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Abstract

Little research exists on the human immunodeficiency virus (HIV)-intimate partner violence (IPV)-mental health (MH) syndemic impact on parenting. The objective of this scoping review is to identify and summarize the available evidence regarding the syndemic relationship between HIV or Acquired Immune Deficiency Syndrome (AIDS), IPV, and poor MH among mothers and caregivers who identify as women. We conducted the review according to the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and meta-analyses extension for scoping reviews guidelines, a comprehensive search was conducted from 2001 to September 2023. The inclusion criteria targeted studies examining at least two of the HIV, IPV, or MH epidemics among participants and their syndemic impact on parenting. Both qualitative and quantitative studies were included. Covidence software was used to screen and extract data. Twenty-three studies were included in the analysis. Most of the studies were conducted in the United States. Furthermore, all the studies used quantitative research designs, with most being longitudinal. Most of the research was concentrated on the IPV-MH syndemic with no research found on the HIV-IPV syndemic impact on parenting. Research on the HIV-IPV-MH syndemic found that an HIV diagnosis exacerbated the negative impacts of IPV-MH on parenting. Research on IPV-MH showed that this syndemic significantly influences parenting, leading to less nurturing and more punitive behaviors. Studies did not find a direct association between IPV and harsh parenting practices, the relationship was mediated by poor MH. Studies examining the HIV-MH syndemic found that anxiety and maternal depression were the most frequent MH disorders. The review revealed that living with the different syndemics, (IPV-MH-HIV, HIV-MH, and IPV-MH) adversely affects parenting practices, resulting in harsher parenting.

Keywords

syndemic HIV or AIDS intimate partner violence mental health parenting

Introduction

Human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) (hereafter referred to as HIV), intimate partner violence (IPV), and poor mental health (MH) are epidemics that influence the overall well-being and quality of life of women and in particular mothers and caregivers in a society (UNAIDS, 2023; World Health Organization [WHO], 2023).

The magnitude of maternal HIV, IPV, and MH globally, is extremely high with widespread impact on society and as a result can be categorized as epidemics. In terms of HIV, there is a plethora of research that has shown that HIV is an epidemic, with over 39 million people globally living with HIV in 2022 and over half of these being women and girls (UNAIDS, 2023; World Health Organization, 2023). Moreover, the widespread nature of IPV globally, and its significant health, social, and economic impact highlight the epidemic nature of the issue (Garcia Moreno et al., 2013). The WHO has defined violence against women as a problem of pandemic proportions, with statistics showing that globally one in three women have experienced either physical or sexual violence in their lifetime by an intimate partner (WHO, 2021). Furthermore, in South Africa, IPV has been ranked as the second highest burden of disease after HIV, contributing substantially to disability adjusted years especially among women (Norman et al., 2010), In terms of poor MH, according to the research, one in eight people are affected by MH disorders globally with anxiety and depressive disorders being the most common among both men and women (WHO, 2022). These epidemics especially when intersecting and co-occurring often lead to complex and long-term challenges for women, significantly affecting their lives and how they parent (Sherr et al., 2016; Suardi et al., 2020).

Women living with HIV often experience violence both in their homes and in healthcare settings which can hinder their ability to access and adhere to treatment. For women in violent relationships, the fear of violence often leads to nondisclosure of HIV status, increased anxiety, and lower adherence to treatment (Orza et al., 2017). In addition, stigma related to each of these epidemics remains high. Research conducted by HSRC in 2022 indicated that 15.4% of participants had experienced stigma related to their HIV-positive status often resulting in their exclusion from social activities (Cloet et al., 2022). The internalized stigma associated with IPV victimization, poor MH, and HIV affects women’s health seeking behaviors, including treatment access and adherence (Alemu et al., 2023; Orza et al., 2017) Poverty often restricts access to healthcare services such as HIV testing, treatment programs such as pre-exposure prophylaxis (Njue et al., 2011; Orza et al., 2017). In addition, poverty limits access to MH services which results in untreated mental and health conditions that worsen over time (South African National Department of Health, 2023). Furthermore, many women living with these epidemics face significant levels of institutionalized violence in primary healthcare settings. This institutionalized violence includes discrimination and mistreatment by healthcare providers which further discourages women from seeking necessary medical care. Studies have shown that women living with HIV often experience breaches of confidentiality, denial of services, and coercive practices within healthcare settings, particularly during the perinatal period (Bogart et al., 2013; Brown & Sprague, 2021; Famoroti et al., 2013; Mena Rosa, 2023; Pantelic et al., 2020).

Parenting is a multifaceted concept. Some researchers have described it as the provision of support, care, and love (Virasiri et al., 2011) and the shaping of a child’s attitudes, behavior, and emotional function (Pflieger & Vazsonyi, 2006). The current review adopts UNICEF’s broad definition of parenting, which encompasses the array of interactions and practices associated with childcare (UNICEF, 2019). Parenting includes both positive aspects, such as the provision of secure environments for the child and responsive caregiving (Maccoby, 1992) as well as harsh and inconsistent aspects, such as harsh discipline and physical aggression which often involves yelling, spanking, and strict or rigid enforcement of rules toward the child (Surjadi et al., 2013; Wang & Qi, 2017; Wang & Wang, 2018). Child abuse on the other hand is a series of acts by a caregiver, parent, or other adult that results in significant harm of the child, this can either be physical, sexual, or emotional. Child neglect involves failure of the child’s caregiver to provide for the child’s basic needs (WHO, 2002).

Child abuse represents a significant global public health issue (Stoltenborgh et al., 2013) with substantial numbers of adults reporting having suffered physical and emotional abuse or neglect during childhood (Stoltenborgh et al., 2013). The consequences of child abuse extend all the way to adulthood, with adults previously abused showing higher rates of poor MH than those who have not, especially depression, suicide attempts, and substance use disorder (Fergusson et al., 2013; Gilbert et al., 2009). Other issues include violence perpetration, increased risk of abuse victimization, high-risk sexual behaviors, and unintended pregnancy (Abbasi et al., 2014).

