Gender-Based Violence (GBV) Lifetime (GBV), specifically physical and sexual violence, is estimated to occur among 39% of women in the general population, with 14% of women experiencing GBV in the past 12 months Lifetime (GBV), specifically physical and sexual violence, is estimated to occur among 39% of women in the general population, with 14% of women experiencing GBV in the past 12 months Among minority women, women from low-income and education groups, lifetime GBV is estimated to occur among 68% of women, with 33% experiencing GBV in the past 12 months Among minority women, women from low-income and education groups, lifetime GBV is estimated to occur among 68% of women, with 33% experiencing GBV in the past 12 months

Intersection of GBV and STI/HIV Risk A history of GBV among women is associated with: A history of GBV among women is associated with: Difficulty negotiating safer sex practices Difficulty negotiating safer sex practices Higher rates of inconsistent condom use Higher rates of inconsistent condom use Unwanted pregnancy Unwanted pregnancy Higher rates of sexually transmitted infections (STIs) and HIV Higher rates of sexually transmitted infections (STIs) and HIV

HIV-positive women, GBV and STIs HIV+ women are more likely to report GBV than HIV- women HIV+ women are more likely to report GBV than HIV- women Physical and sexual violence are associated with STI incidence among HIV+ women Physical and sexual violence are associated with STI incidence among HIV+ women Approximately 30% of HIV+ women continue to engage in high risk sexual practices such as unprotected intercourse Approximately 30% of HIV+ women continue to engage in high risk sexual practices such as unprotected intercourse

OBEJCTIVES Examine the prevalence of recent GBV (rGBV) among HIV+ women (rGBV defined as abuse in the past 3 months) Examine the prevalence of recent GBV (rGBV) among HIV+ women (rGBV defined as abuse in the past 3 months) Determine the association between rGBV and biologically confirmed pregnancy and STIs, condom use practices, and negotiation of safer sexual practices within the abusive relationship Determine the association between rGBV and biologically confirmed pregnancy and STIs, condom use practices, and negotiation of safer sexual practices within the abusive relationship

METHODS Eligibility criteria: Received treatment at one of 7 clinics and health departments providing medical care to women living with HIV/AIDS in GA and AL Received treatment at one of 7 clinics and health departments providing medical care to women living with HIV/AIDS in GA and AL Between 18 and 50 years of age Between 18 and 50 years of age Seeking medical care for HIV/AIDS at a recruitment clinic Seeking medical care for HIV/AIDS at a recruitment clinic Were sexually active in the previous 6 months Were sexually active in the previous 6 months Provided informed consent Provided informed consent 415 women met eligibility criteria; 391 (93.6%) were enrolled in the study 415 women met eligibility criteria; 391 (93.6%) were enrolled in the study

MEASURES Face-to-face interviews conducted by trained females interviewers to assess sociodemographic characteristics, condom use practices, negotiation of sexual practices and other psychosocial characteristics Face-to-face interviews conducted by trained females interviewers to assess sociodemographic characteristics, condom use practices, negotiation of sexual practices and other psychosocial characteristics Vaginal swab specimen collected to test for: Chlamydia, Gonorrhea, Trichomoniasis Vaginal swab specimen collected to test for: Chlamydia, Gonorrhea, Trichomoniasis Urine sample collected to determine pregnancy status Urine sample collected to determine pregnancy status

Measures cont. Recent Gender-Based Violence (rGBV): (1) in the past 3 months, have you been physically abused by your main partner? (1) in the past 3 months, have you been physically abused by your main partner? (2) in the past 3 months, have you been sexually abused by your main partner? (2) in the past 3 months, have you been sexually abused by your main partner? Responses were summed and participants categorized into two groups: (1) women who responded negatively to both questions and (2) women who responded affirmatively to either or both questions Responses were summed and participants categorized into two groups: (1) women who responded negatively to both questions and (2) women who responded affirmatively to either or both questions

RESULTS Mean age = 34 Mean age = 34 74%  less than 12yr education 74%  less than 12yr education 96%  less than $20K/year 96%  less than $20K/year 83%  African American 83%  African American 48%  single 48%  single 70%  unemployed 70%  unemployed

