Characterising the effects of displacement on gender-based violence among women living with HIV in Ukraine: a cross-sectional study.

Introduction: Women living with HIV (WLHIV) in conflict zones are at high risk of sexual and physical violence due to instability, stigma and proximity to military personnel. Given sustained ongoing conflict, this study evaluated the relationship between displacement and gender-based violence (GBV), including experiences of sexual violence, abuse by healthcare workers and reproductive coercion among WLHIV in Ukraine. These forms of violence are conceptualised as severe forms of enacted stigma that are downstream outcomes of social, cultural and political norms, as well as social and structural stigmas related to misogyny and HIV.

Methods: Data were collected in Ukraine in 2020 as part of the People Living with HIV Stigma Index 2.0, led by 100% Life, the largest organisation for people living with HIV in Eastern Europe/Central Asia. WLHIV were recruited throughout Ukraine through limited chain referral and venue-based sampling. All participants completed a sociobehavioural questionnaire. Self-reported outcomes included sexual violence, violence in healthcare settings and reproductive coercion related to pregnancy, sterilisation and contraception. Displaced participants comprised WLHIV who were asylum seekers/refugees or internally displaced. Log binomial regression models estimated adjusted prevalence ratios (aPR) and 95% CIs for associations between displacement and GBV outcomes.

Results: A total of 1062 cisgender WLHIV completed the questionnaire, among whom 144 (13.6%) were displaced. Displaced WLHIV had higher proportions of lifetime experience using drugs (66.7% vs 22.0%, p=<0.01), selling sex (28.5% vs 12.2%, p=<0.01) and facing HIV-related stigma/discrimination (47.9% vs 34.4%, p=<0.01). Displaced WLHIV were significantly more likely to have experienced sexual violence (aPR: 2.74, 95% CI: 1.67 to 4.51), violence in healthcare (aPR: 2.57, 95% CI: 1.49 to 4.43), pregnancy coercion (aPR: 2.60, 95% CI: 1.41 to 4.78), sterilisation coercion (aPR: 4.26, 95% CI: 1.17 to 15.43) and contraception coercion (aPR: 2.48, 95% CI: 1.00 to 6.15) compared with non-displaced WLHIV.

Conclusion: As the war in Ukraine continues, humanitarian and health systems can use these findings to guide integration of GBV referrals and scale-up of trauma-informed care and antiexploitation training into Ukrainian programming. Moreover, additional surveillance methods, including community-led monitoring, can support routine documentation of experiences of coercion and abuse in healthcare settings. Broadly, transformative approaches are needed to tackle structural causes of gender inequality, HIV and violence.