HIV-Testing Rates and Testing Locations Among Women Who Have Experienced Intimate Partner Violence

Abstract

Data from the Centers for Disease Control and Prevention’s (CDC) 2006 Behavioral Risk Factor Surveillance System were analyzed to report the HIV-testing rates and locations of women who have experienced intimate partner violence (IPV). Of the 18,917 women in the sample, 19.8% reported experiencing IPV. Over half of the women who experienced IPV reported testing rates of 52.4%, compared with 35.5% of the overall sample. Testing rates and locations significantly differed by race/ethnicity. Findings and their implications are explored, with an emphasis on increasing access to HIV testing and treatment for women who have experienced IPV and providing sexual safety planning for women accessing HIV-testing services.

Keywords

HIV testing intimate partner violence

Research findings indicate that women who experience emotional, physical, and sexual violence by their male partners have a higher risk of HIV and other sexually transmitted diseases (STDs; El-Bassel et al., 1998; Gielen, Ghandour, Burke, Mahoney, & McDonnell, 2007; Wingood, DiClemente, & Raj, 2000). Intimate partner violence (IPV) includes physical violence, sexual violence, threats of violence, and psychological or emotional abuse (when prior violence has occurred or been threatened) that is perpetrated by a current or former spouse, boyfriend/girlfriend, or dating partner (National Center for Injury Prevention and Control [NCIPC], 2003). Women who have a history of both sexual and physical abuse are more than 3 times as likely to report having an STD during the abusive relationship, 5.6 times as likely to report having multiple STDs, and 5.3 times as likely to report having an STD over the previous 2 months (Wingood et al., 2000). In addition, sexually and physically abused women are 2.7 times as likely to worry about acquiring HIV (Wingood et al., 2000).

Men who are abusive have been shown to report a higher rate of risk-taking behaviors for example, drug use, having multiple sexual partners, and/or sex outside the relationship (El-Bassel, Gilbert, Wu, Go, & Hill, 2005; Raj et al., 2006) which may put women at risk of infection. Not knowing their partners’ risky behavior(s) is a primary factor that accounts for women’s risk of infection (Centers for Disease Control and Prevention [CDC], 2008a). In addition, women in abusive relationships are less likely to have control of sexual decision making, ranging from an inability to negotiate condom use to an inability to prevent sexual abuse (Rountree & Mulraney, 2010; Wingood & DiClemente, 2000).

In addition to their partner’s risk-taking behaviors, there are other factors that increase women’s chances of acquiring HIV if they are in an abusive relationship, including personal risk-taking decisions to socioeconomic factors. Women who have experienced IPV are at higher risk of using drugs and alcohol (Johnson, Cunningham-Williams, & Cottler, 2003) and of having multiple sexual partners (Champion, Shain, & Piper, 2004), both of which increase the chances of HIV infection. Racial minority status is also associated with IPV and HIV risk (Champion et al., 2004). Tjaden and Thoennes’ (2000) prevalence study showed that rates of IPV vary significantly among women of diverse racial backgrounds. Asian/Pacific Islander women and men reported lower rates of IPV than women and men from other minority backgrounds, whereas African American and American Indian/Alaska Native women and men reported higher rates. Differences among minority groups, however, diminished when other sociodemographic and relationship variables were controlled. Likewise, some studies have identified the pattern of a high incidence of violence toward women of color (Bent-Goodley, 2009; Sorenson, Upchurch, & Shen, 1996; Vasquez, 1998), whereas others have attributed women’s heightened exposure to violence to socioeconomic factors (Kantor, Jasinkski, & Aldarondo, 1994; Lockhart, 1987; Taft, Bryant-Davis, Woodward, Tillman, & Torres, 2009). This scholarship clearly indicates that women who have experienced IPV are at greater risk for HIV infection.

Risks Associated With Disclosure of HIV Status to Partner

Not only is IPV a risk factor for HIV, but it also may be a consequence of HIV disclosure to partners. An important consideration when working with women who have experienced IPV is that, if they are still in a relationship with an abusive partner, it is possible that disclosure of HIV-positive status could result in increased abuse: Women who are HIV positive report a higher frequency and severity of abuse than women who are HIV negative (Gielen et al., 2007). Although it is a challenge to determine causation in this relationship, it still raises important ethical questions for practitioners weighing a woman’s safety against the importance of knowing her HIV status and receiving treatment. From an empowerment framework, a woman has the right to weigh the risks associated with knowing her status (e.g., possible subsequent violence) against the benefits of knowing her status (e.g., medical treatment and support). This choice is an important consideration regarding HIV testing with this particular population.

