Association Between Health-Promoting Behaviors and Reproductive Health Needs in Women Experiencing Domestic Violence

Violence against women is considered as one of the most serious social problems in all the societies. It is common that the abused women experience physical, psychological, and health problems, as well as reproductive health issues. Domestic violence affects women's health behaviors and ability to seek any form of health care. This study aimed to investigate the relationship between health-promoting behaviors and reproductive health needs in women experienced domestic violence. This cross-sectional study was conducted from May 5 to September 21, 2021, on 380 abused women. Cluster sampling was performed in health centers of Karaj. Data were collected using demographic survey questions, Domestic Violence Survey, Reproductive Health Needs of Domestic Violated Women scale, and health-promoting behaviors questionnaire. The mean (standard deviation) scores for reproductive health needs and health-promoting behaviors were 158.88 (20.24) and 131.08 (20.53), respectively. Psychological violence had the highest (69.5%) prevalence among all types and 37.6% of women reported severe violence. The results of Spearman's rank correlation coefficient test indicated that all dimensions of the reproductive health needs of abused women (men's participation, self-care, support and health services, and sexual and marital relationships) positively and significantly related to the total score and various dimensions of health-promoting behaviors (interpersonal relationship, health responsibility, physical activity, spiritual growth, nutrition, and stress management). The dimensions of health-promoting behaviors together can explain 21.6% of the changes in reproductive health needs based on linear regression. Violence is a global public concern and paying attention to the various health dimensions in abused women is an important aspect of the health policies. Developing health-promoting behaviors in abused women improves their reproductive health state and society as a whole.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Sexual and Gender-Based Violence and Vulnerability to HIV Infection in Uganda: Evidence from Multilevel Modelling of Population-Level HIV/AIDS Data

Background: Sexual and gender-based violence (SGBV) is highly prevalent in Uganda and its link with HIV infection and compromising access to HIV/AIDS services is known. However, current evidence is controversial. Most of the studies indicate a positive relationship but a few indicate otherwise. Moreover, there is no research examining the effects of community-level SGBV on HIV infection. Objectives: This research explores the association between SGBV and vulnerability to HIV infection. Methods: Multilevel binary logistic regression is applied to secondary data of Uganda AIDS Indicators Survey conducted in 2011. The survey data comprises 12,153 women and 9588 men. Results: SGBV significantly increases the likelihood of HIV infection, with victims having 34%, 1.34 [1.06–1.70] higher odds than non-victims. At the community level, wealth, and pre-sex alcohol abuse are important determinants. Conclusions: Vulnerability to the risk of HIV infection in Uganda is associated with individual-level and community factors. Effective HIV prevention policies need to pay attention to victims of SGBV using individual- and community-level strategies.

An examination of physical violence against women and its justification in development settings in Uganda

This paper uses data from a community cross-sectional survey to examine the factors that are associated with justification of physical violence against women. Results indicate that respondents who were married at the time of the survey were less likely (OR = 0.29; CI = 0.17–0.52) to agree that it is justified for a man to physically assault his partner that their counterparts who were single. The likelihood to justify physical violence was less likely to happen among respondents with primary education (OR = 0.49; CI = 0.39–0.62), secondary education (OR = 0.40; CI = 0.31–0.53) and vocation or tertiary education (OR = 0.28; CI = 0.19–0.41) than among respondents with no education. Protestants were less likely (OR = 0.77; CI = 0.64–0.94) to justify physical violence than the Catholics. Respondents who were not formally employed were more likely (OR = 1.66; CI = 1.32–2.08) to justify physical violence than their counterparts who were in formal employment in the last three months preceding the survey. Respondents who agreed that it is okay for a man to control his partner’s movements (OR = 1.27; CI = 1.04–1.55), it is okay for a man to have sex with his wife anytime (OR = 2.28; CI = 1.87–2.78), alcohol is the main reason for violence against women (OR = 1.67; CI = 1.33–2.10), men need sex more than women (OR = 1.57; CI = 1.23–1.99) and women know where to obtain support in case of violence (OR = 1.42; CI = 1.00–2.02) were more likely to justify physical violence than respondents who disagreed. The likelihood to justify physical violence was less among respondents who agreed that: violence is not the only way to deal with disagreements (OR = 0.54; CI = 0.33–0.86), it is possible for men to stop violence (OR = 0.62; CI = 0.47–0.82) and it is acceptable for a woman to ask her partner to use a condom (OR = 0.61; CI = 0.51–0.73) than their counterparts who disagreed. There is need to increase investment in social norms change programmes in order to strengthen contestation of tolerance of physical violence among men and women in Uganda.

