Participant characteristics: The participants were 15 married women. The ages of the respondents ranged from 30 to 60. Five female's husbands (33.3%), who were interviewed in this study were HIV positive and HCV positive, whilst 10 (66.6%) were HIV positive only. Exception of one couple, all couples had children. Four of the couples (26.6%) had one child, while two couples had four. The age of the females’ children ranged from under seven to over thirty-four. The majority of the females were in their childbearing age, when they discovered their status. Most of the females completed lower secondary school education and three females had a diploma. The majority of the females chose not to disclose their status to their children. Only one member informed her children and one member informed her entire family. The characteristics of participants are presented in Table 1.
The results of the analysis included 96 meaning units, 12 subcategories, four categories and one theme. The main overarching theme emerged entitled: trapped in a vicious cycle of violence. It consisted of four categories of self-directed violence, intimate partner violence, cultural violence and structural violence (table 2).
Main theme: Trapped in a vicious cycle of violence
Violence often occurs in a repeated cycle. The cycle of violence began soon after the awareness of husband's infection and was started with acts such as suicide attempts and a sense of abhorrence for living with an infected person, and continued with confrontation with various types of violence in the family and society.
Category 1: Self-directed violence: A topic raised by study participants was self-directed violence. Women sometimes experienced self-injuries activities in the event of confronting with illness of husband or reactions of relatives.
1-1: Suicidal ideation: Some women reported that their husbands engaged in high-risk sexual behavior such as irregularly extra-marital relationships, which leads to their tendency to commit suicide. In this regard, one participant said: "When I was pregnant, I understood he betrayed me. I was suspicious of my husband’s behaviors and I recently found a condom in his pocket. I was afraid that my surroundings do not accept me. Most of the times I think what should I do? Because of this, I tend to commit suicide for fear of getting AIDS" (P2. 38 Y).
1-2: Self-Injurious Behavior: Many participants spoke about doing self-injurious behavior. The participants mentioned their husband do not pay attention about their likes and dislikes and the decision in their life according to their wish. The husband's acts provoked the women to injure themselves. One female said that, "My husband is not concerned about living expenses, for instance, if I want to buy anything he never agrees with. He sells home appliances and doesn’t pay any attention to the kids. I take care of the children and always seek to give them comfort, but is it just my responsibility? In this condition, I do not want to eat and I like to have hit my head against wall" (P2. 38Y).
1-3: Self-hate: Women participating in the interview mentioned that they experienced restrictions imposed by their husbands. Indeed, they had no power to make any decision at home, without allowance of their husband. It led to their negative feelings about themselves. Only one participant stated that her activities are not limited by her husband: "I can't do anything without my husband's permission. I wish I could work outside and I could be financially independent. But my husband prevents me from working, he does’not financially support me at all. The dependency makes me more vulnerable to my husband’s acts of violence …I sometimes hate myself for not getting divorced" (Touching her face) (P11. 40 Y).
Category2: Intimate partner violence: Women in their serodiscordant relationships with a partner are usually victims of a combination of violence including verbal harassment, psychological aggression, sexual assault and physical harm.
2-1: Verbal harassment: Verbal violence, such as scurrility and screaming often has been experienced by women. Men consider verbal violence as a legal means to meet their needs and as a condition to protect his power over the family. Participants expressed we cannot talk and negotiate to each other in a constructive manner. One woman said that: "When we speak to one another, he uses bad word. He begins to scream and cannot control himself at all. When he comes home, he stars constantly ordering me to do something with a high voice. He feels pride doing it" (P 2. 38Y).
2-2: Psychological aggression: It was reported by serodiscordant women that they are under psychological aggression which is a cause enduring damage to the sense of well-being of the women. The findings showed that almost the majority of the participants in the study mentioned psychological violence by their husband. In some cases, men tend to control their women. Trying to control and doing dominant behaviors by men were forms of psychological violence in women. One woman expressed that, "my husband is very suspicious. He constantly checks my mobile phone, even though my phone is always at home. He consistently says that women are worthless. When my husband says it, my confidence is going down" (P5. 30Y).
