Intimate Partner Violence and HIV Testing in Filipino Women: Analysis of the 2017 Philippine National Demographic and Health Survey

Abstract

We sought to determine the association between intimate partner violence (IPV) and HIV testing among a representative household sample of Filipino women, using data collected from the 2017 National Demographic and Health Survey. In our sample, we found that 23.63% experienced IPV, and only 1.99% were tested for HIV in the past 12 months. We found that IPV was associated with an increased odds of HIV testing in the past 12 months (aOR = 1.42; 95% CI = 1.02, 1.99). Our study highlights the need to consider formal encounters with IPV survivors as opportunities to engage them in the HIV prevention and care continua.

Keywords

intimate partner violence HIV testing Filipino women

Introduction

Globally, the incidence of HIV infection has reduced in recent years (Joint United Nations Programme on HIV/AIDS (UNAIDS), 2019); however, the downward trend in HIV incidence does not seem to hold true for the Philippines. In fact, the Philippines is one of only nine countries worldwide where HIV incidence in adults aged 15–49 years is increasing (i.e., > 25% increase), based on data reported from 2001 to 2011 (Joint United Nations Programme on HIV/AIDS (UNAIDS), 2012). In the last decade, the average number of individuals newly diagnosed with HIV in the Philippines has substantially increased from seven per day in 2011 to 35 per day in 2019 [Department of Health (Philippines) - Epidemiology Bureau, 2019]. Females comprised the majority (62%) of incident HIV cases in the early years (1984–1990) of the HIV epidemic in the Philippines; however, since 1991, males now comprise the overwhelming majority (94%) [Department of Health (Philippines) - Epidemiology Bureau, 2019]. Despite the shift in the sex distribution of incident HIV cases, the absolute number of females newly diagnosed with HIV has been increasing. From January to December 2019, 662 females were diagnosed with HIV, which was almost three times the number of females diagnosed with HIV in 2014 [Department of Health (Philippines) - Epidemiology Bureau, 2019].

There is a lack of published studies examining determinants of HIV infection in the general population of Filipino women. However, a 2010 report that reviewed behavioral and epidemiological conditions contributing to the expansion of the HIV epidemic in the Philippines identified some factors that increase women's vulnerability to HIV infection. The report identified low condom use among female sex workers (FSWs) as an important determinant of HIV risk, with many FSWs asserting that “knowing” their client was reason enough not to use a condom. FSWs and the general female population also tended to believe that the decision to use a condom is up to the man. The report also mentioned that Filipino women are generally not empowered to protect themselves and negotiate for safe sex due to cultural and socio-economic reasons (The Global HIV/AIDS Program - The World Bank & The University of New South Wales, 2010). Consistent with findings from the 2010 report, women's and girls’ vulnerability to HIV infection is shaped by deep-rooted and pervasive gender inequalities, which includes gender-based violence (The Global Coalition on Women and AIDS, 2004). A review published in 2005 indicates that intimate partner violence (IPV) increases the risk of HIV infection in women (Campbell et al., 2008). A pooled analysis of data from demographic and health surveys conducted in 10 sub-Saharan African countries also indicates consistent and strong associations between physical violence, emotional violence, male controlling behavior, and HIV infection in women (Durevall & Lindskog, 2015). Sexual violence—a form of gender-based violence in which the perpetrator can either be the partner or another person—has been linked with HIV infection in multiple geographic settings and across HIV epidemic scenarios (Dunkle et al., 2004; Klot et al., 2013; Ulibarri et al., 2011), with prospective studies establishing the temporal sequence of sexual violence and HIV infection (Jewkes et al., 2010; Klot et al., 2013; Weiss et al., 2008). Sexual IPV—a specific type of sexual violence—has likewise been linked with HIV infection. According to UNAIDS, in some regions of the world, women who have experienced physical or sexual IPV are 1.5 times more likely to acquire HIV than women who have not experienced such violence [Joint United Nations Programme on HIV/AIDS (UNAIDS), 2019].

Several mechanisms have been explored to explain how IPV and HIV infection are related. First, sexual assault may increase HIV risk through forced or coercive unprotected sex with a risky partner, and in most instances, the coercive nature of sex is an ongoing feature of these women's sexual relationships rather than a one-time episode (Kouyoumdjian et al., 2013). Second, it is also possible that women who experience IPV are unable to negotiate safer sex practices with their partners (Kouyoumdjian et al., 2013). In addition, the neglect that abused women may feel in their relationships could also encourage them to seek out other partners with whom they may voluntarily engage in behaviors that could increase HIV risk (Fox et al., 2007; Kouyoumdjian et al., 2013). Lastly, exposure to IPV could result in immune dysfunction, which would increase susceptibility to HIV upon exposure, or more rapid disease progression if the woman is already infected with HIV (Kouyoumdjian et al., 2013).

