Social Science & Medicine 50 (2000) 459±478

www.elsevier.com/locate/socscimed

The intersections of HIV and violence: directions for future

research and interventions
Suzanne Maman a,*, Jacquelyn Campbell b, Michael D. Sweat a,
Andrea C. Gielen c
a
Department of International Health, School of Hygiene and Public Health, Johns Hopkins University, 615 N. Wolfe Street,
Baltimore, MD 21205, USA
b
School of Nursing, Johns Hopkins University, Baltimore, MD, USA
c
Department of Health Policy and Management, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD,
USA

Abstract

The purpose of this paper is to review the available literature on the intersections between HIV and violence and
present an agenda for future research to guide policy and programs. This paper aims to answer four questions: (1)
How does forced sex a€ect women's risk for HIV infection? (2) How do violence and threats of violence a€ect
women's ability to negotiate condom use? (3) Is the risk of violence greater for women living with HIV infection
than for noninfected women? (4) What are the implications of the existing evidence for the direction of future
research and interventions? Together this collection of 29 studies from the US and from sub-Saharan Africa
provides evidence for several di€erent links between the epidemics of HIV and violence. However, there are a
number of methodological limitations that can be overcome with future studies. First, additional prospective studies
are needed to describe the ways which violence victimization may increase women's risk for HIV and how being
HIV positive a€ects violence risk. Future studies need to describe men's perspective on both HIV risk and violence
in order to develop e€ective interventions targeting men and women. The de®nitions and tools for measurement of
concepts such as physical violence, forced sex, HIV risk, and serostatus disclosure need to be harmonized in the
future. Finally, combining qualitative and quantitative research methods will help to describe the context and scope
of the problem. The service implications of these studies are signi®cant. HIV counseling and testing programs o€er
a unique opportunity to identify and assist women at risk for violence and to identify women who may be at high
risk for HIV as a result of their history of assault. In addition, violence prevention programs, in settings where such
programs exist, also o€er opportunities to counsel women about their risks for sexually transmitted diseases and
HIV. # 2000 Elsevier Science Ltd. All rights reserved.

Keywords: HIV; Violence; Women; Sub-Saharan Africa; United States

* Corresponding author. Tel.: +1-410-431-5036; fax:

+1-410-431-5036.
E-mail address: smaman@jhsph.edu (S. Maman)

0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 2 7 0 - 1
460 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461

HIV/AIDS among women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462

Violence against women: scope of the problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463

Physical abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463

Sexual abuse in adulthood, adolescence and childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463

Violence as a risk factor for HIV infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466

Forced/coercive sex as a risk factor for HIV infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Violence limiting women's ability to negotiate condom use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Methods and design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Childhood sexual abuse and HIV risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Methods and design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

HIV infected women at risk for violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478 461

Methods and design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Research implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Prospective studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Standardize de®nitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Inclusion of men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Combining research methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

Cross-cultural studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

Service implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

Voluntary HIV counseling and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

Condom promotion and other HIV prevention programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476

Domestic violence prevention programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477

Introduction (Rothenberg et al., 1995; Temmerman et al., 1995;

HIV and violence are two of the major health pro-
blems a€ecting the lives of millions of women world-
wide. There is evidence from di€erent cultural settings
linking the epidemics of HIV and violence among
women (Zierler and Krieger, 1997). Studies of HIV
risk among women have examined child abuse, inti-
mate partner violence as well as violence perpetrated
by others against women. Investigators have hypoth-
esized at least four mechanisms through which the epi-
demics of HIV and violence overlap in the context of
women's lives. Violence may increase a woman's risk
for HIV infection through forced/coercive sexual inter-
course and by limiting women's ability to negotiate
HIV preventive behaviors. Physical and sexual abuse
during childhood has also been associated with high
sexual risk-taking behavior in adolescence and adult-
hood. The other association between HIV and violence
occurs among women who are already infected with
HIV. The literature from the US and sub-Saharan
Africa indicates that women who disclose HIV serosta-
tus to partners may be at increased risk for violence
Gielen et al., 1997).
This paper will address the implications of the exist-
ing body of literature on the overlapping epidemics of
HIV and violence among women for health care ser-
vice delivery. Evidence suggests that violence against
women may limit the impact of the HIV prevention
strategies that are promoted globally. For example,
HIV prevention programs that emphasize a reduction
in numbers of sexual partners and use of condoms and
do not take into account violence may fail to achieve
their intended goals, because women who are victims
of violence or threats of violence are often not able to
negotiate and enforce these life-saving strategies (Heise
et al., 1995). Similarly, the literature also suggests that
women who have recently been tested for HIV and
decide to share their test results with partners may be
at increased risk of violence. As such, counseling pro-
grams that blindly promote HIV serostatus disclosure
without ®rst assessing the risk of domestic violence
may place women at increased risk for physical vio-
lence and other life-threatening social outcomes.
Additional research is needed to develop risk assess-
462 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478

Table 1
HIV seroprevalence among pregnant women for selected African citiesa

Country Year Geographic area Sample size Prevalence

Botswana 1997 Francistown 802 42.9

Rwanda 1996 Kigali 346 32.7
Zimbabwe 1997 Harare 601 28.0
Kenya 1997 Nairobi 1218 15.9
Ethiopia 1997 Addis Ababa N/a 17.6
Ivory Coast 1996 Abidjan 552 15.9
Uganda 1997 Kampala N/a 14.7
Tanzania 1996 Dar es Salaam 6525 13.7
Congo, Dem. Republic (Zaire) 1997 Kinshasa 511 3.1
Angola 1995 Luanda 1000 1.2

a
United States Census Bureau (1999).

ment tools to identify women at risk for violence fol-
lowing HIV serostatus disclosure and to develop crea-
tive approaches for encouraging safe disclosure among
couples. In addition, given the high prevalence of sexu-
ally transmitted diseases (STDs) among victims of
physical and sexual violence, support services that tar-
get these victims o€er unique opportunities to counsel
women about their risks for STDs and HIV. Clearly,
recognizing and incorporating the areas of overlap into
their respective prevention strategies could strengthen
both HIV and domestic violence programs.
Although there is an increasing body of literature
describing the associations between HIV and violence,
the methodological and conceptual di€erences among
studies make it dicult to compare results and draw
conclusions. The literature included in this review rep-
resents a collection of the published material from the
United States and from selected sub-Saharan African
countries that we found through database searches,
hand searches, secondary reference lists from relevant
papers and through word of mouth from colleagues
involved in this area of research. First we present
background information on the scope of the violence
and HIV epidemics among women. Then we review a
total of 24 published studies describing violence as a
risk factor for HIV and six studies describing the pro-
blem of violence among HIV infected women.
We chose to limit this review of the literature to
published studies from the US and sub-Saharan
African for a number of reasons. First, given the sever-
ity of the HIV/AIDS epidemic in sub-Saharan Africa,
the public health importance of understanding the
dynamics of these overlapping epidemics is critical for
this region. In addition, although there are some pub-
lished studies on violence and some on HIV/AIDS in
other areas of the world, there are few studies that
overlap the two concerns. We found that the majority
of the published studies that did combine the two
could be geographically clustered into these two
regions. We chose to use studies from both of the
regions to try to describe similarities and di€erences
across cultures and because the literature from both
regions needs to inform each other more than it does
currently. Finally, the large number of methodologi-
cally sound studies on violence against women from
the US provides a useful framework by which to com-
pare studies from the sub-Saharan African countries.
HIV/AIDS among women
The dynamics of the HIV/AIDS epidemic have
changed dramatically in the last ten years. The growth
of the AIDS epidemic in North America has slowed in
recent years, largely due to decline in sexual trans-
mission between men. However, the AIDS incidence,
number of new AIDS cases, in certain US population
groups has exploded. Increase in incidence in the 1990s
has been greatest for women compared to men, blacks
and Hispanics compared to whites, and persons
infected through heterosexual contact as compared to
those infected through other modes of transmission.
As a result, AIDS incidence in 1995 was 6.5 times
greater for blacks and four times greater for Hispanics
than for whites; 20% of persons diagnosed with AIDS
were women, and 15% were infected heterosexually
(UNAIDS, 1999). Women as a percentage of all
reported AIDS cases has steadily increased from 7%
in 1985 to 16.2% in 1992 to 18.1% in 1994 (CDC,
1996). In 1994 African-American women represented
53% of all women with AIDS in the US (Buzy and
Gayle, 1996).
The majority of all HIV infections worldwide (93%)
have occurred in the developing world. Africa, in par-
ticular, has borne a disproportionate burden of the
HIV pandemic. While the African continent contains
11% of the world's population, 60% of the world's
total HIV infections are found there (Buzy and Gayle,
 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478 463