Studies focused on the interaction between HIV, IPV, and poor MH often use syndemic theory to analyze these relationships. According to the theory, the synergistic clustering of these conditions influences the health burden of a specific population more than the summation of the additional symptom (Singer, 1996). The theory emphasizes the structural and environmental factors such as poverty, unequal gender relations as well as stigma that often exacerbate the co-occurrence of these epidemics (Singer, 1996). Much of the current research on syndemics has focused on women in the United States (Illangasekare et al, 2013, 2011; Meyer et al., 2011) and on men who have sex with men with a focus on violence victimization and HIV risk (Chakrapani et al., 2019; Safren et al., 2018), and more recently among heterosexual men (Hatcher et al., 2022). Current literature tends to focus more on the microlevel factors because of the immediate and observable nature of these factors. However, this emphasis can lead to limited understanding of the broader structural influences, such as economic policies and social inequalities, potentially oversimplifying the complex interactions in syndemics (Pirrone et al., 2021). Pirrone et al. (2021) examined how context is conceptualized and studied in syndemic research, finding that context is often broadly defined, encompassing microlevel factors (e.g., living and working conditions) and macrolevel factors (e.g., political and economic conditions). Gizamba et al. (2023) further argue that understanding syndemics requires a comprehensive approach that includes micro-, meso-, and macrolevel factors. They highlight the importance of place-related contexts such as neighborhood level influences, and advocate for the integration of diverse analytical methods, including geospatial analysis, to capture the complex, multilevel interactions that shape health outcomes (Gizamba et al., 2023).

According to Singer’s original work, which was further elaborated on by Tsai & Burns (2015), a syndemic requires two criteria, first disease or social conditions must occur within a particular context as a result of harmful social conditions, a phenomenon referred to as disease concentration. Second, these diseases or social conditions must interact within populations and individuals in a way that mutually exacerbates adverse health outcomes, known as disease interaction (Singer, 1996; Tsai & Burns, 2015).

Tsai and Burns (2015) note that few studies employ the correct analytical methods to demonstrate how co-occurring conditions synergistically affect HIV risk. Their systemic review found that most research takes a simplistic approach by merely quantifying the number of psychosocial issues rather than testing their interactions. Studies using syndemic theory have mostly looked at the additive or cumulative effects of the conditions rather than their synergistic or interactive associations, which are central to syndemic theory (Mendenhall, Newfield et al., 2022; Tomori et al., 2018). Furthermore, Singer et al. (2020) in their review of trends in syndemic research revealed several methodological limitations in measuring syndemics. They note that the complexity of interactions between diseases, especially noncommunicable diseases, makes it difficult to establish clear biological interactions and pathways. Although techniques such as regression and latent analysis are used, they often fail to fully specify these interactions, leading to challenges in the empirically supporting syndemic interactions (Singer et al., 2020).

Mendenhall, Newfield et al. (2022) also highlight the need for innovative scholarship in measuring syndemics emphasizing that the complex interactions among co-occurring conditions should be clearly defined and tested.

The interplay of HIV, IPV, and poor MH demands a syndemic approach to fully understand the impact on parenting. Such an approach considers the synergistic effect of co-occurring epidemics as more severe than the sum of their individual effects (Singer, 1996), going beyond additive to explore the interactive associations (Tomori et al., 2018).

Research has shown how HIV, IPV, and poor MH can negatively influence parenting practices. For one there is a risk of psychiatric issues among women living with HIV, as a result of disease-related stress such as poverty and stigma (Bachmann & Booysen, 2006; Kalichman & Grebler, 2010). Furthermore, the compromised MH among mothers and caregivers living with HIV often leads to harsh parenting such as neglect and in some cases aggressive behavior toward the child (Murphy et al., 2010). In relation to IPV, research shows that mothers experiencing IPV are likely to resort to harsh discipline and in some cases, physical abuse, due to fear of aggravating the abuser or in other cases displaced anger (Chiesa et al., 2018). Furthermore, MH disorders in parents can result in less responsive and nurturing behaviors, affecting children’s social and emotional adjustment (Elgar et al., 2004, 2007; Goodman & Gotlib, 1999). Focusing on mothers, who are often primary caregivers and disproportionately affected by these epidemics, is critical. The prevalence of HIV among pregnant women and the heightened risk for IPV and poor MH during and after pregnancy accentuate the need for more research in this area (Kieselbach et al., 2022; WHO, 2022).

Present Study

The objective of this scoping review is to assess the extent of the literature on the HIV-IPV-MH syndemic among mothers and caregivers who identify as women and the relationship to parenting. We aimed to review the intersection of at least two of these epidemics and their impact on parenting. According to Arksey and O’Malley (2005), the aim of a scoping review is to rapidly map the key concepts that underpin a research area and to identify the main sources and type of evidence available (Arksey & O’Malley, 2005). A scoping review is aimed at determining the scope or coverage of a body of literature on a given topic and providing a clear indication of the volume of literature and studies available (Munn et al., 2018; Peters et al., 2020). Although a scoping review follows many of the same steps as a systematic review, it does not include a quality appraisal of the studies (Munn et al., 2018; Peters et al., 2020).

Methodology

The scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews (Peters et al., 2020). Study methods and findings have been reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Moreover, the scoping review has been registered on OSF registries and can be found at https://doi.org/10.17605/OSF.IO/4U67F. The research on the IPV-MH-HIV syndemic in relation to parenting practices is underdeveloped. A scoping review aims to identify and map existing evidence on a broader topic area, in this case, the IPV, MH, and HIV syndemic, without critically appraising individual studies, synthesizing the evidence from different studies nor producing statements for decision-making. This was conducted to identify knowledge gaps on this emerging research topic to help us identify what key factors and concepts are in relation to the syndemic under investigation (Munn et al., 2018). A systematic review is often used in instance where there is an established body of literature to address specific research questions by synthesizing the evidence and critically appraising the included studies (Munn et al., 2018).

