Addressing Violence Against Women

Violence, in addition to being a human rights violation, has been clearly demonstrated as a risk factor for HIV (WHO, 2010f; Stephenson, 2007; Jewkes et al., 2006a; Manfrin-Ledet and Porche, 2003; Dunkle et al., 2004; Quigley et al., 2000b; Silverman et al., 2008). Analysis of DHS data in Rwanda showed that currently married women with few, if any, sexual risk factors for HIV but who have experienced sexual, physical or emotional abuse within their marriages were between 1.61 and 3.46 times more likely to test HIV-positive (Dude, 2009). DHS analysis in Zimbabwe similarly found that currently married women who had experienced physical violence only, or both physical and sexual violence, were significantly more likely to be HIV-positive than those who had not experienced any physical or sexual violence. "Among currently married and formerly married women, husbands are the main perpetrators of violence" (Nyamayemombe et al., 2010: 7). In Brazil, suffering repeated and severe violence was more closely associated with confirmed HIV infection for women (Barros et al., 2011). Another study found that abusive husbands demonstrated increased odds of HIV acquisition outside the marriage and that husbands who were abusive were more likely to transmit HIV to their wives (Decker et al., 2009). Interestingly, a recent analysis of DHS data from the Dominican Republic, Haiti, India, Kenya, Liberia, Malawi, Mali, Rwanda, Zambia and Zimbabwe, however, did not find that intimate partner violence was consistently associated with HIV prevalence among ever-married women in all of the countries (Harling et al., 2010).

Acts that would be punished if directed at an employer, a neighbor, or an acquaintance often go unchallenged when men direct them at women, especially within the family (Heise et al., 2002: S5). "Male violence against women, an extreme manifestation of gender inequality, is the direct result of gender norms that accept violence as a way to control an intimate partner" (Pulerwitz et al., 2010b: 283). Violence against women (VAW), is a more specific form of the category of gender-based violence (GBV), and is considered acceptable behavior in many countries (Andersson et al., 2008).

Violence Against Women is Widespread

A report that analyzed DHS Surveys in Bangladesh, Bolivia, the Dominican Republic, Haiti, Kenya, Malawi, Moldova, Rwanda, Zambia and Zimbabwe found that women experienced a wide variation across countries in the prevalence of physical or sexual violence by their current husband or partner, from 16% in the Dominican Republic to 75% in Bangladesh (USAID, 2008a). Levels of violence are also high for Papua New Guinea, Fiji and East Timor (AusAID, 2007). Inequitable gender norms are related to increased violence: in five of the 10 countries studied (listed above), women who believe that wife beating is justified were more likely to report experiencing physical or sexual violence (USAID, 2008a). A study between 2000 and 2003 with 24,097 women ages 15 to 49 in Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia and Montenegro, Thailand, and Tanzania found that of the 19,568 women who had ever had a partner, 1571% reported they had experienced physical or sexual violence or both at some point in their lives by a current or former partner (Ellsberg et al., 2008). A survey in Vietnam with 465 women found that 37% said they had been beaten by their husbands (Luke et al., 2007). A study in India with 459 women, 216 of whom were living with HIV, found that 40% of HIV-positive women and 30% of HIV-negative women reported being forced to have unwanted sex with their husbands and one in three of all 459 women reported being hit by their in-laws (Gupta et al., 2008b). According to UNICEF, 5-21% of adolescent girls ages 15 to 19 reported that they have ever experienced sexual violence (UNICEF, 2011b).

Both males and females often justify violence as acceptable. For example, a study in Ghana found that 56% of boys and 60% of girls argued that it was acceptable for a boy to beat his girlfriend in some circumstances (Glover et al., 2003 cited in Jejeebhoy and Bott, 2003). Studies in Nigeria and Uganda found that rape was accepted as inevitable among victims because males were uncontrollable, that rape was accepted as a "way to teach a haughty girl a lesson" and the misperception that women enjoy coercive sex (Ajuwon et al., 2001; Hulton et al., 2000 cited in Jejeebhoy and Bott, 2003). Other studies also report the misperception that men's sexual needs are beyond their control (Sodhi and Verma, 2003 cited in Jejeebhoy and Bott, 2003). Gender-based violence is sometimes condoned for supposed religious reasons. A recent study found that of 1,803 women in Tanzania who agreed that "HIV is punishment for sinning" were more likely to have experienced intimate partner violence in the last year (Amuri et al., 2011). A recent review of 65 studies, most in the resource rich settings, found that there is substantial evidence of effectiveness of interventions to improve boys and young men's attitudes toward rape and other forms of violence against women; however, there is little evidence of effectiveness of interventions to actually decrease violent behaviors in the long term (Ricardo et al., 2011). Recent literature indicates that abusive men are more likely to have other sexual partners unknown to their wives (Campbell et al., 2008a). [See also Partner Reduction]

