Reviewer ’s report  
 
Title: Intimate Partner Violence among HIV Positive Women in Care - Results from a National  
Survey, Uganda 2016  
 
Version: 0 Date: 15 Apr 2019  
 
Reviewer: Lucky Lawani  
 
Reviewer's report:  
 
COMMENTS TO THE AUTHORS  
 
General comment  
This is an interesting reproductive health topic in the care of HIV positive women. However, I 
have some comments and recommendations which if addressed will improve the q uality of the 
manuscript. I also recommend thorough English editing to enhance the quality of the manuscript.  
 
Abstract  
Conclusion: Stated that… "Experiencing IPV was associated with circumstances related to the 
relationship between the woman and her male p artner".  
 Comment: Be specific on what relationship.  
 
Main text  
Introduction: The last paragraph states that…. "We analyzed data from this survey to establish 
the prevalence of intimate partner violence against women in HIV care and assess the factors 
associated with experiencing intimate partner violence".  
Comment: What knowledge gap do you hope to address and what is novel about the current 
study?  
 
 
 
Methods:  
 
1. The first paragraph states that…."This was a secondary analysis of data from a facility 
based c ross-sectional study that was conducted across the 5 geographical regions of Uganda to 
assess the uptake of family planning services and establish the unmet need for family planning 
services amo ng HIV infected women in care".  
Comments: The current study h as nothing to do with family planning? This statement contradicts 
the research question and the last paragraph of the introduction. The focus of this paper was 
supposed to be on IPV, how come data from unmet family planning needs of patients were used?  
 
2. The authors stated also in the first paragraph that….."A detailed description of the 
methods including the study sites, sample size determination and sampling procedures have been 
published elsewhere [13]"  
Comments: Since both publications are different , kindly include the details of the methodology 
used in the current study by highlighting; selection of subjects/sampling procedures, sample size 
calculation, inclusion and exclusion criteria etc.  
 
3. Line 124 -126 stated that…. All eligible women were iden tified and randomly selected at 
the sampled health facilities using systematic sampling.  
Comments: Provide detailed explanations on how this was done?  
 
 
Assessment of Intimate Partner Violence:  
 
1. The authors stated that…"For the purposes of this study, the  definition of intimate partner 
violence was restricted to experiencing any physical or sexual violence. A questionnaire was 
used to assess women's experience of any form of physical or sexual violence by their partner".  
Comments: This approach of not appl ying the standard definition (World Health Organization) 
of IPV in the recruitment of subjects will eliminate a large and very significant number of 
women who experienced IPV and constitute a major drawback and source of bias in the current 
study. I recomm end that women with emotional/psychological violence should be included.  
Where and how were the questionnaires administered, especially for those who were 
accompanied by their partner's, considering the challenges of disclosure under such setting?  
 
2. Line 137 -140 stated that….. Participants were also asked about possible predictors such 
as their partner's age, HIV status disclosure to sexual partner (and whether or not both partners 
had mutually shared their HIV results), relationship status and HIV  status of partner, HIV 
treatment status (ART versus non -ART and duration on treatment)…….  
Comments: How possible was this for those who were accompanied by their partners, especially 
when a significant proportion of your subjects have not disclosed their  HIV status and even 
treatment to their partner's (as reflected by the high non -disclosure rate in your results)?  
IPV and these other assessment/evaluation are best conducted one -on-one with strict privacy and 
confidentiality assured, otherwise the true si tuation will never be disclosed or reported?  
 
3. Line 142 -144 stated that….The questionnaire was pre -tested to check the suitability of 
various aspects such as the clarity of the translation, skip patterns and filtering questions.  
Comments: How was it pre tested, on which group of subjects and what number was used?  
 
 
Results:  
 
1. Line 177 -179 stated that….."This study was based on an analysis of data from 5198 HIV 
positive women who participated in a survey to assess the unmet need for family planning 
service s among HIV infected women in care".  
Comments: I am still of the opinion that the current study has nothing to do with family planning 
and this statement contradicts the research question which was supposed to be on IPV among 
HIV positive women in care.  
 
2. Line 185….. "Of the 5198 women that participated in the survey, 1664 (32.1) reported to 
have experienced physical violence"…..  
Comments: 1664 (32.1%).  
3. Line 192 -193 stated that….. "1491 (48.4%) had experienced some form of intimate 
partner violence ". 
Comments: What form of violence does this represent, since only physical and sexual assaults 
were assessed in the present study?  
 
