Kalichman S, Simbayi L, Cloete A, et al. Integrated gender-based violence and HIV risk reduction intervention for South African men: Results of a quasi-experimental field trial. Prev Sci 2009 Apr 8. Epub.
To assess the effect of an intensive, integrated gender-based violence (GBV) and HIV risk-reduction intervention designed to reduce HIV risk behaviors and violence against women
A quasi-experimental design. Two demographically similar communities were selected and randomly assigned to receive either the experimental integrated GBV/HIV intervention or an alcohol/HIV risk-reduction intervention.
Two townships in Cape Town, South Africa
A total of 475 African men (242 in the GBV/HIV intervention group and 233 in the alcohol/HIV comparison group) were enrolled through chain recruitment. Participants were African men of Xhosa cultural heritage, were on average 30.2 years old, and had a mean of 10.8 years of education. The vast majority of men were unemployed (89%), 27 (6%) were married, and 234 (49%) had children. More than half had been tested for HIV, with 15 men (6% of tested) disclosing that they had tested positive for HIV infection. The two communities were relatively homogeneous, with differences indicated only for participant age (mean age 31.6 years in the GBV/HIV intervention group, 28.8 years in the comparison group; P=0.05) and history of domestic violence (56% of men in the GBV/HIV intervention group had hit or pushed a sex partner compared to 47% in the comparison group; P=0.05).
For both conditions, interventions were delivered in small groups consisting of 8 to 12 men per group. A total of 25 group cycles were conducted.
GBV/HIV intervention: The five-session GBV and HIV risk-reduction integrated intervention emphasized sexual transmission risk reduction and GBV reduction through skills building and personal goal setting. In each component of the intervention, men examined the personal and community consequences of gender violence and HIV/AIDS, explored behavioral alternatives, observed models of behavior change, and participated in skills-building activities. Activities also were geared toward addressing gender roles, particularly exploring meanings of masculinity and reducing adversarial attitudes toward women. Condom-use skills were trained through interactive group activities, and sexual communication skills were rehearsed in response to sexual risk scenarios. Participants provided feedback to each other in behavioral rehearsal enactments and worked toward setting goals for reduction of both GBV and HIV risk. The intervention also included a major segment on training men to become vocal advocates for risk-reduction behavior changes with other men in their community.
Alcohol/HIV intervention: The comparison intervention was a 3-hour, single-session HIV prevention intervention. The HIV/AIDS information/education component was similar to the GBV/HIV intervention. Alcohol use was integrated by adapting the World Health Organization's brief alcohol intervention model. Alcohol use in sexual contexts was specifically discussed in relation to risk situations. The final component of the workshop focused on behavioral self-management and sexual communication skills-building exercises. This intervention did not address GBV and it did not include a peer advocacy component.
Sexual risk and GBV behaviors, collected through self-administered questionnaire at 1 month, 3 months and 6 months post-intervention
Sexual risk behaviors: Participants reported that the number of their male and female sex partners and the frequency of vaginal and anal intercourse occasions in the past 1-month and 3-month time frames. Consistent condom use was defined as 100% of intercourse occasions protected by condoms. Participants also reported whether they had talked with a sex partner about condoms in the past 1-month and 3-month periods. Participants indicated whether they drank alcohol before sex and if they had met sex partners at informal drinking establishments.
GBV behaviors: Participants were asked whether they had lost their temper with a woman in the previous month and whether they had hit or pushed a sex partner in the previous month. To assess acceptance of violence against women, a seven-item scale was administered. Example items include "A woman who talks disrespectfully to a man in public should expect trouble," "There are times when a man should hit a woman because of things she has done," and "A woman who teases a man sexually and doesn't finish what she started deserves what she gets." Items were responded to on a four-point scale (1= Strongly disagree, 4= Strongly agree) with higher mean scores representing greater acceptance of violence against women.
Both interventions demonstrated positive effects on some of the outcomes
Sexual risk behaviors: There was limited evidence for enhanced HIV risk reduction in the GBV/HIV integrated intervention. Men in the GBV/HIV condition talked with their partners about condoms more (baseline 4.2%; 1-month follow-up 6.8%) than did men in the alcohol/HIV comparison condition (baseline 3.5%, 1-month follow-up 7.3%; P=0.05) and were significantly more likely to have been tested for HIV at the 1-month (odds ratio [OR]=2.5; 95% confidence interval [CI]: 1.25-5.0) and 3-month follow-ups (OR=2.0; 95% CI: 1.11-3.33). The alcohol/HIV condition reported fewer alcohol-involved sexual encounters (1-month: GBV/HIV 4.0, alcohol/HIV 1.8; P=0.05), and greater condom use (1-month: OR=1.7; 95% CI: 1.1-2.7) than did the GBV/HIV condition at the short-term follow-ups.