The Importance of HIV Testing

HIV testing is a public health priority for women in the United States because early detection of the virus is critical for initiating life-saving treatment. In 2005, HIV/AIDS was diagnosed in approximately 9,708 women, 80% of whom had become infected from heterosexual transmission. Of the nearly 41,000 AIDS diagnoses in the United States, 26% were for women (CDC, 2005). In 1992, women accounted for an estimated 14% of adults and adolescents living with AIDS in the United States (specifically, the 50 states and the District of Columbia). By the end of 2005, this had grown to 23% (CDC, 2005). Despite the efforts of awareness campaigns and educational programs targeted toward women, African American and Latina women have been most heavily affected by this epidemic. Together, the two populations account for 82% of AIDS cases among women, although they make up only 24% of U.S. women (CDC, 2008a). In 2005, Latina women were 4 times as likely as White women to be diagnosed with AIDS, whereas African American women were 23 times as likely to be diagnosed with AIDS compared with White women (CDC, 2008a).

HIV testing is important because it may be related to a decrease in AIDS mortality rates (CDC, 2008b). Although there is no cure for AIDS, there are pharmaceuticals and “drug cocktails” that can increase the life span of an individual with AIDS, especially if the disease is caught early (Apanovitch, McCarthy, & Salovey, 2003). Despite the benefits of testing, the CDC (2008b) estimates that one quarter of those who are infected do not know their status.

The importance of HIV testing is well known, yet there is a gap in the current literature concerning HIV-testing rates and locations of women who have experienced IPV. The purpose of this study is to examine women’s rates of HIV testing and investigate women’s use of different HIV-testing locations to indicate which HIV-testing sites are most commonly accessed, specifically among women who have experienced IPV. It also examines the differences in testing rates and testing locations by a variety of sociodemographics. The conceptual focus in analysis is to provide an initial foundation for implementing appropriate strategies for connecting women who have experienced IPV to HIV-testing services, thereby increasing early detection of HIV diagnosis among this population and linking them to appropriate treatment services.

Method

Data Source

Data were taken from the CDC’s 2006 Behavioral Risk Factor Surveillance System (BRFSS). The data are on the CDC website and can be accessed without a fee. Data were collected from a random sample of adults (one per household, 18 years of age or older) through monthly telephone interviews by trained interviewers. Detailed information on data collection and processing can be accessed online in the 2006 BRFSS overview. The intimate partner module used in BRFSS 2006 polled Arkansas, Hawaii, Louisiana, Montana, Nevada, Virginia, West Virginia, and the U.S. Virgin Islands. As such, all of the data sets used in this study (i.e., IPV prevalence, HIV-testing rates, and locations of women who had experienced IPV) were obtained from these areas. A total of 18,917 women from these areas were interviewed. Approximately 12.7% of the sample was collected from Arkansas, 16.0% from Hawaii, 17.6% from Louisiana, 14.3% from Montana, 8.7% from Nevada, 13.1% from Virginia, 8.8% from West Virginia, and 8.7% from the U.S. Virgin Islands. The current analysis did not examine differences in HIV testing or IPV prevalence by region or state in the sample.

Women’s IPV experience was assessed by three questions pertaining to their lifetime experience of violence from the IPV module in BRFSS 2006. The three questions were as follows: (a) Has an intimate partner ever threatened you with physical violence? This includes threatening to hit, slap, push, kick, or hurt you in any way. (b) Has an intimate partner ever hit, slapped, pushed, kicked, or hurt you in any way? (c) Have you ever experienced any unwanted sex by a current or former intimate partner? Respondents indicating a positive response to any one of the three questions were classified as women who had experienced IPV. Regarding the HIV-testing information, data were extracted from the HIV/AIDS module in BRFSS 2006 and consisted of two questions: (a) Have you ever been tested for HIV? Do not count tests you may have had as part of a blood donation. Include testing fluid from your mouth. Respondents were asked to answer with the dichotomous responses “yes” or “no.” (b) Where did you have your last HIV test? Possible answers for the testing location included at a private doctor’s office or health maintenance office (HMO), at a counseling or testing site, at a hospital, at a clinic, in a jail or prison, in a drug treatment facility, at home, or somewhere else.

