Abstract
Although the prevalence of intimate partner violence (IPV) in Southeast Asia is one of the highest in the world, IPV remains understudied in the region, especially among women living with HIV (WLWH). This study aims to understand how gender and violence norms influence how WLWH interpret and prioritize violence as a health issue. We also explore whether HIV disclosure was seen as a trigger for IPV. We conducted in-depth interviews with 20 WLWH (median age = 35.5 years; range = 28-54 years) in northern Vietnam. Participants were recruited from an outpatient antiretroviral treatment (ART) clinic. Semi-structured interviews were transcribed, translated, and analyzed to identify themes using a gender-focused theoretical framework. Twelve participants reported experiencing IPV by their current or former husbands, most of which occurred before their HIV diagnoses. Only one participant felt her HIV status was a factor for the IPV she experienced; the remaining participants did not explicitly link IPV and HIV. None expressed fear or experience of IPV after disclosing to their husbands. When asked about a woman’s role in society, the majority spoke about the responsibility to build family harmony by doing housework, raising children, making a steady income, and being faithful to her husband. Participants viewed marital conflict as the woman’s problem to avoid by acting docile or to resolve peacefully by bearing violence quietly. Almost all reported contracting HIV from their husbands. Regardless of whether their children were infected (n = 8) or not (n = 10), participants spoke about being compelled to initiate and adhere to ART to care for their children emotionally and financially. In the context of Vietnamese gender norms, participants expressed low urgency for help-seeking after experiencing IPV and high urgency for help-seeking after being diagnosed with HIV. Multilevel interventions are needed to shift social norms around acceptability of IPV.
Background
Globally, 30% of women have experienced intimate partner violence (IPV) in their lifetime (World Health Organization [WHO], 2013). IPV is defined as psychological, physical, or sexual abuse perpetrated toward an intimate partner (Mitchell, Wight, Heerden, & Rochat, 2016). IPV has been shown to lead to a variety of health consequences, including having a low birthweight baby, having an abortion, substance abuse, chronic pain, and depression (Li et al., 2014; WHO, 2013). Evidence has also demonstrated a link between experiencing IPV and HIV (Kouyoumdjian, Findlay, Schwandt, & Calzavara, 2013; Li et al., 2014; WHO, 2013). In some regions of the world, such as Africa, women who have experienced IPV are 1.5 times more likely to contract HIV as compared with women who have not experienced IPV (WHO, 2013). The main pathways in which exposure to IPV can increase women’s HIV risk include forced sex by an infected partner, inability or limited ability to negotiate safer sex practices, and increased risky sexual behaviors (Maman, Campbell, Sweat, & Gielen, 2000).
Research conducted in Africa has also shown a higher prevalence of IPV among women living with HIV (WLWH) as compared with women not living with HIV (Campbell et al., 2008). Although further research is needed to explore the mechanisms that influence risk of IPV among WLWH, multiple studies have demonstrated that HIV disclosure to a partner can increase the risk for IPV among WLWH (Koenig & Moore, 2000; Medley, Garcia-Moreno, McGill, & Maman, 2004).
The prevalence of IPV among women in Southeast Asia is one of the highest (37.7%) in the world (WHO, 2013). A national study in Vietnam showed that over half (58%) of married women reported experiencing IPV by their husbands and about a third (34%) of these women reported experiencing physical or sexual violence (General Statistics Office of Vietnam, 2010). In Vietnam, significant risk factors for experiencing IPV among married women have included individual-level factors, such as childhood experience or exposure to violence, and relationship-level factors, such as husband’s alcohol use (Jansen, Nguyen, & Hoang, 2016; Vung & Krantz, 2009).
Although recent research in Vietnam has focused on understanding the prevalence of and risk factors for IPV among married women, IPV among WLWH remains understudied. WLWH in Vietnam have also been largely overlooked by HIV prevention and treatment programs due to the country’s focus on concentrated HIV epidemics among key populations, especially people who inject drugs (PWID; Nguyen et al., 2008). HIV incidence among women is increasing and now accounts for approximately 33% of new reported cases (National Committee for AIDS, Drugs and Prostitution Prevention and Control, 2014). HIV prevention and treatment services need to be adapted to address women’s needs, including improving accessibility to violence support services (Nguyen et al., 2008; Pells, Wilson, & Hang, 2016). Integration of screening for IPV in voluntary counseling and testing services has been found to be acceptable and to reduce the severity and frequency of violence in other settings (Christofides & Jewkes, 2010; Spangaro, Zwi, & Poulos, 2009).
