Correction to: Effectiveness of a multi-level intervention to reduce men's perpetration of intimate partner violence: a cluster randomised controlled trial.

An amendment to this paper has been published and can be accessed via the original article.

Effectiveness of a multi-level intervention to reduce men's perpetration of intimate partner violence: a cluster randomised controlled trial.

BACKGROUND: Men's perpetration of intimate partner violence (IPV) limits gains in health and wellbeing for populations globally. Largely informal, rapidly expanding peri-urban settlements, with limited basic services such as electricity, have high prevalence rates of IPV. Evidence on how to reduce men's perpetration, change social norms and patriarchal attitudes within these settings is limited. Our cluster randomised controlled trial aimed to determine the effectiveness of the Sonke CHANGE intervention in reducing use of sexual and/or physical IPV and severity of perpetration by men aged 18-40 years over 2 years. METHODOLOGY: The theory-based intervention delivered activities to bolster community action, including door-to-door discussions, workshops, drawing on the CHANGE curriculum, and deploying community action teams over 18 months. In 2016 and 2018, we collected data from a cohort of men, recruited from 18 clusters; nine were randomised to receive the intervention, while the nine control clusters received no intervention. A self-administered questionnaire, using audio-computer assisted software, asked about sociodemographics, gender attitudes, mental health, and the use and severity of IPV. We conducted an intention-to-treat analysis at the cluster level comparing the expected risk to observed risk of using IPV while controlling for baseline characteristics. A secondary analysis used latent classes (LCA) of men to see whether there were differential effects of the intervention for subgroups of men. RESULTS: Of 2406 men recruited, 1458 (63%) were followed to 2 years. Overall, we saw a reduction in men's reports of physical, sexual and severe IPV from baseline to endpoint (40.2% to 25.4%, 31.8% to 15.8%, and 33.4% to 18.2%, respectively). Intention-to-treat analysis showed no measurable differences between intervention and control clusters for primary IPV outcomes. Difference in the cluster-level proportion of physical IPV perpetration was 0.002 (95% confidence interval [CI] - 0.07 to 0.08). Similarly, differences between arms for sexual IPV was 0.01 (95% CI - 0.04 to 0.06), while severe IPV followed a similar pattern (Diff = 0.01; 95% CI - 0.05 to 0.07). A secondary analysis using LCA suggests that among the men living in intervention communities, there was a greater reduction in IPV among less violent and more law abiding men than among more highly violent men, although the differences did not reach statistical significance. CONCLUSION: The intervention, when implemented in a peri-urban settlement, had limited effect in reducing IPV perpetrated by male residents. Further analysis showed it was unable to transform entrenched gender attitudes and use of IPV by those men who use the most violence, but the intervention showed promise for men who use violence less. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02823288. Registered on 30 June 2016.

Prevalence and risk factors for intimate partner violence among Grade 8 learners in urban South Africa: baseline analysis from the Skhokho Supporting Success cluster randomised controlled trial.

BACKGROUND: Intimate partner violence (IPV) is a serious public health problem among adolescents. This study investigated the prevalence of and factors associated with Grade 8 girls' experience and boys' perpetration of IPV in South Africa. METHODS: Participants were interviewed using interviewer-administered questionnaires about IPV, childhood violence, bullying, gender attitudes, alcohol use and risky sexual behaviours. Multiple logistic regression analysis was conducted to assess factors associated with girls' experience and boys' perpetration of IPV. Structural equation modelling (SEM) was conducted to assess the pathways to IPV experience and perpetration. RESULTS: Results show dating relationships are common among girls (52.5%) and boys (70.7%) and high prevalence of sexual or physical IPV experience by girls (30.9%; 95% CI: 28.2-33.7) and perpetration by boys (39.5%; 95% CI: 36.6-42.3). The logistic regression model showed factors associated with girls' experience of IPV include childhood experience of violence, individual gender inequitable attitudes, corporal punishment at home and in school, alcohol use, wider communication with one's partner and being more negative about school. We found three pathways from childhood trauma to IPV experience and perpetration in both models and these are through inequitable gender attitudes and risky sex, bullying and alcohol use. CONCLUSIONS: Prevention of IPV in children needs to encompass prevention of exposure to trauma in childhood and addressing gender attitudes and social norms to encourage positive disciplining approaches. : The trial is registered on ClinicalTrials.gov as NCT02349321.