Table 2
Population-based prevalence studies of violence against womena

Country Sample Prevalence Period of assessment

Antigua 97 women aged 20±45 yr, random subset 30% of women battered as adults Adulthood
of national probability sample
Barbados 264 women, 243 men aged 20±45 yr, 30% of women battered as adults Adulthood
national probability sample
Belgium 956 women between 30±40 yr, random 3% experienced serious violence, 13% Not speci®ed
sample from 62 municipalities moderately serious, 25% less serious
throughout country violence
Cambodia Nationally representative sample of 16% report ever being physically abused Marital period
women and men age 15±49 yr by a spouse
Canada 12 300 women 18 yr and older, nationally 25% (29% of ever married women) Adulthood
representative sample physically assault by current or former (since age 16)
male partner since age 16
Columbia Nationally representative sample of 6097 19% physically assaulted by partner in Lifetime
women in a relationship age 15±49 yr their lifetime
Columbia 3272 urban women, 2118 rural women, 20% physically abused, 33% Marital period
national random sample psychologically abused, 10% raped by
husband
Egypt Nationally representative sample of ever 35% beaten by their husband Marital period
married women age 15±49 yr
Rep. Of Korea 707 women and 609 men who have a 37.5% of wives battered by spouse in the One year
partner for at least 2 yr, three stage last year, 12.4% serious physical abuse
strati®ed random sample of entire within last year
country
Malaysia 713 women and 508 men over 15 yr, 39% physically beaten by partner in One year
national random sample 1989
United States 2143 married or cohabiting couples, 28% report at least one episode of Marital
national probability sample physical abuse (or relationship) period

a
Heise et al. (1995); WHO (1997).

1996; UNAIDS, 1999). The rate of HIV infection
among African women has risen to staggering levels in
some countries. The rate of infection among women
equals, and in many cases surpasses, the rate of infec-
tion among men due to both biological and social risk
factors (Buzy and Gayle, 1996). Table 1 summarizes
the US Census Bureau's 1998 estimates of HIV sero-
prevalence among pregnant women from selected
African cities.
Violence against women: scope of the problem
Physical abuse
Violence against women is a public health problem
that has gained the attention of researchers, policy
makers and practitioners. In reviewing cross-cultural
data several cautions are advised. Variations in de®-
nitions of physical, sexual and psychological violence,
study methods, time frames of assessment (i.e. violence
over a lifetime, in the last year), and sampling frames
all contribute towards the diculty in understanding
the scope and severity of violence against women. To
address these limitations, the World Health
Organization (WHO) is currently supporting a multi-
country study with consistent measures and sampling
frames that will provide a more accurate comparison
of intimate partner violence across the world (WHO,
1998).
Heise et al. (1995) provide a comprehensive review
of the international literature on the scope of violence.
Table 2 summarizes the national probability studies
from their World Bank discussion paper and from a
WHO report on domestic violence (i.e. by an intimate
partner or spouse) documenting the scope of the pro-
blem in di€erent geographic settings. From these ten
national probability samples estimates of abuse ranged
between 16% of women in Cambodia who reported
ever being abused by a spouse to 39% of women in
Malaysia who report being physically abused by a
spouse within a 1 yr period.
Sexual abuse in adulthood, adolescence and childhood
Estimates of sexual abuse are even more dicult to

