Mixed studies review of domestic violence in the lives of women affected by HIV stigma

Figures & data

Table 1. Ovid Medline example of search strategy and terms.

Search History
	Searches	Result
1	prejudice/ or rejection, psychology/ or social discrimination/ or social distance/ or social isolation/ or social marginalization/ or social stigma/ or stereotyping/	56407
2	stigma* or discriminat* or prejud* or marginal* or stereotyp* or reject*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	573857
3	1 or 2	587150
4	domestic violence/ or gender-based violence/ or intimate partner violence/ or spouse abuse/ or physical abuse/	15503
5	(intimate partner violence or IPV or domestic violence or gender based violence or domestic abuse or spouse abuse or battered women).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	22490
6	Battered Women/	2613
7	4 or 5 or 6	22943
8	HIV/ or HIV Infections/	199461
9	(HIV or acquired immunodeficiency syndrome or human immunodeficiency virus).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	402091
10	Acquired Immunodeficiency Syndrome/	76100
11	8 or 9 or 10	402091
12	Disclosure/	13419
13	disclosure.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]	45393
14	12 or 13	45393
15	3 or 14	628667
16	7 and 11 and 15	265
17	limit 16 to (english language and journal article)	247

Table 2. Summary of selected qualitative and mixed methods studies.

Author/Year	Sample size and characteristics	Study design/qualitative methods	Location	Study setting	Stigma analysis
Adeniyi et al., 2017	1709 HIV+ pregnant women	Cross sectional interviews with section to elaborate on reason for non-disclosure	South Africa	Maternity clinics	Although stigma not specifically mentioned as reason for DV, possible violent backlash, blame and rejection can be classified as forms of enacted HIV stigma.
Arrey et al., 2015	28 HIV+ Sub-Saharan African women; 4 HIV/AIDS physicians; 1 therapist nurse, 5 observations.	In-depth interviews with HIV+ women (initial and at 4 months follow up), key informant interviews, observations of physician’s consultations.	Belgium	University teaching hospital/AIDS Conferences	Stigma was rampant in the Sub-Saharan African community in Belgium so most women kept their HIV status a secret. Anticipated or actual experiences of partnership breakdown, rejection, violence and abandonment were reasons for non-disclosure (could be classified as enacted stigma). Discussion mentions anticipated, perceived and most importantly self-stigma which manifested as shame, denial, silence and avoidance were barriers to disclosure.
Ashaba et al., 2017	20 HIV+ pregnant women	In-depth interviews	Uganda	HIV clinic	Stigma and discrimination was reported from healthcare settings which fueled self-stigma for being pregnant while being HIV+. Non-disclosure was associated with fear of gossip and discrimination from the community and DV and abandonment from partners. Women also reported actual experiences of violence included forced treatment interruption by partners after disclosure. Negative reactions from partners were not characterized as forms of stigma although this could be interpreted as such.
Chilemba et al., 2014	12 HIV+ women	In depth interviews	Malawi	Public health clinics	The paper does not mention stigma but the actions they describe as emotional abuse overlap with acts of enacted stigma (humiliation, verbal abuse, abandonment, social exclusion, blame and shame). Internalization of abuse/blame leading to feelings of worthlessness is mentioned and can be characterized as internalized stigma.
Colombini et al., 2016	30 HIV+ women	In-depth interviews	Kenya	Sexual and reproductive health clinics	HIV status disclosure was seen as a period of heightened risk for partner stigma and abuse including physical, emotional and economic abuse and separation. Health providers were seen as a means to reduce some of the fear of anticipated partner stigma and violence and so reduce DV post disclosure.
Derose et al., 2017	30 HIV+ women	In-depth interviews	Dominican Republic	Women registered with HIV study clinics	Study specifically mentions enacted stigma from family, friends, and neighbors manifested as gossip and rejection while that from intimate partners resulted in emotional, physical and sexual abuse which together left women vulnerable to food insecurity and support. The experiences led to internalized stigma which made women hesitant to disclose their status and further isolated them.
