Julia C. Kim

Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial.

BACKGROUND HIV infection and intimate-partner violence share a common risk environment in much of southern Africa. The aim of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study was to assess a structural intervention that combined a microfinance programme with a gender and HIV training curriculum. METHODS Villages in the rural Limpopo province of South Africa were pair-matched and randomly allocated to receive the intervention at study onset (intervention group, n=4) or 3 years later (comparison group, n=4). Loans were provided to poor women who enrolled in the intervention group. A participatory learning and action curriculum was integrated into loan meetings, which took place every 2 weeks. Both arms of the trial were divided into three groups: direct programme participants or matched controls (cohort one), randomly selected 14-35-year-old household co-residents (cohort two), and randomly selected community members (cohort three). Primary outcomes were experience of intimate-partner violence--either physical or sexual--in the past 12 months by a spouse or other sexual intimate (cohort one), unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months (cohorts two and three), and HIV incidence (cohort three). Analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT00242957. FINDINGS In cohort one, experience of intimate-partner violence was reduced by 55% (adjusted risk ratio [aRR] 0.45, 95% CI 0.23-0.91; adjusted risk difference -7.3%, -16.2 to 1.5). The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two (aRR 1.02, 0.85-1.23), and there was no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner (0.89, 0.66-1.19) or HIV incidence (1.06, 0.66-1.69) in cohort three. INTERPRETATION A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in programme participants. Social and economic development interventions have the potential to alter risk environments for HIV and intimate-partner violence in southern Africa.

Understanding the Impact of a Microfinance-Based Intervention on Women's Empowerment and the Reduction of Intimate Partner Violence in South Africa

OBJECTIVES We sought to obtain evidence about the scope of womens empowerment and the mechanisms underlying the significant reduction in intimate partner violence documented by the Intervention With Microfinance for AIDS and Gender Equity (IMAGE) cluster-randomized trial in rural South Africa. METHODS The IMAGE intervention combined a microfinance program with participatory training on understanding HIV infection, gender norms, domestic violence, and sexuality. Outcome measures included past years experience of intimate partner violence and 9 indicators of womens empowerment. Qualitative data about changes occurring within intimate relationships, loan groups, and the community were also collected. RESULTS After 2 years, the risk of past-year physical or sexual violence by an intimate partner was reduced by more than half (adjusted risk ratio=0.45; 95% confidence interval=0.23, 0.91). Improvements in all 9 indicators of empowerment were observed. Reductions in violence resulted from a range of responses enabling women to challenge the acceptability of violence, expect and receive better treatment from partners, leave abusive relationships, and raise public awareness about intimate partner violence. CONCLUSIONS Our findings, both qualitative and quantitative, indicate that economic and social empowerment of women can contribute to reductions in intimate partner violence.

Can social capital be intentionally generated? A randomized trial from rural South Africa

While much descriptive research has documented positive associations between social capital and a range of economic, social and health outcomes, there have been few intervention studies to assess whether social capital can be intentionally generated. We conducted an intervention in rural South Africa that combined group-based microfinance with participatory gender and HIV training in an attempt to catalyze changes in solidarity, reciprocity and social group membership as a means to reduce womens vulnerability to intimate partner violence and HIV. A cluster randomized trial was used to assess intervention effects among eight study villages. In this paper, we examined effects on structural and cognitive social capital among 845 participants and age and wealth matched women from households in comparison villages. This was supported by a diverse portfolio of qualitative research. After two years, adjusted effect estimates indicated higher levels of structural and cognitive social capital in the intervention group than the comparison group, although confidence intervals were wide. Qualitative research illustrated the ways in which economic and social gains enhanced participation in social groups, and the positive and negative dynamics that emerged within the program. There were numerous instances where individuals and village loan centres worked to address community concerns, both working through existing social networks, and through the establishment of new partnerships with local leadership structures, police, the health sector and NGOs. This is among the first experimental trials suggesting that social capital can be exogenously strengthened. The implications for community interventions in public health are further explored.

