Correlates of Safety Strategy Use Among South African Women Living With HIV and at Risk of Intimate Partner Violence

Abstract

Intimate partner violence (IPV) and HIV are correlated and endemic in South Africa. However, safety strategy use to prevent IPV among HIV-positive women is understudied. This study assesses correlates of specific safety strategy use among 166 Black South African women recently experiencing IPV and testing positive for HIV. Associations were observed between consultation with formal (i.e., counselors, clergy, IPV specialists) and informal networks (i.e., friends/family) and participant language (isiZulu, isiXhosa, Sesotho, and English), past year IPV, and engaging in HIV care. Future HIV-IPV programs should consider how characteristics of different IPV safety strategies may influence strategy uptake and ultimately HIV care.

Keywords

HIV counseling and testing intimate partner violence safety strategies South Africa

Introduction

HIV and intimate partner violence (IPV) are intertwined epidemics (Bogart et al., 2005; Centers for Disease Control & Prevention, 2014; Durevall & Lindskog, 2015; Mitchell et al., 2016), particularly in settings such as South Africa where rates of both HIV and IPV are high among women (Abrahams et al., 2009; Peltzer, 2013; Pronyk et al., 2006; S. W. Rigby & Johnson, 2017). Women exposed to IPV are up to 50% more likely to become infected with HIV (AMFAR, 2020; Fox et al., 2007). In addition, the likelihood of experiencing IPV increases for women who are living with HIV or who disclose a positive HIV diagnosis with a partner (Bogart et al., 2005; Centers for Disease Control & Prevention, 2019; Gielen et al., 2000; Marshall et al., 2018; Mkandawire-Valhmu et al., 2013; Olowookere et al., 2015). Women living with HIV who experience IPV are also at an increased risk of stigma-related abuse by intimate partners (Abdool Karim et al., 2008). Consequently, women living with HIV and at risk of IPV experience more barriers to care (UNAIDS, 2018). These barriers contribute to decreased antiretroviral therapy (ART) adherence, lower retention in medical care, and, ultimately, an increased likelihood of unsuppressed viremia (Hatcher et al., 2015).

Little research exists on strategies used to reduce IPV risk and increase safety and access to HIV care among women diagnosed with HIV who have recently experienced IPV. According to the IPV literature, safety planning is the gold standard intervention to reduce risk of IPV (Bloom et al., 2014; Campbell et al., 2009; Glass et al., 2010; Mkandawire-Valhmu et al., 2013; Thackeray et al., 2007; Wood et al., 2019). Common IPV safety strategies include formal consultations with professionals (e.g., legal or medical professionals, IPV specialists, or clergy), informal consultations such as with friends or family, general safety planning strategies (e.g., hiding important belongings in a bag for a quick escape, keeping the IPV emergency hotline number somewhere safe), placating strategies, and resistance strategies (Parker & Gielen, 2014). Research indicates that plans should be tailored to subjective interpretations of violence, levels of danger, available resources, and personal priorities and goals (Bloom et al., 2014; Dienemann et al., 2002; Goodkind et al., 2004; Mkandawire-Valhmu et al., 2013; Parker et al., 2016; Thackeray et al., 2007). IPV interventions in low- or middle-income countries (LMICs) often focus on strategies for remaining safe within abusive relationships (Wood et al., 2019). However, little else is known about the uptake of other safety strategies in such contexts.

HIV Counseling and Testing (HCT) programs may be an effective entry point to introduce safety strategies and reduce the risk of IPV among women who test HIV positive (Christofides & Jewkes, 2010; King et al., 2016). In a recent study, South African women who had both recently experienced IPV and tested positive for HIV during mobile HCT services reported that participating in a personalized safety planning discussion immediately following a positive HIV diagnosis was helpful (Brown & van Zyl, 2018). In addition, 80% reported using at least one safety strategy in the last 30 days. Which safety strategies are used, who is likely to use specific strategies, and the extent to which different strategies are associated with engagement in HIV-related care among women recently diagnosed with HIV have not been studied in any context. Research on correlates of safety strategy use to reduce IPV risk and increase engagement in HIV-related care would provide valuable information for the design of future interventions, especially within HIV-endemic and high-IPV contexts like South Africa.

Current Study

To address this gap in the literature, this exploratory study assesses associations between specific safety strategy use and sociodemographic factors among South African women diagnosed as HIV positive who are at risk of IPV. It also examines the extent to which these strategies are associated with engagement in HIV care within 30 days. Data for this study were collected as part of a parent study that embedded an IPV safety planning intervention within a voluntary mobile HCT program in South Africa (Brown & van Zyl, 2018).

Method

Study Sample

Women identified for inclusion in the parent study met the following criteria: (a) tested positive for HIV while undergoing voluntary mobile HCT during July–November 2015 in Gauteng province, South Africa; (b) aged 18 years or older; (c) currently (or recently) in a romantic relationship; (d) provided a reachable number for telephonic study administration; and (e) able to participate in one of the chosen languages (English, Sesotho, isiZulu, or isiXhosa). The 446 eligible women were invited to participate and verbally informed about the study intent and procedures. Women who provided both verbal and written consent to participate were contacted by phone about 24 hours later and screened for experience with IPV in the past year. This process yielded 255 participants. Out of that participant population, 166 were assigned to the intervention group in the parent study. This study on safety strategy use focuses on that subgroup, as only that group learned about safety planning and subsequently provided data about safety strategy use.

Study Design and Procedure

All research assistants had a bachelor’s degree and were native speakers of at least one language spoken by participants in this study. All identified as Black South African women (except for one woman from a contiguous country). The entire study team received 1 week of intensive HIV-IPV training to ensure that they could appropriately respond to any identified crises or immediate threats to violence. Training followed World Health Organization (2013) guidelines for responding to IPV. The team also received ongoing quality assurance reviews from an onsite project coordinator and worked alongside the HCT personnel.