Sample

The majority (69.9%) of the sample women were White; 13.9% was African American and 6.9% was Latina. Most women were between the ages of 25 and 54; 15.4% of the BRFSS sample was between 18-24. Concerning their educational background, more than half of the respondents received a college education (including some college and college graduates), about one third were high school graduates, and fewer than 10% reported having less than a high school education. Regarding marital status, 61.7% of women reported being married; 38.3% were not married. In addition, about one fourth (24.9%) of respondents indicated their annual household income was less than US$25,000, whereas 48.1% of respondents earned US$50,000 or more annually (see Table 1).

Table 1.

Sample Demographics: IPV and HIV-Testing Rates Among Women in the Eight States.

Social demographic	Sample				IPV^a				HIV^b
	n	%	95% CI		n	%	95% CI		n	%	95% CI
	n	%	LL	UL	n	%	LL	UL	n	%	LL	UL
Total					6,036	19.8	18.92	20.71	10,426	35.51	34.46	36.57
Age (years)
18-24	1,139	15.37	14.13	16.70	348	19.70	16.86	22.90	677	33.09	29.58	36.79
25-34	3,083	20.55	19.42	21.72	1,037	21.55	19.64	23.59	2,587	50.90	48.28	53.51
35-44	4,218	22.79	21.76	23.86	1,506	21.26	19.59	23.04	3,050	44.16	42.14	46.20
45-54	5,466	23.42	22.36	24.51	1,835	20.91	19.07	22.87	2,534	26.90	25.28	28.60
55-64	5,011	17.87	17.04	18.73	1,310	14.32	13.12	15.62	1,578	19.25	17.56	21.07
Education
High school or less	1,607	8.58	7.93	9.27	540	20.10	17.61	22.86	895	30.74	27.83	33.82
High school graduate	5,771	30.49	29.26	31.74	1,783	20.67	19.02	22.43	2,864	32.69	30.93	34.51
Some college	5,255	27.21	26.10	28.36	1,898	23.68	21.95	25.51	3,036	38.83	36.81	40.89
College graduate	6,235	33.72	32.44	35.03	1,807	15.97	14.59	17.46	3,615	36.85	34.87	38.87
Marital status
Married	10,601	61.67	60.29	63.02	2,449	14.88	13.96	15.84	5,239	33.36	32.09	34.65
Not married	8,228	38.33	36.98	39.71	3,565	27.92	26.19	29.71	5,155	38.99	37.15	40.87
Income
<US$25,000	4,792	24.94	23.82	26.09	1,900	28.29	26.23	30.45	2,671	39.10	36.99	41.25
US$25,000-US$34,999	2,100	11.13	10.35	11.96	711	20.42	17.74	23.38	1,163	36.14	32.49	39.96
US$35,000-US$49,999	2,841	15.80	14.84	16.80	952	20.09	18.09	22.25	1,619	35.37	32.94	37.87
US$50,000 or more	6,740	48.14	46.75	49.52	1,926	16.17	14.88	17.55	4,013	35.41	33.71	37.14
Race
White	12,304	69.92	68.62	71.18	4,122	19.67	18.66	20.73	6,299	33.18	31.98	34.41
African American	2,748	13.87	12.93	14.86	706	21.18	18.34	24.32	1,955	50.67	47.66	53.67
Latina	1,100	6.86	6.14	7.67	304	16.10	12.74	20.13	706	37.26	32.14	42.69
Other race	1,476	5.58	4.91	6.33	357	15.62	12.70	19.06	718	29.17	25.09	33.61
Multiracial	1,063	3.77	3.36	4.23	490	31.34	26.77	36.29	634	37.41	32.79	42.27

Note. IPV = intimate partner violence; CI = confidence interval; LL = lower limit; UL = upper limit.

Women who have experienced intimate violence.

HIV-testing rate of women in these states.

Analysis

The prevalence estimates of lifetime IPV- and HIV-testing rates were calculated for the overall sample. Analyses were performed using SAS-Callable SUDAAN (Research Triangle Institute, 2001) and 95% confidence intervals (CIs) were calculated to account for the complex sample design of the BRFSS. A chi-square test was performed to test the percentage of women who had experienced IPV and specific sociodemographic characteristics. In addition, analyses of logistic regression models were constructed to estimate the odds ratio (OR) and the 95% CI so that the authors could evaluate differences in testing rates and testing locations according to specific sociodemographic factors for women who have experienced IPV.