Table 3
Forced/coercive sex and HIV risk
Study Sample and design
Choi et al., 1998 2030 US adults 18±49 yr,
telephone survey, random
probability sample. Cross-
sectional
He et al., 1998 208 nondrug using female sex
partners of male drug users in
Arizona and Oregon. Cross-
sectional
Kalichman et al., 1998 125 African-American women
from low-income housing in
Atlanta. Cross-sectional
Molina and Basinait-Smith, 40 women residing in one of four
1998 randomly selected battered
women's shelters in
Massachusetts. Cross-sectional
Outcome measures
Sexual harassment: unwanted
sexual advances, propositions or
comments in the context of work
or school. Sexual coercion:
pressured to have sexual contact
Physical and sexual abuse: since
you were 13 has a sex partner
ever physically hurt you (beaten
up, slashed with a knife or injured
in some other way)? Ever raped
or sexually assaulted you?
Sexual coercion: have you ever
had sexual intercourse even
though you didn't want to
because a man threatened to leave
you? Have you ever had sexual
intercourse even though you
didn't want to because a man
threatened to use physical force to
make you? and has a man ever
forced you to have sex when you
did not want to? Physical abuse:
has a man that you were involved
with ever hit you?
Psychological, physical and sexual
abuse: an abusive behavioral
observation checklist scale was
used. Severity of abuse was
characterized as low, moderate,
high or severe
Limitations
Cannot determine whether sexual
harassment and/or sexual coercion
preceded sexual risk taking
No information on historic and
immediate precipitating factors of
violent episodes. Cannot
determine which came ®rst sexual
abuse or sexual risk behaviors
Experiences and behaviors not
linked to speci®c relationships.
Cannot determine if men who
were sexually coercive were also
physically violent. Cannot
determine if sexual coercion led
directly toward HIV risk
behaviors. Modest sample size
Modest sample size. Eligibility
criteria not clear. Measures not
described. Cannot determine
whether HIV risk is caused by
abuse
464
Results
Proportion of men with HIV risk
factors higher among sexually
harassed than those not (32 vs.
22%, p = 0.0056). Proportion of
women with HIV risk factors
higher among sexually coerced
than among those not (26 vs.
13%, p = 0.0001)
Women who had experienced
sexual and physical abuse were
more likely to engage in risk
behaviors. Women threatened
with assault by their partners were
more likely to have multiple sex
partners. Women sexually abused
before 13 more likely to have
multiple sex partners
42% women were sexually
coerced. Coerced women more
likely to have been given money/
drugs for sex from most recent
partner ( p = 0.01). Coerced
women less acquainted with most
recent sexual partner ( p < 0.01).
Trend toward di€erence between
the two groups for condom use
during most recent sexual
encounter ( p = 0.06). Coerced
S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
women more likely to be afraid to
ask man to wear condom because
he might strike her ( p < 001)
Multiple HIV risk strongly
correlated with high to extreme
levels of physical, psychological,
and sexual abuse. Psychological
abuse most strongly associated
with risk of HIV exposure
Table 3 (continued )
Study
Van der Straten et al., 1998
Wingood and Diclemente,
1998
Wood et al., 1998
Zierler et al., 1996
Fisher et al., 1995
Van der Straten et al., 1995
Brown et al., 1994
Sample and design
921of the 1335 Rwandan women
in Kigali enrolled in an
epidemiological study of HIV.
Cross-sectional
165 African American low SES
women 18±29 yr from San
Francisco. Cross-sectional
24 pregnant South African
adolescents, 14±18 yr, average
educational of STD 6 or 7. Cross-
sectional, qualitative
262 women who voluntarily
sought HIV counseling and
testing and 152 women who
attended a mobile clinic in Rhode
Island. Cross-sectional
53 long-term homeless women,
equally distributed between day
and night shelters in San Diego.
Cross-sectional
876 Rwandan women enrolled in
HIV epi study who reported one
steady partner in last year. Cross-
sectional
887 female drug users, sexual
partners of drug users, women
who exchange sex for money and
enrolled in an intervention study
in LA; <1% of women were
HIV+. Cross-sectional
Outcome measures
Sexual coercion: does your
partner ever insist you have sexual
intercourse when you don't want
to? What is your partner's
reaction to your refusal to have
sex with him?
Adult rape: has a man ever forced
you to have sex with him when
you didn't want to? (15 yr or
older). Physical abuse: during the
past three months has your
primary partner physically abused
you (i.e. slapped or hit you)?
Semi-structured interviews
focusing on how, why and when
decisions are made by individuals
to have sex and to engage in
speci®c sexual practices. Speci®c
questions not provided
Sexual assault: have you ever been
raped or forced to have sex?
Women with a history of sexual
assault asked details on frequency
and timing of assault
Measures not described
Marital violence: does your
partner ever beat you? Sexual
coercion: what is your partner's
reaction to your refusal to have
sex? Does your partner insist to
have sex when you don't want to
Measures not described
Limitations
Questionnaire not designed to
answer this question. Frequency,
severity of sexual coercion not
assessed. Cannot determine if
sexual intercourse occurred after
sexual coercion
Cannot identify temporal
sequence of adult rape in
association to HIV risk factors.
Selection bias Ð sample based on
self-identi®cation of women who
have been raped. May be
underreporting of rape
Not a representative sample of
pregnant teens. Small sample size.
Speci®c probes not described
Cannot distinguish whether rape
is an active part of women's
experiences with HIV or an
antecedent to infection
Modest sample size. Cannot
determine causal pathways.
Measures not clearly de®ned. No
comparison group
Very broad de®nition of violence.
Cannot determine direct causal
relations between sexual coercion
and HIV infection
Measures not described. Cannot
determine whether abuse and lack
of social support is the result of
HIV risk taking behavior or risk
taking behavior led to abuse and
loss of social support
Results
HIV positive women with positive
partner were more likely to report
sexual coercion. HIV positive
status independently associated to
partner's insistence on sex, when
adjusting for all other variables
14% of women reported adult
rape. Rape survivors six times as
likely to have had sex 10+ times
in last three months; three times
more likely to never use condoms
during last three months; three
times less likely to negotiate
condom use; 11 times more likely
to have physically abusive partner
Violence characterized the
narratives of majority of teenagers
sexual initiation 22 of 24
informants reported beaten by
partners on multiple occasions.
Remaining two threatened with
assault
35% of HIV positive women and
28% of HIV negative women
reported rape during adulthood
(OR=1.4, 90% CI=0.8±2.4)
91% of women ever beaten; 56%
raped, and 15% battered in the
S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
last year 23% of women were in a
high HIV risk group
HIV positive women were more
likely to say their partner coerced
them to have sex. Physical
violence was disproportionately
reported by women with HIV+
partners
27% of women reported being
hurt by a partner as an adult;
29% threatened by a partner and;
20% sexually hurt
465
(continued on next page)
466 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478

compare across studies due to di€erences in measures,

additional risk of acquiring STDs

STDs (gonorrhea 6%, chlamydia
chlamydia after assault 50% had
bacterial vaginosis; 14% of these
26% had pre-existing chlamydia;

assault 22% had trichomoniasis;

rates: gonorrhea 4%; chlamydia

High prevalence of pre-existing
sampling and time frames of assessment. Many studies

at least 33% of these infected

2%; trichomoniasis 12%; BV

cases BV acquired during the

as result of assault (incidence

34%). Lower but substantial
10%; trichomonas 15%; BV
of sexual abuse in the US have been conducted with
university students. From studies in the United States,

3±16% risk of acquiring

it has been estimated that between one in ®ve and one
in seven university women will be a rape victim during

during the assault

her lifetime (Kilpatrick et al., 1992; Koss, 1993). One
study of 6000 US college women found that 42%
reported forced sexual contact or attempted rape
Results

19%)
(Koss and Harvey, 1991).
In developing countries, prevalence estimates on sex-
ual coercion are scarce. In a survey in The Central

patients returned for 1st follow up

follow: 204 examined initially, 109
follow-up at two weeks, 51% lost

African Republic, 22% of women report being raped

Modest sample size 23% lost to

incidence of gonorrhea because

Wide range of follow-up (1±20

as part of their ®rst sexual experience (Van der Straten

at six weeks. Could not assess

weeks). High rate of lost to

et al., 1998). From a study on adolescent sexual and

83% received prophylactic

reproductive health in a peri-urban township outside

of Cape Town, South Africa, Wood et al. (1998)
reports that 31% of pregnant teens surveyed and 18%
and 52 for 2nd

of nonpregnant teens said they were `forced' to have

Limitations

sex the ®rst time. Seventy-one percent of pregnant

penicillin

teens and 60% of nonpregnant teens reported having

had sex against their will. In both groups, 59% of girls
report being beaten by their male partners during an
average of 2.3 yr of sexual activity.
albican and trichomonas vaginalis

Because sexual abuse of children is such a sensitive

trichmonas, herpes simplex virus
trachomatis, gonorrhea, candida

Biological measures: gonorrhea,

Biological measures: chlamydia

issue, there are few population-based studies from

cytomegalovirus, chlamydia,

which its prevalence can be estimated. From popu-

lation-based studies in the US, it is estimated that 27
to 62% of women recall at least one incident of sexual
Outcome measures

abuse that occurred before they were 18 (as cited in

Heise et al., 1995). An anonymous, island-wide prob-
ability survey in Barbados revealed that about 33% of
and HIV

women and 1±2% of men report having been subject

to behavior constituting childhood or adolescent sexual
abuse (Handwerker, 1993). Another study from the US
describes the inter-relationships between childhood sex-
Prospective: examined within 60 h

204 sexually assaulted females (12

76 postpuberal rape victims from

of assault and again two and six

ual abuse and adult abuse. From a random sample of

to 67 yr) in Seattle. Prospective:
examined within 72 h of assault

US adult women, it is estimated that 33 to 68% of sur-

a municipal hospital in NY.

and again 1±20 weeks later

vivors of childhood abuse experienced at least one

rape in adulthood (Russell, 1986).
Sample and design

Violence as a risk factor for HIV infection

weeks later

There are three mechanisms through which violence

is hypothesized to increase women's risk for HIV infec-
tion: (1) through forced or coercive sexual intercourse
with an infected partner, (2) by limiting women's abil-
ity to negotiate safe sexual behaviors, and (3) by estab-
lishing a pattern of sexual risk taking among
Table 3 (continued )

individuals assaulted in childhood and adolescence.

