Strategies to assist HIV positive women experiencing domestic violence in Nigeria
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E. E. Enwereji Ph. D.

Address correspondence to:
E. E. Enwereji Ph. D.
College of Medicine
Abia State University
Uturu, Abia State, Nigeria
Email: hersng@yahoo.com
Phone: 2348036045884
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Key words: domestic violence, partner notification, participation, strategies, Nigeria
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People living positively with HIV/AIDS (PLWHA) especially women are likely to face risks of being beaten, chastised and other violence. In Nigeria, the Demographic Health Survey (2003) states that only 24% of married teenage women ever discussed their HIV status with their husbands. HIV Counselors encourage partner notification to promote safer sex practices and reduce further infection [1]. But most times, PLWHA report domestic violence after disclosure [2,3,4].

Most health surveys targeted at PLWHA including [5] have primarily focused on effects of violence on HIV/AIDS with little or no effort to include PLWHA when planning interventions for them. Nigerian demographic health surveys are therefore designed to determine the prevalence of violence among PLWHA so as to enable policy plannersto plan effectively. Policy planners and programme operators of these surveys are of the view that knowing more about demographics of PLWHA would enable them to plan adequately for interventions to improve their life. These kinds of survey could be problematic in that they aim to isolate social determinants of violence and cut-off levels without involving inputs from PLWHA who experience violence. Moreover, most of these surveys have been house-to-house. They could be expensive, time consuming, and may result in poor services and/or sustainability. These kinds of surveys have been reported as counterproductive especially when services are not followed up [6].

Study involved PLWHA in initiating feasible interventions to reduce domestic violence against them using participatory reservation approach (PRA). PRA framework as used in the study provoked PLWHA participation. PRA is an important approach derived from agricultural surveys that have potentials for more effective sustainability [6]. PRA involves using affected people as active analysts of their own situation and to set priorities on how to change their situations.

PRA has a defined methodology and systematic learning process that stresses changes in behaviour and attitude of individuals through group inquiry and interaction. It is an important tool for planning, and evaluating health programmes as well as for identifying support in service delivery and gaining access to potential influences to community change [7,8]. This framework was used because it recognized views of PLWHA and empowered them to have a sense of ownership to suggested intervention processes. It also enabled the author to gather information from PLWHA with participatory method procedures.

In Nigeria, social perceptions of domestic violence are viewed in context of cultural practices and beliefs in communities. Some communities see domestic violence as an incurable disease [9] while others see it as social problem influenced by religion, socio-economic status, and educational background [10]. These cultural beliefs and perceptions affect how PLWHA are treated as well as socially accepted in society. Negative attitudes of society toward HIV infection influence acceptance of PLWHA [11] and this gives rise to stigmatization of PLWHA [12,13].

Therefore determining how PLWHA with different cultural backgrounds perceive domestic violence could be a good indicator in assessing effectiveness of PRA in planning interventions to minimize violence.

• To use PRA to assist PLWHA identify strategies to minimize domestic violence against them.
  
• To note conditions that encourage PLWHA disclosure of their HIV status.
  
• To identify factors that influence domestic violence against PLWHA
  

Study used qualitative research method. This method helped to access PLWHA perceptions of domestic violence thereby facilitates their participation. Focus group discussions were used to explore views of each PLWHA on relevant interventions. Methodology in using the PRA framework is to initiate interventions that would transform society's negative attitudes and behaviour against PLWHA so as to attract changes that PLWHA in the situation would regard as improvement.
The researcher is of the view that interventions suggested by PLWHA using PRA would create more impact than others. The role of author in this study was to assist PLWHA to achieve the desired change using the interventions they suggested.

Study population:
Study was conducted with a total sample of 96 PLWHA in a network of PLWHA. The sample consisted of (56 females and 40 males) between the ages of 22-65 years.
Network of PLWHA was used because of the difficultly in identifying PLWHA in society. People are not willing to disclose names and addresses of PLWHA and PLWHA themselves are not disposed to disclose their sero-status. Moreover, the network is made up of PLWHA whose sero-statuses are already known.

Men were included in the study because they were thought to have valuable experiences and understanding that would enable them to suggest practical strategies for reaching other men in society. It was also to note the extent to which male PLWHA also experience violence.

