Women with HIV: gender violence and suicidal ideation.

OBJECTIVE: To analyze the relationship between gender violence and suicidal ideation in women with HIV.
METHODS: A cross-sectional study with 161 users of specialized HIV/AIDS care services. The study investigated the presence of gender violence through the Brazilian version of the World Health Organization Violence against Women instrument, and suicidal ideation through the Suicidal Ideation Questionnaire. Statistical analyses were performed with the SPSS software, using the Chi-square test and Poisson multiple regression model.
RESULTS: Eighty-two women with HIV reported suicidal ideation (50.0%), 78 (95.0%) of who had suffered gender violence. Age at first sexual intercourse < 15 years old, high number of children, poverty, living with HIV for long, and presence of violence were statistically associated with suicidal ideation. Women who suffered gender violence showed 5.7 times more risk of manifesting suicidal ideation.
CONCLUSIONS: Women with HIV showed a high prevalence to gender violence and suicidal ideation. Understanding the relationship between these two grievances may contribute to the comprehensive care of these women and implementation of actions to prevent violence and suicide.

INTRODUCTION

AIDS is a significant public health problem, which has increased among the female population in recent years. There are 16 million women with HIV in the world, with the majority living in poor countries. Of the total, 76.0% cases are concentrated in Africa, although there is also a high prevalence in some Asian and Caribbean countries. In Brazil, the epidemic has undergone a process of feminization and the male ratio decreased from 26 to 1.5 men for every woman in the last 10 years.

Among factors associated with the feminization of AIDS is the biological and social vulnerability of women, resulting from an asymmetry of power between the sexes, determining women’s submission to men and the difficulty in practicing safe sex.

Women with HIV are more vulnerable to violence compared with those not infected with the virus, and one in seven infections could have been prevented if women had not been subjected to violence or unequal power in relationships. A Brazilian study estimated that 72.0% of women with HIV suffer gender violence, 63.0% is psychological violence, 52.0% physical violence, and 28.0% sexual violence and that physical and sexual violence, which generally coexist, corresponds to 56.0% of cases.

Violence has negative effects on the physical and mental health of women with HIV and their lifestyle, exposing them to discrimination, loss of financial and social resources, and conflicts in intimate relationships increasing suicide risk. , ,

The causes of suicide are diverse and can be the result of relational problems, chronic diseases, emotional distress, violence, unemployment, economic losses, and gender inequalities. Women with HIV have a high frequency of suicidal behavior due to the psychological, physical, and social effects resulting from infection or disease. Additionally, infected women reported a high incidence of gender violence, a poor quality of life, and fear of death. ,

In Brazil the incidence rate of female suicide is 7/100,000 among young adults and increases to 10/100,000 during midlife and old age. This rate is the average according to the WHO classification, with an upward trend in the 20 to 49 year old age group. These data indicate an aggravation of suicidal behavior in women, which historically had a low incidence rate in Western countries. As for suicidal ideation, the prevalence in Brazil does not differ from research conducted in Europe, the United States of America, and Australia, with estimates between 10.0% and 18.0%.

The presence of HIV and violence enhances the possibility of suicidal ideation and suicide in women, although the advent of antiretroviral therapy and the increased survival of people with HIV may have decreased this risk. To prevent self-destructive behaviors, it is necessary to identify the suicide risk in women with HIV who are victims of violence. Since there are few reports in literature describing this outcome, the present study aimed to examine the relationship between gender violence and suicidal ideation in women with HIV.

METHODS

A cross-sectional study conducted at an HIV/AIDS Serviço de Assistência Especializada (SAE – Specialized Care Service) in a medium-sized municipality of Rio Grande do Sul, Brazil. The choice of location considered the high rates of AIDS and the process of the epidemic’s feminization. The municipality is placed seventh for the number of AIDS cases among Brazilian cities with more than 50,000 inhabitants.

The sample size was calculated estimating a confidence level of 95%, with a margin of error of 3.0%, the presence of 200 women enrolled in the service and an estimated prevalence of 50.0% for violence and suicidal ideation. The sample size stipulated was 136 women; information was collected for all women who visited the service during the study period. Thus, 161 users were interviewed, corresponding to 80.5% of the total; 39 women (19.5%) did not visit the service during the data collection period and were not part of the study.

