HIV-positive diagnoses during pregnancy increases risk of IPV postpartum among women with no history of IPV Ali k. Groves1, Luz McNaughton-Reyes2, Dhayendre Moodley3, AND Suzanne Maman2 American University School of Public Health UNC Gillings School of Global Public Health UKZN Nelson Mandela School of Medicine

background

IPV as a cause and consequence of HIV infection ? Numerous studies document the association between IPV and HIV1,2 Predominant theory is that IPV causes HIV3,4 It is also possible that HIV infection leads to increased IPV5,6 IPV HIV IPV I will start first by reviewing what we know about the intersection between IPV and HIV. Predominant theory is that IPV causes HIV (either directly – through forced sex, or indirectly, through power imbalances in the relationship that affect a woman’s ability to negotiate condom use and places her at risk of HIV) However, it is also possible that HIV infection leads to increased IPV, or that IPV is a consequence of HIV infection. There has been some qualitative research to suggest that women may be at risk of violence following an HIV diagnosis, but to our knowledge, this has not been studied prospectively. So it may be that an HIV diagnosis predicts violence in all relationships. Kouyoumdjian 2013 Li 2014 Jewkes et al 2010 Maman et al. 2000 Mulrenan et al. 2015 Siemieniuk 2013

Dual vulnerability theory It may be that HIV matters for some relationships but not others HIV-positive diagnosis + prior history of IPV = highly vulnerable relationship1,2 HIV-positive diagnosis + no history of IPV = may be more resilient Or it may be that HIV matters for some relationships but not others Per the dual vulnerability theory1,2, when you add an HIV-positive diagnosis to an already stressed relationship (as indicated by IPV history), it may work synergistically to increase risk of future IPV In contrast, women’s relationships where there is no history of IPV may be more resilient to an HIV-positive diagnosis Fox and Benson 2006 Brennan 1997

Aims and hypotheses HIV diagnosis in pregnancy Postpartum IPV The aims of the study were to assess whether HIV is prospectively associated with IPV postpartum, and to determine whether this association varies for women with/without a history of IPV Hypothesis 1: HIV-positive women will be at increased risk of IPV postpartum compared to HIV-negative women Hypothesis 2: The positive association between HIV and IPV will be exacerbated for women with a history of IPV History of IPV in the relationship

methods

South Africa HIV/AIDS Post-test Support Study (SAHAPS) 5 year longitudinal randomized controlled intervention trial Designed to effect behavioral change during pregnancy and postpartum1,2 Enrolled at first antenatal visit All received HIV testing and counseling Setting: public health clinic in township outside Durban Maman et al. 2014 Maman et al. 2007

Sample Data come from SAHAPS (n=1,480) Key eligibility criteria >18 years old in a relationship for >6 months tested HIV-negative more than three months before baseline, or never tested for HIV before Sample consisted of individuals who participated at both baseline and 9 month follow up (n=1,015)

Key Measures Variable Time point assessed Sample item Physical IPV1 (α=.80) 9 months postpartum how many times has your current partner pushed or shoved you? History of IPV in relationship1 Physical IPV in relationship before or during pregnancy same HIV status Pregnancy n/a Physical IPV  6 items from the adapted WHO instrument. Each woman’s response was summed across the six items to create a single binary measure of physical IPV in the postpartum period. History of IPV was assessed using the same items but asking about IPV in the current relationship before or during pregnancy. Binary variable.

Analytic strategy Logistic Regression Analysis Model 1: HIV diagnosis at baseline predicted physical IPV at follow up Model 2: Included an interaction between HIV diagnosis and history of IPV

results

Table 1. Demographic characteristics   HIV- (n=641) HIV+ (n=374) % or mean (SD) Demographic characteristics Age 25.11 (5.68) 26.55 (5.28)*** SES (ref=high) Low 33.70% (216) 41.44% (155)** Middle 40.41% (259) 39.57% (148) Education (ref=HS graduate) ≤ Grade 7 5.46% (35) 6.15% (23) Grades 8-11 36.35% (233) 50.27% (188)*** Length of relationship (yrs) 4.80 (4.46) 3.69 (3.41)*** Live together 23.87% (153) 28.07% (105) Reproductive history Gestational age 24.30 (5.93) 23.51 (5.69)* Pregnancy intention 22.15% (142) 18.18% (68) Previous pregnancy (ref=2) 40.72% (261) 29.95% (112)*** 1 32.14% (206) 42.51% (159)*** History of IPV in the relationship before or during pregnancy 9.20% (59) 10.96% (41) ^p<.10; *p<.05; **p<.01; ***p<.001 Table 1 shows the demographic differences between HIV+ and HIV- participants at baseline . Note that there were a number of differences: HIV+ women were older, poorer, less educated, likely to have been in a relationship for a shorter amount of time. They also came to the clinic slightly earlier in their pregnancy and were more likely to have been pregnant before. Note that there is no difference in history of IPV in the relationship