In the Philippines, the number of cases of violence against women reported to the Philippine National Police has increased from 2004 to 2013, and 54% of reported cases were classified as IPV (Philippine Commission for Women, 2014). In addition, based on the 2017 Philippine National Demographic and Health Survey (NDHS), 24% of ever-married women have experienced violence from their current or most recent husband/partner, with 15% experiencing such violence during the 12 months prior to the survey (Philippine Statistics Authority and ICF, 2018). Women who experience IPV may represent an important contributor to local HIV burden. Thus, it is important for these women to get tested for HIV so that they can become engaged in the HIV prevention and care continua (McNairy & El-Sadr, 2012, 2014).

An important element of engaging IPV survivors in HIV prevention and care is seeking help for the violence experience. However, only 34% of Filipino women aged 15–49 years who have ever experienced physical or sexual violence sought help for the violence (Philippine Statistics Authority and ICF, 2018). One of the main reasons for not reporting abuse among Filipino women is fear for life or safety when the abuse escalates because of help-seeking (United Nations Development Programme, 1997). Moreover, many Filipino women choose to stay in abusive relationships because of emotional and financial dependence on the husband/partner (Estrellado & Loh, 2019), their desired and perceived duty to keep the family intact (Estrellado & Loh, 2019), and a belief that the husband hitting the wife was justified (Ansara & Hindin, 2009). These reasons, which collectively perpetuate stigma towards IPV survivors, reflect the persistence of traditional gender role expectations in a heavily patriarchal Filipino society, with Filipino women believing that they are expected to submit to their husbands/partners and sacrifice their well-being for the family's sake (Estrellado & Loh, 2019).

Engaging IPV survivors in HIV prevention and care also becomes all the more challenging in light of low HIV testing coverage in Filipino women in general, and pervasive HIV-related stigma. HIV testing coverage in the general population of Filipino women remains low, with minimal change in the proportion of women who have ever been tested for HIV from 3% in 2008 to 5% in 2017 (Philippine Statistics Authority and ICF, 2018). On the other hand, several studies have documented HIV-related stigma towards Filipino women perceived to be at increased HIV risk (e.g., female commercial sex workers) (Lee, 1999; Ratliff, 1999; Tan, 1993), and towards pregnant Filipino women who happened to be HIV-positive (Lopez et al., 2017). In light of these contexts, this study seeks to determine if there is an association between IPV and HIV testing among Filipino women aged 15–49 years old.

Methods

Research Design

This study entailed a secondary analysis of data collected from the Philippine National Demographic and Health Survey conducted in 2017. The NDHS used a cross-sectional design to provide up-to-date estimates of basic demographic and health indicators (Philippine Statistics Authority and ICF, 2018). Survey data were collected through one-on-one interviews using two questionnaires: the Household Questionnaire, and the Woman's Questionnaire (Philippine Statistics Authority and ICF, 2018).

Sampling Procedure of the NDHS, and Sample Inclusion of the Study

The NDHS included a nationally representative sample selected using a two-stage stratified sampling design. The sampling methodology of the 2017 NDHS is described elsewhere (Philippine Statistics Authority and ICF, 2018). All women aged 15–49 years who were either permanent residents of selected households or visitors who stayed in the household the night before the survey were eligible to be interviewed. Among women eligible for an individual interview, one woman per household was randomly selected for the domestic violence module. The 2017 NDHS had a household response rate of 98.7%, and an individual response rate of 97.6% (Philippine Statistics Authority and ICF, 2018). For this study, the final analytic sample was limited to women who fulfilled all of the following: (1) must have completed the Household Questionnaire, Woman's Questionnaire, and the domestic violence module; (2) must be currently married or in a common-law partnership; and (3) must be currently cohabiting with or residing in the same housing unit as her husband/partner.

Operational Definition of Study Variables

The main exposure variable is IPV, and this was based on whether or not the current husband or partner has inflicted violent acts on the respondent. The list of the 17 violent acts asked about in the 2017 NDHS is reported elsewhere (Philippine Statistics Authority and ICF, 2018). A respondent was considered to have experienced any IPV if she experienced at least one violent act from her current husband or partner. The specific type of IPV experienced was also ascertained for each respondent based on responses to specific subgroups of violent acts: emotional IPV (e.g., say something or do something to humiliate her in front of others), physical IPV (e.g., push, shake, or throw something at her), and sexual IPV (e.g., physically force her to have sexual intercourse with him when she did not want to). In addition, the number of types of IPV experienced was determined for each respondent, with values ranging from 0 to 3. The outcome variable is HIV testing in the past 12 months (i.e., categorized as “yes” or “no”), and this was determined by asking the respondent if she has ever been tested for HIV in the past 12 months prior to the survey, regardless of whether or not test results were known to her.