Search Strategy

A comprehensive approach to searching was used to find both published and unpublished studies. The search strategy was altered to account for varying syntax, limiters, and expanders in different databases. We piloted the search strategy to check for the appropriateness of the selected electronic databases and the keywords. An iterative process was undertaken during the search strategy as reviewers became more familiar with the evidence base, additional keywords, and sources, and other useful search terms were identified and incorporated.

The following databases and search engines were searched: PubMed, Ebscohost, Scopus, ProQuest, Science Direct, Psych INFO, CINAHL, Proline, Interscience, the Cochrane Library, UNAIDS, and UNICEF. Scoping searches on Google Scholar were also conducted. In addition, the reference lists of eligible articles were checked to identify further relevant studies. A subject librarian was consulted to assist in identifying relevant search terms. A full strategy undertaken with PubMed is detailed in Supplemental Table 1. This search strategy was used in all databases with the necessary adjustments made for truncations and Boolean operators. Following the search, all identified citations were collated and uploaded into Zotero and duplicates removed.

Eligibility Criteria

We included both reviews and empirical studies. In terms of study design both qualitative and quantitative studies were considered. Due to limited resources that prevented the translation of non-English studies, only those published in English were included. Only studies written from 2001 up until September 2023 were included (searches concluded September 30, 2023), we chose 2001 because this period signifies the height of HIV/AIDS research, especially concerning prevention and vertical transmission. This timeframe also allowed for the examination of the era before and after the widespread availability of antiretroviral therapy, including studies on the comorbidities of HIV, IPV victimization, and MH. The participants in the studies had to have experienced at least two of the epidemics concurrently, it could be any combination of the epidemics (IPV-MH, HIV-MH, HIV-IPV, or HIV-IPV-MH), and they had to identify as women and be caregiving for children. Although we were interested in the HIV, IPV, and MH syndemic, studies that did not measure the synergistic effect of the epidemics were also included, we included studies based on the co-occurrence of the epidemics. In terms of the outcome, we included studies that measured parenting practices as well as child maltreatment among women living with at least two of the epidemics.

Studies were excluded if they solely addressed one of the epidemics without exploring their collective impact on parenting. Similarly, research where the epidemics did not co-occur among the participants was omitted. Studies that included men or women who were not caregivers or men who were caregivers were excluded. Commentaries and nonempirical works that did not provide research findings on the interplay between these epidemics and parenting were also excluded from the review.

Screening, Data Extraction, and Synthesis

Titles and abstracts were screened by four independent reviewers against the inclusion criteria in a review software, Covidence. Thereafter full-text screening of shortlisted studies was completed by the first author. When a discrepancy in the decision to include a study in the final review arose among the reviewers, the first author made the final decision. Specific reasons for exclusion of sources of evidence at full text that did not meet the inclusion criteria were recorded and reported in the scoping review. Data were extracted from the articles that were included after the full-text review. The data extracted included the general study information (first author, year of study, the format of the study—book, article, thesis, review); study characteristics (setting, sample size, sample source, study design); sociodemographic information of participants (gender, age, socioeconomic status, and ethnicity); the study design; information about the study variables (measures used to collect data on IPV exposure, MH outcomes, HIV/AID prevalence, parenting practices); key findings which matched the review question and information regarding analysis (metrics, adjustments, and results). The included studies did not undergo a quality appraisal, as such an appraisal is typically not advised for scoping reviews. The purpose of a scoping review is to survey the landscape of available evidence, not to offer a synthesized and clinically pertinent response to a specific question (Peters et al., 2020).

Results

Search Results

As depicted in Figure 1 (see Supplemental Document A), the initial search identified 696 articles. Once duplicates were removed, the search was reduced to 505 articles. After the initial abstract and title screening, 448 studies were excluded as they did not meet the inclusion criteria. The full-text review of the remaining articles was conducted by four authors, which resulted in 18 articles being included in the final analysis. In addition, 5 more studies were found from the reference list of other studies, bringing the total to 23 articles included in the final analysis.

Characteristics of Included Studies

Information on the study characteristics is depicted in Supplemental Table 2. This includes study design, sample characteristics, sample size, and strategy. The studies identified were mostly quantitative studies with one scoping review (Sousa et al., 2022) and one literature review (Rochat et al., 2017). Furthermore, majority of the studies were cross-sectional (Chen et al., 2022; Clark et al., 2022; Cross et al., 2018; Dubowitz et al., 2001; Fujiwara et al., 2012; Graham-Bermann et al., 2009; Gurtovenko & Katz, 2020; Holmes, 2013; Levendosky et al., 2003; Madigan et al., 2015) (Allen et al., 2014; Cross et al., 2018; Fujiwara et al., 2012; Graham-Bermann et al., 2009; Greene et al., 2018; Gurtovenko & Katz, 2020; Holmes, 2013; Howell et al., 2015; Lachman et al., 2014; Levendosky et al., 2003; Mitchell et al., 2010; Murphy et al., 2010; Suardi et al., 2020; Thurston et al., 2021) with 7 being longitudinal (Chen et al., 2022; Clark et al., 2022; Dubowitz et al., 2001; Gustafsson et al., 2012; Madigan et al., 2015; Sherr et al., 2016; Stein et al., 2021) In terms of location, majority of the studies were from high-income countries, with only two from Africa (Allen et al., 2014; Lachman et al., 2014; Sherr et al., 2016). Specifically, fifteen were from the United States (Chen et al., 2022; Clark et al., 2022; Cross et al., 2018; Dubowitz et al., 2001; Graham-Bermann et al., 2009; Greene et al., 2018; Gurtovenko & Katz, 2020; Gustafsson et al., 2012; Holmes, 2013; Howell et al., 2015; Levendosky et al., 2003; Mitchell et al., 2010; Murphy et al., 2010; Stein et al., 2021) one was from Canada (Madigan et al., 2015), one was from Switzerland (Suardi et al., 2020), one from Japan (Fujiwara et al., 2012), two of the studies were from South Africa (Allen et al., 2014; Lachman et al., 2014), one study was conducted both in South Africa and Malawi (Sherr et al., 2016), one was a global scoping review of available literature (Sousa et al., 2022), and one was a literature review (Rochat et al., 2017). The studies were published between 2001 and 2022. In terms of the sample characteristics, 13 of the studies included mother-child dyads (Chen et al., 2022; Clark et al., 2022; Cross et al., 2018; Dubowitz et al., 2001; Fujiwara et al., 2012; Graham-Bermann et al., 2009; Greene et al., 2018; Gurtovenko & Katz, 2020; Holmes, 2013; Levendosky et al., 2003; Madigan et al., 2015; Mitchell et al., 2010; Suardi et al., 2020), two were caregiver-child dyads (Lachman et al., 2014; Sherr et al., 2016) which included the children’s fathers, and four included mothers only (Allen et al., 2014; Howell et al., 2015; Stein et al., 2021), and the articles in the scoping review varied in sample (Sousa et al., 2022).

