Who is killing South African men? A retrospective descriptive study of forensic and police investigations into male homicide.

Not much is known about the perpetrators of male homicide in South Africa, which has rates seven times the global average. For the country's first ever male homicide study we describe the epidemiology of perpetrators, their relationship with victims and victim profiles of men killed by male versus female perpetrators. We conducted a retrospective descriptive study of routine data collected through forensic and police investigations, calculating victim and perpetrator homicide rates by age, sex, race, external cause, employment status and setting, stratified by victim-perpetrator relationships. For perpetrators, we reported suspected drug and alcohol use, prior convictions, gang-involvement and homicide by multiple perpetrators. Perpetrators were acquaintances in 63% of 5594 cases in which a main perpetrator was identified. Sharp objects followed by guns were the main external causes of death. The highest rates were recorded in urban informal areas among unemployed men across all victim-perpetrator relationship types. Recreational settings including bars featured prominently. Homicides clustered around festive periods and weekends, both of which are associated with heavy episodic drinking. Perpetrator alcohol use was reported in 41% of homicides by family members and 50% by acquaintances. Other drug use was less common (9% overall). Of 379 men killed by female perpetrators, 60% were killed by intimate partners. Perpetrator alcohol use was reported in approximately half of female-on-male murders. Female firearm use was exclusively against intimate partners. No men were killed by male intimate partners. Violence prevention, which in South Africa has mainly focused on women and children, needs to be integrated into an inclusive approach. Profiling victims and perpetrators of male homicide is an important and necessary first step to challenge prevailing masculine social constructs that men are neither vulnerable to, nor the victims of, trauma and to identify groups at risk of victimisation that could benefit from specific interventions and policies.

Reflections on the process, challenges, and lessons learned conducting remote qualitative research on Violence against women during COVID-19 pandemic lockdown in South Africa.

BACKGROUND: Violence against women (VAW) research is a sensitive topic, which has been conducted mainly using face-to-face methods. The COVID-19 pandemic lockdown and restrictions on movement presented an opportunity to conduct VAW research using remote methods. We discuss how we adapted methods, reflect on lessons learned, and make recommendations highlighting key considerations when conducting remote research on a sensitive topic of VAW. METHODS: We designed and conducted an exploratory qualitative study using remote methods with 18 men and 19 women, aged 18 years and older, who lived with their partner or spouse during lockdown in South Africa. The aim of the study was to explore experiences of COVID-19 lockdown, and its link to women and children's experiences of violence in the homes. Data presented in this paper draws from researchers' reflections drawn from debriefing sessions during the research process, and from participants' interview transcripts. FINDINGS: Remote recruitment of participants took longer than anticipated, and we had to re-advertise the study. We could not ensure safety and privacy during interviews. Regardless of all the safety and privacy measures we put in place during the research process, some participants had an adult person present in the room during interviews, and the researchers had no control over interruptions. Rapport was difficult to establish without an in-person connection, which limited disclosure about violence experience (amongst women) and perpetration (amongst men). CONCLUSIONS: Given the methodological and ethical challenges which limited disclosure of VAW remotely, we conclude that telephone interviews used in our study impacted on the quality of study data. Therefore, we do not recommend VAW research to be conducted remotely, unless it is essential and participants are already known to the interviewer and trust has been established.

Femicide, intimate partner femicide, and non-intimate partner femicide in South Africa: An analysis of 3 national surveys, 1999-2017.