Perpetration of physical and sexual abuse and subsequent fathering of pregnancies among a cohort of young South African men: a longitudinal study.

BACKGROUND: Young men's involvement in fathering pregnancies has been substantially neglected in unintended pregnancy research. Gender norms give men substantial power and control over sexual encounters, suggesting that understanding men's role is imperative. We tested the hypothesis that young, unmarried South African men who had perpetrated intimate partner violence (IPV) have a greater incidence of fathering pregnancies. METHODS: The data for this study were collected from 983 men aged 15 to 26 who participated in a 2-year community randomized controlled HIV prevention trial in the rural Eastern Cape. Multivariate Poisson models investigated the associations between baseline perpetration of IPV and fathering subsequent pregnancies, while controlling for age, number of sexual partners, socio-economic status, educational attainment, problematic alcohol use, exposure to the intervention, and time between interviews. RESULTS: Of the men in this study, 16.5% (n = 189) had made a girlfriend pregnant over two years of follow up. In addition, 39.1% had perpetrated physical or sexual intimate partner violence and 24.3% had done so more than once. Men who at baseline had perpetrated IPV in the previous year had an increased incidence of fathering, for a first perpetration in that year IRR 1.67 (95% CI 1.14-2.44) and among those who had also been previously violent, IRR 1.97 (95% CI 1.31-2.94). Those who had ever been violent, but not in the past year, did not have an elevated incidence. The incidence among men who had ever perpetrated physical abuse was less elevated than among those who had perpetrated physical and sexual violence IRR 1.64 (95% CI 1.18-2.29) versus IRR 2.59 (95% CI 1.64-4.10) indicating a dose response. CONCLUSION: Young men's perpetration of partner violence is an important predictor of subsequently fathering a pregnancy. The explanation may lie with South African hegemonic masculinity, which valorizes control of women and displays of heterosexuality and virility, and compromises women's reproductive choices.

Risk factors for unplanned and unwanted teenage pregnancies occurring over two years of follow-up among a cohort of young South African women.

BACKGROUND: Although teenage pregnancies in South Africa have declined, the short and longer term health and social consequences are a potential public health concern. This longitudinal study aimed to describe the range of risk and protective factors for incident unwanted and unplanned pregnancies occurring over 2 years of follow-up among a cohort of adolescent women in the Eastern Cape, South Africa. It also investigated the relationship between gender inequality and gender-based violence and subsequent unplanned and unwanted pregnancies among the cohort. OBJECTIVE: Teenage girls, aged 15-18 years (n=19), who were volunteer participants in a cluster randomized controlled trial and who had data from at least one follow-up were included in this analysis. To assess risk and protective factors for incident unwanted or unplanned pregnancies, we constructed multivariate polytomous regression models adjusting for sampling clusters as latent variables. Covariates included age, having a pregnancy prior to baseline, education, time between interviews, study intervention arm, contraceptive use, experience of intimate partner violence, belief that the teenage girl and her boyfriend are mutual main partners, and socioeconomic status. RESULTS: Overall, 174 pregnancies occurred over the 2-year follow-up period. Beliefs about relationship control were not associated with unwanted and unplanned pregnancies, nor were experiences of forced first sex or coerced sex under the age of 15. Hormonal contraception was protective against unplanned pregnancies (OR 0.40; 95% CI 0.21-0.79); however, using condoms was not protective. Physical abuse (OR 1.69; 95% CI 1.05-2.72) was a risk factor for, and having a pregnancy prior to baseline was protective against an unwanted pregnancy (OR 0.25; 95% CI 0.07-0.80). Higher socioeconomic status was protective for both unplanned and unwanted pregnancies (OR 0.69; 95% CI 0.58-0.83 and OR 0.78; 95% CI 0.64-0.96). Believing that the teenage girl and her boyfriend were mutual main partners doubled the odds of reporting both an unplanned and unwanted pregnancy (OR 2.58 95% CI 1.07-6.25, and OR 2.21 95% CI 1.13-4.29). CONCLUSION: Although some of the measures of gender inequity were not associated with unplanned and unwanted pregnancies, there is evidence of the role of both gender power and socioeconomic status. This was evident in teenage girls who experienced physical violence being more likely to have an unwanted pregnancy. Interventions to prevent teenage pregnancies need to be tailored by socioeconomic status because some teenagers may see having a pregnancy as a way to have a more secure future. Interventions that engage with relationship dynamics of teenagers are essential if unwanted and unplanned pregnancies are to be prevented.