Theoretical Framework
The Theory of Gender and Power, developed by Raewyn Connell, aims to explain gender inequities and power imbalances among men and women at various levels of influence, including society, community, work, family, and relationship (Connell, 1987; Sharma, 2016; Smith, White, & Moracco, 2009). In particular, Connell identifies three structures that shape gendered relationships between women and men: the structure of cathexis, or social norms in gendered relationships; the sexual division of labor; and the sexual division of power (Connell, 1987; Sharma, 2016; Wingood & DiClemente, 2000). The structure of cathexis is described as the gender norms that dictate women’s sexual and emotional attachments to men, including norms related to appropriate sexual behavior (Wingood & DiClemente, 2000). The sexual division of labor refers to the pattern of socialization that results in women having low access to socioeconomic opportunities, such as education (Wingood & DiClemente, 2000). Last, the sexual division of power refers to the power differentials in intimate relationships, which can include the role of alcohol in enhancing men’s desire to exercise dominance over women (Wingood & DiClemente, 2000). Connell posits that these three overlapping structures promote the value of masculinity, defined as power and control over others, among males (Connell, 1987; Smith et al., 2009).
The Theory of Gender and Power has been developed further by Wingood and DiClemente (2000) to highlight how gender-based inequities lead to greater exposure to HIV risk factors, including economic, social, and physical factors, among heterosexual women. Nyamhanga and Frumence (2014) also applied Wingood and DiClemente’s (2000) model to understand how IPV among married women in Tanzania increases the sexual risk of acquiring HIV through economic powerlessness, men’s alcohol consumption, marriage norms, and social norms related to women’s sexual behavior. Further research is needed to understand how these structural forces laid out by the Theory of Gender and Power shape IPV in global settings, especially among vulnerable populations, such as WLWH.
In addition to the Theory of Gender and Power, we approached the analysis with an intersectional framework, which emphasizes the importance of examining multiple and intersecting social identities, such as HIV status and gender (Bowleg, 2012; Crenshaw, 1991). This approach is seen as valuable in the field of public health as multiple social identities at the microlevel intersect with macrolevel structural factors to create health disparities (Bowleg, 2012). Conducting single-group analyses using an intersectional approach is valuable for deriving complexity from the “analysis of a social location at the intersection of single dimensions of multiple categories” (McCall, 2005, p. 1781). The intersectional approach was used to examine how gender inequities and power are embedded in the multiple and complex identities among WLWH, such as HIV status, motherhood, and marriage.
In this study, we use the Theory of Gender and Power and an intersectionality framework to understand how gender and violence norms shape the social identities of WLWH and influence how WLWH interpret and prioritize violence as a health issue. In addition, we explore whether HIV disclosure was seen as a trigger for IPV, as supported by previous research (Koenig & Moore, 2000; Medley et al., 2004).
Method
Data Collection
Semi-structured interviews were conducted with 20 WLWH in Thai Nguyen, Vietnam. Thai Nguyen is a semi-urban mountainous northern Vietnamese province with a population of 1.1 million. The province has the highest HIV prevalence among PWID (34%) in Vietnam, making it the focus of PWID-targeted HIV prevention and treatment efforts (National Committee for AIDS, Drugs and Prostitution Prevention and Control, 2014). Women were recruited from an outpatient antiretroviral treatment (ART) clinic in Thai Nguyen.
Two female Vietnamese interviewers with over 10 years of experience with qualitative methods conducted the interviews after completing training on the purpose of the qualitative study and the interview guides. Interviewers obtained written consent from participants prior to completing the 90 to 120 minute interviews, which were conducted in a private room at the ART clinic. The semi-structured interview guide covered the following topics: perceived gender and violence norms in the community, alcohol and substance use, depression, fears and experiences related to HIV disclosure, experiences living with HIV, and experiences and responses to violence. The interview guide was developed by a team including Vietnamese study staff using an iterative process to ensure that the questions were culturally sensitive. Questions were refined over time based on the interviewers’ feedback as well as the interview participants’ responses. The consent, screening, and interviews were all conducted in Vietnamese. Each participant received the equivalent of 10 US Dollars for time and travel to complete the interview. Interviews were audio recorded, and the interviewers also recorded field notes to document their impressions and observations. The audio recordings were transcribed by the two interviewers and translated into English for analysis. Vietnamese study staff reviewed the translated transcripts to ensure that the translation was accurate and of high-quality.
