intimate partner violence (IPV) prevention strategies into HIV prevention
programming led to a significant reduction in HIV incidence and in women’s
experience of physical and sexual violence from intimate partners in Rakai,
Uganda, delegates heard last month at the 20th
International AIDS Conference (AIDS 2014) in Melbourne.
reductions in risk behaviours including spousal rape (adjusted prevalence risk
ratio [aPRR]: 0.80, 95% CI: 0.66-0.97) and increased HIV disclosure were
reported in this cluster randomised trial comprising over 11,000 men and women aged
between 15 and 49 years, Fred Nalugoda, presenting on behalf of the Rakai
Health Services Programme, told delegates.
and psychological violence against women, perpetrated by intimate
partners, is widespread. According to the World Health Organization between 10%
and 69% of women report physical abuse at least once in their lives; between 6%
and 47% of adult women report being sexually assaulted by intimate partners in
their lifetime; and between 7% and 48% of girls and young women aged 10-24
years report their first sexual encounter as coerced.
rates of HIV infection among women, especially among younger women aged 15-24
years, highlight underlying persistent gender inequalities, notably violence
against women. Studies have shown that women and girls experiencing violence
are at increased risk for HIV compared to those who do not.
partner violence is both a risk factor for, and consequence of, HIV infection, so
undermining prevention efforts. The links between IPV and HIV are complex and include
biological, socio-economic and cultural factors.
partner violence contributes directly to HIV transmission through forced or
coercive sexual intercourse with a partner living with HIV.
suggests that intimate partner violence is associated with an increased
likelihood of risk-taking behaviours among women who experience IPV, as well as
among the perpetrators. Moreover, women and girls in settings where violence
against women is the norm have no choice about how and when they have sex and so
are limited in their abilities to negotiate condom use. Violence or fear of
violence may prevent women from seeking HIV testing, disclosing their status or
interventions combining the prevention of intimate partner violence and HIV infection
have been evaluated, none have significantly decreased both outcomes, Dr
Nalugoda told participants.
between 2005 and 2009 this sub-study evaluated the effect of an IPV prevention
intervention (the Safe Homes and Respect for Everyone [SHARE] Project) on IPV
and HIV incidence.
intervention districts comprising 5337 individuals received enhanced HIV
prevention services including supplemental counselling on safe disclosure of
HIV results as well as SHARE’s IPV prevention strategies including advocacy,
men and boys’ programme, youth programme, capacity building and community
education. HIV counsellors and healthcare workers were trained on intimate
group comprised seven districts with a total of 6111 individuals receiving only
standard-of-care HIV services as well as HIV prevention education on the
importance of using condoms, getting tested as a couple and disclosing results.
analysed from three rounds of the parent study (the Rakai Community Cohort
Study – a family planning outreach study) at baseline and at two follow-ups. Timing
of the activities ensured that baseline data were collected before
implementation and that each intervention region had approximately the same
length of exposure to the intervention.
adapted version of the conflicts/tactics scale primary outcomes measured included
three types of IPV: emotional, physical and sexual during the past year. Women
reported as recipients of IPV and men as perpetrators.
outcomes-specific HIV risk behaviours considered direct or indirect links
between IPV and HIV risk included: past year spousal rape, number of total and
extra-marital sexual partners, alcohol use around sex, condom use and disclosure
of HIV status.
declined in both arms, exposure to SHARE was associated with significant reduced
physical and sexual IPV among women compared to the control arm, adjusted
prevalence risk ratio (aPRR): 0.80, 95% CI: 0.68-0.93, and aPRR: 0.82, 95% CI:
SHARE had no
effect on men’s reports of any type of IPV perpetration.
associated with significantly reduced HIV incidence in the total population
(adjusted incident risk ratio [aIRR]: 0.64, 95% CI: 0.43-0.95, p = 0.028; among
men, aIRR: 0.63, 95% CI: 0.39-0.99, p = 0.049; and borderline significance among
women aIRR: 0.69, 95% CI: 0.45-1.06, p = 0.088.
was not associated with changes in the number of partners, alcohol use
surrounding sex or condom use.
concluded HIV prevention programmes should integrate IPV prevention into their
current protocols. The SHARE approach, he added, could be effective for
intimate partner prevention in other settings in Uganda and the region.