Title: Intimate Partner Violence, Behaviours Associated with Risk of HIV Acquisition and
Condom Use in Married Women in Manicaland, East Zimbabwe: An HIV Prevention Cascade
Analysis
Version: 1 Date: 16 Sep 2024
Reviewer:  Robin Schaefer
Reviewer's report:
I thank the editors for inviting us to review this important study on intimate partner violence and
HIV risks among married women in Zimbabwe. The authors provide a comprehensive analysis
of the complex link between IPV and HIV acquisition risks and, further, use the concept of
HIV prevention cascades to highlight possible areas of intervention. The article is well-written
and conclusions are supported by sound analyses, making it a meaningful contribution to the
literature. Below, I provide suggestions on how to strengthen the manuscript further.
Background
- First paragraph and throughout: Please note that there is no “WHO sub-Saharan African
region”. There is only a WHO African region, which largely comprises countries south of the
Sahara. I would suggest to avoid the term sub-Saharan Africa throughout and use “WHO African
region” or “African region” instead. The WHO African region is objectively defined and does
not have the same colonial and racial connotations as sub-Saharan Africa.
- First paragraph: Avoid language such as “unequivocal” as this is subjective.
- Second paragraph and throughout: Avoid the term “HIV-positive women” (and similar terms)
but speak of women living with HIV.
- Second paragraph: Please rephrase the sentence on prevalence of IPV in Zimbabwe as it is not
clear the two percentages refer to (is it 34% sexual violence and 13.5% physical violence?).
- Fourth paragraph: It may be worthwhile to expand on the existing clinical trial evidence for
IPV-related interventions. We know that structural interventions have largely been found to not
result in HIV incidence reductions but they may still have significant impact on other behavioural
or socio-economic factors associated with HIV incidence.
- Fourth paragraph and throughout: I suggest avoiding the term “sexual risk behaviour”
altogether. It unnecessarily labels some behaviours as ‘risky’, which can be considered
stigmatizing. Instead, one can just speak of sexual behaviour in a neutral way, such as
“behaviours associated with HIV acquisition risk”.
- Fourth paragraph: The HIV prevention cascade is mentioned at the end of the paragraph, but a
brief description of the concept should be included. This would be particularly helpful as some
details are mentioned in the methods (2.3.4) without further explanation.
Methods
- Study setting: The last sentence notes that married women accounted for 17% of all new
infections in women aged 15-54. Is this correct? So 83% of infections were in unmarried women?
This is confusing as the study focuses on married women as a priority population.
- Table 1: The questions outlined in the table seem to miss the introductory part (e.g., something
like “have you experienced any of the following”). Please check and complete. Please also
include a reference to the source of these questions (2.3.1 mentions “UNAIDS questions”).
Results
- The whole article is relatively long (almost 5000 words for the main body) and particularly
the results section could be shortened. It is relatively difficult to follow and the described results
can all be found in the included tables. This would improve the overall readability of the article.
Discussion
- First paragraph and elsewhere: I suggest rephrasing the wording around women being “in need”
of HIV prevention methods. This could be seen as paternalistic. Rather, I suggest a phrasing
such as “women who could benefit from HIV prevention methods”.
- Third paragraph: The background section mentions that one survey found that 34% of women
have experienced sexual and/or physical violence in Zimbabwe, so the current study seemed to
have found a lower prevalence, not higher. Please clarify.
- While the authors mention “other efficacious HIV prevention methods”, the article’s sole
focus on condoms almost feels anachronistic, and I encourage some further discussion of the
implications of increasing availability of different PrEP options. I recognize that PrEP use was
very limited during the study period, but rollout has increased significantly since, and Zimbabwe
has been at the forefront of adopting new options. Of course, biomedical prevention options
alone are insufficient to end HIV epidemics – and there is value in addressing IPV unrelated to
the impact of HIV – but these new prevention options are relevant given their women-initiated/-
controlled and discreet nature.