Emusu et al., 2009	26 HIV+ serodiscordant couples (∼50% HIV+ women; 50% HIV- women); only women interviewed	Critical incident technique	Uganda	AIDS Information Centers	Sexual violence in serodiscordant unions (where either the male or female partner was positive) escalating after diagnosis shows that violence was due to HIV status. Although not mentioned as stigma, blame and sexual violence including deliberate infection of partners can be interpreted as forms of enacted stigma.
Gielen et al., 1997	50 HIV+ women	In-depth interviews	U.S.A	Urban teaching hospital outpatient clinic	For a quarter of women actual experiences of violence or fears of violence was associated with status disclosure but this was not specifically characterized as a result of HIV stigma. But paper mentions that destigmatizing the disease could reduce violence experienced by women living with HIV.
Gielen et al., 2000	301 HIV+ women	Mixed methods (cross sectional interviews and 43 in-depth interviews)	U.S.A	Urban teaching hospital HIV primary care clinic	About half of women experienced both intimate and non-intimate partner violence directly due to their HIV status. Blame and violence due to HIV status can be seen as forms of enacted stigma although not characterized as such in the study.
Hatcher et al., 2014	13 pregnant women, 28 key informants	Focus groups with 13 pregnant women, and in-depth interviews with 10 policy makers, 8 health providers, 6 NGOs, 4 community leaders, and 5 abused pregnant women (chosen from focus groups).	South Africa	ANC clinics	Although stigma not specifically mentioned in this study, blame and subsequent physical, sexual and emotional violence following disclosure could be considered a form of enacted stigma.
Hatcher et al., 2016	32 HIV+ women who experienced DV	In-depth interviews	South Africa	ANC clinics	Study investigates the hidden nature of HIV and DV and the two stigmatized conditions make it harder for women to find support for either condition causing women to suffer in silence..
Hershow et al., 2017	20 HIV+ women	In-depth interviews	Vietnam	Outpatient ART clinic	Participants were mostly infected by the husbands and so were not afraid to disclose to them. Role of stigma in DV not mentioned. Women were fearful of disclosing to husband’s family or to the community for bringing stigma to themselves and their families.
Knettel et al., 2019	200 HIV+ pregnant women for quantitative survey, 20 qualitative interviews	Prospective cohort survey (at pregnancy n = 200 and postpartum n = 168) and in-depth interviews (at pregnancy n = 24 and 3 months post-partum n = 18)	Tanzania	HIV clinics	For quantitative part, HIV shame and internalized stigma measured using Scale A (HIV-Related Shame) of the HIV and Abuse Related Shame Inventory (HARSI-A) and non-disclosure was not associated with internalized stigma. But in qualitative interviews, women’s fear of negative consequences following disclosure included partner violence, withdrawal of support, and abandonment and fears of stigma (gossip, social exclusion and labeling) from the family and community. Although violence, withdrawal of support and abandonment treated separately from stigma, the former may also be considered forms of enacted stigma.
Logie et al., 2011	104 HIV+ women (69% ethnic minority; 23% lesbian/bisexual; 22% transgender	Focus groups	Canada	Community agencies	Study examines intersectional stigma and several forms of stigma discussed. Findings include gender discrimination and HIV stigma can result in violence from intimate partners while internalized stigma cause women to be trapped in abusive relationships.
Marais et al., 2019	12 HIV+ women	In-depth interviews	South Africa	HIV maternity clinic at a tertiary hospital	HIV diagnosis and disclosure was a trigger for DV. Study findings showed that HIV stigma was exacerbated in the context of DV through partner blaming and shaming. Dual stigma of HIV and DV caused women to isolate themselves thus leading to depression and mental stress leading to poor engagement in care.
Mepham et al., 2011	100 HIV+ women	Clinical and counselling notes (100 HIV+ women) unstructured interviews (n = 43)	South Africa	Trial clinic	Threats or actual experiences of violence as a result of status disclosure was cited by a number of women. Stigma not specifically mentioned but acts of domestic violence or threats of violence can be interpreted as enacted or anticipated stigma.
