Rachel Jewkes

Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa

BACKGROUND Gender-based violence and gender inequality are increasingly cited as important determinants of womens HIV risk; yet empirical research on possible connections remains limited. No study on women has yet assessed gender-based violence as a risk factor for HIV after adjustment for womens own high-risk behaviours, although these are known to be associated with experience of violence. METHODS We did a cross-sectional study of 1366 women presenting for antenatal care at four health centres in Soweto, South Africa, who accepted routine antenatal HIV testing. Private face-to-face interviews were done in local languages and included assessement of sociodemographic characteristics, experience of gender-based violence, the South African adaptation of the Sexual Relationship Power Scale (SRPS), and risk behaviours including multiple, concurrent, and casual male partners, and transactional sex. FINDINGS After adjustment for age and current relationship status and womens risk behaviour, intimate partner violence (odds ratio 1.48, 95% CI 1.15-1.89) and high levels of male control in a womans current relationship as measured by the SRPS (1.52, 1.13-2.04) were associated with HIV seropositivity. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV serostatus. INTERPRETATION Women with violent or controlling male partners are at increased risk of HIV infection. We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships, and HIV risk behaviours in men, as well as effective interventions, are urgently needed.

Intimate partner violence: causes and prevention

Unlike many health problems, there are few social and demographic characteristics that define risk groups for intimate partner violence. Poverty is the exception and increases risk through effects on conflict, womens power, and male identity. Violence is used as a strategy in conflict. Relationships full of conflict, and especially those in which conflicts occur about finances, jealousy, and womens gender role transgressions are more violent than peaceful relationships. Heavy alcohol consumption also increases risk of violence. Women who are more empowered educationally, economically, and socially are most protected, but below this high level the relation between empowerment and risk of violence is non-linear. Violence is frequently used to resolve a crisis of male identity, at times caused by poverty or an inability to control women. Risk of violence is greatest in societies where the use of violence in many situations is a socially-accepted norm. Primary preventive interventions should focus on improving the status of women and reducing norms of violence, poverty, and alcohol consumption.

The health and health system of South Africa: historical roots of current public health challenges

The roots of a dysfunctional health system and the collision of the epidemics of communicable and non-communicable diseases in South Africa can be found in policies from periods of the countrys history, from colonial subjugation, apartheid dispossession, to the post-apartheid period. Racial and gender discrimination, the migrant labour system, the destruction of family life, vast income inequalities, and extreme violence have all formed part of South Africas troubled past, and all have inexorably affected health and health services. In 1994, when apartheid ended, the health system faced massive challenges, many of which still persist. Macroeconomic policies, fostering growth rather than redistribution, contributed to the persistence of economic disparities between races despite a large expansion in social grants. The public health system has been transformed into an integrated, comprehensive national service, but failures in leadership and stewardship and weak management have led to inadequate implementation of what are often good policies. Pivotal facets of primary health care are not in place and there is a substantial human resources crisis facing the health sector. The HIV epidemic has contributed to and accelerated these challenges. All of these factors need to be addressed by the new government if health is to be improved and the Millennium Development Goals achieved in South Africa.

Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study

BACKGROUND Cross-sectional studies have shown that intimate partner violence and gender inequity in relationships are associated with increased prevalence of HIV in women. Yet temporal sequence and causality have been questioned, and few HIV prevention programmes address these issues. We assessed whether intimate partner violence and relationship power inequity increase risk of incident HIV infection in South African women. METHODS We did a longitudinal analysis of data from a previously published cluster-randomised controlled trial undertaken in the Eastern Cape province of South Africa in 2002-06. 1099 women aged 15-26 years who were HIV negative at baseline and had at least one additional HIV test over 2 years of follow-up were included in the analysis. Gender power equity and intimate partner violence were measured by a sexual relationship power scale and the WHO violence against women instrument, respectively. Incidence rate ratios (IRRs) of HIV acquisition at 2 years were derived from Poisson models, adjusted for study design and herpes simplex virus type 2 infection, and used to calculate population attributable fractions. FINDINGS 128 women acquired HIV during 2076 person-years of follow-up (incidence 6.2 per 100 person-years). 51 of 325 women with low relationship power equity at baseline acquired HIV (8.5 per 100 person-years) compared with 73 of 704 women with medium or high relationship power equity (5.5 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 95% CI 1.05-2.17, p=0.027. 45 of 253 women who reported more than one episode of intimate partner violence at baseline acquired HIV (9.6 per 100 person-years) compared with 83 of 846 who reported one or no episodes (5.2 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 1.04-2.21, p=0.032. The population attributable fractions were 13.9% (95% CI 2.0-22.2) for relationship power equity and 11.9% (1.4-19.3) for intimate partner violence. INTERPRETATION Relationship power inequity and intimate partner violence increase risk of incident HIV infection in young South African women. Policy, interventions, and programmes for HIV prevention must address both of these risk factors and allocate appropriate resources. FUNDING National Institute of Mental Health and South African Medical Research Council.