Results

Women and IPV

Analyses indicated that, on average, one of five women (19.8%; 95% CI = [18.9, 20.7]) reported experiencing IPV (see Table 1). Chi-square tests showed that there were significant differences in sociodemographic variables relative to race/ethnicity. A higher prevalence of IPV was identified among women with lower incomes based on no overlapping CIs (all ps < .001). Likewise, those reporting a not-married status (separated/widowed/divorced/single) were more likely to report experiencing violence by their intimate partner (27.9%; 95% CI = [26.2, 29.7]) compared with women who were married (18.9%; 95% CI = [14.0, 15.8]). Results also showed that women identified as multiracial were more likely to report having experienced IPV (31.3%; 95% CI = [26.8, 36.3]) than White, African American, Latina, and other races (19.7%, 21.2%, 16.1%, and 15.6%, respectively).

Women and HIV Testing

Table 1 indicates that overall, 35.5% (95% CI = [34.5, 36.6]) of women reported having been HIV tested regardless of their IPV experience. Higher HIV-testing rates were reported among women aged 18-44, those with higher education (some college and college graduate), and those with lower incomes. Women who were not married were more likely to report having been HIV tested (separated/widowed/divorced/single, 39.0%; 95% CI = [37.2, 40.9]) than those who were married (33.4%; 95% CI = [32.1, 34.7]). In addition, African American women were more likely to report having been tested for HIV (50.7%; 95% CI = [47.7, 53.7]) than other racial and ethnic groups.

The same results were found in the logistic regression models in Table 2. When adjusted for other demographics, women aged 45-64 were found to have significantly lower HIV-testing rates than younger women (OR = 0.51 for 45-54 years and 0.30 for 55-64 years). Also, women with lower education background, who were married, or had higher incomes tended to have lower HIV-testing rates when compared with their counterparts. The OR of HIV testing among African American women is 1.72 times higher than their White counterparts; however, there is no difference in the OR in terms of the HIV-testing rate among Latina and White women.

Table 2.

HIV-Testing Rate Among Women.

Social demographic	OR	95% CI
Social demographic	OR	LL	UL
Total
Age (years)
18-24	1 (Reference)
25-34	1.87	1.42	2.46
35-44	1.23	0.95	1.59
45-54	0.51	0.39	0.67
55-64	0.30	0.22	0.40
Education
High school or less	1 (Reference)
High school graduate	1.14	0.89	1.46
Some college	1.51	1.18	1.94
College graduate	1.30	1.00	1.70
Marital status
Married	1 (Reference)
Not married	1.2	1.03	1.41
Income
<US$25,000	1 (Reference)
US$25,000-US$34,999	0.84	0.67	1.05
US$35,000-US$49,999	0.69	0.56	0.86
US$50,000 or more	0.79	0.65	0.96
Race
White	1 (Reference)
African American	1.72	1.40	2.13
Latina	1.09	0.77	1.53
Other race	0.67	0.47	0.96
Multiracial	1.16	0.84	1.60

Note. OR = odds ratio; CI = confidence interval; LL = lower limit; UL = upper limit.

HIV-Testing Rates Among Women Who Have Experienced IPV

In general, slightly more than half (52.4%; 95% CI = [47.7, 53.7]) of the women who have experienced IPV reported they had been tested for HIV. Thus, compared with the overall sample, women who had experienced IPV reported a higher testing rate (52.4% vs. 35.5%). This could suggest that women who had experienced IPV were more likely to be tested for HIV, women who were tested for HIV were more likely to experience IPV, or other variables outside this analysis contributed to the association.

Results from the logistic regression models also showed that, when adjusted for other demographics, women aged 45-64 who had experienced IPV were found to have significantly lower HIV-testing rates than younger women who also had experienced IPV (OR = 0.76 for 45-54 years and 0.50 for 55-64 years). In addition, results also indicate that, among women who have experienced IPV, a relatively lower HIV-testing rate seemed to be associated with low education level, with those who are married or with those who had higher incomes. The OR of HIV testing among African American women who have experienced IPV is 2 times higher than their White counterparts. There was, however, no difference in the odds in the HIV-testing rate among Latina and White women who have experienced IPV (see Table 3).