Violence Can Increase Womens HIV Risk

"There are three mechanisms through which violence is hypothesized to increase women's risk for HIV infection: (1) through forced or coercive sexual intercourse with an infected partner, (2) by limiting women's ability to negotiate safe sexual behaviors, and (3) by establishing a pattern of sexual risk taking among individuals assaulted in childhood and adolescence" (Maman et al., 2000: 466). For example, a study in Uganda with 3,422 women ages 15 to 24 found that women who always used condoms were less likely than those who never used condoms or used them inconsistently to report physical violence and sexual coercion (Zablotska et al., 2006). A study in the Central African Republic found that among both men and women ages 15-50, those whose sexual initiation was forced were between 1.77 and 2.47 times more likely to report multiple partners in adulthood, compared to those whose first sex was consensual (Sonse et al., 1993 cited in Jejeebhoy and Bott, 2003). A study in Chile found that women who had suffered intimate partner violence were highly likely to have sexual relations with a partner whose HIV status was unknown, as well as having sex without condoms (Miner et al., 2011). Intimate partner violence tends to be consistently associated with inconsistent condom use, having an unplanned pregnancy or induced abortion, and having an STI, including HIV (Coker, 2007).

"Men never allow us to use condoms. If we suggest they beat us." --Ugandan woman (Karamagi et al., 2006: 7)Violence is both a risk factor for HIV and a consequence of being identified as having HIV (WHO, 2010f; Kouyoumdjian et al., 2013 cited in Abramsky et al., 2014). A review for the U.S. Institute of Medicine based on studies between 1998 and 2007 found that "violence or fear of violence from an intimate partner is an impediment (to) or a consequence of HIV testing" (Campbell et al., 2008b: 2). Many women do not disclose status based of fear of violence and abandonment. While some studies have shown that only a small percentage of women experienced negative responses after disclosure of their HIV status, there is some evidence that women are subjected to violence from their sexual partners as a consequence of HIV testing and disclosure of results (Maman et al., 2001b). Women who do disclose are more likely to be in secure relationships. In-depth interviews with both HIV-positive men and women in Kenya found that both reported that "disclosure was associated with a sense of relief, a lifting of a burden of guilt" (Sarna et al., 2009: 787). [See also HIV Testing and Counseling for Women] Violence can also be a barrier to adherence to treatment as spouses may demand that women share treatment if the spouse does not want to be tested. In cases where women face intimate partner violence, they may take HAART in secret. [See also Treatment]

Women threatened by violence and rape, including married women and adolescents, cannot negotiate condom use. A study with 428 South African men with multiple partners found high rates of intimate partner violence, with 36% reporting perpetrating physical intimate partner violence and 19% reporting sexual intimate partner violence. Inconsistent condom use was significantly related to reporting any kind of intimate partner violence (Townsend et al., 2011). A repeat survey from 2002 in Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia and Zimbabwe found that 40% of women said they would have sex if their partner refused to use a condom, and 40% said that they did not think women have the right to refuse sex with their partner (Andersson et al., 2008). A sample of 575 sexually experienced young women ages 15-19 interviewed in 2001-2002 in Rakai, Uganda, found that 14% reported that their first sexual intercourse had been coerced. Coercion at first intercourse was negatively correlated with subsequent condom use: 24% of unmarried women who reported coerced first sex had used a condom at last sex, compared with 62% of those who reported no coercion at first sex. Respondents who reported coerced first intercourse were less likely than those who did not to say they had used a condom at last intercourse (13% as compared to 33%) (Koenig et al., 2004).

Sexual Abuse of Children Increases Their Risk for HIV

Children who are sexually abused are more at risk as adults of acquiring HIV (Slonim-Nevo and Mukuka, 2007). The first national study on violence against children in Africa was conducted in Tanzania as part of the Together for Girls Initiative and used a nationally representative survey of 3,739 females and males between 13 and 24 years of age to find that nearly 3 in 10 females and approximately one in 7 males experienced violence prior to the age of 18. Of those who had their first sexual experience prior to age 18, 29.1% of female and 17.5% of males reported that their first sexual intercourse was unwilling. The prevalence of engaging in sex with two or more partners in the previous 12 months was significantly higher among both females and males who had experienced childhood sexual violence compared to those who had not experienced childhood sexual violence (UNICEF et al., 2011a). Men report experiencing violence as children in countries such as Brazil, Chile, Croatia, India, Mexico and Rwanda. Childhood experiences of violence are associated with later adoption of inequitable gender attitudes including violence against women (Contreras et al., 2012). [See Transforming Gender Norms]

Pilot programs are beginning to successfully address the needs for post-exposure prophylaxis by children who suffer from rape (Speight et al., 2006). "There is a growing recognition that children in sub-Saharan Africa are vulnerable to HIV transmission through sexual abuse and exploitation including incest, child rape, early (coerced) coitus, 'sugar daddies' and transactional sex" (Lalor, 2008). In the Tanzanian study above, only 1 in 5 females and 1 in 10 males who experienced sexual violence prior to age 18 sought services although 1 in 6 females and males who experienced sexual violence said they would have liked counseling and support from police (UNICEF et al., 2011a). A survey of 613 men in Botswana and of 876 men in Swaziland conducted from 2004 to 2005 found a history of forced sex victimization was strongly correlated with past year perpetration of forced sex by men in both countries (Tsai et al., 2011).