BACKGROUND: In most countries, reliable national statistics on femicide, intimate partner femicide (IPF), and non-intimate partner femicide (NIPF) are not available. Surveys are required to collect robust data on this most extreme consequence of intimate partner violence (IPV). We analysed 3 national surveys to compare femicide, IPF, and NIPF from 1999 to 2017 using age-standardised rates (ASRs) and incidence rate ratios (IRRs). METHODS AND FINDINGS: We conducted 3 national mortuary-based retrospective surveys using weighted cluster designs from proportionate random samples of medicolegal laboratories. We included females 14 years and older who were identified as having been murdered in South Africa in 1999 (n = 3,793), 2009 (n = 2,363), and 2017 (n = 2,407). Further information on the murdered cases were collected from crime dockets during interviews with police investigating officers. Our findings show that South Africa had an IPF rate of 4.9/100,000 female population in 2017. All forms of femicide among women 14 years and older declined from 1999 to 2017. For IPF, the ASR was 9.5/100,000 in 1999. Between 1999 and 2009, the decline for NIPF was greater than for IPF (IRR for NIPF 0.47 (95% confidence interval (CI) 0.42 to 0.53) compared to IRR for IPF 0.69 (95% CI 0.63 to 0.77). Rates declined from 2009 to 2017 and did not differ by femicide type. The decline in IPF was initially larger for women aged 14 to 29, and after 2009, it was more pronounced for those aged 30 to 44 years. Study limitations include missing data from the police and having to use imputation to account for missing perpetrator data. CONCLUSIONS: In this study, we observed a reduction in femicide overall and different patterns of change in IPF compared to NIPF. The explanation for the reductions may be due to social and policy interventions aimed at reducing IPV overall, coupled with increased social and economic stability. Our study shows that gender-based violence is preventable even in high-prevalence settings, and evidence-based prevention efforts must be intensified globally. We also show the value of dedicated surveys in the absence of functional information systems.

South Africa's male homicide epidemic hiding in plain sight: Exploring sex differences and patterns in homicide risk in a retrospective descriptive study of postmortem investigations.

South Africa has an overall homicide rate six times the global average. Males are predominantly the victims and perpetrators, but little is known about the male victims. For the country's first ever study on male homicide we compared 2017 male and female victim profiles for selected covariates, against global average and previous estimates for 2009. We conducted a retrospective descriptive study of routine data collected through postmortem investigations, calculating age-standardised mortality rates for manner of death by age, sex and province and male-to-female incidence rate ratios with 95% confidence intervals. We then used generalised linear models and linear regression models to assess the association between sex and victim characteristics including age and mechanism of injury (guns, sharp and blunt force) within and between years. 87% of 19,477 homicides in 2017 were males, equating to seven male deaths for every female, with sharp force and firearm discharge being the most common cause of death. Rates were higher among males than females at all ages, and up to eight times higher for the age group 15-44 years. Provincial rates varied overall and by sex, with the highest comparative risk for men vs. women in the Western Cape Province (11.4 males for every 1 female). Male homicides peaked during December and were highest during weekends, underscoring the prominent role of alcohol as a risk factor. There is a massive, disproportionate and enduring homicide risk among South African men which highlights their relative neglect in the country's prevention and policy responses. Only through challenging the normative perception of male invulnerability do we begin to address the enormous burden of violence impacting men. There is an urgent need to address the insidious effect of such societal norms alongside implementing structural interventions to overcome the root causes of poverty, inequality and better control alcohol and firearms.

Ntombi Vimbela! Sexual violence risk reduction intervention: pre and one-year post assessments from a single arm pilot feasibility study among female students in South Africa.