Data Analysis
Two investigators reviewed the transcribed interviews prior to developing the codebook. The codebook mostly included topical codes that were derived from the interview guide, such as the code “relationship violence” that was used to capture any descriptions of IPV experienced by the participants. Transcripts were imported into NVivo11 software for coding and analysis. Initially, the two investigators co-coded 10% of the interviews to ensure intercoder agreement. Both investigators coded each transcript individually and then discussed similarities and differences in how codes were applied to refine initial codes. If there were disagreements on how to use a code, the two investigators discussed their differing approaches until a consensus was reached, and the code definition was updated accordingly. During discussion, patterns and themes emerged and additional inductive codes were added to the codebook. After coding each interview, a summary memo was written to highlight key points related to gender norms, HIV, and violence.
After reviewing the code reports and summary memos, a new set of codes were created based on identified patterns. The new set of codes was designed to facilitate a deeper analysis into the data related to gender norms and experiences and responses to IPV and to their own HIV diagnoses. Most of these additional codes were interpretive, such as a code called “protect the family” that was used to capture content related to participants’ needs or strategies to guard family members from shame, stigma, or financial distress. All interviews were re-coded using the new set of codes, and additional summary memos were written for each interview to outline participants’ experiences with IPV and responses post-HIV diagnosis chronologically. Finally, a matrix was created to compare responses across participants and across subgroups (i.e., those who have experienced IPV and those who had not; those who had at least one child who was HIV-infected and those who had no infected children; Miles & Huberman, 1994). After reviewing all memos, coding reports, and matrices, similarities and differences across participants related to experiences with IPV and experiences living with HIV were described. The analysis focused on understanding how perceived gender norms, particularly the need to protect the family, may have shaped perceived violence norms and experiences with IPV and HIV.
Study Participants
The sample consisted of 20 WLWH (Table 1). The participants ranged in age from 28 to 54 years old (median age = 35.5 years). Most participants had completed middle school (n = 9), and a quarter had completed high school (n = 5). The vast majority of participants were employed at the time of the interviews (n = 18), mostly in jobs related to farming and agriculture or selling goods. Participants were either married (n = 8), widowed (n = 7), or separated/divorced (n = 5). The participants learned their HIV status between 2 and 14 years prior to the interviews (median = 7 years) and were on ART for a range of 1 to 9 years (median = 4 years). None of the participants reported using drugs. Nine of the participants reported no alcohol use since their HIV diagnosis and the remaining 11 reported drinking small amounts of alcohol (i.e., one to two cups) occasionally at large events or with friends. Participants were not systematically asked whether their husbands used drugs or alcohol. Thirteen participants mentioned that their current or former husbands either used drugs or they suspected they used drugs, and seven participants mentioned their husbands’ alcohol use in the context of IPV.
Demographic and Behavioral Characteristics of All Interview Participants in Thai Nguyen, Vietnam.
Note. ART = antiretroviral treatment.
Denominator is number of participants who have at least one child (n = 19).
Missing data due to question not being asked: n = 1.
Results
In this article, we start by presenting an overview of participants’ experiences with IPV and intersections between participants’ experiences of IPV and HIV, including fears or experiences of violence after HIV disclosure. Then, we present the bulk of our results on participants’ perceived norms and experiences related to IPV and HIV using the three structures in the Theory of Gender and Power—cathexis (social norms characterized by women’s sexual and emotional attachments to men), sexual division of labor, and sexual division of power (Table 2). For each structure, we highlight the findings on participants’ views or experiences related to (a) broad gender norms, (b) IPV, and (c) living with HIV.
Qualitative Findings by Structure in the Theory of Gender and Power.
Note. IPV = intimate partner violence.
Experiences With IPV
All participants were asked whether they had ever experienced violence from their current or former husbands, and over half reported experiencing at least one type of IPV ever (n = 12). Of these participants, more than half (n = 7) described experiencing only physical violence; three described experiencing physical, emotional, and sexual violence; and one described experiencing sexual violence only, although the interviewers only specifically probed about experience of sexual violence occasionally. One participant was unclear about the type of violence she experienced from her husband.