During the initial phone call in which participants were assessed for study eligibility after receiving a positive HIV diagnosis, research assistants administered a risk and safety assessment. They explained the resulting score and provided information about types of abusive behavior. They also addressed the increased risk of violence after an HIV-positive diagnosis. Research assistants then engaged participants in a safety planning discussion about safety strategies they could use, including: (a) formal network strategies (e.g., IPV specialists, clergy, counselors, and health care professionals), (b) informal network strategies (e.g., friends and family), (c) legal strategies (police and lawyers), (d) placating strategies, (e) resistance strategies (which are not encouraged but are discussed as a means to dissuade their use given that they are shown to increase violence), and (f) general safety planning strategies. They also discussed strategies for safely accessing HIV care and medicine. This additional strategy was informed by the HIV Power and Control wheel created by the National Network to End Domestic Violence (Mkandawire-Valhmu et al., 2013) and insight from exploratory studies on women living with HIV and IPV in southern Africa (van Schalkwyk et al., 2014; Wright et al., 2007).

After this discussion, research assistants worked with participants to create a personalized safety plan based on these seven domains. The intent was to help participants safely access HIV-related care and increase overall safety by encouraging the use of different safety strategies. The direction of the plan depended in part on whether the participant planned to leave the relationship. Participants not planning to leave the relationship were supported in their decision and not encouraged to leave. Each safety planning discussion emphasized strategies participants could use to stay safe, access HIV care, take medicine, and notify their partner of their seropositive status if desired. Research assistants provided participants with information about specific IPV services in their area, the legal options available, and the process for using services such as Orders of Protection. They also gave referrals for IPV and legal services to those who wanted them. Additional strategies also discussed safe places to keep information away from partners who may be potentially harmful. Research assistants contacted 82 of the participants 2 weeks after the initial phone call to review safety plans, process relationship changes and responses to partner notification of serostatus (if any), and discuss any needed resources. They then called all 166 participants 1 month after baseline to record information about safety strategy uptake. There were no differences in outcomes between participants who received one versus two follow-up phone calls. Therefore, they are referred to as one group in this study.

Survey and consent documents were translated and back-translated in an iterative process from English into each language used in this study. The research team reviewed translations to check for colloquial accuracy and solicited feedback on the survey tool from 20 individuals who were not study participants.

Measures

At follow-up, a series of questions elicited which safety strategies participants had used during the past month, if any, and requested participants to indicate yes or no about each strategy. Research assistants also asked participants whether they had been to a clinic or gotten any HIV-related medical care in the past 30 days, such as to get CD4 count results or talk with a counselor about treatment options. A response of yes was classified as “accessing HIV-related care.” Two additional questions elicited whether participants had notified their partner about their positive HIV diagnosis and whether participants had experienced any physical or sexual IPV after partner notification.

During the initial phone call when participants were enrolled in the study, research assistants used an HIV-IPV risk and safety assessment tool to assess an individual’s risk of experiencing IPV. The assessment elicited whether a participant had personally experienced any physical or sexual IPV in the past year or had only experienced nonviolent forms of control. As the tool elicited additional information, an overall score was calculated representing the current danger level a participant faced at initial assessment. This tool included refined items from gold standard subscales as well as one scale created specifically to measure HIV-related IPV for women undergoing HCT. This HIV-IPV risk and safety assessment tool had an acceptable score to support unidimensional scoring. Further details about this assessment are provided in Brown and van Zyl (2018). In addition, research assistants recorded participants’ HIV testing and diagnosis history. Participants were classified as either receiving a positive diagnosis for the first time, or as receiving a positive diagnosis as part of re-testing to receive current CD-4 cell count. Age, race, and chosen language of study administration were also recorded. The extent of sociodemographic information collected was limited to maintain the feasibility of the parent study intervention within the mobile HCT context.

Ethical Considerations

The parent study received ethical approval from the IRB ethics committee at the University of Louisville and was registered with the National Health Research Ethics Council in South Africa. Vanderbilt Human Subjects Research Protection provided approval for secondary data analysis.

Data Analysis

An initial series of multivariable logistic regression models were fitted to assess sociodemographic correlates of safety strategy use (one strategy per model), including age, language, testing history, initial danger level, and history of abuse. Similar models were also fitted to assess the association between accessing HIV-related care and safety strategy use adjusting for the sociodemographic factors.

Results

Participants were 33 years old on average (standard deviation: 10 years). Overall, 116 (70%) participants spoke isiZulu in the interview (Table 1). Ninety-three participants (56%) had tested positive for HIV in the past, and most (119 [72%]) reported experiencing physical or sexual IPV in the past year. The other participants (47 [28%]) reported experiencing only nonviolent control in their relationship in the past year.

Table 1.

Sociodemographic Distribution of Women Testing HIV Positive During a Mobile HIV Counseling and Testing Service in Gauteng Province, South Africa (N = 166).

	Number and percent of participants
Sociodemographic characteristics	n	%
Age
18–25 years	25	15
26–35 years	54	33
36–45 years	60	36
46–65 years	27	16
Language
English	10	6
Sesotho	15	9
isiXhosa	25	15
isiZulu	116	70
HIV testing and diagnosis history
Newly diagnosed positive	73	44
Previously diagnosed positive	93	56
Experienced any intimate partner violence in the past year
Nonviolent control only	47	28
Physical or sexual	119	72

Use of Specific IPV Safety Strategies

The three most used safety strategies were talking to a family member or friend (73 [44%]), talking to a medical professional (73 [44%]), and talking to a counselor (53 [32%]). Use of safety strategies related to HIV care was not as common: 27 (15%) used a strategy to safely take HIV medication, and 25 (15%) to safely access HIV-related care. Few (9 [8%]) reported talking to a lawyer or policeman. Thirty-three (20%) of the participants did not use any safety strategy.

