AIDS and Behavior

, Volume 20, Issue 9, pp 2045–2053

Relationship Power and Sexual Violence Among HIV-Positive Women in Rural Uganda

  • Amy A. Conroy
  • Alexander C. Tsai
  • Gina M. Clark
  • Yap Boum
  • Abigail M. Hatcher
  • Annet Kawuma
  • Peter W. Hunt
  • Jeffrey N. Martin
  • David R. Bangsberg
  • Sheri D. Weiser
Original Paper

Abstract

Gender-based power imbalances place women at significant risk for sexual violence, however, little research has examined this association among women living with HIV/AIDS. We performed a cross-sectional analysis of relationship power and sexual violence among HIV-positive women on anti-retroviral therapy in rural Uganda. Relationship power was measured using the Sexual Relationship Power Scale (SRPS), a validated measure consisting of two subscales: relationship control (RC) and decision-making dominance. We used multivariable logistic regression to test for associations between the SRPS and two dependent variables: recent forced sex and transactional sex. Higher relationship power (full SRPS) was associated with reduced odds of forced sex (AOR = 0.24; 95 % CI 0.07–0.80; p = 0.020). The association between higher relationship power and transactional sex was strong and in the expected direction, but not statistically significant (AOR = 0.47; 95 % CI 0.18–1.22; p = 0.119). Higher RC was associated with reduced odds of both forced sex (AOR = 0.18; 95 % CI 0.06–0.59; p < 0.01) and transactional sex (AOR = 0.38; 95 % CI 0.15–0.99; p = 0.048). Violence prevention interventions with HIV-positive women should consider approaches that increase women’s power in their relationships.