A directed acyclic graph (DAG) of the relationship between IPV and HIV testing was constructed (see Supplemental Material 1) using DAGitty version 3.0 software (Textor et al., 2017) to determine confounders to control for in multivariable analyses. Variables depicted in the DAG, as well as their interrelationships, were determined a priori through a literature review and expert knowledge. For this study, the minimally sufficient conditioning set consists of educational attainment, household wealth quintile, place of residence, engagement in the cash economy, job continuity, health worker visit in the past 12 months, decision-making autonomy, marital control, knowledge on transmission of HIV, and attitude towards HIV/AIDS.

Educational attainment (“no education,” “primary,” “secondary,” and “higher”) refers to the highest education level attained by the respondent. The household wealth quintile, which was based on a principal component analysis of wealth indicators in the NDHS, was categorized as poorest, poor, middle, richer, and richest. Place of residence was categorized as either urban or rural. Engagement in the cash economy refers to whether or not the respondent had work in the past 12 months or is currently working, and was compensated or paid in cash (at least partly). Job continuity refers to whether the respondent is either not working, has work but her job is only seasonal or occasional, or has work and her job is year-round. Health worker visit in the past 12 months refers to whether or not a field health worker visited the respondent for health-related concerns at least once in the past 12 months.

A respondent's decision-making autonomy was based on responses to items assessing (a) who usually decides on the respondent's health care; (b) who usually decides on large household purchases; (c) who usually decides on the respondent's visits to family or relatives; and (d) who usually decides on what to do with the money the husband earns. Response options for these questions included the respondent alone, the respondent and husband/partner, the husband/partner alone, and someone else/others. A respondent is said to have good decision-making autonomy if all responses to items (a) to (d) are either the “respondent” or the “respondent and husband/partner.” A respondent is said to have poor decision-making autonomy if at least one response to items (a) to (d) is either the “husband/partner only” or “someone else.” Marital control was measured based on items that assessed whether or not the husband/partner (a) becomes jealous if the respondent talks to other men; (b) accuses respondent of unfaithfulness; (c) does not permit respondent to meet female friends; (d) tries to limit respondent's contact with her family; and (e) insists on knowing where the respondent is. The respondent's husband/partner is considered to exert controlling behavior if at least one response to items (a) to (e) is “yes.”

HIV transmission knowledge was assessed using a validated nine-item measure (e.g., “Can people reduce their chance of getting the HIV by having just one uninfected sex partner who has no other sex partners?”), with true/false response options (Philippine Statistics Authority and ICF, 2018). A respondent was considered to have “good” knowledge if she answered at least five of the questions correctly; otherwise, the respondent was considered to have “poor” knowledge. Lastly, attitude towards HIV/AIDS was assessed using a validated four-item measure (e.g., “Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?”) with true/false response options (Philippine Statistics Authority and ICF, 2018). A respondent is said to have a positive attitude if all responses to items (a) to (d) are favorable (i.e., nonstigmatizing); otherwise, the respondent was considered to have a negative attitude.

Table 1.

Profile of Respondents in the Final Analytic Sample (n = 11,590).

Characteristic	N	%
Age
Mean + SD	34.16 ± 8.20
Minimum	15
Maximum	49
Educational attainment
No education	189	1.63
Primary	2,487	21.46
Secondary	5,554	47.92
Higher	3,360	28.99
Wealth quintile
Poorest	3,202	27.63
Poorer	2,663	22.98
Middle	2,390	20.62
Richer	1,912	16.5
Richest	1,423	12.28
Place of residence
Urban	3,754	32.39
Rural	7,836	67.61
Engagement in cash economy
Yes	4,854	41.88
No	6,736	58.12
Job continuity
Not working	5,766	49.75
Working, job seasonal/occasional	1,560	13.46
Working, job year-round	4,264	36.79
Decision making autonomy, overall
Good	9,203	80.16
Poor	2,278	19.84
Marital control
Yes	4,033	34.86
No	7,536	65.14
Knowledge on HIV transmission
Good	9,437	81.42
Poor	2,153	18.58
Attitude towards HIV/AIDS
Good	8,649	74.62
Poor	2,941	25.38

Data Analysis

Quantitative variables were summarized using means, standard deviation, and range; qualitative variables were summarized using frequencies and percentages. For bi-variable analysis, the crude association of the following variables with HIV testing was determined using simple logistic regression analysis: IPV experience (any type, number of types, emotional, physical, sexual), educational attainment, household wealth quintile, place of residence, engagement in the cash economy, job continuity, health worker visit in the past 12 months, decision-making autonomy, marital control, HIV transmission knowledge, and attitude towards HIV/AIDS.