Ethical considerations:
Permission to conduct the study was obtained from the President of the network of PLWHA in the State. His approval enabled the researcher to collect information from participants. Instruments used for study did not request the participants to write their names or anything to identify them. In addition, statements of confidentiality were given. Participants were given briefs on objectives of the study. Permission to tape-record the session was made and guaranteed.

Data collection:
Two methods of data collection, focus group discussion and interview guides were used. Interview guide was administered for illiterates and self-administered for literates. In all, 10 focus group discussions were conducted. Each focus group had 9-10 PLWHA.

Focus group discussions were conducted through a trained moderator. All discussions were conducted in the local language to enable participants, even illiterates, to take active part in discussions. All discussions were tape-recorded. Participants were encouraged to talk freely among themselves. PLWHA were invited through their President to their regular meeting place. Open-ended and closed-ended questions characterized the format of the instruments.

Focus group discussions were recorded, transcribed, and translated. Transcript notes were read and cross-checked. Recording equipment used was checked regularly to determine its reliability. Data were coded according to themes, and categorized. Analyses of data were manually done using qualitative and quantitative methods with simple percentages. For clarity, all related information was pooled together and reported.

Demographic variables of the sample:
The age distribution of the PLWHA varied. More than half, 49(51%) of the sample were between the ages of 29-42 years (see Table 1). Findings on the marital status of the sample show that a good number of them, 49(51%) are married. (See Table 2).

Perceptions of domestic violence:
Domestic violence was perceived by PLWHA from three viewpoints; as physical, emotional and social problems. Finding shows that most PLWHA perceived domestic violence from the viewpoints of their experiences. However, during the focus group discussion, PLWHA from the rural areas could not see rape and/or extramarital sexual relationships as serious violence against them unlike those from the urban areas. In this study, participants saw domestic violence as a functional breakdown rather than by related causes. Table 3 contains various perceptions of domestic violence.

Identified PLWHA with domestic violence:
One unique finding in this study is that both male and female PLWHA experienced domestic violence. A total of 65(67.7%) PLWHA experienced violence ranging from chastisement, flogging, beating, discrimination, use of abusive words, to attempted murder, but this was more on those who disclosed their sero-status than others. The finding shows that the main challenges PLWHA faced include whether or not to disclose their HIV status, who to disclose to, and if they eventually disclose, what the consequences would be. Out of 96 PLWHA studied, 35(36.5%) of them disclosed their sero-status to close relations and friends. Using the report of one PLWHA, "when my church pastor learned of my HIV status, he excluded me from church activities especially holy communion and he told other church members about my status and since then, I have never attended church functions."

Another crucial finding in the study was the confusion of the PLWHA on whether or not to get married. The result of the focus group discussion showed that a good number of the PLWHA, especially the singles had the zeal of getting married and raising their own families.

Factors and/or conditions that increased violence:
PLWHA identified five factors and/or conditions that encouraged violence. Table 4 contains the details.

Among the factors listed by PLWHA, negotiation for condom use was the commonest cause of violence against them. Using reports of five PLWHA, "once the issue of using a condom for sex is raised, there would be suspicion that the person has been going out with others. And from that time onwards, there will be no more peace." One important finding in this study is that both male and female gave this report, showing that violence occasioned by use of condom cuts across all sexes of PLWHA.

Another factor that influenced violence was demanding of financial assistance . Using the reports of three PLWHA, "there will be peace as long as one does not demand for money either for food or for drugs." Regrettably, a good number of the PLWHA complained of no meaningful means of livelihood and the few that had jobs reported setbacks in their respective businesses as a result of constant episodes of ill health.

Suggestions on strategies to reduce domestic violence:
There was an overwhelming desire on the part of PLWHA to suggest things that could discourage domestic violence. To express this desire, a good number of the PLWHA freely made suggestions, and justified the reasons why each suggested strategy is considered realistic and important for reducing domestic violence. This justification is considered strength to the study. Table 5 contains the summary of the suggested interventions.

From this Table, encouraging financial independence and organizing theater programs in markets, churches and other public places were the popular strategies suggested. PLWHA stressed that providing them with job opportunities would increase their income generating potentials thereby reduce over dependence on others, thereby reduce unnecessary use of uncomplimentary words on them by relations. Further, PLWHA explained that theater plays would be beneficial if the programmes concentrate on information on gender sensitivity, skills for anger management, and decision-making. According to them, the essence of the strategy is to reach individuals of various classes in the society.

