Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial

Summary

Background

HIV infection and intimate-partner violence share a common risk environment in much of southern Africa. The aim of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study was to assess a structural intervention that combined a microfinance programme with a gender and HIV training curriculum.

Methods

Villages in the rural Limpopo province of South Africa were pair-matched and randomly allocated to receive the intervention at study onset (intervention group, n=4) or 3 years later (comparison group, n=4). Loans were provided to poor women who enrolled in the intervention group. A participatory learning and action curriculum was integrated into loan meetings, which took place every 2 weeks. Both arms of the trial were divided into three groups: direct programme participants or matched controls (cohort one), randomly selected 14–35-year-old household co-residents (cohort two), and randomly selected community members (cohort three). Primary outcomes were experience of intimate-partner violence—either physical or sexual—in the past 12 months by a spouse or other sexual intimate (cohort one), unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months (cohorts two and three), and HIV incidence (cohort three). Analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT00242957.

Findings

In cohort one, experience of intimate-partner violence was reduced by 55% (adjusted risk ratio [aRR] 0·45, 95% CI 0·23–0·91; adjusted risk difference −7·3%, −16·2 to 1·5). The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two (aRR 1·02, 0·85–1·23), and there was no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner (0·89, 0·66–1·19) or HIV incidence (1·06, 0·66–1·69) in cohort three.

Interpretation

A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in programme participants. Social and economic development interventions have the potential to alter risk environments for HIV and intimate-partner violence in southern Africa.

Introduction

HIV/AIDS and intimate-partner violence are major public-health challenges in southern Africa. In South Africa alone, almost 30% of women who visited public antenatal clinics in 2004 were HIV positive.¹ National prevalence surveys suggest that women and girls make up 55% of all infections.² Furthermore, one in four South African women report having been in an abusive relationship,³ and violence has been identified as an independent risk factor for HIV infection.⁴

Underdevelopment, lack of economic opportunities for both sexes, and entrenched inequalities in the distribution of power, resources, and responsibilities between men and women (gender inequalities) create a risk environment that supports high levels of both HIV infection and intimate-partner violence.5, 6, 7, 8, 9, 10, 11, 12 Structural interventions seek to affect risk environments by altering the context in which ill-health occurs.¹³ Such interventions address upstream determinants of health and have the potential to affect multiple endpoints.¹⁴ Although structural interventions are increasingly regarded to be important in the prevention of HIV infection and intimate-partner violence, few have been rigorously assessed in developing countries.15, 16, 17

Microfinance is a development method that provides loans to poor households for income generation. With nearly 100 million clients worldwide,¹⁸ such programmes have the potential to reduce poverty, empower participants, and improve health.19, 20 Furthermore, the benefits of microfinance can diffuse to non-participants who reside in programme areas, lending support to the wider adoption of health practices.²¹

The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study combined a poverty-focused microfinance initiative that targeted the poorest women in communities with a participatory curriculum of gender and HIV education. Our aim was to determine whether the involvement of women in the programme would improve household economic wellbeing, social capital, and empowerment and thus reduce vulnerability to intimate-partner violence. We also aimed to assess whether such measures could raise levels of communication and collective action on HIV and gender issues within communities and reduce the vulnerability of 14–35-year-old household and village residents to HIV infection.