Curr HIV/AIDS Rep (2013) 10:380–389 DOI 10.1007/s11904-013-0173-9

BEHAVIORAL ASPECTS OF HIV MANAGEMENT (RJ DICLEMENTE AND JL BROWN, SECTION EDITORS)

Intimate Partner Violence and HIV: A Review Reed A. C. Siemieniuk & Hartmut B. Krentz & M. John Gill Published online: 14 August 2013 # Springer Science+Business Media New York 2013

Abstract Intimate partner violence (IPV) is a common and negative social determinant of health. IPV also increases vulnerability to risks associated with HIV transmission and contributes to HIV transmission. IPV is therefore predictably common among people living with HIV. It is increasingly being recognized as an important predictor of poor outcomes for those living with HIV by affecting retention to care, mental health, adherence to therapy, frequency of follow-up; all of which lead to more hospitalizations and progression to AIDS. HIV care providers can safely and effectively screen all HIV patients for IPV. Screening offers the opportunity to identify those at risk for poor outcomes and mitigate its effects. Further research is required in further defining the risk factors and outcomes of IPV and optimizing interventions. We review the association between HIV infection and IPV and make recommendations for IPV screening of HIV-positive individuals and those at high risk for HIV. Keywords Intimate partner violence (IPV) . HIV . Behavioral aspects of HIV management . People living with HIV . IPV screening . HIV-positive individuals . AIDS . Mental health . Research

Introduction Intimate partner violence (IPV) is an emerging public health priority that can have severe consequences on the lives of those it affects. IPV is a subcategory of domestic violence and is defined as physical, sexual, or psychological harm by a significant other or spouse (Table 1). Whereas domestic

R. A. C. Siemieniuk University of Toronto, Toronto, Ontario, Canada H. B. Krentz : M. J. Gill University of Calgary, Calgary, Alberta, Canada M. J. Gill (*) Sheldon M. Chumir Health Centre, #3223, 1213 – 4th Street SW, Calgary, Alberta T2R 0X7, Canada e-mail: [email protected]

violence encompasses any abuse perpetrated within a family or home, IPV refers specifically to abuse within an intimate relationship. The nature of IPV is distinctive. It is frequently recurrent and prolonged, often occurring over many years. Both the immediate trauma and long-term cumulative effects of this abuse may have devastating effects on the individual. Victims most often face the violence without any social supports as IPV commonly occurs behind closed doors, unrecognized even by the victim’s closest companions. While most research on IPV has focused on heterosexual women, no demographic (gender or sexual orientation) is immune to IPV victimization and its effects. IPV is endemic in society: the reported lifetime prevalence of IPV is 25-40 % globally for both women and gay men; reported rates however are lower among heterosexual men [1, 2]. IPV and HIV infection are extensively intertwined. The term ‘SAVA syndemic’ was first coined by Singer et al. in 1996 and refers to the synergistic consequences of substance abuse, violence, and AIDS, where each increases the burden of the others in a population [3]. Many studies have identified a higher risk of incident HIV infection among people who experience violence in their intimate relationships. The reasons are multifactorial and will be discussed in this review. There is also a growing body of evidence suggesting that PLWHA (persons living with HIV/AIDS) experience a high burden of IPV, with important consequences that extend beyond those described in HIV-negative populations. While the HIV-positive community is diverse, it also includes many populations who are socially vulnerable: for example, poverty and homelessness, sex-trade workers, injection drug use (IDU), and ethnic and sexual minorities are common. In addition to these underlying vulnerabilities, acquisition of HIV infection amplifies and further extends such vulnerabilities leading to negative social and physical consequences. In this paper, we review recent evidence on the broad spectrum of the IPV and HIV syndemic. We discuss evidence for a causal link between IPV and HIV infection and the underlying pathways that foster this link. We then discuss the consequences of IPV in the setting of established HIV infection and examine the impact IPV has on HIV disease management and care. We address the need of incorporating

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Table 1 Types of intimate partner violence Type

Definition

Pertinent examples

Physical abuse Sexual abuse Emotional/psychological abuse Neglect

Physical contact with the intention of causing bodily harm Forced or coercive sexual acts or the threat thereof Violence intended to cause psychological trauma (e.g., verbal abuse, threats, demeaning) Lack of care or attention resulting in psychological harm

Pushing, punching, biting, hitting, kicking, restraining Sexual assault, exploitation, harassment Put-downs, excessive jealousy, coercion

Isolation Intimidation Financial abuse

Withholding medication or food, not assisting with hygiene if disabled Separating the victim from society and/or social supports Cutting lines of communication with family/friends To intentionally frighten through overt or subtle behaviors Threats to kill/hurt the victim, family, friends, pets Control over the victims economic resources, reducing the Limiting access to money, excessive control on spending, capacity for the victim to support themselves financial dependence

IPVawareness into clinical HIV care and make suggestions on how to effectively accomplish this.