Glaser et al., 1991

Jenny et al., 1990

Summarized below are the results from studies that

address each of these three hypothesized associations
between violence and HIV infection. Several limi-
Study

tations to these studies will be raised at the end of

each section.
 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
Forced/coercive sex as a risk factor for HIV infection
Settings
We have reviewed and summarized 13 studies that
examined the association between forced/coercive sex
and HIV risk behaviors (see Table 3). Eleven of the 13
studies are from the United States. The remaining two
are from Rwanda and South Africa.
Population
Two of the 13 studies were population-based (Choi
et al., 1998; Wingood and DiClemente, 1998). The
other studies were conducted among women in various
clinic or research settings including an emergency
room, prenatal care, HIV counseling and testing clinic,
homeless shelters, low-income housing and women
enrolled in research studies.
Methods
All of the studies are cross-sectional. Only one of
the 13 studies used qualitative research methods to
explore the association between forced sex and HIV
risk taking behaviors (Wood et al., 1998). The one
qualitative study stands out among the 12 because it
helps to contextualize the violent sexual experiences of
South African adolescents. This study also clearly
describes the many factors including peer pressure,
fears of violent retributions, and gifts (both monetary
and in-kind) that women consider when deciding
whether to remain in violent relationships despite the
health risks that they may present. Ten studies were
based on survey methods and two were based on medi-
cal examinations to con®rm sexual assault.
Measures
A wide range of experiences have been grouped
within this category of sexual coercion including: sex-
ual assault, pressure to have sexual contact, and part-
ner insistence on sex against the will of the woman.
Seven of the studies describe the speci®c questions they
used to measure sexual coercion. Two of these seven
studies ask about sexual assault during the woman's
current relationship. The remaining ®ve studies asked
about sexual assault over the course of a lifetime or
since the age of 13.
Conclusions
While the studies found that HIV risk factors in
men and women were associated with sexual coercion
(Brown et al., 1994; Fisher et al., 1995; Molina and
Basinait-Smith, 1998; Kalichman et al., 1998; Wingood
and DiClemente, 1998; Choi et al., 1998; Wood et al.,
1998) and that HIV infected women experienced more
sexual coercion than HIV uninfected women (Van der
Straten et al., 1995, 1998; Zierler et al., 1996) all of the
studies were cross-sectional. Therefore, it is impossible
467
to determine whether there is a direct causal relation-
ship between forced sex and HIV from these studies.
Also given the wide range of experiences that have
been grouped under the category of sexual coercion, it
is dicult to determine whether the risk of HIV are
di€erent for women who have been sexually assaulted
versus those who have been pressured into sex by a
partner. It is clear from these 13 studies that forced
sex is indirectly related to HIV risk. It occurs in the
same underlying context as other HIV risk taking
behaviors (i.e. exchange of sex for money, intravenous
drug use, etc.). By underlying context we are referring
to the situations that characterize the women's lives,
such as poverty, low educational status, poor job
opportunities, public housing, lack of adequate child
support, etc. The two prospective studies that involve
medical examination of women who were raped (Jenny
et al., 1990; Glaser et al., 1991) provide some evidence
that women who are raped are at high risk of having a
pre-existing STD, and that the sexual assault itself pre-
sents a lower but substantial additional risk of STDs.
Violence limiting women's ability to negotiate condom
use
The four studies summarized in Table 4 explore the
association between violence and women's ability to
negotiate condom use in sexual relationships.
Setting
Three of the four studies were conducted in the
United States and the fourth was conducted among
South African sex workers.
Population
One of the three studies (Wingood and DiClemente,
1997a, b) is US population-based and the other three
are based on surveys with women from an STD clinic
in Alabama (Buzy et al., 1996), sex workers at a truck
stop in South Africa (Karim et al., 1995), and women
at a domestic violence shelter (Eby et al., 1995).
Methods and design
All four studies are cross-sectional and only one
study (Karim et al., 1995) is based on a combination
of qualitative and survey research methods.
Measures
Measures for violence were similar across studies,
however the measures of condom use varied. One
study (Cabral et al., 1998) focuses on women's sense of
control over condom use, whereas the study by
Wingood and DiClemente (1997a, b) focuses speci®-
cally on physical abuse related to condom use and the
study by Eby et al. (1995) simply measures the extent

