Abstract
We examined the prevalence of intimate partner violence (IPV) perpetration and characteristics of HIV-infected male perpetrators. The cross-sectional study was conducted in Vietnam with male antiretroviral treatment clients (N = 1099; mean age = 40.2 years). Bivariable associations were tested between psychological or physical/sexual IPV perpetration in the last 12 months and sociodemographic, psychosocial, and sexual behavioral factors using prevalence ratios. Factors significant at p < 0.10 were entered in multivariable models for each IPV outcome using a modified Poisson approach. Results showed 15.6% (N = 171/1099) reported perpetrating psychological IPV and 7.6% (N = 84/1099) perpetrating physical/sexual IPV in the last 12 months. HIV risk behaviors, including hazardous drinking and multiple sexual partners, having witnessed interparental violence as a child, and depressive symptoms were associated with perpetrating IPV. HIV interventions targeting HIV-infected men in Vietnam should intervene on IPV perpetration by addressing the co-occurring factors of sexual risk, depression, alcohol use, and child maltreatment that are correlated with IPV.
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Introduction
Intimate partner violence (IPV) is an urgent global health problem. Approximately 30% of women have ever experienced IPV globally, and the prevalence of experiencing IPV in Southeast Asia is one of the highest in the world (38%) [1]. Studies have found the prevalence of IPV perpetration among men ranges from 25 to 50% across various global regions [2,3,4], with the prevalence ranging from 25 to 80% in Asia and the Pacific [5]. Experiencing IPV can have direct consequences of physical injury and death or indirect consequences, such as substance use and depression [6, 7].
IPV is a major public health issue in Vietnam. A national study found that over half (58%) of married women reported ever experiencing IPV by their husbands, and of these women about a third (34%) reported experiencing physical and/or sexual violence [8]. Thirty-seven percent of men reported having ever perpetrated IPV against their wife [9]. IPV perpetration is largely understudied in Vietnam, especially among unmarried men.
Although research on perpetrators of IPV is limited [5], theoretical and empirical evidence offers insight into potential correlates of IPV perpetration among men in Vietnam. Studies have found that exposure to child maltreatment, including witnessing interparental violence [5, 9,10,11], harmful use of alcohol and illicit drugs [5, 10,11,12,13,14,15,16,17,18,19], depression [5, 10], gender-equitable attitudes [5], attitudes towards IPV [20, 21], and engagement in violence outside the home, including gang involvement and fighting with other men [5, 10, 11], increases the risk of IPV perpetration among men. Bandura’s social cognitive theory has been commonly applied to IPV perpetration research [22, 23]. The theory suggests that individuals who are exposed to violence in the household and/or in their neighborhood as a child develop normative beliefs around the use of IPV [5, 21, 24]. For example, these individuals may feel that violence is an appropriate way to resolve conflict with a partner. As a result, they are then more likely to perpetrate IPV as an adult [5, 21, 24].
IPV perpetration is associated with HIV infection [25,26,27]. One study in South Africa found that young men who perpetrated physical IPV were over two times as likely to be HIV-infected as compared to those who had not [25]. Two studies in the United States found a significant association between IPV perpetration and STI/HIV among men [26, 27]. The link between IPV perpetration and HIV is understudied in Asia, although studies in India and Bangladesh found an association between STI or STI symptoms and IPV perpetration [28, 29]. The relationship between IPV perpetration and HIV among men may be explained by the co-occurrence of IPV perpetration with other forms of HIV risk behavior, such as multiple sexual partners, unprotected sex, and transactional sex [26, 27, 30, 31]. This pattern of behavior may be shaped by gender inequality and sociocultural norms dictating that men should demonstrate their masculinity by controlling women and being sexually promiscuous [26, 32,33,34].
