School of Public Health

Kate S. Wilson

The relationship between intimate partner violence (IPV), unprotected sex, and detectable plasma viral load in HIV-positive female sex workers in Kenya

The studies in this dissertation examine the relationship between intimate partner violence (IPV), unprotected sex, and behaviors related to transmission risk in HIV-positive female sex workers, (FSWs) in Kenya. This work includes: 1) prevalence and correlates of IPV in the past year, 2) a prospective study of recent IPV as a risk factor for unprotected sex, and 3) a prospective study of recent IPV as a risk factor for detectable plasma viral load. Findings from our parallel qualitative study of IPV are also included.

Intimate partner violence, including physical, emotional, and sexual violence by an emotional partner, is associated with many negative health outcomes, including HIV. The relationship between IPV and adverse health outcomes in FSWs in Africa is less clear. In HIV-positive FSWs, exposure to IPV may impede the success of new HIV prevention and treatment strategies designed to improve health and reduce secondary HIV transmission risk. We found that 80% of women had ‘emotional’ partners and that 14.6% reported IPV in the past year (95% confidence interval (CI) 10.9-18.2%). Women’s alcohol use problems and partner controlling behaviors were significant correlates of recent IPV. There was a significant positive association between recent IPV and unprotected sex by self-report (adjusted relative risk (aRR) 1.91, 95% CI: 1.32-2.78) and semen biomarker (aRR 1.54, 95% CI: 1.17-2.04). Unexpectedly, recent IPV was associated with significantly lower risk of detectable viral load (aRR 0.21, 95% CI: 0.05-0.86). Our qualitative research suggests that this association was likely due to unmeasured factors including women’s resilience, relationship characteristics, and social support. These combined results signal the complexity of the relationship between IPV and HIV treatment outcomes in this population.

Results from this dissertation have the potential to inform new comprehensive HIV treatment and prevention strategies for FSWs that support their health and rights. Empowerment-based behavioral interventions to reduce IPV, high-risk alcohol use, and unprotected sex should be evaluated as HIV prevention strategies. Further research is necessary to identify new intervention targets to improve treatment outcomes and well-being in this key population.