Multiple logistic regression analysis was performed to determine the association between any IPV experience and HIV testing, adjusting for the confounders identified in the DAG. To further explore the relationship between IPV and HIV testing, a separate multiple logistic regression model was constructed with the number of IPV types as the exposure and with the same set of confounders as identified in the DAG. In addition, to determine the association between each IPV type and HIV testing, a multiple logistic regression model was constructed where dummy variables for IPV types were simultaneously entered in the model, and with the same set of confounders identified in the DAG. For multivariable models, multicollinearity was assessed using the variance inflation factor (VIF) with a VIF > 2.5 signifying multicollinearity. In addition, the goodness-of-fit of the model was assessed using the Hosmer–Lemeshow chi-square test, with large p-values signifying good model fit. All inferential analyses were performed at a 5% level of significance. STATA SE 16 was used in the data analysis.

Results

Household- and individual-level data were successfully matched for 25,074 (73.91%) women. Among women with matched records, 17,968 (71.66%) were selected and interviewed for the domestic violence module, and among these women, 12,520 (69.68%) were currently in union or living with a man. Finally, among women currently in union or living with a man, 11,590 (92.57%) were currently residing with their husband/partner, and were thus included in the final analytic sample (Supplemental Material 2). All women in the final analytic sample had complete data on both the exposure and outcome variables; thus, no one was excluded on the basis of missing data.

Socio-Demographic Characteristics

On average, respondents in the final analytic sample were 34.16 ± 8.20 years old, with the youngest and oldest respondent at 15 and 49 years old, respectively. The majority of respondents were at most high school graduates (71.01%) and resided in rural areas (67.61%), while half (50.61%) belonged to the poorer to poorest wealth quintiles. Approximately half of the respondents were not working (49.75%), and over half were not engaged in the cash economy (58.12%) (i.e., they were either not working, or working but not compensated or paid in cash). The majority had good decision-making autonomy (84.68%), were in partnerships where the husband/partner is not controlling (65.14%), had good knowledge of HIV transmission (81.42%), and had good/favorable attitudes towards HIV/AIDS (74.62%) (Table 1).

IPV and HIV Testing

The proportion of respondents who have experienced at least one type of IPV was 23.63% (95% CI: 22.87%, 24.41%), with the most common type being emotional IPV (19.94%) (Table 2). In terms of the number of IPV types experienced, 15.43% experienced just one IPV type, 6.19% experienced two IPV types, and 2.02% experienced all IPV types. In terms of HIV testing, 3.23% (95% CI: 2.92%, 3.56%) of respondents in the final analytic sample had ever tested for HIV, while only 1.99% (95% CI: 1.75%, 2.26%) were tested for HIV in the past 12 months.

Table 2.

Intimate Partner Violence Experience, and HIV Testing (n = 11,590).

Characteristic	Frequency	%
Violence experience
Violence experience, any type	2,739	23.63
Violence experience, by type, multiple responses
Emotional intimate partner violence (IPV)	2,311	19.94
Physical IPV	1,184	10.22
Sexual IPV	429	3.7
Violence experience, number of types
None	8,851	76.37
One IPV type	1,788	15.43
Two IPV types	717	6.19
Three IPV types	234	2.02
HIV testing
HIV testing, ever tested	374	3.23
HIV testing, past 12 months	231	1.99

Crude Associations of Covariates With HIV Testing in the Past 12 Months

As shown in Table 3, the following covariates were associated with HIV testing in the past 12 months in unadjusted models: educational attainment, wealth quintile, place of residence, engagement in the cash economy, HIV transmission knowledge, and attitude towards HIV/AIDS. Interestingly, any IPV experience is associated with an increased odds of HIV testing, as are emotional IPV and physical IPV, although the crude associations are not statistically significant. In contrast, sexual IPV is negatively associated with HIV testing, although the crude association is, likewise, not statistically significant. In addition, compared to not having experienced any IPV at all, experience of one IPV type is associated with an increased odds of HIV testing, while experience of two to three IPV types is associated with a decreased odds of HIV testing; however, the crude associations are not statistically significant.

Table 3.

Crude Associations of Covariates with HIV Testing in the Past 12 Months.