Is social capital associated with HIV risk in rural South Africa

The role of social capital in promoting health is now widely debated within international public health. In relation to HIV, the results of previous observational and cross-sectional studies have been mixed. In some settings it has been suggested that high levels of social capital and community cohesion might be protective and facilitate more effective collective responses to the epidemic. In others, group membership has been a risk factor for HIV infection. There have been few attempts to strengthen social capital, particularly in developing countries, and examine its effect on vulnerability to HIV. Employing data from an intervention study, we examined associations between social capital and HIV risk among 1063 14 to 35-year-old male and female residents of 750 poor households from 8 villages in rural Limpopo province, South Africa. We assessed cognitive social capital (CSC) and structural social capital (SSC) separately, and examined associations with numerous aspects of HIV-related psycho-social attributes, risk behavior, prevalence and incidence. Among males, after adjusting for potential confounders, residing in households with greater levels of CSC was linked to lower HIV prevalence and higher levels of condom use. Among females, similar patterns of relationships with CSC were observed. However, while greater SSC was associated with protective psychosocial attributes and risk behavior, it was also associated with higher rates of HIV infection. This work underscores the complex and nuanced relationship between social capital and HIV risk in a rural African context. We suggest that not all social capital is protective or health promotive, and that getting the balance right is critical to informing HIV prevention efforts.

Explaining continued high HIV prevalence in South Africa: socioeconomic factors, HIV incidence and sexual behaviour change among a rural cohort, 2001-2004

Objectives:To estimate HIV incidence and explore evidence for changing sexual behaviour over time among men and women belonging to different socioeconomic groups in rural South Africa. Design and methods:A cohort study conducted between 2001 and 2004; 3881 individuals aged 14–35 years enumerated in eight villages were eligible. At least three household visits were made to contact each eligible respondent at both timepoints. Sexual behaviour data were collected in structured, respondent-focused interviews. HIV serostatus was assessed using an oral fluid enzyme-linked immunosorbent assay at each timepoint. Results:Data on sexual behaviour were available from 1967 individuals at both timepoints. A total of 1286 HIV-negative individuals at baseline contributed to the analysis of incidence. HIV incidence was 2.2/100 person-years among men and 4.9/100 person-years in women, among whom it was highest in the least educated group. Median age at first sex was lower among later birth cohorts. A higher number of previously sexually active individuals reported having multiple partners in the past year in 2004 than 2001. Condom use with non-spousal partners increased from 2001 to 2004. Migrant men more often reported multiple partners. Migrant and more educated individuals of both sexes and women from wealthier households reported higher levels of condom use. Discussion:HIV incidence is high in rural South Africa, particularly among women of low education. Some risky sexual behaviours (early sexual debut, having multiple sexual partners) are becoming more common over time. Condom use is increasing. Existing HIV prevention strategies have only been partly effective in generating population-level behavioural change.

Gaining a foothold: tackling poverty, gender inequality, and HIV in Africa

Over half of adults infected with HIV in Africa are female—but poverty and social structures still prevent many women from protecting themselves The United Nations millennium development goals have set out specific targets for 2015, including commitments to reduce extreme poverty, increase womens empowerment, and reverse the spread of the HIV pandemic. In this respect, they clearly recognise what has been called the triple threat facing Africa: poverty, gender inequalities, and HIV and AIDS.1 Tackling these issues is clearly difficult, and many people have greeted these goals with a sense of scepticism and even futility. We describe why tackling poverty and gender inequalities is central to controlling the HIV pandemic in Africa and suggest how it might be achieved. Two years ago, the UN secretary general Kofi Annan declared that “AIDS has a womans face.”2 Echoing this statement, the Joint United Nations Programme on HIV and AIDS (UNAIDS) has highlighted women, girls, and HIV and AIDS as the theme for their most recent World AIDS Day campaign. Today, women account for nearly half the 40 million people living with HIV worldwide. In sub-Saharan Africa, 57% of adults with HIV are women, and young women aged 15 to 24 are more than three times as likely to be infected as young men.3 Contradictory analyses of Ugandas success in tackling HIV and AIDS have sparked debates over the relative prevention merits of promoting condoms, sexual fidelity, or abstinence. The United States has increased its funding for abstinence-only strategies, while the Catholic Church has questioned the efficacy of condoms, raising concerns about the influence of ideological or religious perspectives in shaping global priorities for prevention.4 Yet a larger question remains. Regardless of their point of emphasis, why are HIV prevention efforts continuing to fail women and girls? The prevention …

“THEY HAVE OPENED OUR MOUTHS”: INCREASING WOMEN’S SKILLS AND MOTIVATION FOR SEXUAL COMMUNICATION WITH YOUNG PEOPLE IN RURAL SOUTH AFRICA