Table 3.

HIV-Testing Rate Among Women Who Have Experienced IPV.

Social demographic	n	HIV test			No HIV test			OR
		%	95% CI		%	95% CI			95% CI
		%	LL	UL	%	LL	UL		LL	UL
Total	5,885	52.39	49.84	54.94	47.61	45.06	50.16
Age (years)
18-24	248	63.94	53.48	73.23	36.06	26.77	46.52	1 (Reference)
25-34	751	70.40	63.89	76.18	29.60	23.82	36.11	2.03	1.63	2.54
35-44	1,104	61.97	57.35	66.39	38.03	33.61	42.65	1.64	1.33	2.02
45-54	1,333	39.11	34.10	44.36	60.89	55.64	65.90	0.76	0.61	0.94
55-64	1,020	25.64	21.92	29.76	74.36	70.24	78.08	0.50	0.40	0.63
Education
High school or less	384	54.44	45.65	62.96	45.56	37.04	54.35	1 (Reference)
High school graduate	1,318	49.94	43.93	55.95	50.06	44.05	56.07	1.24	1.02	1.51
Some college	1,451	55.17	50.49	59.76	44.83	40.24	49.51	1.72	1.39	2.13
College graduate	1,296	56.28	51.41	61.04	43.72	38.96	48.59	1.60	1.30	1.98
Marital status
Married	1,812	51.57	47.99	55.14	48.43	44.86	52.01	1 (Reference)
Not married	2,629	55.54	51.02	59.98	44.46	40.02	48.98	1.19	1.05	1.33
Income
<US$25,000	1,513	58.78	53.67	63.70	41.22	36.30	46.33	1 (Reference)
US$25,000-US$34,999	521	51.81	45.34	58.22	48.19	41.78	54.66	0.84	0.68	1.03
US$35,000-US$49,999	709	47.47	40.94	54.09	52.53	45.91	59.06	0.78	0.67	0.92
US$50,000 or more	1,317	52.82	47.52	58.05	47.18	41.95	52.48	0.85	0.74	0.99
Race
White	3,039	52.58	49.38	55.76	47.42	44.24	50.62	1 (Reference)
African American	550	59.61	48.31	69.98	40.39	30.02	51.69	2.02	1.73	2.35
Latina	236	60.51	45.30	73.92	39.49	26.08	54.70	1.07	0.81	1.43
Other race	248	54.14	41.11	66.63	45.86	33.37	58.89	0.75	0.58	0.96
Multiracial	350	48.42	37.70	59.28	51.58	40.72	62.30	1.11	0.85	1.45

Note. IPV = intimate partner violence; OR = odds ratio; CI = confidence interval; LL = lower limit; UL = upper limit.

HIV-Testing Locations Among Women Who Have Experienced IPV

Results from logistic regression models (see Table 4) showed that among women who experienced IPV, the OR of choosing a private doctor’s office/HMO over other HIV-testing sites was relatively lower for women aged 55-64 (OR = 0.64, 95% CI = [0.44, 0.94]) compared with women aged 18-24. The OR was also lower for Latina women (OR = 0.45, 95% CI = [0.30, 0.69]) compared with women of other races/ethnicities. The OR of choosing a private doctor’s office/HMO over other sites positively correlated with women’s educational level and income.

Table 4.

HIV-Testing Locations Among Women Who Have Experienced IPV.

