Gender Based Violence and HIV Risk: Mediating Pathways and Strategies for Prevention

The studies within this dissertation address gender-based violence (GBV) and its relationship with risk factors for HIV acquisition in African women. Women exposed to GBV have a higher risk of HIV infection, but the mechanisms for this association are not well understood, and the mechanisms may differ according to the patterns of violence experienced. Therefore, a full assessment of pathways to HIV risk requires meaningful GBV classifications that consider variations in GBV type, frequency, and severity. This work: 1) characterizes the patterns of GBV experienced by female sex workers, 2) describes the association of those GBV patterns with mental health and sexual risk behavior, and 3) examines the relationship between GBV and adherence to pre-exposure prophylaxis (PrEP) among HIV-uninfected women in HIV serodiscordant couples. Using latent class analysis, we identified 4 GBV patterns in female sex workers, labeled Low (21% prevalence), Sexual (23%), Physical/Moderate Emotional (18%), and Severe (39%). Compared to women with Low GBV, those with Severe GBV had higher symptom scores for depression, posttraumatic stress disorder (PTSD), and alcohol abuse, and higher numbers of sex partners. Women with Sexual GBV had higher symptom scores for alcohol abuse only, but there were no differences in sexual risk behavior. Women with Physical/Moderate Emotional GBV had higher numbers of sex partners and a higher prevalence of unprotected sex, but no differences in mental health symptoms. Among women in HIV serodiscordant couples, those with recent GBV had lower PrEP adherence than women with no GBV, and the effect increased with increasing number of violent episodes. This research has contributed to HIV prevention in high-risk African women by providing a more nuanced understanding of how the relationship between GBV and on HIV risk varies by GBV type, frequency, and severity. It also provides new data on the impact of GBV on PrEP adherence, which has not been previously studied. Prevention programs for women should screen for violence and address these multiple pathways to effectively reduce HIV incidence in this vulnerable population.