title: Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission.
abstract: BACKGROUND
  Prevention of mother-to-child transmission (PMTCT) has the potential to eliminate new HIV infections among infants. Yet in many parts of sub-Saharan Africa, PMTCT coverage remains low, leading to unacceptably high rates of morbidity among mothers and new infections among infants. Intimate partner violence (IPV) may be a structural driver of poor PMTCT uptake, but has received little attention in the literature to date.
  
  
  METHODS
  We conducted qualitative research in three Johannesburg antenatal clinics to understand the links between IPV and HIV-related health of pregnant women. We held focus group discussions with pregnant women (n=13) alongside qualitative interviews with health care providers (n=10), district health managers (n=10) and pregnant abused women (n=5). Data were analysed in Nvivo10 using a team-based approach to thematic coding.
  
  
  RESULTS
  We found qualitative evidence of strong bidirectional links between IPV and HIV among pregnant women. HIV diagnosis during pregnancy, and subsequent partner disclosure, were noted as a common trigger of IPV. Disclosure leads to violence because it causes relationship conflict, usually related to perceived infidelity and the notion that women are "bringing" the disease into the relationship. IPV worsened HIV-related health through poor PMTCT adherence, since taking medication or accessing health services might unintentionally alert male partners of the women's HIV status. IPV also impacted on HIV-related health via mental health, as women described feeling depressed and anxious due to the violence. IPV led to secondary HIV risk as women experienced forced sex, often with little power to negotiate condom use. Pregnant women described staying silent about condom negotiation in order to stay physically safe during pregnancy.
  
  
  CONCLUSIONS
  IPV is a crucial issue in the lives of pregnant women and has bidirectional links with HIV-related health. IPV may worsen access to PMTCT and secondary prevention behaviours, thereby posing a risk of secondary transmission. IPV should be urgently addressed in antenatal care settings to improve uptake of PMTCT and ensure that goals of maternal and child health are met in sub-Saharan African settings.
authors.affiliation: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa; Division of HIV/AIDS, University of California, San Francisco, CA, USA; ahatcher@wrhi.ac.za.
authors.forename: Abigail M
authors.initials: AM
authors.lastname: Hatcher
authors.affiliation: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Nataly
authors.initials: N
authors.lastname: Woollett
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Christina C
authors.initials: CC
authors.lastname: Pallitto
authors.affiliation: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Keneuoe
authors.initials: K
authors.lastname: Mokoatle
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Heidi
authors.initials: H
authors.lastname: Stöckl
authors.affiliation: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa; Collaborative Research Network for Mental Health and Wellbeing, University of New England, New South Wales, Australia.
authors.forename: Catherine
authors.initials: C
authors.lastname: MacPhail
authors.affiliation: Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Sinead
authors.initials: S
authors.lastname: Delany-Moretlwe
authors.affiliation: Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Claudia
authors.initials: C
authors.lastname: García-Moreno
mesh_terms: D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control / Q000628:therapy / Q000635:transmission*; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D007407:Interviews as Topic; D008297:Male; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology*; D012742:Sex Offenses; D013019:South Africa
keywords: HIV; adherence; intimate partner violence; pregnancy; prevention of mother-to-child transmission