VOICE-C Participant Narratives of Rape: What they Mean for Female-initiated HIV Prevention Products

Background: Numerous recent trials have sought to develop female-initiated methods of HIV prevention; in part to address barriers to women's prevention rooted in unequal gender norms. Understanding the gender-related context in which these products may be used, including levels of violence against women, is critical. MTN-003C (VOICE-C), a qualitative sub-study of the MTN-003 (VOICE) HIV prevention trial, examined socio-cultural barriers and facilitators to product use within the Johannesburg site. Methods: We conducted and analyzed focus group discussion (FGD), in-depth interview (IDI), and serial ethnographic interview data from 102 female VOICE participants, 22 male partners, 17 community advisory board (CAB) members, and 23 community stakeholders. Violence was not a designated interview topic; however it arose through discussions of community context, interpersonal relationships, and product use. For this analysis, all textual data coded as “violence” was systematically reviewed. Results: The data revealed the prominence of sexual violence in women's lives. Rape was discussed in 2/4 FGDs with CAB members, 2/3 FGDs with stakeholders and among a quarter of interviews/FGDs with VOICE female participants; two of whom described personal experiences of rape. These narratives demonstrated a pervasive perception that women are vulnerable to rape and that this threat contributes to their susceptibility to HIV. The possibility of rape was used to reframe their HIV risk as external to their own or their partner's behavior and was ultimately used to rationalize the importance of female-initiated products in HIV prevention. Conclusions: Fear or experience of rape is pervasive in this community, reflecting underlying gender inequalities, which in turn are likely to influence how HIV prevention products are perceived and used. While the actual impact on product use in VOICE is uncertain, results illustrate how women, in contexts of high sexual violence, may utilize existing unequal gender norms to negotiate their use. Language: en