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  • Ethics approval was given by the Medical Research Council's Ethics Committee. The study was undertaken in 2008 in three districts in the Eastern Cape and KwaZulu-Natal provinces of South Africa. These form a contiguous area, and include rural areas with communally-owned land under traditional leadership, as well as commercial farms, small towns, villages, and a city, inhabited by people of all South African racial groups, several ethnic groups (predominantly Xhosa and Zulu) and socio-economic backgrounds. The sample used a two stage proportionate stratified design to identify a representative sample of men aged 18–49 years living in the three districts. Using the 2001 census as the primary sampling frame, 222 census enumeration areas (EAs) were selected as the primary sampling unit, stratified by district and with numbers proportionate to district population size. The sample was drawn by Statistics South Africa. Households in each EA were mapped and twenty were systematically selected. In each household one eligible man was randomly selected to take part in the interview. Men were eligible for the study if they were aged 18–49 years and had slept there the night before. Eligible men were asked to complete a questionnaire and provide a blood sample for HIV testing. This analysis includes only those who agreed to provide blood. There was no replacement. Of the 222 selected EAs, two (0.9%) had no homes, and in five (2.3%) we could not interview because permission from the local political gatekeepers was declined (1) or we could not access any eligible home after multiple visits at different times of day (4). In all the latter EAs, we established that many households were ineligible due to age or absence of a man. We completed interviews in 215 of 220 eligible EAs (97.7%), and in these in 1,737 of 2,298 (75.6%) of the enumerated and eligible households. However only 70.8% (N = 1,229) of men interviewed provided blood i.e. 53.5% of enumerated and eligible men. Men who did not give blood did not differ in age or race from those who did, but they were more highly educated (47.9% has completed school v. 37.6% of those who gave blood) and less likely to have perpetrated physical IPV (25.0% v. 30.7% of those who gave blood). Questionnaires were administered in isiXhosa or isiZulu and English using APDAs (Audio-enhanced Personal Digital Assistants) and took 45–60 minutes to complete. They included categorical variables measuring age, education, race, employment and income. Health questions asked about circumcision and history of a genital ulcer. Alcohol consumption in the past 12 months was assessed through a question on frequency of having 5 or more drinks per drinking day. A 12-item scale assessed men's power and control in their main relationship with a female partner, after Pulerwitz et al [18], as adapted for South Africa by Dunkle et al [6]. These items were summed to derive a score (Cronbach's alpha 0.78). A typical question was “when I want sex I expect her to agree”. Men were asked about lifetime perpetration of physical intimate partner violence using the modified WHO violence against women instrument [19]. Specific acts of violence were asked about in five items ranging from slapping to threats with or use of a weapon. We have followed previous practice of categorising physical intimate partner violence into none or one episode versus more than one [2], [6], [11], [12]. We asked about frequency of condom use in the past year and about the number of primary and non-primary partners in the past year and lifetime. Concurrency was assessed by asking about having a khwapheni (an indigenous category of definitionally concurrent non-primary partner). We asked about transactional sex with women, defined as sex that was primarily motivated by a desire for material gain on the part of the woman. This was defined as providing food, cosmetics, clothes, transportation, items for children or family, school fees, somewhere to sleep, handyman work, or cash [6]. Interviewees were asked if they had ever had “sex with a prostitute”. Rape of women and girls was assessed using seven questions adapted for the study from previously used items, and further validated through cognitive interviewing [20]. A typical item was “How many times have you slept with a woman or girl when she didn't consent to sex or after you forced her?”. Questions asked about rape of a current or ex-girlfriend or wife, rape of a non-partner, gang rape and rape of a woman who was drunk. Men were then asked two questions about perpetration of rape of a man or boy. We also asked about the age of the youngest victim raped. The HIV tests were conducted on dried blood spots. These were tested with a screen ELISA (Genscreen, Bio-Rad, Steenvorde, France) and positive results confirmed with a second ELISA (Vironostika, bioMérieux, Marcy d'Etoile, France). They were analysed by the National Institute for Communicable Diseases, which participates in a programme supported by the Center for Communicable Diseases Control that has shown these methods can optimally identify HIV-1 from dried blood spots. The men signed informed consent for the interview and separately for blood, if they agreed to a sample being taken. To recognise their research contribution, they were given R50 (US $6.5). The questionnaire asked men to disclose having engaged in a range of criminal acts. The nature of South African law meant that men could only be protected from possible legal repercussions through complete anonymity. To do this we had to keep no identifying information on interviewees, and this meant that we could not make return visits to offer HIV test results. HIV testing is free and widely available in South Africa and all men received a leaflet and were encouraged to go to their nearest clinic for HIV testing. Data were downloaded from the APDA memory cards and merged with the HIV test results. The resulting dataset provided a self-weighted sample. Analyses on participants who agreed to give blood (n = 1229) were carried out using Stata 10.0. All procedures took into account the two stage structure of the dataset, with stratification by district and the EAs as clusters. The social, demographic characteristics, sexual and violent practices and established HIV risk factors were summarised as percentages (or means) with 95% confidence limits, using standard methods for estimating confidence intervals from complex multistage sample surveys (Taylor linearization). Pearson's chi was used to test associations between categorical variables. No efforts were made to replace missing data. To account for clustering of men within EAs, a random effects logistic regression model was fitted to identify factors associated with having HIV. Candidate variables for the model included social and demographic characteristics of the men, their sexual practices, relationship control, intimate partner violence (>1 episode v. none or one), any rape perpetration, substance abuse, having had anal sex, having had a genital ulcer and circumcision. The variables were entered into the model in groups and backwards elimination was used (p<0.2) to derive a final model. A term for stratum was included in the model. Variables for the final model were retained at p≤0.05. We tested for interactions between retained variables and found a significant interaction between perpetration of physical IPV and age; therefore present the association between physical IPV and HIV stratified by age of respondent.
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