Understand the linkages between HIV/AIDS and violence against women and girls

Since HIV and AIDS emerged over 25 years ago, the percentage of HIV-positive people who are girls and women has increased globally. The ‘feminization’ of the HIV epidemic has resulted in more women than men living with HIV. In sub-Saharan Africa, young women aged15-24 are as much as eight times more likely than men to be HIV positive. In Asia overall, women account for a growing proportion of HIV infections: from 21% in 1990 to 35% in 2009 (UNAIDS, 2010).

Studies are consistently showing a statistical association between experiences with violence and HIV infection:
- In all settings in various countries, women who had experienced intimate partner violence were more than two times likely to be at risk of HIV/STI infection compared to those with no history of intimate partner violence (Devries K et al., 2010)
- In India, women who had experienced both physical and sexual violence from intimate partners were over three times more likely to be HIV positive than those who had experienced no violence (Silverman, 2008)
- In Rwanda, women who had been sexually coerced by male partners were 89% more likely to be HIV positive (van der Straten A et al.1995 and 1998)
- In South Africa, women seeking routine antenatal care who had experienced physical or sexual violence were 53% more likely to test HIV positive and those experiencing high levels of gender power inequality in relationships were 56% more likely to test HIV positive (Dunkle, 2004).
- In the United Republic of Tanzania, women seeking voluntary counseling and testing who had experienced violence were also more likely to be HIV positive; among women under 30 years, those who had experienced violence were about 10 times more likely to be HIV positive (Maman, 2009).

For additional statistics, see the 2009 Global AIDS Alliance Fact Sheet.

Although there has been increased attention in recent years to understanding linkages between HIV and AIDS and violence against women, the evidence base still remains weak due to gaps in information (Harvard School of Public Health, 2009). This is at least partly due to the nature of the fundamental issues involved with these dual pandemics: sex and violence (CWGL, 2006). In many contexts around the world sex and violence are viewed to be private concerns and not community or governmental issues. The silence that typically accompanies these dual pandemics makes it difficult for women to access information and services for treatment, care and prevention of both HIV and violence. This in turn makes accurate data collection about the intersection of violence and HIV difficult (CWGL, 2006).

The United Nations Trust Fund to End Violence against Women Investing in Evaluation and Learning on the linkages of VAW and HIV

The limited evidence-base on what works to address violence against women and girls and HIV prompted the United Nations Trust Fund to open special grant-making windows in 2005 and 2006 on ‘reducing the twin pandemics of HIV/AIDS and violence against women’. With generous support from Johnson & Johnson, the UN Trust Fund established a cutting-edge learning initiative with seven of the successful applicants, who were brought together as a ‘learning cohort’ to develop and showcase effective practices in three main areas to address the intersections: 1) understanding and Influencing knowledge, attitudes and practices of men and women, 2) improving services and reducing barriers to support and treatment, and 3) laying the foundations – the Contribution of research.

The grantees in the cohort include:

Breakthrough (India) - At the Intersection of Gender-Based Violence – Empowering Women against HIV/AIDS, and the Stigma and Discrimination Resulting from Infection.

Equal Access (Nepal) - A Grassroots Call to Action to End Stigma and Discrimination on Violence against Women and HIV/AIDS Using the Voices of affected Women. See the impact assessment and watch a video on this initiative.

Raks Thai Foundation (Thailand) - Supporting HIV-affected Women to Reduce and Respond to Sexual Violence (SHAW).

Civil Resource Development and Documentation Centre (Nigeria) - Bridges to End Gender Based Violence as Strategy for HIV/AIDS Prevention & Stigma Reduction. Watch a video on their work.

