SHARE trial impacts on intimate partner violence and HIV incidence

Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.

Wagman JA, Gray RH, Campbell JC, Thoma M, Ndyanabo A, Ssekasanvu J, Nalugoda F, Kagaayi J, Nakigozi G, Serwadda D, Brahmbhatt H. Lancet Glob Health. 2015 Jan;3(1):e23-33. doi: 10.1016/S2214-109X(14)70344-4. Epub 2014 Nov 28.

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, 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.

Abstract  Full-text [free] access

Editor’s notes: There are a very limited number of programme trials that have illustrated impacts on HIV incidence. This trial adds to the evidence base. The Safe Homes and Respect for Everyone (SHARE) project, incorporates both community programming elements, to shift social norms on gender inequality and violence, along with a clinic based screening and brief activity, to promote safe HIV disclosure and risk reduction. This study showed that the SHARE project had an impact on women's experience of violence and HIV incidence. The findings suggest that, when compared with the provision of standard HIV treatment alone, SHARE plus HIV treatment had a significant impact on HIV incidence and women’s experiences of physical and sexual partner violence. The findings complement previous trials, that illustrate that intimate partner violence can be prevented, and strengthen the case for the need to invest in programmes to address gender inequality and violence as part of the HIV response. Further research is needed to better understand the pathways through which HIV incidence may have been reduced, especially given that the study did not document impacts on reported numbers of sexual partners or condom use.

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