Prevalence and correlates of intimate partner violence among PrEP-eligible men and women in Coastal Kenya

This study of PrEP-eligible individuals in coastal Kenya reveals a substantial prevalence of intimate partner violence, particularly among women and those involved in sex work or parenthood, highlighting the critical need to integrate IPV risk assessment into HIV prevention programs.

The Gist

Imagine you are trying to build a sturdy house to protect a family from a storm. In this story, the storm is HIV, and the house is a daily pill called PrEP (Pre-Exposure Prophylaxis). This pill is a powerful shield; if taken correctly, it almost completely stops the virus from entering your body.

Kenya has been handing out blueprints for this house for years, hoping everyone at risk would build it. But, surprisingly, many people aren't moving in, or they move in and then leave because they forget to take their daily bricks (the pills).

This paper is like a detective story trying to figure out why some people are struggling to build or stay in their protective house. The detectives (the researchers) went to the coastal region of Kenya and looked at a specific group of people: those who are eligible for the PrEP shield. They wanted to see if a hidden, toxic force was knocking the house down before it could even be built.

That toxic force is Intimate Partner Violence (IPV)—basically, abuse from a boyfriend, girlfriend, husband, or wife. This could be physical hitting, scary threats, or forced sex.

Here is the breakdown of what they found, using some simple metaphors:

1. The Hidden Anchor

Imagine PrEP is a boat trying to sail toward safety. IPV is a heavy, rusty anchor tied to the bottom of the boat. Even if the engine (the pill) is working, the anchor drags the boat down, making it hard to move forward.

The study found that this anchor is surprisingly heavy for many people:

• The Big Picture: About 1 in 4 people (24%) in this group had experienced this abuse at some point in their lives.
• Recent Trouble: About 1 in 20 people (5.6%) had been abused in the last month.
• The Gender Gap: Women carried heavier anchors than men. They faced more physical hitting, more scary threats, and more forced sex.

2. Who is Most Likely to Have the Anchor?

The researchers looked for clues to see who was most likely to be weighed down. They found two main "anchor points":

• The "Parent" Anchor: For women, having children was a huge factor. Think of it like this: When you have kids, you might feel like you can't leave a dangerous relationship because you need to protect your children or because you rely on that partner for money. The study found that women with children were twice as likely to have experienced abuse compared to those without.
• The "Survival Job" Anchor: For both men and women, doing sex work (trading sex for money or favors) was a major risk. Imagine walking a tightrope without a safety net; the people on the other side (clients or partners) might hold the power to hurt you. Both men and women who did this work were much more likely to face violence.

3. Why Does This Matter for the HIV Shield?

You might ask, "Why does abuse stop someone from taking a pill?"

Think of the PrEP pill as a secret weapon. If you are living with an abusive partner, you might be afraid to take the pill because:

• The Fear of Discovery: If your partner finds the pill, they might get angry, think you are cheating, or become violent.
• The Control: An abusive partner might hide your medicine, lock it away, or force you to skip doses.
• The Stress: When you are in survival mode, trying to stay safe from violence, remembering to take a daily pill for a disease you don't have yet feels like a luxury you can't afford.

4. The "Survivor Selection" Twist

There is one tricky part of this story. The researchers had to be very careful to keep people safe. If someone said, "I am being abused right now," they were not allowed to join this specific study (because the study wasn't set up to handle immediate crises).

This is like a doctor only treating patients who have already survived a car crash but aren't currently bleeding out. While this was the right thing to do for safety, it means the study might have missed the people with the heaviest anchors—the ones currently in the most danger. So, the numbers in this paper are likely the "best-case scenario" and the real problem might be even bigger.

The Bottom Line

The researchers are saying: "We can't just hand out the PrEP shield and hope for the best."

If a person is being abused at home, giving them a pill without also giving them a safe place to hide it, or without connecting them to someone who can help them leave the abuse, is like giving a life raft to someone who is being held underwater by a rope.

The Solution?
Hospitals and clinics in Kenya need to check for the "anchor" (abuse) at the same time they hand out the "shield" (PrEP). They need to offer support, safety plans, and counseling alongside the medicine. Only by untangling the knot of violence can the HIV prevention tools truly work for everyone, whether they are men or women, parents or sex workers.

Technical Summary

1. Problem Statement

Despite the integration of Pre-exposure Prophylaxis (PrEP) into Kenya's national HIV prevention plan in 2017, uptake and adherence remain suboptimal. Intimate Partner Violence (IPV) is a recognized syndemic that acts as a significant barrier to HIV prevention services. While the impact of IPV on women's PrEP use is documented, there is a critical data gap regarding:

• The prevalence of IPV among men eligible for PrEP.
• The specific correlates of IPV within the PrEP-eligible population.
• How IPV intersects with HIV risk behaviors (e.g., sex work) in both genders.

