title: Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: analysis of an intervention in an existing cluster randomised cohort.
abstract: BACKGROUND
  Intimate partner violence (IPV) is associated with HIV infection. We aimed to assess whether provision of a combination of IPV prevention and HIV services would reduce IPV and HIV incidence in individuals enrolled in the Rakai Community Cohort Study (RCCS), Rakai, Uganda.
  
  
  METHODS
  We used pre-existing clusters of communities randomised as part of a previous family planning trial in this cohort. Four intervention group clusters from the previous trial were provided standard of care HIV services plus a community-level mobilisation intervention to change attitudes, social norms, and behaviours related to IPV, and a screening and brief intervention to promote safe HIV disclosure and risk reduction in women seeking HIV counselling and testing services (the Safe Homes and Respect for Everyone [SHARE] Project). Seven control group clusters (including two intervention groups from the original trial) received only standard of care HIV services. Investigators for the RCCS did a baseline survey between February, 2005, and June, 2006, and two follow-up surveys between August, 2006, and April, 2008, and June, 2008, and December, 2009. Our primary endpoints were self-reported experience and perpetration of past year IPV (emotional, physical, and sexual) and laboratory-based diagnosis of HIV incidence in the study population. We used Poisson multivariable regression to estimate adjusted prevalence risk ratios (aPRR) of IPV, and adjusted incidence rate ratios (aIRR) of HIV acquisition. This study was registered with ClinicalTrials.gov, number NCT02050763.
  
  
  RESULTS
  Between Feb 15, 2005, and June 30, 2006, we enrolled 11 448 individuals aged 15-49 years. 5337 individuals (in four intervention clusters) were allocated into the SHARE plus HIV services group and 6111 individuals (in seven control clusters) were allocated into the HIV services only group. Compared with control groups, individuals in the SHARE intervention groups had fewer self-reports of past-year physical IPV (346 [16%] of 2127 responders in control groups vs 217 [12%] of 1812 responders in intervention groups; aPRR 0·79, 95% CI 0·67-0·92) and sexual IPV (261 [13%] of 2038 vs 167 [10%] of 1737; 0·80, 0·67-0·97). Incidence of emotional IPV did not differ (409 [20%] of 2039 vs 311 [18%] of 1737; 0·91, 0·79-1·04). SHARE had no effect on male-reported IPV perpetration. At follow-up 2 (after about 35 months) the intervention was associated with a reduction in HIV incidence (1·15 cases per 100 person-years in control vs 0·87 cases per 100 person-years in intervention group; aIRR 0·67, 95% CI 0·46-0·97, p=0·0362).
  
  
  CONCLUSIONS
  SHARE could reduce some forms of IPV towards women and overall HIV incidence, possibly through a reduction in forced sex and increased disclosure of HIV results. Findings from this study should inform future work toward HIV prevention, treatment, and care, and SHARE's ecological approach could be adopted, at least partly, as a standard of care for other HIV programmes in sub-Saharan Africa.
  
  
  BACKGROUND
  Bill & Melinda Gates Foundation, US National Institutes of Health, WHO, President's Emergency Plan for AIDS Relief, Fogarty International Center.
authors.affiliation: Division of Global Public Health, School of Medicine, University of California, San Diego, La Jolla, CA, USA. Electronic address: jwagman@ucsd.edu.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Wagman
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Ronald H
authors.initials: RH
authors.lastname: Gray
authors.affiliation: School of Nursing, Johns Hopkins University, Baltimore, MD, USA.
authors.forename: Jacquelyn C
authors.initials: JC
authors.lastname: Campbell
authors.affiliation: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Marie
authors.initials: M
authors.lastname: Thoma
authors.affiliation: Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda.
authors.forename: Anthony
authors.initials: A
authors.lastname: Ndyanabo
authors.affiliation: Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda.
authors.forename: Joseph
authors.initials: J
authors.lastname: Ssekasanvu
authors.affiliation: Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Nalugoda
authors.affiliation: Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda.
authors.forename: Joseph
authors.initials: J
authors.lastname: Kagaayi
authors.affiliation: Rakai Health Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda.
authors.forename: Gertrude
authors.initials: G
authors.lastname: Nakigozi
authors.affiliation: School of Public Health, New Mulago Hospital Complex, Makerere University, Kampala, Uganda.
authors.forename: David
authors.initials: D
authors.lastname: Serwadda
authors.affiliation: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Heena
authors.initials: H
authors.lastname: Brahmbhatt
mesh_terms: D000293:Adolescent; D000328:Adult; D003376:Counseling / Q000379:methods; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic / Q000379:methods; D012307:Risk Factors; D012736:Sex Education / Q000379:methods; D012725:Sexual Behavior; D013179:Spouse Abuse / Q000517:prevention & control* / Q000706:statistics & numerical data; D014454:Uganda; D055815:Young Adult