IPV and Increased Vulnerability to HIV Infection In 2001, the United Nations General Assembly adopted the Declaration of Commitment on HIV/AIDS [4] and officially recognized the importance of addressing IPV in the ongoing battle against the HIV pandemic. The UN acknowledged that the battle against HIV could not be won unless its underlying social drivers were addressed, one of which was identified as being IPV against women. The scientific evidence of the link between IPV and HIV supporting the declaration was compelling, but based on cross-sectional studies [5]. Since that time, many and more extensive cross-sectional studies have confirmed an association between HIV and IPV against women throughout the world [6–15], while fewer did not [16]. Fewer studies have addressed the importance of IPV against men in HIV prevention but recently studies have started to replicate the finding seen in abused women in gay and bisexual males [17–19], heterosexual males [6, 7], and transgendered women [20]. It is however difficult to interpret these cross-sectional studies, due to the bidirectional relationship between HIV infection and IPV. In other words, while IPV can lead to new HIV infections, the opposite – HIV infection leading to new IPV victimization may also occur. It was not until 2010 that Jewkes et al. published the first prospective study that showed a connection between IPV and incident HIV infection [21]. They followed 1099 HIVnegative South African women for two years in the context of a randomized trial. In a multivariable post-hoc analysis, they found that the adjusted incidence of HIV was 51 percent higher (95 % confidence interval [CI]=4-121) among women who experienced one or more lifetime episodes of IPV. Twelve percent of new HIV infections were attributed to IPV in that population.

A second prospective study, from Uganda, confirmed and extended our understanding of the relationship between IPV and subsequent HIV infection [22••]. A total of 10,252 women were followed for over five years and asked at baseline whether they had ever experienced IPV. Similar to the study by Jewkes et al. [21], there was a 55 percent (95 % CI=25-91) increase in adjusted risk of subsequent HIV infection, however a higher proportion of HIV infections (22 %) were attributed to IPV because of a higher prevalence of IPV. The only other prospective study evaluated current IPV among serodiscordant couples and risk of subsequent HIV infection [6]. The multicountry African study found a similar increase in adjusted odds of 1.62 for incident HIV infection among men and women experiencing IPV, which had a wide confidence interval (0.59–4.47) due to a low prevalence of IPV. The current evidence linking IPV to subsequent HIV infection is convincing. There is still a need, however, for further prospective studies examining the context, nature, and impact of IPV on HIV incidence in communities outside of SubSaharan Africa. Prospective research is also lacking and urgently needed on other high-risk groups such as gay men and transgendered populations.

Pathways from IPV to HIV Susceptibility There are numerous routes that IPV leads to a higher risk of HIV infection (Fig. 1). The most common routes for personto-person transmission of HIV are through sexual encounters and injection drug use (IDU). We discuss mechanisms by which IPV increases the risk of HIV transmission through these pathways. Sexual Transmission of HIV IPV can increase the risk of sexual transmission of HIV both directly and indirectly: the most obvious risk is through coercive or forced sex (rape). Forced sex causes

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Fig. 1 Relationships between IPV and HIV infection. a An overview of observed pathways explaining the increased risk of HIV infection among victims of IPV. IPV can lead to HIV infection directly (green arrows) through rape or indirectly (blue arrows) through substance use and sexual transmission . Perpetrator factors are increasingly being recognized as an

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important component of the HIV risk. b Among those in fected with HIV, IPV leads to poor outcomes through a number of pathways. This can occur directly through trauma or indirectly through poor engagement in care, which in turn leads to suboptimal management of HIV infection as well as its complications and comorbidities