Some differences in specific safety strategy use existed between participants speaking different languages (Table 2). For example, 60% of English speakers, 45% of isiZulu speakers, 40% of isiXhosa speakers, and 33% of Sesotho speakers reported talking to friends or family (p = .015), and 60% of English speakers, 34% of isiZulu speakers, 16% of isiXhosa speakers, and 27% of Sesotho speakers reported talking to an IPV counselor (p = .026). There were no differences in the prevalence of uptake for each strategy between subcategories for age and testing and diagnosis history. Within 30 days, 69 (42%) participants had accessed HIV-related care, and 5 (3%) participants reported experiencing IPV upon partner notification of HIV status.

Table 2.

Prevalence of Safety Strategy Uptake Among Women Testing HIV Positive By Potential Explanatory Factors (N = 166).

Sociodemographic characteristics	Talk to friend or family	Talk to medical professional	Talk to counselor	Talk with clergy	Talk with IPV specialist	Talk to police or lawyer	Use of general safety plan	Use of safe linkage to care plan	Use of safe medicine plan
Total	44%	44%	32%	24%	10%	8%	13%	15%	15%
Age
18–25 years	56%	48%	36%	36%	12%	12%	12%	20%	28%
26–35 years	43%	43%	31%	24%	9%	7%	11%	17%	15%
36–45 years	42%	43%	30%	15%	10%	7%	17%	12%	10%
46–65 years	41%	44%	33%	33%	7%	7%	7%	15%	15%
p value^a	.983	.957	.104	.946	.633	.820	.585	.476	.680
Language
English	60%	70%	60%	40%	20%	10%	30%	40%	50%
Sesotho	33%	60%	27%	7%	7%	0%	20%	20%	20%
isiXhosa	40%	20%	16%	8%	0%	0%	8%	4%	4%
isiZulu	45%	45%	34%	28%	11%	10%	11%	15%	14%
p value^a	.015	.080	.026	.163	.618	.203	.558	1.000	.193
HIV testing and diagnosis history
Newly diagnosed positive	47%	48%	33%	25%	8%	12%	11%	16%	18%
Previously diagnosed positive	42%	41%	31%	24%	11%	4%	14%	14%	13%
p value^a	.431	.868	1.000	.792	.637	.080	.732	.732	.642
Experienced any intimate partner violence in the past year
Nonviolent control only	45%	53%	38%	26%	6%	6%	17%	9%	13%
Physical or sexual	44%	40%	29%	24%	11%	8%	11%	18%	16%
p value^a	1.000	.165	.274	.841	.561	1.000	.351	.157	.810
P value for independent samples t testof difference in mean danger level bystrategy uptake	.438	.034	.067	.618	.342	.074	.087	.592	.167

Note. IPV = intimate partner violence.

Values of p are based on Fisher tests as part of chi-square testing for differences of prevalence in safety strategy uptake between categories within a factor.

Correlates of Specific IPV Safety Strategy Use

Estimates from multivariable logistic regression analyses indicated variation in relationships between correlates and specific safety strategy use. Risk of danger at baseline was associated with five out of the nine strategies (Table 3). Language was also associated with use of certain safety strategies. For example, IsiXhosa speakers were less likely to talk to a medical professional than were isiZulu speakers (adjusted odd ratio [AOR] = 0.30, 95% confidence interval [CI]: 0.10, 0.89, p value = .030). IsiXhosa speakers were also less likely to talk to clergy (AOR = 0.22, 95% CI: 0.05, 0.99, p value = .048). English speakers were 5.68 times more likely to use a safety plan to take medicine than were isiZulu speakers (95% CI: 1.36, 23.72, p value = .017). There was some evidence that English speakers were more likely to use other strategies than other language speakers, though most of those associations were imprecisely estimated.

Table 3.

Adjusted Odds Ratios Estimating Odds of Safety Strategy Use Among Women in South Africa Diagnosed as HIV Positive and Recently Experiencing Intimate Partner.