IPV at 9 months postpartum Table 2. Associations between HIV status, history of IPV and IPV postpartum   IPV at 9 months postpartum Model 1 Model 2 OR 95% CI Focal Independent Variables HIV diagnosis 1.24 (.78, 1.97) 2.17* (1.06, 4.42) History of IPV 5.72*** (3.68, 8.90) 8.56*** (4.65, 15.76) Interaction HIV diagnosis*History of IPV -- 0.40* (.17, .96) Demographic characteristics Age 0.97 (.91, 1.02) SES (ref=high) Low 1.14 (.65, 2.00) 1.13 (.64, 1.98) Middle 0.72 (.41, 1.25) Education (ref=HS graduate) ≤ Grade 7 0.69 (.24, 2.01) 0.67 (.23, 1.96) Grades 8-11 1.09 (.70, 1.71) 1.08 (.69, 1.68) Length of relationship (years) 1.07* (1.01, 1.14) Live together 1.69^ (.98, 2.92) 1.75* (1.02, 3.01) Reproductive history Gestational age 1.01 (.96, 1.06) Pregnancy intention 0.61^ (.34, 1.09) Previous pregnancy (ref=2) 1.97^ (.90, 4.30) 1.93^ (.88, 4.22) 1 2.24* (1.17, 4.30) 2.21* (1.15, 4.24) HIV status disclosure to partner 0.62 (.34, 1.14) 0.64 (.35, 1.16) ^p<.10; *p<.05; **p<.01; ***p<.001 Table 2 shows the results of the logistic regression analysis. First column shows the main effects model (Model 1) As you can see in the main effects model, HIV is not significantly associated with IPV at 9 months postpartum. Second column shows the interaction model (Model 2) As you can see in this model, there was a statistically significant interaction between HIV diagnosis and history of IPV.

We probed the interaction to determine the simple slopes for the effect of HIV status on postpartum IPV for women with a history of IPV (blue line) and without a history of IPV (red line) Among women who had a history of IPV (blue line), an HIV positive diagnosis in pregnancy was NOT significantly associated with IPV at 9 months postpartum. Notice here how women who had a history of IPV had a high probability of postpartum IPV regardless of the outcome of the HIV test, much higher than those women without a history of IPV. However, among women who did not have a history of IPV (red line), an HIV positive diagnosis in pregnancy was associated with IPV at 9 months postpartum. Specifically, the odds of reporting IPV at 9 months postpartum were 2.17 times higher for HIV-positive women as compared to HIV-negative women. Simple slopes for effect of HIV diagnosis OR (95% CI) IPV history _______ 0.87 (0.49,1.55) No IPV history _______ 2.17* (1.06, 4.42)

discussion

Discussion HIV IPV HIV diagnosis is prospectively associated with IPV postpartum, but only for some women HIV diagnosis in pregnancy did not predict postpartum IPV among women who had a history of IPV in their relationship did predict postpartum IPV among women who did not have a history of IPV in their relationship The findings were the opposite of what we hypothesized. Specifically we found that HIV diagnosis was prospectively associated with IPV postpartum, but only for some women (that is, those without a history of IPV) So what is happening with women who have a history of IPV in their relationship? It may be that in these relationships, the partner already had a sense of the woman’s HIV status. That is, these couples may have had IPV in the past over his HIV risk behaviors or her HIV risk behaviors, and therefore finding out she is HIV infected is not a total surprise. Another possibility is that the factors that contribute to the IPV may be so similar to the factors driving the HIV diagnosis that the diagnosis does not add anything new. For example, power imbalances that led to the women getting infected may also have contributed to IPV in the past. Remember the blue line in the figure? Women who had a history of IPV in their relationship had a high probability of IPV regardless of the results of the HIV test. For these women, IPV is already well established in the relationship, an HIV-positive diagnosis adds nothing new.  On the other hand, an HIV-positive diagnosis in a relationship that has never had violence may add new stress to the relationship, which may incite violence

Implications IPV screening is needed IPV prevention interventions during perinatal period are needed Such interventions will positively impact women and their children National PMTCT guidelines do not include screening for IPV but encourage partner testing. Surely, IPV screening is needed before women are encouraged to disclose or request partners to be tested. Counselors should screen all women for IPV in their current relationship during HIV testing. Those who do not have a history of IPV but do test positive for HIV during pregnancy should receive additional counseling regarding their potential IPV risk. Of course, those who screen positive for a history of IPV should also receive support and services to address pre-existing IPV in their relationships. In short, IPV prevention interventions are needed during the perinatal period to maximize the health of South African women and their children.

acknowledgements South African women who were our study participants Our funders ((NICHD R01 1-R01-HD050134001-A1, Open Society Institute, Elton John AIDS Foundation)

questions?