4. Line 199 -203 stated that…. "Women in relationships where the partner was younger were 
more likely to experience any for m of intimate partner violence PRR= 1.43, 95% CI: 1.14 -1.79, 
as were women in relationships where the partner was <10 years older PRR= 1.20 .95% CI: 
1.00-1.43, and women in relationships where the partner was ≥10 years older PRR=1.31, 95% 
CI: 1.05 -1.64".  
Comments: This result and its significance are difficult to appreciate, as it is not clear cut. The 
results shows that women who had either younger or older partners (equal/less than 10 years and 
equal/greater than 10 years) had greater risk of experiencin g IPV, indicating that age is not a 
significant contributor as reported by the authors - The results show that both younger and older 
partners have higher risks of IPV.  
 
5. Line 203 -206 stated that…."Compared with women who did not have any biological 
child ren, women with 3 -4 biological children were more likely to experience any form of 
intimate partner violence PRR= 1.27 95% CI: 1.00 -1.59 as were those with 5 or more biological 
children PRR=1.34 95% CI: 1.06 -1.71".  
Comments: I think the authors should com pare those with biological children vs those without 
biological children, instead of comparing no children vs 3 -4 and >5 biological children.  
 
 
 
 
 
 
 
 
Tables  
 
Table 1:  
1. What does -n- indicates?  
2. What is the difference between Pentecostal/Born Again/Evangelical and Anglican and 
protestant?  
3. What is the difference between "in relationship but never married" and the group "never 
married"?  
4. Why not classify region of residence as urban or rural ? 
5. What is significance of owning a radio, mobile phone or bicycle in the current study?  
6. What do ART and HC mean? Please indicate full meaning on first use.  
 
Table 2:  
1. Table 2 is too congested, kindly edit  
2. All is not a variable, do you mean total?  
3. What does "any violence" represent? The methodology indicates that this group was 
excluded. Please indicate what constitute any violence?  
 
Table 3:  
1. Just like Table 2, table 3 is also too congested. Can only important variables be 
considered? Indicate  p-values that are statistically significant.   
2. What does P indicate?  
 
 
 
 
 
Discussion  
1. Line 272 -275 stated that…. "In addition, the lower prevalence of IPV in sero -discordant 
relationships might reflect the extra support and attention these couples receiv e in anticipation of 
the violence compared with their positive concordant counterparts in a setting like Uganda where 
the prevalence of IPV is already high".  
Comments: The message is not clear. It appears you mean that sero -discordant partners get extra 
support and care as compensation or in anticipation for IPV which will occur? Kindly rephrase to 
make statement more explicit.  
 
2. Line 286 -287 stated that…." excluding emotional/ psychological violence and controlling 
behavior both of which were not assess ed". 
Comments: So what does any violence in table 2 mean or what constitute any violence? This is a 
major limitation, as there are likely to be more emotional/psychological torture than physical and 
sexual assault in the African setting where families/cou ples are likely to keep their HIV status as 
a secret to society, making physical violence a red flag to neighbors. In such cases the prevalence 
of emotional/psychological violence are likely to be concealed and even higher. Therefore, 
excluding women who e xperienced emotional/psychological violence is a major flaw.  
 
Conclusion  
1. This is too long and contains a lot of irrelevant information; please edit to make 
conclusion more concise by highlight the key findings and recommendations in one or two 
sentences . 
2. Paragraph 1, line 293 -295 reads…."This violence could dampen the attitudes of these 
women towards seeking care and treatment and thereby retard the likelihood of viral 
suppression".  
Comment: The current study did not assessed or show that women who suffer IPV were less 
likely to access treatment and care, therefore this ca nnot be part of the conclusion.  
3. Line 295 -297 stated that…."Health care workers offering HIV care and treatment  
services should screen women for intimate partner violence and offer or recommend the 
appropriate psychosocial or medical assistance".  
Comment: The approach used to screen women in the current study is subject to bias due to lack 
of confidentiality, espe cially for respondents who were accompanied by their partners. Kindly 
follow the standard approach for screening women for IPV.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does  the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing  interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript,  either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any pat ents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing  interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I have  no competing interests'  
 
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