Gender -based violence as a risk factor for HIV infection among women attending antenatal clinics in Soweto, South Africa.

Abstract

Researchers and policy makers have increasingly cited gender-based violence and gender inequality as critically important determinants of women's HIV risk, yet empirical research on possible connections remains limited, especially within sub-Saharan Africa. This dissertation presents data from 1,395 interviews with women attending antenatal clinics in Soweto, South Africa between November 2001 and April 2002 who accepted routine HIV testing. Experience of intimate partner violence (IPV) was prevalent and included financial (13.7%), emotional (67.5%), physical (50.4%), and sexual (20.1%) abuse; 55.5% of study participants reported lifetime history of physical or sexual assault by a male partner. Adult sexual assault by non-partners (ASA-np) (7.9%), child sexual assault (CSA) (8.0%), and forced first intercourse (FFI) (7.3%) were also common. CSA and FFI were associated with increased risk of IPV and ASA-np. IPV, CSA, FFI and ASA-np were generally associated with increased HIV risk behaviors, as were mid or high scores on the Sexual Relationship Power Scale (SRPS). Overall, 21.1% of participants reported sex with a non-primary male partner in exchange for material goods or money. Women who reported IPV, problematic substance use, urban residence, ever working, or living in substandard housing were more likely to report transactional sex, while women who delayed first coitus, were married, or had a post-secondary education were less likely. Transactional sex was associated with increased risk of HIV (OR = 1.54; 95% CI: 1.07, 2.21), while having non-primary partners without transactional sex was not. After adjustment for demographics and risk behavior, broad versus limited or no IPV (OR = 1.54; 95% CI: 1.19, 1.99) and high versus low SRPS score (OR = 1.56; 95% CI: 1.15, 2.11) were associated with HIV seropositivity, suggesting that IPV and women's subjective perception of relationship control are independently important predictors of HIV serostatus. CSA, FFI and ASA-np were not associated with HIV serostatus; CSA and FFI seem to impact women's HIV risk primarily through increasing the risk of IPV. We hypothesize that abusive and controlling men are more likely to be HIV-positive and to infect their female partners. Research with men regarding possible connections between perpetration of violence and sexual risk behavior is urgently needed.