Perceived Barriers to HIV Care and Viral Suppression Comparing Newly Diagnosed Women Living with HIV in Rural Uganda with and without a History of Intimate Partner Violence

Abstract

Intimate partner violence (IPV) is associated with poor HIV care linkage and retention, medication adherence, and viral suppression. However, limited knowledge exists regarding potential mechanisms linking IPV to these outcomes. We aimed to (a) identify the top barriers to accessing HIV care experienced by women living with HIV (WLHIV) who report a history of IPV and have suppressed viral load (VL) versus unsuppressed VL and (b) understand how these barriers influence VL, comparing WLHIV with a history of IPV to WLHIV without a history of IPV. Study data come from newly diagnosed WLHIV in rural Uganda participating in the standard-of-care control arm of a randomized trial ( n = 152). Descriptive results ranking mean scores from highest to lowest showed that, among women with a history of IPV, irrespective of viral suppression status, paying for transportation to come to clinic, having to wait at the clinic for long periods of time, and finding a clinic within reasonable travel distance were the top three barriers to accessing HIV care. WLHIV with a history of IPV were significantly more likely to have unsuppressed VL versus suppressed VL if they reported higher levels of difficulty finding a clinic within reasonable travel distance (RRR = 1.7, 95% CI [1.1–2.7]), getting permission to take time off from work (RRR = 1.5, 95% CI [1.0–2.9]), and finding time to come to the clinic for an appointment (RRR = 1.6, 95% CI [1.0–2.6]). The same relationships were not present among WLHIV without a history of IPV, suggesting these barriers and their effect on VL may be uniquely related to IPV. Interventions should address IPV and HIV care continuum outcomes in tandem, targeting barriers to accessing HIV care likely associated with IPV. Additional research is necessary to better understand how IPV relates to HIV care barriers and VL.

Intimate Partner Violence and the HIV Care and Treatment Cascade Among Adolescent Girls and Young Women in DREAMS, South Africa

“…6 A range of potential pathways from IPV to reduced engagement in care, adherence, and suppression have been described, including ongoing fear of HIV disclosure leading to hiding medication 7,10 and greater challenges in attending medical appointments because of less control over money and mobility. 7,10 The systematic review, however, only drew on literature from high-income settings in North America and included no studies among younger female patients. More recent work from sub-Saharan Africa has demonstrated similar impacts of IPV on the HIV-treatment cascade, 7,11,12 but without a focus on young women, nor population-based samples.…”

“…5 One key driver of poor engagement in the cascade of HIV care and treatment for women is exposure to intimate partner violence (IPV). 6 Studies suggest among women who experience violence HIV-testing maybe reduced because of fear of disclosure if HIV positive, 7,8 although others suggest testing may increase as women realize they may be more at risk of acquiring HIV. 9 A systematic review found women who experienced IPV were less adherent and had poorer engagement in HIV care and lower odds of viral suppression.…”

“…9 A systematic review found women who experienced IPV were less adherent and had poorer engagement in HIV care and lower odds of viral suppression. 6 A range of potential pathways from IPV to reduced engagement in care, adherence, and suppression have been described, including ongoing fear of HIV disclosure leading to hiding medication 7,10 and greater challenges in attending medical appointments because of less control over money and mobility. 7,10 The systematic review, however, only drew on literature from high-income settings in North America and included no studies among younger female patients.…”

“…7,10 The systematic review, however, only drew on literature from high-income settings in North America and included no studies among younger female patients. More recent work from sub-Saharan Africa has demonstrated similar impacts of IPV on the HIV-treatment cascade, 7,11,12 but without a focus on young women, nor population-based samples. This gap in the extant literature has limited our understanding of the impact of IPV on the 90:90:90 cascade, particularly among adolescent girls and young women in lowincome and middle-income settings.…”

Impacts of intimate partner violence and sexual abuse on antiretroviral adherence among adolescents living with HIV in South Africa

“…There is more evidence amongst adult women: a 2015 meta-analysis of 13 cross-sectional studies found that IPV was associated with lower self-reported ART adherence and viral load suppression [ 18 ], with this finding supported by a scoping review in 2019 [ 19 ]. Since these reviews, associations between IPV and nonadherence have been found in cross-sectional studies of adult women in Kenya [ 20 , 21 ], Uganda [ 22 ], and longitudinally in South Africa [ 23 ].…”