The strong link between IPV and HIV underscores the need to incorporate IPV prevention into HIV prevention efforts [35]. However, most HIV and IPV prevention interventions have engaged women at risk for both HIV and IPV and observed mixed results for HIV and IPV outcomes [35]. Intervention strategies have included community mobilization [36, 37], microfinance programs for women [38], and educational sessions for women, men, or couples [39, 40]. Future interventions should build on the successes of these interventions, but aim to better engage men to achieve large-scale, sustained improvements in IPV and HIV prevention [35, 41, 42]. To develop effective IPV prevention interventions to incorporate into HIV prevention efforts, research on the prevalence and drivers of IPV perpetration among men at high risk for IPV perpetration and HIV is needed.
There is limited research on IPV perpetration among men living with HIV. Men living with HIV are an important group to study because of their high risk for IPV perpetration and HIV transmission to uninfected sexual partners. Studies demonstrate an elevated prevalence of hazardous alcohol use and depression among men living with HIV [43,44,45], both of which are known correlates of IPV perpetration [5, 10, 11] and other HIV transmission risk factors, such as poor antiretroviral treatment (ART) adherence [46,47,48,49] and/or inconsistent condom use [31, 50].
In this study, we aimed to examine the prevalence and correlates of IPV perpetration overall and by marital status among men living with HIV in Vietnam. Potential correlates were selected based on empirical and theoretical evidence with men in the broader population; they include sociodemographic characteristics, psychosocial factors, and sexual behavior [5, 10, 11, 22, 34, 51,52,53]. We identified correlates of both psychological IPV perpetration and physical and/or sexual IPV perpetration. While the health consequences of experiencing psychological, physical, or sexual IPV are similar [7, 54,55,56], studies have demonstrated that risk factors may differ by type of IPV perpetration [5]. Further, we conducted sensitivity analyses stratified by marital status to explore whether characteristics of IPV perpetrators differed between those who are married or living with a partner and those who are not. Stratified analyses were conducted as IPV perpetration among unmarried men is understudied in this setting, and IPV prevalence and dynamics are known to differ by relationship status [57, 58]. Study findings will improve understanding on the extent of the problem in a group at high risk for IPV perpetration and forward HIV transmission and may help inform IPV prevention interventions targeting men living with HIV in Vietnam and other global settings.
Methods
This study is a secondary analysis of a cross-sectional study conducted in Thai Nguyen, a semi-urban province in northern Vietnam located approximately 75 km north of Hanoi with a population of 1 million. This paper presents data from a baseline questionnaire that was administered to all participants who were screened for eligibility in a randomized controlled trial (RCT), including those who were later deemed ineligible for enrollment. Individuals were approached for recruitment for an RCT evaluating the effects of two alcohol reduction interventions on alcohol use and viral load among men with HIV and hazardous alcohol use [59].
Recruitment and Data Collection
Individuals were recruited from all seven ART community clinics in Thai Nguyen. All recruitment was exhausted in one clinic, meaning no new ART clients were available for recruitment, before moving on to recruit participants from the next clinic. Clinics were approached for recruitment in a random order. After introducing the project, researchers obtained written informed consent to participate in the baseline questionnaire. Eligibility criteria for participating in the baseline questionnaire included: (1) current ART client at one of the recruitment clinics; (2) interested in participating; and (3) 18 years of age or older.
Trained interviewers administered questionnaires through face-to-face interviews in a private room at an ART clinic. The questionnaire collected data on sociodemographics, HIV medical and treatment history, substance use, sexual behavior, mental health, and violence. For this secondary analysis, the only additional eligibility criterion was that participants who completed the baseline questionnaire identified as male, regardless of sex at birth.
The study protocol received ethical approval from the Institutional Review Boards at the University of North Carolina-Chapel Hill and Thai Nguyen Center for Preventive Medicine.