Table 4
Violence and threat of violence limiting women's HIV self-protective behaviors
Study Sample and design
Cabral et al., 1998 546 of 1461 eligible women 18±34
yr who attend the STD clinics of
the Health Department of
Birmingham and Huntsville,
Alabama. Cross-sectional
Wingood and Population-based sample of 165
DiClemente, 1997a, b women aged 18±29 recruited from
a predominantly lower socio-
economic, African American
community in San Francisco.
Cross-sectional
Eby et al., 1995 110 women residing at a shelter
for women with abusive partners
who were part of a larger
longitudinal study on the e€ects
of advocacy intervention. Cross-
sectional
Karim et al., 1995 12 women engaged in sex work at
a popular truck stop in South
Africa. Cross-sectional, qualitative
and survey
Outcome measures
Partner violence: con¯ict tactic
scale (Straus et al., 1996); yelled,
throw something, pushed,
grabbed, slapped, hit or kicked,
threatened with a knife or gun,
forced sex. Perceived control of
condom use: how much control
do you have over whether or not
your regular partner uses a
condom? Measured on a visual
analog scale
Abusive consequences of condom
use: when you asked your primary
partner to use a condom how
often were you physically abused?
Threatened with physical abuse?
Threatened with abandonment?
Presence of a physically abusive
partner: during the past three
months has your primary partner
physically abused you (i.e. slapped
or hit you?)
Sexual violence: three
dichotomously scored items (0.81
Cronbach alpha). Physical abuse:
modi®ed CTS. Risk for STD/
HIV: modi®ed 17 item risk
assessment questionnaire (number
of sex partner, use of alcohol/
drugs, condom use, etc.)
Measures not described
Limitations
High rate of refusal and
nonparticipation may indicate
biased sample. Recent experience
with STD testing and treatment
may have in¯uenced couple's
condom use. Women at high risk
for STDs were selectively included
Ccannot determine whether
physically abusive partner caused
low condom use. No measure of
severity of abuse to assess whether
there was a relationship between
severity of abuse and condom use
No comparison group
Participants had left abusive
relationships and therefore are not
representative of all battered
women
Small sample size
468
Results
Most women believed they had
control over condom use. 62%
women predicted if they were to
refuse sex with partner without
condom he would use condom;
1% said that he would force them
to have sex; 6% of women feared
sexual coercion as result of
con¯ict over condom use
Women with abusive primary
partners more likely to (1) report
never using condoms; (2) use
condoms less frequently; (3)
report being verbally abused,
threatened with physical abuse
and abandonment when asked
partner to use condoms as
compared with women who do
not have an abusive partner
62% of women reported that they
did not use condoms or
spermicides in previous six
months
S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
Three respondents with average of
84 clients per week never asked to
use condoms. Women reported
condom use was responsible for
client loss and nonpayment.
Condom use led to abuse by
clients
Table 5
Child abuse and HIV risk
Study Sample and design
Jinich et al., 1998 Two separate population-based
samples of 1941 gay and bisexual
men residing in Tucson and
Portland. Cross-sectional
Vlahov et al., 1998 765 HIV+ women and 367 HIVÿ
women with history of injection
drug use enrolled in longitudinal
study in Baltimore, Bronx and
Detroit. Cross-sectional
Wingood and Diclemente, Population-based sample of 165
1997 women aged 18±29 yr recruited
from a predominantly lower
socio-economic, African American
community in San Francisco.
Cross-sectional
Zierler et al., 1996 262 women who voluntarily
sought HIV counseling and
testing at a clinic and 152 women
who accessed a mobile clinic in
Rhode Island. Cross-sectional
Outcome measures
Childhood sexual abuse: when
you were under the age of 16, do
you recall having sexual
experience or set of experiences
that involved someone at least ®ve
years older than you? Also asked:
how much do you feel it was done
against your will?
Physical abuse: participants asked
about physical abuse during
childhood and as adults. Sexual
abuse/rape: participants asked
about sexual abuse during
childhood and as adults. `Attack'
and `abuse' not further de®ned for
participants
Childhood sexual abuse: has a
man every forced you to have sex
with him when you didn't want
to? (<16 yr). Physical abuse:
during the past three months has
your primary partner physically
abused you (i.e. slapped or hit
you)?
Sexual assault: have you ever been
raped or forced to have sex?
Women who acknowledged
history of sexual assault asked for
details on frequency and timing of
assault
Limitations
No questions about duration or
frequency of the abuse, number of
older partners, personal response
to the experiences, reactions by
others to disclosure of abuse
Measurement of abuse unclear.
No measures of the type,
frequency, or intensity of abuse.
High risk group of participants.
Can only be generalized to like
group
Cannot identify causal pathways
Modest sample size. No data on
duration and severity of abuse
Cannot distinguish whether rape
is an active part of women's
experiences with HIV or an
antecedent to infection
Results
Abused men more likely to report
more sexual events in the last 30
days, more male partners, more
sexual encounters with
nonprimary male partners and
more sexual episodes under
in¯uence of drugs
41.3% of HIV+ women and
43.3% of HIVÿ women report
physical abuse as a child (OR
95% CI: 0.76±1.30 Ð controlling
for age, education, race, income,
main partner and drug use). 41%
of HIV+ women and 45.8% of
HIVÿ women reported sexual
abuse as a child (OR 95% CI:
0.71±1.21)
Prevalence of childhood sexual
abuse 13.3%. Women with history
of childhood abuse were 14 times
more likely to report STD, 3.8
times as likely to have anal sex,
5.1 times as likely to have been
abused within three months, 2.6
times as likely to have abusive
partner when asked to use
condom
S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
HIV+ women more severely
a€ected by early sexual
experiences, having an average of
three or more sexual partners per
year
(continued on next page)
469
Table 5 (continued )
Study Sample and design
Lodico and DiClemente, 2582 female 9 and 12th graders
1994 surveyed in 90% of Minnesota's
school districts. Cross-sectional
Handwerker, 1993 407 heterosexual men and women
age 20±45 yr selected randomly
from all strata of the national
population of Barbados. Cross-
sectional
Zierler et al., 1991 83 females and 80 males at risk
for HIV who were enrolled in a
counseling program. Cross-
sectional
James and Meyerding, 228 streetwalkers in a large
1977 western city. Cross-sectional
Outcome measures
Childhood sexual abuse: has any
adult or older person outside the
family ever touched you sexually
against your wishes or forced you
to touch them? And has any older
or stronger member of your
family ever touched you or had
you touch them sexually?
Violence: how often a woman was
hit, or hurt physically in some
other ways. Emotional abuse: how
often a woman was the subject of
demeaning remarks. Child abuse:
questions about: slapping/hitting,
beating and other forms of
physical/ verbal abuse
Childhood sexual abuse: a history
of rape or forced sex at least once
during childhood or as a teenager
Measures of sexual experience:
age at ®rst intercourse, early
sources of info about sex,
relationship with 1st sexual
partner, sexual partners,
`signi®cant' relationships, incest
and rape
Limitations
Abuse not precisely de®ned and
could capture a range of
behaviors. No information on
severity, chronicity or the
respondents age at time of abuse
Concepts are abstract and
variables used to measure
concepts are similarly complex
Study did not identify other
factors within the family that may
be associated with HIV risk.
Cannot identify the speci®c causal
pathways. Modest sample size
Measures not well de®ned
Analysis of age at ®rst intercourse
is dicult to follow. No
comparison group
470
Results
Sexually abused adolescents more
likely to report being sexually
active (71.8 vs. 48.4%, 1.5 RR).
Adolescents reporting sexual
abuse initiated sexual activity
earlier and less likely to report
condom use. Sexually abused
adolescents more likely to report
sexual contact was forced
Childhood sexual, physical and
emotional exploitation powerful
determinants of adolescent sexual
mobility. Violent homes
associated with high risk sexual
behavior among the children
Survivors of childhood sexual
abuse were: (1) ®ve times more
likely to have worked as a
prostitute; (2) reported 40%
excess frequency of a history of
sex with someone they did not
know; (3) slightly more likely to
have HIV; (4) no di€erence in
condom use
Subjects initiated sexual
intercourse at an early age. 46%
of subjects reported that an older
S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
person attempted sexual
intercourse with her as a child
Table 6
HIV associated violence
Study Sample and design