Early adolescent pregnancy increases risk of incident HIV infection in the Eastern Cape, South Africa: a longitudinal study.

INTRODUCTION: Adolescents having unprotected heterosexual intercourse are at risk of HIV infection and unwanted pregnancy. However, there is little evidence to indicate whether pregnancy in early adolescence increases the risk of subsequent HIV infection. In this paper, we tested the hypothesis that adolescent pregnancy (aged 15 or younger) increases the risk of incident HIV infection in young South African women. METHODS: We assessed 1099 HIV-negative women, aged 15-26 years, who were volunteer participants in a cluster-randomized, controlled HIV prevention trial in the predominantly rural Eastern Cape province of South Africa. All of these young women had at least one additional HIV test over two years of follow-up. Outcomes were HIV incidence rates per 100 person years and HIV incidence rate ratios (IRRs) estimated by Poisson multivariate models. Three pregnancy categories were created for the Poisson model: early adolescent pregnancy (a first pregnancy at age 15 years or younger); later adolescent pregnancy (a first pregnancy at age 16 to 19 years); and women who did not report an adolescent pregnancy. Models were adjusted for study design, age, education, time since first sexual experience, socio-economic status, childhood trauma and herpes simplex virus type 2 infection. RESULTS: HIV incidence rates were 6.0 per 100 person years over two years of follow-up. The adjusted IRR was 3.02 (95% CI 1.50-6.09) for a pregnancy occurring at age 15 or younger. Women with pregnancies occurring between 16 and 19 years of age did not have a higher incidence of HIV (IRR 1.08; 95% CI 0.64-1.84). Early adolescent pregnancies were associated with higher partner numbers and a greater age difference with partners. CONCLUSIONS: Early adolescent pregnancies increase the incidence of HIV among South African women. The higher risk is associated with sexual risk behaviours such as higher partner numbers and a greater age difference with partners rather than a biological explanation of hormonal changes during pregnancy.

Intimate partner violence among adolescents in Cape Town, South Africa.

This study aimed to describe potentially preventable factors in intimate partner violence (IPV) perpetration and victimization among South African 8th grade students. Data were collected during a pilot evaluation of a classroom 8th grade curriculum on gender-based violence prevention in nine public schools in Cape Town through self-completed interviews with 549 8th grade students, 238 boys and 311 girls. Structural equation models (SEM) predicting IPV were constructed with variables a priori hypothesized to be associated. The majority of students (78.5 %) had had a partner in the past 3 months, and they reported high rates of IPV during that period (e.g., over 10 % of boys reported forcing a partner to have sex, and 39 % of girls reported physical IPV victimization). A trimmed version of the hypothesized SEM (CFI = .966; RMSEA = .051) indicated that disagreement with the ideology of male superiority and violence predicted lower risk of IPV (p < .001), whereas the frequency of using negative conflict resolution styles (e.g., walking off angrily, sending angry text messages, or refusing to talk to them) predicted high IPV risk (p < .001) and mediated the impact of heavy alcohol drinking on IPV (Sobel test, z = 3.16; p < .001). The model fit both girls and boys, but heavy drinking influenced negative styles of resolving conflict more strongly among girls than boys. Findings suggest that interventions to reduce IPV among South African adolescents should challenge attitudes supportive of male superiority and violence; encourage use of positive conflict resolution styles; and discourage heavy alcohol use among both boys and girls.

Prevalence of consensual male-male sex and sexual violence, and associations with HIV in South Africa: a population-based cross-sectional study.

BACKGROUND: In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male-male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. METHODS AND FINDINGS: In a cross-sectional study conducted in 2008, men aged 18-49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male-male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26-12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22-7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24-7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17-10.9). CONCLUSIONS: In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male-female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male-male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.

Prevalence and factors associated with depressive symptoms among young women and men in the Eastern Cape Province, South Africa.

