London School of Hygiene & Tropical Medicine

A trial which combines microfinance with gender and HIV education has contributed to a 55% drop in the incidence of intimate partner violence, a key factor in HIV transmission, among a group of poor South African women.

The results of the IMAGE trial, published online today in The Lancet, coincide with both World Aids Day on 1 December and the 16 Days of Activism on Violence Against Women campaign, which runs until 10 December. The trial was singled out at the opening plenary of the International AIDS Conference in Toronto this year as an important piece of social and behavioural intervention work addressing the specific needs of women and girls, and has already transformed the lives of thousands of women.

IMAGE stands for Intervention with Microfinance for AIDS and Gender Equity Study and is a joint initiative between the University of Witswatersrand in South Africa, the London School of Hygiene & Tropical Medicine and a microfinance provider called Small Enterprise Foundation (SEF). It is a 3-year randomized study involving 850 women and 4,000 young people from the rural Sekhukuneland District of South Africa's Limpopo Province.

South Africa is currently experiencing some of the highest rates of HIV infection in the world. National antenatal prevalence data place infection rates in the area of 22.4% of sexually active adults. The country also had the highest burden of rape in the world - with over 55,000 reported cases last year alone. Rural women are at high risk of HIV because their social and economic conditions place further constraints on their opportunities and life choices.

The women are offered access to microfinance, so they can set up businesses and become economically self-sufficient, and gender and HIV education, to help them better negotiate sexual relationships and challenge negative attitudes within the community. This is the first time that the links between poverty, violence and HIV - the so-called 'triple threat' to development - have been explored in this way and the trial is the first in Africa to have found a link between this approach and a reduction in levels of intimate partner violence.

The IMAGE intervention targets the poorest. Nearly three quarters of women involved in the study note that, for their families, having enough food to eat is a daily concern. After two years of involvement in the programme, their levels of economic well-being improved, and there was clear evidence of changes in women's empowerment (eg greater self confidence, more influence over household decisions, and the challenging of traditional gender norms). Among women participating in the intervention, their experience of physical and/or sexual violence in the past year was reduced by half, relative to a control group of women from villages that didn't receive the intervention.

Microfinance is a well-established means of development; it gives small loans to poor women to help them to set up businesses and become self-sufficient. There are more than 100 million microfinance recipients worldwide. The global pioneer of microfinance, Professor Muhammad Yunus, was recently awarded the Nobel Peace Prize for more than two decades of work with the Grameen Bank in Bangladesh which now has several million members.

The IMAGE research team sought to combine these loans with a gender and HIV training programme which coincided with fortnightly loan centre meetings. Loans as small as 500 Rand helped women to set up as dressmakers, sell fruit and vegetables or set up their own shops.

Dr Julia Kim, a clinical research fellow at the London School of Hygiene & Tropical Medicine and co-founder of the project, comments: 'The conventional "ABC" HIV prevention message - abstain, be faithful, use a condom - is just not having enough impact. In South Africa, as in many places around the world, poverty and gender inequalities are shaping the nature of sexual relationships; if you're in a violent relationship, asking your husband to use a condom could provoke suspicion and further violence, and there's little value in being faithful if your husband sees his own infidelity as part of "being a man"'.

'With women making up the majority of those infected with HIV in sub-Saharan Africa, and young women at three times the risk of young men, it was clear to us that more needed to be done', she continues. 'This programme works on the principle of "women supporting women", and the idea that there is strength in numbers. It looks at the deep cultural messages that surround sex and relationships in South Africa, and the way women and girls are expected to behave, and tries to question them'.

The IMAGE Trial has been partly-funded by the UK Department for International Development.

Hilary Benn, Secretary of State for International Development, said:
'More adult women than ever before are living with HIV, 15 million in sub-Saharan Africa alone. Violence against women and extreme poverty only makes those at risk even more vulnerable.

'Changing cultural behaviour, especially attitudes towards sex and relationships, and tackling the stigma that underlies AIDS is one of the greatest challenges we face in our response to the disease.

'That is why the innovation of the IMAGE programme is an excellent example of a really practical way of dealing with a complex issue. The study helps give women more choices and power, and it is that which is helping change the lives of those most at risk.'

• Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate partner violence and HIV in rural South Africa: Results of a cluster randomized trial. The Lancet, 368, 1973-1983, Dec 2, 2006.