HIV and Partner Violence: Implications for HIV Voluntary Counseling and Testing Programs in Dar es Salaam, Tanzania

Executive Summary

"An important component of HIV voluntary counseling and testing (VCT) programmes is encouraging clients to inform partners of their serostatus. Yet many clients do not disclose results to partners. Studies have found that a serious barrier to disclosure for women is fear of a violent reaction by male partners and that HIV-infected women are at increased risk for partner violence (Gielen et al.1997; Rothenberg et al. 1995; Temmerman et al. 1995). Building on previous research, this study explored the links between HIV infection, serostatus disclosure, and partner violence among women attending the Muhimbili Health Information Center (MHIC), a VCT clinic in Dar es Salaam, Tanzania.

The study first collected qualitative data from women, men, and couples (n = 67) who were MHIC clients. In the second phase, researchers enrolled 340 women after pretest counseling and prior to collection of test results; 245 of these women were followed and interviewed three months after enrollment and testing.1 Nearly a third of the sample were HIV-positive, almost half were married,and 50 percent were between the ages of 18 and 29 years and had less than seven years of education. The study followed WHO ethical and safety protocols for conducting research on violence against women.

Key Findings

Many women lack autonomy to make decisions about HIV testing.

Male and female informants frequently referred to the need for women to 'seek permission' from partners prior to testing. Men, on the contrary, generally made the decision to test on their own without soliciting prior consent. Most women in the study thought about testing for at least a month prior to actually seeking services.

Disclosure to partners by HIV-positive women has increased over time but is still significantly less than that for HIV-negative women.

During a VCT study conducted at MHIC in the mid-1990s, only 27 percent of HIV-positive women who were tested as individuals disclosed their test results to a partner within six months after being tested (Grinstead, personal communication, 2000). In this study 64 percent of HIV-positive women who enrolled as individuals shared test results with a partner within three months of testing.

While the figure for disclosure among HIV-positive women is high, it is significantly lower than the 83 percent of HIV-negative women in the study sample who disclosed their test results to a partner. Overall the major reason for non-disclosure (52 percent) among all women, regardless of HIV serostatus, is fear of the partner's reaction, principally fear of abuse or abandonment.

Partner violence is a serious problem among many female VCT clients.

More than a fourth of women interviewed agreed with the statement, 'Violence is a major problem in my life. 'Male and female informants described violence as a way to 'correct' or 'educate' women, and said that violence that does not leave a physical mark on a woman is justifiable.

When asked about lifetime violence by an intimate partner, 38.5 percent of women had had at least one partner who had been physically abusive and 16.7 percent had had at least one partner who had been sexually abusive. Physical violence by a current partner was also commonly reported. Nearly a third of women had experienced at least one physically violent episode perpetrated by a current partner, such as slapping, twisting an arm, grabbing, punching, and kicking, in the three-month period prior to testing.

A small proportion of women who disclosed their serostatus to partners reported a negative reaction.

Most women said that partners showed support and understanding when told the test results. However, the proportion of women who reported this positive reaction is significantly greater among HIV-negative women compared to HIV-positive women (66 percentvs. 37 percent, p = .000). Regardless of the women's serostatus, only a small percentage of women's male partners said they would come for HIV testing.

Twelve women (5 percent) reported one or more negative responses by a partner after disclosing their test results. This included being blamed for the results or for getting tested (two HIV-negative women and 8 HIV-positive women), physically assaulted (one HIV-negative woman and two HIV-positive women), and/or told to leave the house or abandoned (two HIV-positive women and one HIV-negative woman). Given the prevalence of violence among women in this study, there is considerable and justifiable fear of a partner's violent reaction, but little evidence that serostatus disclosure frequently leads to physical abuse and abandonment.

Women's HIV status is strongly associated with partner violence.

Without adjusting forother variables, HIV-positive women were 2.68 times more likely than HIV-negative women to have experienced a violent episode by a current partner. Examining the interaction between women's age and HIV status and controlling for other sociodemographic variables, young HIV-positive women (18-29 years) were ten times more likely to report partner violence than young HIV-negative women. The strong association between prior history of violence and HIV infection does support the theory that violence plays a role in women's risk for HIV infection in this population.

Programme and Policy Recommendations

Encourage couple communication about HIV/AIDS and HIV testing when promoting VCT.

This may make it easier for couples to get tested together and for individual women and men to share test results with sexual partners.

Train HIV counselors to ask questions about partner violence and to encourage disclosure when appropriate.

At the time of this study counselors did not ask clients about experiences with partner violence. Counselors have an important role to play in helping clients develop safe disclosure plans, which include finding out about the role violence plays in their lives.Therefore counselors need to be trained in how to ask sensitive questions about violence and to usethis information to foster but not force disclosure among clients. Counselors must also be made aware of existing services to help women living in violent relationships so that they can make appropriate referrals when necessary.

Ensure that clients are the ones to make decisions about partner notification of test results.

Given the high prevalence of physical violence reported among these female VCT clients, involuntary disclosure of women's test results through a provider-referral system of notificationmay have negative consequences for women. A provider-referral system may also have a negative backlash on the number of clients who seek VCT services. A better alternative is to have counselors discuss disclosure plans with clients but to let the client decide whether to share results with a partner.

Institute community-based efforts to address sexuality and violence.

Women are often at risk for both HIV infection and violence because of the behavior of their sexual partners.Developing an ethic of respect among men and women for the health and wellbeing of their intimate partners needs to be the foundation of both violence prevention and HIV prevention efforts. Implementing programmes that focus on changing negative norms about male and female sexuality and on conflict resolution is crucial.

Conduct further research on HIV and violence.

The findings from this study highlight the need to:

• Assess client-initiated approaches to facilitating serostatus disclosure, such as the use of a third party (e.g., a counselor, friend, religious person) chosen by the client to mediate disclosure to apartner.
• Identify the pathways through which partner violence increases women's risk of HIV infection.
• Examine the relationship between VCT clients' serostatus, their rate of serostatus disclosure to partners, and the incidence of negative outcomes of serostatus disclosure among women and men at other sites.
• Evaluate community-based HIV-prevention interventions that address partner violence to change harmful attitudes and norms about sexuality and violence."