Covariate	Not tested for HIV in the past 12 months		Tested for HIV in the past 12 months		Crude OR	95% confidence interval
Covariate	N	%	N	%	Crude OR	LL	UL
Violence experience, any type
No	8,680	98.07	171	1.93	Referent
Yes	2,679	97.81	60	2.19	1.14	0.84	1.53
Violence experience, number of types
None	8,680	98.07	171	1.93	Referent
One type	1,744	97.54	44	2.46	1.28	0.92	1.79
Two to three types	935	98.32	16	1.68	0.87	0.52	1.46
Violence experience, emotional
No	9,096	98.03	183	1.97	Referent
Yes	2,263	97.92	48	2.08	1.05	0.76	1.45
Violence experience, physical
No	10,200	98.02	206	1.98	Referent
Yes	1,159	97.89	25	2.11	1.07	0.70	1.62
Violence experience, sexual
No	10,933	97.96	228	2.04	Referent
Yes	426	99.3	3	0.7	0.34	0.11	1.06
Age
Mean ± SD	34.22 ± 8.21		31.47 ± 6.99		0.96	0.94	0.97
Educational attainment
None/Primary	2,657	99.29	19	0.71	Referent
Primary	5,463	98.36	91	1.64	2.33	1.42	3.83
Secondary	3,239	96.40	121	3.60	5.22	3.21	8.50
Wealth quintile
Poorest	3,175	99.16	27	0.84	Referent
Poorer	2,618	98.31	45	1.69	2.02	1.25	3.27
Middle	2,343	98.03	47	1.97	2.36	1.47	3.80
Richer	1,855	97.02	57	2.98	3.61	2.28	5.73
Richest	1,368	96.13	55	3.87	4.73	2.97	7.53
Place of residence
Urban	3,595	95.76	159	4.24	Referent
Rural	7,764	99.08	72	0.92	0.21	0.16	0.28
Engagement in cash economy
No	6,634	98.49	102	1.51	Referent
Yes	4,725	97.34	129	2.66	1.78	1.37	2.31
Job continuity
Not working	5,655	98.07	111	1.93	Referent
Working, job seasonal/occasional	1,540	98.72	20	1.28	0.66	0.41	1.07
Working, job year-round	4,164	97.65	100	2.35	1.22	0.93	1.61
Decision making autonomy
Poor	2,228	97.81	50	2.19	Referent
Good	9,024	98.05	179	1.95	1.13	0.82	1.55
Marital control
No	7,383	97.97	153	2.03	Referent
Yes	3,956	98.09	77	1.91	0.94	0.71	1.24
Knowledge on HIV transmission
Poor	2,144	99.58	9	0.42	Referent
Good	9,215	97.65	222	2.35	5.74	2.94	11.19
Attitude towards HIV/AIDS
Poor	2,914	99.08	27	0.92	Referent
Good	8,445	97.64	204	2.36	2.61	1.74	3.90

Multivariable Analyses

As shown in Table 4, any IPV experience is associated with a 42% increased odds of HIV testing in the past 12 months, controlling for confounders identified in the DAG (aOR = 1.42; 95% CI = 1.02, 1.99). In addition, compared to not having experienced any IPV at all, experience of one IPV type is associated with a 53% increased odds of HIV testing (aOR = 1.53; 95% CI = 1.07, 2.21), while experience of two to three IPV types is also associated with a slight increase in the odds of HIV testing, although the adjusted association is not statistically significant (aOR = 1.16; 95% CI = 0.67, 2.03). Despite controlling for confounders, the adjusted associations are not statistically significant, although emotional IPV (aOR = 1.28, 95% CI = 0.87, 1.87) and physical IPV (aOR = 1.37, 95% CI = 0.85, 2.21) appear to increase odds of HIV testing in the past 12 months. In contrast, sexual IPV was associated with a marginally significant decrease in the odds of HIV testing in the past 12 months (aOR = 0.31, 95% CI = 0.09, 1.01).

Table 4.

Adjusted Associations Between Intimate Partner Violence (IPV) Experience and HIV Testing in the Past 12 Months.^a

Exposure	OR	SE	p-value	95% CI
Exposure	OR	SE	p-value	LL	UL
Violence, any type	1.42	0.24	.04	1.02	1.99
Violence, number of types
None	1.00
One type	1.53	0.28	.02	1.07	2.21
Two to three types	1.16	0.33	.59	0.67	2.03
By type^b
Violence, emotional	1.28	0.25	.21	0.87	1.87
Violence, physical	1.37	0.34	.20	0.85	2.21
Violence, sexual	0.31	0.19	.05	0.09	1.01

All models controlled for educational attainment, household wealth quintile, place of residence, engagement in cash economy, job continuity, health worker visit in the past 12 months, decision-making autonomy, marital control, knowledge on transmission of HIV, and attitude towards HIV/AIDS.

Model constructed by entering dummy variables for IPV type simultaneously in the model.