GBV behaviors: Men in the GBV/HIV intervention indicated significantly less acceptance of violence against women at the 1-month follow-up assessment (2.2 on the 7-item scale for the alcohol/HIV intervention vs. 2.4 for the GBV/HIV intervention; P=0.05), with the difference no longer significant at the subsequent assessments. In addition, men in the
GBV/HIV intervention were significantly less likely to have lost their temper with a woman 1 month (OR=0.5, 95% CI: 0.3-0.7) and 6 months (OR=0.5, 95% CI: 0.3-0.8) following the intervention. Men in the GBV/HIV intervention also were significantly less likely to have hit or pushed a sex partner at the 6-month assessment (OR=0.3, 95% CI: 0.2-0.4).
The authors conclude that an intervention model that addresses alcohol use in relation to both GBV and HIV/AIDS behavioral risks may prove most promising.
This study was of low quality. It is primarily limited by the use of a two-community quasi-experimental design. Although the two communities were fairly homogeneous, the study design did not randomize participants to conditions. Relying on two communities randomized to two conditions yields an inherently weak study design, particularly in terms of examining individual-level behavior change. Furthermore, although retention was high in both communities, there were differences between the two groups, with 95% of men in the experimental community and 87% of men in the comparison community completing 6-month follow-ups (P=0.01). The study also was limited by the reliance entirely on self-reported behaviors, most of which are socially sanctioned. Because reports of sexual risks and domestic violence behaviors may be sensitive to social desirability influences, the rates of risk and violent behaviors observed in this study should be considered lower-bound estimates.
Although few in number, there are community-based programs that target men for HIV risk-reduction in South Africa. The Men as Partners in Reproductive Health (MAP) is a program throughout southern Africa that engages small groups of men for five consecutive full-day workshops that address gender-based violence, attitudes toward women, and HIV and sexually transmitted infection (STI) risk reduction.(1) Although widely implemented, the MAP program has no published outcomes evaluations. Another program that focuses on younger men, Stepping Stones, has been tested in a randomized trial in South Africa, and outcomes showed that the program did not reduce HIV transmission, although there were significant gains in preventing herpes simplex virus (HSV) transmission, increasing condom use, reducing number of unprotected sex acts, and reducing incidents of GBV.(2) Given the pattern of results, the lack of HIV prevention outcomes in this trial is perplexing, especially because the study was designed for sufficient statistical power to detect changes in HIV incidence. Addressing GBV for HIV prevention also is a focus of structural interventions, such as those that empower women with financial independence to reduce GBV.(3,4,5) Alcohol also is a known risk correlate to both HIV/AIDS and GBV. Interventions that directly address alcohol in relation to sexual risks have demonstrated short-term efficacy in previous intervention trials in South Africa.(6) The results of the reviewed study indicate that a combined approach to address alcohol use, HIV risk, and GBV may have a synergistic effect.
The results suggest that there may be benefits to be gained from both types of interventions. There is a need for future research to examine more complex integrated models, such as a tripartite intervention approach that integrates alcohol reduction, gender violence prevention, and HIV risk reduction for men.
- Peacock D, Levack A. The Men as Partners program in South Africa: Reaching men to end gender-based violence and promote sexual and reproductive health. Int J Men Health 2004;3:173-88. Abstract not available.
- Jewkes R, Nduna M, Levin J, et al. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial. BMJ 2008;337:a506.
- Andersson N, Cockcroft A, Shea B. Gender-based violence and HIV: Relevance for HIV prevention in hyperendemic countries of southern Africa. AIDS 2008;22:S73-S86.
- Jan S, Pronyk P, Kim J. Accounting for institutional change in health economics evaluation: A program to tackle HIV/AIDS and gender violence in Southern Africa. Soc Sci Med 2008;66, 922-32.
- Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: A cluster randomised trial. Lancet 2006;368:1973-83.
- Kalichman SC, Simbayi LC, Kaufman M, Cain D, Jooste S. Alcohol and HIV/AIDS risk behaviors in southern Africa: Systematic review of empirical findings. Prev Sci 2007;8:141-51.