A questionnaire was employed for individual interviews, with questions about sociodemographic characteristics (age, marital status, ethnicity, education, religion, per capita household income, and number of children), sexual and reproductive characteristics (age at first sexual intercourse, affective-sexual partner, condom use, and children with HIV) and clinical characteristics (time since HIV diagnosis, antiretroviral treatment, and opportunistic infections), as well as the presence of gender violence and suicidal ideation.

To evaluate the prevalence and types of gender violence, 13 questions were extracted from the Brazilian version of the World Health Organization Violence Against Women (WHO VAW) instrument and were used in an international multicenter study coordinated by the WHO, validated in Brazil by Schraiber et al. The instrument considers that each affirmative response corresponds to one point (+1) in the final score, although the presence of a single point already indicates the presence of violence.

Acts of psychological, physical, and sexual violence suffered at some point in life were considered. The most frequent type of violence was considered indicative of the overall prevalence of violence. Gender-based violence committed by an intimate partner or ex-partner, strangers, family members, acquaintances, friends, neighbors, or colleagues.

To identify the presence of suicidal ideation, the Questionário de Ideação Suicida (QIS – Suicide Ideation Questionnaire) was used; it is the Portuguese version of the Suicide Ideation Questionnaire adapted by Ferreira & Castela.

The QIS evaluates the frequency and severity of suicidal thoughts at some point in life, which range from mild to very severe. The instrument consists of 30 items on a Likert-type scale, and seven response alternatives are available for each question with their respective scores: (0) Never, (1) Almost Never, (2) Rarely, (3) Sometimes, (4) Frequently, (5) Almost Always, and (6) Always. Each question had a frequency level from 0 to 6, resulting in a total score between 0 and 180. A score ≤ 41 was considered indicative of suicide risk.

The SPSS program, version 20.0, was used to perform the statistical analyses. The dependent variable was suicidal ideation and the independent variables were: gender violence and sociodemographic, sexual, reproductive, and clinical characteristics of women with HIV. The associations between variables were evaluated by the Chi-square statistical test and by Poisson multiple regression, which estimated the adjusted prevalence ratios for suicidal ideation.

The prevalence ratios were estimated using the robust adjustment of variance. A confidence interval of 95% was estimated and a significant level of 0.05 was implemented. The independent variables that showed statistical significance in the Chi-square test were included in the regression model: violence, time since HIV infection, age at first sexual intercourse, number of children, and income.

The research protocol was approved by the Research Committee of the Universidade Federal do Rio Grande do Sul (Process 22,209 of 12/7/2011). All participants signed an informed consent and those at risk were referred for psychological services at the SAE.

RESULTS

The number of women with HIV interviewed was 161, and all were users of a specialized care service. The group was young, with 38.0% aged < 20 years. Most were single, white, catholic, had studied between 1 and 8 years, and had low income, receiving less than twice the minimum wage. Most were sexually active before the age of 15 years, did not have a partner or child infected with HIV, and had less than two children. Over half of the participants did not use condoms during sex (56.5%) and had been living with HIV for more than five years; 68.0% made use of antiretroviral therapy, and 67.0% had not developed opportunistic diseases.

There was a high prevalence of gender violence (72.0%), whose average score was 6.2 points on the WHO VAW instrument, on a scale from zero to 13. There was 50.0% suicidal ideation, with an average of 65.4 points on the QIS scale.

Table 1 presents the sociodemographic, sexual, reproductive, as well as clinical characteristics and violence according to the presence of suicidal ideation. Most of the women with suicidal ideation were young, unmarried, with little education and low income. The percentage of black women was 47.0%, when the average percentage of the black population in the studied area was 15.0%. They reported being sexually active before the age of 15, did not use condoms and had been living with HIV on average for 9 years. Low income (p = 0.003), high number of children (p < 0.001), first sexual intercourse before the age of 15 (p < 0.001), and greater amount of time living with HIV (p < 0.001) were factors associated with suicidal ideation. There was a high prevalence of gender violence among women who expressed suicidal thoughts (p < 0.001).