Moreno, 2007	42 HIV+ women	3 focus groups (n = 32), in-depth interviews (n = 5 from focus groups), community meetings (n = 30 including 20 from focus groups)	U.S.A	Latino community agencies	No discussion of stigma as such in relation to DV, but findings showed that infecting partner often left women once they were infected. The virus also defined the quality of their relationships, with men being more controlling or domineering because of the woman's serostatus, which could be interpreted as acts of enacted stigma.
Mulrenan et al., 2015	19 HIV+ women	In-depth interviews	Swaziland	Public health facilities	Violence as a result of interpersonal triggers (eg status disclosure, vertical transmission) and normative tensions (eg opposing contraception and fertility intentions) discussed. However, blame, physical violence and coercive control could be seen as forms of enacted stigma, although not mentioned in this analysis.
Odiachi et al., 2018	100 HIV+ women (25 newly diagnosed, 26 in PMTCT care, 28 postpartum ART, 21 lost to follow up (not on ART)	Cross sectional mixed methods interview	Nigeria	Primary and secondary healthcare facilities	Worries about disclosure to intimate partners resulting in DV or divorce was common for all four groups. 20% did not plan to disclose due to fears of negative reactions and stigma (where stigma was more from family rather than partners). However, actual acts and fears of blame, verbal abuse, physical violence, abandonment and financial abuse could be seen as forms of enacted or anticipated stigma.
Orza et al., 2015	945 HIV+ women (832 web survey from 94 countries, 113 in focus groups from 7 countries)	Mixed methods participatory survey	94 countries	Global listservs and clinical networks of women living with HIV	Study reported that for a third of women reported violence from an intimate partner since HIV diagnosis and that DV escalated for some after diagnosis. Recommended that stigma and discrimination should be recognized as gender based violence (IPV/violence from family/community/health settings) for women living with HIV and GBV is common for women living with HIV.
Pool et al., 2001	208 pregnant women	Focus groups	Uganda	Maternity clinics	Stigma and discrimination was a real fear among women if they had to undergo voluntary counseling and testing. Husbands finding out could possibly lead to blame, conflict and breakdown of marriage which could be interpreted as acts of enacted stigma and the fear of it as anticipated stigma.
Rujumba et al., 2012	15 HIV+ and 15 HIV- pregnant women, 6 key informants	In-depth interviews with women and key informant interviews	Uganda	ANC clinics	All those who tested positive disclosed to their partners while most women testing positive did not for fear of violence, abandonment, and blame. The fear of such negative consequences could be seen as forms of anticipated stigma but this was not described as such in this study.
Turan et al., 2016	Quantitative (pregnant women n = 614), qualitative (pregnant women n = 29, male partners n = 32, service providers n = 20, post intervention FGDs, 2 groups with n = 17, IDIs n = 25), IPV screening data (n = 134)	Baseline and follow up quantitative interviews, in-depth interviews and focus groups, key informants, clinic IPV screening data (part of a larger IPV/GBV study)	Kenya	ANC clinics	HIV testing and disclosure could be a reason for women to be “sent packing”. Study shows that such acts of forced migration results in shame, stigma and loss of status (stigma of being thrown out of the house) while also being a consequence of HIV stigma.
Zamudio-Haas et al., 2012	28 HIV+ women	In-depth interviews	Zimbabwe	Hospital with HIV, ANC and reproductive health clinic	Women living with HIV could be stigmatized for having children. For almost half the participants disclosure resulted in physical and verbal abuse/humiliation, threats of being thrown out of the house and abandonment, all of which can be interpreted as acts of enacted stigma, although not specifically mentioned in the study.
Zunner et al., 2015	61 participants (HIV+ women, healthcare providers, community leaders)	In-depth interviews (n = 30), focus groups (n = 4)	Kenya	HIV clinic	Women and key informants described acts of physical, sexual, psychological and financial abuse due to HIV status which could be interpreted as manifestations of enacted HIV stigma. Feelings of hopelessness leading to depressive symptoms including suicidal ideation could be seen as an outcome of internalized stigma.