Discussion

In this nationally representative sample of women aged 15–49 years who are cohabitating with a male partner, we found that 23.63% experienced violence of at least one type (19.94% experienced emotional IPV, 10.22% experienced physical IPV, 3.7% experienced sexual IPV), but only 1.99% were tested for HIV in the past 12 months. We also found that IPV experience of any type was associated with an increased odds of HIV testing in the past 12 months. Our results also indicate that emotional and physical IPV appear to be associated with an increased odds of HIV testing; in contrast, sexual IPV was marginally significantly associated with a decreased odds of HIV testing.

Our finding on the positive association between IPV experience of any type and HIV testing is consistent with findings from published studies. Using data from the 2005 US Behavioral Risk Factor and Surveillance System (BRFSS), Nasrullah et al. (2013) found that IPV experience of any type was associated with a 52% increased odds of being tested for HIV (Nasrullah et al., 2013). In addition, analysis of data from the 2006 and 2007 BRFSS showed that women survivors of IPV were almost twice more likely to have had an HIV test compared to women who have never experienced IPV (Brown et al., 2013). Similarly, using data from the Central Pennsylvania Women's Health Study (a cohort study conducted from 2004 to 2007), McCall-Hosenfeld et al. (2012) found that women exposed to IPV in the past 12 months had greater odds of receiving a test for sexually transmitted infections including HIV within the 2-year follow-up period compared to women who had not been exposed to IPV (McCall-Hosenfeld et al., 2013). Outside of the United States, in a secondary analysis of data from the 2007 Zambian Demographic Health Survey of women aged 15–49 years, Nelson et al. (2015) found a positive crude association between IPV and consent to HIV testing; however, in multivariable analyses, the association was not statistically significant (Nelson et al., 2015).

In contrast, published studies contradict some of our findings regarding the association between each IPV type and HIV testing. For instance, our study indicates a positive association between physical IPV and HIV testing; however, a cross-sectional study conducted in Addis Ababa, Ethiopia found that physical IPV was associated with a 74% decreased odds of being tested for HIV (Mohammed et al., 2017). A similar negative association was found in a study in Malawi, although the association was not statistically significant (Conroy, 2014). Similarly, our study also indicates a positive association between emotional IPV and HIV testing; however, a cross-sectional study of 79 HIV-negative, high-risk women aged 18–50 years in Atlanta, Georgia, United States showed that psychological abuse (measured using the 33-item Index of Psychological Abuse; higher scores represented worse psychological abuse) was significantly associated with less past-year HIV testing (Etudo et al., 2016). On the other hand, our finding about the negative association between sexual IPV and HIV testing is consistent with findings from a study conducted in Addis Ababa, Ethiopia, which showed that sexual IPV is associated with a decreased odds of being tested for HIV, although their effect size was small and the association was not statistically significant (Mohammed et al., 2017). This is in contrast with the study conducted in Malawi, which reported a positive association between sexual IPV and HIV testing, although the finding also was not statistically significant (Conroy, 2014).

There are several likely explanations for the observed positive associations between IPV experience (specifically, any IPV type, emotional IPV, and physical IPV) and HIV testing. It is possible that the higher HIV testing rate among IPV survivors may be due to increased referrals for STI/HIV testing services by individuals who interact professionally with IPV survivors (e.g., law enforcement officers in women and children protection units, social workers, and healthcare workers in outpatient and emergency healthcare facilities). However, in the Philippines, seeking help from formal sources (e.g., physician or medical personnel, police, lawyer, or social work organization) for violence is relatively uncommon. For instance, only 1.1% of women who have ever experienced physical or sexual violence have sought help from a physician (Philippine Statistics Authority and ICF, 2018). In addition, based on our analyses (not shown), among women who have experienced at least one IPV type in the past 12 months, the odds of HIV testing in the past 12 months is 45% lower in IPV survivors who have sought help for violence from formal sources compared to those who have not, although the unadjusted association is not statistically significant. In view of these empirical findings, the observed positive association between IPV experience and HIV testing may be due to other mechanisms that are independent of formal help-seeking for violence. One possible explanation is that IPV survivors may be more pro-active in seeking health care (including STI/HIV testing) to address the adverse physical, emotional, and mental consequences of having experienced IPV. In addition, given the cross-sectional nature of the study, it is also possible that women experience IPV as a result of their partners finding out that they availed of an STI/HIV test.

