Title: Life loaded with threat and vulnerability: A Qualitative Inquiry into the Experiences of
HIV Negative Married Women in Serodiscordant Heterosexual Relationships
Version: 4 Date: 19 Mar 2021
Reviewer:  Renee Heffron
Reviewer's report:
Summary: The authors present an interesting exploration into an underrepresented population’s
perspectives and experiences of intimate partner violence. A strength of the work is that it
highlights the myriad forms of violence felt by these women. Understanding their perspectives
is important for safely engaging this population; however it is not clear how the proposed
mechanisms align with the results and information shared by the participants and the
recommendations for programming/medical care.
1. TITLE: The title does not properly reflect the content of this manuscript. The text focuses
on HIV- women in sero-different relationships—it does not offer perspectives of their HIV+
partners. The title could be refined by focusing highlighting the research emphasis on HIV-
women whose husbands are HIV-.
2. ABSTRACT: It is a bit unusual to have citations in the abstract.
• Methods don’t make clear that we’re talking about the spouses of these women. Might specify
that your participants are married to the HIV+ men with whom they live.
• Methods state a qualitative descriptive approach but results appear very interpretivist.
• What is meant by “cycle” of violence?
• The key conclusion (i.e., to focus intervention on healthcare providers) seems incongruous
with the stated recomendations of your research findings.
3. INTRODUCTION:
Consider providing a typology of violence to provide clarity about the different types of violence
to which you are referring.
• https://www.who.int/violence_injury_prevention/violence/world_report/en/summary_en.pdf
There is a lack of information about the HIV epidemic in Iran and the burden of IPV in Iran
and HIV serodiscordant couples.
This manuscript focuses only on heterosexual serodifferent couples but this is not clearly
established. What is the rationale for excluding same-sex serodifferent couples from this
research?
Similarly, this manuscript focuses only on female members of HIV serodifferent couples. What
is the rationale for excluding men who experience IPV from this research?
There is a key publication with data from HIV- Iranian women and perspectives of violence in
their marriage that is not referenced:
• Lotfi, R., Tehrani, F. R., Khoei, E. M., Yaghmaei, F., & Dworkin, S. L. (2013). How do women
at risk of HIV/AIDS in Iran perceive gender norms and gendered power relations in the context
of safe sex negotiations?. Archives of sexual behavior, 42(5), 873-881.
METHODS
What was done to protect participants from violence as a result of providing an interview? This
needs to be described.
The description of the QD study are vague.
It was not immediately clear that the participants were married to the HIV+ men with whom
they lived. Please clarify this.
What language were interviews conducted in? What language were they analyzed in?
Please clarify how participants were compensated to allow reader to understand that they were
not coerced into research participation.
I believe the software that was used is called MAXQDA (not MAXQD).
Please describe how review of the field notes, which contained the researcher’s thoughts and
feelings, impressions, as well as the interpretation of interviewees’ non-verbal cues and body
language enhanced credibility.
How was your codebook developed? Did you use deductive and/or inductive reasoning?
RESULTS
Describe IQR for the length of marriage in the results. If possible also indicate the time since
knowing that they are in HIV serodiscordant relationship.
After reading the whole manuscript, I don’t understand why “trapped in a vicious cycle of
violence” is the main theme? This seems interpretivist despite use of QD analysis approach.
Considering writing out hepatitis C to introduce this new acronym. Why is it important to
indicate Hep-C status here?
This sentence “Five female's husbands (33.3%), who were interviewed in this study were HIV
positive and HCV positive, whilst 10 (66.6%) were HIV positive only” reads as if men were
interviewed as well. Please alter the language to be clear.
Some women reported that their husbands engaged in high-risk sexual behavior such as
irregularly extra-marital relationships, which leads to their tendency to commit suicide. How do
we understand that the extra-marital relationships are irregular? The phrase “tendency to commit
suicide” is unclear since one either commits suicide or attempts suicide.
Only one participant stated that her activities are not limited by her husband: "I can't do anything
without my husband's permission.  I wish I could work outside and I could be financially
independent. But my husband prevents me from working, he does’not financially support me at
all. The dependency makes me more vulnerable to my husband’s acts of violence … I sometimes
hate myself for not getting divorced" (Touching her face) (P11. 40 Y).
• The quote that you use is strong; however you introduce it with a conflicting statement about the
participant who said that her actions were NOT limited by her husband. Consider emphasizing
that most participants did indicate that they were limited by their spouse.