PLWHA's suggestion on the need to use male peer groups to sensitize the communities was aimed at encouraging gender equity as well as creating situations that would enable females to express their problems openly. The idea PLWHA gave for advocating use of influential adults to organize workshops/seminars in communities is to enable influential adults to sensitize individuals on the effects of violence on HIV infection. These suggestions point towards practical ways and opportunities PLWHA perceived would reduce domestic violence.

The study shows that PRA is useful in identifying PLWHA with domestic violence. However, there were discrepancies on what constituted domestic violence. While PLWHA from urban areas viewed rape and extramarital sex as domestic violence, PLWHA from rural areas did not. They saw extramarital sexual relationships as men's way of life. From perspectives of social, physical, and emotional problems, PLWHA viewed domestic violence in terms of restricted activity and participation in social functions. This finding agrees with that of [4,5] that stigmatization and rejection dominated life experiences of PLWHA, and that they view their life along this way. This implies that stigmatization (restrictiveness) is a major concern of PLWHA, especially females.

Surprisingly, male PLWHA who are traditionally major decision makers, also experienced domestic violence like females. This finding suggests that social welfare of these males like that of females is neglected. However, the fact that both sexes experienced violence is a significant finding. This finding underlies challenges that each sex had .

Two popular strategies dominated suggestions of PLWHA. These are providing job opportunities to encourage financial independence 69(71.8%), and organizing theatre plays in public places 54(56.3%). These suggestions reflected challenges PLWHA encountered in their life experiences.

One unique benefit of this study is that PRA encouraged consensus among PLWHA. It ensured cohesiveness and flow of quality information. Similar findings were reflected in the study of [14].

The time span for this study was limited. There was no time allotted for evaluating and monitoring the outcome of all interventions suggested. However, it could be noted that using PRA approach proved fast and inexpensive way of identifying practical activities for reducing domestic violence against PLWHA. The speedy nature of identifying problems using PRA was also highlighted in the studies by (1, 6, 14). It could be argued that using PRA in this study served as an educational intervention method. PRA enabled PLWHA to have a better understanding of interventions that are capable of minimizing violence as well as their roles in the sustainability of interventions suggested.
Study showed that 36.5% of PLWHA disclosed their HIV status. This figure is higher than that of 24% found in Nigeria by [5]. This increase in proportion of PLWHA who disclosed their sero-status is of advantage to HIV prevention and could be partly due to the increased number of people who are recently joining the network of PLWHA where they attract care and support from each other.

The commonest factor that encouraged domestic violence among PLWHA was negotiation for condom use. Negotiation for condom use occasioned suspicion for sexual promiscuity. This finding is disturbing because of negative reactions that followed the word 'condom' among \ participants. Participants complained of experiencing violence on mere mention of condom use. This \ attitude might have partly stemmed from traditional belief that condom use is synonymous with sexual immorality. This could be partly why a good number of PLWHA took risks of having sex without a condom. The finding that negotiation for condom use encouraged violence agrees with the findings of [4].

The fact that PLWHA lacked financial support shows the extent to which relations and others provide care and support. Expecting PLWHA with no meaningful means of livelihood to support self and other \ dependents, is arguably domestic violence. This trend of argument is in line with that of [3,11],that abandonment falls under the ambit of domestic violence.

Instigating violence against PLWHA just because of spells of ill-health would further expose them to untold hardship. The best approach to improve health of PLWHA is to provide them with good nutrition and also make treatment facilities accessible and affordable.

From types of domestic problems PLWHA encountered, and interventions they suggested, it could be safe to assume that they were exposed to traumatic situations.

Including theatre plays in public places among strategies to reduce violence had some advantages. Theatre plays are broad-based with some feasible psychological undertone (debriefing), needed in conflict management. It may not be an illusion to state that theatre plays promoted coherence in PLWHA social interactions.

Findings point to clear need for counseling and health education which would emphasize benefits of conflict management, condom use, and disclosure of HIV status.

To ensure community involvement and sustainability of the programme, the suggested strategies should be integrated into the primary health care system.

This work is self-sponsored. The corresponding author bore all financial implications of this work. She conceived the ideas, carried out the survey, data collection, collation, analysis and report writing.

This manuscript was presented during an international conference on reproductive health and HIV/AIDS organized by the association of reproductive health rights at the 2nd African conference on sexual health and rights held in Nairobi Kenya from 19th -21st June 2006. The paper has not been submitted in part or in full to any other journal for publication.

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