Jennifer A. Wagman

Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.

BACKGROUND Intimate partner violence (IPV) is associated with HIV infection. We aimed to assess whether provision of a combination of IPV prevention and HIV services would reduce IPV and HIV incidence in individuals enrolled in the Rakai Community Cohort Study (RCCS), Rakai, Uganda. METHODS We used pre-existing clusters of communities randomised as part of a previous family planning trial in this cohort. Four intervention group clusters from the previous trial were provided standard of care HIV services plus a community-level mobilisation intervention to change attitudes, social norms, and behaviours related to IPV, and a screening and brief intervention to promote safe HIV disclosure and risk reduction in women seeking HIV counselling and testing services (the Safe Homes and Respect for Everyone [SHARE] Project). Seven control group clusters (including two intervention groups from the original trial) received only standard of care HIV services. Investigators for the RCCS did a baseline survey between February, 2005, and June, 2006, and two follow-up surveys between August, 2006, and April, 2008, and June, 2008, and December, 2009. Our primary endpoints were self-reported experience and perpetration of past year IPV (emotional, physical, and sexual) and laboratory-based diagnosis of HIV incidence in the study population. We used Poisson multivariable regression to estimate adjusted prevalence risk ratios (aPRR) of IPV, and adjusted incidence rate ratios (aIRR) of HIV acquisition. This study was registered with ClinicalTrials.gov, number NCT02050763. FINDINGS Between Feb 15, 2005, and June 30, 2006, we enrolled 11 448 individuals aged 15-49 years. 5337 individuals (in four intervention clusters) were allocated into the SHARE plus HIV services group and 6111 individuals (in seven control clusters) were allocated into the HIV services only group. Compared with control groups, individuals in the SHARE intervention groups had fewer self-reports of past-year physical IPV (346 [16%] of 2127 responders in control groups vs 217 [12%] of 1812 responders in intervention groups; aPRR 0·79, 95% CI 0·67-0·92) and sexual IPV (261 [13%] of 2038 vs 167 [10%] of 1737; 0·80, 0·67-0·97). Incidence of emotional IPV did not differ (409 [20%] of 2039 vs 311 [18%] of 1737; 0·91, 0·79-1·04). SHARE had no effect on male-reported IPV perpetration. At follow-up 2 (after about 35 months) the intervention was associated with a reduction in HIV incidence (1·15 cases per 100 person-years in control vs 0·87 cases per 100 person-years in intervention group; aIRR 0·67, 95% CI 0·46-0·97, p=0·0362). INTERPRETATION SHARE could reduce some forms of IPV towards women and overall HIV incidence, possibly through a reduction in forced sex and increased disclosure of HIV results. Findings from this study should inform future work toward HIV prevention, treatment, and care, and SHAREs ecological approach could be adopted, at least partly, as a standard of care for other HIV programmes in sub-Saharan Africa. FUNDING Bill & Melinda Gates Foundation, US National Institutes of Health, WHO, Presidents Emergency Plan for AIDS Relief, Fogarty International Center.

Combined Intimate Partner Violence and HIV/AIDS Prevention in Rural Uganda: Design of the SHARE Intervention Strategy

Intimate partner violence (IPV) has a bidirectional relationship with HIV infection. Researchers from the Rakai Health Sciences Program (RHSP), an HIV research and services organization in rural Uganda, conducted a combination IPV and HIV prevention intervention called the Safe Homes and Respect for Everyone (SHARE) Project between 2005 and 2009. SHARE was associated with significant declines in physical and sexual IPV and overall HIV incidence, and its model could be adopted as a promising practice in other settings. In this article we describe how SHAREs IPV-prevention strategies were integrated into RHSPs existing HIV programming and provide recommendations for replication of the approach.

