Factors Contributing to Domestic Violence Among HIV-Discordant Couples in Kicukiro District, Rwanda

Domestic violence is a pervasive global public health and social challenge, profoundly affecting the well-being of millions, especially women ^{1, 2}. According to the World Health Organization, nearly one in three women worldwide experiences domestic violence, with significant variations driven by economic, cultural, and social contexts ³. In this study, domestic violence refers specifically to physical, sexual, psychological, and economic abuse occurring between intimate partners in marital or cohabiting relationships, significantly impacting physical and mental health, social stability, and economic productivity.

Domestic violence is particularly problematic in relationships affected by HIV, notably among sero-discordant couples’ partnerships ⁴, where one partner is HIV-positive and the other is HIV-negative. In such relationships, domestic violence risk is heightened by stigma, fear, mistrust, and economic pressures associated with HIV status disclosure and disease management ⁵. Domestic violence in these contexts not only harms individual well-being but also undermines adherence to antiretroviral therapy (ART) and increases HIV transmission risks ^{6, 7}.

While domestic violence among HIV-discordant couples is a concern globally, its prevalence and severity are more pronounced in low- and middle-income countries due to limited resources, pervasive HIV stigma, and socioeconomic hardships⁸. In sub-Saharan Africa, approximately 40% of women living with HIV experience domestic violence, often exacerbated by entrenched gender inequalities, economic vulnerability, and inadequate healthcare infrastructure ^{3, 7, 9}. For instance, studies from Uganda and Kenya indicate domestic violence prevalence rates between 35-45% among HIV-discordant couples, highlighting how traditional gender roles, economic pressures, and stigma significantly influence domestic violence occurrence^{4, 5}.

In Rwanda, significant strides have been made in addressing both HIV and domestic violence, yet challenges remain substantial, particularly among HIV-discordant couples. Nationally, approximately 12% of couples are HIV-discordant, with about 35% reporting experiences of domestic violence^{10, 11}. Contributing factors in Rwanda include persistent HIV stigma, gender inequality, and economic hardship, especially in rural settings^{10, 12}. Although national and community-level interventions have been implemented to address domestic violence and HIV stigma, targeted approaches addressing the specific vulnerabilities of HIV-discordant couples remain limited ¹³.

In Kicukiro District, Kigali City, approximately 6.5% of couples are HIV-discordant, with around 37% reporting domestic violence experiences ¹⁴. Stigma surrounding HIV, coupled with financial difficulties, insufficient support systems, and traditional gender norms, exacerbates vulnerability to domestic violence in this district^{15, 16}. The consequences of domestic violence are profound, adversely affecting family dynamics, HIV treatment adherence, mental health, and overall quality of life. While local initiatives such as counselling, stigma reduction programs, and economic empowerment are operational, there remains a critical need to understand the determinants of domestic violence specifically among HIV-discordant couples in this setting.

Thus, this study aims to bridge this knowledge gap by assessing the prevalence of domestic violence and identifying the socio-economic, behavioural, and contextual factors contributing to domestic violence among HIV-discordant couples in Kicukiro District. The findings of this research are expected to inform targeted interventions, policy formulation, and integrated support services, ultimately improving health outcomes and enhancing the resilience of affected populations.

This study revealed alarmingly high rates of domestic violence among HIV discordant couples in Kicukiro District, with 42.7% experiencing some form of abuse in the past year. While emotional abuse was most prevalent (52.3%), substantial proportions also experienced physical violence (41.1%) and sexual coercion (34.1%). These prevalence rates substantially exceed many national estimates and reflect the complex intersection of HIV-related challenges with broader socio-economic vulnerabilities.

The pronounced gender disparity, with women experiencing nearly twice the violence rate of men, reflects entrenched patriarchal norms and power imbalances common in sub-Saharan Africa^{5, 7}. This finding aligns with regional studies demonstrating women's heightened vulnerability in HIV discordant relationships, where HIV status may further compromise their position within relationships¹³.

The inverse relationship between education and violence suggests that education serves as a protective factor, potentially through enhanced self-advocacy skills, rights awareness, and economic opportunities¹⁷. Similarly, employment and financial security appeared protective, highlighting how economic dependency creates vulnerability to abuse. The finding that economic autonomy significantly reduces violence risk underscores the importance of financial empowerment in violence prevention^{8, 12}.

The progressive increase in violence prevalence with age may reflect cumulative relationship stressors, entrenched conflict patterns, or longer exposure to abusive dynamics. This contrasts with some studies showing higher violence among younger couples but aligns with research indicating persistent abuse in long-term relationships⁷.

The strong associations between substance use and domestic violence support established literature linking alcohol and drug use to impaired judgment and increased aggression¹⁸. The finding that conflict resolution methods strongly predicted violence outcomes underscores the critical importance of communication skills in relationship dynamics and the potential for intervention through couples counseling and communication training.

Partner jealousy and controlling behaviors emerged as powerful predictors, reflecting the role of coercive control in domestic violence. These psychological abuse patterns often escalate to physical violence and significantly impact mental health and autonomy ^{8, 19}. The finding that religious coping appeared protective requires careful interpretation, as religious frameworks may promote both conflict resolution and, in some contexts, tolerance of abuse.

The association between HIV disclosure and increased violence risk highlights a critical dilemma in HIV care. While disclosure is essential for treatment adherence and transmission prevention, it may expose individuals to blame, rejection, or retaliation¹⁸. This paradox underscores the need for comprehensive pre-disclosure counseling and partner preparation strategies.

Partner reactions to disclosure emerged as a crucial determinant, with hostile responses associated with doubled violence risk. This emphasizes the importance of couple-centered approaches to HIV counseling that prepare both partners for disclosure and promote supportive responses ¹³. The strong association between HIV-related stigma and violence reflects how internalized and enacted stigma create relationship stress and reduce empathy between partners.

Domestic violence among HIV discordant couples in Rwanda is driven by a complex interplay of socio-economic, behavioral, and HIV-related contextual factors. Women, economically dependent partners, and those experiencing stigma or hostile partner reactions to HIV disclosure face vulnerability. The high prevalence of violence across multiple domains underscores the urgent need for comprehensive, integrated interventions that simultaneously address HIV care and violence prevention.

Healthcare providers should incorporate routine domestic violence screening into HIV services, while policymakers must invest in economic empowerment, stigma reduction, and community education initiatives. Only through addressing the multiple intersecting vulnerabilities can we effectively reduce domestic violence and improve health outcomes for HIV discordant couples.

The cross-sectional design limits causal inference about relationships between risk factors and violence. Social desirability bias may have affected reporting of sensitive behaviors, potentially leading to underestimation of violence prevalence. The study focused on couples receiving care, potentially missing those avoiding services due to violence or other barriers. Future longitudinal studies are needed to establish temporal relationships and assess intervention effectiveness.

The authors thank the study participants and health facility staff who facilitated data collection.

ART - Antiretroviral therapy

DV - Domestic violence

HIV - Human immunodeficiency virus

RDHS - Rwanda Demographic Health Survey

SD - Standard deviation

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