Intimate partner violence and HIV infection among married Indian women

Jay G. Silverman, PhD; Michele R. Decker, ScD; Niranjan Saggurti, PhD; Donta Balaiah, PhD; Anita Raj, PhD

JAMA. 2008;300(6):703-710.

Context  Despite reductions in prevalence of human immunodeficiency virus (HIV) infection among the general population of India, women account for a rising percentage of all HIV cases with husbands' risk behavior described as the major source of women's infection. Intimate partner violence (IPV) has been described as being associated with heterosexual transmission of HIV to women in India and elsewhere.

Objective  To assess the relationship between experiencing IPV and the occurrence of HIV infection in a nationally representative sample of married Indian women tested for HIV.

Design, Setting, and Participants  The Indian National Family Health Survey 3 was conducted across all Indian states in 2005 through 2006. The nationally representative sample included 124 385 married women; analyses conducted in 2007 and 2008 were limited to 28 139 married women who provided IPV data and HIV test results via systematic selection into respective subsamples.

Main Outcome Measures  Prevalence estimates of lifetime IPV and HIV infection were calculated and demographic differences assessed. Intimate partner violence was conceptualized as physical violence with or without sexual violence and then was further categorized as physical violence only vs physical and sexual violence. Regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for HIV infection among Indian women based on experiences of IPV after adjusting for demographics and women's HIV risk behaviors.

Results  One-third of married Indian women (35.49%) reported experiencing physical IPV with or without sexual violence from their husbands; 7.68% reported both physical and sexual IPV, and 27.80% reported experiencing physical IPV in the absence of sexual violence. Approximately 1 in 450 women (0.22%) tested positive for HIV. In adjusted models, married Indian women experiencing both physical and sexual violence from husbands demonstrated elevated HIV infection prevalence vs those not experiencing IPV (0.73% vs 0.19%; adjusted OR, 3.92; 95% CI, 1.41-10.94; P = .01). Physical IPV alone was not associated with risk of HIV infection. Women's personal sexual risk behaviors were not associated with HIV infection.

Conclusions  Among married Indian women, physical violence combined with sexual violence from husbands was associated with an increased prevalence of HIV infection. Prevention of IPV may augment efforts to reduce the spread of HIV/AIDS.

     

Prevalence of intimate partner violence and its associated risk factors among Saudi female patients attending the primary healthcare centers in Western Saudi Arabia

Objectives:

To estimate the prevalence of intimate partner violence (IPV) among female patients, age 18-60 years, attending primary health care centers (PHCCs) and to measure its determinants, and reporting behavior.

Methods:

A cross-sectional study design using validated, translated, and self-administered questionnaire among 497 Saudi female patients attending PHCCs in Taif, Kingdom of Saudi Arabia (KSA) from January to February 2015 was employed. A 2-stage probability sampling was adopted for selection of PHCCs in the first stage, and then participants in the second stage.

Results:

The estimated prevalence of IPV during the last year was 11.9%. Predictors of IPV related to abused women included divorced status and divorced parents; while those related to abusers (husbands) included widowed parents, exposure to violence in childhood, and alcohol or drugs addiction. Most of the abused wives (56%) talked regarding their IPV to their families, their husbands’ families (15.2%), or their friends (11.8%); while only a minority (3.3%) complained to the police or to a judge, and no one reported this to a family physician, or to women protection agency.

Conclusion:

One out of 10 women is a victim of IPV in Taif, KSA. Intimate partner violence is significantly associated with a number of victim and abuser-related psychosocial factors, the detection of which might help screening for individuals at risk.Intimate partner violence (IPV) is defined as any behavior within an intimate relationship that causes physical, sexual, or psychological harm. The present study examines IPV within the context of marriage,1 and focuses only on physical and psychological violence. Sexual violence, which is an important type of IPV was not assessed due to the sensitivity of the issue, and the expectation that there would be few instances to be reported. Intimate partner violence has major short- and long-term social, mental, and physical wellness effects.2 Nationwide surveys in Canada and the United Kingdom found that approximately 25% of women experienced IPV.3 In some Arab countries, IPV is still not properly investigated despite its relatively high prevalence.4 It is difficult to calculate the financial burden of IPV on the health system,5 but some studies estimate the cost to be from 1.7 - 10 billion US$ per year in the US,6 and approximately 400 million Swiss Francs in Switzerland.7 Many risk factors are associated with IPV, such as young age, low socioeconomic status, marital conflicts, a past history of violence in childhood, alcohol and drug addictions,1,6 disempowerment of women, stress, and jealousy.1 Intimate partner violence is a significant public health issue that is associated with serious health outcomes, including depression, suicide attempts, and death.1 Eldoseri8 conducted a cross-sectional study in Jeddah, Kingdom of Saudi Arabia (KSA) and interviewed women attending the primary health care centers (PHCCs), found that the prevalence of physical IPV was 45.5% that was significantly associated with husbands having alcohol or drug addictions, exposure to violence during childhood, and unemployment status. Al-Faris et al9 conducted a study in Riyadh, KSA on 222 women at a teaching hospital and found that 12.2% of them experienced lifetime physical abuse, which was significantly associated with unemployment, past exposure to violence, and living in rented houses. In Iraq, Al-Atrushi et al10 conducted a cross-sectional study at 2 community hospitals and found 58% of visiting women experienced lifetime IPV with physical violence accounting for 38.9%, and sexual violence accounting for 21.1% of the IPV. Due to the discrepancy in the prevalence rate of IPV across the country, a common simple measure is needed to assess and compare IPV in future studies. Therefore, the current study was conducted to measure IPV and its associated risk factors among female patients attending PHCCs in Taif, KSA, and to assess wives’ reporting behavior.     

Prevalence and correlates of herbal medicine use among Anti-Retroviral Therapy (ART) clients at Queen Elizabeth Central Hospital (QECH), Blantyre Malawi: a cross-sectional study

BackgroundThere has been an unprecedented explosion in the popularity of herbal preparations during the last few decades. Herbal medicines are commonly used by HIV/AIDs clients. There is limited data on the prevalence of herbal medicine and correlating factors of herbal medicine use in Malawi. This study establishes prevalence and factors contributing to the use of herbal medicine among HIV/AIDS clients attending the ART clinic at QECH, Blantyre Malawi.MethodsA cross-sectional study design was used to interview 211 conveniently sampled clients at QECH ART clinic. The questionnaire addressed socio-demographic, clinical characteristics, NCD-HIV comorbidity, and herbal medicine utilization. The main outcome of the study was herbal medicine use since the initiation of ART. Logistic regression analysis was done in Stata version 16. Both unadjusted and adjusted models were fitted for potential confounders.ResultsThe prevalence of use of herbal medicine was reported in 17.5% (n=37) of the ART clients. The adjusted logistic regression analysis showed that urban residence was statistically associated with reduced use of herbal medicine (adjusted Odds Ratio – AOR: 0.04, 95% CI: 0.169, 0.976).ConclusionThere is a high prevalence of use of herbal medicine among clients taking ART. Herbal Medicine has the potential to cover the gaps in health coverage in rural communities.     

Integration of nutrition in the antiretroviral therapy scale up plan for Malawi

Malawi is one of the countries experiencing an unprecedented HIV/AIDS epidemic in an environment where malnutrition is rampant. In 2001 Malawi started providing ARVs to HIV patients. This ARV programme is now being scaled up to cover the whole country. Since underlying malnutrition is associated with adverse ART outcomes, the Malawi government commissioned a study to design a programme for integrating nutrition in the ARV scale up plan. This study used a Participatory qualitative research methodology. The study recommends that nutritional support should include therapeutic feeding, food supplements and take home ration and proposes a clear enrolment and discharge criteria.     