DV = domestic violence; IPV = intimate partner violence, GBV = gender based violence, ART = anti-retroviral therapy, FGD = focus group discussion, IDI = in-depth interviews, PMTCT = prevention of mother-to-child transmission, ANC = antenatal care

Table 3. Summary of selected quantitative studies.

Author/year	Sample size & characteristics	Study design	Location	Study setting	Stigma Analysis
Abuogi et al., 2019	200 HIV+ women, 12 months postpartum	Cross sectional survey	Kenya	Primary healthcare facilities	Stigma measured using (i) anticipated stigma scale (adapted from relevant research) and (ii) internalized/self stigma (modified self stigma subscale from PLHIV Index). 55% reported internalized HIV stigma and 57% reported anticipated HIV stigma. And non-disclosure was associated with both.
Aryal et al., 2012	43 HIV+ women	Cross sectional survey	Nepal	HIV care organizations	Emotional violence escalated upon diagnosis while economic abuse started only after diagnosis. Definition of emotional violence included isolation, discrimination, humiliation, shame which can also be seen as forms of enacted stigma although not described as such in this study. Self-humiliation or internalization of abuse was a major consequence of violence.
Chakraborty et al., 2016	99 HIV+ couples, 100 HIV- couples (only responses of wives analyzed; if man is positive and wife negative, wife is analyzed in the HIV+ group)	Cross sectional survey	India	HIV care organization (HIV+ group), hospital (HIV- group)	HIV stigma was not mentioned specifically as a reason for violence but over a quarter of women attributed their HIV status as a reason for their quarrels. Women in the HIV+ group reported significantly higher levels of recent sexual DV. Discussion mentioned that quarrels due to HIV possibly escalated into physical and sexual DV, which could be one cause of higher levels of domestic violence in the group.
Ezeanochie et al., 2011	305 HIV+ pregnant women	Cross sectional survey	Nigeria	ANC clinic at a university teaching hospital	Stigma not mentioned in this study, but those experiencing violence before diagnosis were at greater risk of experiencing violence after. Authors mention that HIV+ status is not just a predictor of DV but worsens pre-existing DV.
Ezechi et al., 2009	652 HIV+ pregnant women	Cross sectional study	Nigeria	Large comprehensive HIV treatment centre	Although stigma not mentioned, for 74% of women, violence started after diagnosis and for those who experienced violence before, about half reported an escalation of violence after diagnosis. Non-disclosure was due to fear of stigma, violence and rejection. Most women were afraid to report violence for fear of making status public.
Fiorentino et al., 2019	894 HIV+ women	Cross sectional survey	Cameroon	Hospitals	73% of women had experienced HIV related stigma as measured by the Berger HIV Stigma Scale. Frequent physical DV was significantly associated with experiencing HIV related stigma and ART interruption for over 1 month.
Hardy et al., 2020	129 HIV+ women in discordant relationships.	Cross sectional survey	Ghana	HIV clinic of a tertiary health facility	Although stigma not specifically mentioned, study shows high proportion of post-disclosure violence among sero-discordant couples with violence escalating post-disclosure in relationships where violence was already present. Reasons for non-reporting of DV included fear of status disclosure.
Hyginus et al., 2012	110 HIV+ and 110 HIV- pregnant women	Comparative cross- sectional survey	Nigeria	University teaching hospital	Although stigma not studied, women with HIV suffered more violence than women without HIV in the year prior to pregnancy. Of women experiencing violence, 75% women reported increased violence after disclosure of status to partners. Reporting of violence more for women with HIV. Discussion mentions women with HIV were being abused probably due to the stigma associated with HIV.
Iliyasu et al., 2011	289 HIV+ women	Cross sectional survey	Nigeria	Teaching hospital	Although role of stigma not explored in the study. Higher prevalence of violence was seen for women living with HIV compared to that in the general population in the same region. Women who had disclosed to partners were twice as likely to experience violence compared to those who did not.
Jiwatram-Negron et al., 2018	249 HIV+ women	Cross sectional survey	Kazakhstan	AIDS centers, HIV health clinics, HIV NGOs, snowballing participants.	Women reporting HIV related stigma, as measured by the Berger Stigma Scale, were significantly more likely to report DV and also HIV-status specific abuse. Women experiencing HIV related abuse were more likely to be depressed possibly due to internalized HIV stigma. HIV+ women who also traded sex had a higher relative risk of HIV-specific abuse possibly representing the dual stigma from this status.
Kabwama et al., 2019	5198 HIV+ women	Secondary data analysis from a national cross sectional survey	Uganda	HIV clinics	Study shows high level of DV for women with HIV in care but this is similar to levels in general population. Also, women in serodiscordant relationships experience less DV than women in seroconcordant relationships. Study indicates that DV is not related to HIV status or stigma.