Key Measures
Psychological, physical, and sexual IPV perpetration in the last 12 months was measured with the six-item shortened Conflict Tactics Scale 2 (CTS2) [60]. The CTS2 has been validated [60] and used with high reliability in Asia, including in Vietnam [61, 62]. All participants were asked to respond to the CTS2 items and to consider any current or previous partner when answering the questions. Psychological IPV perpetration was measured using two items (i.e., I insulted or swore or shouted or yelled at my partner); physical IPV perpetration was measured using two items (i.e., I pushed, shoved, or slapped my partner); and sexual IPV perpetration was measured using two items (i.e., I insisted on sex when my partner did not want to or insisted on sex without a condom (but did not use physical force)). Response options included: “More than once in the past year”, “Once in the past year", “Not in the past year, but it did happen before”, or “This has never happened.” For each item measuring psychological, physical, or sexual IPV perpetration, responses were dichotomized to those who reported IPV perpetration at least once in the past year and those who did not. Those who refused to answer or didn’t know the answer were marked as missing. Two binary outcome variables were created using the six-item CTS2: psychological IPV perpetration in the past 12 months; and physical and/or sexual IPV perpetration in the past 12 months. The combined physical and/or sexual IPV perpetration outcome variable was used as the characteristics for both types of IPV are similar in the literature [63]; as a result, it is a commonly used outcome in IPV research, making our findings comparable across similar studies. The physical and/or sexual IPV perpetration variable was also created as the prevalence estimates of physical IPV perpetration in the last 12 months (N = 41, 3.7%) and sexual IPV perpetration in the last 12 months (N = 49, 4.5%) were small, resulting in large confidence intervals for effect estimates.
Psychosocial variables were measured using widely used and validated items or scales; cut-off points for scales were determined based on previous research using the scales in global settings, including in Vietnam [64,65,66,67,68,69,70,71,72]. Alcohol use was measured using the 10-item alcohol use disorders identification test (AUDIT; Cronbach’s alpha = 0.87), and a composite score was calculated for each participant [64, 65]. Those who scored 8 or more were categorized as screening positive for hazardous alcohol use; those who scored 0 to 7 were categorized as screening negative for hazardous alcohol use [64, 65]. The 9-item patient health questionnaire-9 (PHQ-9) scale was used to measure depressive symptoms (Cronbach’s alpha = 0.84), and a composite score was calculated for each participant [66,67,68]. Those who scored 10 or more were categorized as screening positive for severe depressive symptoms; those who scored 5 to 9 were categorized as screening positive for moderate depressive symptoms; and those who scored 0 to 4 were categorized as screening negative for depressive symptoms [66, 67]. The 7-item Generalized Anxiety Disorder (GAD-7) scale was used to measure anxiety symptoms (Cronbach’s alpha = 0.90), and a composite score was calculated for each participant [70, 72]. Those who scored 8 or more were categorized as screening positive for anxiety symptoms, and those who scored 0 to 7 were categorized as screening negative for anxiety symptoms [70, 72].
Attitudes towards IPV was measured using one item from the Gender-Equitable Men (GEM) scale: A woman should tolerate violence in order to keep her family together [73, 74]. Attitudes towards man-on-man violence was measured using one item from the Violence Approval scale: A man should not walk away from a physical fight with another man [75]. Both attitudinal items were scored on a four-point Likert scale from Strongly Disagree to Strongly Agree; responses were then dichotomized as having favorable or unfavorable attitudes towards violence. Witnessing interparental violence as a child [21] was measured using one item: When you were a child, did you ever see or hear your mother being hit by your father (or her husband or boyfriend)? Responses were categorized as having witnessed interparental violence as a child or not. Involvement in community violence was measured using two items from the Modified Aggression scale [76] that asked if they had ever experienced or perpetrated physical violence in the community. Response options included: “More than once in the past year”, “Once in the past year", “Not in the past year, but it did happen before”, or “This has never happened.” For each item, responses were dichotomized as reporting involvement in community violence at least once in the past year or not. Exploratory analyses showed that both perpetrating and experiencing community violence were positively associated with the IPV outcomes; both are also known risk factors for IPV perpetration [10, 11, 77, 78]. As a result, we created a composite variable for involvement in community violence.