The sampling methods and strategies used in the studies varied. Most of the studies used convenience sampling techniques such as handing out of fliers at grocery stores, laundromats, and apartment complexes (Allen et al., 2014; Cross et al., 2018; Levendosky et al., 2003; Suardi et al., 2020). Purposive sampling was also used (Fujiwara et al., 2012; Graham-Bermann et al., 2009; Gurtovenko & Katz, 2020; Holmes, 2013; Madigan et al., 2015; Mitchell et al., 2010; Stein et al., 2021) and one study used both purposive and convenience sampling (Dubowitz et al., 2001). Furthermore, two studies used simple random sampling (Gustafsson et al., 2012; Howell et al., 2015; Sherr et al., 2016) and four used stratified random sampling (Greene et al., 2018; Lachman et al., 2014; Thurston et al., 2021). Three studies used both convenience sampling in the initial recruitment and then random assignment to assign participants to either treatment or comparison groups (Clark et al., 2022; Howell et al., 2015; Murphy et al., 2010) and one study used a three-stage stratified random sampling strategy (Chen et al., 2022). In terms of sample size, there was considerable variation across the studies, with the smallest study including 56 mother-child dyads (Suardi et al., 2020) and the largest one involving 2,477 caregiver-child dyads (Lachman et al., 2014).

The results of the included studies can be found in Supplemental Table 3, this table includes the last name of the author, year the study was published, syndemic, and measures and measurement scales used in the studies and the results of the articles. Five studies examined the HIV-MH syndemic and its impact on parenting practices (Allen et al., 2014; Lachman et al., 2014; Madigan et al., 2015; Murphy et al., 2010; Rochat et al., 2017; Sherr et al., 2016) and one study investigated the IPV-MH syndemic and the moderating effect of HIV (Thurston et al., 2021). The remaining 17 studies focused on the IPV-MH syndemic and its impact on parenting (Chen et al., 2022; Clark et al., 2022; Cross et al., 2018; Dubowitz et al., 2001; Fujiwara et al., 2012; Graham-Bermann et al., 2009; Greene et al., 2018; Gurtovenko & Katz, 2020; Gustafsson et al., 2012; Holmes, 2013; Howell et al., 2015; Levendosky et al., 2003; Madigan et al., 2015; Mitchell et al., 2010; Sousa et al., 2022; Stein et al., 2021; Suardi et al., 2020).

Co-occurring HIV-IPV-MH and Impact on Parenting

Thurston et al. (2021) found that the added burden of HIV moderates the association with depressive symptoms and parenting practices among mothers with recent IPV exposure. The study compared mothers with IPV experience and HIV against those with only IPV. According to this study, there was a significant association between depressive symptoms, HIV status, and harsh parenting. Living with HIV in the context of IPV exposure is argued to have led to an increase in parental stress which contributed to harsher parenting practices. Harsh parenting practices included inconsistency, poor monitoring, and corporal punishment. For mothers exposed solely to IPV, the association between depressive symptoms and harsh parenting practices was not significant.

Co-occurring IPV-MH and Impact on Parenting

Of the studies reviewed, investigating the IPV-MH syndemic and its effect on parenting, there was a strong emphasis on the mediating role of maternal MH. Nine of the studies particularly stressed the mediating role of depression between IPV and harsher parenting practices (Chen et al., 2022; Clark et al., 2022; Dubowitz et al., 2001; Fujiwara et al., 2012; Gustafsson et al., 2012; Holmes, 2013; Mitchell et al., 2010; Sousa et al., 2022; Stein et al., 2021) while two studies highlighted post-traumatic stress disorder as a key mediator (Cross et al., 2018; Suardi et al., 2020). In addition, three other studies found that both PTSD and depression served as mediating factors between IPV and harsh parenting practices (Graham-Bermann et al., 2009; Howell et al., 2015; Levendosky et al., 2003). The prevailing evidence suggests a correlation between higher levels of IPV exposure and MH conditions such as depression and PTSD, which in turn influence harsh parenting behaviors. Support for this was also found in one study which looked at the efficacy of an intervention study with women who had experienced IPV, the study reported positive changes in maternal parenting practices linked to reduced levels of depression (Stein et al., 2021). Moreover, one study reported that ending a relationship with the abusive partner was not completely effective in ending harsh parenting practices as the MH challenges persisted beyond the end of the relationship (Fujiwara et al., 2012).

The types of harsh parenting behaviors reported in the studies looking at the IPV-MH syndemic included neglect, absence of praise (Fujiwara et al., 2012), diminished maternal warmth as well as both physical and psychological abuse (Holmes, 2013), lack of responsive parenting, reduced sensitivity to the child’s needs and a decline in communication (Sousa et al., 2022; Suardi et al., 2020), the use of corporal punishment and decreased capacity for effective child supervision (Graham-Bermann et al., 2009; Holmes, 2013), intrusive behavior such as denying the child’s autonomy in play or completing tasks (Gustafsson et al., 2012).