Keywords

Relationship power Sexual violence Transactional sex HIV/AIDS Africa 

References

  1. 1.
    Campbell JC. Health consequences of intimate partner violence. Lancet. 2002;359(9314):1331–6.CrossRefPubMedGoogle Scholar
  2. 2.
    Heise L, Moore K, Tourbia N. Sexual coercion and women’s reproductive health: a focus on research. New York: Population Council; 1995.Google Scholar
  3. 3.
    Heise LL. Violence against women: global organizing for change. In: Edleson J, Eisikovits Z, editors. Future interventions with battered women and their families. Thousand Oaks: Sage publications; 1996. p. 7–33.Google Scholar
  4. 4.
    Hatcher AM, Smout EM, Turan JM, Christofides N, Stocki H. Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis. AIDS. 2015;29(16):2183–94.CrossRefPubMedGoogle Scholar
  5. 5.
    Schafer KR, Brant J, Gupta S, et al. Intimate partner violence: a predictor of worse HIV outcomes and engagement in care. AIDS Patient Care STDS. 2012;26(6):356–65.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Weber K, Cole A, Anastos K, et al. The effect of gender based violence (GBV) on mortality: a longitudinal study of US women with and at risk for HIV. Paper presented at the international AIDS conference, Washington, DC, 2012.Google Scholar
  7. 7.
    Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet. 2006;368:1260–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Karamagi CAS, Tumwine JK, Tylleskar T, Heggenhougen K. Intimate partner violence against women in eastern Uganda: implications for HIV prevention. BMC Public Health. 2006;6:284.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Wagman J, Baumgartner JN, Geary CW, et al. Experiences of sexual coercion among adolescent women: qualitative findings from Rakai District, Uganda. J Interpers Violence. 2008;24(12):2073–95.CrossRefPubMedGoogle Scholar
  10. 10.
    Luke N, Kurz KM. Cross-generational and transactional sexual relations in sub-Saharan Africa: prevalence of behavior and implications for negotiating safer sexual practices. Research Paper Series. Washington, D.C.: International Center for Research on Women, Population Services International; 2002.Google Scholar
  11. 11.
    Verheijen J. Complexities of the “transactional sex” model: non-providing men, self-providing women, and HIV risk in rural Malawi. Ann Anthropol Pract. 2011;35:116–31.CrossRefGoogle Scholar
  12. 12.
    Poulin M. Sex, money, and premarital partnerships in southern Malawi. Soc Sci Med. 2007;65:2383–93.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Wamoyi J, Fenwick A, Urassa M, Zaba B, Stones W. ‘‘Women’s bodies are shops’’: beliefs about transactional sex and implications for understanding gender power and HIV prevention in Tanzania. Arch Sex Behav. 2011;40:5–15.CrossRefPubMedGoogle Scholar
  14. 14.
    Bene C, Merten S. Women and fish-for-sex: transactional sex, HIV/AIDS and gender in African fisheries. World Dev. 2008;36(5):875–99.CrossRefGoogle Scholar
  15. 15.
    Dunkle KL, Jewkes R, Nduna M, et al. Transactional sex with causal and main partners among young South African men in the rural Eastern Cape: prevalence, predictors, and associations with gender-based violence. Soc Sci Med. 2007;65:1235–48.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Fleming PJ, DiClemente RJ, Barrington C. Masculinity and HIV: dimensions of masculine norms that contribute to men’s HIV-related sexual behaviors. AIDS Behav. 2015;20(4):788–98.CrossRefGoogle Scholar
  17. 17.
    Jewkes R, Morrell R. Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. J Int AIDS Soc. 2010;13:6.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Moore AM, Biddlecom AE, Zulu EM. Prevalence and meanings of exchange of money and gifts for sex in unmarried adolescent sexual relationships in sub-Saharan Africa. Afr J Reprod Health. 2007;11:44–61.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Luke N, Goldberg R, Mberu BU, Zulu EM. Social exchange and sexual behavior in young women’s premarital relationships in Kenya. J Marriage Fam. 2011;73(5):1048–64.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Luke N. Economic status, informal exchange, and sexual risk in Kisumu, Kenya. Econ Dev Cult Change. 2008;56(2):375.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Dunkle KL, Jewkes RK, Brown HC, et al. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Soc Sci Med. 2004;59:1581–92.CrossRefPubMedGoogle Scholar
  22. 22.
    Jewkes R. Intimate partner violence: causes and prevention. Lancet. 2002;359:1423–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Blanc A. The effect of power in sexual relationships on sexual and reproductive health: an examination of the evidence. Stud Fam Plan. 2001;32(3):189–213.CrossRefGoogle Scholar
  24. 24.
    Connell RW. Gender and power. Stanford: Stanford University Press; 1987.Google Scholar
  25. 25.
    Wingood GM, DiClemente RJ. Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Educ Behav. 2000;27:539–65.CrossRefPubMedGoogle Scholar
  26. 26.
    Dixon-Mueller R. The sexuality connection in reproductive health. Stud Fam Plan. 1993;24:269–82.CrossRefGoogle Scholar
  27. 27.
    Worth D. Sexual decision-making and AIDS: why condom promotion among vulnerable women is likely to fail. Stud Fam Plan. 1989;20(6):297–307.CrossRefGoogle Scholar
  28. 28.