Challenges of Childhood TB/HIV Management in Malawi

The diagnosis and management of childhood tuberculosis (TB) are major challenges in countries such as Malawi with high incidence of TB and human immunodeficiency virus (HIV) infection. Diagnosis of TB in children often relies only on clinical features but clinical overlap with the presentation of HIV and other HIV-related lung disease is common. The tuberculin skin test (TST), the standard marker of M. tuberculosis infection in immune competent children, has poor sensitivity in HIV-infected children and is not usually available in Malawi. HIV test should be routine in children with suspected TB as it improves clinical management. HIV-infected children are at increased risk of developing active disease following TB exposure which justifies the use of isoniazid preventive therapy (IPT) once active disease has been excluded but this is difficult to implement and appropriate duration of IPT is unknown. HIV-infected children with active TB experience higher mortality and relapse rates on standard TB treatment compared to HIV-uninfected children, highlighting the need for further research to define optimal treatment regimens. HIV-infected children should also receive appropriate supportive care including cotrimoxazole prophylaxis and anti-retroviral treatment (ART) if indicated. There are concerns about concurrent use of some anti-TB drugs such as rifampicin with some ARTs.     

亲密伴侣暴力的临床后果及识别与处理技巧

亲密伴侣暴力（IPV）是最常见的一种家庭暴力，不仅危害受害人的身心健康和生命安全，还会影响其婚姻家庭和子女成长。IPV广泛存在于各种社会经济、宗教和文化群体中。中国约有1/4的女性曾遭受过配偶不同形式的IPV。绝大多数患者不会以IPV为主诉就诊，所以在各种非特异的症状和体征中快速识别出可能的IPV是临床医生工作的重点和难点。目前，我国尚没有官方指南指导IPV的诊疗，IPV相关研究也较少。本文通过对IPV研究相关英文文献进行证据综述，重点总结了IPV的临床后果及识别与处理技巧，并讨论了如何将这些证据应用于中国。     

Factors associated with antiretroviral treatment interruption in human immunodeficiency virus (HIV)-1-infected children attending the Jos University Teaching Hospital,Jos, Nigeria

Background:

Interrupting anti-retroviral therapy (ART) for any number of reasons is an indication of a compromised adherence to ART. Several factors, including the pill burden from other drugs used in treating co-infections in children with human immunodeficiency virus (HIV), may influence ART adherence. The aim of this study was to identify the factors associated with ART interruption in HIV-1-infected children.

Materials and Methods:

A retrospective cohort study analysing data on 580 children consecutively enrolled on ART between February 2006 and December 2010 at the paediatric HIV clinic of Jos University Teaching Hospital (JUTH), Jos. Subjects were children aged 2 months — 15 years diagnosed with HIV-1 infection and on first-line ART. Cotrimoxazole prophylaxis was usually commenced at diagnosis while awaiting ART commencement. Children diagnosed with tuberculosis (TB) were also placed on multiple individual anti-TB drugs.

Statistical analysis used:

A comparison of the data on children with and without ART interruption was made. Variables associated with ART interruption in a univariate analysis were fit in a multivariate logistic model to determine the factors that were associated with ART interruption.

Results:

Children on anti-TB drugs were twice more likely to interrupt ART compared to those who were not, (adjusted odds ratio, AOR = 1.84 (1.03-3.28); P = 0.04). But children on cotrimoxazole prophylaxis had a 57% reduction in the odds of interrupting ART compared to those who were not, (AOR = 0.43 (0.20-0.93); P = 0.03).

Conclusion:

Children on ART and also taking multiple individual anti-TB drugs should be monitored closely for ART adherence. Cotrimoxazole prophylaxis should be encouraged in children diagnosed with HIV while awaiting ART commencement as this may prime them for a better ART adherence.     

Adolescent pregnancy outcomes at Queen Elizabeth Central Hospital,Malawi: a cross-sectional study