Koenig et al., 2002	336 HIV+ and 298 HIV- at risk pregnant women	Cross sectional survey	U.S.A.	Health departments and clinics	Violence was reported by about 9% women, and violence was not associated with relationship type (abusive and non-abusive partners) and did not differ significantly between women with and without HIV. Role of stigma not explored and disclosure related violence was reported rarely and included relationship termination, anger and physical assault.
Maher et al., 2000	490 at risk women	Cross sectional survey	U.S.A.	STD clinics	Stigma not specifically discussed but there was no association on test non-uptake with partner violence/fear of partner violence or experiences/fears of partner notifications. 12% participants reported taking the test feared partner violence, humiliation or rejection if they tested positive which can be interpreted as forms of anticipated stigma.
Malaju & Alene, 2013	400 pregnant women	Cross sectional survey	Ethiopia	ANC clinics in public health facilities	79% of women expected negative reactions from male partners upon disclosing positive test results. Women who did not have stigmatizing attitudes towards people living with HIV were twice as likely to anticipate positive reaction from male partners upon disclosure of HIV status but reasons for findings not explored.
Maman et al., 2016	403 HIV+ and 689 HIV- pregnant and postpartum women	Prospective cohort study	South Africa	Primary health clinic	For women who disclosed their status, HIV status was not associated with DV. But for women who had not disclosed, there was a five-times higher likelihood of reporting DV. Findings, suggest post-disclosure DV is not a result of HIV stigma but rather a marker of a violent relationship.
Matseke et al., 2016	673 HIV+ pregnant women	Cross sectional survey	South Africa	Community health centers	Internalized stigma was measured using the Kalichman AIDS-related Stigma Scale. Higher level of internalized stigma and depression was associated with physical and psychological DV.
Mehta et al., 2019	135 HIV+ women	Cross sectional survey	India	ART center at tertiary care hospital	Perceived stigma and discrimination (enacted stigma) was measured in the study. 41% participants reported discrimination including rejection, shifting of home, and divorce from spouse while 50% reported domestic violence (treated separate from discrimination). 82% reported perceived stigma including blame, shame and fear of family rejection.
Ojikutu et al., 2016	299 HIV+ women (100 Thailand, 100 Brazil, 99 Zambia)	Multi-site longitudinal, observational cohort	Thailand, Brazil, Zambia	HIV clinics	Perceived community stigma and anticipated stigma were measured using Likert scales. For all women in this study, anticipated stigma and severe depression were predictors of non-disclosure of HIV status to partners. Among the subset of unmarried or non-cohabiting women, perceived community stigma was a further predictor of non-disclosure to intimate partners.
Olowookere et al., 2015	360 HIV+ women	Cross sectional survey	Nigeria	ART clinic in secondary health care facility	Disclosure of HIV status was a predictor of DV with about a quarter experiencing violence since diagnosis. Almost half reported non-disclosure as a means to reduce DV. Although role of stigma not explored authors recommend reducing stigmatization as a means of reducing DV among women living with HIV.
Onono et al., 2014	281 postpartum women (104 HIV+, 123 HIV-, 54 unknown HIV status)	Post-hoc analysis of data from subset of participants from a prospective study	Kenya	ANC clinics	High levels of anticipated stigma (measured using stigma scale adapted from relevant research) and fears of negative male partner reaction, including DV was observed and this was associated with non-disclosure of HIV status.
Osinde et al., 2011	317 HIV+ pregnant women	Cross sectional survey	Uganda	HIV treatment center at regional hospital	Almost 30% of women reported DV in the last 12 months. Although HIV stigma not mentioned as possible reason for DV, women who were on ART were twice as likely to report DV in the last 12 months.
Ramlagan et al., 2019	673 HIV+ pregnant women	Cross sectional survey	South Africa	Community health centers	Perceived HIV Stigma Scale and the Kalichman AIDS Related Stigma Scale was used to measure HIV/AIDS stigma. DV was significantly associated with experiencing personalized stigma which possibly leads to greater perceived HIV-related stigma.
Shamu et al., 2014	1951 postpartum women (299 HIV+ and 1652 HIV-)	Cross sectional survey	Zimbabwe	Public clinics	Women disclosing test results, both positive and negative experienced violence, but more women testing positive experienced violence (41%) than those testing negative (32%). Also, significant portion of these women experienced violence for the first time after disclosure, with those testing positive more likely to experience violence. Role of stigma in violence not measured.
Turan et al., 2011	1525 pregnant women (94 refused testing, 1431 accepted testing (254 HIV+ and 1177 HIV-)).	Cross sectional survey	Kenya	ANC clinics	Anticipated stigma scale was adapted from relevant research and perceived community stigma measured using a scale from National Institute of Mental Health Project Accept. Women who anticipated male partner stigma were twice as likely to refuse an HIV test and as were women with a lack of knowledge about male partner’s HIV testing status. Anticipated stigma from others and perceived community stigma was not associated with refusal of HIV testing.