    Kuate-Defo B. Young people’s relationships with sugar daddies and sugar mummies: what do we know and what do we need to know? Afr J Reprod Health. 2004;8(2):13–37.CrossRefPubMedGoogle Scholar
  29. 29.
    Miller CL, Bangsberg DR, Tuller DM, et al. Food insecurity and sexual risk in an HIV endemic community in Uganda. AIDS Behav. 2011;15:1512–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Weiser S, Leiter K, Bangsberg D, et al. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland. PLoS Med. 2007;4(10):1589–97.CrossRefPubMedGoogle Scholar
  31. 31.
    Tsai A, Hung K, Weiser S. Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil. PLoS Med. 2012;9(4):e1001203.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Kalichman S, Watt M, Sikkema K, Skinner D, Pieterse D. Food insufficiency, substance use, and sexual risks for HIV/AIDS in informal drinking establishments, Cape Town, South Africa. J Urban Health. 2012;89(6):939–51.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    McCoy S, Ralph L, Njau P, Msolla M, Padian N. Food insecurity, socioeconomic status, and HIV-related risk behavior among women in farming households in Tanzania. AIDS Behav. 2014;18(7):1224–36.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Tsai A, Weiser S. Population-based study of food insecurity and HIV transmission risk behaviors and symptoms of sexually transmitted infections among linked couples in Nepal. AIDS Behav. 2014;18:2187–97.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    McMahon JM, Volpe EM, Klostermann K, Trabold N, Xue Y. A systematic review of the psychometric properties of the sexual relationship power scale in HIV/AIDS research. Arch Sex Behav. 2015;44(2):267–94.CrossRefPubMedGoogle Scholar
  36. 36.
    van der Straten A, King R, Grinstead OA, et al. Sexual coercion, physical violence, and HIV infection among women in steady relationships in Kigali, Rwanda. AIDS Behav. 1998;2:61–73.CrossRefGoogle Scholar
  37. 37.
    Maman S, Mbwambo JK, Hogan NM, et al. HIV-positive women report more life-time partner violence: findings from a voluntary counselling and testing clinic in Dar es Salaam, Tanzania. Am J Public Health. 2002;92:1331–7.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Farmer P, Simmons J, Conners M. Women, poverty, and AIDS: sex, drugs, and structural violence. Monroe: Common Courage Press; 1996.Google Scholar
  39. 39.
    Simbayi LC, Kalichman SC, Strebel A, et al. Internalised stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007;64:1823–31.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Hatcher AM, Tsai AC, Kumbakumba E, et al. Sexual relationship power and depression among HIV-infected women in rural Uganda. PLoS One. 2012;7(12):1–7.CrossRefGoogle Scholar
  41. 41.
    Siedner MJ, Tsai AC, Dworkin S, et al. Sexual relationship power and malnutrition among HIV-positive women in rural Uganda. AIDS Behav. 2012;16:1542–8.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Singer M. AIDS and the health crisis of the U.S. urban poor: the perspective of critical medical anthropology. Soc Sci Med. 1994;39(7):931–48.CrossRefPubMedGoogle Scholar
  43. 43.
    Tsai A, Burns B. Syndemics of psychosocial problems and HIV risk: A systematic review of empirical tests of the disease interaction concept. Soc Sci Med. 2015;139:26–35.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Tsai A, Venkataramani A. Syndemics and health disparities: a methodological note. AIDS Behav. 2015;20(2):423–30.CrossRefGoogle Scholar
  45. 45.
    Tsai AC, Wolfe WR, Kumbakumba E, et al. Prospective study of the mental health consequences of sexual violence among women living with HIV in rural Uganda. J Interpers Violence. 2014. doi:10.1177/0886260514567966.Google Scholar
  46. 46.
    Pulerwitz J, Gortmaker SL, DeJong W. Measuring relationship power in HIV/STD research. Sex Roles. 2000;42(7/8):637–60.CrossRefGoogle Scholar
  47. 47.
    Zablotska IB, Gray RH, Koenig MA, et al. Alcohol use, intimate partner violence, sexual coercion and HIV among women aged 15–24 in Rakai, Uganda. AIDS Behav. 2009;13:225–33.CrossRefPubMedGoogle Scholar
  48. 48.
    Bradley K, Bush K, Epler A, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med. 2003;163:821–9.CrossRefPubMedGoogle Scholar
  49. 49.
    Bush K, Kivlahan D, McDonell M, Fihn S, Bradley K. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789–95.CrossRefPubMedGoogle Scholar
  50. 50.
    Antelman G, Fawzi MCS, Kaaya S, et al. Predictors of HIV-1 serostatus disclosure: a prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania. AIDS. 2001;15:1865–74.CrossRefPubMedGoogle Scholar
  51. 51.
    Broadhead W, Gehlbach SH, de Gruy FV, Kaplan BH. The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients. Medical Care. 1988;26(7):709–23.CrossRefPubMedGoogle Scholar
  52. 52.
    Coates J, Frongillo EA, Rogers BL, Webb P, Wilde PE, Houser R. Commonalities in the experience of household food insecurity across cultures: what are measures missing. J Nutr. 2006;136(5):1438S–48S.PubMedGoogle Scholar
  53. 53.
    Swindale A, Bilinsky P. Development of a universally applicable household food insecurity measurement tool: process, current status, and outstanding issues. J Nutr. 2006;136(5):1449S–52S.PubMedGoogle Scholar
  54. 54.