The studies exploring the IPV-MH syndemic found that the type of victimization experienced by the mother also had an impact on parenting outcomes, the results found that mothers who had experienced both physical and sexual abuse reported worse outcomes than mothers who had experienced one type of abuse or who did not have a history of child abuse. Women who had multiple forms of abuse in childhood and adulthood reported harsher parenting practices than mothers who reported no history of victimization or who experienced victimization only in childhood (Dubowitz et al., 2001).

Co-occurring HIV-MH and Impact on Parenting

Four studies found that there were higher levels of maternal depression in mothers and caregivers with HIV (Allen et al., 2014; Lachman et al., 2014; Rochat et al., 2017; Sherr et al., 2016) while another identified increased levels of maternal anxiety and stress in this population (Murphy et al., 2010). These MH disorders when combined with an HIV diagnosis were correlated with harsh parenting practices such as harsh physical discipline (Allen et al., 2014; Lachman et al., 2014; Murphy et al., 2010; Rochat et al., 2017; Sherr et al., 2016). Some studies explored the mechanisms through which the HIV-MH syndemic negatively affects parenting. For instance, Allen et al. (2014) found that mothers using negative religious coping strategies exhibited parent-child dysfunction, characterized by poor communication, lack of emotional attachment, and unresolved conflicts. This type of coping involves interpreting difficult situations as a form of divine punishment or as one’s own failings in religious terms, the later can contribute to increased stress and negative psychological outcomes. Negative religious coping strategies were measured by Allen et al. (2014) using the Religious Coping Scale, which included items that reflected religious attitudes and practices, for instance, a negative religious coping strategy from the scale would be, “I have been asking myself what I have done to God to punish me like this.” Rochat et al. (2017) noted that, particularly 2 years postpartum, mothers with the HIV-MH syndemic commonly used avoidant coping strategies such as distraction, emotional venting, and substance use. These coping strategies were linked to parenting stress and diminished parental attention and responsiveness.

According to Rochat et al. (2017), an additional factor exacerbating harsh parenting practices among women with the HIV-MH was HIV-related stigma. Mothers preoccupied with stigma and concerns about life expectancy experienced increased stress and depressive symptoms, which further undermined their parenting abilities. According to Rochat et al. (2017), these cognitive processes such as ruminations and preoccupations related to stigma and life expectancy acted as mediators between an HIV diagnosis and harsh parenting. In terms of observable parenting practices, mothers with the HIV-MH syndemic demonstrated poorer parent-child communication, less consistent discipline, and lower levels of child engagement in family routines (Murphy et al., 2010).

Discussion

The findings of the current review highlight the complex relationships existing between the HIV, IPV, and MH epidemics and their collective impact on parenting practices. The review contributes significantly to the existing literature by identifying the limited literature available on the HIV-IPV-MH syndemic and its impact on parenting thereby directing focus to areas necessitating further research. Nonetheless, the review highlights important findings in relation to the syndemic impact on parenting. In relation to the HIV-IPV-MH syndemic, the findings revealed that among women experiencing IPV-MH, having HIV worsened the impact on parenting practices, where these women often engaged in harsher parenting practices. Furthermore, depression and PTSD were the most common MH disorders among mothers and caregivers living with the IPV-MH syndemic, MH was a mediating factor between IPV and harsher parenting practices. Research on the HIV-MH syndemic found that there were higher levels of maternal depression and anxiety among mothers with HIV, which through maladaptive coping strategies and internalized stigma often led to harsher parenting practices.

HIV-IPV-MH and Parenting Practices

The findings in the current review align with previous research which found that HIV-IPV-MH are often co-occurring. In a systematic review, it was found that MH disorders are among the most common comorbidities among people living with HIV globally, with depression as the most common disorder (Brandt, 2009). This aligns with the research conducted by Thurston et al. (2021) as reported in our scoping review. Furthermore, the broader literature suggests a significant impact of caregiver well-being and cumulative parental stressors, such as trauma, poor MH, and health conditions like HIV, on parenting practices (Belsky, 1984). The latter can help explain how HIV acts as a moderating factor in the relationship between IPV, poor MH, and parenting outcomes. Notably, as evidenced by the current review, there remains a notable dearth of research specifically examining the combined impact of these three epidemics on parenting. This gap is particularly critical to address, given the widespread prevalence of this triple syndemic among women, who often serve as primary caregivers of children. The implications of how these interrelated epidemics affect both women and their children are profound and necessitate further investigation.

IPV-MH and Parenting Practices

In terms of the IPV-MH syndemic, the studies in the review highlight that maternal MH significantly mediates the impact of IPV on parenting practices. This finding highlights the need for interventions that address the MH of women affected by IPV, as their mental well-being is critical in determining parenting practices.

Depression and PTSD were reported as the prominent MH disorders mediating the relationship between IPV and harsh parenting practices. This is consistent with extensive research demonstrating a positive association between IPV and mental disorders (Castellví et al., 2017; Chuang et al., 2012; Coker et al., 2002; Desmarais et al., 2014; Devries et al., 2013; Khalifeh et al., 2015; Lacey et al., 2015; Oram et al., 2022; Ruiz-Pérez et al., 2017). A systematic review by Lagdon et al. (2014) further revealed that IPV victims face greater adverse MH effects, especially depression, PTSD, and anxiety, compared to those without such experiences (Lagdon et al., 2014).

The review also revealed that mothers and caregivers subjected to multiple victimizations in adulthood and childhood tend to adopt harsher parenting practices. This correlation might be attributed to the association of revictimization with various psychological conditions, including mood and affective disorders, anxiety, PTSD, dissociation, and substance use disorder (Papalia et al., 2021; Scoglio et al., 2021; Sharratt et al., 2023; Walsh et al., 2021). Tailored, trauma-informed interventions that address unresolved and/or current trauma and promote adaptive coping strategies are necessary for this group. There is also a need to develop spaces that are preventative of the occurrence of trauma such as safer environments and spaces for women as well as a more responsive justice system.