Social demographic	n	Private doctor’s office/HMO			Clinic			Hospital			Jail/prison, drug treatment facility, at home, or somewhere else
		OR	95% CI		OR	95% CI		OR	95% CI		OR	95% CI
		OR	LL	UL	OR	LL	UL	OR	LL	UL	OR	LL	UL
Total	2,252
Age (years)
18-24	153	1 (Reference)			1 (Reference)			1 (Reference)			1 (Reference)
25-34	554	1.05	0.75	1.46	0.72	0.51	1.01	1.68	1.14	2.48	1.12	0.68	1.84
35-44	678	0.90	0.65	1.26	0.53	0.37	0.74	2.42	1.66	3.54	1.49	0.91	2.45
45-54	568	0.71	0.51	1.00	0.56	0.40	080	2.98	2.03	4.37	1.62	0.99	2.63
55-64	299	0.64	0.44	0.94	0.44	0.29	0.65	3.01	2.02	4.50	2.37	1.35	4.16
Education
High school or less	201	1 (Reference)			1 (Reference)			1 (Reference)			1 (Reference)
High school graduate	617	1.60	1.16	2.19	0.8	0.57	1.13	0.83	0.60	1.15	0.78	0.50	1.21
Some college	764	1.67	1.21	2.29	0.7	0.49	1.01	0.98	0.70	1.35	0.78	0.51	1.20
College graduate	667	1.60	1.15	2.24	0.82	0.56	1.19	0.82	0.58	1.16	0.80	0.51	1.24
Marital status
Married	832	1 (Reference)			1 (Reference)			1 (Reference)			1 (Reference)
Not married	1,413	1.07	0.90	1.27	1.15	0.94	1.40	0.65	0.54	0.79	0.97	0.77	1.22
Income
<US$25,000	824	1 (Reference)			1 (Reference)			1 (Reference)			1 (Reference)
US$25,000-US$34,999	251	1.03	0.77	1.38	1.09	0.77	1.54	0.63	0.46	0.86	1.23	0.84	1.81
US$35,000-US$49,999	340	1.37	1.06	1.77	0.81	0.61	1.08	0.62	0.47	0.81	1.35	0.95	1.94
$50,000 or more	650	1.41	1.11	1.78	0.76	0.59	0.99	0.61	0.48	0.77	1.39	1.01	1.91
Race
White	1,457	1 (Reference)			1 (Reference)			1 (Reference)			1 (Reference)
African American	339	0.92	0.74	1.13	1.19	0.92	1.52	1.18	0.93	1.49	0.72	0.52	0.98
Latina	141	0.45	0.30	0.69	2.19	1.38	3.47	1.07	0.72	1.58	0.55	0.34	0.89
Other race	117	0.58	0.40	0.82	1.32	0.92	1.89	1.66	0.97	2.85	0.85	0.57	1.27
Multiracial	180	0.69	0.50	0.97	1.37	0.96	1.95	1.02	0.70	1.50	1.04	0.67	1.60

Note. IPV = intimate partner violence; HMO = health maintenance office; OR = odds ratio; CI = confidence interval; LL = lower limit; UL = upper limit.

Older women (aged 55-64) who experienced IPV were less likely to choose a clinic over other sites (OR = 0.44, 95% CI = [0.29, 0.65]) compared with younger women (aged 18-24). Women who reported higher incomes were less likely to be tested at a clinic (OR = 0.76, 95% CI = [0.59, 0.99]) compared with women with lower incomes. The OR of choosing a clinic over all other sites was significantly higher for Latina women (OR = 2.19, 95% CI = [1.38, 3.47]).

The OR is higher for older women and for women who have lower income to be tested at a hospital site. The OR of being tested at a hospital was not affected by educational level. Women who were not married were less likely to be tested at a hospital (OR = 0.65, 95% CI = [0.54, 0.79]) than their counterparts.

In addition, there was a small percentage of women who experienced IPV and had their HIV testing conducted at a jail/prison (0.9%), a drug treatment facility (1.1%), at home (2.4%), or somewhere else (8.6%). The logistic regression results showed that age and race were the significant predictors for having the HIV test at these locations compared with the others. Older women and White women who had experienced IPV were more likely than their counterparts to have had their HIV test in jail/prison, at a drug treatment facility, at home, or somewhere else.

Discussion

In the current sample, the overall percentage of women who had experienced IPV is 19.8%. This percentage is consistent with previous studies, which report a 21-39% lifetime prevalence of IPV among women in clinical settings and population surveys (Breiding, Black, & Ryan, 2008; Collins et al., 1999; Jones et al., 1999; NCIPC, 2003). Also congruent with earlier studies (Belle, 1990; Goodman, Smyth, Borges, & Singer, 2009; Sorenson et al., 1996), our findings showed that a lower socioeconomic status was associated with women’s risk of experiencing IPV. Potential explanations for this pattern include psychosocial stressors such as poverty, social isolation, homelessness, and unemployment, which have been found to be associated with HIV risk and IPV (Rodrigo & Rajapakse, 2010; Zierler et al., 2000). Additional efforts must be made to reach this population because the problems associated with poverty might limit access to quality health care, HIV testing, and HIV-prevention education (CDC, 2006).