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macro- and micro-lacerations in the genital mucosa, facilitating the transmission of HIV. However, the overall risk of transmission per sexual act is relatively low at ~1 transmission per 1000 coital acts [23] and for that reason, single episode rape likely plays only a minor role in HIV transmission. The risk of transmission increases significantly, however, when forced sex occurs repeatedly over prolonged periods as often may occur in intimate relationships [10, 22••]. A recent review of 21 retrospective studies examining the impact of sexual violence against women (including within intimate relationships) noted that most studies had identified an association of the sexual violence with incident HIV infection [24•]. Sexual IPV is associated with other high HIV-risk behaviors that, in combination, may increase the risk of transmission through indirect pathways. Low sexual assertiveness (a common result of sexual IPV) often leads to unprotected sex through coercion, or the threat thereof, in intimate relationships [24•, 25]. It is not just sexual IPV, however, that has been shown to be associated with riskier sexual practices. IPV in a broader sense is associated with both more unprotected sex and a higher percent of sex that is unprotected [26]. Condom use is one of the most effective ways to prevent HIV transmission [27]; all forms of IPV have been found to result in reduced condom use [22••, 26, 28–33]. A qualitative study of women concluded that IPV caused lower confidence in negotiating condom use with partners [31], in keeping with the suggestion that IPV is associated with low sexual assertiveness [25, 34]. Condom use alone, however, is an oversimplification of the complex nature of risky sexual behavior and its associated risk of HIV. Indeed, prospective studies have found that inconsistent condom use does not significantly mediate the increased risk of HIV infection in the setting of IPV [21, 22••]. This calls into question the theory that inconsistent condom use is the dominant link between IPV victimization and HIV infection. Sexual compulsivity, which is characterized by hypersexual thoughts and behaviors that interfere with personal and interpersonal pursuits, is associated with IPV among women [26] as well as gay men [17]. The cause of this is uncertain but is thought to be due to underlying psychological distress and emotional dysregulation associated with IPV. Some [17] but not all [26] research has found that depression and substance abuse mediate the relationship between IPV and sexual compulsivity. In addition to sexual compulsivity, epidemiologic studies have found that victims of IPV tend to have more sexual partners [7, 13, 32], which then leads to higher HIV infection rates [7]. Sexually transmitted infections (STIs) increase the risk of HIV transmission per sexual act by damaging mucous membranes, causing a dysregulation of the local immune response, and altering the local flora [35]. IPV is associated with STIs, through the riskier sexual practices noted above [30, 32, 33]. Herpes simplex virus type 2 (HSV-2) infection, which is

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known to increase the risk of HIV infection and is a common co-morbid STI, partially mediated the link between IPV and HIV infection [21]. Victim Substance use and the SAVA Syndemic Illicit drug use is a commonly reported risk factor for HIV acquisition, both directly through IDU [36] and indirectly through high-risk lifestyles associated with it [37]. It is also known from prospective studies that recreational drug use can lead to IPVand that IPV can lead to recreational drug use, with variations between types of illicit drugs used [38]. This SAVA syndemic describes this circle of substance abuse, violence, and AIDS [3]. Accordingly, an additional proposed mechanism for the increased HIV incidence among victims of IPV beyond sexual transmission is through the effects of direct transmission via IDU and indirectly via associated behaviors [18, 20, 32, 38]. Epidemiological data has, however, not been entirely consistent as some studies found that drug use mediates the interaction between IPV and HIV [18], while others have not [26]. Indirect causes of HIV transmission associated with recreational drug use in the context of IPV include higher risk sexual behaviors, as described among gay men with polysubstance use [17]. In addition, partners often also use drugs and victims of IPV report that violence (including sexual violence) often occurs while their partner is under the influence of illicit drugs or alcohol [39]. Epidemiological evidence also suggests that when both partners use drugs, there is a higher risk of IPV, compared to when none or one of the partners uses drugs [40]. Future studies should aim to delineate various types of substance use and their interactions with IPV and pathways to HIV infection. Perpetrator Factors An examination of the pathways between IPV and HIV infection is incomplete without examining the behavioral characteristics of the perpetrators of IPV. Overall, population-based studies show that although the absolute increase may be small, perpetrators of IPV tend to have a higher prevalence of HIV infection [15, 41]. This puts victims at a clearly higher risk of acquiring HIV from their partner. Perpetrators also tend to have riskier sexual practices, further increasing the risk of transmitting STIs and HIV to their partner. For example, having multiple sexual partners [8, 42, 43], less condom use [42], coercive sex [42, 43], and paying for sex [43] are all more common among IPV perpetrators. Victims of IPV who are also HIV-positive often have a legitimate fear of new or increased violence if they disclose their HIV status, which may lead to unprotected sex and an increased risk of HIV transmission to the perpetrator [44, 45•].

