Intimate partner violence and HIV: embracing complexity
Authors: Guy Harling, Alexander C Tsai, S V Subramanian
Journal: The Lancet Global Health (2015)

Dick Durevall and Annika Lindskog (January, 2015) explore the association between intimate partner violence (IPV) and HIV infection in Demographic and Health Survey (DHS) data.1Durevall D Lindskog A Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us?.Lancet Glob Health. 2015; 3: e34-e43Summary Full Text Full Text PDF Scopus (107) Google Scholar We welcome Durevall and Lindskog's examination of the confluence of risk factors that might place women at risk of HIV infection, building from our earlier analysis of an overlapping set of DHS datasets,2Harling G Msisha W Subramanian SV No association between HIV and intimate partner violence among women in 10 developing countries.PLoS One. 2010; 5: e14257Crossref PubMed Scopus (46) Google Scholar and their careful interpretation of the results they find. However, we believe that Sunita Kishor's interpretation of their study,3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar in relation to our earlier study on the same question,2Harling G Msisha W Subramanian SV No association between HIV and intimate partner violence among women in 10 developing countries.PLoS One. 2010; 5: e14257Crossref PubMed Scopus (46) Google Scholar necessitates some elaboration to ensure an accurate interpretation of this analysis.Kishor praises Durevall and Lindskog's use of a “clean”3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar control group of women who have experienced no forms of IPV or male controlling behaviour in making comparisons with women who have experienced each combination of the exposures under investigation. Although this approach is informative, it answers a question that is fundamentally different from those addressed in previous studies, including ours, comparing all women with each exposure to the remaining sample. Durevall and Lindskog are implicitly making the case that the multiple dimensions of IPV and male controlling behaviour are intertwined and acting jointly, and that analysing their impact individually is not meaningful. This situation might well be the case, but their approach does not allow the identification of which specific exposure (ie, violence or controlling behaviour) is driving any apparent association with HIV risk. We suggest that both the “clean” approach and previously employed specifications (such as our own) are valid and useful methods for risk assessment.Kishor also offers a broad-stroke conclusion: that Durevall and Lindskog's work confirms that “women who experience intimate partner violence have an increased risk of being HIV positive”.3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar In fact, their pooled analysis finds a significant association between IPV and HIV in three high HIV prevalence countries, but not elsewhere, for women experiencing both violence and male controlling behaviour. Rather than concluding that IPV and HIV are inextricably linked, we read Durevall and Lindskog's findings as highlighting an emerging theme in the literature: that non-negligible associations between IPV and HIV can be seen in high-prevalence settings for women in highly vulnerable situations who face many deprivations, including multiple forms of violence.4Jewkes RK Dunkle K Nduna M Shai N Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study.Lancet. 2010; 376: 41-48Summary Full Text Full Text PDF PubMed Scopus (842) Google Scholar, 5Kouyoumdjian FG Calzavara LM Bondy SJ et al.Intimate partner violence is associated with incident HIV infection in women in Uganda.AIDS. 2013; 27: 1331-1338Crossref PubMed Scopus (137) Google ScholarNotwithstanding the fact that controlling, coercive violence has many other negative effects that make it well worth tackling for its own sake, in the context of an HIV epidemic facing resource constraints it is crucial to understand where, when, and for whom such experiences are associated with HIV, and in what settings and in which ways this association can be nullified. Drivers are likely to be found at the individual, interpersonal, and institutional levels. As Kishor notes: “what is less understood is the ‘why’ behind these associations and the direction of causality”.3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar We agree that obtaining such knowledge will be crucial to effecting change.We declare no competing interests. Dick Durevall and Annika Lindskog (January, 2015) explore the association between intimate partner violence (IPV) and HIV infection in Demographic and Health Survey (DHS) data.1Durevall D Lindskog A Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us?.Lancet Glob Health. 2015; 3: e34-e43Summary Full Text Full Text PDF Scopus (107) Google Scholar We welcome Durevall and Lindskog's examination of the confluence of risk factors that might place women at risk of HIV infection, building from our earlier analysis of an overlapping set of DHS datasets,2Harling G Msisha W Subramanian SV No association between HIV and intimate partner violence among women in 10 developing countries.PLoS One. 2010; 5: e14257Crossref PubMed Scopus (46) Google Scholar and their careful interpretation of the results they find. However, we believe that Sunita Kishor's interpretation of their study,3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar in relation to our earlier study on the same question,2Harling G Msisha W Subramanian SV No association between HIV and intimate partner violence among women in 10 developing countries.PLoS One. 2010; 5: e14257Crossref PubMed Scopus (46) Google Scholar necessitates some elaboration to ensure an accurate interpretation of this analysis. Kishor praises Durevall and Lindskog's use of a “clean”3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar control group of women who have experienced no forms of IPV or male controlling behaviour in making comparisons with women who have experienced each combination of the exposures under investigation. Although this approach is informative, it answers a question that is fundamentally different from those addressed in previous studies, including ours, comparing all women with each exposure to the remaining sample. Durevall and Lindskog are implicitly making the case that the multiple dimensions of IPV and male controlling behaviour are intertwined and acting jointly, and that analysing their impact individually is not meaningful. This situation might well be the case, but their approach does not allow the identification of which specific exposure (ie, violence or controlling behaviour) is driving any apparent association with HIV risk. We suggest that both the “clean” approach and previously employed specifications (such as our own) are valid and useful methods for risk assessment. Kishor also offers a broad-stroke conclusion: that Durevall and Lindskog's work confirms that “women who experience intimate partner violence have an increased risk of being HIV positive”.3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar In fact, their pooled analysis finds a significant association between IPV and HIV in three high HIV prevalence countries, but not elsewhere, for women experiencing both violence and male controlling behaviour. Rather than concluding that IPV and HIV are inextricably linked, we read Durevall and Lindskog's findings as highlighting an emerging theme in the literature: that non-negligible associations between IPV and HIV can be seen in high-prevalence settings for women in highly vulnerable situations who face many deprivations, including multiple forms of violence.4Jewkes RK Dunkle K Nduna M Shai N Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study.Lancet. 2010; 376: 41-48Summary Full Text Full Text PDF PubMed Scopus (842) Google Scholar, 5Kouyoumdjian FG Calzavara LM Bondy SJ et al.Intimate partner violence is associated with incident HIV infection in women in Uganda.AIDS. 2013; 27: 1331-1338Crossref PubMed Scopus (137) Google Scholar Notwithstanding the fact that controlling, coercive violence has many other negative effects that make it well worth tackling for its own sake, in the context of an HIV epidemic facing resource constraints it is crucial to understand where, when, and for whom such experiences are associated with HIV, and in what settings and in which ways this association can be nullified. Drivers are likely to be found at the individual, interpersonal, and institutional levels. As Kishor notes: “what is less understood is the ‘why’ behind these associations and the direction of causality”.3Kishor S Intimate partner violence and HIV: clearing up confusion.Lancet Glob Health. 2015; 3: e4-e5Summary Full Text Full Text PDF Scopus (2) Google Scholar We agree that obtaining such knowledge will be crucial to effecting change. We declare no competing interests. Intimate partner violence and HIV in ten sub-Saharan African countries: what do the Demographic and Health Surveys tell us?The findings indicate that male controlling behaviour in its own right, or as an indicator of ongoing or severe violence, puts women at risk of HIV infection. HIV prevention interventions should focus on high-prevalence areas and men with controlling behaviour, in addition to violence. Full-Text PDF Open Access