Risk and Protective Correlates of Young Women's First Sexual Experiences in Rakai, Uganda

CONTEXT Sexually active young women bear the brunt of the HIV epidemic in Sub-Saharan Africa. Information is needed on risk and protective correlates at the family, partner and individual level for the design of programs to encourage safer sexual behaviors and reduce HIV risk among young women. METHODS The study was conducted among 1,675 sexually experienced women aged 15-24 living in Rakai, Uganda. The sample was taken from an ongoing community cohort study initiated in 1994 in 56 villages by the Rakai Health Sciences Program. Contextual variabless at the family, partner and individual levels were analyzed in relation to three outcome variables: sex before the age of 15, coerced first sex and condom use at first sex. RESULTS At the family level, young females who did not live with both parents were more likely than those who did to have had sex before the age of 15 and to have experienced sexual coercion at first sex. Those whose mothers had some secondary education and whose female caregiver did not consume alcohol had elevated odds of using a condom at first sex. Having initiated sex at age 15 or older was the strongest individual-level characteristic associated with having used a condom at first sex. CONCLUSIONS Reproductive health interventions should target adolescents and their parents to delay the onset of sexual activity, prevent sexual coercion and encourage condom use. Both adolescents and their parents should be educated about the risks associated with different types of sexual partnerships.

Husband’s Alcohol Use, Intimate Partner Violence, and Family Maltreatment of Low-Income Postpartum Women in Mumbai, India

Husbands’ alcohol use has been associated with family-level stress and intimate partner violence (IPV) against women in India. Joint family systems are common in India and IPV often co-occurs with non-violent family maltreatment of wives (e.g., nutritional deprivation, deprivation of sleep, blocking access to health care). Alcohol use increases for some parents following the birth of a child. This study examined 1,038 postpartum women’s reports of their husbands’ alcohol use and their own experiences of IPV (by husband) and non-violent maltreatment from husbands and/or in-laws. We analyzed cross-sectional, quantitative data collected in 2008, from women (ages 15-35) seeking immunizations for their infants <6 months at three large urban health centers in Mumbai, India. Crude and adjusted logistic regression models estimated associations between the independent variable (husbands’ past month use of alcohol) and two dependent variables (postpartum IPV and maltreatment). Overall, 15% of husbands used alcohol, ranging from daily drinkers (10%) to those who drank one to two times per week (54%). Prevalence of postpartum IPV and family maltreatment was 18% and 42%, respectively. Prevalence of IPV among women married to alcohol users was 27%. Most abused women’s husbands always (27%) or sometimes (37%) drank during violent episodes. Risk for IPV increased with a man’s increasing frequency of consumption. Women who lived with a husband who drank alcohol, relative to non-drinkers, were more likely to report postpartum IPV, aOR = 2.0, 95% confidence interval (CI) = [1.3, 3.1]. Husbands’ drinking was marginally associated with increased risk for family maltreatment, aOR = 1.4, 95% CI = [1.0, 2.1]. Our findings suggest that men’s alcohol use is an important risk factor for postpartum IPV and maltreatment. Targeted services for Indian women contending with these issues are implicated. Postpartum care offers an ideal opportunity to screen for IPV, household maltreatment, and other health risks, such as husband’s use of alcohol. There is need to scale up proven successful interventions for reducing men’s alcohol use and design strategies that provide at-risk women protection from alcohol-related IPV.

Addressing Intimate Partner Violence Among Female Clients Accessing HIV Testing and Counseling Services: Pilot Testing Tools in Rakai, Uganda.

The World Health Organization recommends that HIV counseling and testing (HCT) programs implement strategies to address how intimate partner violence (IPV) influences women’s ability to protect themselves from and seek care and treatment for HIV infection. We discuss the process used to adapt a screening and brief intervention (SBI) for female clients of HCT services in Rakai, Uganda—a setting with high prevalence of both HIV and IPV. By outlining our collaborative process for adapting and implementing the SBI in Rakai and training counselors for its use, we hope other HCT programs will consider replicating the approach in their settings.

HIV-Risk Behaviors of Men Who Perpetrate Intimate Partner Violence in Rakai, Uganda

Little is known about men who perpetrate IPV in communities also at risk for HIV infection. Using data from the Rakai Community Cohort Study (RCCS), five survey rounds were used (n = 21,157, observation from n = 10,618 men) to examine HIV risk and prevention behaviors among men who reported acts of violence against their wife/primary partner in the past 12 months. Overall, 10.4% men reported perpetrating physical violence and 17.3% perpetrating verbal violence, 3.1% reported sexual violence, 3.1% used violence to have sex with their wife/partner, and 1.1% used verbal coercion. Factors associated with IPV were: age 20-24 years, lower socio-economic status, being married, no male circumcision, drinking alcohol before sex, no consistent condom use, multiple sex partners in the past 12 months, multiple partners ever, and working in a bar. Protective HIV behaviors predicted fewer reports of perpetration and HIV-risk behaviors predicted more reports of perpetrating IPV.