Malawi has a growing population with a high Maternal Mortality Ratio (MMR) of 439 per 100,000 live births to which adolescents contribute 25%. Current data suggests adolescent pregnancies in low resource settings are at an increased risk of both maternal and neonatal morbidity.ObjectivesThis study assessed the pregnancy outcomes amongst adolescents while using women from the early adulthood (20 – 24-year-old) and advanced maternal age (35 years old and above) groups as reference.MethodsThis was a cross-sectional study, carried out at the Chatinkha maternity (labour) and post-natal wards at QECH, and included all adolescents (10 – 19 years old) and women between 20 – 24 years old (early adulthood) and 35 years old or older (advanced maternal age), presenting in labor, at any gestational age ≥ 28 weeks or with a birth weight of 1000 grams or above.ResultsThe study found the prevalence of adolescent pregnancy to be 20.4% (N=5035) out of all the deliveries during the recruitment period. Sexually transmitted infections were proportionally higher in the adolescent group, with 12% testing HIV seroreactive and 10% syphilis seroreactive. Neonatal outcomes of birth asphyxia (3.5%), low birth weight (5%), prematurity (4.3%) and early neonatal death (4.3%) were not statistically different from the outcomes of the older age groups. The major causes of maternal morbidity were determined to be a high caesarean section rate of 31.9% and intrapartum diagnosis of urinary tract infection (7.4%), malaria (7.4%) and hypertensive disorders (14.5%).ConclusionsAdolescents are a significant proportion of the pregnant population in Malawi. These adolescents are at increased risk of some pregnancy and peripartum complications when compared to women of older age groups. However, our study determined that these outcomes appear to be more likely related to the peripartum care received and not solely specific to maternal age.     

提高HIV/AIDS抗病毒治疗依从性的理论模型研究

通过对治疗相关依从性的回顾性研究,在界定HIV/AIDS抗病毒治疗依从性概念的基础上,分析依从性对治疗艾滋病的重要性和意义,从病人、疾病、治疗、医患关系、环境等方面探讨影响HIV/AIDS抗病毒治疗依从性的因素,构建由医疗机构、家庭、社区组织提供支持的提高依从性的理论模型。     

Seroprevalence of TORCH infections in antenatal and HIV positive patient populations

Background

The TORCH (Toxoplasma gondii, Rubella, Cytomegalovirus (CMV) and the Herpes Simplex Virus) cause range of diseases in pregnant women and HIV patients and lead to adverse fetal outcomes when not treated on time, in HIV positive can cause life threating infections. There is inadequate data available of these infections in India.

Methods

A retrospective study was undertaken to determine the seroprevalence of the TORCH infections in antenatal and HIV/AIDS patients at a tertiary care centre. The laboratory data pertaining to the period Jan 2012–May 2014 was analyzed. The study population involved 162 antenatal cases and 729 HIV/AIDS patients under review at an ART centre. Laboratory testing was done for the presence of IgM and IgG antibodies against the TORCH infections by ELISA method.

Results

Among the antenatal cases, 30 (18.52%) samples were found to be seropositive for Toxoplasma IgM, CMV IgM antibodies were found in 47 (29.01%) samples, HSV IgM antibodies were found in 12 (7.40%) samples, Rubella IgM antibodies were found in 13 (8.02%) samples, indicating recent infection. Among the HIV/AIDS cases, indicative of recent or current infection, 160 (21.94%) samples were positive for Toxoplasma IgM, CMV IgM was found in 99 (13.58%), HSV IgM antibodies were found in 98 (13.44%) and Rubella IgM in 47 (6.44%).

Conclusions

The study showed a high seroprevalence of the infections caused by the TORCH complex amongst pregnant women and HIV/AIDS patients despite improved hygiene conditions and health awareness. Maximum seroprevalence for CMV was observed followed by Rubella and HSV infection.     

Effects of Antiretroviral Therapy and HIV Exposure in Utero on Adverse Pregnancy and Infant Outcomes:A Prospective Cohort Study in Guangzhou,China

Objective This study aimed to evaluate the effects of in-utero exposure to HIV and ART on pregnancy outcome and early growth of children.Methods This cohort study enrolled 802 HIV-infected pregnant women between October 2009 and May 2018 in Guangzhou, China. The women were assigned to receive combination ART(c ART) or mono/dual ART or no treatment. The primary outcomes were the combined endpoints of any adverse pregnancy outcome [including ectopic pregnancy, spontaneous abortion, stillbirth, preterm birth, small for gestational age(SGA)] and adverse early growth outcome(including infant death, HIV infection of mother-to-child transmission, and underweight, wasting and stunting of infants at 4 weeks of age).Results Adverse pregnancy outcomes occurred in 202(35.1%) of all enrolled HIV-infected women, and121(31.3%) of all infants exhibited adverse effects on early growth at 4 weeks of age. The rates of adverse pregnancy outcomes, spontaneous abortion, ectopic pregnancy, stillbirth, infant death and perinatal HIV infection were higher among women not receiving ART, compared to those treated with c ART or mono/dual ART(P 0.05). However, women treated with c ART had a higher rate of SGA,compared to untreated women(P 0.05). No differences in early infant growth were observed among the different treatment regimens.Conclusion Our findings underscore the essentiality of prioritizing HIV-positive pregnant women for ART, as even mono/dual ART available in resource-limited countries could improve pregnancy outcomes and infant survival.     