Intersection between IPV and HIV
Almost all participants did not mention HIV when they described experiences of IPV. For this reason, it was unclear whether a few participants’ reported experiences of IPV happened before and/or after their own HIV diagnoses. For the remaining participants, almost all reported that instances of IPV happened before their HIV diagnoses. This was not apparent because the participants explicitly stated this, but because of the information we had about the timing and details around their diagnoses. For example, one participant spoke about her ex-husband beating her, but only found out she was diagnosed when she married her second husband.
When participants were asked about their HIV disclosure process, no participants who were infected by their husbands expressed fear of disclosing to their husbands. In fact, these participants seemed much more concerned with disclosing their status to community members or the husband’s family, as they were fearful of bringing stigma onto themselves and their family. Participants who found out their own HIV status before their husbands often encouraged their husbands to get HIV tested and start ART.
For the few participants who had not been infected by their current husbands, experiences around HIV disclosure varied, although fear of stigma from community and family members remained prominent. One participant who thought that she was infected when she got a tattoo said her uninfected husband was very loving and supportive when she disclosed her status initially. Later on, however, he took up a steady girlfriend and physically abused her, both of which she attributed to her HIV status. Another participant who was infected by a sexual partner before marrying her current, uninfected husband chose not to disclose her status to him. This participant said she was fearful of disclosing because she was afraid it would make him depressed.
Cathexis: The Importance of Upholding Family Harmony
All participants were asked to describe the qualities of a good or ideal woman. The vast majority of participants responded by talking about a woman’s responsibility to build family harmony by caring for both immediate and extended family on the maternal and paternal side. When describing how women should care for their families, they often mentioned the importance of doing housework and educating their children to be hardworking and independent. Other common qualities included making a steady income, being faithful to your husband, and being sociable and pleasant with community members. A few women also mentioned the importance of women’s external beauty.
Family harmony and IPV
Most participants, regardless of whether they had experienced IPV or not, explained that women were at fault for the IPV perpetrated by their male spouses as it signaled a failed ability to uphold family harmony. These participants described specific instances of IPV they had witnessed or heard about among neighbors, family, or friends. Although they did not seem to know the context for IPV in these instances, they often surmised that the women incited the violence by being argumentative or too talkative with their husbands. Even when participants spoke about violence against women in their community broadly, they often expressed that the women were most likely at fault. When one participant was asked how she would advise a friend or sister who was beaten by a partner, she responded, If they only told me that they are beaten by their husband, without reason, I do not know how to advise them. Maybe she is stubborn, insulting her husband, or her husband scolded her, then she used violence first, then her husband beat her . . . (Married woman with no children; 28 years)
Since these women felt that they were ultimately responsible for upholding family harmony, any marital conflict seemed to be the woman’s problem to either avoid by acting docile or resolve peacefully by bearing violence quietly.
The view that women should resolve IPV-related issues on their own seemed connected to a strong belief that help-seeking was unacceptable. The majority of participants agreed that IPV was a private family matter that should not be intervened on by police, neighbors, or family members, unless the violence was extreme. One participant said if a woman was beaten until her limbs were broken, it should become a police matter. Mostly, however, participants felt that the police should only handle neighborhood violence, and it would be inappropriate for women to ask for help after experiencing IPV.
Family harmony and HIV
Although the need to uphold family harmony led most participants to speak about the need to bear IPV quietly, the same gender expectation seemed to shape responses to their own HIV diagnoses differently. In particular, participants spoke about how their own HIV diagnoses influenced them to focus on mitigating the impact of HIV on their children by personally maintaining good ART adherence to try to stay healthy. When asked about their primary concerns in the time immediately post diagnosis, all participants with children discussed their fears about their children’s HIV statuses. Participants with uninfected children commonly explained that they were intensely relieved when they eventually found out their children were HIV-negative, even explaining it as a turning point post-diagnosis that made them motivated to be healthy and “live for my children” (Widowed woman with two uninfected children; 28 years). Participants with at least one infected child described feeling devastated when they found out their children’s diagnoses but expressed being similarly committed to ensuring their children were healthy by supporting them to maintain good ART adherence and preparing them to face community stigma.
Sexual Division of Labor: Economic Distress
The majority of participants noted that women are now responsible for making an income for their family, which many attributed to improvements in gender equality in society. However, some participants also spoke about the burden and stress of taking on family economics in addition to their other responsibilities.
