Exploring the effects of intimate partner violence on prevention of mother-to-child transmission service uptake: a nested cohort study
Date
2017
Authors
Hatcher, Abigail Mae
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Abstract
Introduction: Prevention of mother-to-child transmission (PMTCT) has potential to eliminate new
HIV infections among infants. Yet, in many settings in sub-Saharan Africa, women are unable to
adhere to PMTCT recommendations due to social constraints. One such factor may be intimate
partner violence (IPV), or any actions taken by a relationship partner that cause physical, sexual, or
psychological harm. Despite theoretical and empirical rationale for understanding the links between
IPV and PMTCT adherence, few studies in the extant literature have explored this association.
Methods: This thesis draws upon four distinct studies that interface using an overall mixed method
study design. The first study is a systematic review of the literature around women’s experience of
lifetime IPV and adherence to anti-retroviral treatment (ART). The second study is formative
qualitative research with pregnant women, health workers, and other local stakeholders that explores
how IPV may be related to PMTCT in the urban Johannesburg setting. The third study is a deeper
qualitative examination of women living with both IPV and HIV, aiming to understand the
mechanisms that link partner violence to PMTCT behaviors using a social constructionist lens. The
final study is a quantitative cohort study nested within a randomized control trial testing an
intervention for IPV in pregnancy. Using regression techniques and structural equation modeling, I
aim to determine the association between IPV and ART adherence in pregnancy and postpartum and
identify pathways that mediate the relationship between partner violence and PMTCT.
Results: This doctoral research contributes several new findings to the extant literature around
PMTCT. I find that IPV is related to ART adherence among HIV-positive women in extant
literature, with meta-analysis showing significantly worse odds of ART uptake, self-reported
adherence, and viral suppression among women reporting lifetime IPV. In one of first of studies
among women in sub-Saharan Africa, I learn that impact of IPV on ART adherence in pregnancy
and postpartum is marked. I identify several mechanisms through which IPV influences PMTCT
adherence. Mental health emerges as a robust pathway linking IPV to worse adherence in both
qualitative and quantitative papers. Partner non-disclosure due to IPV can impede adherence, or
women can navigate this challenge through hiding their HIV status or medication. Women
experiencing IPV may attend fewer antenatal clinic visits, leading to worsened adherence. An
unexpected finding was that women in our qualitative and quantitative studies were resilient and
used strategies to adhere despite IPV. Motherhood seems to be a central feature of women who are
resilient to the effects of IPV on adherence.
Conclusion: The findings of this research have implications for research, policy, and practice.
Research should incorporate social factors, such as IPV, into future studies testing PMTCT
adherence interventions. Clinical practice and HIV programs should recognize that partner-level
dynamics such as IPV may drive persistent gaps in PMTCT coverage. HIV policy urgently needs to
incorporate ethical and safety considerations for women who experience IPV around the time of
pregnancy. Women living with recent or past IPV are highly resilient and often want to protect their
own health and that of their children. Only by recognizing and addressing their experience within the
context of HIV care can future PMTCT programs and studies ensure maternal and infant health.
Description
A thesis completed by published work,
Submitted to the School of Public Health, Faculty of Health Sciences,
University of the Witwatersrand,
in fulfillment of the requirements for the degree of
Doctor of Philosophy
Johannesburg, South Africa
24 May 2017.
Keywords
Citation
Hatcher, Abigail Mae (2017) Exploring the effects of intimate partner violence on prevention of mother-to-child transmission service uptake: a nested cohort study, University of the Witwatersrand, Johannesburg, <http://hdl.handle.net/10539/23086>