PURPOSE: There is little research on prevalence of depressive symptoms and associated factors among youth in sub-Saharan Africa. This paper explores factors associated with depressive symptomatology in South Africa. METHODS: A cross-sectional analysis of interviews with 1 415 women and 1 368 men aged 15-26 was undertaken. The Centre for Epidemiological Studies on Depression Scale (CESD Scale) was used to establish depressive symptomatology. RESULTS: The prevalence of depressive symptoms was 20.5% in women and 13.5% in men. For women, depressive symptoms were associated with increased childhood adversity (aOR 1.34 95% CI 1.116, 1.55); drug use (aOR 1.98 CI 1.17, 3.35); experience of intimate partner violence (aOR 2.21 CI 1.16, 3.00); sexual violence before the age of 18 years (aOR 1.45 CI 1.02, 2.02) and lower perceptions of community cohesion (aOR 1.23 CI 1.07, 1.40). For men, depressive symptoms were associated with a mother's death (aOR 2.24 CI 1.25, 4.00); childhood adversity (aOR 1.61 CI 1.38, 1.88); alcohol abuse (aOR 1.63 CI 1.13, 2.35), sexual coercion by a woman (aOR 2.36 CI 1.47, 3.80) and relationship conflict (aOR 1.07 CI 1.01, 1.12). CONCLUSIONS: Depressive symptoms were more highly prevalent in women than in men. Depressed mood was associated with childhood adversity, sexual violence and substance misuse in both women and men. This study further suggests gender differences in that for women, depressive symptoms were associated with intimate partner violence and lower perceptions of community cohesion, while for men the associations were with a mother's death and relationship conflict.

Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in the Eastern Cape, South Africa.

BACKGROUND: Psychological factors are often neglected in HIV research, although psychological distress is common in low- to middle-income countries, such as South Africa. There is a need to deepen our understanding of the role of mental health factors in the HIV epidemic. We set out to investigate whether baseline depressive symptomatology was associated with risky sexual behaviour and relationship characteristics of men and women at baseline, as well as those found 12 months later. METHODS: We used prospective cohort data from a cluster randomized controlled trial of an HIV prevention intervention in the Eastern Cape Province of South Africa. Our subjects were 1002 female and 976 male volunteers aged 15 to 26. Logistic regression was used to model the cross-sectional and prospective associations between baseline depressive symptomatology, risky sexual behaviors and relationship characteristics. The analysis adjusted for the clustering effect, study design, intervention and several confounding variables. RESULTS: Prevalence of depressive symptoms was 21.1% among women and 13.6% among men. At baseline, women with depressed symptoms were more likely to report lifetime intimate partner violence (AOR = 2.56, 95% CI 1.89-3.46) and have dated an older partner (AOR = 1.37, 95% CI 1.03-1.83). A year later, baseline depressive symptomatology was associated with transactional sex (AOR = 2.60, 95% CI 1.37, 4.92) and intimate partner violence (AOR = 1.67, 95% CI 1.18-2.36) in the previous 12 months. Men with depressive symptoms were more likely to report ever having had transactional sex (AOR = 1.48, 95% CI 1.01-2.17), intimate partner violence perpetration (AOR = 1.50, 95% CI 0.98-2.28) and perpetration of rape (AOR = 1.81, 95% CI 1.14-2.87). They were less likely to report correct condom use at last sex (AOR = 0.50, 95% CI 0.32-0.78). A year later, baseline depressive symptomatology was associated with failure to use a condom at last sex among men (AOR = 0.60, 95% CI 0.40-0.89). CONCLUSIONS: Symptoms of depression should be considered as potential markers of increased HIV risk and this association may be causal. HIV prevention needs to encompass promotion of adolescent mental health.

Associations between childhood adversity and depression, substance abuse and HIV and HSV2 incident infections in rural South African youth.