BACKGROUND: The extremely high prevalence of sexual violence victimisation reported among female students in South African public higher education demands urgent action to develop, rigorously evaluate and scale effective prevention interventions. This article details findings from a pilot feasibility study of Ntombi Vimbela! a campus sexual violence risk reduction intervention developed to tackle the high burden of sexual violence in higher education institutions in South Africa. METHODS: Ntombi Vimbela! (NV!) is a sexual violence risk reduction intervention that comprises sexuality empowerment, gender and social norm change, early-risk identification, self-defence, resistance and mental wellbeing components. NV! is comprised of ten workshop sessions running for 3.5 h each. Workshops are co-delivered by two trained peer facilitators per group of at most 20 first-year female students. One-year post-intervention quantitative outcome assessments were remotely completed by 98 participants who participated in the NV! pilot workshops. Qualitative assessments were conducted with 35 participants through in-depth telephone interviews (IDTIs). FINDINGS: One year after attending NV! workshops, most participants reported improved awareness of sexual rights, assertive communication, shifts in gender equitable beliefs, reductions in rape myth acceptance, improved expressed sexual relationship power sexual decision-making, and improved negotiation within their intimate relationships. Participants' depressive symptoms also significantly decreased. Many participants improved awareness of sexual assault risk and vigilance, including using self-protection strategies such as removing themselves from environments where alcohol intoxication posed sexual assault risks. Some participants used assertive communication to withstand peer pressure to engage in risky sexual behaviours. Most participants scored highly on the self-defence efficacy scale. Some participants were exposed to and successful in using verbal and physical resistance strategies in potential sexual assault risky situations. CONCLUSION: These findings indicate the potential beneficial effects of NV! as a campus sexual violence risk reduction intervention at one-year post-intervention, which must be evaluated in a future rigorous randomised control trial. PILOT TRIAL REGISTERED AT: ClinicalTrials.gov NCT04607564 on 29/10/2020.

Symptoms of posttraumatic stress partially mediate the relationship between gender-based violence and alcohol misuse among South African women.

BACKGROUND: The association of traumatic experiences with problematic alcohol use has been described, but data on possible mediation effects of mental distress are sparse. We examined whether mental ill-health mediated the association between trauma exposure across the lifespan and alcohol use. METHOD: We analysed cross-sectional data from a sample of rape-exposed and non-rape-exposed women, living in KwaZulu-Natal, with self-reported data on alcohol misuse (AUDIT-C cut-off ≥ 3) and exposure to childhood maltreatment (CM), intimate partner violence (IPV), non-partner sexual violence (NPSV), other traumatic events, and mental ill-health. Logistic regression and multiple mediation models were used to test the mediation effects of symptoms of depression and PTSS on the association between abuse/trauma and alcohol misuse. RESULTS: Of 1615 women, 31% (n = 498) reported alcohol misuse. Exposure to any CM (adjusted odds ratio (aOR): 1.59, 95% confidence interval (CI): 1.27-1.99), as well as to sexual, physical and emotional CM, were independently associated with alcohol misuse. Lifetime exposure to any IPV (aOR:2.01, 95%CI:1.59-2.54), as well as to physical, emotional and economic IPV, NPSV (aOR: 1.75, 95%CI: 1.32-2.33), and other trauma (aOR:2.08, 95%CI:1.62-2.66), was associated with alcohol misuse. Exposure to an increasing number of abuse types, and other traumatic events, was independently associated with alcohol misuse. PTSS partially mediated the associations of CM, IPV, NPSV and other trauma exposures with alcohol misuse (ps ≤ 0.04 for indirect effects), but depression symptoms did not. CONCLUSIONS: These findings highlight the need for trauma-informed interventions to address alcohol misuse that are tailored to the needs of women who have experienced violence.

The stated preferences of community-based volunteers for roles in the prevention of violence against women and girls in Ghana: A discrete choice analysis.

Violence against women and girls (VAWG) is a human rights violation with substantial health-related consequences. Interventions to prevent VAWG, often implemented at the community level by volunteers, have been proven effective and cost-effective. One such intervention is the Rural Response System in Ghana, a volunteer-run program which hires community based action teams (COMBATs) to sensitise the community about VAWG and to provide counselling services in rural areas. To increase programmatic impact and maximise the retention of these volunteers, it is important to understand their preferences for incentives. We conducted a discrete choice experiment (DCE) among 107 COMBAT volunteers, in two Ghanaian districts in 2018, to examine their stated preferences for financial and non-financial incentives that could be offered in their roles. Each respondent answered 12 choice tasks, and each task comprised four hypothetical volunteering positions. The first three positions included different levels of five role attributes. The fourth option was to cease volunteering as a COMBAT volunteer (opt-out). We found that, overall, COMBAT volunteers cared most for receiving training in volunteering skills and three-monthly supervisions. These results were consistent between multinomial logit, and mixed multinomial logit models. A three-class latent class model fitted our data best, identifying subgroups of COMBAT workers with distinct preferences for incentives: The younger 'go getters'; older 'veterans', and the 'balanced bunch' encompassing the majority of the sample. The opt-out was chosen only 4 (0.3%) times. Only one other study quantitatively examined the preferences for incentives of VAWG-prevention volunteers using a DCE (Kasteng et al., 2016). Understanding preferences and how they vary between sub-groups can be leveraged by programme managers to improve volunteer motivation and retention. As effective VAWG-prevention programmes are scaled up from small pilots to the national level, data on volunteer preferences may be useful in improving volunteer retention.