In old days, it was only conceptualized that the good women had to stay home, while now the perfect women have to be good at both at society and at home as well, must be good in all aspects, both social and home work. (Widowed woman with one infected child and one uninfected child; 40 years)
No participants mentioned any opportunities to share their other responsibilities, such as housework, with their husbands. In fact, few women could rely on their husbands or husbands’ families to contribute to their family income, especially among participants with husbands who were addicted to injection drugs.
Economic distress and IPV
Many participants described their husbands’ drug addiction as the driver of IPV. These participants mentioned that the violence would start if their husbands asked for money and the women refused. Even among participants who said they had never experienced IPV, they often mentioned having “quarrels” (Widowed woman with two uninfected children; 37 years) over money with their husbands who were addicted to drugs. The majority of these participants noted that they could no longer rely on their husbands or husbands’ families to contribute to their family income and were single-handedly supporting their family with their income.
In addition to disagreements over money being a driver of IPV, one participant described such a disagreement leading her to respond verbally to her husband after experiencing IPV. The participant had been repeatedly beaten by her husband in the past, but she had endured the violence quietly. On one occasion, however, her husband gambled away her money and beat her. She reflected on what she said to him: “I cursed loudly that, ‘The money made by me is for raising up our child, not for gambling. You should live in a manner to be worth as a father’” (Married woman with one uninfected child; 32 years). It seems that the participant felt this instance of violence was unacceptable not because he was physically violent toward her but because he compromised their child’s future.
Economic distress and HIV
Participants often spoke about the negative impact of their HIV status on their ability to provide sufficient money for their family, which they described as an important quality of a “good woman” in their community. These participants explained that living with HIV affected their ability to work hard enough to earn a respectable income or complete the housework because they grew tired easily or were stigmatized by community members and seen as unemployable. For example, one participant shared that her sales went down once people in the community found out her HIV status and she had to eventually quit the business.
Sexual Division of Power: Beliefs About Women’s Needs to Be Submissive
Many participants explained that women were responsible for building positive relationships within their families and neighborhoods to avoid conflict. “ . . . Socially, if you are divergent with other people, when you are in difficulty and danger, then nobody would help you. So we have to live peacefully” (Widowed and remarried woman with one uninfected child; 41 years). Participants also spoke about how women should avoid conflict by acting “cheerful” (Widowed woman with two children [HIV status unknown]; 54 years) or speaking “gently” (Widowed woman with two uninfected children; 37 years) to their children, even if facing difficulties in life. One participant explained, “I think an ideal woman is the one who can go through all difficulties in life smiling” (Widowed woman with two uninfected children; 36 years).
Women’s submission and IPV
Participants often described themselves as passive receptors of IPV perpetrated by their husbands, especially when speaking about experiences of IPV driven by their husbands’ alcohol use. One participant spoke about the effect of alcohol on her husband: “. . . normally without alcohol, beer, then I could talk freely. But with only a few cups of alcohol, then I only said a few words, then he could easily slap me” (Married woman with one uninfected child; 32 years). Participants often described alcohol as a substance that made a man unable to control his actions.
However, regardless of whether alcohol was involved or not, most described responding passively to their husbands after violent episodes. These participants commonly stated that they either took the abuse quietly or ran away from their home for a night if their husband became violent. Participants’ passive responses to IPV seemed to be borne out of the strong belief that asking for help after experiencing IPV was unacceptable.
Almost all participants who experienced IPV said that they did not ask for help after experiencing IPV, often explaining further that they had no one they could ask for support. One participant described being physically abused by her husband when he needed money for drugs. She explained what happened when she did not provide him with money:
. . . He beat me, he ran after me with a knife, if I did not run away fast enough, then I might die, who would dissuade for me.
What do the people think when seeing one woman is beat by her husband?
Thinking what, each plant each flower, each family each situation . . . I am not lucky to meet a decent husband, then I am suffered. (Widowed and remarried woman with one uninfected child; 41 years)
Since these women did not feel they could or should ask for help, they often spoke about enduring the violence on their own.
Participants who were widowed, divorced, or separated from their husbands spoke about the issue being resolved because they no longer had to live with their abusers. One widowed participant said, “Before, when my husband was at home, we also had some clashes as he asked for money to use drugs. But now he is not at home, so we are in peace” (Widowed woman with two uninfected children; 28 years). In the vast majority of these cases, the women did not make active strides to live away from their husbands and instead ended up living alone due to their husbands’ actions or decisions.