Colectiva Mujer y Salud (Dominican Republic) - Reducing the Risk and Vulnerability of Women to HIV/AIDS and Violence on the Dominican-Haitian Border

Women’s Affairs Department, Ministry of Labour and Home Affairs, Government of Botswana - Reducing the Twin Pandemics of Violence against Women and HIV/AIDS

Institute of Gender and Development Studies (Trinidad and Tobago) - Breaking the Silence: Child Sexual Abuse and HIV Infection: A Multi-Sectoral Intervention

The initiative places particular emphasis on monitoring and evaluation to generate evidence across the projects that can eventually enable adaptation and upscaling. To this end, the cohort of grantees has been accompanied since the early planning and design stages by lead experts at PATH (Program for Appropriate Technology in Health, Washington D.C.) to assist with baseline survey development, selection of indicators and survey tools, and development of monitoring and evaluation plans, with ongoing tailored support and site visits to the projects provided by the UN Trust Fund Secretariat and UNIFEM expertise in the area of HIV.

The Trust Fund has supported a number of other projects to improve the evidence-base on the linkages, including research conducted by Fundación para studio e Investigación de la Mujer in Argentina, Brazil, Chile and Uruguay on the feminization of HIV. See a video on their work.

Learn more about these initiatives and others supported by the United Nations Trust Fund to End Violence against Women and Girls by visiting the website.

Nevertheless, the growing body of data suggests that violence against women and girls is linked to an increase in HIV risk. Broadly, the evidence shows:
- significant overlap in prevalence
- intimate partner violence as a risk factor for HIV infection among women and men
- past and current violent victimization increasing HIV risk behaviours
- violence or fear of violence from an intimate as an impediment or as a consequence of HIV testing
- fear of partner violence as a barrier to accessing and uptaking prevention of mother to child transmission (PMTCT) services
- partner violence as a risk factor for sexually transmitted infections (STIs), which increases the rate of HIV infection
- women who have violent partners are less likely to negotiate condom use and more likely to be abused when they do.
- economic violence may increase the risk of acquiring HIV by deepening gender inequalities and increasing vulnerability.
- various adverse health effects related to intimate partner violence compromise women’s immune systems in a way that increases their risk of HIV
- abusive men are more likely to have other sexual partners unknown to their wives
- women who have experienced childhood sexual abuse are more likely to engage in HIV risk behaviours as an adolescent/adult.

Sources: excerpted from Kimberly A. Scott, Rapporteur, Planning Committee for a Workshop on Violence Prevention in Low- and Middle-Income Countries. 2008. Institute of Medicine; Harvard School of Public Health, 2009. Final Draft Report; Devries et al., 2010; Maman, personal communication, 2010; and WHO/UNAIDS, 2010)