	Talk to friend or family		Talk to medical professional		Talk to counselor
Sociodemographic characteristics	AOR (95% CI)	p value	AOR (95% CI)	p value	AOR (95% CI)	p value
Age	0.99 (0.96, 1.02)	.682	1.00 (0.96,1.03)	.943	1.00 (0.96, 1.04)	.820
Language (vs. isiZulu)
English	1.80 (0.46, 6.99)	.397	2.18 (0.50, 9.45)	.297	2.60 (0.65, 10.44)	0.178
Sesotho	0.69 (0.22, 2.21)	.533	1.45 (0.46, 4.60)	.529	0.52 (0.15, 1.83)	0.308
isiXhosa	0.81 (0.33, 1.96)	.636	0.30 (0.10, 0.89)	.030	0.38 (0.12, 1.21)	0.101
Newly diagnosed (vs. previously diagnosed)	1.08 (0.55, 2.11)	.830	1.28 (0.63, 2.59)	.497	0.95 (0.45, 2.01)	0.895
Experienced any sexual or physical IPV in the past year (vs. nonviolent control only)	1.07 (0.51, 2.22)	.865	0.41 (0.19, 0.89)	.024	0.47 (0.21, 1.04)	0.064
Danger level at initial assessment	0.92 (0.75, 1.13)	.425	1.30 (1.05, 1.63)	.018	1.31 (1.05, 1.64)	0.018
	Talk with clergy		Talk with IPV specialist		Talk to police or lawyer
	AOR (95% CI)	p value	AOR (95% CI)	p value	AOR (95% CI)	p value
Age	0.99 (0.95, 1.03)	.733	0.98 (0.92, 1.04)	.508	0.99 (0.92,1.06)	.844
Language (vs. isiZulu)
English	1.58 (0.40, 6.27)	.517	2.31 (0.39, 13.57)	.355	0.46 (0.05,4.59)	.510
Sesotho	0.16 (0.02, 1.33)	.090	0.47 (0.05, 4.19)	.502	0 (0, Inf)	.994
isiXhosa	0.22 (0.05, 0.99)	.048	0 (0, Inf)	.990	0 (0, Inf)	.993
Newly diagnosed (vs. previously diagnosed)	0.86 (0.38, 1.94)	.712	0.48 (0.14, 1.64)	.243	3.06 (0.75,12.48)	.119
Experienced abuse in past year (vs. nonviolent control only)	0.79 (0.33, 1.87)	.587	1.64 (0.40, 6.82)	.493	0.57 (0.12,2.64)	.472
Danger level at initial assessment	1.09 (0.86, 1.39)	.457	1.16 (0.84, 1.59)	.367	1.64 (1.15,2.32)	.006
	Use of general safety plan		Use of safe linkage to care plan		Use of safe medicine plan
	AOR (95% CI)	p value	AOR (95% CI)	p value	AOR (95% CI)	p value
Age	1.00 (0.94, 1.05)	.993	1.00 (0.95, 1.05)	.997	0.99 (0.94, 1.04)	.617
Language (vs. isiZulu)
English	3.45 (0.71, 16.86)	.126	4.13 (0.91, 18.84)	.067	5.68 (1.36, 23.72)	.017
Sesotho	1.38 (0.32, 5.88)	.662	1.10 (0.26, 4.76)	.896	1.43 (0.34, 6.03)	.623
isiXhosa	0.73 (0.15, 3.55)	.696	0.27 (0.03, 2.18)	.221	0.28 (0.03, 2.20)	.224
Newly diagnosed (vs. previously diagnosed)	0.60 (0.20, 1.76)	.351	0.89 (0.33, 2.39)	.811	1.00 (0.37, 2.67)	.992
Experienced abuse in past year (vs. nonviolent control only)	0.38 (0.12, 1.20)	.098	1.67 (0.48, 5.84)	.420	1.19 (0.39, 3.67)	.759
Danger level at initial assessment	1.40 (1.04, 1.89)	.029	1.35 (1.04, 1.75)	.025	1.16 (0.89, 1.51)	.285

Note. AOR = adjusted odd ratio; CI = confidence interval; IPV = intimate partner violence.

Participants who had experienced physical or sexual abuse in the past year were less likely to consult with a medical professional than were participants who had not experienced such abuse (AOR = 0.41, 95% CI: 0.19, 0.89, p value = .024). Age, tester type, and treatment assignment were not associated with type of safety strategy used.

Accessing HIV Care and Specific IPV Safety Strategy Use

The relationship between safety strategy uptake and accessing HIV-related care varied across safety strategy. Participants consulting with friends or family were more likely to access HIV-related care within 30 days (AOR = 3.27, 95% CI: 1.66, 6.45, p value < .001) than participants who did not. However, participants consulting with a counselor, clergy, or IPV service were less likely to access HIV-related care within 30 days than those who did not use such formal services (Supplemental Tables 1A–1I).

Discussion

Using data collected as a follow-up to a joint HIV-IPV intervention among South African women at risk of IPV and testing positive for HIV during mobile HCT services, this study assessed use of different formal and informal safety strategies to prevent future IPV incidents and promote engagement in HIV-related care. There are three key findings. First, while most participants used at least one safety strategy, the specific safety strategies used varied across participants. Second, participants’ preferred communication language was associated with use of some safety strategies but not others. The level of danger a participant faced at initial assessment also varied across language. Finally, accessing HIV-related care within 30 days varied across use of different safety strategies. Overall, this study provides novel evidence that conducting a safety plan with multiple options as part of HCT may encourage use of different safety strategies to prevent IPV and some strategies to improve access to HIV care.

This study adds to the IPV literature base by exploring correlates of specific safety strategy use within a population facing both HIV- and IPV-related challenges. Prior work refrains from assessing specific safety strategy use and generally describes populations within the United States or in lower-income countries who are part of antenatal/clinic-based samples (Abramsky et al., 2012; Hatcher et al., 2015; Marshall et al., 2018; O’Campo et al., 2002; Peltzer, 2013; Wechsberg et al., 2013). In addition, most prior studies on safety strategy use in IPV survivors have either focused on HIV-negative populations or have not compared outcomes by HIV status (Parker & Gielen, 2014; Wood et al., 2019). This study is also the first to assess the extent to which safety strategies are associated with engagement in HIV-related care among women who test HIV positive in a mobile program. Most relevant studies do not investigate HIV-related IPV or the impact of IPV on engagement in HIV-related care following mobile HCT testing or diagnosis (Abramsky et al., 2012, 2014; Hatcher et al., 2015).

Discussing a variety of options spanning different levels of resources and types of contacts may help women at risk of IPV to engage in at least one strategy. In general, the use of informal family and friend networks among HIV-positive women as a safety strategy is consistent with findings from studies in low- and middle-income countries focused only on IPV, particularly in urban settings (Deuba et al., 2016; Gillum et al., 2018; Horn et al., 2016; Mannell et al., 2016; Wood et al., 2019). Consultation with a medical professional was greater in this study compared with past work (Ansara & Hindin, 2010; Glass et al., 2010; Parker & Gielen, 2014). This may be partially attributable to the study design partnering with an HCT services’ call center to contact participants and promote linkage to medical care. The use of clergy consultation was similar to that observed in another South African study (Ansara & Hindin, 2010; Parker & Gielen, 2014; Peltzer et al., 2003). Consultation with legal services was low in this study, but still higher than that reported in another study in sub-Saharan Africa (Mkandawire-Valhmu et al., 2013).

The finding that preferred language was related to use of some safety strategies is a new contribution to the IPV and HIV literature. The pathways upholding these relationships are unknown. Perhaps language is a proxy for culture. For example, language may reflect a shared worldview of its speakers, define group membership, and influence behavior by activating culturally patterned stimuli/responses and thoughts that determine shared interpretations of social exchange (Krauss & Chiu, 1998). Language may also be a proxy for socioeconomic status, which is likely related to the kinds of formal and informal supports to which people may reach out for assistance. Language could be an easily obtainable indicator when the need for parsimony (in interventions or study administration) precludes other traditional markers of risk. Furthermore, it might be useful to tailor safety strategy protocols to patterns emerging by language type.

