Integrating 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.
Significant 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.
Physical, sexual 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.
The high 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.
Intimate 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.
Intimate partner violence contributes directly to HIV transmission through forced or coercive sexual intercourse with a partner living with HIV.
Evidence also 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 seeking treatment.
While few interventions combining the prevention of intimate partner violence and HIV infection have been evaluated, none have significantly decreased both outcomes, Dr Nalugoda told participants.
Undertaken 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.
Four study 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 partner violence.
The control 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.
Data were 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.
Using an 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.
Secondary 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.
While IPV 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: 0.69-0.99, respectively.
SHARE had no effect on men’s reports of any type of IPV perpetration.
SHARE was 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.
However, SHARE was not associated with changes in the number of partners, alcohol use surrounding sex or condom use.
Dr Nalugoda 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.
Wagman J et al. A cluster randomised trial of the impact of an intimiate partner violence and HIV prevention intervention on emotional, physical and sexual abuse, sexual risk and HIV incidence in Rakai, Uganda, 20th International AIDS Conference, Melbourne, abstract THAC0103, July 2014.