	Specific Forms of Violence and Risk of HIV
Type of Violence	HIV Risk
Sexual Assault	Sexual assault increases the vulnerability of HIV infection amongst women and girls in both direct and indirect ways. Directly, sexual assault can result in trauma and tissue tearing that facilitates HIV infection. This is pronounced amongst young women and girls whose reproductive tracts are not yet mature (CWGL, 2006). Indirectly, the threat of sexual assault makes it difficult for women and girls to negotiate condom use and/or try to refuse sex all together (Black, 2001 cited in Ward et al., 2005; USAID and UNICEF, 2005). Experiencing sexual assault can also increase the likelihood of future risk taking behaviours such as: unprotected sex, multiple partners, substance use, and sex work (Ward, 2008). Additionally, in many contexts, the stigma attached to being sexually assaulted can prevent women and girls from seeking medical treatment, including post-exposure prophylaxis (CWGL, 2006).
Coerced Sex	Girls who have experienced coercive first sex may be more likely to be HIV-positive (Harvard School of Public Health, 2009). Across the world between 7 and 48% of young women and girls report that their first sexual experience was coerced (Krug et al. eds., 2002; Reza et al./CDC and UNICEF, 2008; and WHO/UNAIDS, 2010). As with sexual assault, sexual coercion often involves unequal power relations, which limit the extent to which a woman or girl can exercise control over condom use or take other measures to protect herself from HIV infection. In some parts of the world, ‘Sugar daddies’—older men who seduce girls into sexual relationships in exchange for food, money, and/or gifts, often prefer to exploit those who they believe are virgins and therefore HIV-negative (Ward, 2008). To the extent that these men fail to use protection, they put girls at risk of contracting HIV. Adolescent girls who have experienced sexual coercion may also be more likely to be non-users of contraception and to have unintended pregnancies.
Intimate Partner Violence	In cases of intimate partner violence, inequality of power within the sexual relationship is linked to the risk of HIV transmission (Jewkes et al., 2010). For example, when intimate partner violence is present fear of violence and abuse can prevent women and girls from negotiating safe sex, even when they fear a partner may be HIV-positive. This is especially dangerous given that abusive men are more likely than non-abusive men to have multiple sex partners, be adulterous, and to have STI symptoms (Dunkle et al., 2005 & Martin et al., N.d. cited in Makunda, 2009). A study using data from 96 countries demonstrated that women who had experienced intimate partner violence were more than two times as likely to contract HIV (Watts cited in Hale and Vasquez/Development Connections, International Community of Women Living with HIV/AIDS and Un Women, 2011).
Child Marriage	Because of biological factors, young wives are more physically vulnerable than mature women to contracting sexually transmitted infections, including HIV, from an infected partner—a danger which only increases given the fact that young girls are even less likely to be able to negotiate safe sex with their partners than older women (Ward, 2008). A study conducted in Rwanda found that 25 percent of girls who became pregnant at age 17 years or younger were infected with HIV, even though many reported having sex only with their husbands. According to the study, the younger the age at sexual intercourse and first pregnancy, the higher was the incidence of HIV infection (Excepted from USAID and UNICEF, 2005, pg. 9 citing UNICEF 1994 in Black, 2001 cited by Ward et al., 2005). Additionally, a study conducted in Uganda found that girls aged 13 to 19 years who were HIV positive were twice as likely to be married as girls who were HIV negative (Otoo-Oyortey and Pobi, 2003 cited by Ward et al., 2005).
Trafficking	Epidemics of sexually transmitted infections, including HIV, have increased the demand for sex with children, who are believed to be less likely to be infected than adults. While overall data is not available on the risk of HIV transmission related to trafficking, sexual exploitation is a high-risk factor for HIV (Ward, 2008).
Female Genital Mutilation/ Cutting	Female genital mutilation/cutting may also contribute to the risk of HIV infection among women and girls. This is because of the unsterilized instruments sometimes used to perform such procedures, and also because the scarred or dry vulva of a woman who has undergone female genital mutilation is more likely to be torn during intercourse, which can facilitate transmission from an infected partner (Centre for Reproductive Rights, 2005 cited in Ward, 2008). More 3 million girls are at risk of FGM/C every year (WHO, 2008a). For country statistics on FGM/C, see: the Multiple Indicator Cluster Survey (UNICEF), the Demographic and Health Surveys (MEASURE) and Female Genital Mutilation/ Cutting: Data and Trends (Population Reference Bureau, 2010). For more information and tools for medical professionals to address FGM/C, see the World Health Organization website page on Female Genital Mutilation and Other Harmful Practices.
Other Harmful Traditions	Traditional practices across the world that both support and intensify violence against women and girls can contribute to HIV transmission. These include: Polygamy is when a person has more than one spouse. In most parts of the world, the most common practice of polygamy is polygyny, where a husband has multiple wives. Unprotected sex with multiple concurrent partners is a proven risk factor for HIV transmission and in cases of polygyny the husband may not use condoms with his wives. Wife inheritance is when a widow is given to a male family member of the deceased husband. Cases of wife inheritance usually involve unequal power relations where a woman or girl may be forced into the practice. This lack of power may increase the chances of sexual assault or coerced sex. These unequal power relations can also limit the extent to which a woman or girl can exercise control over condom use or take other measures to protect herself from HIV infection. Widow Cleansing is when new widows are forced to have sex with a member of their late husband’s family or with a member of the community as a cleansing rite after the death. With this practice emphasis is placed on the sex being unprotected. This practice increases HIV risk factors through: a) the unequal power relations where a woman or girl may be forced into the practice and b) the lack of condom use.
Discrimination in Property and Inheritance Laws	In some parts of the world property ownership is traditionally passed patrilinearly. Because of these traditions even women who do inherit property may be at risk of eviction or ‘property grabbing’ by extended family (Ward, 2008). The impacts of HIV/AIDS, for example the premature death of a husband, may serve to accelerate disinheritance and/or property grabbing. For widows and their children, this practice is particularly harmful given that the related economic vulnerability can force them into situations of transmission risk. For example, HIV-orphaned girls who become heads of households may be forced into sex work in order to survive and support their siblings (Fleishman, 2002).
Discrimination in Education	Lack of education appears to have an effect on female vulnerability to HIV: According to one study, “women with at least a primary education are three times more likely than uneducated women to know that HIV can be transmitted from mother to child” and “completion of secondary education was related to lower HIV risk, more condom use and fewer sexual partners, compared to completion of primary education.” (World Bank, 2002, and Boler and Hargreaves, 2006, in Action Aid, 2007 cited in Ward, 2008).