Finally, this study provides novel evidence that consultation with counselors, clergy, or IPV specialists was associated with decreased odds of accessing HIV-related care compared with those who did not consult with these specialists. Meanwhile, consultation with friends and family was associated with increased odds of accessing HIV-related care compared with not consulting with friends or family. Participants who access formal forms of support during the 30 days after receiving a joint HIV diagnosis and IPV risk assessment and safety plan may have less time to devote to accessing HIV care. Further research is warranted about the unintended consequences of using each kind of IPV safety strategy.

Implications for Practice

The observed higher engagement with friends or family highlights the possible benefit of purposely including close social ties as treatment supporters in future interventions to reduce IPV risk and facilitate engagement in HIV-related care. Engagement with family and friends is frequently the first step in seeking formal help (Deuba et al., 2016), and programs involving treatment supporters have been associated with improvements in HIV-care outcomes (Goudge & Ngoma, 2011; Nachega et al., 2006). The lower engagement in HIV-related care following consultation with formal supports suggests that future interventions should assess methods for helping women to juggle safety and health needs simultaneously. In addition, future interventions might consider strategies effective in assisting women from various language backgrounds.

Overall, the current findings indicate that women at risk of IPV could benefit from individually tailored safety planning discussions that walk through the availability of different safety strategies. This kind of risk assessment and detailed discussion could be included as a modification to standard HCT programs for women and assist in addressing the entwined epidemics of HIV and IPV. This combination could be especially effective at reducing risk, as women who have experienced IPV are more likely to access health-related services than formal IPV services, particularly in developing countries (Chibber & Krishnan, 2011). The COVID-19 pandemic has highlighted the need to scale up IPV-reduction efforts (CARE, 2020; Chuku et al., 2020; Ntseku, 2020; J. Rigby, 2020). Recently, the South African government pledged to devote $75 million to improve gender-based violence (GBV) (Government of South Africa, 2019). Providers may be considering how best to integrate GBV responses into standards of care if pledged funding becomes available. Discussion around specific safety strategies that involve connecting with both formal and informal supports will need to be adjusted to address limitations associated with the pandemic. For example, safety planning protocols might include consideration for how women who prefer to consult with informal networks of friends and family may do so during lockdown periods. Strategies could also be tailored to anticipate virtual platforms or mechanisms for acquiring resources to support such platforms. Notably, the current study depicts correlates of safety strategy use following a telephonic intervention, underscoring the potential significance of our findings in the COVID-19 era in which many services have been shifted to virtual platforms.

Implications for Future Research

The findings of the current study are exploratory. Further investigation of the association between consultation with counselors, clergy, and IPV specialists is warranted. Additional research on the lower odds of accessing HIV-related care could uncover circumstances where this might not be the case (among certain women or certain formal network types, for example). Such studies might also probe for differences in types of discussions during all consultations to better understand the mechanisms reinforcing these relationships and uncover areas for modification. In addition, future research might seek to uncover how consultation with friends and family specifically facilitates engagement in HIV-related care (e.g., perhaps friends and family are easier to talk with about most subjects, including serostatus) and the types of HIV-related care being accessed. Finally, developers of future research protocols might consider adopting methods that can best harness the benefits of a social support network combined with formal interventions.

Limitations

The current study has several notable limitations. First, several potential confounding factors, such as economic status, substance use, and the presence of children in participants’ households, were not assessed. Some of these factors (e.g., socioeconomic status) might overlap with language. Second, data on accessed HIV-related care after 30 days were not collected. Perhaps women using formal strategies accessed HIV-related care at a later point, but not so late that it influenced their HIV outcomes in a negative way. Third, the safety planning intervention focused on acceptable safety strategies often used in the United States, as gleaned from literature available at the time of the parent study’s design. However, participants might have used other safety strategies more common to this setting, such as those related to removing stressors, minimizing damage through enduring violence, and building personal resources outside of the other domains (Wood et al., 2019). Finally, findings may not be generalizable to all Black South African women who test positive for HIV. South Africa is a diverse country where provinces vary in the saturation of different cultural groups (Xhosa in the Eastern Cape, for example) and norms. Urban versus rural differences might also impact how safety planning is tailored.

Conclusion

This novel exploratory study of IPV prevention safety strategy uptake among women testing positive for HIV in South Africa provides initial evidence that discussing a variety of safety strategies as part of a combined HIV-IPV intervention may help to increase safety strategy use. A particularly salient finding from the current study was the popularity of talking with family/friends and medical professionals as safety strategies. Future efforts to refine HCT services and IPV response should consider the inclusion of family/friend engagement and the inclusion of IPV screening and safety planning as part of standard HCT care. Further research is needed to assess unintended consequences of engagement with formal networks for support.

Supplemental Material

sj-docx-1-vaw-10.1177_10778012211021108 – Supplemental material for Correlates of Safety Strategy Use Among South African Women Living With HIV and at Risk of Intimate Partner Violence

Supplemental material, sj-docx-1-vaw-10.1177_10778012211021108 for Correlates of Safety Strategy Use Among South African Women Living With HIV and at Risk of Intimate Partner Violence by Leslie Lauren Brown, Jessica Mayson Perkins, Jami Lynn Hargrove, Kathryn Elenor Pahl, Phepo Mogoba and Michiel Adriaan van Zyl in Violence Against Women

Supplemental Material

sj-pdf-1-vaw-10.1177_107780122110211083 – Supplemental material for Correlates of Safety Strategy Use Among South African Women Living With HIV and at Risk of Intimate Partner Violence

Supplemental material, sj-pdf-1-vaw-10.1177_107780122110211083 for Correlates of Safety Strategy Use Among South African Women Living With HIV and at Risk of Intimate Partner Violence by Leslie Lauren Brown, Jessica Mayson Perkins, Jami Lynn Hargrove, Kathryn Elenor Pahl, Phepo Mogoba and Michiel Adriaan van Zyl in Violence Against Women

Footnotes

Acknowledgements

Thank you to the staff of Shout-it-Now, for all of your tireless work to end the HIV epidemic in South Africa. Thank you to the Commission on Diversity and Racial Equity at the University of Louisville, USA, for supporting this research. Most of all, we acknowledge our respect and gratitude to the women who participated in this study, sharing personal accounts of their struggles with HIV and intimate relationships.