Results cont. N=304 (women who indicated they had been sexually active with a single partner in the past 6 months) N=304 (women who indicated they had been sexually active with a single partner in the past 6 months) 10.2% reported rGBV 10.2% reported rGBV 15.8% tested positive for one of the 3 STIs 15.8% tested positive for one of the 3 STIs Bivariate analyses indicated that marital status and current employment were related to rGBV and were therefore used as covariates in subsequent models Bivariate analyses indicated that marital status and current employment were related to rGBV and were therefore used as covariates in subsequent models

Results cont. Condom use practices: Women with a history of rGBV were more likely to report: Inconsistent condom use (past 30 days) Inconsistent condom use (past 30 days) AOR=2.91; p=.025 AOR=2.91; p=.025 Inconsistent condom use (past 6 months) Inconsistent condom use (past 6 months) AOR=4.35; p=.001 AOR=4.35; p=.001 No condom use at last intercourse No condom use at last intercourse AOR=2.64; p=.016 AOR=2.64; p=.016 Never used condoms past 30 days Never used condoms past 30 days AOR=3.49; p=.013 AOR=3.49; p=.013 Higher mean of unprotected sex episodes (30 days) Higher mean of unprotected sex episodes (30 days) rGBV M=5.63; no GBV M=1.86 adj. mean diff. =3.74 p=.002 rGBV M=5.63; no GBV M=1.86 adj. mean diff. =3.74 p=.002 Lower proportion of condom use (30 days) Lower proportion of condom use (30 days) rGBV M=51; no GBV M=77 adj. mean diff. =26 p=.004 rGBV M=51; no GBV M=77 adj. mean diff. =26 p=.004

Results cont. Negotiation of sexual practices: Women with a history of rGBV were more likely to report that they were: Threatened when asked for condom use Threatened when asked for condom use AOR=8.86; p=.0001 AOR=8.86; p=.0001 Hit when asked for condom use Hit when asked for condom use AOR=14.88; p=.0001 AOR=14.88; p=.0001 No significant differences for: No significant differences for: asking the partner to use a condom (p=.237) asking the partner to use a condom (p=.237) refusing sex without a condom (p=.505) refusing sex without a condom (p=.505)

Results cont. STIs and Pregnancy: women with a history of rGBV were more likely to be pregnant women with a history of rGBV were more likely to be pregnant AOR=5.40; p=.024 AOR=5.40; p=.024 No significant differences were found between the groups with regard to STIs. (p=.961) No significant differences were found between the groups with regard to STIs. (p=.961)

DISCUSSION Prevalence of rGBV among a sample of HIV+ women is 10% Prior research with young African American women (not HIV+) found a 17% prevalence of rGBV Prior research with young African American women (not HIV+) found a 17% prevalence of rGBV Strong association between having an abusive partner and inconsistent condom use, higher proportion of unprotected sex episodes Implications for infection of HIV- partners as well as re-infection of women themselves Implications for infection of HIV- partners as well as re-infection of women themselves

Discussion cont. Increased pregnancy rates among women with a history of rGBV Implications for mother-to-child transmission, access to health care resources, adherence to medication regimen Implications for mother-to-child transmission, access to health care resources, adherence to medication regimen Significant associations between threats of abuse and actual abuse as a result of asking partners to use a condom Consistent trend with findings from prior studies with HIV- women; however, in our sample 29% of women reported abuse when negotiating condom use compared to 5% in studies with HIV-women Consistent trend with findings from prior studies with HIV- women; however, in our sample 29% of women reported abuse when negotiating condom use compared to 5% in studies with HIV-women

Discussion cont. No significant STI differences in this sample Small sample size, insufficient power Small sample size, insufficient power Measure of GBV did not assess frequency and severity of GBV Measure of GBV did not assess frequency and severity of GBV

LIMITATIONS Cross-sectional data Cross-sectional data No data on male partners No data on male partners Restricted generalizabilitiy Restricted generalizabilitiy With exception of STIs and pregnancy, data are based on self-report With exception of STIs and pregnancy, data are based on self-report No data on frequency and severity of GBV No data on frequency and severity of GBV

CONCLUSIONS Need to address adverse impact of rGBV in the lives of HIV+ women and their partners through multiple interventions: Screening of HIV+ women and referrals to advocacy programs for women Screening of HIV+ women and referrals to advocacy programs for women Address perpetrators of abuse through multisystems approach (police, hospitals, courts, women’s advocacy groups, perpetrator programs) Address perpetrators of abuse through multisystems approach (police, hospitals, courts, women’s advocacy groups, perpetrator programs)

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