OBJECTIVES: To describe prevalence of childhood experiences of adversity in rural South African youth and their associations with health outcomes. METHODS: We analyzed questionnaires and blood specimens collected during a baseline survey for a cluster randomized controlled trial of a behavioral intervention, and also tested blood HIV and herpes simplex type 2 virus at 12- and 24-month follow up; 1,367 male and 1,415 female volunteers were recruited from 70 rural villages. RESULTS: Both women and men before 18 had experienced physical punishment (89.3% and 94.4%), physical hardship (65.8% and 46.8%), emotional abuse (54.7% and 56.4%), emotional neglect (41.6% and 39.6%), and sexual abuse (39.1% and 16.7%). Incident HIV infections were more common in women who experienced emotional abuse (IRR 1.96, 95% CI 1.25, 3.06, p=.003), sexual abuse (IRR 1.66 95% CI 1.04, 2.63, p=.03), and physical punishment (IRR 2.13 95% CI 1.04, 4.37, p=.04). Emotional neglect in women was associated with depression (aOR 1.82, 95% CI 1.15, 2.88, p=.01), suicidality (aOR 5.07, 95% CI 2.07, 12.45, p<.0001), alcohol abuse (aOR 2.17, 95% CI .99, 4.72, p=.05), and incident HSV2 infections (IRR 1.62, 95% CI 1.01, 2.59, p=.04). In men emotional neglect was associated with depression (aOR 3.41, 95% CI 1.87, 6.20, p<.0001) and drug use (aOR 1.98, 95% CI 1.37, 2.88, p<.0001). Sexual abuse was associated with alcohol abuse in men (aOR 3.68, 95% CI 2.00, 6.77, p<.0001) and depression (aOR 2.16, 95% CI 1.34, 3.48, p=.002) and alcohol abuse in women (aOR 3.94, 95% CI 1.90, 8.17, p<.0001). PRACTICE IMPLICATIONS: Childhood exposure to adversity is very common and influences the health of women and men. All forms of adversity, emotional, physical and sexual, enhance the risk of adverse health outcomes in men and women. Prevention of child abuse need to be included as part of the HIV prevention agenda in sub-Saharan Africa. Interventions are needed to prevent emotional, sexual, and physical abuse and responses from health and social systems in Africa to psychologically support exposed children must be strengthened.

Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study.

BACKGROUND: Cross-sectional studies have shown that intimate partner violence and gender inequity in relationships are associated with increased prevalence of HIV in women. Yet temporal sequence and causality have been questioned, and few HIV prevention programmes address these issues. We assessed whether intimate partner violence and relationship power inequity increase risk of incident HIV infection in South African women. METHODS: We did a longitudinal analysis of data from a previously published cluster-randomised controlled trial undertaken in the Eastern Cape province of South Africa in 2002-06. 1099 women aged 15-26 years who were HIV negative at baseline and had at least one additional HIV test over 2 years of follow-up were included in the analysis. Gender power equity and intimate partner violence were measured by a sexual relationship power scale and the WHO violence against women instrument, respectively. Incidence rate ratios (IRRs) of HIV acquisition at 2 years were derived from Poisson models, adjusted for study design and herpes simplex virus type 2 infection, and used to calculate population attributable fractions. FINDINGS: 128 women acquired HIV during 2076 person-years of follow-up (incidence 6.2 per 100 person-years). 51 of 325 women with low relationship power equity at baseline acquired HIV (8.5 per 100 person-years) compared with 73 of 704 women with medium or high relationship power equity (5.5 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 95% CI 1.05-2.17, p=0.027. 45 of 253 women who reported more than one episode of intimate partner violence at baseline acquired HIV (9.6 per 100 person-years) compared with 83 of 846 who reported one or no episodes (5.2 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 1.04-2.21, p=0.032. The population attributable fractions were 13.9% (95% CI 2.0-22.2) for relationship power equity and 11.9% (1.4-19.3) for intimate partner violence. INTERPRETATION: Relationship power inequity and intimate partner violence increase risk of incident HIV infection in young South African women. Policy, interventions, and programmes for HIV prevention must address both of these risk factors and allocate appropriate resources. FUNDING: National Institute of Mental Health and South African Medical Research Council.

Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa.

