Intimate Partner Violence, Antiretroviral Therapy adherence and Women’s Health
By Bornice Biomndo
Earlier this year, my colleagues and I published a paper on how experiencing intimate partner violence (IPV) negatively affects the ability to maintain high rates of antiretroviral therapy (ART) adherence. For this study, 410 HIV positive women who had been on ART for at least six months were sampled from 12 public hospitals in Kenya. After their routine check-up, women who agreed to participate in the study were asked whether their current partner had ever been physically, sexually, or emotionally abusive to them (as defined by Demographic Health Survey module on Domestic Violence). They were also asked if their partners had ever exhibited controlling behaviour such as limiting her contact to friends and family.
IPV has long been identified and proven as a risk factor for HIV infection among women. This is because women who experience it are more likely to be exposed to risky sexual behaviour, violent sexual acts, forced sex a
re rarely in a position to negotiate for condom use. They also seldom access healthcare services. Recent literature also suggests that in countries with high HIV prevalence, violent men are more likely to be HIV positive therefore increasing the risk for the women. It was therefore, unfortunately, not surprising to find that 76% of the women interviewed had experienced some form of IPV from their current partner. This prevalence rate is higher than Kenya’s national average, 46%.
When compared to their ART adherence rate in the last 30 days, women who had experienced physical IPV, sexual IPV or controlling behaviour were more likely to report taking between 0- 94% of their ARV doses. Those who had never experienced IPV mostly reported 100% adherence
rates. The healthcare providers who interviewed the women offered some explanations for this. One is that during violent encounters, some women are chased or forced to flee their homes and therefore may not be able to carry their medication with them. Additionally, that their newfound refuge may make it difficult for them to maintain their medication schedule or clinic appointments because of distance or fear of disclosure. Our rationale, which was also the foundation of our research hypothesis, is that living in an environment where IPV occurs (whether past or ongoing) affects a woman’s ability to adhere to treatment. Research has a
lready shown that living in such an environment can lead to psychological distress, depression and poor mental health, which are also predictors of lower ART adherence. Additionally, our study revealed that controlling behaviour, which is often simply dismissed as overprotective or jealous behaviour, may be psychologically more detrimental than previously estimated.
One of the reason behind conducting this study was to contribute to the growing scientific evidence of the adverse e
ffects IPV has on women’s health. Specifically, that IPV should not only be viewed as a social or legal issue, but rather a public health problem, even when it does not end in femicide. Studies by the World Health Organisation (WHO) have established forms of IPV as underlying causes of physical injury (morbidity), ill mental health which led to emotional distress and suicide, chronic health problems (pain syndrome, severe headaches, coronary heart disease, stomach ulcers) and mortality among women globally. An analysis I did for UNFPA Swaziland a few years back revealed a significantly higher rate of IPV among women with unwanted pregnancies, women who had ever had an abortion or miscarriage, and pregnant women who attended antenatal care clinics less frequently.
With regards to migration, IPV is not necessarily significantly higher among migrant groups as compared to the general native population. IPV occurs at all social, economic, racial, cultural, and religious realms. However, the process of migrating or migration status can aggravate the vulnerability and experiences of IPV among women. There are different levels at which this occurs. First, from a practical level, migrant women who experience IPV may lack access to helpful resources because they may not know of their existence or how to get to them. Even when they do, they may lack the finances or language skills to engage with the services providers or may face discrimination.
From a social aspect, migrant women may lack the social support that helps to overcome an abusive relationship because they left their friends and families back in their home countries. This social isolation gives their abusive partner even more power to control them especially if the woman does not have contact to the host population through work, education e.t.c. In this case, the informal communities
which migrants usually form in foreign lands may help to mitigate this isolation and may also act as a source of support and information about rights and resources. However, depending on the social and cultural norms of the community, some women may fear leaving their abusive relationship because they would not want to be ostracized and lose the only social connection, they have in the host country.
From a legal aspect, for many migrant women, their legal status is linked to their partners’ e.g., family reunification laws. Most
immigration laws require that the pair remain together for a certain period for the partnership to be legally recognised and before separation or divorce can be filed. Therefore, women would endure the abuse in silence because they are afraid to jeopardize the process. For
those with partners who are citizens or have legal residency, this dependency may be used in blackmailing them into staying in the abusive relationship.
Nevertheless, there are good examples which show that given the proper interventions and support, both at government level and from local programs in host countries, migrant women experiencing IPV can remove themselves and their children from abusive thus dangerous situations. An example being Syrian refugees in Germany and Sweden who used the laws in the host countries to separate from their abusive partners and build independent lives for themselves and their children.