2-3: Sexual assault: A few of serodiscordant women talked about sexual assault. This type of violence affects free living opportunities and social status of women. They indicated having constant arguments and disputes towards sexual issues. One woman has mentioned forced unprotected sex with her husband: "I strongly believe condom continue to be used before a cure is found for HIV. But he doesn’t want to use the condom. He said, I don’t like using a condom. In this condition I cannot protect myself,because my husband doesn’t put on a condom. I am forced to give him sex because I fear that he embarrasses my children" (P11. 40Y).
1-4: Physical harm: The effects of physical assault are usually more stated than other forms of violence. It is a way for the continuation and strengthening of the women's’ obedience for men, where men do not achieve their goals through mental violence. The data showed that men use their physical strength or even cold weapons to threaten or cause physical pain to the women. One female stated: "he beat me up in front of kids. He used physical force such as hands and feet for choking and shoving me. I begged him to stop, but he said I like killing you and the kids" (P7. 37 Y).
Category3: Cultural violence: Cultural beliefs could play an important role for HIV / AIDS patients and their families in adapting, coping with the disease and violence toward them and their families. Participants said that when relatives became informed that their spouse is HIV positive; they reject them from the family. Also, it was resulted in labeling and stigmatization in the community. Their relatives considered them distracting from the usual norms of society and prevented them from being accepted as a normal citizen in the community.
3-1: Social marginalization: Serodiscordant women chose not to disclose their status to their family and friends, as they found that women who disclosed their status were rejected by their relatives. The following quote explain this point: "My family' behavior has changed toward me. I am seronegative, but some people, who see me at the clinic with my HIV positive husband, they think that I am positive too.My family used to gather and eat together, but when they know that my husband is HIV positive, left their habit. In our society when people hear that such a woman has a HIV positive husband it is a very shameful condition. I think, this is an example of overt violence. I say to my husband that I am really suffering from this problem" (P 4. 45 Y).
3-2: Stereotypes and cultural norms: The patriarchal values and the unequal gender-based distribution of power in the family and neighbors, directly or indirectly, affect the violence against women. The women explained that due to the interference of people they have to face several problems. A participant specifically mentioned about her mother-in-law interference: "She believes in women's complete obedience to men and inherent aggression against them. My husband spends most of his time at her home and used to listen to his mother advice, who is not a right person for consultation. For example, she said to my husband you have power and you can transfer it (HIV) to your wife and you can infect her. My mother- in-low and I is always arguing together" (P 6.34 Y).
Category4: Structural Violence: Structural violence, which reveals inequality in the distribution of jobs and resources among people living with HIV / AIDS, was one of the issues that serodiscordant women experienced due to living with HIV positive men. They confronted with deprivation from economic participation, the lack of legal protection and also health disparity.
4-1: Deprivation of the right to economic participation: Participants stated that their husbands lost their job and sources of income when their employer was informed of their status. One woman mentioned "my husband decided to disclose his status to the company, but they told her that they couldn’t give her a job. He is unemployed. He afraid to go to otherfactories to look for a job, you know, because he feels that he will be approached the same. Several times I went to look for a job for him, but did not approached well. In this situation he’s become more nervous with me and the kids"(P 8. 39Y/O).
4-2: The lack of legal protection: From the interviews conducted with the women, it was found that the majority of the women still has not reported the violence to the legal organization. One woman mentioned, as they thought that they would not be supported by the legal system: "The law does not give sufficient protection for women in instances of violence. Men also know it. Once I went to court to divorce, but the judge did not pay any attention to me and said, you are a mother, you must endure" (P 12.36 Y).
4-3: Health disparities: The majority of participants in this study had strong relationships with their health care providers. They said that the Infection Disease Clinic plays a big role in providing support for us. But a few participants referred to the bad experiences from the healthcare providers in hospital. A woman who had a good relationship with her husband in this relation said: "When he (my husband) got sick, I strongly believed that, it is my responsibility to accompany her for going to the hospital without shame, but in the hospital where we went for care, one of the care providers loudly said that he is HIV positive. Also, the nurse gave care to my husband with a violent behavior, you know, and when I protested him, he, with a bad tone, said, your husband is HIV positive and I should take care of myself. In this situation, I just cried and came out of the room. I felt so bad" (Lip biting) (P 13. 35 Y).