Table 1

Sociodemographic, sexual, reproductive, and clinical characteristics, and gender violence of women with HIV according to suicidal ideation. Rio Grande do Sul, Southern Brazil, 2013.

Variable/Suicidal ideation	Yes (N = 82)		No (N = 79)		p
	n	%	n	%
Sociodemographic characteristics
Age (years)					0.195
< 20	3	4.8	59	95.2
20 to 39	40	68.9	18	31.1
40 to 70	39	95.1	2	4.9
Marital status					0.376
Married	13	54.2	11	45.8
Single	31	55.3	25	44.7
Other	38	46.9	43	53.1
Ethnicity					0.766
White	44	53.6	38	46.4
Black	38	48.1	41	51.9
Years of study					0.735
None	10	43.5	13	56.5
1 to 8	59	51.8	55	48.2
9 to 11	13	54.2	11	45.8
Religion					0.525
Catholic	50	48.5	53	51.5
Evangelical	14	50.0	14	50.0
Other	18	60.0	12	40.0
Income (times the minimum wage)					0.003
≤ 2	75	54.7	62	45.3
> 2	7	29.2	17	70.8
Children					< 0.001
≤ 3	65	45.8	77	54.2
> 3	17	73.9	6	26.1
Sexual and reproductive characteristics
Age at first sexual intercourse (years)					< 0.001
≤ 15	58	71.6	23	28.4
> 15	24	30.0	56	70.0
Partner with HIV					0.992
Yes	29	50.9	28	49.1
No	53	51.0	51	49.0
Use of condom					0.455
Yes	38	54.3	32	45.7
No	44	48.4	47	51.6
Child with HIV					0.226
Yes	2	28.6	5	71.4
No	80	51.9	74	48.1
Clinical characteristics
Time with HIV (years)					< 0.001
≤ 5	19	25.7	55	74.3
> 5	63	72.1	24	27.9
Antiretroviral treatment					0.742
Yes	57	51.8	53	48.2
No	25	49.0	26	51.0
Opportunistic disease					0.998
Yes	27	50.9	26	49.1
No	55	50.9	53	49.1
Violence					< 0.001
Yes	78	66.7	39	33.3
No	4	9.1	40	90.9

Table 2 presents the prevalence rates of suicidal ideation according to the characteristics that remained in the final regression model: time living with HIV, age at first sexual intercourse, number of children, and violence. The variable income lost statistical significance, possibly because most of the sampled population had low income.

Table 2

Adjusted prevalence ratio of sociodemographic, sexual, reproductive, and clinical characteristics, and gender violence for suicidal ideation among women with HIV. Rio Grande do Sul, Southern Brazil, 2013.

Variable	RPadjusted	95%CI	p
Time with HIV (years)			0.018
≤ 5	1	–
> 5	2.66	1.10;2.74
Age at first sexual intercourse (years)			0.044
≤ 15	1	–
> 15	2.53	1.52;2.94
Children			0.012
≤ 3	1	–
> 3	2.16	1.14;2.75
Income (times the minimum wage)			0.286
> 2	1	–
≤ 2	1.20	0.74;1.31
Violence			< 0.001
No	1	–
Yes	5.70	1.83;17.67

Gender violence was strongly associated with suicidal ideation (p < 0.001), showing a higher prevalence ratio among the variables studied (RP = 5.70), i.e., women who suffered gender violence had a six times greater risk of manifesting suicidal ideation.

DISCUSSION

The women who expressed suicidal ideation were the poorest, reported their first sexual intercourse at a young age, had a high number of children, had lived longer with HIV, and reported a high prevalence of violence. The factors that were related to suicidal ideation in women living with the virus were: sexual initiation, number of children, amount of time living with HIV, and violence.