HIV-MH and Parenting Practices

In terms of the co-occurrence of HIV-MH, the scoping review reveals a notable prevalence of MH challenges among PLWH, aligning with existing literature. Studies have consistently indicated that the mental and physical health of people living with HIV, especially in West, East, Southern and Central and Africa (WESCA) which has the highest HIV burden globally, is often compromised (James et al., 2018; Naghavi et al., 2017). Compared to the general population, people living with HIV are more susceptible to MH disorders such as depression, anxiety, suicidality, and substance use disorder (Brandt, 2009; Catalan et al., 2011; Chibanda et al., 2016; Clucas et al., 2011; Hughes et al., 2016; Lachman et al., 2014). This is corroborated by our review, which identified significantly higher rates of depression and anxiety in mothers living with HIV (Allen et al., 2014; Lachman et al., 2014; Murphy et al., 2010; Rochat et al., 2017; Sherr et al., 2016).

Furthermore, our review highlights that mothers and caregivers living with HIV-MH often engage in harsher parenting practices. Key factors contributing to this include maladaptive coping strategies and preoccupation with HIV-related stigma. The stigma associated with HIV, both internalized and externally experienced, has been linked to depression (Serafini, 2015), which, as demonstrated in the review, adversely affects parenting practices. For instance, Bhadra et al. (2020) found that stigma anticipation led participants to avoid social interactions, affecting their children’s involvement in activities (Bhadra et al., 2020).

In terms of coping strategies, qualitative research conducted by Silima et al. (2024) suggests that women living with HIV-MH often resort to family support, religious faith, and self-reliance to overcome these challenges. These women reportedly use religion positively to draw strength and acceptance, in contrast to the negative religious coping strategies identified in our review (Allen et al., 2014). This positive use of religion and spirituality as a sustenance strategy amid HIV challenges has been echoed in other studies (Bukhori et al., 2022).

While we found only four studies in the review which directly addressed the impact of the HIV-MH syndemic on parenting, this limited number reflects the existing research gap and highlights the need for further research. However, the evidence points to the central role of poor MH across various syndemic combinations, highlighting the importance of psychosocial support as a critical component in any intervention aimed at this demographic.

It must be recognized that the parenting practices observed in the studies of women living with the interrelated epidemics of IPV, MH, and HIV often result directly from the trauma they have experienced in their own lives. This trauma can significantly affect their parenting practices and may have roots extending back to their own childhoods. Qualitative research by Silima et al. (2024) on women living with these interrelated epidemics found that the majority of women had experienced trauma in their childhood, including instances of childhood sexual abuse (Silima et al., 2024; Taccini et al., 2024). A review by Lomanowska et al. (2017) revealed that early adversities in childhood often affect parenting in adulthood. Specifically research by Newcomb and Locke showed that child maltreatment is associated with subsequent harsh parenting such as low warmth, aggression, and neglect (Lomanowska et al., 2017; Newcomb & Locke, 2001). In addition, the cumulative impact of ongoing violence, stigma, and economic hardship exacerbates these epidemics, making it difficult for these women to provide stable and nurturing environments for their children (Sherr et al., 2016; Suardi et al., 2020). Despite the significant challenges faced by women living with the epidemics, these women demonstrate remarkable resilience and agency in addressing the challenges in their lives and their children’s lives. Women actively engage in community-based initiatives, peer support networks, and advocacy programs to combat the effects of the syndemic. For instance, interventions such as the Stepping Stones with Children training program in Tanzania have shown that women and their children can build resilience, improve their relationships, and enhance their well-being through structured, supportive activities (Holden et al., 2019).

Understanding HIV-IPV-MH From a Syndemic Lens

None of the studies identified in the scoping review specifically examined the syndemic impact of the epidemics or measured the interactions between them. The studies reported on the moderating or mediating relationships. Evidently this suggests a gap in our understanding of how the combined presence of these intersecting epidemics exacerbates the challenges experienced by mothers and caregivers, leading to worse outcomes, than would be the case when the epidemics appear in isolation.

Limitations

Although this scoping review provides valuable insights, it must be noted that there were some limitations. First, while the review used multiple large electronic databases to search for relevant articles for inclusion, we acknowledge that other relevant papers, particularly gray literature may have been missed during the search process. According to Dunaway et al. (2022), gray literature often contains rich, diverse perspectives and insights that are sometimes absent in traditional academic publications. The exclusion of these materials may have resulted in gaps in the evidence base and may have overlooked the voices and experiences of those most affected by the issues under study. Moreover, we only included studies written in English, which may have excluded some relevant articles. Furthermore, there was only one study that explored the HIV-IPV-MH syndemic and the impact on parenting, thus our conclusions are based on this single study, which may not fully represent the complexities of the syndemic impact on parenting practices. The identified studies were also mostly from high-income countries, with limited research from regions with a high burden of the epidemics such as WESCA, thus limiting the generalizability of the findings to this particular context. The absence of qualitative studies is a major limitation, as qualitative research is able to provide insights and an understanding of the complexities of the syndemic that are not easily captured through quantitative studies.

Implications and Future Research

The review highlights the prevalence of MH disorders among women living with HIV and IPV experience. This indicates the importance of IPV- and MH-centered interventions, particularly those addressing depression, anxiety, and PTSD. Furthermore, there is a need for psychological screening among those testing positive for HIV and for women who seek health services that show signs of IPV. Moreover, as recommended by the WHO (2017), interventions for women living with these interrelated epidemics should integrate care for them into existing health services. This can be achieved by establishing centers where women can receive medical care and psychological support in one location; incorporating routine screening for IPV and poor MH into regular health visits especially in HIV care settings and finally ensuring that services for MH, sexual and reproductive health, and HIV care are both physically and operationally integrated. In addition, it would be equally important to create safe spaces within healthcare facilities where women can be free to disclose violence and receive care without fear of judgment (WHO, 2017).