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IPV is known to occur more frequently when the perpetrator is under the influence of, or withdrawing from drugs or alcohol [39]. Moreover, IPV and severity of IPV is associated with perpetrator illicit drug use, notably heroin, crack cocaine [40], as well as alcohol [46]. Perpetrator drug use can lead to HIV transmission to their partner through riskier sexual practices, forced sex, and through IDU. The delineation of the social determinants that link IPV to subsequent HIV infection is becoming clearer, but remain incompletely understood. There is often more than one social risk factor complicating the lives of victims of IPV, which leads to confounding and difficulty interpreting studies. However, this speaks to the enormity of the challenges that people experiencing IPV face. Often times, HIV infection is one result of a complex series of difficulties in the lives of IPV victims.

IPV Among People Living with HIV While IPV increases risk of HIV acquisition, the presence of HIV also increases the risk of new or worsening IPV. The trauma from IPV in the context of HIV infection may not only have important negative social implications but also may have significant clinical consequences on HIV care.

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populations [55]. The risk during pregnancy may be amplified in HIV-positive women: 2/3 HIV-positive women disclosed lifetime IPV at a Nigerian antenatal clinic [56] and 1/3 reported IPV while pregnant at a different Nigerian antenatal clinic [57]. Pregnant women may be particularly vulnerable to poor HIVrelated and –unrelated outcomes because they may feel the need to prioritize the wellbeing of their child over their own. Gay Men Living with HIV Gay relationships are often erroneously assumed to be relationships of equals. Moreover, the prevailing advocacy discourse on IPV most often focuses on violence against women, which can minimize or even neglect IPV occurring within gay relationships. However IPV in gay relationships can be severe. Gay men also regularly encounter discrimination on the basis of their sexual orientation and experience high rates of mental health disorders as a result, which may increase vulnerability to the negative effects of IPV [58]. A few studies looking at IPV in gay men living with HIV have shown a 22-54 % prevalence of IPV [52••, 53] and also mentioned that those that do experience IPV usually experience multiple types of IPV.

Impact of HIV on IPV Frequency and Severity A. Prevalence of IPV in Select Populations with HIV The prevalence of IPV among HIV patients seems to vary by geographic region, patient sub-population, and screening tool used; unfortunately, few studies have used a population-based or random-selection approach for describing prevalence. A large population-based study from Canada, however, reported a lifetime prevalence of 35 % [47]. Groups that are overrepresented in the HIV epidemic also tend to be more commonly affected by IPV. HIV-positive women [43, 47, 48••, 49–51], gay men [47, 52••, 53], Aboriginal North Americans [47, 52••], and people who use injection drugs [47, 48••, 54] have all been noted to have an IPV prevalence of at least 50 % in at least one study.

Studies show that HIV infection can lead to an increased frequency and severity of IPV [45•] – that is, abuse directly related to HIV status [44, 45•]. Many experience IPV at the time of HIV disclosure [45•], where victims are often blamed or shunned for being ‘dirty’ or otherwise undesirable. IPV related to HIV infection may be expressed differently among different populations. However, a common theme is the explicit or implied threat of being ‘outed’ as HIV-positive, which may add to any pre-existing abuse. For example, among the gay and bisexual population, IPV can manifest as the threat of ‘double outing’ where one partner exerts control with threats of revealing the sexual orientation and/or HIV-status of the other [52••]. These multiple pressures can often lead to a feeling that there is no safe escape.

Women Living with HIV Impact of IPV on HIV Care Women living with HIV are particularly at high risk of IPV (also commonly referred to as violence against women): a meta-analysis of IPV prevalence among observational studies of HIV-positive women in Western countries found a lifetime prevalence of 55 % (95 % CI=36-74 %) [9], while populationrepresentative studies reported lifetime a prevalence of 40 % and 36 % in Canadian [48••] and Ugandan populations [51], respectively. Women also face higher rates of IPV during pregnancy, which is well documented among HIV-seronegative

The effects of abuse on a victim’s life are well described in HIV-negative populations ranging from trauma and mental health issues to poor physical health [59]. However the added challenges of a severe and often stigmatizing illness may exacerbate such ill effects and additionally, have an impact on chronic HIV care. The negative health consequences of IPV in HIV populations have been infrequently described; however some recent studies have found important consequences.

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Sexual and Public Health

Hospitalizations

IPV against HIV-positive persons may lead to higher risk of transmission. A Nigerian study found that women experiencing IPV were less likely to have disclosed their status to their partner [44]. In addition, as found in HIV-negative populations, there is a consistent association with reduced condom use [52••, 54], increased incidence of STIs [54], and IDU across a variety of populations [47, 48••]. Many of these patients may also have uncontrolled viral replication as a result of erratic adherence to care and thereby be at high risk for transmitting HIV [52••].