Pooled analysis of the association between food insecurity and violence against women: Evidence from low- and middle-income settings.

Background: Intimate partner violence impacts relationships across the socioeconomic spectrum, nonetheless its prevalence is reported to be highest in areas that are most socio-economically deprived. Poverty has direct and indirect impacts on intimate partner violence (IPV) risk, however, one of the postulated pathways is through food insecurity. The aim of this paper is to describe the association between food insecurity (household hunger) and women's experiences, and men's perpetration, of intimate partner violence and non-partner sexual violence in data from Africa and Asia. Methods: We conducted a pooled analysis of data from baseline interviews with men and women participating in six Violence Against Women prevention intervention evaluations and present a meta-analysis using mixed-effects Poisson regression models. Data were from South Africa (two studies), Ghana, Rwanda (two data sets), and Afghanistan and comprised interviews with 6545 adult women and 8104 adult men. We assessed food insecurity with the Household Hunger Scale. Results: Overall, 27.9% of women experienced moderate food insecurity (range from 11.1% to 44.4%), while 28.8% of women reported severe food insecurity (range from 7.1 to 54.7%). Overall food insecurity was associated with an increased likelihood of women experiencing physical intimate partner violence, adjusted incidence rate ratio (aIRR) = 1.40 (95% CI = 1.23 to 1.60) for moderate food insecurity and aIRR = 1.73 (95% CI = 1.41 to 2.12) for severe food insecurity. It was also associated with an increased likelihood of men reporting perpetration of physical IPV, with aIRR = 1.24 (95% CI = 1.11 to 1.39) for moderate food insecurity and aIRR = 1.18 (95% CI = 1.02 to 1.37) for severe food insecurity. Food insecurity was not significantly associated with women's experience of non-partner sexual violence, aIRR = 1.27 (95% CI = 0.93 to 1.74) for moderate or severe food insecurity vs none, nor men's perpetration of non-partner sexual violence aIRR = 1.02 (95% CI = 0.90 to 1.15). Conclusions: Food insecurity is associated with increased physical intimate partner violence perpetration and experience reported by men and women. It was not associated with non-partner sexual violence perpetration, although there was some evidence to suggest an elevated risk of non-partner sexual violence among food-insecure women. Prevention programming needs to embrace food insecurity as a driver of intimate partner violence perpetration, however, non-partner sexual violence prevention needs to be shaped around a separate understanding of its drivers.

Challenges and opportunities in coproduction: reflections on working with young people to develop an intervention to prevent violence in informal settlements in South Africa.

Coproduction is widely recognised as essential to the development of effective and sustainable complex health interventions. Through involving potential end users in the design of interventions, coproduction provides a means of challenging power relations and ensuring the intervention being implemented accurately reflects lived experiences. Yet, how do we ensure that coproduction delivers on this promise? What methods or techniques can we use to challenge power relations and ensure interventions are both more effective and sustainable in the longer term? To answer these questions, we openly reflect on the coproduction process used as part of Siyaphambili Youth ('Youth Moving Forward'), a 3-year project to create an intervention to address the social contextual factors that create syndemics of health risks for young people living in informal settlements in KwaZulu-Natal province in South Africa. We identify four methods or techniques that may help improve the methodological practice of coproduction: (1) building trust through small group work with similar individuals, opportunities for distance from the research topic and mutual exchanges about lived experiences; (2) strengthening research capacity by involving end users in the interpretation of data and explaining research concepts in a way that is meaningful to them; (3) embracing conflicts that arise between researchers' perspectives and those of people with lived experiences; and (4) challenging research epistemologies through creating spaces for constant reflection by the research team. These methods are not a magic chalice of codeveloping complex health interventions, but rather an invitation for a wider conversation that moves beyond a set of principles to interrogate what works in coproduction practice. In order to move the conversation forward, we suggest that coproduction needs to be seen as its own complex intervention, with research teams as potential beneficiaries.

