Understanding Prevalence and Correlates of Violence in Adulthood Among Women Living with HIV in Canada: Implications for Intersectional and Multi-Level Interventions

Objectives:Worldwide women experience high rates of violence related to entrenched gender inequities. Gender-based violence is a risk factor for HIV infection, yet less is known about the influence of violence among women living with HIV. Violence may be exacerbated for women living with HIV, who experience HIV-related stigma among other forms of marginalization. Violence against women living with HIV has been associated with deleterious health outcomes and poor engagement in care. Most studies on violence among women living with HIV have used small sample sizes, and have not explored associations between violence and other inequalities. We assessed the prevalence of, and factors associated with, experiencing violence in adulthood among women living with HIV enrolled in a Canadian cohort.

Methods:Baseline survey data were analyzed for women with HIV (≥16 years) enrolled in a community-based research cohort study in British Columbia (BC), Ontario (ON), and Québec (QC). Violence was assessed through self-reported experiences of physical, sexual, verbal, or emotional violence in adulthood (>16 years). Multivariable logistic regression was used to identify factors associated with having experienced any form of violence in adulthood.

Results:Of 1322 participants, (25%-BC, 50%-ON, 25%-QC) the median age was 43 (IQR=36-51) years and 22% identified as Indigenous, 28% African, Caribbean or Black (ACB), 42% white/Caucasian, and 8% other. Most (80%) participants reported ever experiencing any adulthood violence, including physical (62%), sexual (45%), verbal (74%), and emotional (46%). 1004 participants with complete data on violence were included in the multivariable analysis. Factors significantly associated with having experienced any adulthood violence included: recreational drug use in the past 3 months (AOR: 17.89, 95% CI: 4.29-74.59); post-traumatic stress disorder (PTSD) (AOR: 2.27, 95% CI: 1.49-3.47); gender discrimination (AOR: 1.05, 95% CI: 1.02-1.07); and age (AOR: 1.02, 95% CI: 1.00-1.04). Participants taking anti-retrovirals (AOR: 2.70, 95% CI: 1.69-4.34), Indigenous women (AOR: 1.89, 95% CI: 1.10-3.27) and Caucasian women (AOR: 1.91, 95% CI: 1.26-2.89) in comparison with ACB women, were also more likely to report adulthood violence.

Conclusions: Four out of five women with HIV in this study experienced violence in adulthood, with high rates of physical and sexual violence. Experiences of adulthood violence were associated with PTSD symptoms and recreational drug use, highlighting the need for trauma-informed and harm reduction approaches to engage women in the HIV care continuum. Women who experience gender discrimination and other forms of social exclusion, including women who use drugs and Indigenous women, reported disproportionate rates of violence. Higher rates of violence among women who take anti-retrovirals needs to be further explored; taking anti-retrovirals may result in disclosure of HIV status and elevate exposure to violence. Intersectional approaches that address gender discrimination are crucial to reduce gender-based violence experienced by women with HIV. Implications for social work include: provision of integrated support services that address violence, substance use and trauma; and interventions to reduce violence against women that adopt an intersectional approach to address the vulnerabilities of women living with HIV, women who use drugs, Indigenous women, and women at the intersection of these identities.