The remaining potential correlates, including sexual behavior and sociodemographic variables, were also measured using self-report. All sexual behavior variables asked about HIV-related sexual risk behaviors in the last month, including having multiple female sexual partners (defined as having two or more female sexual partners or not), condom use with a main sexual partner (defined as always, sometimes, or never using a condom during sexual intercourse), involvement in transactional sex, and alcohol use prior to sexual intercourse.
Data Analysis
Descriptive and correlational statistical analyses were performed using SAS version 9.4. A total of 1559 participants enrolled in the study. Men with missing data on IPV outcomes (N = 12/1559), women (N = 438/1559), and those with missing data on gender (N = 10/1559) were removed from the analysis, resulting in a sample size of 1099 male participants. We report frequencies and percentages for categorical variables and means with standard deviation (SD) for continuous variables. We tested bivariable associations between the two IPV perpetration outcomes and potential risk factors using prevalence ratios (PRs) and 95% Confidence Intervals (CIs).
We built a multivariable model for each IPV outcome. Variables that were significantly associated with an IPV outcome at p < 0.10 in bivariable analyses were included in the outcome’s final multivariable model. Adjusted prevalence ratios (aPRs) and 95% CIs were calculated using a modified Poisson approach with robust error variances for all models [79].
Finally, as a sensitivity analysis, we stratified the bivariable and multivariable analyses by marital status. This allowed us to assess whether significant correlates differed for those who reported being married or living with a partner (N = 765) versus those who reported being single, widowed, divorced, or separated (N = 334).
Results
The sample comprised 1099 men living with HIV (Table 1). The mean age of participants was 40.2 years (SD = 6.1). Three quarters of the sample were employed full- or part-time (N = 828; 75.3%), and the majority were married or living with a partner (N = 765; 69.6%). Less than half screened positive for hazardous alcohol use (N = 507; 46.1%), and a quarter of participants screened positive for moderate (N = 207; 18.9%) or severe (N = 76; 6.9%) depressive symptoms. For attitudes towards violence, 17.7% (N = 194) reported favorable attitudes towards IPV, and 39.9% (N = 435) reported favorable attitudes towards man-on-man violence. Over a quarter of participants (N = 300; 27.4%) reported witnessing interparental violence as a child. The median duration of years since HIV diagnosis was 7.0 years (SD 4.0).
Over half of participants had ever perpetrated any form of IPV (N = 603; 54.9%), with psychological IPV perpetration (N = 517; 47.0%) more prevalent than physical and/or sexual IPV perpetration (N = 414; 37.7%; Table 2). Approximately 18.6% of participants had perpetrated any form of IPV in the last 12 months (N = 204). Psychological IPV perpetration in the last 12 months was over twice as prevalent (N = 171; 15.6%) as physical and/or sexual IPV perpetration in the last 12 months (N = 84; 7.6%). All IPV perpetration prevalence estimates were higher among those who reported being married or living with a partner versus those who reported being single, widowed, divorced, or separated.
Bivariable Analyses
Psychological IPV Perpetration
Of the sociodemographic variables, only marital status was significantly associated with psychological IPV perpetration in the last 12 months (Table 3). Individuals who were single (PR 0.17, 95% CI 0.08, 0.36, p < 0.0001) or widowed/divorced/separated (PR 0.29, 95% CI 0.15, 0.57, p = 0.0004) were less likely to perpetrate psychological IPV in the last 12 months compared to those who were married or living with a partner.
