Violence victimization and virologic failure among adolescents and young adults living with HIV in Zambia
Merrill, Katherine Gannett
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Background: Data are lacking on the prevalence and perpetrators of violence against adolescents and young adults (AYA) living with HIV in sub-Saharan Africa and how violence may relate to HIV outcomes. This dissertation used a sequential mixed-methods design to study the relationship between violence victimization and virologic failure among AYA in Ndola, Zambia. Methods: We analyzed baseline trial data from 272 AYA (15-24 years), consecutively sampled from four HIV clinics. We estimated the weighted prevalence and perpetrators of physical violence, psychological abuse, and forced sex. Using logistic regression, we derived associations between multiple forms of past-year violence victimization and viral load (VL) failure (≥1,000 copies/mL). In-depth interviews with 41 AYA with varied experiences of violence and VL were thematically coded. Results: Almost three-quarters of AYA experienced any past-year violence (72.0% male, 74.5% female); males experienced more violence than females from a friend/peer (74.3% vs. 45.1%, p<0.001), while females experienced more than males from a romantic partner (33.3% vs. 5.0%, p<0.001), parent/caregiver (32.4% vs. 17.6%, p<0.05), and stranger (19.7% vs. 5.2%, p<0.001). AYA with a high frequency of any violence (scores of 12-42) versus none (adjusted odds ratio, aOR: 3.58; 95%CI: 1.14-11.27) and a high frequency of psychological abuse (scores of 6-18) versus none (aOR: 3.32; 95%CI: 1.26-8.70) had greater odds of VL failure. Regarding perpetrators, we found any versus no violence from a family member other than a parent/caregiver for physical violence (aOR: 2.18, 95%CI: 1.05-4.54), and psychological abuse (aOR: 2.50; 95%CI: 1.37-4.54), as well as any versus no physical violence from a friend/peer (aOR: 2.14, 95%CI: 1.05-4.36), were associated with VL failure. Two-thirds of qualitative participants described negative effects of violence on their HIV self-management. Verbal abuse—especially in homes and schools—and sexual violence against females were particularly damaging. AYA described physical discipline as having few effects. Conclusions: Violence is related to VL failure and may be critical to address to improve AYA virologic outcomes. Prevention and response efforts are needed in HIV clinics, homes, schools, and communities to support AYA who experience a high frequency of violence, especially psychological abuse, and violence from family members and peers.