RELATIONSHIPS BETWEEN STIGMA AND INTIMATE PARTNER VIOLENCE AMONG FEMALE SEX WORKERS LIVING WITH HIV IN SANTO DOMINGO, DOMINICAN REPUBLIC Amelia Clement Rock A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Health Behavior in the Gillings School of Global Public Health. Chapel Hill 2020 Approved by: Clare Barrington H. Luz McNaughton Reyes Vivian Go Suzanne Maman Florence Babb ©2020 Amelia Clement Rock ALL RIGHTS RESERVED ii ABSTRACT Amelia Clement Rock: Relationships Between Stigma and Intimate Partner Violence Among Female Sex Workers Living with HIV in Santo Domingo, Dominican Republic (Under the direction of Clare Barrington) Background: Intimate partner violence (IPV) victimization is associated with numerous adverse health outcomes, including suboptimal HIV treatment. Violence against female sex workers (FSW) perpetrated by intimate partners outside of sex work (e.g. boyfriends or husbands) has received little attention. Stigma negatively influences economic resources, social relationships, and psychological and behavioral outcomes of the stigmatized, which may increase IPV risk. Informed by stigma, economic, and alcohol use motivation theories, I assessed relationships between HIV and sex work stigma and IPV among FSW living with HIV, including indirect effects via income, savings, and alcohol use. Methods: I analyzed cross-sectional and longitudinal survey data from a cohort of FSW living with HIV in Santo Domingo, Dominican Republic (n=266). I used multivariable logistic regression to assess relationships between enacted, anticipated, and internalized HIV and sex work stigma and recent IPV victimization (Aim 1), and path analysis to examine mediated relationships between stigma and IPV via income, savings, and alcohol use (Aim 2). Results: Participants reporting HIV-related job loss had 5.6-times the odds of IPV compared to others (95% CI: 1.9, 16.2). A higher level of fear of family exclusion due to HIV was associated with a 1.8-fold increase in IPV odds (95% CI: 1.12, 2.82), and a higher level of fear of colleagues taking your clients if you revealed your status was associated with a 1.7-fold increase in IPV odds (95% CI: 1.2, 2.6). Indirect effects were insignificant. Social HIV iii discrimination was negatively associated with income, and alcohol use and savings were positively associated with IPV. Conclusions: HIV stigma may undercut economic resources, social ties, and mental health, creating barriers to ending abusive relationships, or causing stress and couple conflict leading to IPV. Stigma-driven economic precarity may heighten the importance of maintaining intimate partner relationships, despite violence. Fears of family rejection may discourage HIV disclosure, diminishing social support that protects against IPV, or create a specter of isolation that hampers ending abusive relationships. Curbing workplace HIV discrimination could reduce IPV vulnerability by protecting against economic losses and precarity. Community mobilization interventions could address IPV by increasing peer support and providing the experience of supportive community. iv ACKNOWLEDGEMENTS I first want to thank my advisor, Dr. Clare Barrington, for supporting me in this and many other projects during my time at UNC. Clare never failed to give thoughtful and substantive feedback and guidance, while intentionally giving space for my ideas to unfold. I took pleasure and inspiration in working with Clare and my other dissertation Committee members: Dr. Luz McNaughton Reyes, Dr. Vivian Go, Dr. Suzanne Maman, and Dr. Florence Babb. I thank you all for your input and support—I think I just might have your voices in my head providing commentary on my work from this day on! I also must extend hearty thanks to Dr. Cathy Zimmer and Dr. Chris Wiesen of the UNC Odum Institute, who provided me with invaluable technical support on my research, with kindness, care, humor, and a down-to-earth attitude that simply made my life better. I am also indebted to Dr. Deanna Kerrigan (George Washington University), Marta Perez, Dr. Yeycy Donastorg, and Hoisex Gomez (Instituto Dermatologico y Cirugia de Piel Dr. Humberto Bogart Diaz in Santo Domingo) for welcoming me and shaping my contributions to the work in the Dominican Republic. Deanna’s work has inspired me since the beginning of my career. I benefited immensely from Marta’s, Yeycy’s, and Hoisex’s expertise, as well as from their warmth—I doubt many visitors to the Dominican Republic can say they have been invited to a special Dominican Christmas in July. I am deeply grateful to the women who participated in the Abriendo Puertas intervention study for their essential contributions to this important body of knowledge. v My friends and colleagues in the UNC Department of Health Behavior provided essential commiseration, practice runs, laughs, and problem-solving. I know that wherever I am in years to come, I will miss the special mix of fierce intelligence, incredible work ethic, collegiality, and unassumingness that characterizes so many of the people I have gotten to know at UNC. My family, especially my husband Mark and my parents, provided me with care, genuine interest, patience, advice, and encouragement that helped me get through the hardest times and celebrate achievements along the way. I cannot say that my 19 month old son, Julian, helped with this dissertation or doctoral program completion, exactly, but he does bring me unbelievable joy every day. I was supported in completing this work by multiple sources of funding, including the Population Research Training grant (T32 HD007168) and the Population Research Infrastructure Program (R24 HD050924) awarded to the Carolina Population Center at The University of North Carolina at Chapel Hill by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the STD/HIV Pre-Doctoral Training Award (T32AI007001) awarded to the Institute of Global Health and Infectious Disease at the University of North Carolina at Chapel Hill by the National Institute of Allergy and Infectious Disease, the UNC Graduate Student Opportunity Fund, the USAID LINKAGES project, and the UNC Health Behavior Department. vi TABLE OF CONTENTS LIST OF TABLES ......................................................................................................................... xi LIST OF FIGURES ..................................................................................................................... xiii LIST OF ABBREVIATIONS ...................................................................................................... xiv CHAPTER 1. INTRODUCTION: AIMS AND OVERVIEW ....................................................... 1 CHAPTER 2. BACKGROUND ..................................................................................................... 5 2.1 Contextualizing this study: critical perspectives on sex work, terminology, and gaps in the research ................................................................................. 5 Perspectives on sex work ............................................................................................. 5 Key terminology used in this study ........................................................................... 10 Gaps in research on violence and IPV against female sex workers .......................... 14 2.2 Intimate partner violence against women ................................................................... 16 Terminology .............................................................................................................. 16 Prevalence and outcomes ........................................................................................... 17 Theoretical standpoints .............................................................................................. 18 Socio-ecology and structural drivers of IPV ............................................................. 19 Correlates of IPV ....................................................................................................... 21 2.3 Violence against female sex workers .......................................................................... 23 Prevalence and correlates .......................................................................................... 23 Public health interventions addressing IPV against female sex workers ...................................................................................................................... 41 2.4 Study context: the Dominican Republic ..................................................................... 44 Socioeconomic and HIV epidemiological context .................................................... 44 vii 2.5 IPV in the Dominican Republic .................................................................................. 45 Context of violence against women ........................................................................... 45 Prevalence and consequences of IPV ........................................................................ 47 Correlates of IPV ....................................................................................................... 48 2.6 Violence against female sex workers in the Dominican Republic ............................. 49 2.7 Sex work in the Dominican Republic ......................................................................... 50 Female sex worker population