Experiences of sexual violence among women seeking services at a family planning unit in Sweden

Abstract

Background: Experiences of sexual violence among women can lead to ill health and increase the risk of lifetime co-occurrence of violence. Identifying risk factors and victims facilitates development of effective programmes for treatment and prevention of additional violence. The primary aim of this study was to assess the prevalence and correlates of sexual violence experiences among women seeking care at a family planning unit in Sweden. A secondary aim was to examine associations between sexual violence and other types of violence.

Methods: Women (n?=?1226) seeking services at a family planning unit, Uppsala University Hospital, Sweden, answered a questionnaire and were interviewed about experiences of sexual violence. Bivariate associations were examined using the chi-square test.

Results: Experiences of sexual violence were reported by 27% of the participants, of which 57% were exposed when they were younger than 18 years old. Women with experiences of sexual violence were more likely to have lower education (P?=?0.024), were students or without occupation (P?=?0.037), and were not in a current relationship (P?<?0.001). Women with experiences of non-partner sexual violence were more likely to have experiences of intimate partner violence (P?<?0.001).

Conclusion: Prevalence of sexual violence was high among the respondents. Many women were young when they were exposed to violence, and lifetime co-occurrence of violence was common among women with experiences of non-partner sexual violence.     

Pattern,challenges and correlates of condom use among Nigerians living with HIV infection.

ObjectiveTo determine the pattern, challenges and correlates of condom use among Nigerians living with HIV Infection.MethodsA cross sectional questionnaire study among HIV positive adults attending an HIV treatment centre in Lagos, Nigeria. Data entry and analysis were done with Epi-info version 3.5.1.ResultsThe mean age of respondents was 35 (SD=7.7; range: 17–58 years) and mean age at sexual debut was 20 years old (range: 7–37 years). Majority were women (66.6%), had at least secondary school education(91.1%), married (68.2%)), on ART (50.7%) and knew their partners HIV status(60.9%). The rate of condom use at last sex act was 65.9%, but only 48.8% used condom consistently. Factors associated with condom use were male gender (OR=2.43, CI=1.35–4.33, P=0.002), less than secondary school education (OR=3.12, CI=1.04–9.28, P=0.05) and Not knowing partner's HIV status (OR=1.90, CI=1.04–3.80, P=0.04). Refusal to use condom (28.4%) were as a result of pregnancy intention, undesirability of condom in marriage and decreased sexual pleasure.ConclusionThere is low consistent condom use rate of 48.8% among this cohort despite their exposure to behavioural change messages. A review of the present counselling strategy and combination prevention is therefore advocated.     

Exploring the cultural appropriateness of a psychosocial intervention,the Thinking Healthy Programme-Peer delivered (THPP), for perinatal depression in Lilongwe,Malawi