Vlahov et al., 1998 765 HIV+ women and 367 HIVÿ
women with a history of injection
drug use enrolled in a longitudinal
cohort study in Baltimore, the
Bronx and Detroit. Cross-
sectional
Gielen et al., 1997 55 HIV infected women served at
a large urban teaching hospital in
Baltimore. Cross-sectional
Rothenberg et al., 136 medical and mental health
1995 providers involved in the care of
HIV infected female patients.
Cross-sectional
Temmerman et al., 243 HIV+ women enrolled in a
1995 study examining the e€ects of
maternal HIV infection on
pregnancy in Nairobi, Kenya.
Cross-sectional
Outcome measures
Recent history of violence: women
were asked about recent history of
violence, which combined physical
and sexual attacks within the past
six months. `Abuse' or `attack'
were not further de®ned for
participants
When you found out you were
HIV positive whom did you tell?
How did they react when you told
them? Did anyone get violent with
you when they found out you
were HIV positive? Would you be
scared to tell someone that you
were HIV infected because you
think they might get violent
towards you in some way?
Physical violence: hitting,
slapping, shoving or grabbing.
Emotional abuse: threats of
violence or intimidation.
Abandonment: withdrawal of
®nancial support, shelter or access
to family member or belongings
Spontaneous reports of violence
recorded by investigators
including (beaten up, chased from
home, suicide). Not systematically
measured among women
Limitations
Physical and sexual abuse not
speci®cally de®ned by
investigators
No standardized de®nition of
violence used
High rate of nonresponders
(49%). Sample likely to be biased
towards those providers most
concerned about the issue
No pre-test rate of violence. No
comparison group of HIVÿ
women. No systematic
measurement of violence
Results
98.3% of the seronegative and
85.3% of the seropositive women
who had primary partners
disclosed test results ( p = 0.001).
Among HIV+ women the rate of
physical or sexual attack did not
di€er by disclosure. History of
recent violence less common in
HIV+ (5.1%) women than HIVÿ
women (8.3%). Inverse
association between rates of
violence and both low CD4 cell
counts and number of symptoms
among HIV positive women
All but one woman disclosed HIV
status to someone. 76% reported
acceptance, support, and
understanding after disclosure.
25% reported negative
consequences of disclosure
including: rejection, abandonment,
verbal and physical abuse
24% had at least one female
patient who experienced physical
violence following disclosure to a
partner. 38% had patients who
S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
experienced emotional abuse and
37% abandonment upon
disclosure to partners
66 (27.2%) communicated their
test results to partners Of whom
11 were chased away from their
home or replaced by a second
wife; seven were beaten up by
partner; one committed suicide
(continued on next page)
471
Table 6 (continued )
Study Sample and design
Keogh et al., 1994 55 HIV+ Rwandan women
drawn from cohort of 1458
women enrolled in a prospective
study of HIV. Prospective: 55
women interviewed in 1988 and
48 women re-interviewed in 1991
Heyward et al., 1993 187 HIV+ and 177 matched
HIVÿ women enrolled in study of
perintal HIV transmission in
Kinshasa, Zaire. Prospective:
women interviewed at time of
HIV counseling and testing and
again 1 yr later
Outcome measures
Self-reported physical and mental
status, pregnancy choices, condom
use, partner testing, support from
relatives, childcare, counseling
preferences and material needs
Measures not described
Limitations
Absence of an HIVÿ control
group. Modest sample size
Disclosure experiences were not a
major focus of the interviews
472
Results
After 2.5 yr, 17% did not tell
partners test result. Among the
eight who did not tell partners,
®ve said they feared rejection and
blame. Women in common law
marriages (as compared to formal
marriages) less likely to disclose
(64 vs. 88%, p = 0.18).
Acceptance, understanding and
sympathy, the most common
initial reaction of partners after
disclosure (55, 48 and 45%,
respectively). Overall, 17%
reported a negative reaction
(blame, anger). Over 25% said
their marriages deteriorated after
disclosure
At baseline, 70% of women
intended to tell their partner of
their HIV status. HIV+ (47%)
less likely to state this intention.
Of those who did not intend to
disclose, most common reasons
were fear of divorce (63%), or
accusations of in®delity (86%). At
12 months no women reported
divorce or separation. Only 8% of
the 101 women who had
requested assistance in notifying
S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
their partner returned with
partner for testing
 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
of condom use within the study population of battered
women.
Conclusions
The results from these studies provide modest sup-
port of the relationship between intimate partner vio-
lence and lack of condom use. Limitations of the
designs in three of the four studies (Eby et al., 1995;
Karim et al., 1995; Cabral et al., 1998) make it dicult
to draw de®nitive conclusions about the impact of
physically abusive partners on women's ability to
enforce condom use. In their study among women
attending an STD clinic. Cabral et al. (1998) found
that the majority of women perceived they had sub-
stantial control over condom use by their main part-
ner. Most of the women (85%) reported no objections
to condom use by current partners. There are some
limitations to this study that make interpretation of
the results dicult. The refusal/nonparticipation rate
(49%) was high and it is likely that those women who
did agree to participate and return for the interview
were a biased sample of the women served by this
clinic. The limited sample size of Karim et al.'s (1995)
study makes it dicult to interpret and generalize
results to other populations. The 12 commercial sex
workers interviewed for this study report infrequent
condom use with their clients. The reasons they cite
for low condom use include client loss, nonpayment
and physical abuse by clients. The study by Eby et al.
(1995) reports a ``notable lack of condom use'' among
partners of women in the domestic violence shelter.
However, due to the lack of a comparison group it is
not possible to determine whether the proportion of
sexual partners who did not use condoms among bat-
tered women is lower than what one would expect
among partners of a comparable group of women with
no history of abuse. In their community-based sample
of African-American women, Wingood and
DiClemente (1997a, b) provide the most convincing
evidence of an association between abusive partners
and low condom use. The authors found that women
with abusive partners were more likely than others to
report never using condoms (71.4 vs. 42.6%, p = 0.04)
or to use condoms less frequently (22 vs. 44%,
p = 0.04). Women who had a physically abusive pri-
mary partner compared to those who did not were 4.2,
9.2 and 3.7 times more likely, respectively, to report
being verbally abused, threatened with physical abuse
and threatened with abandonment when they asked
their primary partner to use condoms. There is a need
to replicate studies similar to Wingood and
DiClemente's with larger sample sizes in di€erent cul-
tural settings in order to draw conclusions about phy-
sically abusive partners and condom use.
Other studies (Worth, 1989; Gupta and Weiss, 1993)
have found that gender norms, together with women's
473
social and economic dependency can limit a woman's
ability to negotiate safer sexual behavior. In her
anthropological study among women attending urban
health care centers in Cleveland, Sobo (1995) presents
a di€erent and compelling perspective on the relation-
ship between empowerment and condom use. She
observed that women themselves often do not request
condom use due to the felt need to establish and main-
tain intimacy with their partners. So perhaps the re-
lationship between risk reduction and empowerment is
actually mediated by women's risk perception, or
maybe the lack of risk perception is actually a manifes-
tation of the lack of power. Among a sample of stu-
dents from the University of California, Berkeley, Lear
(1995) found that condom use is negotiated based on a
construction of personal risk and trust between part-
ners that does not always re¯ect reality. In the context
of casual relationships, for example, some women
choose not to suggest condom use in order to maintain
the pretense that the relationship involved more com-
mitment than it actually did. Furthermore, as long as
traditional gender norms for sexual relationships per-
sist, de®ned by men pressuring women and women
resisting, negotiation of condom use by women
remains dicult. Talking about condoms implies a
lack of trust, sexual desire and sexual experience, ex-
pressions that run counter to the traditional gender
norm expectations for women. The results from all of
these studies suggest that women may choose not to
use condoms for a number of reasons. However, for
those women who would like to enforce condom use in