Hazardous drinking (PR 2.00, 95% CI 1.50, 2.67, p < 0.0001), having depressive symptoms (Moderate: PR 1.74, 95% CI 1.28, 2.38, p = 0.0005; Severe: PR 2.06, 95% CI 1.36, 3.13, p = 0.0007), having witnessed interparental violence as a child (PR 1.68, 95% CI 1.27, 2.22, p = 0.0003), and involvement in community violence in the last 12 months (PR 2.52, 95% CI 1.70, 3.74, p < 0.0001) were positively associated with psychological IPV perpetration in the last 12 months. The only sexual behavior variable significantly associated with psychological IPV perpetration in the last 12 months was alcohol use prior to sexual intercourse in the last month (PR 1.74, 95% CI 1.31, 2.31, p = 0.0001).
Physical and/or Sexual IPV Perpetration
Age and marital status were both significantly associated with physical and/or sexual IPV perpetration in the last 12 months. Younger men were more likely to perpetrate physical and/or sexual IPV compared to older men (t = 2.29, p = 0.02). Single men were less likely to perpetrate physical and/or sexual IPV compared to men that were married or living with a partner (PR 0.39, 95% CI 0.18, 0.84, p = 0.02).
Hazardous drinking (PR 1.63, 95% CI 1.08, 2.48, p = 0.02), injection drug use in the last three months (PR 1.53, 95% CI 1.01, 2.33, p = 0.04), depressive symptoms (Moderate: PR 2.19, 95% CI 1.37, 3.48; p = 0.001; Severe: PR 3.10, 95% CI 1.75, 5.48, p = 0.0001), anxiety symptoms (PR 3.44, 95% CI 1.87, 6.33, p = 0.0001), having witnessed interparental violence as a child (PR 3.14, 95% CI 2.08, 4.73), favorable attitudes towards IPV (PR = 2.00, 95% CI 1.29, 3.12, p = 0.002), and involvement in community violence in the last 12 months (PR 4.29, 95% CI 2.61, 7.05, p < 0.0001) were positively associated with physical and/or sexual IPV perpetration in the last 12 months. Of the sexual behavior variables, having multiple sexual partners in the last month (PR 3.01, 95% CI 1.84, 4.91, p < 0.0001) and alcohol use prior to sexual intercourse in the last month (PR 2.45, 95% CI 1.61, 3.75, p < 0.0001) were significantly associated with physical and/or sexual IPV perpetration in the last 12 months.
Multivariable Analyses
For the multivariable model for psychological IPV perpetration in the last 12 months, hazardous drinking (aPR 1.45, 95% CI 1.04, 2.02, p = 0.03), having witnessed interparental violence as a child (aPR 1.51, 95% CI 1.13, 2.02, p = 0.005), involvement in community violence in the last 12 months (aPR 1.76, 95% CI 1.20, 2.60, p = 0.004), and having depressive symptoms (Moderate: aPR 1.70, 95% CI 1.24, 2.32, p = 0.001; Severe: aPR 1.78, 95% CI 1.09, 2.90, p = 0.02) remained significant (Table 4).
For physical and/or sexual IPV perpetration in the last 12 months, having witnessed interparental violence as a child (aPR 2.29, 95% CI 1.45, 3.61, p = 0.0004), favorable attitudes towards IPV (aPR 1.70, 95% CI 1.06, 2.74, p = 0.03), having depressive symptoms (Moderate: aPR 1.71, 95% CI 1.07, 2.75, p = 0.03; Severe: aPR 2.70, 95% CI 1.50, 4.89, p = 0.001), having multiple sexual partners (aPR 2.15, 95% CI 1.26, 3.68, p = 0.005), and alcohol use prior to sexual intercourse in the last month (aPR 1.74, 95% CI 1.07, 2.82, p = 0.03) remained significant.
Sensitivity Analysis
When the bivariable and multivariable analyses were stratified by marital status, significant correlates for those who reported being married or living with a partner were largely similar to the analyses with the full sample (Table 5). The only difference was that the relationship between alcohol use prior to sexual intercourse and physical and/or sexual IPV in the last 12 months became non-significant (aPR 1.62, 95% CI 0.99, 2.62, p = 0.05).