An important measure of ill health is the number of admissions to hospital. While women experiencing IPV have been found to have additional hospitalizations (including those unrelated to HIV) [48••], gay and bisexual males did not have the increased rate [52••]. Results are however more consistent if one looks at hospitalizations directly attributable to HIV infection. The HIV-related hospitalizations that are most preventable in this case are those that occur after the initial HIV diagnosis because patients experiencing IPV tend to present to care earlier in the course of disease. Indeed, the highest risk (greater than 2 times) of HIV-related hospitalizations, compared to patients who have not experienced IPV, occurs after the opportunity to engage in outpatient care [48••, 52••]. Among gay men with IPV, there was also a higher risk of progressing to AIDS after the patients were engaged into care [52••]. HIV-related hospitalizations and AIDS have been mostly preventable with early diagnosis and good adherence to care since the development of highly active antiretroviral therapy. Given that patients experiencing IPV tend to present early in the course of infection and yet still have more HIVrelated hospitalizations and AIDS diagnoses, it follows that these poor outcomes are likely mediated though suboptimal engagement in HIV care.

Mental Health Poor mental health not only carries significant morbidity and mortality independent of HIV infection but also has negative implications for HIV outcomes [60]. One study reported a three times increased risk of poor self-reported mental health among women who have experienced IPV [49]. Moreover, IPV has been shown to increase depressive symptoms among women [61] and men who have sex with men [52••]. Among men and women experiencing IPV, there are also strong associations with diagnosed depressive disorders, anxiety disorders, in addition to an increased use of psychiatric resources [47, 48••, 52••]. Self-reported suicide attempts were significantly increased among women experiencing IPV [48••].

Health Outcomes Victims of IPV have poor health outcomes as a result of the challenges that they face. Health-related quality of life, a selfreported measure of morbidity, is significantly reduced among gay and bisexual men [52••] and women [48••] living with HIV who have experienced IPV. Health-related quality of life is a strong prognostic predictor, including death, in patients with HIV [62]. Victims of IPV living with HIV have increased contact with the healthcare system. For this reason, some victims of IPV are often diagnosed earlier in the course of their disease (i.e., higher CD4 counts) [47, 48••], which should be associated with improved outcomes. However, despite the early diagnosis, there is a delay before engaging in outpatient HIV care [47]. A number of studies have evaluated CD4 count at the time of IPV screening: while some have reported lower CD4 counts [61, 63•], others did not find a significant difference [47, 48••, 52••, 53]. Nevertheless, most studies have reported that uncontrolled viral replication (a detectable serum HIV viral load) occurs more frequently among victims of IPV [48••, 63•].

Antiretroviral Therapy Effective management of HIV infection usually requires a lifelong commitment by the patient to daily therapy, which may be especially difficult for victims of IPV. The turmoil in the lives of victims of IPV can make adequate adherence to HIV treatment and attendance for regular medical assessments problematic as patients may be prioritizing the immediate health of themselves or their families over the longer-term consequences of HIV infection. Moreover, other health needs, such as poor mental health as a result of IPV, may have more immediate consequences that again take precedence over the effects of HIV that might be perceived as distant and uncertain. Several studies have examined ART use and adherence among patients affected by IPV. Of three North American studies examining ART use in women or illicit drug users, two reported less use of ART among patients exposed to IPV [48••, 54], while one was non-significant [61]. Studies thus far, however, have failed to find any differences in ART use or adherence among gay men [52••, 53]. Close follow-up with an HIV care provider is recommended at least every 4 months to monitor for efficacy and complications of ART [64]. Studies have consistently reported a higher number of missed appointments among patients who have experienced IPV [48••, 61, 63•]. Moreover, among hospitalized HIV-positive crack cocaine users, those experiencing

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IPV were less likely to have received any HIV care in the past year [54]. Similarly, of the women receiving care in one outpatient setting: victims of IPV were twice as likely to have been disconnected from care for one year or more [48••]. Finally, gay men were also twice as likely to disconnect from care for more than one year and then return to care with an uncontrolled viral load [52••].