"I Don't Want to Be Known as a Weak Man": Insights and Rationalizations by Male Students on Men's Sexual Violence Perpetration against Female Students on Campus.

Understanding how men view rape is foundational for rape prevention, but it is not always possible to interview men who rape, especially in a college campus context. We explore male students' insights into and rationalizations for why men on campus perpetrate sexual violence (SV) against female students by analysing qualitative focus group discussion data with male students. Men contended that SV is a demonstration of men's power over women, yet they did not perceive sexual harassment of female students as serious enough to constitute SV and appeared to be tolerant of it. Men perceived "sex for grades" as exploitative and rooted in the power asymmetry between privileged male lecturers and vulnerable female students. They were disdainful of non-partner rape, describing it as acts exclusively perpetrated by men from outside campus. Most men felt entitled to have sex with their girlfriends, although an alternative discourse challenged both this entitlement and the dominant masculinity linked to it. Gender-transformative work with male students is needed to support them to think and do things differently while they are on campus.

Pooled analysis of the association between mental health and violence against women: evidence from five settings in the Global South.

OBJECTIVES: To describe associations between men's poor mental health (depressive and post-traumatic stress symptomatology) and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV), and women's mental health and their experiences of IPV and NPSV in five settings in the Global South. DESIGN: A pooled analysis of data from baseline interviews with men and women participating in five violence against women and girls prevention intervention evaluations. SETTING: Three sub-Saharan African countries (South Africa, Ghana and Rwanda), and one Middle Eastern country, the occupied Palestinian territories. PARTICIPANTS: 7021 men and 4525 women 18+ years old from a mix of self-selecting and randomly selected household surveys. MAIN OUTCOME MEASURES: All studies measured depression symptomatology using the Centre for Epidemiological Studies-Depression, and the Harvard Trauma Scale for post-traumatic stress disorder (PTSD) symptoms among men and women. IPV and NPSV were measured using items from modified WHO women's health and domestic violence and a UN multicountry study to assess perpetration among men, and experience among women. FINDINGS: Overall men's poor mental health was associated with increased odds of perpetrating physical IPV and NPSV. Specifically, men who had more depressive symptoms had increased odds of reporting IPV (adjusted OR (aOR)=2.13; 95%CI 1.58 to 2.87) and NPSV (aOR=1.62; 95% CI 0.97 to 2.71) perpetration compared with those with fewer symptoms. Men reporting PTSD had higher odds of reporting IPV (aOR=1.87; 95% CI 1.44 to 2.43) and NPSV (aOR=2.13; 95% CI 1.49 to 3.05) perpetration compared with those without PTSD. Women who had experienced IPV (aOR=2.53; 95% CI 2.18 to 2.94) and NPSV (aOR=2.65; 95% CI 2.02 to 3.46) had increased odds of experiencing depressive symptoms compared with those who had not. CONCLUSIONS: Interventions aimed at preventing IPV and NPSV perpetration and experience must account for the mental health of men as a risk factor, and women's experience.

Understanding drivers of female sex workers' experiences of external/enacted and internalised stigma: findings from a cross-sectional community-centric national study in South Africa.