Ugandan Health Care Professionals' Response to Sexual Violence Survivors: Exploring Local Strategy and International Guidelines

This survey-based study gathered information on health professionals' attitudes and behaviors regarding victims of sexual assault, focusing on the applicability and utility of best practices put forth by the World Health Organization and the United Nations. This cross-sectional study involved a self-administered, 84-question survey to health care professionals affiliated with Mulago National Referral and Kayunga Hospitals in Uganda. The survey included demographic questions as well as questions about participants' attitudes toward sexual violence and the role of HPs in addressing sexual violence. The remainder of the survey transformed two sets of international guidelines into a series of statements with which participants could agree or disagree using a Likert-type scale. In total, 75 partially or fully completed surveys were collected, 45 from Mulago, and 30 from Kayunga. A minority of participants indicated that the guidelines were unrealistic (4.1%) or culturally inappropriate (14.1%). Most HPs agreed (91.8%) with the key components of recommended care. However, many respondents highlighted the need for additional training (68%). Nearly half of participants were uncertain or disagreed that there was a clear protocol for care of survivors of sexual violence (48%). Targets for improvement identified by participants included enhanced support of staff, access to resources, and relationships with community partners. Ugandan HPs have been receptive to the World Health Organization and United Nations guidelines. The majority of participants felt that the guidelines were realistic and culturally appropriate. Furthermore, many of these guidelines have been implemented. However, additional steps identified by Ugandan health workers could be undertaken to further improve the care received by survivors of sexual violence.

Experiences of violence among adolescent girls and young women in Nairobi's informal settlements prior to scale-up of the DREAMS Partnership: Prevalence, severity and predictors

Introduction

We sought to estimate the prevalence, severity and identify predictors of violence among adolescent girls and young women (AGYW) in informal settlement areas of Nairobi, Kenya, selected for DREAMS (Determined Resilient Empowered AIDS-free, Mentored and Safe) investment.

Methods

Data were collected from 1687 AGYW aged 10–14 years (n = 606) and 15–22 years (n = 1081), randomly selected from a general population census in Korogocho and Viwandani in 2017, as part of an impact evaluation of the “DREAMS” Partnership. For 10–14 year-olds, we measured violence experienced either in the past 6 months or ever using a different set of questions from those used for 15–22 year-olds. Among 15–22 year-olds we measured prevalence of violence, experienced in the past 12 months, using World Health Organization (WHO) definitions for violence typologies. Predictors of violence were identified using multivariable logit models.

Results

Among 606 girls aged 10–14 years, about 54% and 7% ever experienced psychological and sexual violence, respectively. About 33%, 16% and 5% experienced psychological, physical and sexual violence in the past 6 months. The 10–14 year old girls who engaged in chores or activities for payment in the past 6 months, or whose family did not have enough food due to lack of money were at a greater risk for violence. Invitation to DREAMS and being a non-Christian were protective. Among 1081 AGYW aged 15–22 years, psychological violence was the most prevalent in the past year (33.1%), followed by physical violence (22.9%), and sexual violence (15.8%). About 7% experienced all three types of violence. Severe physical violence was more prevalent (13.8%) than moderate physical violence (9.2%). Among AGYW aged 15–22 years, being previously married/lived with partner, engaging in employment last month, food insecure were all risk factors for psychological violence. For physical violence, living in Viwandani and being a Muslim were protective; while being previously married or lived with a partner, or sleeping hungry at night during the past 4 weeks were risk factors. The odds of sexual violence were lower among AGYW aged 18–22 years and among Muslims. Engaging in sex and food insecurity increased chances for sexual violence.

Conclusions

Prevalence of recent violence among AGYW is high in this population. This calls for increased effort geared towards addressing drivers of violence as an early entry point of HIV prevention effort in this vulnerable group.

Marital Rape and HIV Risk in Uganda: The Impact of Women's Empowerment Factors

This study used Uganda Demographic Health Survey data (2011) to examine the role of women's empowerment in reducing HIV risk among married women who experienced sexual violence in Uganda. The sample size was 8,674 ever-married women aged 15-49 years. Significant differences were revealed for marital rape, women's empowerment variables, and reducing HIV risk according to sociodemographic characteristics. Women's labor force participation partially mediated the relationship between sexual violence and reducing HIV risk, but decision making did not. Findings highlight the need for the development and implementation of policies and programs to address marital rape and reduce HIV risk within institutions of marriage.

Male partners of young women in Uganda: Understanding their relationships and use of HIV testing

BACKGROUND

Substantial concern exists about the high risk of sexually transmitted HIV to adolescent girls and young women (AGYW, ages 15-24) in Eastern and Southern Africa. Yet limited research has been conducted with AGYW's male sexual partners regarding their perspectives on relationships and strategies for mitigating HIV risk. We sought to fill this gap in order to inform the DREAMS Partnership and similar HIV prevention programs in Uganda.