Just as violence against women and girls can increase their risk of HIV transmission, HIV infection can also increase the risk of violence against women and girls and worsen the effects of other forms of gender discrimination. A study conducted in four countries in Asia Pacific found that HIV positive women are significantly more likely than men to experience discrimination, violence and be forcefully removed from their homes (Amnesty International, 2004, cited in CWGL, 2006). Across the world many women have reported experiencing different forms of violence following the disclosure of their HIV status, or even after disclosing that they have gone for HIV testing (Harvard School of Public Health, 2006). Fear of these repercussions can prevent women from being tested, revealing their status and/or seeking treatment care and support.

HIV positive women face various forms of violence, because of their HIV status - physical, psychological and economic abuse, in addition to: being shunned or rejected by family and the community; eviction from home and loss of assets; denied access to their children; ill-treatment by service providers; loss of livelihoods and denied work opportunities; and abuse by police, including extortion (Hale and Vasquez, 2010).

To hear about the experiences of HIV positive women, see the videos produced by the Salamander Trust.

Given the acknowledged intersections between the pandemics of violence against women and girls and HIV/AIDS, it is clear that the integration of prevention and response programming requires a two-way process where:

a) HIV programmes incorporate violence against women and girls interventions; and

b) Violence against women and girls services incorporate HIV interventions.

Example: The United States President’s Emergency Plan for AIDS Relief (PEPFAR) was launched in 2003 and, to date, is the largest effort by any nation to address a single disease. During its first five years the focus was on establishing and scaling up prevention care and treatment programmes in low-resource settings. In recognizing that addressing gender issues is an essential component to reducing the vulnerability of both women and men to HIV infection, the President’s Emergency Plan for AIDS integrates gender through the following five cross-cutting gender strategic areas: 1) Increasing gender equity in HIV/AIDS programmes and services, 2) Reducing violence and coercion, 3) Addressing male norms and behaviours, 4) Increasing women’s legal protection, and 5) Increasing women’s access to income and productive resources.

See the President’s Emergency Plan for AIDS Relief five-year strategy (2009-2014).

See the 2006 report on Gender-based Violence and HIV/AIDS.

From 2007-2010, PEPFAR supported an initiative to further the evidence-base and improve services for sexual and gender-based violence in Rwanda, South Africa and Uganda. To read more about this initiative see a brief produced by AIDSTAR-One and the project overview produced by implementing partner Population Council.

Download the baseline study, reports and tools associated with this initiative from the Population Council website.

See Gender-based Violence and HIV: A Prpgram Guide for Integrating Gender-based Violence Prevention and Response in PEPFAR Programs. 2011, by USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. Available in English.

See Gender-based Violence and HIV: Emerging Lessons from the PEPFAR Initiative in Tanzania. 2012, by Center for Strategic and International Studies. Available in English.