To deepen our understanding of sex work stigma, and to its drivers and their interrelation, we conducted an analysis using structural equation modelling of the South African National Sex Worker Survey. We enrolled 3005 women in sex work using multi-stage sampling across all South Africa's provinces. Experience of external/enacted and internalised stigma was widespread. Non-partner rape, intimate partner violence and partner controlling behaviour (often expressions of external/enacted stigma) compounded internalised stigma. These experiences of violence, other manifestations of external/enacted stigma and food insecurity, were key drivers of internalised stigma, and often had an impact on mental health. We found that considerable protection against stigma emanated from viewing sex work positively. This resistance to stigma provided opportunities to shift the narrative. Reducing sex workers' exposure to external/enacted stigmatising behaviour, including by enabling more to work indoors, and providing greater protection from partner violence and rape, are critical for better health and well-being. Ending the criminalisation of sex work is foundational for safer working conditions and better health outcomes for sex workers, similarly providing adequately funded mental and physical health and social care through sex work specific programmes.

Sex work and young women: a cross sectional study to understand the overlap of age and sex work as a central tenet to epidemic control in South Africa.

Adolescent girls and young women (AGYW) engaging in sex-for-money transactions are at risk of HIV infection. A better understanding of the demographic, socio-economic factors and risks of HIV acquisition is required to guide appropriate public health interventions targeting young sex workers in South Africa. A cross-sectional survey of Female Sex Workers (FSWs), using a chain referral sampling method, was conducted across 12 sites in South Africa in 2019. Three thousand and five participants were enrolled and interviewed assessing demographic characteristics, sexual behaviour, substance use and HIV testing and treatment. Of 3005 women, 13.3% were ≤24 years old (young FSWs); of these, 60.0% entered sex work aged ≤19 years. Economic factors were the primary drivers of entry into sex work. HIV prevalence amongst young FSWs was 40.4%, with 12.4% recently infected. Younger FSWs were significantly less likely to know they were HIV positive (87.6% versus 92.1%), to report any ART exposure (75.2% versus 87.6%) and to be virally suppressed (58.1% versus 75.2%) compared to older FSWs. Our findings highlight that many FSWs enter sex work at a young age. It is essential to develop tailored services and interventions that improve access to HIV prevention and treatment services addressing specific needs.

The relationship between fathers' heavy episodic drinking and fathering involvement in five Asia-Pacific countries: An individual participant data meta-analysis.

BACKGROUND: This study aims to increase understanding of the relationship between heavy episodic drinking (HED) and fathers' involvement in parenting in five countries. The potential moderating effect of fathers' experiences of childhood trauma is also studied, controlling for the possible confounding of the effect of HED by father's attitudes toward gender equality, father's age and father's education. METHOD: United Nations Multi-Country Study on Men and Violence (UNMCS) survey data from 4562 fathers aged 18-49 years from Cambodia, China, Indonesia and Papua New Guinea (PNG) and Sri Lanka were used to assess the relationship between fathering involvement (e.g., helping children with their homework) and self-reported HED of 6+ drinks in one occasion vs. non-HED and abstaining. Moderating effects of a 13-item fathers' childhood trauma (FCT) scale were tested and analyses were adjusted for gender-inequitable attitudes using the Gender-Equitable Men scale score. Bivariate and adjusted individual participant meta-analyses were used to determine effect estimates for each site and across all sites. RESULTS: Fathers' HED was associated with less positive parental involvement after adjusting for gender-equitable attitudes, FCT, age and education. No overall interaction between HED and FCT was identified. Gender equitable attitudes were associated with fathering involvement in some countries but not overall (p = 0.07). CONCLUSIONS: Heavy episodic drinking was associated with reduced positive fathering involvement. These findings suggest that interventions to increase fathers' involvement in parenting should include targeting reductions in fathers' HED. Structural barriers to fathers' involvement should be considered alongside HED in future studies of fathers' engagement with their children.

Quantitative evaluation of Zindagii Shoista (Living with Dignity) intervention to prevent violence against women in Tajikistan.

