Partner violence may undermine use of female-controlled forms of HIV prevention

Women who experience violence from their male partner are less likely to use condoms or diaphragms, an international team of investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Intimate partner violence (IPV) increased the risk of condom non-use by up to 47% and non-use of diaphragms by a quarter.

The authors believe the association between partner violence and not using a diaphragm could have implications for research into microbicides and other forms of HIV prevention under female control: “IPV is likely to impede adherence to HIV prevention interventions, even those that are specially designed to give women greater control over protecting their sexual health.”

HIV and intimate partner violence are highly prevalent in southern Africa. Previous research has shown that women who experience violence from a male partner are more likely to report inconsistent condom use, multiple sexual partners and to have higher rates of sexually transmitted infections and HIV.

“Women who experience IPV may be unsuccessful in their efforts to negotiate condoms, or be less likely to refuse sex or to suggest the use of condoms because they fear violence,” write the authors.

Female-initiated methods of HIV prevention can potentially give women more control over sexual decision-making. However, investigators were concerned that the real-world effectiveness of these interventions may be reduced for women experiencing intimate partner violence.

To see if this was the case they designed a 24-month longitudinal study involving 4505 women recruited to the Methods for Improving Reproductive Health in Africa (MIRA) study. Recruitment took place between 2003 and 2006 in South Africa and Zimbabwe. Participants were randomised to receive diaphragms, lubricant and condoms or condoms alone.

The women were interviewed about their experiences of intimate partner violence at baseline and again twelve and 24 months after randomisation. Data were gathered on adherence to diaphragm and condom use and the investigators explored the association between intimate partner violence and non-adherence.

Overall, 55% of women reported intimate partner violence during at least one follow-up visit.

Specifically, 41% reported fearing violence from their male partner, 34% reported that their male partner had emotionally abused them, 16% said their male partner had physically assaulted them and 15% reported that their male partner had forced them to have sex.

After adjusting for potential confounders, there was a significant relationship between intimate partner violence and condom non-adherence (intervention arm =  AOR, 1.47; 95% CI, 1.28-1.69; control arm =  AOR, 1.41; 95% CI, 1.24-1.61).

Experiencing intimate partner violence also associated with diaphragm non-adherence (AOR,1.24; 95% CI, 1.06-1.45).

At all study points, there was a significant relationship between partner violence and non-adherence to condom or diaphragm use.

Women in the control arm who experienced persisting (AOR, 2.02; 95% CI, 1.54-3.1) and incident partner violence (AOR, 1.69; 95% CI, 1.08-2.6) had higher odds of reporting condom non-adherence compared to women who did not report violence at baseline or at the twelve month follow-up visit.

Women in the intervention arm who reported persisting violence were significantly more likely than women who did not report intimate partner violence to report condom non-adherence (AOR, 1.53; 95% CI, 1.06-2.2) and diaphragm non-adherence (AOR, 2.0; 95% CI, 1.39-2.9).

“Interventions and policies that explicitly address IPV and the links to HIV infection risk are urgently needed,” comment the authors. “Research that identifies multilevel determinants of men’s perpetration of IPV and evaluates targeting young men and women should be a high priority.”