Domestic violence a driver of HIV
There has been a glaring absence of awareness and appropriate action internationally to address the link between intimate-partner dysfunctionality and HIV infection. Yet the reality is that intimate-partner violence is a hidden driver of the HIV epidemic, increasing psychosocial distress, risky sexual behaviour and sexually transmitted infections.
Cumulatively, intimate-partner violence decreases the capacity for sustainable livelihood and markedly increases the risk for developing new HIV infection.
In South Africa, the intimate femicide rate is the highest globally. This refers to the murder of women by current or former intimate partners or by a rejected would-be lover. Such violence appears to be twice as common in rural settings as in urban ones and there is a complex interplay of racial, gender and economic forces maintaining women in abusive situations. The use of violence to maintain dominance is a cross-cultural cornerstone of masculinity in South Africa, where inherent gender inequities are socially reinforced by chauvinistic entitlement.
Gender-based violence is an umbrella term for forms of interpersonal violence characterised by gendered power imbalances. Fitting within this, intimate-partner violence refers to emotional, spiritual, physical, sexual and financial abuse between people who are intimate. It also fits within broader subcategories of gender-based violence, namely family and domestic violence.
South African laws and policy on violence against women acknow-ledges it to be a significant human rights and public health issue, yet extreme levels of gender-based violence, poverty and HIV infection among women expose a chasm between the daily lives of female citizens and apparent gains in the public sphere. The World Health Organisation now positions intimate-partner violence towards women as an urgent public health priority. Although this may be culturally normal in many communities, it nevertheless severely breaches human rights and has profound mental and physical health consequences that impact on entire family systems over generations.
The burden of disease affects women especially, because they experience more extreme physical violence, greater sexual violence and more coercive control from partners.
Given the state of our nation, with Human Rights Watch dubbing South Africa as the rape capital of the world, it is critical that healthcare providers identify the survivors of intimate-partner violence and address their needs more effectively. In South African primary care, the linking of cases is not practised routinely and such violence remains hidden behind other diagnoses. Healthcare providers are mostly reluctant to ask about intimate-partner violence and patients rarely disclose the problem spontaneously. Providers are also unsure how to manage it because it has complex clinical, mental, social and legal implications. They tend not to accept that it is a health problem and in a system already overburdened by other challenges, they are often unwilling to legitimise it as part of their work.
But there are new developments in this area of research and intervention, not just in South Africa but also globally. On a recent visit to the United States as a guest of the director of global initiatives for the University of Maryland, Dr Joe O’Neill, I was privileged to lead an interdisciplinary team of colleagues from the University of Maryland in meetings with the director of the National Aids Commission, who is a senior adviser to President Barack Obama on disability policy, as well as the senior adviser to Vice-President Joe Biden on women’s health and the senior adviser for gender at the state department’s Office of the US Global Aids Co-ordinator.
The meetings highlighted links between the epidemics that South Africa and the US share: violence limits women’s ability to engage in HIV preventive habits; women abused at an early age are likely to engage in behaviour that places them at greater risk for HIV; violently abused women are more likely to be in partnerships with men at elevated risk for HIV; and the stigma of being HIV positive diminishes self-esteem and quality of life. All these result are compounded by the reluctance of abused women to seek help and of providers to assist.
The meetings also focused in particular on the comprehensive approach I have developed with Professor Bob Mash, the head of family medicine and primary care at Stellenbosch University, to identify intimate-partner violence and intervene constructively. It seemed to be a new conversation and one that the Americans welcomed. Our vision of creating a global interdisciplinary research-education and treatment-service network to address this complex issue was supported by the presidential office and state department. They were particularly interested in looking at the same issue in the same way, using the intervention in the US and South Africa simultaneously.
To this end, the founding campus of the University of Maryland is mobilising its schools of medicine, dentistry, pharmacy, nursing, law and social work to participate in the piloting of a similar intervention for intimate-partner violence in Baltimore HIV clinics and emergency care facilities. The University of Maryland’s shock trauma centre is the premier trauma centre in the US. Its global leadership position makes it an ideal venue from which to integrate gender violence and HIV broadly into emergency health systems.
On the local front, in 2011 the director general of health for the Western Cape authorised that my intimate-partner violence intervention be piloted in two subdistricts of the province in close collaboration with the department of social development. Critically, this should provide necessary evidence of relevant costs and benefits, thereby expanding the global community’s ability to provide best practice to a vulnerable but remarkably prevalent subpopulation. To its credit, Witzenberg, as the chosen rural subdistrict, has invested sufficient effort and energy to galvanise this process into action.
The pilot started in April and will run for a year, aiming to provide an integrated service for women experiencing such violence. The police and priests have also reacted enthusiastically to training opportunities and many are keen to combine forces with our pilot.
My doctorate was the first of its kind in South Africa. Its findings were recently published in the British Medical Journal and PLoS ONE. In total, 168 women were assisted and 124 (73.8%) returned for follow-up care. More than 75% perceived all aspects of their care as helpful. They reported significant benefits to their mental health, reduced alcohol abuse, improved relationships, increased self-esteem and reduced abusive behaviour. Two characteristics seemed particularly important: the style of interaction with the nurse and the comprehensive nature of the assessment.
In conclusion, women experiencing intimate-partner violence and who access primary care, including emergency services, benefit from an empathetic, comprehensive approach to assessing and assisting with clinical, psychological, social and legal aspects. The managers of health systems should find ways to integrate this into services and evaluate it further. Case identification of female survivors of intimate-partner violence and comprehensive biopsychosocial care has the potential to reduce such violence and HIV rates while improving outcomes for family systems, leading to increased resiliency. Further research should focus on how this may decrease the incidence of HIV infection, improve antiretroviral adherence and enhance comprehensive HIV care.
Dr Kate Joyner is programme co-ordinator: mental health and gender-based violence nursing at Stellenbosch University’s faculty of health sciences