UCLA UCLA Electronic Theses and Dissertations Title Association between Intimate Partner Violence and HIV Infection among Married Indian Women in Theni District, Tamil Nadu, India Permalink https://escholarship.org/uc/item/7xm426wd Author Thirumalai, Dhanalakshmi Publication Date 2017 Peer reviewed|Thesis/dissertation eScholarship.org Powered by the California Digital Library University of California UNIVERSITY OF CALIFORNIA Los Angeles Association between Intimate Partner Violence and HIV Infection among Married Indian Women in Theni District, Tamil Nadu, India A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Epidemiology by Dhanalakshmi Thirumalai 2017 © Copyright by Dhanalakshmi Thirumalai 2017 ABSTRACT OF THE DISSERTATION Association between Intimate Partner Violence and HIV Infection among Married Indian Women in Theni District, Tamil Nadu, India by Dhanalakshmi Thirumalai Doctor of Philosophy in Epidemiology University of California, Los Angeles, 2017 Professor Roger Detels, Chair The prevalence of HIV infection among women in India is on the rise accounting for nearly 40% of all HIV infections in the country. This calls for further investigation since the majority of women at risk for HIV live in a monogamous marital relationship with no risk factors of their own. Intimate partner violence against women not only increases their risk of acquiring HIV infection, it also diminishes their ability to protect from HIV, and thwarts their access to care. Hence, we investigated the association between HIV and IPV among married Indian women who were currently living with their husbands. We conducted a case control cross-sectional study in Theni district of Tamil Nadu in South India. A total of 763 women participated in the study consisting 256 HIV+ve ii women and 507 HIV-ve women. We used two type of interviews, face to face interviews (FTFI) and Audio Computer Assisted Self Interviews (ACASI) to collect both sensitive information as well as non-sensitive information from each participant. Our results showed that it is common for women to experience violence in the hands of intimate partners. HIV positive women were more likely to report lifetime sexual abuse (FTFI: AOR – 2.54, 95% CI: 1.11-5.82; ACASI: AOR – 3.31, 95% CI: 1.91-5.75) than HIV negative women. We found a positive association between HIV infection and the combined experience of physical and sexual abuse compared to no abuse (FTFI: RRR – 2.44, 95% CI 1.06-5.62; ACASI: RRR – 3.03, 95% CI: 1.76-5.21). Husband’s alcohol use, husband’s controlling behaviors, previous abuse by non-partners and IPV among parents were associated with women’s experience of intimate partner abuse. Women who were HIV positive (ACASI: AOR – 2.02, 95% CI 1.08-3.74) and victims of previous IPV (FTFI: AOR – 9.88, 95% CI 5.37-18.18; ACASI: AOR – 7.26, 95% CI 3.70-14.21) were very likely to engage in violence against their husbands. HIV positive women with a previous history of partner abuse were also very likely to experience adverse reactions from their husbands following HIV disclosure (FTFI: AOR – 3.51, 95% CI: 1.66-7.42; ACASI: AOR – 2.74, 95% CI: 1.31-5.70). We found more number of women irrespective of their HIV status reporting positively for sensitive behaviors in ACASI than FTFI indicating that ACASI can be an efficient tool for collecting sensitive information. iii The dissertation of Dhanalakshmi Thirumalai is approved. Sung-Jae Lee Abdelmonem A. Afifi Pamina M. Gorbach Roger Detels, Committee Chair University of California, Los Angeles 2017 iv Dedicated To my husband Shankar v TABLE OF CONTENTS Abstract ii List of Tables vii List of Figures ix List of Abbreviations x Acknowledgements xii Vita xiv Chapter 1. Introduction 1 References 24 Chapter 2. Methods 34 References 40 Chapter 3. Results: Consistency in the reporting of sensitive and non-sensitive behaviors between Audio Computer Assisted Self Interviews (ACASI) and Face to Face Interviews (FTFI) - Results from a case cross over study of HIV positive and HIV negative women in a semi-rural district in Tamil Nadu, India 41 References 73 Chapter 4. Results: Association between HIV and intimate partner violence – A study of married women in Theni district, Tamil Nadu, India using Audio Computer Assisted Self Interviews (ACASI) and Face to Face Interviews (FTFI) 78 References 113 Chapter 5. Results: Intimate partner violence and the disclosure of HIV among HIV positive women in a semi-rural setting in South India 121 References 147 Chapter 6. Conclusion 153 vi LIST OF TABLES Table Page 3.1 2X2 table showing agreement between ACASI and FTFI 51 3.2 Socio demographic characteristics of currently married women by HIV status in Theni district, Tamil Nadu, India 66 3.3 Comparison of ACASI and FTFI in reporting of sensitive and non-sensitive behaviors by HIV positive women in Theni district, Tamil