The observed negative association between sexual IPV and HIV testing may be explained by the greater stigma attached to sexual IPV, which may inhibit survivors’ formal help-seeking and disclosure to law enforcement officers and health care providers. Lower testing rates among survivors of sexual IPV may also be due to fear of violent reactions from partners who learn about women's use of HIV testing services; these concerns may be escalated among women who receive an HIV-positive test result. For instance, a qualitative study conducted in Uganda reported that men might consider HIV testing by their female partner as evidence of “prostitution” (Karamagi et al., 2006).

The inconsistencies between our findings and those from other studies may due, in part, to methodological differences. For instance, a study (Mohammed et al., 2017) that contradicted our finding on the positive association between physical IPV and HIV testing restricted study participation to women who had given birth in the 12 months prior to the study, whereas our study did not restrict inclusion according to pregnancy status. In the previously published study, well-baby visits to health care facilities may have provided more opportunity for health care providers to screen for IPV and consequently offer STI/HIV testing services.

To our knowledge, this is the first study that examines the relationship between IPV experience and HIV testing in a representative household sample of Filipino women. However, findings from the study should be interpreted in light of several limitations. First, given the cross-sectional nature of the survey from which this study was derived, it is not possible to infer the temporal sequence between IPV experience and HIV testing. As mentioned, it is possible that obtaining an HIV test leads to IPV, as can be the case when the male partner finds out about the HIV test and reacts negatively about it. Second, HIV testing was determined through a one-on-one interview and relied solely on self-report; thus, there is a possibility of participants underreporting HIV testing because of the stigma associated with the procedure. However, we believe that the outcome misclassification is likely to be nondifferential with respect to exposure given that the objective of this study is not known to survey respondents at the time of data collection. Similarly, the exposure variable might also be misclassified because of stigma associated with being an IPV survivor. Third, a literature review complemented with expert knowledge was conducted to identify confounders to control for in the analysis; however, there is still a possibility of residual confounding. For example, having talked about HIV testing with a partner or a health worker is an important confounder of the IPV experience—HIV testing relationship, but this construct was not measured in the survey and was not controlled for in the analysis.

It is worth noting that only 2.19% of IPV survivors in this sample have actually tested for HIV; that is, the remaining 97.81% of IPV survivors had not tested for HIV in the 12 months prior to the survey. Given that IPV is a risk factor for HIV infection (Campbell et al., 2008; Durevall & Lindskog, 2015), HIV testing should be routinely included in the package of health, social, and legal services and referrals provided to IPV survivors in the Philippines. Any encounter with IPV survivors should be considered an opportunity to engage them in a range of preventative, curative, and rehabilitative services, including HIV prevention. Specifically, persons who encounter IPV survivors (e.g., law enforcement officers, health care providers) should more proactively offer STI/HIV testing and counselling services, or refer IPV survivors to facilities where such services can be offered more effectively. STI/HIV testing and counselling is especially crucial for survivors of sexual IPV, who are less likely to have undergone HIV testing. Linking IPV survivors to HIV prevention and care requires that health providers, social workers, and law enforcement officers are competent enough to do so. To our knowledge, there is a dearth of published empirical studies assessing the readiness of said stakeholders in responding to IPV survivors. However, in one study involving health care providers in a private medical center in Metro Manila, only 27.2% were well prepared (i.e., combination of fairly well, well, and quite well) to appropriately respond to disclosures of IPV, only 28.4% were well prepared to identify indicators of IPV based on a patient's clinical history and physical examination, and only 32.1% were well prepared to make appropriate referrals for IPV (Cortes & Quinio, 2017). Thus, it is equally important to invest in and build the capacity of stakeholders to competently respond to the needs of IPV survivors in an ethical, safe, and gender-sensitive manner.

Effectively preventing and responding to gender-based violence at large, and IPV in particular, also requires the involvement of civil society through nongovernment organizations and foundations. In the Philippines, various civil society organizations provide safety and survival services for women affected by violence (Tamagno & Varnadoe, 2017). As an example, the Women Crisis Center (WCC), established in 1989, pioneered crisis work with women in the Philippines, and has since provided temporary shelter, medical assistance and advocacy, legal assistance and advocacy, and stress management to women in crises. In addition, WCC has advocated for a feminist approach to counselling women that has since been adapted in almost all crisis centers in the Philippines (Tamagno & Varnadoe, 2017).