Interventions are needed to reduce the incidence of sexual abuse, as well as to address the consequences of abuse. Furthermore, education-related exposure to violence needs to be addressed. Research conducted by Human Rights Watch in Zambia in 2002 found that long commute times to and from school was a significant factor associated with sexual assault among young girls. Approximately 100 girls under the age of 18 were interviewed in a largely open-ended format that covered a variety of topics and 36 NGOs and a number of government officials were contacted and visited. "The length of the girls' commute to school is an important factor here, since they risk sexual abuse by minibus drivers or conductors, if they take transportation, or abuse by others along the road, if they walk, can be significant" (Chimuka, 2002 cited in Fleischman, 2002: 49).

Evidence for Interventions is Scant

Some evidence exists that violence prevention interventions are effective, particularly by developing nurturing relationships between parents and children, by developing life skills in children and adolescents and by changing gender norms (WHO, 2009d). A study in South Africa found that integrating HIV prevention services into services for women who suffered abuse -- through workshops about negotiation skills and economic independence -- resulted in women reporting a decrease in unprotected sex from 20% to 14% (Sikkema et al., 2009). However, "...much of the available literature lacks evidence on how to forge essential linkages between HIV programs and services for preventing and responding to sexual and gender-based violence" (Raifman et al., 2011: 11). Programs and evaluations to work with men to reduce violence have been limited (Ricardo and Barker, 2008).

Eliminating Violence Against Women Requires a Comprehensive Approach

Eliminating violence against women requires primary prevention of violence, responding to survivors of violence and responding to violence against positive women. A comprehensive response, based on principles of human rights and ensuring survivor-centered and empowering approaches, is needed to address violence against women; including political commitment and resource mobilization, legal, and judicial and security sector reform, health sector responses, response from the education sector, use of mass media and community mobilization (UNIFEM, 2010; Jina et al., 2010).

How best to provide services that address both violence and HIV in various settings has been an ongoing challenge. "Research is urgently needed to build the evidence base and address the current lack of information on effective programmes for primary prevention" (i.e. approaches that prevent violence before it occurs) (WHO, 2010d: 76). Programs that integrate violence screening with VCT programs can be helpful, but only if they are ongoing. A study in South Africa found that women who went for HIV voluntary testing and counseling found screening for violence at VCT centers acceptable; however, one year after training for lay staff who conducted the VCT and violence screening, violence screening did not continue. Women also had unrealistic expectations that lay VCT counselors could stop their partners' violence, believing that their counselors could talk to the partner of the woman and convince him to stop (Christofides and Jewkes, 2010).

Campaigns and public education can challenge the acceptance of violence against women and raise awareness of the adverse impact of violence on women's health. Comprehensive gender-based violence policies are needed that "include primary prevention targeting men and boys; policies to engage men and boys in making public spaces free of violence for women and girls; programs for male perpetrators that are integrated with [the] judicial sector; implementation of gun control; control over alcohol sales; and legal, financial and psychological supports for survivors of violence, both women and men (Barker et al., 2010a). Efforts to stop violence against women will not succeed unless male attitudes and behavior are addressed. [See Transforming Gender Norms] Since exposure to violence in childhood has also been correlated with violence perpetration against women (Clark et al., 2010), violence prevention efforts that start with children may be warranted. Innovative programs such as One Man Can in South Africa are good examples of working with men to reduce violence (Colvin, 2009). Political, religious and community leaders, along with the media can play a significant role in changing social norms. Improved awareness and attitudes need to be supported by the enforcement of laws that prohibit violence against women and punish the perpetrators. Women's advocacy organizations have been key in raising awareness and working with governments to strengthen legal solutions. Women who experience violence, including from intimate partners, need counseling, health services and support. "To date, there have been few initiatives worldwide designed to respond to violence against positive women; consequently, evidence regarding promising practices... is limited" (Hale and Vazquez, 2011).