In 2010, PEPFAR committed an additional $30 million to scale-up gender-based violence prevention programming in the Democratic Republic of Congo, Mozambique and Tanzania.

Source: excerpted from the PEPFAR website and AIDSTAR-One.

Case Study: Liverpool Voluntary Counseling, Care and Treatment (LVCT) in Kenya addresses the Intersections is a non-governmental organization at the forefront of integrating gender and violence against women and girls’ interventions into national HIV/AIDS policy and programming in Kenya, particularly through the development, implementation, evaluation and scale-up of comprehensive post-rape care services.

An initial diagnosis phase of operational research revealed that the state of post-rape care services in the community was characterized by poor community understanding of the boundaries between forced, coercive and consensual sexual intercourse; no regulatory framework, policies or standard documentation systems; inconsistent service delivery of both medical and psychosocial support interventions; and limited human and technical capacity. In response, the programme developed and piloted a standard of care for rape survivors in three diverse district hospitals with VCT facilities. The standards included protocols for physical examinations, legal documentation, clinical management and counselling; client flow pathways and job aides; and a post-rape carepackage including essential drugs (PEP, emergency contraception and STI treatment) and an evidence-collection kit. The standard also introduced a chain of custody for evidence, and standard data-collection and monitoring tools. In the initial evaluation phase, 84% of 784 survivors seen in three pilot sites arrived within the 72 hour window for receipt of PEP; 99% of those who were eligible received drugs. Notably, survivors who received initial trauma and HIV counselling were more likely to complete HIV PEP medication. These services have since been scaled-up to create integrated post-rape care within HIV services in government facilities. The comprehensive package offered includes long-term psychosocial care, HIV pre- and post-test counselling, PEP-adherence counselling and preparation for interface with the criminal justice system. One important element in advocating for scale-up was a study to estimate expected costs for scaling-up the services within existing policy frameworks and standards. These estimates provided the basis for discussions with the Ministry of Finance and Planning to advocate for funding for scale-up. Generating cost and benefit analyses thus proved to be an important tool for approaching policy-makers to allocate funding for roll-out of the intervention.

Read more about the post-rape care services, public health model.

Download the National Guidelines on Sexual Violence.

Download the training manual for rape trauma counselors. Visit the LVCT website.

Source: excerpted from Maman et al., 2006. Addressing Violence against Women in HIV Testing and Counseling: A Meeting Report. Geneva, Switzerland. WHO, p. 17 and Addressing violence against women and HIV/AIDS What works?

Additional Resources:

Addressing Violence against Women and HIV/AIDS: What Works? (WHO and UNAIDS, 2010). Available in English.

Gender and HIV/AIDS Web Portal. UN Women in collaboration with UNAIDS has developed this comprehensive gender and HIV/AIDS web portal to provide up-to-date information on the gender dimensions of the HIV/AIDS epidemic. The site aims to promote understanding, knowledge sharing, and action on HIV/AIDS as a gender and human rights issue. Available in English.

What Works for Women and Girls: Evidence for HIV/AIDS Interventions, launched by Open Society Institute (OSI) at the XVIII International AIDS Conference with presentations by authors Jill Gay, Karen Hardee, Melanie Croce-Galis and Shannon Kowalski, is a comprehensive review of successful HIV programming for women and girls spanning 2,000 articles and reports with data from more than 90 countries. Published by OSI's Public Health Program, this valuable resource contains—in one centralized, searchable location—the evidence of successful gender-specific programming from global programmes and studies, with a focus on the Global South. Available in English.

AIDStar-One: AIDS Support and Technical Assistance Resources (USAID). This website provides a promising practices database, including programmes aimed at reducing violence and coercion. Available in English.

AIDS Portal (UK Consortium on AIDS). This website facilitates knowledge sharing and networking in the response to HIV and AIDS, by providing links to literature, tools, organizations and people. Available in English and Spanish.

HIV/AIDS and Gender-Based Violence Literature Review (Harvard School of Public Health, Program on International Health and Human Rights, 2006). Available in English.

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