In India, married women who have experienced both physical and sexual violence by their husbands are nearly four times as likely to be infected with HIV as women who have not experienced either type of intimate partner violence, according to a large national study.1 Physical partner violence alone was not associated with HIV infection among the married, reproductive-age women who were surveyed, nor were women's sexual risk behaviors. However, women who were poorer and less educated were more likely than their wealthier and better educated counterparts to have experienced physical abuse at the hands of their husbands.
The data came from the 2005–2006 National Family Health Survey, a nationally representative, household-based study that collected health information on more than 124,000 women aged 15–49. Subsamples of women completed questions on intimate partner violence and were tested for HIV. The present study used data from the 28,139 currently married, sexually experienced women who had completed both the intimate partner violence and HIV components.
Women were considered to have experienced physical intimate partner violence if they reported that their husbands had ever pushed, shaken, slapped, punched, kicked or dragged them; beaten or thrown something at them; tried to choke or burn them; or threatened or attacked them with a knife, gun or other weapon. Those who reported that their husbands had ever physically forced them to perform any sexual act (including intercourse) when they did not want to were classified as having experienced sexual interpersonal violence. Women were also asked about social and demographic characteristics, as well as two HIV risk factors: their lifetime number of sex partners and lifetime use of condoms for contraception. Ninety-five percent of eligible women completed the survey, and 91% of those selected for HIV testing provided consent. HIV status was determined via standard diagnostic testing of dried blood spots collected from respondents.
Most of the women were Hindu (81%), and 47% had no education. Fewer than 2% had had more than one sex partner, and the vast majority (85%) had never used a condom. More than one-third had experienced physical intimate partner violence, either by itself (28%) or in combination with sexual intimate partner violence (8%). About one in 450 women (0.2%) tested positive for HIV.
The lifetime prevalence of any intimate partner violence was greater among women aged 25 or older (36–37%) than among younger respondents (32%). It was higher among women with no education than among those with at least a secondary education (45% vs. 22%), and it increased with declining wealth, peaking at 47% among women in the lowest wealth quintile. Intimate partner violence was reported more often by Hindu (35%) and Muslim (39%) women than by those with neither religious affiliation (29%). Both sexual risk behaviors were associated with partner violence: Fifty-two percent of women who had had more than one sex partner had been abused, compared with 35% of those who had had only one partner, and women who had never used condoms were more likely to have been abused than those who had used them (36% vs. 31%). The prevalence of HIV infection among physically and sexually abused women was 0.7%, compared with 0.2% among women who had experienced no abuse. The only demographic measure associated with HIV status was religion: The prevalence among Hindu women (0.3%) was more than three times that among Muslim or other women (0.1%). Neither sexual risk behavior was associated with HIV.
In a regression analysis that adjusted for demographic characteristics and women's sexual risk behaviors, women who had experienced both physical and sexual intimate partner violence were more likely to be HIV positive than those who had not experienced either type of violence (odds ratio, 3.9). Physical abuse alone was not associated with HIV status. Women's own sexual risk behaviors (lifetime number of partners and lifetime condom use) did not predict their HIV status.
The researchers posit that sexual intimate partner violence increases HIV risk because the physical trauma (e.g., lacerations) women may experience as a result of forced sex may provide the virus with a means of entry. Furthermore, other studies have shown that abusive husbands are more likely than nonabusive ones to participate in risky sexual behaviors and to control their wives' sexual and protective behaviors. According to the researchers, recognizing that intimate partner violence "may represent both a risk marker and risk factor for increased HIV prevalence among women" is vital to serving survivors of abuse, as well as to providing preventive education to both men and women. They point specifically to the need for "innovative efforts to work with men to change gender norms that promote both abusive and HIV risk behaviors."—H. Ball
1. Silverman JG et al., Intimate partner violence and HIV infection among married Indian women, Journal of the American Medical Association, 2008, 300(6):703– 710.