In the multivariable analyses for those who reported being single, widowed, divorced, or separated, results differed substantially when compared to the analyses with the full sample. No factors were significantly associated with psychological IPV perpetration in the last 12 months (Table 6). Additionally, having witnessed interparental violence as a child (aPR 3.11, 95% CI 1.07, 8.99, p = 0.04) and alcohol use prior to sexual intercourse in the last month (aPR 3.59, 95% CI 1.15, 11.18, p = 0.03) were the only factors significantly associated with physical and/or sexual IPV perpetration in the last 12 months.
Discussion
To our knowledge, this is the first study to investigate the prevalence of and factors associated with IPV perpetration among a sample of men living with HIV. It was challenging to compare prevalence estimates across Vietnam studies as the measures often differed and no studies estimated prevalence among unmarried men [9, 21, 61]. In a regional study on IPV perpetration in Asia and the Pacific, the lifetime prevalence of physical and/or sexual IPV perpetration ranged from 25 to 80% [5]. The prevalence estimate found in our study was 38%. While IPV perpetration prevalence estimates were expectedly lower among those who were single, divorced, widowed, or separated, IPV perpetration remained prevalent. Future IPV research in Vietnam should include unmarried men to better understand the extent of the problem in this group.
Results showed that having multiple sexual partners, depressive symptoms, and hazardous drinking were significantly associated with IPV perpetration; all of these are also HIV transmission risk factors as they are associated with inconsistent condom use and/or poor ART adherence [5, 10, 11, 44, 47, 80,81,82,83]. The findings are consistent with research in Vietnam and other settings showing that HIV risk behaviors, including IPV perpetration, often co-occur among men, thereby increasing the risk of HIV infection and/or transmission [11, 26, 27, 30, 31]. This pattern of intersecting behavior demonstrates that men living with HIV are at heightened risk for forward HIV transmission, especially due to the elevated prevalence of depressive symptoms and hazardous drinking in this group [43,44,45]. While there are longitudinal studies establishing that alcohol use leads to IPV perpetration [84, 85], further research is needed to understand how these other HIV risk behaviors relate to IPV perpetration over time [86].
The associations between hazardous drinking, depressive symptoms, and sexual risk behavior with IPV perpetration demonstrate the importance of addressing co-occurring HIV risk behaviors through IPV prevention interventions for men living with HIV [26, 32,33,34, 42]. There is limited evidence of effective IPV prevention interventions targeting our study population. However, research with other high-risk groups, such as men with alcohol dependence, suggests that incorporating psychosocial counseling that addresses IPV perpetration, hazardous drinking, and depression into HIV care and treatment may help reduce IPV perpetration and other overlapping HIV transmission risk behaviors [15, 17, 87,88,89].
Our analyses demonstrated that significant correlates differed slightly by type of IPV and substantially by marital status. In the multivariable models for the full sample, having witnessed interparental violence as a child and having moderate or severe depressive symptoms were the shared significant factors for both IPV outcomes. Hazardous drinking and involvement in community violence were unique correlates for psychological IPV perpetration. Favorable attitudes towards IPV, having multiple sexual partners, and alcohol use prior to sexual intercourse were unique correlates for physical and/or sexual IPV perpetration. For the stratified analyses, the multivariable models for those who reported being married or living with a partner had the same significant correlates as the models with the full sample, with the exception that alcohol use prior to sexual intercourse was not significantly associated with physical and/or sexual IPV perpetration. The multivariable models for those who reported being single, widowed, divorced, or separated were different from the models with the full sample. In fact, no factors were significant in the psychological IPV perpetration model, and the only significant factors in the physical and/or sexual IPV perpetration model were having witnessed interparental violence as a child and alcohol use prior to sexual intercourse. These diverging results among those who are single, widowed, divorced, or separated may be due to the diversity of the sub-group.