BACKGROUND: Violence against women and girls (VAWG) is a major problem in Tajikistan, driven by conservative gender norms, the culturally ascribed position of young women, and poverty. OBJECTIVE: We evaluated Zindagii Shoista (Living with Dignity), an intervention developed with the aim of reducing VAWG through a combination of gender norm change, communication skills, and income-generating activities (IGA) over a period of 30 months. METHODS: The evaluation used a mixed-methods approach, combining quantitative and qualitative data collection. Eighty families from four villages were enrolled in the intervention and surveyed at baseline and on three subsequent occasions. From these families, 134 women and 102 men were interviewed at baseline, 153 women and 89 men 8 months later, 153 women and 93 men 15 months later, and 143 women and 82 men, 30 months after the baseline. Generalised random effects regression models were used to assess the trend in proportions or mean score over time. RESULTS: Over the 30 months, the proportion of women and men earning in the past month rose from 17.9% to 56.6% and 44.1% to 72%, respectively. Women and men's gender attitudes became significantly less patriarchal, and they reported less harmful gender norms in the community. Women and men reported less male controlling behaviour and greater woman involvement in decision-making. Women's reports of experience of emotional, physical, and sexual IPV significantly reduced. Depressive symptoms and suicidal thoughts reduced significantly for men and women, and self-rated health improved. CONCLUSIONS: The quantitative findings are confirmed by the findings of the qualitative research and monitoring data. They demonstrate that Zindagii Shoista is a very promising intervention for strengthening gender relations, reducing IPV, and improving mental health and socio-economic circumstances for younger married women and their families in Tajikistan.

Disparities in intimate partner violence among women at the intersection of disability and HIV status in South Africa: a cross-sectional study.

OBJECTIVE: Previous research suggests a significant relationship between intimate partner violence (IPV) and HIV infection in women and that the risk of IPV is heightened in women with disabilities. Women with disabilities, particularly those residing in low-income and middle-income countries, may experience additional burdens that increase their vulnerability to IPV. We aimed to examine the association between having disability and HIV infection and the risk of IPV among women in South Africa. DESIGN: Using the 2016 South Africa Demographic and Health Survey, we calculated the prevalence of IPV and conducted modified Poisson regressions to estimate the unadjusted and adjusted risk ratios of experiencing IPV by disability and HIV status. PARTICIPANTS: Our final analytical sample included 1269 ever-partnered women aged 18-49 years, who responded to the IPV module and received HIV testing. RESULTS: The prevalence of IPV was twice as high in women with disabilities with HIV infection compared with women without disabilities without HIV infection (21.2% vs 50.1%). Our unadjusted regression analysis showed that compared with women without disabilities without HIV infection, women with disabilities with HIV infection had almost four times higher odds (OR 3.72, 95% CI 1.27 to 10.9, p<0.05) of experiencing IPV. It appeared that women with disabilities with HIV infection experience compounded disparity. The association was compounded, with the OR for the combination of disability status and HIV status equal to or more than the sum of each of the individual ORs. CONCLUSIONS: Women with disabilities and HIV infection are at exceptionally high risk of IPV in South Africa. Given that HIV infection and disability magnify each other's risks for IPV, targeted interventions to prevent IPV and to address the complex and varied needs of doubly marginalised populations of women with disabilities with HIV infection are critical.

Associations of childhood maltreatment with hypertension in South African women: a cross-sectional study.

