Prevention of vertical transmission of HIV among pregnant and breastfeeding women in sub-Saharan Africa: the impact of violence against women

Women living with HIV (WLH) face challenges in antiretroviral therapy (ART) adherence and viral suppression despite progress in the prevention of vertical transmission of HIV in sub-Saharan Africa. Existing evidence suggests violence against women, including intimate partner violence (IPV), has a negative impact on HIV care and treatment for pregnant and breastfeeding WLH, but is understudied. The overall aim of this thesis is to understand the impact of violence against women on women’s HIV care and treatment during pregnancy and breastfeeding for the prevention of vertical transmission in sub-Saharan Africa. Population-based, quantitative data pooled from multiple sub-Saharan African countries is used to investigate the: 1) risk factors, including violence against women, for unsuppressed viral load, and 2) association between violence against women and ART adherence. Qualitative interview data from South Africa and Kenya is used to explore the nature of IPV, and mechanisms linking IPV and suboptimal HIV care and treatment. Results from quantitative analyses shows the prevalence of viral suppression among pregnant and breastfeeding WLH is suboptimal and relationship dynamics around partner nondisclosure is an important risk factor for unsuppressed viral load. Among reproductive age women, sexual violence against women is associated with suboptimal ART adherence, with a greater effect among pregnant and breastfeeding WLH. Qualitative data shows pregnant and postpartum women experience multiple types of IPV, including psychological and financial. Women described multiple ways in which IPV impacts HIV care including through poor mental health and access to money and food, ART sabotage and partner control, migration after physical IPV, and partner nondisclosure. These findings suggest violence against women has a negative impact on perinatal women’s HIV care and treatment. To improve maternal health for WLH and end vertical transmission of HIV, efforts to end violence against women including IPV, should be prioritized in policy, programming, and healthcare.