A large nationally representative study of people living with HIV in the United States found that 26% of people living with HIV had experienced physical intimate partner violence in their lifetime, with 4% experiencing it in the previous year. Bisexual women and those experiencing homelessness were especially likely to report a lifetime or recent history of violence. Recent experiences of violence were associated with behaviours that can increase the risk of HIV transmission, unmet support needs, mental health problems, and poor HIV health outcomes.
Intimate partner violence negatively impacts short-term and long-term physical and mental health. Previous studies have shown that people who experience intimate partner violence are at increased risk of acquiring HIV, and people living with HIV who experience intimate partner violence may be at risk for negative HIV health outcomes and mental health outcomes.
Despite these risks, there were no nationally representative estimates of the prevalence of intimate partner violence among people living with HIV prior to this study. This research sought to fill that gap as well as determining demographic factors that were associated with an increased risk of experiencing intimate partner violence.
Led by Ansley Lemon-Lyn of the Centers for Disease Control and Prevention, researchers reviewed medical record data and conducted interviews with people living with HIV between 2015 and 2017 through the Medical Monitoring Project. The project is an annual survey with an unbiased, two-stage sampling process used to produce nationally representative estimates of sociodemographic, behavioural, and clinical characteristics of people living with HIV in the United States.
The study assessed experiences of physical violence through self-report. Researchers asked respondents “How many of your romantic or sexual partners had ever slapped, punched, shoved, kicked, choked, or otherwise physically hurt you?”. Those indicating one or more partners were then asked the same question in relation to the last 12 months. Of note, the Medical Monitoring Project only collects data about physical violence, not other forms of intimate partner violence such as sexual or emotional violence.
A total of 11,768 people living with HIV were included in the study. The proportions of people of different ages, genders and ethnicities reflect the population of people living with HIV in the US. Nine percent of total respondents reported being homeless – defined as living outside, in a shelter, in a vehicle, or in a single room occupancy hotel – in the preceding 12 months.
Overall, 26 per cent of respondents reported having ever experienced physical intimate partner violence in their lifetime, which is similar to national estimates in the general population.
Rates of reported violence had significant differences (p <0.01) by all demographic characteristics collected by researchers. White and multiracial people reported more lifetime violence (31%) than Black and Hispanic people (23% and 24%, respectively). The 25–34-year-old age group had the highest rates of lifetime violence at 31%, followed by 35-44 years (30%).
Thirty-six per cent of cisgender women reported a lifetime history of violence, compared to 29% of transgender people and 23% of cisgender men. Responses differed by sexual orientation, with 52% of bisexual women reporting a history of violence, 35% of heterosexual women, 28% of gay men, 25% of bisexual men, 22% of lesbian women, and 14% of heterosexual men. Those reporting homelessness in the last 12 months were more likely to report a lifetime history of violence than those who weren’t.
In the 12 months preceding study participation, 4% of participants reported experiencing physical intimate partner violence. Responses significantly differed (p <0.01) by age, sexual orientation, and housing status. Of those aged 25-34, 11% reported experiencing physical violence in the previous 12 months, followed by 18-24 (9%), 35-44 (5%), 45-55 (3%), and over 55 (2%). Bisexual women were again the most impacted group, with 15% reporting violence in the preceding 12 months. Those experiencing homelessness in the preceding 12 months reported recent violence at higher rates than those who hadn’t (13% and 4%, respectively).
The study then looked at behaviours and the mental health of those reporting violence in the preceding 12 months compared to those who hadn’t. All measures studied by researchers showed statistically significant differences between these two groups (p<0.01). People who had experienced violence reported more binge drinking, non-injection drug use, injection drug use, depression or anxiety in the past two weeks, transactional sex in the past 12 months, and high-risk sex (i.e., condom-less anal and/or vaginal sex with partners of negative or unknown status in the absence of PrEP with a detectable HIV viral load) in the past 12 months.
Only 9% of people experiencing recent violence received domestic violence services, with 14% reporting unmet needs for such services. Overall, people experiencing recent violence reported high rates of having any unmet support need (77%) compared to those reporting no recent violence (53%).
Considering HIV health outcomes, those reporting physical intimate partner violence in the preceding 12 months had worse care retention (p=0.01). They were also less likely to be on antiretroviral therapy, had more no-show medical appointments, and had more emergency room visits, hospital admissions, and overnight hospital stays in the preceding 12 months (all p<0.001). They were also less likely to be virally suppressed, although this was of borderline statistical significance (p=0.04).
This study had several important limitations. Experiences of intimate partner violence, substance use, and sexual behaviours are sensitive subjects and may be under-reported. Further, this study only looked at physical violence, not sexual or emotional violence, and therefore doesn’t capture the full impact of intimate partner violence among people living with HIV. The study design can only show associations, not causal relationships between intimate partner violence and the measured outcomes.
The authors call for screening for intimate partner violence to be done during initial HIV testing, during emergency room visits, and during routine medical care. People reporting intimate partner violence should be offered supportive services, which may improve their health and safety. Violence prevention programmes should be tailored for marginalised groups, such as LGTBQ+ people and racial and ethnic minorities.