The impact of intimate partner violence on women's contraceptive use: Evidence from the Rakai Community Cohort Study in Rakai, Uganda

A systematic review of longitudinal studies suggests that intimate partner violence (IPV) is associated with reduced contraceptive use, but most included studies were limited to two time points. We used seven waves of data from the Rakai Community Cohort Study in Rakai, Uganda to estimate the effect of prior year IPV at one visit on womens current contraceptive use at the following visit. We used inverse probability of treatment-weighted marginal structural models (MSMs) to estimate the relative risk of current contraceptive use comparing women who were exposed to emotional, physical, and/or sexual IPV during the year prior to interview to those who were not. We accounted for time-fixed and time-varying confounders and prior IPV and adjusted standard errors for repeated measures within individuals. The analysis included 7923 women interviewed between 2001 and 2013. In the weighted MSMs, women who experienced any form of prior year IPV were 20% less likely to use condoms at last sex than women who had not (95% CI: 0.12, 0.26). We did not find evidence that IPV affects current use of modern contraception (RR: 0.99; 95% CI: 0.95, 1.03); however, current use of a partner-dependent method was 27% lower among women who reported any form of prior-year IPV compared to women who had not (95% CI: 0.20, 0.33). Women who experienced prior-year IPV were less likely to use condoms and other forms of contraception that required negotiation with their male partners and more likely to use contraception that they could hide from their male partners. Longitudinal studies in Rakai and elsewhere have found that women who experience IPV have a higher rate of HIV than women who do not. Our finding that women who experience IPV are less likely to use condoms may help explain the relation between IPV and HIV.

Process evaluation of the SHARE intervention for preventing intimate partner violence and HIV infection in Rakai, Uganda

The Safe Homes And Respect for Everyone (SHARE) intervention introduced an intimate partner violence (IPV) prevention approach into Rakai Health Sciences Program, an established HIV research and service organization in Uganda. A trial found exposure to SHARE was associated with reductions in IPV and HIV incidence. This mixed methods process evaluation was conducted between August 2007 and December 2009, with people living in SHARE intervention clusters, to assess awareness about/participation in SHARE, motivators and barriers to involvement, and perceptions of how SHARE contributed to behavior change. Surveys were conducted with 1407 Rakai Community Cohort Study participants. Qualitative interviews were conducted with 20 key informants. Most (77%) were aware of SHARE, among whom 73% participated in intervention activities. Two-thirds of those who participated in SHARE felt it influenced behavior change related to IPV. While some felt confident to take part in new IPV-focused activities of a well-established program, others were suspicious of SHAREs motivations, implying awareness raising is critical. Many activities appealed to the majority (e.g., community drama) while interest in some activities was limited to men (e.g., film shows), suggesting multiple intervention components is ideal for wide-reaching programming. The SHARE model offers a promising, acceptable approach for integrating IPV prevention into HIV and other established health programs in sub-Saharan Africa.

Female Gender and HIV Transmission Risk Behaviors Among People Living with HIV Who Have Ever Used Injection Drugs in St. Petersburg, Russia

Among persons who inject drugs, women have a higher HIV prevalence (than men) in many settings. Understanding how gender affects risk for infection among HIV-negative, and transmission among HIV-positive people who currently or previously injected drugs is key to designing effective prevention and treatment programs. We analyzed data from 291 persons living with HIV who had ever injected drugs. Participants were drawn from the Russia Alcohol Research Collaboration on HIV/AIDS cohort (2012–2015) to examine associations between female gender and HIV transmission risk. Primary outcomes were sharing drug injecting equipment (e.g., needle/syringes) and condomless sex. Secondary outcomes were alcohol use before sharing drug injecting equipment; before condomless sex; and both sharing drug injecting equipment and condomless sex. Logistic regression models assessed associations between gender and outcomes, controlling for demographics, partner HIV status and use of antiretroviral treatment. Female gender was not significantly associated with sharing drug injecting equipment [aOR = 1.45, 95% confidence interval (CI) 0.85–2.46, p value = 0.18] but was associated with condomless sex (aOR = 1.91, 95% CI 1.12–3.23, p = 0.02) in adjusted models. Female gender was not significantly associated with any secondary outcomes. Better understanding of risky sex and drug use behaviors among people who currently or previously injected drugs can support the design of effective gender-tailored HIV prevention interventions.