1. 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

2. 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

3. 3 Male Gender Roles in the Townships Traditional Power and Control

4. Couples’ Health CoOp (CHC) Study Cape Town, SA Funded by NIAAA Addressing AOD, sexual risk, gender roles and HIV risk reduction R01AA018076

5. 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

6. Mapping Drinking Establishments

7. 300 COUPLES WERE RECRUITED PEER LED INTERVENTIONS IN LOCAL 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

8. Experimental Design

9. 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.

10. Example from Intervention about the intersection of AOD, Sexual Risk and Violence

11. 11 The Couples Health CoOp Biological Results Baseline Prevalence (300 couples) The Couples Health CoOp Biological Results Baseline Prevalence (300 couples) Men n=300 Women n=300 HIV confirmed12%25% Pregnancy--8% Alcohol4%1% Mandrax12%3% Cocaine0% Methamphetamine14%3% Opiates1%0% Marijuana32%8% R01AA018076

12. Serodiscordance of HIV among couples

13. 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…

14. 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

15. Relationship Control (women) Comparisonβ95% CIP-value Couples vs. Women’s CoOp -0.60-1.29, 0.100.09 Gender Separate vs. Women’s CoOp 0.66-0.05, 1.370.07 Couples vs. Gender Separate -1.26-1.94, -0.57<0.001

16. Relationship Control (men) Comparisonβ95% CIP-value Couples vs. WHC-0.30-1.07, 0.460.43 Gender Separate vs. WHC 0.34-0.44, 1.130.39 Couples vs. Gender Separate -0.65-1.39, 0.100.09

17. Relationship Communication (women) ComparisonΒ95% CIP-value Couples vs. WHC-1.94-2.86, -1.01<0.001 Gender Separate vs. WHC -0.671.61, 0.260.157 Couples vs. Gender Separate -1.26-2.17, -0.360.007

18. Relationship Communication (men) ComparisonΒ95% CIP-value Couples vs. WHC 1.200.02, 2.380.045 Gender Separate vs. WHC 0.97-0.24, 2.180.116 Couples vs. Gender Separate 0.23-0.91, 1.370.69

19. (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

20. (No) Victimization (males) There were no significant differences in self-reports of victimization between any of the study arms by males

21. 21 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