The high prevalence of gender violence and suicidal ideation confirmed the hypothesis of this study and other studies that found similar results. , , , , More than half of the respondents reported situations of violence and suicidal thoughts, although many did not identify the violence they experienced and denied suicidal thoughts, as this topic is still taboo in society. ,

The relationship between living with HIV, suffering violence, and thinking about suicide is the expression of multiple inequalities that affect the female population. The consequences of power inequalities between the sexes, which make women vulnerable and expose them to violence, contribute to the epidemic’s feminization, causing emotional distress and suicidal thoughts. ,

Suicidal ideation was more frequent in the group of women who experienced their first sexual intercourse before the age of 15 years. Age at first sexual intercourse is a gender marker, as sex often occurs without a young woman’s consent and may be sexual abuse. , ,

Society encourages the early sexualization of young women and leaves them more exposed to risks. Moreover, in consumer societies, where everything is merchandised, the bodies of poor girls are exchanged for clothes, amusement, and electronic equipment, a process stimulated by the media and networks of human traffickers. Thus, sexualization at a young age may be associated with sexual exploitation, non-consensual sex, and abuse, situations that have contributed to the feminization of the AIDS epidemic.

Another factor associated with suicidal ideation was a high number of children. In patriarchal societies, motherhood is a necessity for women. The desire to have a child cannot be separated from the social function, as it represents the idea of family ties, gives meaning to marriage, and ensures the place of women in the social sphere as wives and mothers.

When a woman realizes that she is infected with HIV during pregnancy, she must accept her diagnosis and deal with the possibility of transmitting the virus to the child. Suicidal ideation can emerge from the suffering experienced by getting the disease and the guilt of contaminating the child.

A higher frequency of suicidal ideation was also found among women who had the disease for a longer period. After the introduction of antiretrovirals, AIDS began to resemble other chronic diseases and people have lived for longer periods with the disease, requiring them to coexist with prejudice, discrimination, side effects of medication, and the restrictions imposed by the illness. ,

Despite the increase in life expectancy, living with HIV imposes social, professional, and affective constraints, difficulties in maintaining relationships and impasses in reproductive decisions. Even for people who adhere to the treatment, AIDS gradually worsens quality of life and the possibility of dying continues to be present in the social imaginary, causing the fact of living with HIV to become a situation of suffering, stress, and depression. Additionally, symptoms become more aggravated throughout the disease process, and feelings of despair, worthlessness, and thoughts of death intensify.

Although the income variable did not remain in the final model of the statistical analyses, it should be discussed. In this study, suicidal ideation occurred mainly among the poorest individuals, who had a household income of less than twice the minimum wage.

Over the last decade, there has been an increase in the incidence of AIDS among poor populations, where there are high rates of single-parent families headed by women earning low wages, who work in precarious conditions, indicating that poverty and gender are conditions that act unitedly and contribute to the disease’s feminization. , , The presence of poverty and gender, race and generational inequality constitute the current profile of the AIDS epidemic in Brazil, although the poor population should not be stigmatized or stereotyped because of the grievances they suffer.

In this study, the variable that presented the strongest association with suicidal ideation was violence. In this case, the two phenomena are modulated by the gender roles imposed and by the way that the respondents are socialized, which contribute to HIV infection, the outbreak of violence in these women’s lives (before or after infection), and finally with the death wish. , ,

We tried not to focus on suicidal ideation as a disease, understanding that mental suffering and suicide are socially produced and need not be pathologized. The literature shows an overestimation of the association between suicide and mental disorders; , , self-annihilation is considered a symptom of individual psychopathology rather than a social behavior, in which inequality and gender violence can be the most distal determinants. , ,

Femininities and masculinities molded in the patriarchal system, wherein men hold the power to control, have penalized women with regard to HIV, violence, and self-aggressive behavior. For the hierarchy between genders, self-annihilation can be perceived as the last strategy available to those with less power to influence the behavior of those with a greater share of power.

Submission to the social norms of gender is a part of life for women living with HIV, who express suicidal tendencies. This ideation is exacerbated in women subjected to violence, with a high number of children, who experienced their first sexual intercourse before the age of 15 years, and who have been ill for long. This finding corroborates the results of studies showing that women in contexts of inequality and oppression have high suicide rates. , ,

This study, despite the limitation of including only users from one SAE, has shown that among women who live with HIV, those who suffered gender violence have a higher frequency of suicidal ideation. It reinforces the importance of using the category of gender in epidemiological studies.