METHODS

We conducted 94 in-depth interviews, from April-June 2017, with male partners of AGYW in three districts: Gulu, Mukono, and Sembabule. Men were recruited at community venues identified as potential transmission areas, and via female partners enrolled in DREAMS. Analyses focused on men's current and recent partnerships and HIV service use.

RESULTS

Most respondents (80%) were married and 28 years old on average. Men saw partner concurrency as pervasive, and half described their own current multiple partners. Having married in their early 20s, over time most men continued to seek out AGYW as new partners, regardless of their own age. Relationships were highly fluid, with casual short-term partnerships becoming more formalized, and more formalized partnerships characterized by periods of separation and outside partnerships. Nearly all men reported recent HIV testing and described testing at distinct relationship points (e.g., when deciding to continue a relationship/get married, or when reuniting with a partner after a separation). Testing often stemmed from distrust of partner behavior, and an HIV-negative status served to validate respondents' current relationship practices.

CONCLUSIONS

Across the three regions in Uganda, findings with partners of AGYW confirm earlier reports in Uganda of multiple concurrent partnerships, and demonstrate substantial HIV testing. Yet they also unearth the degree to which these partnerships are fluid (switching between casual and/or more long-term partnerships), which complicates potential HIV prevention strategies. Context-specific findings around these partnerships and risk are critical to further tailor HIV prevention programs.

Microfinance and health interventions: Factors influencing loan repayment success with young men in Dar es Salaam, Tanzania

Poverty is associated with numerous poor health outcomes. Youth unemployment in Tanzania is approximately 13.7%, and concentrates in urban areas. These youth lack relevant job skills and access to financial capital. Microfinance continues to be implemented globally to address poverty, and increasingly has been linked to health interventions. Men less frequently are recipients of microfinance loans. We offered microcredit to young men in an area of Dar es Salaam with high poverty as part of a randomised controlled-trial to assess the efficacy of a microfinance and health leadership intervention in preventing STI acquisition. We used mixed methods to understand predictors of successful loan repayment. Our qualitative sub-study showed that leader influence, prior business experience, personal motivation, and planning facilitated repayment. Using a modified Poisson approach, our quantitative analysis showed that successful repayment was associated with business experience, education, increasing number of children, community of residence, percentage of network members trained in business, and repayment success of peer leaders. Our results suggest that enforcing group accountability and repayment rules, offering ongoing training, and using successful entrepreneurs as role models could increase repayment success in similar populations. These strategies could provide financial opportunity for men while minimising risk for microfinance institutions.

Prevalência e fatores associados da violência sexual contra a mulher: revisão sistemática

La revisión se propuso identificar en la literatura la prevalencia y factores asociados con la violencia sexual (VS) contra las mujeres adolescentes y adultas. Se revisaron estudios poblacionales, publicados entre 2011 y 2016, en inglés, portugués y español, en las bases de datos PubMed/Medline, Lilacs y SciELO. Los estudios fueron descritos y analizados, detallando sus características e informaciones sobre prevalencia y factores asociados a la VS. Entre los 3 002 artículos encontrados, de acuerdo con los criterios de inclusión, 15 estudios fueron objetos de esta revisión. La mayoría de los estudios se concentran en Asia y África, que también presentan las mayores prevalencias de VS. El grupo de edad predominante fue de 15 a 49 años. Se observó una gran variación de la prevalencia de VS entre los países. Con respecto a la VS cometida por una persona íntima, ésta varió del 1 % en Alemania al 92 % en Zimbabue. En cuanto a los factores asociados, se destacan la baja escolaridad, la juventud, las condiciones de salud mental y la salud sexual y reproductiva, así como el uso de alcohol y otras drogas. La revisión muestra la necesidad de profundizar en estudios sobre la violencia sexual, para contribuir a las políticas públicas, a detener la violencia contra las mujeres y la equidad de género.

Inequitable Gender Norms From Early Adolescence to Young Adulthood in Uganda: Tool Validation and Differences Across Age Groups

PURPOSE

We aimed to describe and compare gender norms among 10- to 14-year-olds versus 15- to 24-year-olds and to conduct a rigorous evaluation of the GEM Scale's performance among these two age groups.

METHODS

We conducted a two-stage cluster-sampled survey among 387 females and 583 males, aged 10-24 years, in rural and urban communities near Kampala, Uganda. We applied, assessed, and adapted the GEM Scale (Pulerwitz and Barker, 2008), which measures views toward gender norms in four domains. We describe levels of support for (in)equitable norms, by gender and age, and associations with key health outcomes (partner violence). Confirmatory factor analysis and multi-group measurement invariance analysis were used to assess scale performance.

