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Intimate Partner Violence and Condom and Diaphragm Nonadherence Among Women in an HIV Prevention Trial in Southern Africa

Kacanek, Deborah ScD*; Bostrom, Alan PhD; Montgomery, Elizabeth T. MPH, PhD; Ramjee, Gita PhD§; de Bruyn, Guy MBBCh, MPH; Blanchard, Kelly SM; Rock, Amelia SM#; Mtetwa, Sibongile MS**; van der Straten, Ariane MPH, PhD‡,††for the MIRA Team

JAIDS Journal of Acquired Immune Deficiency Syndromes: December 1st, 2013 - Volume 64 - Issue 4 - p 400–408
doi: 10.1097/QAI.0b013e3182a6b0be
Epidemiology and Prevention

Background: We longitudinally examined the effect of intimate partner violence (IPV) on condom and diaphragm nonadherence among women in the Methods for Improving Reproductive Health in Africa study, a phase III HIV prevention trial in southern Africa.

Methods: Recent IPV (fear of violence, emotional abuse, physical violence, or forced sex, in past 3 months), condom nonadherence, and diaphragm nonadherence were assessed at baseline, 12 month, and exit visits (up to 24 months). The association between IPV and (1) condom nonadherence or (2) diaphragm nonadherence across visits was modeled using Generalized Estimating Equations adjusting for potential confounders.

Results: Of 4505 participants, 55% reported recent IPV during their trial participation. Women reported fearing violence (41%), emotional abuse (38%), being physically assaulted (16%), and forced sex (15%) by their regular male partner. IPV was associated with condom nonadherence in both study arms [adjusted odds ratio (AOR): 1.41, 95% confidence interval (CI): 1.24 to 1.61 (control arm) and AOR: 1.47, 95% CI: 1.28 to 1.69, (intervention arm)] and with diaphragm nonadherence (AOR 1.24, 95% CI: 1.06 to 1.45) adjusting for age, study sites, number of sex partners, and knowledge of male partner infidelity. Modeling effects of each form of IPV separately on nonadherence outcomes yielded similar results.

Conclusions: Prevalence of recent IPV was high and associated with condom and diaphragm nonadherence during the trial. Counseling in prevention trials should proactively address IPV, for its own sake, and in product and risk-reduction counseling. Strategies to encourage men's positive involvement in product use and prevent IPV perpetration should be considered.

*Department of Biostatistics, Harvard School of Public Health, Boston, MA;

Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA;

RTI International, Women's Global Health Imperative, San Francisco, CA;

§HIV Prevention Unit of the South African Medical Research Council, Durban, South Africa;

Sanofi Pasteur, Swiftwater, PA;

Ibis Reproductive Health, Cambridge, MA;

#JSI Research and Training Institute, Washington, DC;

**University of Zimbabwe, Harare, Zimbabwe; and

††Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA.

Correspondence to: Deborah Kacanek, ScD, Center for Biostatistics in AIDS Research, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115 (e-mail:

Supported by Bill and Melinda Gates Foundation Grant 21802.

Presented at the XVIII International AIDS Conference, 2010, Vienna, Austria.

The authors have no conflicts of interest to disclose.

D.K. is the primary author who designed the study and led the writing. A.B. was primarily responsible for conducting the statistical analysis of the data. D.K., E.T.M., G.d.B., G.R., K.B., A.R., S.M., A.v.d.S. were involved in the conduct of the MIRA protocol. For D.K., most work for this study was conducted at Ibis Reproductive Health. All authors contributed to interpretation of the results and to drafting and editing the manuscript. All authors have approved the final manuscript.

For E.T.M. and A.v.d.S., most work for this study was conducted at the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco. For G.d.B., all work for this study was conducted at the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg.

Received February 23, 2013

Accepted July 23, 2013

© 2013 by Lippincott Williams & Wilkins