Health Services Can Play a Critical Role to Respond to Survivors of Violence

A baseline survey of nine sexual violence services in Uganda and eight in Rwanda found that in practice, much also needs to be done to meet the needs of survivors, including provision of adequate equipment and supplies; adherence to legal requirements that physicians be present when services were provided; client follow-up; awareness by providers of community services; privacy for clients; reduction in stigmatizing attitudes of providers; and community outreach so that survivors know where to go (Elson and Keesbury, 2010). Changes are needed in health care organizations to address violence using a systems approach, which includes awareness of laws, ongoing training and support for staff, referral networks, protocols and education for clients. [See also Structuring Health Services to Meet Women’s Needs] A study in the Dominican Republic conducted in 2006 with 31 women living with HIV who were victims of violence and 39 providers for either HIV or violence services, including HIV physicians, counselors, social workers, etc. found that few HIV providers had training on services for women who suffered from violence; and few providers for violence services had training on HIV. Almost all the providers did not know the pertinent legislation related to violence and more than a third believed that women provoke violence. Protocols are needed for to establish linkages between HIV and violence services (Betances and Alba, 2009). A randomized survey among 100 obstetricians-gynecologists in Pakistan in 2002 found that "the significant mismatch between perceptions of prevalence of domestic violence in Pakistani society (30%) and in clinical practice (10%) suggests that obstetricians are socially aware of the enormous public health burden but cannot associate an equivalent magnitude among their clientele..." (Fikree et al., 2004: 64). Only 8% of the survey participants had ever received domestic violence training related to case identification and management, however, 83% reported that it was important to receive such training (Fikree et al., 2004).

It is vital that health providers do not further compound the suffering of a woman or girl who has been raped by blaming her for the rape (Carretta, 2008). Health care providers must remain objective in the case of a sexual assault. Based on a review of the evidence, the International Federation of Obstetricians and Gynecologists notes: "Except in survivors who are unable to give consent, it is impossible for a health professional to know whether a rape has occurred. Indeed it is the task of the judge to determine whether a rape occurred" (Jina et al., 2010: 89). Providers should support a woman who comes to services in cases of rape. Services are also needed for young girls and adolescents (Keesbury and Askew, 2010).

Ensuring Rape Victims Have Access to PEP and Emergency Contraception Is Essential

In many countries, there are few services for women who are subjected to violence -- and fewer for girls. In some countries, women fear rape most because of the fear of acquiring HIV (Gharoro et al., 2011). Rape victims need timely access to post-exposure prophylaxis (PEP) and the International Federation of Obstetricians and Gynecologists note that rape survivors also need access to and counseling concerning emergency contraception within five days of rape (Jina et al., 2010). "The risk of HIV transmission after rape is estimated to be very low, yet is of grave concern to survivors" (Jina et al., 2010). A review of barriers to PEP in 13 PEPFAR countries found that requiring HIV testing to access PEP, reporting rape to police to access PEP and the need for no-cost services and quality counseling were gender-related barriers to accessing PEP (Herstad, 2009). A record review of 390 clients of a rape crisis center in South Africa that saw, on average, 26 women per month over 15 months from 2003 to 2004 found that up to 36% of women were HIV-positive at the time of presentation. Acceptance of HIV testing and provision of PEP was high; however, adherence to antiretroviral therapy and return for testing were low. Only 57% of clients filled the four weekly PEP prescriptions, possibly because of travel costs and distance. Making services more user-friendly may increase uptake of completion of PEP (Carries et al., 2007). Children also need access to PEP. A qualitative study was conducted in Kenya to better understand the reasons for the low uptake of post-rape care services in health facilities and to establish perceptions of sexual violence in Kenya. Thirty-four key informants were interviewed and 16 focus group discussions with women and men were held in three districts in Kenya. Important implications for the delivery of HIV post exposure prophylaxis (PEP) after sexual violence include the need for gender-aware patient-centered training for health providers and for HIV PEP interventions to strengthen on-going HIV prevention counseling efforts (Kilonzo et al., 2008a).

The need to address post-conflict violence in relationship to HIV has been the subject of some controversy, but few evaluated interventions were found.

Stronger Links Are Needed Between The Health and Justice Systems

Linkages between the justice system and the health system in many sub-Saharan countries is weak, making women more reluctant to seek judicial justice for crimes of rape (Kilonzo et al., 2009b). "Laws need to be reformed and implemented to sanction all forms of gender-based violence and to provide survivors with access to justice" (Ellsberg and Betron, 2010). [See also Advancing Human Rights and Access to Justice for Women and Girls]

Guidelines for the management of female survivors of sexual assault from the International Federation of Gynecology and Obstetrics are available (Jina et al., 2010). Additional evidence and resources for working with all sectors -- health, legal, police, justice, education, and in conflict settings are available at (UNIFEM, 2010). Guidance for integrating gender-based violence into PEPFAR programming is available: ( (USAID/AIDSTAR-One, 2011a) as is USAID guidance for child abuse and violence (USAID, 2011b). See also the programming tool: 16 Ideas for Addressing Violence Against Women in the Context of the HIV Epidemic (WHO/UNAIDS).