The current study successfully recruited and engaged a large sample of South African men into two community-based prevention interventions. Confirming previous research, the men in our study demonstrated high-risk for HIV infection, with one in five having been diagnosed with an STI and nearly half reporting two or more sex partners in the previous month. The sample also indicated high-rates of relationship violence, with more than half of men reporting a history of physically assaulting a sex partner and one in five having been detained for domestic violence. Men in the current study therefore reaffirm the urgent need for interventions to prevent both HIV/AIDS and gender-based violence in South Africa.
The results of our quasi-experimental trial partially supported the hypothesized effects of an integrated gender-based violence and HIV/AIDS prevention intervention. We observed reductions in negative attitudes toward women and reductions in the propensity to act violently against women among participants in the GBV/HIV intervention. Men in the GBV/HIV intervention also increased their talking with sex partners about condoms and were more likely to get tested for HIV over the follow-up period, both behaviors that are conceptually consistent with partner protective actions. The GBV/HIV intervention did not, however, demonstrate evidence for efficacy in reducing unprotected sex acts, reducing numbers of sex partners or increasing condom use. The pattern of risk behavior changes observed actually suggests that the alcohol/HIV prevention intervention offered greater potential for sexual risk reduction than that realized in the GBV/HIV prevention intervention. These results are therefore intriguing and suggest that future research may examine more complex integrated models, such as a tripartite intervention approach that integrates alcohol reduction, gender violence prevention, and HIV risk reduction for South African men.
The current study is limited by its use of a two-community quasi-experimental design. Although the two communities in our study were rather homogeneous, the study design did not randomize participants to conditions. Relying on two communities randomized to two conditions yields an inherently weak study design, particularly in terms of examining individual level behavior change. The baseline differences between communities in history of gender violence may have resulted from the chain recruitment procedures and represents another limitation of the study. Our participants were primarily unemployed and were therefore able to attend lengthy workshops, suggesting another limitation of our sample’s generalizability. The GBV/HIV intervention also did not include intersession intervals, reducing men’s opportunities for practicing new skills during the course of the intervention. The two interventions in this study differed in multiple and important ways. The difference in intervention duration, for example, may account for the differential attrition in follow-up assessments as well as potential influences on behavioral response reporting. Our measures were also limited to a relatively few constructs, especially those regarding gender-based violence. Our findings may therefore be explained by constructs that were not assessed in our study. In addition, some of our measures were limited by ceiling effects, most notably AIDS knowledge, reducing our sensitivity for detecting change. The study was also limited by relying entirely on self-reported behaviors, most of which are socially sanctioned. Because reports of sexual risks and domestic violence behaviors may be sensitive to social desirability influences, the rates of risk and violent behaviors observed in this study should be considered lower-bound estimates. The high-degree of variability in our measures, as evidenced by the large standard deviations for variables, also cautions against drawing definitive conclusions from our findings. Our study is also limited by intervening with men from only one of the many cultural groups in South Africa. Future attempts to reduce HIV transmission and gender-based violence risks with men should examine multiple cultural groups.
With these limitations considered, we believe that our current study findings offer new information for HIV prevention efforts in South Africa. HIV/AIDS and gender-based violence remain in great need of immediate effective interventions in South Africa. We are intrigued by the potential effects of both the GBV/HIV and alcohol/HIV intervention outcomes. Alcohol is a known risk correlate to both HIV/AIDS and gender-based violence in South Africa (Abrahams et al., 2004
; Phorano et al., 2005
). Interventions that directly address alcohol in relation to sexual risks have demonstrated short-term efficacy in previous intervention trials in South Africa (Kalichman et al., 2007
; Kalichman, Vermaak et al., 2008
). An intervention model that addresses alcohol use in relation to both gender-based violence and HIV/AIDS behavioral risks may prove most promising.