Furthermore, there is a need for interventions that are trauma aware. (Decker et al., 2016; Dhairyawan et al., 2013). Implementing trauma-aware practices can create safe opportunities for women to seek help. A trauma-aware model ensures that the organizational culture is both safe for staff and clients, regardless of the disclosure of violence (Gormley et al., 2022). Key components include recognizing the widespread impact of trauma, understanding the potential recovery paths, and training staff to support survivors effectively. It is also essential to ensure the physical and emotional safety of service users by creating a welcoming and respectful environment and allowing participants in the intervention to control their level of engagement and content covered (Kahan et al., 2020).

Parenting interventions need to look at addressing the syndemic in tandem rather than in isolation and tailoring programs specifically for parents living with the syndemic. An example of such interventions is the Equimundo parenting program which both violence against women and violence against children simultaneously (Equimundo & Sonke Gender Justice, 2018).

In addition, it must be recognized that the work that is already being conducted by women’s rights organizations on these challenges is very underresource (International Development Committee, 2024; The Equality Institute & Accelerator for GBV Prevention, 2023; UN Women, 2021). Women living with the epidemics are actively engaged in overcoming the challenges that come with living with these issues, their efforts often including grassroots advocacy, peer support programs, and community-based interventions which are essential for mitigating the adverse effects of the syndemic (Htun & Weldon, 2012). Moreover, it is critical to ensure that the efforts of these women are adequately resourced and supported through sufficient funding and resources for the initiatives (Connolly, 2017). It is also essential to support and expand existing community-based programs that address these epidemics through sustained funding and support as these programs play a critical role in immediate and long-term support for the women (Kohrt et al., 2018).

The findings of this review have highlighted a significant gap in research regarding the combined impact of the IPV-MH-HIV, IPV-MH, and HIV-MH syndemics on parenting practices. The syndemic disproportionately affects women, who are often the primary caregivers, and as a result also detrimentally influences parenting. There is a critical need for further research exploring the synergistic interactions among these epidemics. A deeper understanding of these interactions is vital for designing efficient, holistic interventions and programs that are able to effectively address the consequences of these complex challenges.

Furthermore, the majority of existing studies originate from the United States, with limited research conducted in WESCA. Studies within this context are critical for the development of interventions that can be tailored to the unique challenges and resource limitations of the region, potentially allowing for more impactful solutions that either address multiple issues concurrently or prioritize the most pressing concerns.

We recommend more qualitative studies be conducted on the HIV-IPV-MH syndemic. Qualitative research is indispensable for capturing the lived experiences of affected women, offering rich, nuanced insights that quantitative data alone cannot provide. For instance, qualitative work by Silima et al (2024) is a good example of how the syndemic affects the parenting experiences and practices of mothers and caregivers living with these epidemics. Such research is invaluable in identifying key factors associated with the syndemic, thereby informing the development of more effective, targeted interventions.

The review also revealed that there is a need for more longitudinal research, to assist in a better understanding of the HIV-IPV-MH syndemic over time, a reliance on cross-sectional studies limits us from inferring causality, as well as understanding whether developed interventions are actually working.

In addition, we also recommend, future reviews on the subject matter to include gray literature which would include articles, films, interviews, and other materials that provide diverse perspectives and critical insights, this would provide a more holistic view and ensure that the diverse experiences and insights of the women living with the epidemics are adequately represented (Dunaway et al., 2022). Furthermore, research that ensures the meaningful involvement of women living with these epidemics is crucial. Their participation in the design, implementation, and evaluation of studies will ensure that the research addresses their real needs and concerns (Dunaway et al., 2022).

Finally, it would be valuable to have more research that looks at the synergistic effects of the syndemic, as well as the multiplicative effects. A syndemic understanding is critical in developing tailored interventions that address the syndemic in tandem.

A syndemic framework for interventions has important implications for public health. Current public health practices often compartmentalize diseases, hindering the implementation of syndemic-based interventions (Douglas-Vail, 2016). Understanding the drivers of disease interaction and the contexts in which they occur allows for a strategic and innovative interventions that address clusters of the social and health conditions rather than individual disease (Singer & Clair, 2003) Clinicians and policy makers can develop holistic approaches to care that tackle multiple interconnected issues simultaneously. This perspective enables policy makers to use the insights from syndemic theory to create comprehensive health programs that integrate social determinants of health (Tsai & Venkataramani, 2016). Applying a syndemic lens in clinical setting requires addressing both the medical conditions and the nonmedical determinants of health such as structural violence, stigma, and socioeconomic factors. Interventions need to be context-specific, addressing the unique interaction and driver in each setting (Mendenhall, Kohrt et al., 2022). Mendenhall, Kohrt et al., (2022) emphasize the need for modeling syndemic care in clinical contexts, which includes a comprehensive approach that spanning multiple levels of research and clinical practice. By integrating research and clinical practice across these domains, healthcare systems can develop more effective, context-specific interventions that improve health outcomes for populations experiencing syndemic conditions(Mendenhall, Kohrt et al., 2022).

In response to the need for further research in this area especially in low- and middle-income countries, the research team has already conducted additional studies, including qualitative and quantitative analyses studies Silima et al (2024). These efforts aim to fill the gaps in the scoping review and contribute to a more comprehensive understanding of the IPV, MH, and HIV syndemic.

Conclusion

The current review reveals that living with the different syndemics (HIV-IPV-MH; IPV-MH; HIV-MH) adversely affects parenting resulting in harsher and inconsistent parenting practices. Parenting interventions that seek to address the syndemic impact are critical, considering the public health importance of harsh parenting. Furthermore, more qualitative and longitudinal research on the syndemic would allow for more evidence-based interventions seeking to address the syndemic impact on parenting.