The study aims to fill these gaps by analyzing IPV prevalence and its correlates among PrEP-eligible men and women in coastal Kenya.

2. Methodology

Study Design and Setting:

• Type: Secondary analysis of data from the "Tambua Mapema Plus" (TMP) trial.
• Location: Six healthcare facilities in coastal Kenya (Kilifi and Mombasa counties).
• Timeline: December 2017 – March 2020.
• Original Trial: A modified stepped-wedge trial comparing opt-out point-of-care HIV-1 nucleic acid amplification testing (NAAT) against standard provider-initiated rapid testing.

Study Population:

• Inclusion Criteria: HIV-negative, sexually active in the last 6 weeks, and meeting PrEP eligibility criteria based on Kenya's Rapid Assessment Screening Tool (RAST).
• Exclusion Criteria: Participants experiencing ongoing IPV were excluded at screening for safety and referred to counseling.
• Final Sample: 638 participants (402 women, 236 men) met PrEP eligibility criteria.

Data Collection & Variables:

• IPV Assessment: Three screening questions covering physical, verbal/threatening, and sexual violence. Participants were asked about the timing (ongoing, past month, or >1 month ago).
• PrEP Eligibility Criteria: HIV-negative status + sexual activity in 6 weeks + at least one risk factor (e.g., partner with HIV, condomless sex with unknown status, transactional sex, STI diagnosis, needle sharing, or same-sex partners).
• Demographics: Age, sex, marital status, education, employment, parenthood, and specific risk behaviors (transactional sex, same-sex partners).

Statistical Analysis:

• Descriptive: Chi-square tests for differences by sex.
• Regression: Modified Poisson regression with robust standard errors to calculate Risk Ratios (RR) and Adjusted Risk Ratios (ARR) with 95% Confidence Intervals (CI).
• Stratification: Analyses were performed on the total population and stratified by gender.

3. Key Results

Prevalence of IPV:

• Lifetime Exposure: 24.1% (n=154) of PrEP-eligible participants reported lifetime IPV.
• Past-Month Exposure: 5.6% (n=34) reported IPV in the last month.
• Gender Disparities: Women reported higher rates across all categories compared to men:
  • Verbal IPV: 14.9% (Women) vs. 11.0% (Men).
  • Physical IPV: 15.2% (Women) vs. 9.7% (Men).
  • Sexual IPV: 11.2% (Women) vs. 6.4% (Men).
  • Note: The difference in sexual IPV was statistically significant (p=0.04).

Correlates of IPV (Multivariable Analysis):

• Overall Population:
  • Having Children: Increased risk of IPV (ARR = 2.09; 95% CI 1.32–3.32).
  • Engaging in Sex Work: Increased risk of IPV (ARR = 1.81; 95% CI 1.13–2.80).
• Stratified by Gender:
  • Women: Having children was the strongest predictor (ARR = 2.30; 95% CI 1.29–4.24).
  • Men: Engaging in sex work was the strongest predictor (ARR = 2.37; 95% CI 1.15–4.68).

4. Key Contributions

1. Gender-Specific Data: Provides rare empirical data on IPV prevalence specifically among men eligible for PrEP, a group often overlooked in HIV prevention literature.
2. Identification of Structural Vulnerabilities: Highlights that parenthood is a distinct risk factor for women, while transactional sex is a critical risk factor for both genders, but particularly predictive for men.
3. Syndemic Analysis: Explicitly links IPV with PrEP eligibility, suggesting that IPV is not just a social issue but a structural barrier to the HIV care continuum.
4. Methodological Insight: Demonstrates the "survivor-selection effect" where excluding ongoing IPV cases (for safety) likely results in conservative prevalence estimates, potentially underrepresenting the most vulnerable populations.

5. Significance and Implications

• Programmatic Integration: The high prevalence of IPV (24.1% lifetime) among PrEP-eligible individuals underscores the necessity of integrating IPV risk assessment into standard PrEP delivery models in Kenya.
• Tailored Interventions:
  • For women, interventions must address the specific vulnerabilities associated with having children (e.g., economic dependency, caregiving burdens).
  • For men, particularly those in sex work, programs must address compounded stigma and barriers to help-seeking.
• PrEP Adherence: IPV is a known driver of low PrEP adherence. Identifying IPV risk allows providers to offer trauma-informed care, safer medication storage strategies, and discreet PrEP options (e.g., long-acting formulations) to mitigate partner interference.
• Policy Recommendation: The authors advocate for routine IPV screening within PrEP programs, accompanied by robust referral pathways and provider training to ensure identification does not inadvertently increase risk for the patient.

Limitations Noted:

• Geographic restriction to coastal Kenya limits generalizability.
• Self-reported data may be subject to recall or social desirability bias.
• Exclusion of ongoing IPV cases likely led to an underestimation of true prevalence.
• Small sample sizes for specific subgroups (e.g., men who have sex with men, needle users) prevented granular subgroup analysis.