Alcohol use-related variables, including hazardous drinking and alcohol use prior to sexual intercourse, were significant risk factors across multivariable models. This is consistent with previous Vietnam research with the broader population showing that husband's alcohol use is associated with women's experience of IPV [11]. Hazardous drinking was associated with psychological IPV perpetration in the multivariable model with the full sample. In the stratified analyses, however, hazardous drinking only remained significant in the model for those who reported being married or living with a partner. Qualitative research among women living with HIV in northern Vietnam suggests that male partners living with HIV often come home from a night of drinking and quarrel with or yell at their partners [13]. This finding is also supported by empirical and theoretical evidence showing that a pattern of problem drinking may lead to relationship conflict, which then leads to IPV [90,91,92]. Additionally, alcohol use prior to sexual intercourse was significantly associated with physical and/or sexual IPV perpetration in the multivariable model with the full sample. When results were stratified, the factor only remained statistically significant in the model for those who reported being single, widowed, divorced, or separated. This relationship may be explained by the immediate intoxication effects of alcohol consumption, such as lowered inhibitions or distorted perceptions of cues, which can lead to IPV perpetration [84, 85, 93]. These findings suggest that alcohol use may increase risk of both psychological and physical and/or sexual IPV perpetration among men living with HIV, though the pathways through which alcohol use leads to IPV perpetration may differ by type of IPV and relationship status.
Depressive symptoms and having witnessed interparental violence as a child were identified as important characteristics of men who perpetrate IPV. Exposure to interparental violence as a child is a well-documented risk factor for IPV perpetration, including in Vietnam [21, 52, 94,95,96]. Bandura’s social cognitive theory is often used to explain the relationship between exposure to violence as a child and IPV perpetration. Social cognitive theory posits that children who witness interparental violence develop accepting attitudes towards the use of IPV and later model the violent behavior as adults [22, 53]. However, other theorists assert that social cognitive theory does not adequately address the role of gender when explaining the intergenerational transmission of violence [97]. Vietnamese culture is influenced greatly by the philosophy and religion of Confucianism, which is characterized by patriarchy and gendered family roles [98,99,100]. As men are expected to be in control of their wife and family, violence may be a learned behavior used to maintain superiority [9, 98, 99]. In particular, men living with HIV may use violence because they feel they are losing authority due to HIV-related stigma and discrimination, loss of employment, or lack of social support [13, 101].
Notably, in our analysis, favorable attitudes towards IPV was only found to be significantly associated with physical and/or sexual IPV perpetration in bivariable and multivariable analyses. As other research in Vietnam does not examine psychological IPV perpetration as an outcome, we are not able to compare our findings to other studies [9, 21]. Favorable attitudes towards IPV may not have been associated with psychological IPV perpetration because it is highly normative, as evidenced by the particularly high prevalence estimates in our study. For men, being assertive and even aggressive is seen as necessary to maintain a superior position over their wife and family in Vietnam [98, 99]. Thus, participants who reported unfavorable attitudes towards IPV may not have understood the description of psychological IPV to be a form of violence. IPV prevention interventions in Vietnam may need to consider men’s nuanced views on different forms of IPV and how that may influence behavior change. These interventions may also need to address anger with emotion regulation or anger management training [102,103,104], especially as men living with HIV may experience feelings of anger or hostility due to their HIV infection [105]. Additionally, attitudes towards IPV was only measured using one item from a multi-item scale, suggesting that the variable may not have been accurately measured [73]. Utilizing the full, validated scale measuring gender-equitable attitudes may better capture the construct in future research [73].
The strong associations between having witnessed interparental violence as a child and IPV perpetration suggest that interventions for men living with HIV in Vietnam are needed to disrupt the intergenerational transmission of violence. There is limited research on child maltreatment interventions for men living with HIV. Integrating screenings for child maltreatment history into HIV care and treatment may be beneficial. Research with other populations suggests that offering psychosocial counseling on past traumatic experiences as part of alcohol treatment and other prevention programs for people living with HIV may be an effective approach to utilize [88, 106].