Supplemental Material

sj-docx-1-tva-10.1177_15248380241268807 – Supplemental material for Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review

Supplemental material, sj-docx-1-tva-10.1177_15248380241268807 for Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review by Mpho Silima, Nicola Christofides, Hannabeth Franchino-Olsen, Nataly Woollett, Jingying Wang, Ari Ho-Foster, Kabelo Maleke and Franziska Meinck in Trauma, Violence, & Abuse

Supplemental Material

sj-docx-2-tva-10.1177_15248380241268807 – Supplemental material for Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review

Supplemental material, sj-docx-2-tva-10.1177_15248380241268807 for Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review by Mpho Silima, Nicola Christofides, Hannabeth Franchino-Olsen, Nataly Woollett, Jingying Wang, Ari Ho-Foster, Kabelo Maleke and Franziska Meinck in Trauma, Violence, & Abuse

Footnotes

Acknowledgements

For the purpose of open access, the author has applied a “Creative Commons Attribution (CC BY)” license to any Author Accepted Manuscript version arising from this submission.

Author Contributions

Conceptualization: Ms Mpho Silima, Dr Nicola Christofides, Dr Franziska Meinck; Data collection: Ms Mpho Silima, Ari Ho-Foster, Jingying Wang, Kabelo Maleke; Formal analysis: Ms. Mpho Silima, Dr Nicola Christofides; Funding acquisition: Dr Franziska Meinck; Methodology: Ms Mpho Silima & Dr Nicola Christofides; Software: Dr. Franziska Meinck; Supervision: Ms Mpho Silima, Dr Nicola Christofides, Dr Franziska Meinck, Dr Nataly Woollett, Hannabeth Franchino-Olsen; Validation: Ms Mpho Silima; Writing – original draft: Ms Mpho Silima; Writing – review & editing: Mpho Silima, Nicola Christofides, Nataly Woollett, Hannabeth Franchino-Olsen, Franziska Meinck.

Data Availability Statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online Supplemental information. Relevant data are included as online supplemental information. Extended data available by request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is funded by the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation program [Grant Agreement Number 852787].

ORCID iDs

Mpho Silima

Hannabeth Franchino-Olsen

Nataly Woollett

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Mpho Silima, MPH, is a PhD student in the School of Public Health at the University of Witwatersrand. She is a qualitative researcher with extensive public health research experience. She has a strong interest in gender equity-related issues and the intersections of violence, HIV, mental health, and parenting, reframing health concerns using an ecological lens that includes the social determinants of health.

Nicola Christofides, PhD, is an associate professor in the School of Public Health, University of Witwatersrand. She directs the Division on Health and Society. Nicola has over 20 years of research experience in GBV, HIV, and evaluating social and behavior change programs. Her research focuses on survivors of sexual violence service delivery and the role GBV plays in reproductive and sexual health outcomes.

Hannabeth Franchino-Olsen (she/her), PhD, is a faculty fellow at The Ohio State University focusing on issues of violence against children, gender-based violence, and intergenerational violence transmission. Her work examines violence across the life course using the lens of polyvictimization to prevent violence for children, adolescents, and young adults and to halt violence transmission across family generations.

Nataly Woollett, PhD, is an interdisciplinary social scientist and therapist with training in psychology, art, and play therapy. Her research is informed by her therapeutic practice, with an emphasis on mental health, violence, HIV, and child/adolescent development. She is interested in intersections of violence against children and violence against women and enhancing understanding of prevention mechanisms of intergenerational transmission of violence.

Jingying Wang, MSc, is a student in the SNSF research project “Labour Markets as Emergent Mobility Networks”. Jingying completed an MSc degree at the University of Edinburgh in Social Research with a specialization in social science research methods and social network analysis. Her main research interests are occupational mobility and advanced statistical modeling. As part of her PhD project, she currently aims to unpack the structure of occupational intermarriage and its impact on income inequality and social segregation.

Ari Ho-Foster, MSc, is a Senior Research Fellow at the University of Botswana. As an Epidemiologist, he managed and co-investigated in large-scale, community-level epidemiological intervention studies in Canada, Pakistan, and Southern Africa with the CIETgroup (1998–2010), before serving as an Epidemiologist and Country Operations Officer for the Botswana-UPenn Partnership (BUP; 2010–19). He is currently a PhD student at University of Witwatersrand.

Kabelo Maleke, BA Hons, Public Health Researcher with more than 13 years’ experience in the HIV/AIDS field, with in-depth key populations research and program expertise. He has exceptional experience in program initiation, research implementation and data analysis, with publications. Kabelo has worked on numerous research projects in seven of the nine provinces in South Africa on formative assessments, RDS, and other research methodologies.

Franziska Meinck, DPhil, is an associate professor at the University of Edinburgh and honorary associate professor at the University of the Witwatersrand. Her research focuses on violence against children and intergenerational transmission of violence.

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Supplementary Material

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Co-occurring Intimate Partner Violence,Mental Health,Human Immunodeficiency Virus,and Parenting Among Women: A Scoping Review

Abstract

Keywords

Introduction

Present Study

Methodology

Search Strategy

Eligibility Criteria

Screening, Data Extraction, and Synthesis

Results

Search Results

Characteristics of Included Studies

Co-occurring HIV-IPV-MH and Impact on Parenting

Co-occurring IPV-MH and Impact on Parenting

Co-occurring HIV-MH and Impact on Parenting

Discussion

HIV-IPV-MH and Parenting Practices

IPV-MH and Parenting Practices

HIV-MH and Parenting Practices

Understanding HIV-IPV-MH From a Syndemic Lens

Limitations

Implications and Future Research

Conclusion

Supplemental Material

sj-docx-1-tva-10.1177_15248380241268807 – Supplemental material for Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review

Supplemental Material

sj-docx-2-tva-10.1177_15248380241268807 – Supplemental material for Co-occurring Intimate Partner Violence, Mental Health, Human Immunodeficiency Virus, and Parenting Among Women: A Scoping Review

Footnotes

Acknowledgements

Author Contributions

Data Availability Statement

Declaration of Conflicting Interests

Funding

ORCID iDs

Supplemental Material

Author Biographies

References

Supplementary Material