The present study finds that women who experienced IPV were more likely to report an HIV test compared with the overall sample of women (52.4% vs. 35.5%). This higher testing rate could in part be attributed to the efforts of HIV-prevention workers or domestic violence specialists, who are in opportune positions to educate IPV survivors of their HIV/AIDS risk and refer them to appropriate testing services. Or, the correlation could be because higher risk women experience IPV as a result of being tested for HIV or other factors not measured by the present study. Whatever the reason, this higher testing rate is a testament to the women who have endured abuse situations and their resiliency as they strive for healthy lives.

At the same time, although it is a good sign that the majority of women who had experienced domestic violence in this sample had been tested, almost half of the sample had not (n = 2,801, 48%), indicating they were unaware of their HIV status. This indicates the importance of increased prevention efforts at various testing locations, as well as the need for outreach efforts that involve additional screening for both HIV and IPV. As advocated by Silverman, Decker, Saggurti, Balaiah, and Raj (2008), clinicians—especially those who focus on the care of STDs—should incorporate inquiries regarding possible experiences of IPV when treating women. Physicians, nurses, therapists, and social workers need to be informed about the intersection between HIV and domestic violence so that they can tell their patients about their increased risk status and encourage HIV testing. Those who offer testing need to follow up with additional support, referrals for treatment if the status is positive, safety planning, sexual safety planning, and referrals to domestic violence services to help prepare women for the greater risk they are likely to face following disclosure to an abusive partner if their status is positive. Moreover, there must be careful consideration of safety planning when it comes to reporting the diagnosis to the health department and the implementation of partner counseling and referral services (PCRS). Valid questions include the following: Does the increased risk for violence due to HIV disclosure necessitate that women should not know their HIV status? Do practitioners encourage an abuse survivor not to know her status because she may be further abused by her partner? A woman’s safety—from both HIV infection and domestic violence—and the safety of her current and future sex partners all deserve consideration.

There is also an opportunity for HIV-prevention efforts at domestic violence shelters. As a primary resource for women with abuse experience, domestic violence shelters are strategic locations for providing women with information on HIV/AIDS and offering them referrals for testing. An additional consideration for this is that if a client is HIV positive, the shelter will need to have the capacity to link her to medical treatment and support services. Each domestic violence program will need to consider the best way for their agency to provide this support. For example, should domestic violence shelters offer HIV-prevention and testing services themselves, or should they establish partnerships with HIV/AIDS organizations?

When considering HIV prevention for women who have experienced IPV, it is important to keep in mind the context of their experiences and the fact that they are managing the trauma of the violence in their lives. In addition, they may be facing the challenge of building a new life for themselves. Issues that demand attention often include finding housing, employment, child care, and mental health and substance abuse treatment. With all of these life challenges taking priority, sexual health and sexual safety planning often diminish in importance. Increased educational efforts, however, can help women make the connection that treatment for HIV-positive individuals is necessary to keep them alive and well. Thus, it is essential to find ways to increase their urgency in seeking HIV testing, treatment, and prevention.

Women in this sample who had experienced IPV and been tested for HIV were more likely to be tested in a private doctor’s office/HMO as apposed to a clinic or hospital. This was particularly the case for White women, women with more education, and women with higher income levels. Among women exposed to IPV, Latinas were more likely than other races to be tested at a clinic. Although the current sample had a small proportion of both African Americans and Latinas, this finding corresponds to earlier studies (Rountree, Chen, Brown, & Pomeroy, 2009) in which Latinas were more often tested at clinics. This trend can possibly be explained by barriers to health care related to immigration status and lack of insurance to cover private doctor’s office/HMO services (Rodríguez, Bustamante, & Ang, 2009). To address possible accessibility problems to HIV testing, a preventive approach for women who have experienced IPV should incorporate contextual, cultural, and evidence-based HIV-prevention strategies, including the use of outreach.

Overall, these findings that among women who have experienced IPV, those with lower incomes are more likely to be tested in hospitals, those with more education and higher incomes are more likely to be tested in private doctor’s office/HMO, and those who are Hispanic or with lower incomes are more likely to be tested in clinics offer important implications for HIV outreach and prevention strategies. Using these findings on trends in testing location, individuals designing outreach and educational efforts can ensure that testing and prevention messages are targeted based on the most likely testing location for that population choice. For example, prevention messages targeting Hispanic or low-income women should provide information on local free or low-cost clinics.