Although most participants felt that women should not seek help after experiencing IPV, a few said they left their husbands due to the abuse. A couple of these participants said they left their husbands after being beaten once, both explaining that violence was unacceptable. Interestingly, these participants’ views on violence and gender did not differ substantially from other participants, as they endorsed similar social norms, such as women’s role as caretakers and men’s alcohol use as a driver of violence. Another participant who reported experiencing physical, emotional, and sexual violence from her husband said the reason she divorced her husband was because she thought he would eventually kill her.
Women’s submission and HIV
Just as when speaking about IPV, participants often described themselves as passive receptors of the HIV infection. Almost all participants reported contracting HIV from their husbands, while a couple reported contracting HIV from sexual partners when unmarried. One participant was unsure and thought she had contracted HIV when she got a tattoo.
Participants often noted that the mode of transmission (husband to wife) was common knowledge among community and family members, as their husbands’ reputation as an injection drug user or “playboy” (Married woman with one infected child and one uninfected child; 35 years) was well-known. Although this did not seem to protect the women from experiencing community or family stigma, it did seem to be a point of comfort for participants. When talking about being infected by their husbands, participants reflected without anger, commonly stating that their husbands could not be blamed for becoming HIV-infected or that it was not helpful for their own mental health to blame their husbands. Some also explained that their husbands could not be blamed for becoming HIV-infected because men could not be held responsible for doing behaviors that men inherently do, such as having extramarital sexual relations with female sex workers.
Discussion
Our findings highlight how perceived gender and violence norms shape participants’ experiences with IPV and living with HIV. We anticipated that participants would frame their experiences of IPV in the context of living with HIV due to other qualitative research on IPV with WLWH (Colombini, James, Ndwiga, Integra team, & Mayhew, 2016; Kosia, Kakoko, Semakafu, Nyamhanga, & Frumence, 2016). Instead, we found that participants often spoke about these events separately. In fact, although over half of participants reported experiencing IPV ever, only one participant mentioned her own HIV status as a factor for the IPV she experienced. Although unexpected, this separation in the data facilitated the intersectional analysis and demonstrated how perceived gender norms may distinctly shape participants’ experiences related to IPV and to living with HIV as women. Overall, due to differences in the perceived impact of the health issues on their families, participants tended to express low urgency for help-seeking after experiencing IPV and high urgency for help-seeking after being diagnosed with HIV.
Our findings aligned with the three main structures identified in Connell’s Theory of Gender and Power, although the participants seemed to translate the gender norms differently when speaking about their social identity as women and as people living with HIV (PLHIV). On cathexis, participants’ actions related to IPV seemed to be predominantly shaped by the belief that women are wholly responsible for protecting the family from shame and stigma. Gender norms in Vietnam dictate that women need to uphold family harmony by taking care of the home, children, and husband (Penz & Kirchler, 2011; Schuler et al., 2006; Teerawichitchainan, Knodel, Vu, & Vu, 2009). This gender expectation seemed to make participants feel that they must serve and care for all family members before themselves, even if they are experiencing violence by their husbands. Furthermore, it seemed to lead participants to feel that they should cope with experiences of IPV on their own without seeking help to protect their family from shame.
When speaking about their HIV status, the need to uphold family harmony led participants to focus on their children’s health. In particular, participants’ concerns for their children seemed to drive their need to access HIV care and treatment, as they wanted to live longer so they could care for them. These results demonstrate that participants may respond with more urgency to IPV if they better understood the potential impact of IPV on their children’s health (Prosman, Wong, & Lagro-Janssen, 2014).
On sexual division of labor, participants often explained that they were responsible for earning a steady income for their family on top of their other responsibilities to uphold family harmony. While Vietnam has seen increased gender equity in the workforce since the declaration of the socialist government in 1945, the country has also had more recent improvements in educational attainment, income, and job mobility for women (Teerawichitchainan et al., 2009). A recent Vietnam study found that one of the significant risk factors for experiencing IPV among married women was women’s financial empowerment (wife contributing more to the household than her husband), suggesting that although positive changes in gender equity in the workforce have been seen, this improved sexual division of labor at the institutional level has not translated to improvements in gender equity in relationships (Jansen et al., 2016; Penz & Kirchler, 2011). In fact, these institutional changes may have led to increases in IPV, as men may exercise violence to reinforce traditional gender norms that continue to be pervasive (Jansen et al., 2016). In regard to living with HIV, however, participants’ role as income earners seemed to drive them to invest in their own HIV care and treatment more seriously. Participants wanted to continue to provide money for their family to ensure that their children had prosperous futures.