BackgroundPerinatal depression is a common and disabling mental health problem in Malawi and other Low- and middle-income countries. There is evidence for effective psychosocial interventions for perinatal depression, but no such intervention has been developed for use in Malawi. The broad aim of this study was to explore the cultural appropriateness of a psychosocial intervention for perinatal depression called the Thinking Healthy Programme-Peer delivered for adaptation and use in Lilongwe, Malawi.MethodsA qualitative exploratory design was used. Data were collected through conducting five Focus Group Discussions, involving thirty-eight purposefully selected participants including pregnant women, community volunteers and their supervisors, the Health Surveillance Assistants and maternal health care workers at implementation and policy level following observations of video recorded role plays of the Thinking Healthy Programme-Peer delivered sessions in theatre testing. A content analysis approach was used to analyse data.ResultsSix main themes were generated regarding the appropriateness of the content and delivery of the Thinking Healthy Programme-Peer delivered intervention, including: 1) Focus of the intervention; 2) Cultural appropriateness of the content; 3) Language used; 4) Context; 5) Provider of the intervention; and 6) Flexibility in the delivery of the intervention. The Thinking Healthy Programme-Peer delivered intervention was deemed appropriate for the target population, though with recommendations to: review illustrations to enhance clarity, use culturally appropriate stories and idioms, use daily spoken language, and adapt the number and duration of sessions to meet the needs of individual clients.ConclusionsThese findings highlight important areas to inform adaptation of the Thinking Healthy Programme-Peer delivered and add to the growing evidence of cultural adaptation of psychosocial interventions for perinatal depression.     

Integrating cervical cancer screening with HIV care in a district hospital in Abuja,Nigeria

Background:

Human immunodeficiency virus positive (HIV+) women have a higher risk of developing invasive cervical cancer compared with uninfected women. This study aims to document programmatic experience of integrating cervical cancer screening using Visual Inspection and Acetic Acid (VIA) into HIV care as well as to describe patients’ characteristics associated with positive VIA findings amongst HIV+ women.

Materials and Methods:

A cross-sectional study analysed routine service data collected at the antiretroviral therapy (ART) and cervical cancer screening services. Our program integrated screening for cervical cancer using VIA technique to HIV care and treatment services through a combination of stakeholder engagement, capacity building for health workers, creating a bi-directional referral between HIV and reproductive health (RH) services and provider initiated counselling and screening for cervical cancer. Information on patients’ baseline and clinical characteristics were captured using an electronic medical records system and then exported to Statistical Package for the Social Sciences (SPSS). Logistic regression model was used to estimate factors that influence VIA results.

Results:

A total of 834 HIV+ women were offered VIA screening between April 2010 and April 2011, and 805 (96.5%) accepted it. Complete data was available for 802 (96.2%) women. The mean age at screening and first sexual contact were 32.0 (SD 6.6) and 18.8 (SD 3.5) years, respectively. VIA was positive in 52 (6.5%) women while 199 (24.8%) had a sexually transmitted infection (STI). Of the 199 who had a STI, eight (4.0%) had genital ulcer syndrome, 30 (15.1%) had lower abdominal pain syndrome and 161 (80.9%) had vaginal discharge syndrome. Presence of lower abdominal pain syndrome was found to be a significant predictor of a positive VIA result (P = 0.001). Women with lower abdominal pain syndrome appeared to be more likely (OR 47.9, 95% CI: 4.8-480.4, P = 0.001) to have a positive VIA result.

Conclusion:

The high burden of both HIV and cervical cancer in developing countries makes it a necessity for integrating services that offer early detection and treatment for both diseases. The findings from our study suggest that integrating VIA screening into the package of care offered to HIV+ women is feasible and acceptable.     

Supplementary feeding in the care of the wasted HIV infected patient

Wasting and food insecurity are commonly seen in patients receiving antiretroviral treatment (ART) programs in sub-Saharan Africa and south Asia, and supplementary feeding is often offered in conjunction with ART. Evidence for the effectiveness of such supplementary feeding is scant. A randomised, investigator-blinded, controlled clinical trial of two types of supplementary food, corn/soy blended flour and a ready-to-use peanut butter-based lipid paste, in wasted adults in Blantyre, Malawi is described and the results summarised. A historical control group who did not receive supplementary food is described as well. Provision of about half of the daily energy requirement as a supplementary food for 14 weeks resulted in more rapid restoration of a normal BMI; and the energy-dense, ready-to-use paste was associated with more rapid weight gain than the blended flour. Survival was similar among the 3 groups. The strong association between lower BMI and survival indirectly suggests that there may well be clinical benefit from supplementary feeding in this population. No differences were seen in ART adherence or quality of life with more rapid restoration of BMI. Further research is urgently needed concerning the widespread practice of supplementary feeding in HIV/AIDS care to most effectively utilize this intervention.