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: L.L.B. acknowledges support from Tennessee Center for AIDS Research grant P30 AI110527. J.M.P. acknowledges salary support from NIH K01MH115811.

ORCID iD

Leslie Lauren Brown

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Leslie Lauren Brown, PhD, LCSW, is an assistant professor of psychiatry & behavioral sciences in the School of Medicine at Meharry Medical College and an adjunct assistant professor of medicine at Vanderbilt University Medical Center. She serves on the Executive Committee for the Tennessee Center for AIDS Research and has years of experience as a psychotherapist treating sexual assault survivors as well as survivors of intimate partner violence. She received her PhD in social work from the Kent School of Social Work at the University of Louisville, Louisville, KY, USA.

Jessica Mayson Perkins, PhD, is an assistant professor in the Department of Human and Organizational Development at Vanderbilt University and a Faculty Affiliate of the Vanderbilt Institute of Global Health. Her current research projects focus on social determinants of HIV prevention, substance use, and intimate partner violence in Uganda and in the United States. The goal is to design community-based interventions to increase health-promoting behavior. Her work is supported by funding from the National Institute of Mental Health and Tennessee Center for AIDS Research. She received her PhD in Health Policy (with a focus in medical sociology) from Harvard University, Cambridge, MA, USA.

Jami Lynn Hargrove, LMSW, is a psychotherapist at Nashville CARES and has worked for more than 8 years in the HIV field, both domestically and internationally, concentrating on HIV testing and providing clinical services for people living with HIV who have experienced psychological trauma or have dual diagnoses (mental health and substance use). She served as a community health HIV/AIDS educator with the Peace Corps in rural Eswatini and as a patient advocate for survivors of sexual assault and/or interpersonal violence. She received her master of science in social work from the University of Tennessee College of Social Work in Nashville, TN.

Kathryn Elenor Pahl, PhD, served as the managing director of Shout-it-Now in Cape Town, South Africa, for the past 15 years and currently serves on their board of directors. She received her PhD in social work from the Kent School of Social Work at the University of Louisville, Louisville, KY, USA.

Phepo Mogoba, MPH, is a data analyst in the Division of Epidemiology and Biostatistics at the School of Public Health & Family Medicine, University of Cape Town. Her research work focuses on the HIV care continuum, with previous appointments as a study coordinator and data manager within the same division. She holds a master of public health (MPH) degree in biostatistics and epidemiology, and recently received a UCT Fogarty Fellowship toward a PhD in HIV implementation science.

Michiel Adriaan van Zyl, PhD, MSW, is the director of the University of South Florida School of Social Work. Prior to this role, he was the associate dean of research and professor at the University of Louisville, Kent School of Social Work. He received his master’s of social work from the Rand Afrikaans University and his PhD from the University of Natal in South Africa.

References

Abdool Karim

Meyer-Weitz

Mboyi

Carrara

Mahlase

Frohlich

J. A.

Abdool Karim

S. S.

(2008). The influence of AIDS stigma and discrimination and social cohesion on HIV testing and willingness to disclose HIV in rural KwaZulu-Natal, South Africa. Global Public Health, 3(4), 351–365. https://doi.org/10.1080/17441690802076496

Abrahams

Jewkes

Martin

L. J.

Mathews

Vetten

Lombard

(2009). Mortality of women from intimate partner violence in South Africa: A national epidemiological study. Violence and Victims, 24(4), 546–556. https://doi.org/10.1891/0886-6708.24.4.546

Abramsky

Devries

Kiss

Francisco

Nakuti

Musuya

, et al. (2012). A community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda (the SASA! Study): Study protocol for a cluster randomised controlled trial. Trials, 13, Article 96. https://doi.org/10.1186/1745-6215-13-96

Abramsky

Devries

Kiss

Nakuti

Kyegombe

Starmann

, et al. (2014). Findings from the SASA! Study: A cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Medicine, 12(1), Article 122. https://doi.org/10.1186/s12916-014-0122-5

AMFAR. (2020). Statistics: Women and HIV/AIDS. https://www.amfar.org/about-hiv-and-aids/facts-and-stats/statistics–women-and-hiv-aids/

Ansara

D. L.

Hindin

M. J.

(2010). Formal and informal help-seeking associated with women’s and men’s experiences of intimate partner violence in Canada. Social Science and Medicine, 70(7), 1011–1018. https://doi.org/10.1016/j.socscimed.2009.12.009

Bloom

T. L.

Glass

N. E.

Case

Wright

Nolte

Parsons

(2014). Feasibility of an online safety planning intervention for rural and urban pregnant abused women. Nursing Research, 63(4), 243–251. https://doi.org/10.1097/NNR.0000000000000036

Bogart

L. M.

Collins

R. L.

Cunningham

Beckman

Golinelli

Eisenman

Bird

C. E.

(2005). The association of partner abuse with risky sexual behaviors among women and men with HIV/AIDS. AIDS and Behavior, 9(3), 325–333. https://doi.org/10.1007/s10461-005-9006-1

Brown

L. L.

van Zyl

M. A.

(2018). Mitigating intimate partner violence among South African women testing HIV positive during mobile counseling and testing. AIDS Care, 30(1), 65–71. https://doi.org/10.1080/09540121.2017.1366414

10.