Impact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial

Objective To assess the impact of Stepping Stones, a HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour. Design Cluster randomised controlled trial. Setting 70 villages (clusters) in the Eastern Cape province of South Africa. Participants 1360 men and 1416 women aged 15-26 years, who were mostly attending schools. Intervention Stepping Stones, a 50 hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2. Main outcome measures Primary outcome measure: incidence of HIV. Other outcomes: incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse. Results There was no evidence that Stepping Stones lowered the incidence of HIV (adjusted incidence rate ratio 0.95, 95% confidence interval 0.67 to 1.35). The programme was associated with a reduction of about 33% in the incidence of HSV-2 (0.67, 0.46 to 0.97; P=0.036)—that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1000 people exposed. Stepping Stones significantly improved a number of reported risk behaviours in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women desired behaviour changes were not reported and those in the Stepping Stones programme reported more transactional sex at 12 months. Conclusion Stepping Stones did not reduce incidence of HIV but had an impact on several risk factors for HIV—notably, HSV-2 and perpetration of intimate partner violence. Trial Registration Clinical Trials NCT00332878.

The epidemiology of rape and sexual coercion in South Africa: an overview.

During 1999 the issue of rape in South Africa was debated at the highest levels. The epidemiology of rape has become an issue of considerable political importance and sensitivity, with President Mbeki demanding an answer to the question: how much rape is there in South Africa? The purpose of this paper is both to summarise and synthesise the findings of research to provide an overview of the epidemiology of rape of women in South Africa and to show how difficult it is to answer the Presidents question. The review begins by considering why rape is so difficult to research. Data available shows that rape reported to the police (240 incidents of rape and attempted rape per 100,000 women each year) represents the tip of an ice berg of sexual coercion. Representative community-based surveys have found, for example, that in the 17-48 age group there are 2070 such incidents per 100,000 women per year. Non-consensual sex in marriage and dating relationships is believed to be very common but is usually not well reported in surveys. Forced sexual initiation is reported by almost a third of adolescent girls. In addition coerced consensual sex is a common problem in schools, workplaces and amongst peers. Knowledge of causal and contributory factors influencing the high levels of rape are also discussed. We conclude that the rape statistic for the country is currently elusive but levels of non-consensual and coerced sex are clearly very high. International comparison needs to be approached with caution because most developing countries lack the infrastructure for accurate crime reporting and do not have such a substantial body of survey data.

Violence and injuries in South Africa: prioritising an agenda for prevention

Violence and injuries are the second leading cause of death and lost disability-adjusted life years in South Africa. The overall injury death rate of 157.8 per 100,000 population is nearly twice the global average, and the rate of homicide of women by intimate partners is six times the global average. With a focus on homicide, and violence against women and children, we review the magnitude, contexts of occurrence, and patterns of violence, and refer to traffic-related and other unintentional injuries. The social dynamics that support violence are widespread poverty, unemployment, and income inequality; patriarchal notions of masculinity that valourise toughness, risk-taking, and defence of honour; exposure to abuse in childhood and weak parenting; access to firearms; widespread alcohol misuse; and weaknesses in the mechanisms of law enforcement. Although there have been advances in development of services for victims of violence, innovation from non-governmental organisations, and evidence from research, there has been a conspicuous absence of government stewardship and leadership. Successful prevention of violence and injury is contingent on identification by the government of violence as a strategic priority and development of an intersectoral plan based on empirically driven programmes and policies.

