Challenging Gender Roles among Serodiscordant Couples to

Reduce Risks in South Africa

W. Zule, A. Minnis, I. Doherty, B. Myers, J. Ndirangu, J., & W. Wechsberg

Funded by NIAAA grant number R01AA018076

Background

South Africa: Intersection of AOD, HIV and GBV

• Alcohol and other drug (AOD) use is high, and intersecting with men being abusive and gender-based violence.

• Women (especially young women) are at greatest risk of victimization

• SA also has a high prevalence of physical and sexual violence and victimization

• SA also has more people living with HIV, especially among women from heterosexual transmission

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Male Gender Roles in the TownshipsTraditional Power and Control

Couples’ Health CoOp (CHC)Study

Cape Town, SAFunded by NIAAA

Addressing AOD, sexual risk,

gender roles and HIV risk reduction

R01AA018076

Advantages of Bringing Couples Together

• Responsibility for HIV risk reduction is placed on both members of the couple

• Safe environment to disclose sensitive issues

• Can address gender power imbalances re: sexual coercion, condom negotiation, and needle sharing

• Improve communication skills in vivo with a third party

• STI and HIV risk reduction can be combined with reproductive health

El-Bassel et al., JAIDS, 2010

Mapping Drinking Establishments

300 COUPLES WERE RECRUITEDPEER LED INTERVENTIONS INLOCAL COMMUNITY CENTERS

• Developed and Adapted Men Health CoOp intervention

• Tweaked the Women’s Health CoOp• Developed the Couples Health CoOp

intervention• Mapped 1296 bars using GIS and made into 30

communities that were randomized

Pretest to Pilot test to RCT

Experimental DesignGIS Mapped Shebeens and Surrounding Neighborhoods

HCT & WHC

Eligible Men Women Main Partners

MHC & WHC CHC

Randomization of neighborhoods

Eligible Men Women Main Partners Eligible Men Women Main

Partners

HCT WHC2-sessions

MHC2-sessions

WHC2-sessions

CHC2-sessions

6-monthfollowup

6-monthfollowup

6-monthfollowup

6-monthfollowup

6-monthfollowup

6-monthfollowup

HCT – HIV counseling and testingWHC -- Women’s Health CoOpMHC -- Men’s Health CoOpCHC – Couples’ Health CoOp

-- Included in current analysis

Goals of Study• Understand how AOD &

gender roles relate to risk behaviors and violence.

• How time in shebeens affects relationships.

• Enhance risk reduction skills & reduce risk behavior.

• Increase communication & problem solving skills.

• Learn how to enjoy & value each other more.

Example from Intervention about the intersection of

AOD, Sexual Risk and Violence

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The Couples Health CoOp Biological Results

Baseline Prevalence(300 couples)

The Couples Health CoOp Biological Results

Baseline Prevalence(300 couples)

Men n=300

Womenn=300

HIV confirmed 12% 25%

Pregnancy -- 8%

Alcohol 4% 1%

Mandrax 12% 3%

Cocaine 0% 0%

Methamphetamine 14% 3%

Opiates 1% 0%

Marijuana 32% 8%

R01AA018076

Serodiscordance of HIV among couples

Woman Neg / Man HIV+4%

Both NEGATIVE70%

Woman HIV+ / Man Neg

17%

Both HIV+9%

Bio behavioral outcomes

• Favored the Couples Health CoOp intervention

• With reduced seroincidence and AOD (will be reported Thursday)

However, we went further into the entrenched cultural gender roles…

Outcome Measures

• Relationship control evaluated as “shared decision making” (8 items).

• Relationship communication regarding HIV prevention/risk (e.g. condom use and HIV risk behaviors) (11 items).

• (No) victimization (i.e. physical or sexual abuse) by partner

Relationship Control (women)

Comparison β 95% CI P-value

Couples vs. Women’s CoOp

-0.60 -1.29, 0.10 0.09

Gender Separate vs. Women’s CoOp

0.66 -0.05, 1.37 0.07

Couples vs. Gender Separate

-1.26 -1.94, -0.57 <0.001

Relationship Control (men)

Comparison β 95% CI P-value

Couples vs. WHC -0.30 -1.07, 0.46 0.43

Gender Separate vs. WHC

0.34 -0.44, 1.13 0.39

Couples vs. Gender Separate

-0.65 -1.39, 0.10 0.09

Relationship Communication (women)

Comparison Β 95% CI P-value

Couples vs. WHC -1.94 -2.86, -1.01 <0.001

Gender Separate vs. WHC

-0.67 1.61, 0.26 0.157

Couples vs. Gender Separate

-1.26 -2.17, -0.36 0.007

Relationship Communication (men)

Comparison Β 95% CI P-value

Couples vs. WHC 1.20 0.02, 2.38 0.045

Gender Separate vs. WHC

0.97 -0.24, 2.18 0.116

Couples vs. Gender Separate

0.23 -0.91, 1.37 0.69

(No) Victimization (women)

• Women in the separate (MHC/WHC) arm were more likely than women in the Couples arm to report no victimization.

• Odds ratio = 3.05; 95% C.I. = 1.55, 6.00

(No) Victimization (males)

• There were no significant differences in self-reports of victimization between any of the study arms by males

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Conclusions• Overall the results were mixed regarding the benefits

of working with partners separately versus working with them as a couple.

• Working with both partners in a couple with regard to gender roles appears to work better with the female partner in a gender specific group

• In one instance (Communication) men appeared more responsive

• Our next step will be to perform couple-level analyses to assess how benefits are distributed within and across couples

• Implement the WHC in health care settings with even stronger evidence