A mother plays with her child while waiting for services at Jose Maria Cabral y Baez Hospital in Santiago, Dominican Republic. Health workers and supervisors from this hospital participated in a workshop to improve the quality of services to eliminate mother-to-child transmission of HIV. / Wendy Tactuk, courtesy of CapacityPlus and IntraHealth International
This week we mark World AIDS Day. Appropriately, it occurs during the Sixteen Days of Activism Against Gender-Based Violence. Why so appropriate? Because we know that gender-based violence (GBV) prevention and response are critical to effectively treating and reducing the spread of HIV. Though not always self-evident, the connection is clear.
For me, the linkages were driven home during recent conversations I had with health experts in Ghana. While discussing our health programs, I casually asked how important attention to GBV was within efforts to treat and stem the spread of the HIV. As soon as I asked the question, the room’s atmosphere changed palpably. Everyone sat up and leaned in. People began speaking all at once, tripping over one another to respond. The passion was tangible and the analysis compelling. It was all the more persuasive because it is backed up by research.
In Ghana, the HIV rate is low and declining, though the rate is 15 – 20 times higher for key populations at risk of contracting HIV, which include female sex workers (FSWs) and men who have sex with men.
GBV is particularly common among female sex workers (FSWs), 24 – 37 percent of whom are HIV-positive. How do GBV and HIV rates correlate and relate, and how do we bear that in mind in our work to prevent and treat the infected?
A traditional leader discusses multiple concurrent partnerships, a key driver of HIV in Zambia, during a November 2013 training on HIV/AIDS leadership messaging in Kanyembo Chiefdom, Luapula Province. / JSI/SHARe II
Many of my conversations in Accra focused on how to help people change behavior to decrease the risk of transmitting the virus and to increase the likelihood of seeking testing and treatment. The experts discussed how much more difficult it is for a woman or a man to negotiate condom use with an abusive partner.
The victim is less likely to try to persuade the abuser to use protection. The perpetrator is less likely to listen. The practitioners also talked about how victims of gender-based violence have less self-esteem and a lowered sense of self-worth. As a result, victims of abuse don’t believe they have the “right” to receive health services. It is much harder to coax people who face GBV or who fear violence or abandonment to seek services, test for HIV, or to successfully access or adhere to treatment.
A 2010 study of FSWs in Karnataka state, south India, confirmed what the Ghanaians explained to me; fear of partner violence prevented women and girls from seeking health services and from asking their partners to use condoms. The study found that condom use was some 20 percent lower those who had been beaten or raped within the last year compared with those who had not faced such violence.
The experts I spoke with also mentioned how gender-based violence cements relationships in which one partner is clearly dominant; they discussed how that feeling of dominance can give the abusive partner a sense of invincibility, reducing his or her willingness to practice prevention.
If you don’t believe you are vulnerable to harm or disease, there is no need to protect yourself. A 2014 study in South Africa supported this contention. The study, which considered women and girls attending four health centers in Soweto, found that abusive relationships with high levels of male control were “associated with HIV seropositivity.” In relationships where men had a great deal of power or where violence was frequent, researchers found that females were less likely to request condom use and had about a 12 percent greater likelihood of being HIV-positive.
Sometimes, the statistics were actually pretty astonishing. A 2012 study in Moscow, Russia found that FSWs were more than 20 percent more likely to be HIV-positive or to carry a sexually transmitted infection (STI) if they experienced client violence. In addition, over forty percent of FSWs who were coerced into sex with the police were STI/HIV infected. Researchers concluded that reducing the risk of infection would require decreasing client, pimp and police abuse and coercive behavior.
A 2013 WHO systematic global review and analysis of studies across different HIV epidemic settings underscored the association between GBV and HIV, finding that intimate partner violence increases the risk for HIV infection among women and girls by more than 50 percent, and in some instances up to four-fold.
There are two bottom lines to the research and experiential data. First, reducing and responding to gender-based violence should be a key tool in efforts to prevent the spread of HIV. Second, additional research is needed to understand those violence-reducing interventions that best reinforce HIV prevention and treatment.
USAID has seen important dividends from integrating GBV prevention and response into HIV and AIDS programs in collaboration with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). In Tanzania, USAID has supported development of National Management Guidelines for Health Response and Prevention to GBV, which provide a framework to guide comprehensive management of GBV survivors.
The Guidelines have led to training of health care providers and roll-out of a GBV register at health facilities across the country. In Zambia, USAID with PEPFAR funding, is collaborating with the British Department for International Development (DFID) and six government ministries to strengthen the response to GBV; this includes doubling the number of one-stop centers in several provinces, reaching 5 million adults and children with preventive messages, assisting 47,000 survivors, and training 200 police and justice sector personnel through 2018.
All told, USAID has contributed significantly to important results under PEPFAR; in FY2013, 2.5 million people in 12 countries were reached by efforts to address GBV and coercion, and an additional 800 health facilities began offering GBV screening, assessment and/or referrals to service providers.
The connection between gender-based violence and HIV infection is unambiguous. The data combined with the experience and perspectives of field experts make it clear. As we renew our commitments this week both to combat the spread of AIDS and to prevent GBV, let’s recognize and ensure that programs address the intersection. It could make the difference between the success and failure of efforts around the world.