Campbell

J. C.

Webster

D. W.

Glass

(2009). The danger assessment: Validation of a lethality risk assessment instrument for intimate partner femicide. Journal of Interpersonal Violence, 24(4), 653–674. https://doi.org/10.1177/0886260508317180

11.

CARE. (2020). More than 50 women stand #TogetherForHer with the Charlize Theron Africa outreach project, CARE, and entertainment industry foundation to address gender-based violence during COVID-19. PR Newsire. https://www.prnewswire.com/news-releases/more-than-50-women-stand-togetherforher-with-the-charlize-theron-africa-outreach-project-care-and-entertainment-industry-foundation-to-address-gender-based-violence-during-covid-19-301055986.html

12.

Centers for Disease Control & Prevention. (2014). Intersection of intimate partner violence and HIV in women—February. http://www.cdc.gov/violenceprevention/pdf/ipv/13_243567_green_aag-a.pdf

13.

Centers for Disease Control & Prevention. (2019). Intimate partner violence. http://www.cdc.gov/violenceprevention/intimatepartnerviolence/

14.

Chibber

K. S.

Krishnan

(2011). Confronting intimate partner violence: A global health priority. Mount Sinai Journal of Medicine, 78, 449–457. https://doi.org/10.1002/msj.20259

15.

Christofides

Jewkes

(2010). Acceptability of universal screening for intimate partner violence in voluntary HIV testing and counseling services in South Africa and service implications. AIDS Care—Psychological and Socio-Medical Aspects of AIDS/HIV, 22(3), 279–285. https://doi.org/10.1080/09540120903193617

16.

Chuku

Mukasa

Yenice

(2020). Putting women and girls’ safety first in Africa’s response to COVID-19. The Brookings Institute.

17.

Deuba

Mainali

Alvesson

H. M.

Karki

D. K.

(2016). Experience of intimate partner violence among young pregnant women in urban slums of Kathmandu Valley, Nepal: A qualitative study. BMC Women’s Health, 16(1), 1–10. https://doi.org/10.1186/s12905-016-0293-7

18.

Dienemann

Campbell

Landenburger

Curry

M. A.

(2002). The domestic violence survivor assessment: A tool for counseling women in intimate partner violence relationships. Patient Education and Counseling, 46(3), 221–228. https://doi.org/10.1016/S0738-3991(01)00216-6

19.

Durevall

Lindskog

(2015). Intimate partner violence and HIV infection in sub-Saharan Africa. World Development, 72, 27–42. https://doi.org/10.1016/j.worlddev.2015.02.012

20.

Fox

A. M.

Jackson

S. S.

Hansen

N. B.

Gasa

Crewe

Sikkema

K. J.

(2007). In their own voices: A qualitative study of women’s risk for intimate partner violence and HIV in South Africa. Violence Against Women, 13(6), 583–602. https://doi.org/10.1177/1077801207299209

21.

Gielen

A. C.

McDonnell

K. A.

Burke

J. G.

O’Campo

(2000). Women’s lives after an HIV-positive diagnosis: Disclosure and violence. Maternal and Child Health Journal, 4(2), 111–120. https://doi.org/10.1023/A:1009522321240

22.

Gillum

T. L.

Doucette

Mwanza

Munala

(2018). Exploring Kenyan women’s perceptions of intimate partner violence. Journal of Interpersonal Violence, 33(13), 2130–2154. https://doi.org/10.1177/0886260515622842

23.

Glass

Eden

K. B.

Bloom

Perrin

(2010). Computerized aid improves safety decision process for survivors of intimate partner violence. Journal of Interpersonal Violence, 25(11), 1947–1964. https://doi.org/10.1177/0886260509354508

24.

Goodkind

J. R.

Sullivan

C. M.

Bybee

D. I.

(2004). A contextual analysis of battered women’s safety planning. Violence Against Women, 10(5), 514–533. https://doi.org/10.1177/1077801204264368

25.

Goudge

Ngoma

(2011). Exploring antiretroviral treatment adherence in an urban setting in South Africa. Journal of Public Health Policy, 32(S1), S52–S64. https://doi.org/10.1057/jphp.2011.22

26.

Government of South Africa. (2019). President Cyril Ramaphosa: Joint sitting of parliament on gender-based violence. https://www.gov.za/speeches/address-president-cyril-ramaphosa-joint-sitting-parliament-crisis-violence-south-africa

27.

Hatcher

A. M.

Smout

E. M.

Turan

J. M.

Christofides

Stöckl

(2015). Intimate partner violence and engagement in HIV care and treatment among women: A systematic review and meta-analysis. AIDS, 29(16), 2183–2194. https://doi.org/10.1097/QAD.0000000000000842

28.

Horn

Puffer

E. S.

Roesch

Lehmann

(2016). “I don’t need an eye for an eye”: Women’s responses to intimate partner violence in Sierra Leone and Liberia. Global Public Health, 11(1–2), 108–121. https://doi.org/10.1080/17441692.2015.1032320

29.

King

E. J.

Maman

Namatovu

Kiwanuka

Kairania

Ssemanda

J. B.

, et al. (2016). Addressing intimate partner violence among female clients accessing HIV testing and counseling services: Pilot testing tools in Rakai, Uganda. Violence Against Women, 23(13), 1656–1668. https://doi.org/10.1177/1077801216663657

30.

Krauss

R. M.

Chiu

C.-Y.

(1998). Language and social behaviour. In Gilbert

Fiske

Lindsey

(Eds.), Handbook of social psychology (4th ed., Vol. 2, pp. 41–88). McGraw-Hill. https://doi.org/10.1177/003803857300700340

31.

Mannell

Jackson

Umutoni

(2016). Women’s responses to intimate partner violence in Rwanda: Rethinking agency in constrained social context. Global Public Health, 11(1–2), 65–81. https://doi.org/10.1080/17441692.2015.1013050

32.