    Filmer D, Pritchett LH. Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography. 2001;38(1):115–32.PubMedGoogle Scholar
  55. 55.
    Hosmer D, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000.CrossRefGoogle Scholar
  56. 56.
    Dunkle KL, Jewkes RK, Brown HC, et al. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363:1415–21.CrossRefPubMedGoogle Scholar
  57. 57.
    Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376:41–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Frieze IH. Investigating the causes and consequences of marital rape. Signs. 1983;8:532–53.CrossRefGoogle Scholar
  59. 59.
    Gage AJ, Hutchinson PL. Power, control, and intimate partner violence in Haiti. Arch Sex Behav. 2006;35:11–24.CrossRefPubMedGoogle Scholar
  60. 60.
    Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med. 2002;55:1603–17.CrossRefPubMedGoogle Scholar
  61. 61.
    Jewkes R, Dunkle K, Koss MP, et al. Rape perpetration by young, rural South African men: prevalence, patterns and risk factors. Soc Sci Med. 2006;63:2949–61.CrossRefPubMedGoogle Scholar
  62. 62.
    Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S. Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings. Prev Sci. 2007;8:141–51.CrossRefPubMedGoogle Scholar
  63. 63.
    Shannon K, Leiter K, Phaladze N, et al. Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland. PLoS One. 2012;7(1):1–8.CrossRefGoogle Scholar
  64. 64.
    Zablotska IB, Gray RH, Serwadda D, et al. Alcohol use before sex and HIV acquisition: a longitudinal study in Rakai, Uganda. AIDS. 2006;20(8):1191–6.CrossRefPubMedGoogle Scholar
  65. 65.
    Morojele NK, Kachieng’a MA, Mokoko E, Nkoko MA, Parry CDH, Nkowane AM. Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa. Soc Sci Med. 2006;62:217–27.CrossRefPubMedGoogle Scholar
  66. 66.
    Jewkes R, Abrahams N. The epidemiology of rape and sexual coercion in South Africa: an overview. Soc Sci Med. 2002;55:1231–44.CrossRefPubMedGoogle Scholar
  67. 67.
    Hatcher AM, Woollett N, Pallitto CC, et al. Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission. J Int AIDS Soc. 2014;17:19233.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS. 2012;26(16):2059–67.CrossRefPubMedGoogle Scholar
  69. 69.
    Katz IT, Ryu AE, Onuegbu AG, et al. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc. 2013;16(3 Suppl 2):18640.PubMedPubMedCentralGoogle Scholar
  70. 70.
    Heise L, Raikes A, Watts C, Zwi A. Violence against women: a neglected public health issue. Soc Sci Med. 1994;39:1165–79.CrossRefPubMedGoogle Scholar
  71. 71.
    WHO. 16 Ideas for addressing violence against women in the context of the HIV epidemic: a programming tool. Geneva: World Health Organization; 2013.Google Scholar
  72. 72.
    WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013.Google Scholar
  73. 73.
    Moyer V. Screening for intimate partner violence and abuse of elderly and vulnerable adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(6):478–86.CrossRefPubMedGoogle Scholar
  74. 74.
    Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From treatment to healing: the promise of trauma-informed primary care. Women’s Health Issues. 2015;25(3):193–7.CrossRefPubMedGoogle Scholar
  75. 75.
    Wyatt GE, Hamilton AB, Myers HF, et al. Violence prevention among HIV-positive women with histories of violence: healing women in their communities. Women’s Health Issues. 2011;21(6):S255–60.CrossRefPubMedGoogle Scholar
  76. 76.
    Turan J, Hatcher AM, Odero M, et al. A community-supported clinic-based program for prevention of violence against pregnant women in rural Kenya. AIDS Res Treat. 2013;2013:Article ID 736926.Google Scholar
  77. 77.
    Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006;368(9551):1973–83.CrossRefPubMedGoogle Scholar
  78. 78.
    Wagman JA, Gray RH, Campbell JC, et al. Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort. Lancet Glob Health. 2015;3(1):e23–33.CrossRefPubMedGoogle Scholar
  79. 79.
    Conroy AA. Marital infidelity and intimate partner violence in rural Malawi: a dyadic investigation. Arch Sex Behav. 2014;43(7):1303–14.CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    Burton J, Darbes LA, Operario D. Couples-focused behavioral interventions for prevention of HIV: systematic review of the state of evidence. AIDS Behav. 2010;14:1–10.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Amy A. Conroy
    • 1
  • Alexander C. Tsai
    • 2
  • Gina M. Clark
    • 3
  • Yap Boum
    • 4
  • Abigail M. Hatcher
    • 5
    • 6
  • Annet Kawuma
    • 4
  • Peter W. Hunt
    • 6
  • Jeffrey N. Martin
    • 7
  • David R. Bangsberg
    • 2
    • 8
  • Sheri D. Weiser
    • 6
  1. 1.Center for AIDS Prevention Studies, Department of MedicineUniversity of California - San FranciscoSan FranciscoUSA
  2. 2.Center for Global HealthMassachusetts General HospitalBostonUSA
  3. 3.Department of PsychiatryKaiser PermanenteSan FransciscoUSA
  4. 4.Faculty of MedicineMbarara University of Science & TechnologyMbararaUganda
  5. 5.Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
  6. 6.Division of HIV/AIDS, Department of MedicineUniversity of California - San FranciscoSan FranciscoUSA
  7. 7.Department of EpidemiologyUniversity of California - San FranciscoSan FranciscoUSA
  8. 8.Department of MedicineHarvard UniversityBostonUSA

Personalised recommendations