While the literature strongly supports the relationship between exposure to violence as a child and IPV perpetration, the relationship between depressive symptoms and IPV perpetration is not as well established, especially in Vietnam [5, 43, 107, 108]. Since mental health issues often manifest as internalized anger and may lead to self-control impairment, experiencing depressive symptoms may increase risk for aggressive behavior [102, 109,110,111]. Depression is common among men living with HIV [44]; one Vietnam study found that 44% of HIV-infected men who inject drugs reported severe depressive symptoms [43]. As men living with HIV face numerous psychosocial stressors, such as unemployment, lack of support, and stigma and discrimination, they are particularly vulnerable to developing depressive symptoms [44], which may increase their risk of IPV perpetration. Notably, depressive symptoms were not significantly associated with IPV outcomes in the multivariable models for those who reported being single, widowed, divorced, or separated. This suggests that individuals in stable, long-term relationships may face unique stressors that other individuals do not. Having a low-quality relationship defined by poor communication and conflict with a stable, long-term intimate partner may increase risk for depressive symptoms and IPV perpetration [102]. Prior findings suggest that intervening on depression may reduce IPV perpetration among men living with HIV who are married or living with a partner [104]. Future studies should measure anger and relationship quality to examine if these factors explain the depressive symptoms-IPV relationship.
Generalizability of our findings to men living with HIV across Vietnam is limited as participants were only recruited from one province in Vietnam. Participants were also recruited from ART clinics, demonstrating that the sample represents men living with HIV who are aware of their HIV status and are on ART. We are not able to conclude that all participants had female sexual partners or that all participants' main partners were female due to missing data (N = 415/1099). However, among the available data (N = 684/1099), all participants reported having female sexual partners and/or female main partners, including two participants who reported having both female and male sexual partners in the last month. Further, as cross-sectional research cannot establish temporality, longitudinal research is needed to determine the direction of causality between factors and IPV perpetration over time. However, IPV perpetration is understudied globally, especially among men living with HIV, and this study provides valuable insights that will guide future research and intervention development.
As all variables were measured using self-report, responses may have been biased due to social desirability, leading to more conservative estimates of IPV perpetration. Additionally, as IPV research is limited in Vietnam, measures may not have accurately captured the dynamics of IPV in this context. Despite these limitations, the scale used to measure IPV perpetration, CTS2, is a reliable tool as it has been widely used in global settings, including in Vietnam [61].
Conclusions
Overall, our study underscores the need to incorporate IPV prevention activities into HIV interventions for men living with HIV. Our findings also suggest that IPV perpetration among men living with HIV does not occur in isolation and is influenced by co-occurring psychosocial and behavioral factors, such as sexual risk behavior, alcohol use, depression, and exposure to interparental violence as a child [112, 113]. Incorporating screening for IPV prevention, alcohol reduction, and mental health services into HIV care and treatment may address critical public health problems for men living with HIV and reduce HIV transmission risk [14, 15, 18, 44, 104, 114,115,116,117]. A multifaceted approach is needed to prevent IPV perpetration and forward HIV transmission among men living with HIV.
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Acknowledgments
This study was funded by the National Institute on Drug Abuse of the National Institutes of Health under grant R01 DA037440. This work was also supported by the University of North Carolina at Chapel Hill Center for AIDS Research (CFAR) under grant P30 AI050410 and the National Institute of Allergy and Infectious Diseases under grant T32-AI007001. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We would also like to thank the Thai Nguyen Center for Preventive Medicine for their support.
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Hershow, R.B., Ha, T.V., Sripaipan, T. et al. Perpetration of Intimate Partner Violence Among Men Living with HIV in Northern Vietnam. AIDS Behav 24, 2555–2571 (2020). https://doi.org/10.1007/s10461-020-02813-5
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DOI: https://doi.org/10.1007/s10461-020-02813-5