Clinical Screening for IPV Persons at High-Risk for HIV Infection Discussing and screening for IPV is a delicate but important task for caregivers. A growing number of organizations now recommend routine IPV screening for most women [65–67]. No national or international organization has made an official recommendation regarding screening among other populations at higher risk of HIV infection. However, screening should also be considered for all patients at high risk of HIV-infection given that 1) there is a high prevalence of IPV among persons at risk for HIV infection, and 2) IPV is associated with incident HIV infection and other health outcomes. Given the higher rates of HIV infection among persons experiencing IPV, HIV testing should be routine among all patients disclosing IPV. IPV screening was well accepted by clients at a voluntary counseling and HIV testing facility in South Africa when providers were trained and experienced with gender issues [68]. Moreover, a psychosocial intervention focused on HIV prevention was effective at decreasing sexual risk factors among female victims of IPV in the USA [69]. Healthcare workers should be aware of IPV-specific resources in their community and efforts to improve access to these services should be made in areas where they are not easily accessible. HIV-Positive Persons We strongly recommend screening all HIV patients for IPV rather than symptom-directed case finding, as IPV usually occurs in secret and there are no reliable outward signs of IPV. However, we recognize that initiating a discussion on IPV with patients can be difficult for healthcare practitioners as it is a sensitive topic. Further, it is not always easy to routinely incorporate these discussions into a busy medical practice. HIV practitioners are however ideally suited to perform the essential task of IPV screening for a number of reasons. First, screening is important as there is a high prevalence of IPV within HIV-positive populations and unrecognized IPV may have serious negative implications for both HIV and non-HIV care. Second, as HIV infection requires close, lifelong medical follow-up, HIV care practitioners tend to develop trusting relationships with patients. Such trust between patient

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and practitioner is vital for disclosure. Finally, HIV-specific healthcare workers are well suited to recognize vulnerabilities of their patients and can well understand the unique implications of IPV in the context of HIV infection. IPV screening, in this setting, has been well accepted among patients and HIV practitioners alike [45•, 47]. There have been multitudes of screening tools for IPV that have been developed for healthcare settings. Based on current evidence, they all have similar operational characteristics [70]. However, they have been validated against more extensive questionnaires of specific violent acts rather than a true gold standard. Because no screening tool is clearly the best, we recommend adopting a method of screening that is specific to each clinical, social, and geographic setting. We suggest a short preamble defining IPV in terms that the patient can easily understand followed by an open-ended question asking if the patient has experienced IPV; our approach can be found in reference [47]. This allows each patient the ability to respond in his or her own words (reflecting the diversity of IPV) and allows the patient to discuss aspects most important to them. Moreover, this approach may better elicit clinically significant IPV when compared to asking about specific acts of violence (as most questionnaires do). In other words, in response to an open-ended question, many patients may disclose IPV only if it has had a significant impact on their lives. Screening for IPV is a delicate task however and is best approached sensitively and tactfully. For example, for safety reasons, screening must occur in a private setting and confidentiality must be assured, as screening has the potential to lead to more violence [45•]. The healthcare practitioner should offer empathetic support as required and be familiar with appropriate places for referring those revealing IPV. Domestic violence shelters, IPV support centers, a social worker, or a psychiatrist may be appropriate options depending upon the patient’s needs. Symptoms of mental illness, including depression and posttraumatic stress disorder should be considered and if found, the patient should be offered a referral to a specialist for evidencebased therapy [71, 72]. Our approach, in a busy clinic setting, is to offer a prompt referral to an in-house social worker who can then discuss the problem in depth [47]. The social workers offer further support and can refer to local support services as required.

Conclusion IPV is common in vulnerable communities and is well known to increase the risk for HIV infection. IPV is not surprisingly prevalent in HIV populations and is a key but poorly appreciated negative social determinant of patient health. IPV, in the context of HIV, is important not just to the individual affected but also to wider society as it contributes significantly to ongoing HIV transmission. HIV prevention campaigns need

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to identify and explicitly address IPV in order to optimize their effectiveness. The links between IPV and HIV infection, however, are multifactorial and involve both direct and indirect pathways. HIV prevention efforts should also address the social conditions associated with IPV. IPV is linked to poor medical outcomes in those living with HIV infection. This is mediated through several mechanisms including poor retention to HIV care, limited adherence to ART and more often becoming lost to follow-up. HIV care providers are optimally suited to screen all of their patients for IPV with the dual goals of reducing both the clinical and social effects of IPV. Future prospective studies are however needed to define the spectrum and intensity of IPV as well as to fully understand the links between IPV and poor outcomes in HIV. Evidencebased interventions to mitigate the negative effect of this common negative social condition are also urgently needed.

Compliance with Ethics Guidelines Conflict of Interest Reed A.C. Siemieniuk and Harmut B. Krentz declare that they have no conflict of interest. M. John Gill is a member of National Advisory Boards to Abbvie, Merck, Janssen Gilead and ViiV Healthcare. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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