ART = antiretroviral therapy, DV = domestic violence, ANC = antenatal care, STD = sexually transmitted disease

Figure 1. PRISMA diagram for data extraction.

Table 4. Geographic location of selected studies.

Geographical location	Study
Sub-Saharan Africa	Abuogi et al., 2019; Adeniyi et al., 2017; Ashaba et al., 2017; Chilemba et al., 2014; Colombini et al., 2016; Emusu et al., 2009; Ezeanochie et al., 2011; Ezechi et al., 2009; Fiorentino et al., 2019; Hardy et al., 2020; Hatcher et al., 2016; Hatcher et al., 2014; Hyginus et al., 2012; Iliyasu et al., 2011; Kabwama et al., 2019; Knettel et al., 2019; Malaju & Alene, 2013; Maman et al., 2016; Marais et al., 2019; Matseke et al., 2016; Mepham et al., 2011; Mulrenan et al., 2015; Odiachi et al., 2018; Olowookere et al., 2015; Onono et al., 2014; Osinde et al., 2011; Pool et al., 2001; Ramlagan et al., 2019; Rujumba et al., 2012; Shamu et al., 2014; Turan et al., 2011; Turan et al., 2016; Zamudio-Haas et al., 2012; Zunner et al., 2015.
North America	Gielen et al., 2000; Gielen et al., 1997; Koenig et al., 2002; Logie et al., 2011; Maher et al., 2000; Moreno, 2007
South America	Derose et al., 2017
Europe	Arrey et al., 2015
Central Asia	Jiwatram-Negron et al., 2018
South and Southeast Asia	Aryal et al., 2012; Chakraborty et al., 2016; Hershow et al., 2017; Mehta et al., 2019.
Multi-country	Ojikutu et al., 2016; Orza et al., 2015

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Arrey, A. E., Bilsen, J., Lacor, P., & Deschepper, R. (2015). “It’s My secret”: Fear of disclosure among Sub-Saharan African migrant women living with HIV/AIDS in belgium. PLoS ONE, 10(3), e0119653. https://doi.org/10.1371/journal.pone.0119653

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