The HIV care continuum is the standard commonly used to measure effectiveness from a clinical and public health perspective and to assess health outcomes for people with HIV -- with the ultimate goal being viral suppression. Factors such as stigma and access are often considered barriers to achieving the goal of all people with HIV becoming undetectable. A panel at the 13th annual International Conference on HIV Treatment and Prevention Adherence discussed the ways in which violence, too, complicates outcomes along the continuum.
Violence, in this context, is intimate partner violence (IPV) -- commonly referred to as domestic violence. Much of the existing research focuses on violence perpetrated on cisgender women in heterosexual relationships, while often excluding people of various gender identities and sexual orientations.
About one-third of women have experienced IPV, which includes rape, physical assault, or stalking, according to the U.S. Centers for Disease Control and Prevention (CDC). Comparatively, more than 55% of women living with HIV have experienced IPV. Less is known about men's experience with IPV, whether as perpetrators or victims.
Suzanne Maman, Ph.D., professor of health behavior at the University of North Carolina (UNC), presented on the panel alongside Abigail Hatcher, Ph.D., senior researcher at University of the Witwatersrand, and Rob Stephenson, Ph.D., professor of health behavior and education at the University of Michigan. Maman's research asserts that "an established link" exists between IPV's effects on risk for HIV, and for the health outcomes of persons living with HIV, from both psychosocial and biological standpoints. Biologically, violence weakens the immune system due to spiked stress levels. From a psychosocial perspective, violence compromises negotiation around sex (when to have sex, what type of sex to have, condom use) and can possibly lead to the avoidance of testing, disclosure, and uptake of antiretroviral treatment. People living with HIV are also more likely to drop out of care without the support of intimate partners.
Disclosure is tangential to IPV, and the disclosure process remains a difficult terrain to navigate, Maman said.
Whether a person with HIV as disclosed their status or not to their partner(s), each milestone throughout the continuum is also an entry point that can be significantly obstructed by the presence of IPV. For instance, Maman's research shows that women with a history of IPV are less likely to be routinely tested for HIV and less likely to take up antiretroviral treatment when prescribed.
Simultaneously, each part of the continuum serves as a gateway for interventions to address IPV, Maman said. Interventions, if they are audience and setting specific, can be used at each stage. Providing tailored support for persons in violent relationships can bolster linkage to care, which can potentially strengthen viral suppression efforts. Programs aimed at engaging men and adolescents may have the best chance of reducing IPV, according to Maman.
Hatcher led a systematic review using meta-analysis which found 13 articles that supported the premise that IPV can hamper adherence. From this review, Hatcher found that women have significantly lower odds of using antiretroviral treatment when experiencing IPV. The odds of staying adherent on treatment are halved, and the odds of viral suppression are 36% lower.
"IPV has a more marked effect on [antiretroviral treatment] adherence for a woman than many of the other factors that are routinely addressed in clinics globally," Hatcher said. "If as researchers and clinicians we are starting to address things like pill burden, depression, stigma, why are we not routinely assessing and responding to intimate partner violence?"
"There are several important gaps in the literature to date," she said. "There are no longitudinal studies, which precludes our ability to assess causality. We could identify no studies among special populations of women, such as pregnant women or female sex workers."
"We know less about same-sex male couples," Stephenson added.
Stephenson has led research focusing on men in gay and bisexual couples, particularly because of the lack of inclusion of same-sex couples and the need for expanded gender analysis within the IPV field. He developed a model to assess violence called the IPV-GBM Scale. The four constructs of the scale include physical and sexual violence, emotional violence, monitoring behaviors, and controlling violence. An additional HIV-related violence category may better demonstrate the intersection of HIV treatment adherence.
"Violence is more than being hit," Stephenson said. "Violence has to have a power dynamic. If my partner and I got into an argument over TV and we punch each other, that would be dysfunction. Violence has to have a victim and perpetrator and to be enshrined in these power dynamics where one person is using those acts to control the other."
Stephenson's previous research delves into gender performance. In a paper he co-authored, "Struggling to Be the Alpha," he wrote that when two men are vying for alpha male status in a relationship, one of the ways to be the alpha male is to be violent.
"Somebody who's living with HIV and also exposed to violence may not be able to access care physically and emotionally, and they feel a sense of shame if they go to care," Stephenson said.
Maman credits increased awareness of IPV to the "recognition of toxic masculinity and gender norms."
Stephenson concurs. "I have a hunch that a lot of this is because of traditional constructs of masculinity and relationship patterns," he said. "We need relationship skills building."
The panelists noted urgent gaps in the research, including studies on violence-specific measures in HIV research and on combined individual strategies and community-based interventions that could be used in clinical settings -- and vice versa.
Hatcher, who conducts research in South Africa and Kenya, recommends that researchers evaluate crucial pathways and develop interventions that target those pathways specific to physiological and immunologic responses and relationship control.
"We can train researchers to be skillful in their response. We can even do that in very under-resourced rural areas that may not have typical responses to violence," Hatcher said. "Coming with a consensus in the HIV community that this work is possible in the research field is one of the first steps to getting the data we need."