The prevalence of IPV found in this study and the finding that almost half of the women who had experienced IPV had not been tested for HIV has important implications for social work practice and policy. As a profession, there are two important responsibilities related to these circumstances. First, we need to help women who have experienced IPV get tested and know their HIV/AIDS status. Primarily, this calls for increased outreach and educational efforts through media campaigns and networking within neighborhoods and communities through important social institutions, such as churches and faith-based organizations, schools, and health care clinics and agencies. Increasing public dialogue and awareness can decrease stigma and increase women’s motivation to get tested. In addition, it is important to increase the accessibility of testing sites. Offering free testing in frequented, easy-to-reach locations, as well as increasing the availability of this information are important public health priorities.

Second, as research reports higher rates of IPV among HIV-positive women and women’s fear of disclosure-related violence (Gielen, McDonnell, Burke, & O’Campo, 2000; Rothenberg & Paskey, 1995), women need to be able to access treatment safely, without being put at further risk of violence by an abusive partner. On a clinical level, this primarily means developing sexual safety planning. Although there is currently no research that examines sexual safety planning and its impact on HIV risk among women who experience IPV, one qualitative study among IPV survivors found sexual safety planning to be an important need for this population as related to HIV risk reduction (Rountree & Mulraney, 2010). Safety planning as a practice has long been a part of the domestic violence movement, and has proven effective in helping women find safer living environments and helping connect them to resources (Kendall et al., 2009). A new framework in which sexual safety planning is incorporated into traditional safety planning could be highly beneficial to helping women protect themselves from HIV and other STDs. Sexual safety planning would assist with sexual assertiveness skills, having a plan for getting out of dangerous situations, how to negotiate safe sex with a partner without increasing one’s risk for violence, and provide links to testing locations. Currently, the field of domestic violence, as prompted by the CDC, is moving toward a primary prevention perspective, in which violence against women is prevented from happening in the first place at the community and societal levels. This could be an opportunity to link domestic violence primary prevention efforts with sexual safety planning and HIV and STD prevention efforts, highlighting the relationship between these health concerns and reinforcing the notion that protecting oneself sexually is important to one’s overall health and well-being.

For future research, a large sample of domestic violence shelters or other organizations that serve abused women should be studied to focus on building capacity of HIV-testing accessibility and the feasibility of HIV-prevention interventions targeted to this population. There is also a need to examine the efficacy of sexual safety planning and its impact on women who have experienced IPV. In addition, further research is necessary to assess HIV/AIDS organizations’ ability to offer sexual safety planning in the event their clients have abusive partners as well as how prepared they are to help women with PCRS or other types of partner notifications. Finally, there is the opportunity to explore, through phenomenological study, the reasons women who are at risk for HIV and have abuse histories do or do not get tested for HIV and the accessibility of resources for the co-occurrence of HIV and domestic violence.

Limitations

The current data represent a sample of women who have experienced IPV and their HIV-testing rates and locations from the intimate partner module used in BRFSS 2006. Current findings should be interpreted in light of several limitations. First, because the survey data were conducted by telephone interview, the sample did not include those persons who are homeless or institutionalized (including shelters) or who do not have telephone (or only cell phone) access. Second, the intimate partner module used in BRFSS 2006 is limited to only the eight areas cited earlier; hence, the results do not allow for making generalizations to other areas.

Conclusion

This study provides valuable insight into HIV-testing rates and HIV-testing locations among women who have experienced IPV. The fact that a large percentage of women who had experienced IPV had not been tested for HIV reaffirms the need for increased outreach, contextually and culturally relevant educational and prevention methods, as well as accessible testing locations. The implementation of sexual safety planning for women who have experienced abuse deserves specific attention as a public health priority, as well as incorporating HIV-prevention initiatives at domestic violence service agencies. Through collaboration across these two public health fields, researchers and practitioners can holistically address women’s sexual and physical safety.

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) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Michele A. Rountree, PhD, is an associate professor at University of Texas at Austin, School of Social Work, and her scholarship focuses on the areas of health promotion, disease prevention, and health disparities as it relates to meeting the needs of marginalized populations.

Lynn Chen, PhD, research associate, shares similar research interests and received her PhD from the University of Texas at Austin.

Meredith Bagwell, MSW, joined the research team because of her research interest in the area of women’s experiences of intimate partner abuse and heightened risk for HIV/AIDS.

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