Marshall

K. J.

Fowler

D. N.

Walters

M. L.

Doreson

A. B.

(2018). Interventions that address intimate partner violence and HIV among women: A systematic review. AIDS and Behavior, 22(10), 3244–3263. https://doi.org/10.1007/s10461-017-2020-2

33.

Mitchell

Wight

Van Heerden

Rochat

T. J.

(2016). Intimate partner violence, HIV, and mental health: A triple epidemic of global proportions. International Review of Psychiatry, 28(5), 452–463. https://doi.org/10.1080/09540261.2016.1217829

34.

Mkandawire-Valhmu

Stevens

P. E.

Kako

P. M.

Dressel

(2013). Safety planning in focus groups of Malawian women living with HIV: Helping each other deal with violence and abuse. Violence Against Women, 19(11), 1331–1349. https://doi.org/10.1177/1077801213514859

35.

Nachega

J. B.

Knowlton

A. R.

Deluca

Schoeman

J. H.

Watkinson

Efron

, et al. (2006). Treatment supporter to improve adherence to antiretroviral therapy in HIV-infected South African adults: A qualitative study. Journal of Acquired Immune Deficiency Syndromes, 43(SUPPL. 1), 127–133. https://doi.org/10.1097/01.qai.0000248349.25630.3d

36.

Ntseku

(2020). Shelters taking strain as domestic violence rises during Covid-19 lockdown. Independent Online. https://www.msn.com/en-za/news/crime/shelters-taking-strain-as-domestic-violence-rises-during-covid-19-lockdown/ar-BB12BYur

37.

O’Campo

McDonnell

Gielen

Burke

Chen

Y. H.

(2002). Surviving physical and sexual abuse: What helps low-income women? Patient Education and Counseling, 46(3), 205–212. https://doi.org/10.1016/S0738-3991(01)00214-2

38.

Olowookere

S. A.

Fawole

O. I.

Adekanle

D. A.

Adeleke

N. A.

Abioye-Kuteyi

E. A.

(2015). Patterns and correlates of intimate partner violence to women living with HIV/AIDS in Osogbo, southwest Nigeria. Violence Against Women, 21(11), 1330–1340. https://doi.org/10.1177/1077801215594889

39.

Parker

E. M.

Gielen

A. C.

(2014). Intimate partner violence and safety strategy use: Frequency of use and perceived effectiveness. Women’s Health Issues, 24(6), 584–593. https://doi.org/10.1016/j.whi.2014.08.001

40.

Parker

E. M.

Gielen

A. C.

Castillo

Webster

D. W.

Glass

(2016). Intimate partner violence and patterns of safety strategy use among women seeking temporary protective orders: A latent class analysis. Violence Against Women, 22(14), 1663–1681. https://doi.org/10.1177/1077801216631436

41.

Peltzer

(2013). Intimate partner violence among new HIV positive mothers in South Africa. Gender and Behaviour, 11(1), 5056–5063.

42.

Peltzer

Mashego

T. A.

Mabeba

(2003). Attitudes and practices of doctors toward domestic violence victims in South Africa. Health Care for Women International, 24(2), 149–157. https://doi.org/10.1080/07399330390178431

43.

Pronyk

P. M.

Hargreaves

J. R.

Kim

J. C.

Morison

L. A.

Phetla

Watts

, et al. (2006). Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: A cluster randomised trial. Lancet, 368(9551), 1973–1983. https://doi.org/10.1016/S0140-6736(06)69744-4

44.

Rigby

(2020). Three-quarters of refugee women in Africa report rise in domestic violence during Covid-19; “Reducing exposure to the virus increased exposure to violence for women and girls.” The Sunday Telegraph: Web Edition. https://www.telegraph.co.uk/global-health/women-and-girls/three-quarters-refugee-women-africa-report-rise-domestic-violence/

45.

Rigby

S. W.

Johnson

L. F.

(2017). The relationship between intimate partner violence and HIV: A model-based evaluation. Infectious Disease Modelling, 2(1), 71–89. https://doi.org/10.1016/j.idm.2017.02.002

46.

Thackeray

Stelzner

Downs

S. M.

Miller

(2007). Screening for intimate partner violence: The impact of screener and screening environment on victim comfort. Journal of Interpersonal Violence, 22(6), 659–670. https://doi.org/10.1177/0886260507300206

47.

UNAIDS. (2018). Miles to go: Closing gaps, breaking barriers, righting injustices. https://www.unaids.org/en/20180718_GR2018

48.

van Schalkwyk

Boonzaier

Gobodo-Madikizela

(2014). “Selves” in contradiction: Power and powerlessness in South African shelter residents’ narratives of leaving abusive heterosexual relationships. Feminism & Psychology, 24(3), 314–331. https://doi.org/10.1177/0959353513514245

49.

Wechsberg

W. M.

Jewkes

Novak

S. P.

Kline

Myers

Browne

F. A.

, et al. (2013). A brief intervention for drug use, sexual risk behaviours and violence prevention with vulnerable women in South Africa: A randomised trial of the Women’s Health CoOp. BMJ Open, 3(5), 1–10. https://doi.org/10.1136/bmjopen-2013-002622

50.

Wood

S. N.

Glass

Decker

M. R.

(2019). An integrative review of safety strategies for women experiencing intimate partner violence in low-and middle-income countries. Trauma, Violence, & Abuse, 22, 68–82. https://doi.org/10.1177/1524838018823270

51.

World Health Organization. (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy and guidelines. http://www.who.int/reproductivehealth/publications/violence/9789241548595/en/

52.

Wright

Kiguwa

Potter

(2007). The significance of sheltering in the lives of four women affected by abusive relationships. South African Journal of Psychology, 37(3), 616–637. https://doi.org/10.1177/008124630703700314

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