"He Did It Because He Could:" a Thematic Analysis of Intimate Partner Violence and HIV-Specific Forms of Abuse Among Women Living with HIV

Background and Purpose: Over a million people are living with HIV in the U.S., and women living with HIV (WLHIV) are less likely to be virally suppressed and die of all causes relative to men living with HIV. Extant literature has demonstrated that intimate partner violence (IPV) is a key driver in the acquisition of HIV, and that WLHIV who are exposed to IPV experience higher rates of co-infection, difficulty accessing care and maintaining a medication schedule, and achieve lower rates of viral suppression. This qualitative analysis examines the experiences of IPV and HIV-specific forms of abuse, and the synergistic impacts on engagement in the HIV care continuum among WLHIV. Secondarily, the analysis explores programmatic needs to improve patient engagement in care.

Methods: Purposive and snowball sampling was used to recruit WLHIV from a hospital system serving a racially and socioeconomically diverse urban patient population in a Southwestern U.S. state. Specifically, participants were recruited from across multiple departments including the women’s health clinic, emergency room, and the HIV treatment center, as well as through word-of-mouth, to participate in a 60-minute virtual interview on Zoom as part of a larger mixed-methods study. Interviews occurred between 2022-2023, and participants included 11 women, ranging from 45 to 66 (M=52) years old, who identified as Black/African American(n=9), Hispanic/Latino(n=1), and Caucasian/White(n=1). Interviews were transcribed and uploaded to Dedoose for coding, using an inductively-derived codebook and a thematic analytical approach (Braun & Clarke, 2006).

Results: The analysis identified seven themes: (1) Varied experiences of emotional, physical, economic, and sexual IPV, and entrapment and controlling behaviors; (2) HIV-specific forms of abuse such as impeding women’s engagement in services by creating transportation barriers and verbal abuse (e.g. calling a participant by the name of their HIV medication), among others; (3) Deeply stigmatizing, and often traumatic behaviors from partners and non-partners, including emotional and physical distancing following disclosure; (4) Complex responses to IPV and HIV-specific abuse, including mental health distress, substance use, and self-isolation; (5) Paradox of having a social support network with other WLHIV and certain providers, whilst simultaneously experiencing disconnection from partners, family members, co-workers/friends, and other providers; (6) Resilience and agency in exiting toxic relationships, advocating for oneself and others, and seeking services to support mental and physical health; and (7) Desires for programmatic supports that are both culturally congruent and positively attuned to the lived experiences of WLHIV, i.e., HIV 101 for newly diagnosed women, peer support, and group services.

Conclusions and Implications: Syndemic and trauma-informed approaches to service design and delivery that account for WLHIV’s experiences, mental and physical health concerns, substance use, fractures in social support, and socioeconomic needs may serve to mitigate the deleterious linkage between IPV and HIV. Further, recognizing that HIV-specific forms of abuse fall between the cracks of existing social service delivery, findings underscore the potential of programs that link linguistically and culturally informed community-based sources of support within the formal health care system in improving engagement and success in the HIV continuum of care.