We also found that participants, especially those with husbands who inject drugs, often spoke about having disagreements over money with their husbands that sometimes resulted in IPV. In sub-Saharan Africa, WLWH have been found to be economically dependent on their male partners and thus are pressured to be sexually compliant (Nyamhanga & Frumence, 2014). Participants in our study were also influenced by gender norms to be submissive to their husbands. However, instead of being compliant due to economic powerlessness, they seemed to be compliant due to their duty to uphold family harmony.
On sexual division of power, participants commonly spoke about the right of men to exercise power against women by providing justifications for IPV, such as alcohol use. Similarly, participants seemed to feel that their husbands were not at fault for contracting HIV by having extramarital sex or using injection drugs, because it was traditional behavior for men. Again, the submission of women seemed to be tied to the belief that women were responsible for upholding family harmony, as participants often referred to the importance of avoiding any forms of conflict in their marriages, families, or communities. Interventions aiming to shift social norms around gender and violence should be implemented. A community mobilization intervention aiming to prevent IPV and HIV in Uganda has been shown to reduce HIV-related risk behaviors and improve relationship dynamics at the community level (Kyegombe et al., 2014).
Contrary to what has been found in other studies, most of which were conducted in sub-Saharan Africa, HIV disclosure was not described as a trigger for IPV among participants (Colombini et al., 2016; Koenig & Moore, 2000; Medley et al., 2004). This may be the case because the majority of participants were aware of their husbands’ risky behavior (i.e., injection drug use) and how it can lead to HIV infection, which may be the result of HIV prevention efforts in the Thai Nguyen province. These women may also have been confident that their husbands would similarly understand the HIV risk pathways and know that they had contracted HIV and spread it to their wives, instead of placing the blame on their wives, as is often the case in sub-Saharan Africa (Colombini et al., 2016). A few participants also found out their HIV-positive statuses after their husbands had already passed away. Further research in Vietnam and other countries with concentrated epidemics should explore IPV as a risk factor for HIV as well as IPV risk among WLWH to understand how gender norms and epidemic dynamics may influence pathways for HIV and IPV risk. In countries with primarily male-focused injection-driven epidemics, HIV disclosure may not pose as large a risk for IPV among women as compared with countries where heterosexual intercourse is the primary mode of HIV transmission.
In addition, although participants seemed to be well aware of the HIV risk associated with injection drug use and unprotected sex, they did not seem to be similarly aware of the HIV risk associated with IPV. The majority of participants who reported IPV described experiencing IPV before being diagnosed with HIV. Despite this, however, participants never considered it as a pathway for HIV infection, suggesting that HIV prevention interventions should also highlight IPV as a potential HIV risk. Awareness campaigns on IPV and HIV risk should be implemented in conjunction with other HIV prevention campaigns focused on injection drug use in high prevalence provinces like Thai Nguyen (Kyegombe et al., 2014).
There are limitations to this research. In particular, there was a small sample size, especially among those experiencing IPV. However, this did allow us to compare gender and violence norms among WLWH who have experienced IPV and those who had not. In addition, participants were asked to speak about past events, including both pre-HIV and post-HIV diagnosis, which may have introduced recall bias into the study. For example, participants may have remembered events post-HIV diagnosis as more or less traumatic than reality. We are also not able to generalize findings to uninfected women in Vietnam, as all participants were living with HIV.
Despite these limitations, this study addresses a large gap in the literature on IPV among WLWH and provides suggestions for future research. These findings also help us understand the gender and violence norms that promote acceptability of IPV and hinder help-seeking when responding to IPV among female ART clients.
Overall, multilevel interventions that engage both women and men are urgently needed to shift social norms around acceptability of IPV and help-seeking after experiencing IPV (Jewkes, Flood, & Lang, 2015). To promote accessibility and uptake of violence support services among female ART clients, it may be effective to integrate IPV screening into HIV services and to spread awareness on the impact of IPV on family harmony.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the UNC Institute for Global Health & Infectious Diseases and was also supported in part by the Doris Duke Charitable Foundation.