OBJECTIVES: To examine the associations of childhood maltreatment (CM) with hypertension, and the mediating effects of hypertension risk factors on the associations in South African women, using baseline data of the Rape Impact Cohort Evaluation longitudinal study. DESIGN: Cross-sectional SETTING AND PARTICIPANTS: Self-reported data on CM exposure and its severity in 18-40-year-old women living in KwaZulu-Natal province were assessed. Logistic regression models, adjusted for traditional hypertension risk factors, rape exposure, HIV-infection, other traumatic exposures, depression scores and acute stress reactions (ASR) scores were used to examine the CM-hypertension associations. RESULTS: Among 1797 women, 220 (12.2%) had hypertension; CM prevalence was higher in women with hypertension than without hypertension overall (70.9% vs 57.2%) and for each abuse type: sexual abuse (20.9% vs 12.4%), physical abuse (51.8% vs 41.5%), emotional abuse (40% vs 27.6%) and parental neglect (35% vs 25.7%). Exposures to 1-2 types and 3-4 types of CM were 46.4% and 24.5%, respectively, in women with hypertension, and lower in women without (42.9% and 14.3%, respectively). Exposures to any CM (adjusted OR: 1.62; 95% CI: 1.19 to 2.25), sexual abuse (1.64; 95% CI: 1.12 to 2.37), emotional abuse (1.57; 95% CI: 1.16 to 2.13), physical abuse (1.43; 95% CI: 1.07 to 1.92) and parental neglect (1.37; 95% CI: 1.00 to 1.86) were associated with hypertension. Exposures to an increasing number of abuse types and cumulative severity of CM overall (1.13; 95% CI: 1.05 to 1.21) and for each CM type were associated with increased odds of hypertension. Alcohol use, other trauma experienced, depression and ASR partially mediated these associations. CONCLUSION: CM was associated with hypertension; the effects were greater with multiple abuse types and severe abuse, and were partially mediated by alcohol use, depression, ASR and other traumatic exposures. While CM must be prevented, effective mental health interventions to curb the uptake of unhealthy behaviours and the development of hypertension in women exposed to CM are key.

HIV incidence estimation among female sex workers in South Africa: a multiple methods analysis of cross-sectional survey data.

BACKGROUND: Although numerous studies have investigated HIV risk factors and shown high HIV prevalence among female sex workers in South Africa, no national HIV incidence estimate exists for this potentially important group for HIV transmission. We aimed to estimate HIV incidence among female sex workers in South Africa who could be accessed through sex worker programmes, and to refine and describe the methods that enabled analysis. METHODS: This study was embedded in a cross-sectional national survey of female sex workers who were linked to sex worker programmes. We aimed to enrol 3000 female sex workers aged at least 18 years who had sold or transacted in sex in the preceding 6 months in 12 randomly selected districts of the 22 districts with sex worker programmes, ensuring coverage of all provinces of South Africa. Women who self-reported as current victims of human trafficking were excluded from enrolment. We used a multistep process to sample districts and then hotspots, and a chain referral method to recruit participants. We collected cross-sectional data for self-reported HIV status, demographic characteristics, and exposure to violence. Two rapid tests were used to ascertain diagnostic markers, a viral load assay was used to ascertain clinical markers, and the Maxim Limiting Antigen Avidity EIA was used to ascertain infection-staging HIV markers. Given the challenges of estimating HIV incidence, especially cross-sectionally, multiple methods of estimation were adapted to our setting, leveraging the age structure of HIV prevalence, recency-of -infection biomarker results (ie, where recent infection is classified as ≤1·5 normalised optical density [ODn] on the avidity assay and viral load of ≥1000 copies per mL), and reported testing histories. FINDINGS: Of 3005 female sex workers who were enrolled and interviewed between Feb 4 and June 26, 2019, 2999 who had HIV test results were included in this analysis. The median age of participants was 32 years (IQR 27-38). 1714 (57·2%) of 2999 participants self-reported as being HIV positive, and 1447 (48·3%) of 2993 participants reported client sexual violence in the past year. The measured HIV prevalence was 62·1% (95% CI 60·3-65·7) and peaked at approximately age 40 years. Using recency-of-infection biomarker results, we obtained a base case estimate of HIV incidence of 4·60 cases per 100 person-years (95% CI 1·53-8·45) for the population. Estimates were generally consistent by method, and outlying incidence estimates calculated by self-reported testing histories were considered unreliable. Various sensitivity analyses produced estimates up to 11 cases per 100 person-years, and we did not detect differences by age and region. INTERPRETATION: We found that female sex workers have extraordinarily high HIV incidence of approximately 5 cases per 100 person-years, emphasising the need to sustain and strengthen efforts to mitigate risk and provide adequate care. The notable role that sex work has in HIV transmission demands substantial investment in ongoing epidemiological monitoring. FUNDING: South African Medical Research Council, South African National Treasury, Global Fund, South African Department of Science and Innovation, Wellcome Trust.