Nadu, India 67 3.4 Comparison of ACASI and FTFI in reporting of sensitive and non-sensitive behaviors by HIV negative women in Theni district, Tamil Nadu, India 68 3.5 Agreement in test results for ACASI and FTFI in the reporting of sensitive and non-sensitive behaviors for HIV positive women in Theni district, Tamil Nadu, India 69 3.6 Agreement in Test Results for ACASI and FTFI in the reporting of sensitive and non-sensitive behaviors for HIV negative women in Theni district, Tamil Nadu, India 70 4.1 Selected characteristics of currently married women in Theni district, Tamil Nadu, India by HIV sero status 103 4.2 Selected characteristics of spouses as reported by currently married women in Theni district, Tamil Nadu, India by women’s HIV sero status 105 4.3 Proportions, odds ratios and adjusted odds ratios with 95% confidence intervals for husband’s controlling behavior and types of abuse by HIV infection in currently married women in Theni district, Tamil Nadu, India 106 4.4 Relative risk ratios (RRR) from multinomial regression analysis of correlates of intimate partner violence by type of violence in currently married women in Theni district, Tamil Nadu, India 108 4.5 Association between perpetration and victimization of abuse in currently married women in Theni district, Tamil Nadu, India 110 5.1 Selected characteristics of 251 women living with HIV in Theni district, Tamil Nadu, India 141 vii 5.2 Odds ratios (OR) & adjusted odds ratios (AOR) of experiencing any adverse reactions following the disclosure of HIV infection to husbands – Results from multiple logistic regression analysis 143 viii LIST OF FIGURES Figure Page 1.1 Factors affecting intimate partner violence in married Indian women 23 2.1 District map of Tamil Nadu state, highlighting the district of Theni 35 2.2 Enrollment of study participants 39 3.1 Enrollment of study participants 45 3.2 Screen shots of different types of questions as they appear in Audio Computer Assisted Self Interview (ACASI) using tablet computers 72 4.1 District map of Tamil Nadu state 83 4.2 Frequencies of intimate partner abuse types reported in face to face interviews by women in Theni district, Tamil Nadu, India (n=763) 111 4.3 Frequencies of intimate partner abuse types reported in Audio Computer Assisted Self Interviews by women in Theni district, Tamil Nadu, India (n=705) 112 5.1 Disclosure of HIV status by 251 HIV positive women in Theni district, Tamil Nadu, India 144 5.2 Time to disclosure of HIV status to husband by 250 HIV positive women in Theni district, Tamil Nadu, India 144 5.3 Reasons for the disclosure of HIV infection to husbands by 251 HIV positive women in Theni district, Tamil Nadu, India 145 5.4 Adverse reactions following the disclosure of HIV status to husband in 251 HIV positive women in Theni district, Tamil Nadu, India 146 ix LIST OF ABBREVIATIONS ACASI Audio Computer Assisted Self Interview AIDS Acquired Immunodeficiency Syndrome AOR Adjusted Odds Ratio ART Anti-Retroviral Therapy BI Bias Index CASI Computer Assisted Self Interview CAPI Computer Assisted Personal Interview CI Confidence Interval CTS Conflict Tactics Scale DHS Demographic and Health Surveys FTFI Face to face interview HIV Human Immunodeficiency Virus ICTC Integrated Counseling and Testing Center IDU Injection Drug Use IPV Intimate Partner Violence MCTS Modified Conflict Tactics Scale NACO National AIDS Control Society NFHS National Family Health Survey NGO Non-Government Organization OR Odds Ratio x PABAK Prevalence and Bias Adjusted Kappa PCA Principal Component Analysis PI Prevalence Index RRR Relative Risk Ratio STD Sexually Transmitted Disease STI Sexually Transmitted Infections UCLA University of California Los Angeles UNAIDS Joint United Nations Program on HIV/AIDS VCASI Video Computer Assisted Self Interview VCT Voluntary Counseling and Testing WHO World Health Organization xi ACKNOWLEDGEMENTS First and foremost, I owe my sincere thanks to my advisor Professor Roger Detels, whose guidance and support was immensely valuable not only for this research but also for my entire duration of study at UCLA. I also thank the rest of my committee members Dr. Gorbach, Dr. Afifi & Dr. Jae for providing their valuable feedbacks & contributions to my dissertation. I extend my special note of thanks to Late Dr. Visscher for her guidance during the early years of my graduate program. I thank all of my teachers at UCLA and the staff who work tirelessly to help the students. Particularly, I thank Wendy Aft and Joy Miller for their continued support throughout these years. I offer my deepest gratitude to my mom who never stops believing in me. Special thanks to my dad, for teaching me to fight any adversities in life and to never give up. I also thank my brothers Kannan and Anand, without whom I would not have travelled across the globe to pursue my education.