I recommend that you read WHO or NIAD language guides to HIV. Reference to people living
with HIV as AIDS patients is discouraged and it is important to differentiate between people
living with HIV and people with HIV that has progressed to AIDS because they represent
different groups with very different treatment and engagement in care. Also person-centered
language is much preferred as means to show respect for the people who have been part of the
work.
• https://www.hptn.org/sites/default/files/inline-files/NIAID%20HIV%20Language%20Guide
%20-%20March%202020.pdf
The patriarchal values and the unequal gender-based distribution of power in the family and
neighbors, directly or indirectly, affect the violence against women. The women explained that
due to the interference of people they have to face several problems. A participant specifically
mentioned about her mother-in-law interference: "She believes in women's complete obedience
to men and inherent aggression against them. My husband spends most of his time at her home
and used to listen to his mother advice, who is not a right person for consultation. For example,
she said to my husband you have power and you can transfer it (HIV) to your wife and you can
infect her. My mother- in-low and I is always arguing together" (P 6.34 Y).
• The last line could be a damaging perspective as it seems to imply that is is culturally normal to
encourage men living w HIV to transmit the virus to their spouse. Last line also seems to focus
more on biological violence than culturally normed behavior.
DISCUSSION:
In general for the Discussion section, it is important to provide sufficient context for your
research but also should avoid introducing a lot of new information.
Sexual violence was presented by fewer women, since, it seems that women were faced with
a standard for allegorical.
• This is not clear. Do you mean that women allow sex to their spouse because they have a sense
of duty/perspective of gender norms to do so?
In general, women in our study not only lacked social support, but were also subjected to violence
by relatives.
• It might be helpful to share a graphic of different types of violence to help your reader
differentiate between interpersonal violence (like that perpetrated by a mother-in-law, father,
other family members), gender based violence and intimate partner violence. These are all
related, interconnected, but distinct.
Traditional beliefs that men have a right to control women and its acceptance by women has
made women and girls vulnerable to violence and led to greater gender discrimination in the
communities.
• What type of discrimination do you mean, specifically? Was this a key finding from your
research?
I don’t think that it is a limitation that the study focuses on perspectives of Iranian women –
this is actually a strength of the study since there are limited data about Iranian women. Other
limitations may be time bias from a large discrepancy from when a woman finds out that she is in
a serodiscordant relationship to the time of the interview. Her reflections may be distorted simply
different from someone who is more proximate to the event (i.e., awareness of serodiscordant
status). Could be helpful to indicate median time from awareness of being in serodiscordant
relationship for this sample.
You could indicate that the perspectives of males are missing here and is an important
compliment to perspectives of their female, HIV- spouses.
You indicate that the study focused on serodiscordant couples when this does not seem to be
true—it appears to focus on the HIV - women in these couples.
RECOMMENDATION
According to the findings of this study, it is recommended that HIV intervention programs
should address gender-based violence among serodiscordant couples. This recommendation
does not totally make sense to me. It seems that many of the HIV- women would not be attending
clinic visits with their HIV+ spouse. Your research focuses on HIV- female spouses and their
perspectives so I would expect for the proposed recommendation to target this population.
Where would you have to go in order to effectively target this population? Perhaps focus
on empowerment and social interventions outside of the HIV clinic that address some of the
challenges of social norms and cultural violence and that support these couples to have better
conflict management skills and to rethink patriarchal patterns of thought and behavior. Another
recommendation could be understanding the dynamics that erode the marriage/trust and that
create environments where men are acquiring HIV outside of their relationship. Longitudinally
understanding how HIV- women are experiencing violence following disclosure of their HIV
+ spouse.
CONCLUSION: The key conclusions seem incongruous with the main takeways of this study.
A healthcare provider focused solution does not seem well aligned with your primary findings.
CONCLUSION: Women experienced all types of violence—would be helpful to outline what
“all types of violence” you mean perhaps in a figure in the text. For example, neglect is an
important form of violence — it usually manifests in settings of intimate partner violence and in
interpersonal violence like when the family does not take care of the woman and her children.
This is a form of violence that has not been articulated here however you say that the women
experienced all types of violence.
TABLE: Fairly appropriate economic status? What does this mean? In the text it says all women
have children but the table dos not corroborate this.
Table: It would be much more informative to see a true data table with frequencies and other
summary statistics of each characteristics, rather than a line listing of participant information.