SHARE: a milestone in joint programming for HIV and intimate partner violence
Authors: Rachel K Jewkes
Journal: The Lancet Global Health (2014)

Intimate partner violence is highly prevalent in sub-Saharan Africa and its role in increasing women's risk of HIV acquisition is well recognised, although many aspects of the mechanisms through which HIV increases women's risk remain unclear.1Devries KM Mak JY Garcia-Moreno C Petzold M Child JC et al.Global health. The global prevalence of intimate partner violence against women.Science. 2013; 340: 1527-1528Crossref PubMed Scopus (850) Google Scholar, 2Jewkes RK Dunkle K Nduna M Shai N Intimate partner violence, relationship gender power inequity, and incidence of HIV infection in young women in South Africa: a cohort study.Lancet. 2010; 367: 41-48Summary Full Text Full Text PDF Scopus (846) Google Scholar, 3WHOGlobal and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. World Health Organisation, Geneva2013Google Scholar The most important challenge for researchers is to develop combination interventions that effectively reduce both the risk of HIV acquisition and the risk of intimate partner violence. Thus far there have been key trials in South Africa with the Stepping Stones4Jewkes R Nduna M Levin J et al.Impact of Stepping Stones on incidence of HIV, HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial.BMJ. 2008; 337: a506Crossref PubMed Scopus (549) Google Scholar intervention and the IMAGES study,5Pronyk P 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: 1973-1983Summary Full Text Full Text PDF PubMed Scopus (645) Google Scholar which combine microfinance and a gender intervention. However, both interventions reduced intimate partner violence but had no effect on HIV acquisition. In The Lancet Global Health, Jennifer Wagman and colleagues6Wagman JA Gray RH Campbell JC et al.Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.Lancet Glob Health. 2014; 3: e23-e33Summary Full Text Full Text PDF Scopus (180) Google Scholar report findings of their SHARE study in Rakai, Uganda—the first behavioural intervention to reduce both HIV incidence and intimate partner violence reported in women. SHARE is a multi-component intervention that involves mainly community action to change of social norms that support violence and to provide enhanced HIV counselling, including information on intimate partner violence and safety for women who test positive for HIV. It has been hypothesised that community-wide interventions that focus on social norm change are an important next direction for prevention of violence against women because, by definition, they intervene upstream and are positioned to change the conditions that might undermine sustainability of impact. An assessment of Sasa!, a similar intervention in Uganda, did not show significant effect on physical intimate partner violence, but this finding was probably because of insufficient power.7Abramsky T Devries K Kiss L et al.Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda.BMC Med. 2014; 12: 122Crossref PubMed Scopus (280) Google Scholar Wagman and colleagues'6Wagman JA Gray RH Campbell JC et al.Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.Lancet Glob Health. 2014; 3: e23-e33Summary Full Text Full Text PDF Scopus (180) Google Scholar findings provide important support for an intervention model. Although social norm change was not the only component of SHARE and the effect of enhanced counselling on women's risk of intimate partner violence is not known, it is hard to imagine that it was an important driver of the main finding given that only 56 women in the intervention communities in the study had seroconverted and so might have been using services. The intervention did not have a significant effect on self-reported male perpetration of intimate partner violence. Men could have been less honest in their disclosure of perpetration than were women, and this difference might have made their reports unreliable as an outcome. However, previous population-based studies generally note that women's reports of intimate partner violence tend to be the same as men or lower in prevalence than men's of perpetration, but perhaps what is seen here is a trial effect.8Fulu E Warner X Miedema S et al.Why do some men use violence against women and how can we prevent it. UN Development Programme, UN Population Fund, UN Women, UN Volunteers, Bangkok2013Google Scholar Assessments of interventions against violence have an inherent weakness in that biological measures do not exist to valuate self-reports. In view of the stressfull effect of home exposure to violence, a future development in the assessment of interventions against intimate partner violence should include biological markers of stress, (eg, cortisol) as an indicator of effect. Compared with individuals in control clusters given only standard HIV services, individuals in the SHARE intervention groups reported significantly less past-year physical (346 [16%] vs 217 [12%] in intervention groups; adjusted prevalence risk ratio 0·79, 95% CI 0·67–0·92) and sexual (261 [13%] vs 167 [10%]; 0·80, 0·67–0·97) intimate partner violence after 24 months. Findings were not significant at 12 months (follow-up 1). These findings support those of Stepping Stones Study4Jewkes R Nduna M Levin J et al.Impact of Stepping Stones on incidence of HIV, HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial.BMJ. 2008; 337: a506Crossref PubMed Scopus (549) Google Scholar and IMAGE trial,5Pronyk P 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: 1973-1983Summary Full Text Full Text PDF PubMed Scopus (645) Google Scholar both of which show that the effects of major interventions evolve with interventions rather than attenuate. This difference shows the need for researchers and donors to be mindful of the need for longer term follow-up in these trials to avoid prematurely negative findings. The evidence base for prevention interventions for intimate partner violence and dual programming to reduce HIV acquisition in sub-Saharan Africa is still very small. Assessments need to be replicated and translation research carried out into the conditions and inputs required to scale-up effects, and its cost and effectiveness. To advance, the specialty needs injections of donor funds to replicate proven interventions and increase evidence. In this regard, the Department for International Development global programme What Works to Prevent Violence Against Women and Girls could escalate the science of prevention of intimate partner violence and evidence of intervention outcomes in several regions worldwide. However, substantially more large-scale and long-term investment is needed to advance towards a goal of ending violence against women and girls. I am supported by the Medical Research Council of South Africa and have received funding from Department for International Development (DFID). This Comment is output from the What Works to Prevent Violence: a Global Programme, which is funded by UK Aid from the DFID. The views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them. Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohortSHARE 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. Full-Text PDF Open Access