In this issue, Pyra et al.1 report on the associations between sexual minority status and violence exposure among women living with or at risk of HIV. Using data from the Women's Interagency HIV Study (WIHS) cohort, the authors found that women who identified as bisexual at baseline and those who reported having sex with men and women had relatively higher odds of experiencing ongoing sexual and physical violence, as well as partner psychological abuse. High-risk sex (having multiple partners or engaging in transactional sex) and ongoing substance use were identified as mediators, and childhood sexual abuse was a persistent confounder. These findings are robust, given 3 years of collected data per participant with retention rates exceeding 85 %, and time-updated variables that captured dynamic behaviors.

The study identifies a population of women who are marginalized from networks of support and care, and likely encounter “intersectional stigma” because they are sexual and racial/ethnic minorities, victims of violence, of low socioeconomic status, use drugs, and are involved in commercial sex work.2 Though not described by the investigators, marginalization is frequently compounded and complicated by co-occurring psychiatric disorders and involvement with the criminal justice system.3 Substance abuse is often the major disabling factor to women’s engagement in support and healthcare services—indeed, prevalence of sexual and physical partner violence is higher in drug-involved women than in women who do not use drugs— but these issues may be impossible to disentangle.

The really compelling story here is, to prevent ongoing violence victimization among a target population of sexual minority women, integrated comprehensive interventions must simultaneously address ongoing sex-related and drug-related risk-taking behaviors and structural factors (like homelessness, unemployment, and poverty) that are disempowering and limit women’s autonomy to modify their drug use. Evidence-based treatment for substance dependence includes medication-assisted therapies that not only effectively reduce ongoing substance use, but reduce HIV-associated risk behaviors and are stabilizing in terms of HIV treatment outcomes.4 Engagement in substance abuse treatment may also alleviate partner dependency and reduce violence,5 although this has not been systematically evaluated among sexual minority women and represents an area for future interventional research.