Rakai, Uganda is characterized by a mature HIV epidemic and high rates of intimate partner violence (IPV). In 2005, adult HIV prevalence was 16% (women) and 12% (men) and incidence was 1.5/100 person-years (PY);while 20% and 14.5% of women reported physical or sexual IPV (respectively) during the past year. This represents a significant public health concern because women who experience IPV are at increased risk for HIV acquisition and HIV-infected women are at increased risk for IPV. Although select interventions have independently reduced HIV and IPV, no one-dimensional approach has successfully decreased both outcomes. The objective of the proposed research is to assess the impact of the Safe Homes And Respect for Everyone (SHARE) Project, a combination HIV/IPV intervention conducted by Rakai Health Sciences Program (RHSP). The SHARE design was based on the Transtheoretical Model of behavior change and included work with community volunteers, health mobilization and education, capacity building activities, advocacy, media and special events. A cluster randomized trial design was used and data were collected via the parent study, the Rakai Community Cohort Study (RCCS), which collects survey and biological data every 12-18 months with all consenting people aged 15-49. At baseline there were 47 active RCCS communities grouped into 11 clusters, 4 of which were assigned to the intervention arm and 7 to the control arm of the trial. Intervention areas were exposed to SHARE and RHSP services including HIV testing, provision of ART and pre-ART care, general medical care, prevention of mother-to-child HIV transmission, family planning, health education and community mobilization. Control areas were not exposed to SHARE but were exposed to RHSP services. Impact assessment was done through RCCS surveys and HIV serology done pre-intervention (Feb 2005-June 2006) and at 2 post-intervention follow-ups (Aug 2006-Nov 2009). A total of 14,119 participants (3,316 in intervention communities and 10,803 in control communities) were enrolled at baseline. The proposed research has 3 aims.
Aim 1 : To assess the impact of the intervention on the period prevalence of physical and/or sexual IPV in the past 12 months compared to the control communities. Adjusted prevalence risk ratios (PRR) will be estimated using log-binomial or modified Poisson regression with random effects models to account for within-cluster correlation.
Aim 2 : To assess the impact of the intervention on HIV incidence compared with control communities. An intention-to-treat approach will be followed using a log link and Poisson distribution to estimate the incidence rate ratios (IRR) of HIV acquisition per 100 PY, using random effects models to account for intra-cluster correlation and adjusting by cluster.
Aim 3 : To assess the impact of the intervention on sexual risk behaviors (non-marital partnerships in the past year, condom use over the past 6 months and use of alcohol before sex) compared to the control communities. PRRs will be estimated using log-binomial or modified Poisson regression with random effects models to account for correlation within clusters.
Intimate partner violence (IPV) and HIV infection are inter-related public health problems associated with serious adverse affects, yet no single prevention approach has succeeded in reducing both outcomes. This NRSA application proposes to analyze data from a community randomized trial conducted to evaluate the impact of an original combination IPV/HIV prevention intervention conducted in rural Uganda where levels of IPV and HIV are high. Findings from the evaluation have potentially important implications for the development of effective, feasible and reproducible models for interdisciplinary violence and HIV prevention strategies in low-resource settings, such as sub-Saharan Africa.