The Philippines’ Republic Act 9710 (or the Magna Carta for Women) and its implementing rules and regulations prescribe the creation of violence against women (VAW) desks in all local governing units (referred to as barangays), and stipulates that these desks should be staffed by an individual who is trained on the gender-sensitive handling of cases. One of the core functions of the VAW desk is to coordinate with and refer cases to government agencies, nongovernment organizations, institutions, and other service providers as necessary (RA, 9710: Magna Carta for Women, and Its Implementing Rules and Regulations, 2010). As VAW desks are likely to be the first point of contact of IPV survivors for formal help, responders should be cognizant not only of the physical signs of abuse but also of sexual risks (including HIV risks) associated with IPV. The prompt recognition of sexual risks at the first point of contact for formal help can help ensure that IPV survivors can access appropriate care, including being engaged in the HIV prevention and care continua. However, our descriptive findings indicate that 16.26% of IPV survivors in the study sample were not aware of barangay VAW desks. Thus, even if recognition and referral of IPV survivors are strengthened at the level of the barangay, there is also an equally important need to ensure that women know from whom or where to ask for help, should the need for it arise. There is also a need to ensure that VAW desks are sufficiently staffed with competent providers. However, in a study commissioned by UN Women, UNICEF, and UNFPA, service providers who participated in focus groups noted that there are not enough social work positions available in all areas of the country, such that the access to comprehensive VAW services is predicated on whether there are enough social workers in a given location (UNICEF East Asia and the Pacific Regional Office et al., 2020). In addition, while social work guidelines call for a more holistic family assessment in VAW (as well as violence against children) cases, implementation of this practice is dependent on the service provider's skills and capacity (UNICEF East Asia and the Pacific Regional Office et al., 2020).

Health care providers involved in HIV testing and counselling services in the Philippines should be cognizant of women who might have been survivors of IPV. In settings where STI/HIV testing is warranted and/or offered, testing refusal should raise the possibility of IPV, specifically sexual IPV. In our analyses, we found that 26.62% of IPV survivors have never told anyone else about their violence experience (note, however, that 59.26% of IPV survivors in the study did not respond to this question in the NDHS); thus, health care providers should be attentive to signs of abuse such as refusal to disclose sexual risks or to submit to STI/HIV testing. Health care providers can then develop clinical management plans that take these underlying factors into account. Specifically, health care providers can assist IPV survivors in developing safe disclosure plans, in providing social support and counselling, or in referring them to those who can. Additionally, HIV testing and counselling locations or activities can also be reconfigured in such a way that these provide safe and confidential settings for targeted IPV screening.

In summary, this article reveals high rates of IPV in addition to alarmingly low rates of HIV testing among Filipino women who are currently partnered and cohabitating with their partner. Findings indicate an urgency to build on the national policy framework to support women's access to gender-sensitive IPV services at the local level in the Philippines. Enhanced staff training and linkages between IPV and HIV services are warranted in light of the observed associations between IPV history and recent HIV testing. Low rates of HIV testing among survivors of sexual IPV are especially concerning. Ongoing quality assessment of local services provided at VAW desks will be necessary to identify areas for improvement and strengthening. Further research is needed to explore opportunities for integrated and empowering health, social, and legal services to improve women's sexual health agency in the Philippines.

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Footnotes

Acknowledgment

We wish to convey our appreciation to Dr. Jennifer Nazareno, Dr. Arjee Restar, John Guigayoma, Ma. Irene Quilantang, Olivia Sison, Maylin Palatino, and Maria Isabel Diaz for helpful comments on an earlier draft of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research has been supported by the grants from NIH Fogarty International Center (D43TW000237) and NIAID (P30AI042853). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iD

Amiel Nazer C. Bermudez

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Author Biographies

Amiel Nazer C. Bermudez is a PhD student in epidemiology at the School of Public Health, Brown University. He is also a faculty member at the Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines (UP) Manila. He obtained his Doctor of Medicine degree in 2009 from the UP College of Medicine, and his Master's of Public Health degree in 2014 from the UP College of Public Health. His research interests include HIV–AIDS, communicable diseases, maternal health, intimate partner violence, systematic reviews and meta-analyses of clinical interventions, and clinical practice guideline development.

Kim L. Cochon is a PhD student in Public Health at the JC School of Public Health, the Chinese University of Hong Kong. She obtained an MSc in Public Health (Biostatistics) from the University of the Philippines College of Public Health. Her research interests include maternal and child health, gender disparities, systematic reviews and meta-analyses of clinical interventions, and clinical practice guideline development.

Don Operario is a professor of behavioral and social sciences at the School of Public Health, Brown University. His research addresses two interrelated areas. The first general area concerns the social and psychological determinants of HIV, mental health, and related health issues in historically marginalized communities, with an emphasis on developing and evaluating theory-based social and behavioral interventions that are relevant for delivery in complex communities. A second research area concerns the lived experiences associated with social inequality, with an emphasis on understanding the perspectives of intersectional identities and addressing health and psychosocial disparities. His NIH-funded projects examine these public health issues among racial and ethnic minority populations as well as sexual and gender minority populations in the United States, the Philippines, China, South Korea, Kenya, and South Africa.

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