OBJECTIVES: To examine associations between the perpetration of intimate partner violence and HIV risk behaviour among young men in rural South Africa. DESIGN: An analysis of baseline data from men enrolling in a randomized controlled trial of the behavioural intervention, Stepping Stones. METHODS: Structured interviews with 1275 sexually experienced men aged 15-26 years from 70 villages in the rural Eastern Cape. Participants were asked about the type, frequency, and timing of violence against female partners, as well as a range of questions about HIV risk behaviours. RESULTS: A total of 31.8% of men reported the perpetration of physical or sexual violence against female main partners. Perpetration was correlated with higher numbers of past year and lifetime sexual partners, more recent intercourse, and a greater likelihood of reporting casual sex partners, problematic substance use, sexual assault of non-partners, and transactional sex. Men who reported both physical and sexual violence against a partner, perpetration both before and within the past 12 months, or more than one episode of perpetration reported significantly higher levels of HIV risk behaviour than men who reported less severe or less frequent perpetration of violence. CONCLUSION: Young men who perpetrate partner violence engage in significantly higher levels of HIV risk behaviour than non-perpetrators, and more severe violence is associated with higher levels of risky behaviour. HIV prevention interventions must explicitly address the links between the perpetration of intimate partner violence and HIV risk behaviour among men, as well as the underlying gender and power dynamics that contribute to both.

"Other patients are really in need of medical attention"--the quality of health services for rape survivors in South Africa.

OBJECTIVE: To investigate in the South African public health sector where the best services for rape survivors were provided, who provided them, what the providers' attitudes were towards women who had been raped and whether there were problems in delivering care for rape survivors. METHODS: A cross-sectional study of facilities was carried out. Two district hospitals, a regional hospital and a tertiary hospital (where available) were randomly sampled in each of the nine provinces in South Africa. At each hospital, senior staff identified two doctors and two nurses who regularly provided care for women who had been raped. These doctors and nurses were interviewed using a questionnaire with both open-ended and closed questions. We interviewed 124 providers in 31 hospitals. A checklist that indicated what facilities were available for rape survivors was also completed for each hospital. FINDINGS: A total of 32.6% of health workers in hospitals did not consider rape to be a serious medical condition. The mean number of rape survivors seen in the previous six months at each hospital was 27.9 (range = 9.3-46.5). A total of 30.3% of providers had received training in caring for rape survivors. More than three-quarters of regional hospitals (76.9%) had a private exam room designated for use in caring for rape survivors. Multiple regression analysis of practitioner factors associated with better quality of clinical care found these to be a practitioner being older than 40 years (parameter estimate = 2.4; 95% confidence interval (CI) = 0.7-5), having cared for a higher number of rape survivors before (parameter estimate = 0.02; 95% CI = 0.001-0.03), working in a facility that had a clinical management protocol for caring for rape survivors (parameter estimate = 2; 95% CI = 0.12-3.94), having worked for less time in the facility (parameter estimate = -0.2; 95% CI = -0.3 to -0.04) and perceiving rape to be a serious medical problem (parameter estimate = 2.8; 95% CI = 1.9-3.8). CONCLUSION: There are many weaknesses in services for rape survivors in South Africa. Our findings suggest that care can be improved by disseminating clinical management guidelines and ensuring that care is provided by motivated providers who are designated to care for survivors.

Why are women still aborting outside designated facilities in metropolitan South Africa?

OBJECTIVE: To explore why South African women still abort outside designated services where there is substantial legal service provision. DESIGN: Descriptive study. SETTING: Three hospitals in Gauteng Province in South Africa. Sample Forty-six women attending hospital with incomplete abortion who had abortions induced outside of designated facilities. METHODS: An interviewer-administered questionnaire with open and closed questions was completed. Induction status was determined from answers to a set of closed questions. Open-ended questions explored the circumstances of induction. Main focus of interviews Methods of induction used, barriers to legal service use. RESULTS: Nearly two-thirds of women (n= 38) had self-induced or had consulted a traditional healer. A minority of these women (n= 11) indicated that they did this because they experienced barriers to legal service use. For others it was presented as a 'natural' response to a health problem (unwanted pregnancy). Several women (n= 10) were given misoprostol by a doctor, nurse, or pharmacist. Fifty-four percent of the women had not used legal services because they did not know about the law, while 15% knew of their legal rights, but did not know of a legal facility. Others did know where to access legal services but feared rude staff (17%) or breaches of confidentiality (6.5%). Others (6.5%) had been unable to get a legal abortion early enough in pregnancy to comply with the law. CONCLUSIONS: Lack of information on abortion rights under the Act and perceived poor quality of designated facilities were the most important barriers to access and should be addressed by policymakers and health service management. The willingness of women to self-medicate and visit traditional healers in these circumstances may influence the overall ability of the new legislation to reduce abortion morbidity.

Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa.

Gender-based violence is a key health risk for women globally and in South Africa. The authors analyzed data from 1,395 interviews with women attending antenatal clinics in Soweto, South Africa, between November 2001 and April 2002 to estimate the prevalence of physical/sexual partner violence (55.5%), adult sexual assault by nonpartners (7.9%), child sexual assault (8.0%), and forced first intercourse (7.3%). Age at first experience of each type of violence was modeled by the Kaplan-Meier method, and Cox hazard models with time-varying covariates were used to explore whether child sexual assault and forced first intercourse were associated with risk of violent revictimization in adulthood. Child sexual assault was associated with increased risk of physical and/or sexual partner violence (risk ratio = 2.43, 95% confidence interval: 1.93, 3.06) and with adult sexual assault by a nonpartner (risk ratio = 2.33, 95% confidence interval: 1.40, 3.89). Forced first intercourse was associated with increased risk of physical and/or sexual partner violence (risk ratio = 2.64, 95% confidence interval: 2.07, 3.38) and nonsignificantly with adult sexual assault by a nonpartner (risk ratio = 2.14, 95% confidence interval: 0.92, 4.98). This study confirms the need for increased attention by the public health community to primary and secondary prevention of gender-based violence, with a specific need to reduce risk among South African adolescents.

Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection.

Sex workers have long been considered a high-risk group for HIV infection, but to date little quantitative research has explored the association between HIV risk and exchange of sex for material gain by women in the general population. The objective of this study was to estimate the prevalence of such transactional sex among women attending antenatal clinics in Soweto, South Africa, to identify demographic and social variables associated with reporting transactional sex, and to determine the association between transactional sex and HIV serostatus. We conducted a cross-sectional study of women seeking antenatal care in four Soweto health centres who accepted routine antenatal HIV testing. Private face-to-face interviews covered socio-demographics, sexual history and experience of gender-based violence. 21.1% of participants reported having ever had sex with a non-primary male partner in exchange for material goods or money. Women who reported past experience of violence by male intimate partners, problematic substance use, urban residence, ever earning money, or living in substandard housing were more likely to report transactional sex, while women who reported delayed first coitus, were married, or had a post-secondary education were less likely to report transactional sex. Transactional sex was associated with HIV seropositivity after controlling for lifetime number of male sex partners and length of time a woman had been sexually active (OR = 1.54, 95% CI: 1.07, 2.21). Women who reported non-primary partners without transactional sex did not have increased odds of being HIV seropositive (OR = 1.04, 95% CI: 0.75, 1.43). We conclude that transactional sex may place women at increased risk for HIV, and is associated with gender-based violence, substance use and socio-economic disadvantage. Research, policy and programmatic initiatives should consider the role of transactional sex in women's HIV risk, with attention to the intersecting roles of violence, poverty, and substance use in shaping women's sexual behaviour.

Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa.

BACKGROUND: Gender-based violence and gender inequality are increasingly cited as important determinants of women's HIV risk; yet empirical research on possible connections remains limited. No study on women has yet assessed gender-based violence as a risk factor for HIV after adjustment for women's own high-risk behaviours, although these are known to be associated with experience of violence. METHODS: We did a cross-sectional study of 1366 women presenting for antenatal care at four health centres in Soweto, South Africa, who accepted routine antenatal HIV testing. Private face-to-face interviews were done in local languages and included assessement of sociodemographic characteristics, experience of gender-based violence, the South African adaptation of the Sexual Relationship Power Scale (SRPS), and risk behaviours including multiple, concurrent, and casual male partners, and transactional sex. FINDINGS: After adjustment for age and current relationship status and women's risk behaviour, intimate partner violence (odds ratio 1.48, 95% CI 1.15-1.89) and high levels of male control in a woman's current relationship as measured by the SRPS (1.52, 1.13-2.04) were associated with HIV seropositivity. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV serostatus. INTERPRETATION: Women with violent or controlling male partners are at increased risk of HIV infection. We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships, and HIV risk behaviours in men, as well as effective interventions, are urgently needed.