RESULTS

All participants reported high levels of support for inequitable gender norms; 10- to 14-year-olds were less gender equitable than their older counterparts. For example, 74% of 10- to 14-year-olds and 67% of 15- to 24-year-olds agreed that "a woman should tolerate violence to keep her family together." Comparing responses from males and females indicated similar support for gender inequity. Analyses confirmed a one-factor model, good scale fit for both age groups, and that several items from the scale could be dropped for this sample. The ideal list of items for each age group differed somewhat but covered all four scale domains in either case. An 18-item adapted scale was used to compare mean GEM Scale scores between the two age groups; responses were significantly associated with early sexual debut and partner violence.

CONCLUSIONS

Young people internalize gender norms about sexual and intimate relationships, and violence, at early ages. Programs to address negative health outcomes should explicitly address inequitable gender norms and more consistently expand to reach younger age groups. In this first application of the GEM Scale among 10- to 14-year-olds, we confirm that it is a valid measure in this setting.

Cost and cost-effectiveness analysis of a community mobilisation intervention to reduce intimate partner violence in Kampala, Uganda

BACKGROUND

Intimate partner violence (IPV) poses a major public health concern. To date there are few rigorous economic evaluations of interventions aimed at preventing IPV in low-income settings. This study provides a cost and cost effectiveness analysis of SASA!, a community mobilisation intervention to change social norms and prevent IPV.

METHODS

An economic evaluation alongside a cluster randomised controlled trial. Both financial and economic costs were collected retrospectively from the provider's perspective to generate total and unit cost estimates over four years of intervention programming. Univariate sensitivity analysis is conducted to estimate the impact of uncertainty in cost and outcome measures on results.

RESULTS

The total cost of developing the SASA! Activist Kit is estimated as US$138,598. Total intervention costs over four years are estimated as US$553,252. The annual cost of supporting 351 activists to conduct SASA! activities was approximately US$389 per activist and the average cost per person reached in intervention communities was US$21 over the full course of the intervention, or US$5 annually. The primary trial outcome was past year experience of physical IPV with an estimated 1201 cases averted (90% CI: 97-2307 cases averted). The estimated cost per case of past year IPV averted was US$460.

CONCLUSION

This study provides the first economic evaluation of a community mobilisation intervention aimed at preventing IPV. SASA! unit costs compare favourably with gender transformative interventions and support services for survivors of IPV.

TRIAL REGISTRATION

ClinicalTrials.gov # NCT00790959.

Perceptions of the effects of armed conflict on maternal and reproductive health services and outcomes in Burundi and Northern Uganda: a qualitative study

Background

Armed conflict potentially poses serious challenges to access and quality of maternal and reproductive health (MRH) services, resulting in increased maternal morbidity and mortality. The effects of armed conflict may vary from one setting to another, including the mechanisms/channels through which the conflict may lead to poor access to and quality of health services. This study aims to explore the effects of armed conflict on MRH in Burundi and Northern Uganda.

Methods

This is a descriptive qualitative study that used in-depth interviews (IDIs) and focus group discussions (FGDs) with women, health providers and staff of NGOs for data collection. Issues discussed include the effects of armed conflict on access and quality of MRH services and outcomes, and the mechanisms through which armed conflict leads to poor access and quality of MRH services. A total of 63 IDIs and 8 FGDs were conducted involving 115 participants.

Results

The main themes that emerged from the study were: armed conflict as a cause of limited access to and poor quality of MRH services; armed conflict as a cause of poor MRH outcomes; and armed conflict as a route to improved access to health care. The main mechanisms through which the conflict led to poor access and quality of MRH services varied across the sites: attacks on health facilities and looting of medical supplies in both sites; targeted killing of health personnel and favouritism in the provision of healthcare in Burundi; and abduction of health providers in Northern Uganda. The perceived effects of the conflict on MRH outcomes included: increased maternal and newborn morbidity and mortality; high prevalence of HIV/AIDS and SGBV; increased levels of prostitution, teenage pregnancy and clandestine abortion; and high fertility levels. Relocation to government recognised IDP camps was perceived to improve access to health services.

Conclusions

The effects of armed conflict on MRH services and outcomes are substantial. The mechanisms through which armed conflict leads to poor access and quality of MRH services vary from one setting to another. All these issues need to be considered in the design and implementation of interventions to improve MRH in these settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12914-015-0045-z) contains supplementary material, which is available to authorized users.

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 SHARE's 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, President's Emergency Plan for AIDS Relief, Fogarty International Center.