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Women in HIV serodiscordant relationships less likely to take PrEP consistently if they experience intimate partner violence
Michael Carter, 2016-06-20 07:20:00
intimate partner violence is associated with an increased risk of poor
adherence to HIV pre-exposure prophylaxis (PrEP) among women in serodiscorant
relationships in sub-Saharan Africa, investigators report in the online edition
of the Journal of Acquired Immune
Deficiency Syndromes. Overall, 16% of women experienced intimate partner
violence (IPV) and this increased the risk of sub-optimal adherence to PrEP by
50%, when measured by either pill count or plasma tenofovir concentrations.
“This is the first
study to examine the association between IPV and PrEP adherence,” write the
authors. “Women who reported IPV in the past 3 months had an increased risk of
low PrEP adherence.”
PrEP has been
shown to reduce the risk of infection with HIV in a range of populations,
including gay men, heterosexual men and women and injecting drug users. WHO
therefore recommend PrEP as part of comprehensive HIV prevention programmes
targeted at high-risk populations.
of PrEP is related to adherence. Intimate partner violence has been associated
with higher HIV incidence, reduced condom use and sub-optimal adherence to
antiretroviral therapy. It is therefore possible that intimate partner violence
may also affect adherence to PrEP.
the recent Partners PrEP study therefore
analysed data obtained from 1785 HIV-negative women in sero-discordant
relationships and enrolled in the study. At monthly face-to-face interviews,
the women were asked to report their experience of verbal, physical or economic
intimate partner violence.
The investigators assessed the relationship
between partner abuse and sub-optimal adherence to PrEP. Two measures were used
to assess adherence: pill count (less than 80% of doses defined as low
adherence) and measurement of plasma tenofovir levels (low adherence defined as
levels below 40 ng/ml). In-depth interviews with a sub-set of women provided
insights as to how intimate partner violence affected adherence and also the
strategies individuals used to maintain adherence to PrEP in the context of
Participants had a mean age of 33 years and 70%
had earned an income in the previous three months. The vast majority (99%) were
married. The mean relationship duration was 13 years and women had been in
mutually disclosed sero-discordant relationships for a mean of 1.4 years.
During 35 months of follow-up, 288 women (16%)
reported intimate partner violence at 437 study visits (0.7% of total). Of
these women, 69% reported intimate partner violence at one visit, 20% at two
visits, 7% at three visits and 5% at four or more visits. The most common form
of intimate partner violence reported was verbal, followed by physical and
Women reporting intimate partner violence in
the past month were less likely than women reporting no partner abuse to have
had recent sex with their study partner (69% vs. 81%) but more likely to report
recent unprotected sex (22% vs. 13%). They were also more likely to have had
partners who reported sex with another partner (20% vs. 15%).
Those reporting intimate partner violence were
similar in most respects to women who did not report violence from their
Adherence as assessed by pill count was high
(95%) among most women, regardless of reported intimate partner violence. Pill
count suggested adherence below 80% at 7% of study visits and 32% of plasma
tenofovir measurements were below optimum levels.
Overall, women were 50% more likely to have
sub-optimal adherence to PrEP if they had experienced intimate partner violence
in the previous three months. This association was consistent regardless of
whether adherence was measured by pill count (aRR, 1.51; 95% CI, 1.17-1.89, p =
0.001) or plasma concentrations of tenofovir (aRR, 1.51; 95% CI, 1.06-2.15, p =
However, the impact of intimate partner
violence on adherence ceased to be significant after three months.
When types of intimate partner violence were
considered separately, the investigators found a significant relationship
between sub-optimal adherence and verbal abuse (aRR = 1.65; 95% CI, 1.17-2.33,
p = 0.005) and low adherence and economic
partner violence (aRR = 1.48; 95% CI, 1.14-1.92, p = 0.003). The relationship
between poor adherence and physical partner violence was not significant, but
increased frequency of physical abuse from a partner was associated with lower
adherence to treatment (p < 0.001).
There were a total of 48 new HIV infections among
the women. However, experiencing intimate partner violence did not
significantly increase the risk of sero-conversion.
Seven women discussed intimate partner violence
during in-depth interviews with staff. Reasons why abuse form partners affected
adherence included stress and forgetfulness, running away and leaving
medication behind and partners throwing pills away. Strategies to overcome
these challenges and maintain high adherence included sending children to
retrieve pills that had been thrown away, or explaining events to clinic staff
who were able to offer replacement therapy.
“Efforts to target PrEP towards women with IPV
should recognise the low risk of adherence, and interventions should be
evaluated to promote PrEP adherence in the context of violence,” conclude the
authors. “Some women in our study reported strategies to maintain adherence in
the face of IPV, and lessons from these examples of resilience could help in
developing successful interventions. Such interventions could increase the
benefit of PrEP by promoting effective use in a population at high risk of