Women in South Africa with violent male partners, or those who are in relationships with low equality, are more likely to become infected with HIV compared to women who do not experience such behaviour. Nearly one in seven new HIV infections could be prevented if women were not subjected to physical or sexual abuse or relationship inequalities, according to an Article published in this week's edition of The Lancet.
Previous research has shown a potential link between male partner violence, relationship inequalities, and increased risk of HIV infection in women. However, this evidence has not been substantiated by longitudinal research to support a causal association. This has limited the resources allocated to HIV prevention programmes and interventions that focus on gender issues, despite most new HIV infections in high prevalence areas occurring in women.
To further examine the effects of male partner violence and power inequity in relationships on incidence of HIV infection, Rachel Jewkes from the Medical Research Council in South Africa and colleagues did a longitudinal analysis of data from a randomised trial in South Africa. They studied 1099 young African women who were HIV negative at the start of the study and who had at least one subsequent HIV test over 2 years of follow-up. Women were given face-to-face interviews to assess exposure to violence and gender equality in their relationships.
Women in relationships with low equality at the start of the study had a higher incidence of HIV compared to women with medium or high relationship power (51 of 325 women vs 73 of 704 women). Additionally, women who reported more than one episode of abuse at the start of the study were more likely to acquire HIV than those who experienced one or no episodes of abuse (45 of 253 women vs 83 of 846 women).
The researchers estimated that if gender inequalities were improved so that no women were in relationships with low power, 13.9% of new HIV infections could be prevented. Additionally, 11.9% of new HIV infections could be avoided if women were not subjected to more than one episode of physical or sexual abuse by their partner.
The authors say: "This study provides strong temporal evidence to support a causal association between intimate partner violence or relationship inequity and HIV infection…Replicating this association in the context of trials to assess effective interventions should be a priority."
They conclude: "Organisations driving HIV prevention agendas for women, particularly UNAIDS and WHO, need to ensure that policies, programmes, and interventions to build gender equity and prevent partner violence are developed and widely implemented. Donors and researchers must invest in efforts and resources in developing and testing new interventions."
In a Comment, Jay Silverman from the Harvard School of Public Health, Boston, USA, says that these findings highlight the importance of altering gender-based abusive behaviour and the norms that drive both men's abuse and their sexual risk in order to prevent the transmission of HIV to women.
According to Silverman, because the fastest growing sector of those infected with HIV across Asia and Africa is women whose main risk factor is sex with a male partner, and there is a lack of "effective HIV-prevention programmes for women who fall outside of 'most at-risk populations'…the global HIV community must move to make targeting such male behaviours a central focus of prevention efforts."
Professor Rachel Jewkes, Medical Research Council, Pretoria, South Africa. T) +27 82 442 3655 (mobile) E) rjewkes@mrc.ac.za
Professor Jay Silverman, Harvard School of Public Health, Boston, USA. Please contact Todd Datz T) +1 617-998-8819 E) TDATZ@hsph.harvard.edu / jsilverm@hsph.harvard.edu
For full Article and Comment see: http://press.thelancet.com/equityhiv.pdf
Journal
The Lancet