Justification of PrEP use as protection from rape

Negotiating the use of female-initiated HIV prevention methods in a context of gender-based violence: the narrative of rape.

Hartmann M, Montgomery E, Stadler J, Laborde N, Magazi B, Mathebula F, van der Straten A. Cult Health Sex. 2015 Nov 9:1-14. [Epub ahead of print]

Female-initiated methods of HIV prevention are needed to address barriers to HIV prevention rooted in gender inequalities. Understanding the sociocultural context of pre-exposure prophylaxis (PrEP) trials, including gender-based violence, is thus critical. MTN-003C (VOICE-C), a qualitative sub-study of the larger MTN-003 (VOICE) trial, examined sociocultural barriers and facilitators to PrEP amongst women in Johannesburg. We conducted focus-group discussions, in-depth interviews and ethnographic interviews with 102 trial participants, 22 male partners, 17 community advisory board members and 23 community stakeholders. We analysed how discussions of rape are emblematic of the gendered context in which HIV risk occurs. Rape emerged spontaneously in half of discussions with community advisory board members, two-thirds with stakeholders and among one-fifth of interviews/discussions with trial participants. Rape was used to reframe HIV risk as external to women's or partner's behaviour and to justify the importance of PrEP. Our research illustrates how women, in contexts of high levels of sexual violence, may use existing gender inequalities to negotiate PrEP use. This suggests that future interventions should simultaneously address harmful gender attitudes, as well as equip women with alternative means to negotiate product use, in order to more effectively empower women to protect themselves from HIV.

Abstract access [1] 

Editor’s notes: This paper presents qualitative research which explored the broader context of gender-based violence surrounding PrEP use. The study was an ancillary study alongside the VOICE trial at the South Africa site, which evaluated daily oral and vaginal PrEP. Participants in the ancillary study included women participants, male partners and community stakeholders. The authors found that the issue of rape was spontaneously mentioned by the majority of participants, with the exception of male partners. From these discussions of rape, issues of gender norms emerged, which revealed a continuum from what was called gender exploitative and gender accommodating. The context of gender exploitative was expressed as rape as a reflection of women’s vulnerability. In this context women’s vulnerability to rape and HIV provides a rationale for the use of PrEP. This includes protecting them against sexual violence victimisation. The study highlights that rape provides justification for the use of PrEP but reveals that such justification is complex in that women are seen as both vulnerable to rape but also blamed for rape through unacceptable behaviours including drinking alcohol. The authors conclude that the focus on rape by strangers hides women’s vulnerability to sexual violence from partners and argue that any move to legitimise PrEP for the threat of rape may undermine its use in consensual sex and reinforces negative gender norms about women’s vulnerability to strangers. They suggest that initiatives surrounding PrEP need to recognise and challenge harmful gender norms. This study has highlighted that while PrEP has not been imagined as a gendered HIV prevention tool, in contrast to microbicides, it does in fact emerge as a tool that will be gendered in potentially harmful ways. 

Africa [5]
South Africa [6]
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