South African Women in Relationships With Violent Male Partners Have Increased Risk of HIV Infection
Women in South Africa who are in relationships with violent or domineering men have a more than 50% increased risk of contracting HIV than women who are not involved in abusive relationships, according to a study published in the May 1 issue of the journal Lancet, AFP/Yahoo! News reports (AFP/Yahoo! News, 4/29). University of Michigan epidemiologist Kristin Dunkle, Rachel Jewkes of the South African Medical Research Council and colleagues interviewed 1,366 pregnant South African women at four prenatal clinics in Soweto about their partners, their sexual behavior and violence in their relationships, and each woman underwent routine prenatal HIV testing, according to Reuters (Reaney, Reuters, 4/29). Participants ranged in age from 16 to 44 years and were six to 41 weeks pregnant. The researchers found that 55% of participants reported a history of physical or sexual assault from a male partner, and 33.5% of women tested HIV-positive on the day of their interview (Dunkle et al., Lancet, 5/1). After accounting for age, relationship status and other risk behaviors, the researchers found that women in relationships involving physical abuse were 48% more likely to be HIV-positive than women not in abusive relationships and women in relationships with domineering men had a 52% increased risk of HIV infection than women not in relationships with controlling men (Reuters Health, 4/29). However, child sexual assault, forced first intercourse and adult sexual assault by non-partners were not associated with an increased risk of HIV, according to the study (Lancet, 5/1).
"We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners," Dunkle said (AFP/Yahoo! News, 4/29). The researchers also hypothesized that abusive men are more likely to be infected with other transmissible diseases such as herpes, which can make women more vulnerable to HIV infection (Lancet, 5/1). Therefore, research on "connections between social constructions of masculinity, intimate partner violence, male dominance in relationships and HIV risk behaviors in men" and effective interventions to target them are "urgently needed," according to the researchers (Reuters Health, 4/29). The researchers conclude, "Ultimately, addressing problems of gender-based violence and HIV will require broad community and societal level transformations that challenge entrenched cultures of violence and male-dominant norms of gender relations" (Lancet, 5/1).
Implementation and assessment of efforts to stop gender-based violence are "critical" to the success of new global health initiatives, including the President's Emergency Plan for AIDS Relief, Sandra Martin and Sian Curtis of the University of North Carolina's Department of Maternal and Child Health write in an accompanying Lancet commentary. PEPFAR includes strategies to educate communities about sexual violence; implement workplace and school-based sexual violence prevention education programs; train health providers to identify, counsel and refer sexual violence survivors to health services; and work with governments and other organizations to "eliminate gender inequalities in the civil and criminal code," according to the authors. However, the plan's use of the ABC prevention method -- abstinence, be faithful, use condoms -- "will be of limited use in settings in which many young women are forced to have sex against their will," Martin and Curtis say. Women also may not be able to access testing and counseling services for fear that their partners would "react violently" if the women test HIV-positive, they say. In addition, PEPFAR's focus on condoms for high-risk groups rather than for everyone "could act to further stigmatize [them] and decrease their use," the authors say. Furthermore, many women may not be able to negotiate condom use, according to Martin and Curtis. The authors conclude that health organizations, policy makers, women's groups and others must "work together to turn the global rhetoric into effective action to reduce gender-based violence and increase the effectiveness of HIV/AIDS programs" in order to "help health interventions achieve their full potential and simultaneously address a broader public health and human rights issue" (Martin/Curtis, Lancet, 5/1).