Optimizing the integration of gender-based violence screening and referral in HIV care settings

Abstract

Uganda faces a disproportionate burden of syndemic HIV and gender-based violence (GBV). There are national guidelines calling for implementation of strategies that concurrently address challenges of GBV and HIV (i.e., via GBV identification and referral for clients in HIV care settings); however, there is limited evidence outlining the extent to which this guidance is presently implemented in HIV care settings in Uganda. We aimed to generate evidence facilitating the transition from tested approaches to evidence-based interventions that concurrently address the GBV and HIV syndemic. Our first study leveraged secondary data from a cohort of serodifferent couples in Uganda to assess the relationship between intimate partner violence (IPV) exposure and PrEP or ART adherence among both members of the couple. Secondarily, we assessed the relationship between perceived relationship powerlessness and PrEP or ART adherence. We observed that, among partners living with HIV, recent IPV exposure was associated with lower ART adherence compared to those without recent IPV exposure. We did not observe this association for HIV-negative partners. Among HIV-negative partners, we found that those reporting low perceived relationship powerlessness were more likely to be PrEP adherent. We did not observe this association for partners living with HIV. Our second evaluation leveraged a mixed methods approach to assess providers’ implementation of GBV screening and referral in public ART clinics in Uganda. This assessment was guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance implementation evaluation framework. We found that most providers were trained to administer GBV screening to clients in ART clinics. Additionally, we found that screening supported the identification of GBV among ART clinic clients. In qualitative in-depth interviews with ART clinic providers and referral partners, socio-cultural norms and financial constraints were identified as threats to supporting clients who were struggling with interpersonal violence. Interview respondents recommended financial support to facilitate referrals and joint meetings to reinforce the referral network as potential strategies to address key threats to successfully support GBV-expose ART clinic clients. In our third evaluation we qualitatively assessed barriers and facilitators to providers offering GBV screening and referral to clients in ART clinics. This analysis was informed by the Theoretical Domains Implementation Science determinants framework. Our results from this evaluation revealed that socio-cultural factors (e.g., harmful gender norms and fear of judgment associated with being a GBV survivor) negatively influenced the provision of GBV screening and referral to clients seeking care in ART clinics. Providers’ negative expectations about referral partners’ ability to provide meaningful support to clients, financial burden associated with pursuing referral services and ineffective referral networks were also identified as barriers to referral.