sexual partnerships their actual ability to do so is
probably determined by both cultural gender norms
and related decision-making between partners.
Childhood sexual abuse and HIV risk
We reviewed eight studies that measured the re-
lationship between childhood sexual abuse and HIV
risk taking behaviors in adulthood (see Table 5).
Settings
Seven of the eight studies were conducted in the
United States. Handwerker's (1993)work is the only
non-US study that explores the issues among a nation-
ally representative sample of individuals from
Barbados.
Populations
Four of the eight studies were population based and
the remaining four were sampled from women enrolled
in a research study, an HIV counseling and testing
clinic, and a convenience sample of commercial sex
workers.
474 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
Methods and design
All of the studies are cross-sectional and all eight
studies used survey methods. The study by
Handwerker (1993) includes a combination of qualitat-
ive and quantitative methods.
Measures
The questions used to measure childhood sexual
abuse varied across the seven studies. At least three of
the studies refer to the respondents' relationship to the
abuser (someone at least 5 yr older, an older/stronger
member of your family). In all but one study
(Wingood and DiClemente, 1997a, b) the speci®c age
cut-o€ points that were used to de®ne `childhood sex-
ual abuse' were not described. The de®nitions of sexual
abuse used by most of the studies are nonspeci®c (i.e.
`touched you sexually,' `sexually abused you,' `having
sexual experiences,') thereby making it likely that the
authors have captured a wide range of experiences
with their de®nitions.
Conclusions
Despite some of the measurement limitations of
these studies, the results suggest that individuals with a
past history of childhood sexual assault are more likely
to engage in HIV risk taking behaviors. However, for
those individuals already at high risk for HIV infec-
tion, a past history of childhood sexual assault will not
predict who actually becomes infected with HIV. The
studies by Vlahov et al. (1998) and Zierler et al. (1991)
provide no clear evidence of higher HIV prevalance
among individuals who report childhood sexual abuse.
Zierler found that women who reported childhood sex-
ual assault were only 1.3 times more likely (90%
CI=0.82±2.0) than women who did not report child-
hood sexual assault to be HIV infected. Vlahov et al.'s
(1998) study among injection drug users found that
there were no signi®cant di€erences between the pro-
portions of HIV positive and HIV negative women
who reported physical or sexual abuse during child-
hood. The other studies (Handwerker, 1993; Lodico
and DiClemente, 1994; Zierler et al., 1996; James and
Meyerding, 1977; Wingood and DiClemente, 1997;
Jinich et al., 1998) do provide strong evidence for the
relationship between childhood sexual assault and HIV
risk taking behaviors in adulthood (i.e. anal sex, early
sexual initiation, commercial sex work, sex with unfa-
miliar partners, and low rates of condom use).
HIV infected women at risk for violence
The other major association between HIV and vio-
lence that has been explored in the literature relates to
an increased risk for violence among women living
with HIV infection. There is a small but growing body
of literature on violence among HIV infected women.
We found six studies examining the experiences of
HIV infected women with violence (see Table 6).
Settings
Half of the studies were based in the United States
(Rothenberg et al., 1995; Gielen et al., 1997; Vlahov et
al., 1998) and the other half were based in sub-
Saharan Africa, including Zaire (Heyward et al., 1993),
Rwanda (Keogh et al., 1994) and Kenya (Temmerman
et al., 1995).
Populations
Three of the studies included only HIV infected
women (Keogh et al., 1994; Temmerman et al., 1995;
Gielen et al., 1997). Two studies included a compari-
son group of HIV negative women (Heyward et al.,
1993; Vlahov et al., 1998) and one study surveyed
health care providers of HIV infected women
(Rothenberg et al., 1995).
Methods and design
Four of the six studies were cross-sectional and the
remaining two were prospective. Four of the studies
used survey methods (Heyward et al., 1993; Keogh et
al., 1994; Rothenberg et al., 1995; Vlahov et al., 1998),
one was based on spontaneous reports of violence
(Temmerman et al., 1995) and the last was based
entirely on qualitative research methods (Gielen et al.,
1997).
Measures
The measures used by most of the studies were not
well described. In four of the six studies, `violence' was
not speci®cally de®ned for the participants. In only
one of the studies (Rothenberg et al., 1995) was physi-
cal violence behaviorally de®ned for the participants
(hitting, shoving, slapping, grabbing). Measures of dis-
closure are also not often clear, including variations in
time of disclosure and persons to whom women dis-
close (partners, family, friends, etc.).
Conclusions
The results from these six studies provide con¯icting
evidence of an association between HIV serostatus dis-
closure and risk of violence. A signi®cant proportion
of the women interviewed (or the subjects of the inter-
views) in the studies by Rothenberg et al. (1995),
Temmerman et al. (1995) and Gielen et al. (1997) ex-
perienced negative consequences of serostatus disclos-
ure, including physical violence. Heyward et al. (1993)
and Keogh et al. (1994) found that many women inter-
viewed in their studies did not disclose serostatus to
partners because they feared the negative conse-
quences.
However, it cannot be overlooked that Keogh et al.
(1994), Gielen et al. (1997) and Heyward et al. (1993)
 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
also found that the partners of most women were sym-
pathic, understanding and supportive upon learning of
the woman's HIV serostatus. It may be that the ma-
jority of women can expect positive reactions from
their partners, but for those women already in abusive
relationships, disclosure of HIV-positive test results
may provide another trigger for additional violence. A
major limitation of these studies is that they failed to
take into account women's previous history of vio-
lence. Furthermore, most of these studies assessed
partner's reactions immediately following HIV serosta-
tus disclosure. It is possible that knowledge of the
woman's HIV status may change the dynamics of the
relationship over a longer term. For example, a
woman may feel she has less `leverage' to leave abusive
relationships when she knows she is HIV infected.
Vlahov et al. (1998) found that a greater proportion
of HIV negative women than HIV positive women
reported violence within the last six months.
Furthermore, the authors learned that recent violence
was inversely associated with CD4 cell count and
AIDS symptoms, suggesting that women who are HIV
infected and sicker are at lower risk for violence.
However, the cross-sectional nature of the study and
the lack of information on partners and the relation-
ship status of the women make it dicult to draw de-
®nitive conclusions. Similarly, it is possible that the
relationship between CD4 count and violence that the
authors describe may be due to the length of time the
women have been infected. Women with lower CD4
count are likely to have been living with HIV for a
longer period of time, and thus the their social situ-
ation may have changed with aging (fewer drugs, more
stable relationships or no relationships).
Discussion
Through this synthesis of existing literature we have
addressed the questions we set out the answer in this
paper: (1) How does forced sex during childhood and
adulthood a€ect women's risk for HIV infection as an
adult? (2) How do violence and threats of violence
a€ect women's ability to negotiate condom use with
sexual partners? (3) Is the risk of violence greater for
women living with HIV infection than noninfected
women? Finally, in the discussion below we attempt to
answer the fourth and ®nal question for this paper,
namely, what are the implications of the existing evi-
dence for the direction of future research and interven-
tions?
Research implications
There are a number of methodological limitations in
this collection of literature that can be overcome with
475
future studies to clarify the associations between HIV
and violence among women.
Prospective studies
Prospective studies are needed to describe the re-
lationship between forced sex and HIV infection and
to describe how being HIV infected a€ects violence
risk. Given the very high prevalence of HIV infection
and forced sex in some areas, the sexual dynamics of
some relationships (young, not fully developed adoles-
cent girls with older men) and the evidence of high
STD risk among sexually assaulted women, the direct
association between forced sex and HIV risk needs to
be further examined and clari®ed through prospective
studies. Studies of violence among women living with
HIV infection, have failed to take into account the
background levels of violence among women. Studies
