Intimate partner violence among HIV index case testing clients in Malawi, a mixed-methods study

While its prevalence in sub-Saharan Africa is high, intimate partner violence (IPV) is rarely reported during routine index case testing (ICT) services in Malawi. We retrospectively explored the occurrence of IPV in a large, PEPFAR-supported HIV care and treatment program, among people with HIV (PWH) who had previously accessed ICT services. Between July-August 2022, we enrolled PWH aged ≥18 years, at 15 health facilities, who had received ICT services as new ART-initiators <6 months ago. We used a validated World Health Organization tool to measure IPV in domains of physical, sexual and emotional abuse, and controlling behaviors in the past 12 months. To understand reasons for IPV non-reporting, we randomly selected a sub-set of PWH who had experienced IPV and healthcare workers (HCWs) providing ICT services, for in-depth interviews (IDIs). We enrolled 149 PWH, 71.8% were female, 58.4% married, mean age 34 (IQR 25-40) years. Overall IPV prevalence was 71.1% (95%CI: 63.8%-78.5%), 76.6% (95%CI 68.5%-84.8%) among females and 57.1% (95%CI: 41.5%-72.8%) among males. Controlling behavior (65.7%) was the most common form of IPV, followed by physical (24.8%), emotional (33.6%), and sexual abuse (20.8%). Twenty-two percent related the IPV event to the HIV diagnosis. We analyzed 24 IDIs (15 PWH, 9 HCWs). Only two PWH (13.3%) had reported IPV to a HCW. Major barriers to reporting IPV for PWH were believing it is inappropriate discussing IPV with HCWs, concerns that discussing IPV would cause delays for others, and limited privacy. HCWs attributed IPV non-reporting to insufficient screening, high workload among ICT staff, negative HCW attitudes, and PWH's fear of unintended consequences of IPV reporting. IPV prevalence was high among PWH who had recently undergone ICT, but IPV is often not reported. Multiple barriers to IPV reporting must be addressed urgently, given IPV's adverse impact on HIV treatment and other health outcomes.