Communication between parents and young people about sex has been identified as a positive influence on young peoples sexual behavior. This article presents findings from South Africa, where a social intervention to reduce levels of HIV and intimate partner violence actively promoted sexual communication between adults and young people. We assessed this component of the program using quantitative and qualitative methods, collecting data through surveys, direct observation, interviews, and focus group discussions. Women participating in intervention activities reported sexual communication with children significantly more often than matched women in the control group (80.3% vs. 49.4%, adjusted risk ratio 1.59 (1.31-1.93). The content of communication with young people also appears to have shifted from vague admonitions about the dangers of sex to concrete messages about reducing risks. The congruence between these findings and existing literature on parent-child sexual communication suggests that conceptual frameworks and programs from developed settings can be adapted effectively for resource-poor contexts.

Assessing household wealth in health studies in developing countries: a comparison of participatory wealth ranking and survey techniques from rural South Africa.

BackgroundAccurate tools for assessing household wealth are essential for many health studies in developing countries. Household survey and participatory wealth ranking (PWR) are two approaches to generate data for this purpose.MethodsA household survey and PWR were conducted among eight villages in rural South Africa. We developed three indicators of household wealth using the data. One indicator used PWR data only, one used principal components analysis to combine data from the survey, while the final indicator used survey data combined in a manner informed by the PWR. We assessed internal consistency of the indices and assessed their level of agreement in ranking household wealth.ResultsFood security, asset ownership, housing quality and employment were important indicators of household wealth. PWR, consisting of three independent rankings of 9671 households, showed a high level of internal consistency (intraclass correlation coefficient 0.81, 95% CI 0.79–0.82). Data on 1429 households were available from all three techniques. There was moderate agreement in ranking households into wealth tertiles between the two indicators based on survey data (spearman rho = 0.69, kappa = 0.43), but only limited agreement between these techniques and the PWR data (spearman rho = 0.38 and 0.31, kappa = 0.20 and 0.17).ConclusionBoth PWR and household survey can provide a rapid assessment of household wealth. Each technique had strengths and weaknesses. Reasons for differences might include data inaccuracies or limitations in the methods by which information was weighted. Alternatively, the techniques may measure different things. More research is needed to increase the validity of measures of socioeconomic position used in health studies in developing countries.

Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study

Problem Although international guidelines specify the central role of the health sector in providing comprehensive care, including HIV post-exposure prophylaxis (PEP), after sexual assault, in both industrialised and developing countries there are many challenges to providing timely and comprehensive services. Design A nurse driven model of post-rape care was integrated into existing hospital services; the before and after study design evaluated impacts on quality of care, reviewing 334 hospital charts and conducting interviews with 16 service providers and 109 patients. Setting 450 bed district hospital in rural South Africa. Key measures for improvement Quality of care after rape (forensic history and examination, provision of emergency contraception, prophylaxis for sexually transmitted infections, referrals); provision of HIV counselling and testing and provision and completion of full 28 day course of PEP; and service utilisation (number of service providers seen on first visit and number of rape cases presenting to hospital per month). Strategies for change After completing baseline research, we introduced a five part intervention model, consisting of a sexual violence advisory committee, hospital rape management policy, training workshop for service providers, designated examining room, and community awareness campaigns. Effect of change Existing services were fragmented and of poor quality. After the intervention, there were considerable improvements in clinical history and examination, pregnancy testing, emergency contraception, prophylaxis for sexually transmitted infections; HIV counselling and testing, PEP, trauma counselling, and referrals. Completion of the 28 day course of PEP drugs increased from 20% to 58%. Lessons learnt It is possible to improve the quality of care after sexual assault, including HIV prophylaxis, within a rural South African hospital at modest cost, using existing staff. With additional training, nurses can become the primary providers of this care.

Economic evaluation of a combined microfinance and gender training intervention for the prevention of intimate partner violence in rural South Africa

OBJECTIVE Assess the cost-effectiveness of an intervention combining microfinance with gender and HIV training for the prevention of intimate partner violence (IPV) in South Africa. METHODS We performed a cost-effectiveness analysis alongside a cluster-randomized trial. We assessed the cost-effectiveness of the intervention in both the trial and initial scale-up phase. RESULTS We estimated the cost per DALY gained as US