that included pre- and post-test measures of violence
among women who receive HIV counseling and testing
will be able to determine whether the risk of violence
increases after HIV testing and disclosure to partners.
This would allow us to target violence prevention pro-
grams to women who are at greatest risk for violence
following HIV serostatus disclosure.
Standardize de®nitions
There is an important need to standardize de®nitions
and measurement tools for physical, sexual and
psychological violence, HIV risk, condom use, and
HIV serostatus disclosure across di€erent studies so
that results can be directly compared and conclusions
can be drawn. By adapting scales to measure concepts
in di€erent settings, we can begin to make comparisons
across sites. If not standardizing de®nitions, at least
clearly describing the de®nitions used in the various
studies would help to make comparisons between stu-
dies.
Inclusion of men
There is a glaring absence of men in these research
studies. Men's perspective on both HIV sexual risk
behavior and violence is crucial to developing e€ective
interventions. Moreover, coercive sex, physical assault
of women and use of condoms are male behaviors.
While we support the goal of women's empowerment
and control of their lives, the power disparities
between men and women that underlie violent and
risky relationships should not be expected to be
addressed by programs targeting only women. Men's
perspective in future studies is crucial to developing
prevention strategies that do not place an undue bur-
den of responsibility for safe sex on women alone.
Combining research methods
The cross-sectional survey techniques that have been
used in previous studies have not illuminated the ways
476 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
in which HIV and forced sex are associated.
Qualitative research can help to describe the contextual
factors that increase the risk of HIV among women
who were violated as children and as adults.
Qualitative research could also help to describe
women's experiences with disclosure to help determine
what speci®c factors trigger violent reactions by part-
ners. Furthermore, studies that include a combination
of qualitative and quantitative research methods will
provide information on the context and scope of the
problem. More complex models that explore a range
of moderating and mediating relationships would also
help to describe the causal pathways between sexual
assault and HIV risk behaviors.
Cross-cultural studies
Within each of the four major sections of this paper
there were not sucient numbers of studies from sub-
Saharan Africa to draw de®nitive conclusions on the
commonalties and disparities between developed and
developing countries. There is an urgent need to look
more closely at the direct association between forced
sex and STDs in the contexts of some sub-Saharan
African countries where the rates of STDs, including
HIV, are alarming and where the literature suggests
that forced sex is a reality for many women. More
cross-cultural studies are needed to determine whether
physical violence is a stronger determinant of condom
use in societies with more traditional gender norms
and relatively low status of women than in cultures
with relatively high status of women. Finally, the need
for a clearer understanding of the association between
HIV testing, serostatus disclosure and violence is para-
mount in the developing world where rates of HIV
infection are very high, the economic and social status
of women is marginalized and the support services
available for female victims of violence are scarce.
Service implications
The evidence from these studies on HIV and vio-
lence require that we begin to develop innovative and
multi-disciplinary approaches to the problem. As with
other health problems, these two threats for women do
not occur in isolation. It has been argued in this paper
that parallel e€orts to address the problems of HIV
and violence will have limited impact. Recognizing and
incorporating the areas of concentric overlap into their
respective prevention strategies will strengthen both
HIV and violence prevention programs. Speci®cally,
the service implications of the intersections between
HIV and violence are discussed below.
Voluntary HIV counseling and testing
Voluntary HIV counseling and testing (VCT) o€ers
a unique opportunity to address the problem of vio-
lence among women living with or at risk for HIV
infection. In many settings, particularly throughout the
developing world, the demand and the availability of
HIV counseling and testing is growing. In the e€ort to
create feasible antiretroviral treatment regimens in
developing countries to reduce the risk of perinatal
transmission of HIV and to delay the onset of AIDS,
participants of medical research are being tested for
HIV. By nature of the study designs and procedures it
is dicult or even impossible for the female partici-
pants of some of these studies to conceal their serosta-
tus from spouses/partners. Therefore, it is clearly in
the interest of the scientists to understand the risk of
negative consequences of disclosure (including vio-
lence) that their participants face. Without fully under-
standing the risks that women face by disclosing their
HIV serostatus the science and ethics of these studies
may be jeopardized. Until more is known about the
magnitude and determinants of risk for violence in the
context of HIV risk and how these may change over
time, caution would seem to be warranted. All oppor-
tunities to screen and counsel women about violence
should be fully pursued so that proper protections can
be o€ered.
Also, there is now clear evidence that VCT can pro-
mote behavior change and as a result the demand for
VCT as a prevention strategy, in and of itself, is
increasing (Gregorich et al., 1998). In settings where
women voluntarily seek counseling and testing for
HIV, trained counselors can maximize this opportunity
to screen clients for histories of sexual and physical
assault in childhood and as adults. This screening may
serve two purposes: (1) to refer women who are cur-
rently in abusive relationships to other services that
may address the problem of domestic violence, and (2)
to identify women who may be at high risk for HIV as
a result of their history of physical and/or sexual
assault. Counseling and testing programs also o€er an
opportunity to help women who want to safely dis-
close their HIV tests results to partners. Furthermore,
the risks (potentially life threatening) for violence fol-
lowing HIV serostatus disclosure may outweigh the
bene®ts for some women, and through HIV counseling
and testing programs these women can be identi®ed
and counseled against HIV serostatus disclosure.
Condom promotion and other HIV prevention programs
Condom promotion and other HIV prevention pro-
grams will have limited impact unless they take into
account the role of violence in women's lives. Women
who are victims of violence or threats of violence by
intimate partners often do not have the means of HIV
protection within their personal control (Heise and
Elias, 1995). Condom promotion programs that target
men and those that use structural level changes to
enforce condom use have been highly successful.
 S. Maman et al. / Social Science & Medicine 50 (2000) 459±478
Results from a condom promotion program among
sex workers in Thailand illustrated that structural
interventions to enforce condom use in the brothels
signi®cantly increased condom use and reduced STD
rates among commercial sex workers
(Rojanapithayokorn and Hanenberg, 1996). Sharing
the responsibility of HIV prevention with men and
creating structural level changes to enforce condom
use can help to remove the sole responsibility of pre-
vention from women whose ability may be limited by
threats of abuse. Similarly, the development of HIV
prevention methods for women, controlled by women,
such as vaginal microbicides should also be encour-
aged.
Domestic violence prevention programs
Finally, domestic violence programs o€er an oppor-
tunity to identify and counsel women who are high
risk for STDs and HIV. There are many examples of
successful community-based violence prevention strat-
egies from around the world including: education pro-
grams through schools and batterer programs in the
United States, women's police stations in Brazil, thea-
ter groups in Jamaica and promotion of the cultural
traditions of `compadres' to mediate arguments among
new couples in Ecuador to name a few (McKee, 1992;
Davis, 1994). Where these programs are already in
place, the opportunity to educate and counsel women
about HIV should not be overlooked. In addition, the
growing recognition that violence against women is
fuelling the AIDS epidemic has recently prompted
multi-lateral organizations such as UNAIDS to call
for a global commitment on the part of nations to
develop community-based programs that challenge
gender sterotyping, promote nonviolent con¯ict resol-
ution and enforce sanctions against men who batter
women (Gordon and Crehan, 1999).
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