He forced me to love him: putting violence on adolescent sexual health agendas

Violence against women within sexual relationships is a neglected area in public health despite the fact that, in partially defining womens capacity to protect themselves against STDs, pregnancy and unwanted sexual intercourse, it directly affects female reproductive health. This paper presents the findings of a qualitative study conducted among Xhosa-speaking adolescent women in South Africa which revealed male violent and coercive practices to dominate their sexual relationships. Conditions and timing of sex were defined by their male partners through the use of violence and through the circulation of certain constructions of love, intercourse and entitlement to which the teenage girls were expected to submit. The legitimacy of these coercive sexual experiences was reinforced by female peers who indicated that silence and submission was the appropriate response. Being beaten was such a common experience that some peers were said to perceive it to be an expression of love. Informants indicated that they did not terminate the relationships for several reasons: beyond peer pressure and the probability of being subjected to added abuse for trying to end a relationship, teenagers said that they perceived that their partners loved them because they gave them gifts of clothing and money. The authors argue that violence has been particularly neglected in adolescent sexuality arenas, and propose new avenues for sexuality research which could inform the development of much-needed adolescent sexual health interventions.

Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study

The aim of the paper is to investigate associations between a range of markers of gender inequity, including financial, psychological and physical violence, and two proximal practices in HIV prevention, namely discussion of HIV between partners and the woman suggesting condom use. The paper presents an analysis of data from a cross-sectional study of a representative sample of women from three South African Provinces which was primarily undertaken as an epidemiological study of gender-based violence. A multi-stage sampling design was used with clusters sampled with probability proportional to number of households. Households were randomly selected from within clusters. One randomly selected woman aged 18-49 years was interviewed in each selected home. One thousand three hundred and six women were interviewed (90.3% of eligible women). One thousand one hundred sixty four women had a partner in the previous year and were asked questions related to HIV prevention and gender inequalities in the relationship. The results indicate that discussion of HIV was significantly positively associated with education, living in Mpumalanga Province, the man being a migrant, the woman having multiple partners in the past year and having no confidante. It was significantly negatively associated with living in the Northern Province, the relationship being poor and there being a substantial age difference between partners. The woman suggesting condom use was significantly positively associated with her education, her having multiple partners, domestic violence prior to the past year and financial abuse. It was negatively associated with the relationship being poor. We conclude that this suggests that some indicators of gender inequalities are significantly associated with discussion of HIV and condom use but the direction of association found was both positive and negative. This highlights the need for a more nuanced understanding of gender inequalities and their relationship to HIV risk. Suggestions for key research questions are made.

Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa

Objectives:To examine associations between the perpetration of intimate partner violence and HIV risk behaviour among young men in rural South Africa. Design:An analysis of baseline data from men enrolling in a randomized controlled trial of the behavioural intervention, Stepping Stones. Methods:Structured interviews with 1275 sexually experienced men aged 15–26 years from 70 villages in the rural Eastern Cape. Participants were asked about the type, frequency, and timing of violence against female partners, as well as a range of questions about HIV risk behaviours. Results:A total of 31.8% of men reported the perpetration of physical or sexual violence against female main partners. Perpetration was correlated with higher numbers of past year and lifetime sexual partners, more recent intercourse, and a greater likelihood of reporting casual sex partners, problematic substance use, sexual assault of non-partners, and transactional sex. Men who reported both physical and sexual violence against a partner, perpetration both before and within the past 12 months, or more than one episode of perpetration reported significantly higher levels of HIV risk behaviour than men who reported less severe or less frequent perpetration of violence. Conclusion:Young men who perpetrate partner violence engage in significantly higher levels of HIV risk behaviour than non-perpetrators, and more severe violence is associated with higher levels of risky behaviour. HIV prevention interventions must explicitly address the links between the perpetration of intimate partner violence and HIV risk behaviour among men, as well as the underlying gender and power dynamics that contribute to both.