Addressing Violence Against Women
Violence, in addition to being a human rights violation, has been clearly demonstrated as a risk factor for HIV (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 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).
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). 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). Women are “blamed” for bringing HIV into the family; women are kicked out of their homes and denied property, leading to further vulnerability to infection.
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). Inequitable gender norms may be 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, 15–71% 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).
Both males and females often justify violence as an acceptable gender norm. 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).
Women threatened by violence and rape, including married women and adolescents, cannot negotiate condom use. A 2006 to 2007 study in Thailand with 205 women living with HIV and 86 women who had experienced violence found that 12% of HIV-positive women had forced first sexual intercourse and 34% had partners who refused condom use. Women who had suffered violence before testing HIV-positive were beaten more after disclosing their serostatus (Grisurapong, 2009). 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). 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).
Violence Can Increase Women’s Risk for HIV
“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., 2009). 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). 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).
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, 2001b). Women who disclose are more likely to be in secure relationships. [See also Chapter 6. HIV Testing and Counseling for Women] Violence is also a barrier to adherence to treatment as spouses may require that women share treatment if their partners do not want to be tested. Women may take HAART in secret. [See also Chapter 7. Treatment]
Some evidence exists that violence prevention is 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). Programs and evaluations to work with men to reduce violence have been limited (Ricardo and Barker, 2008). More recent literature indicates that abusive men are more likely to have other sexual partners unknown to their wives (Campbell et al., 2008a). A 2003 study in Uganda found that those women whose husband had another partner were more than twice as likely to have a higher risk of intimate partner violence. The women expressed reluctance to test for HIV, disclose HIV results and request to use condoms because of fear of intimate partner violence (Karamagi et al., 2006).
Sexual Abuse Puts Children At Risk for HIV
Children who are sexually abused are more at risk as adults of acquiring HIV (Slonim-Nevo and Mukuka, 2007). 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). Family, non-family, acquaintance, and non-acquaintance perpetrators abuse young girls. 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).
Eliminating Violence Against Women Requires a Comprehensive Approach
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 reform, health sector responses, response from the education sector, use of mass media and community mobilization (UNIFEM, 2010; Global AIDS Alliance, 2008). 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., 2010). Efforts to stop violence against women will not succeed unless male attitudes and behavior are addressed. 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.
Health Services Can Play a Critical Role to Assist Women Who Suffer From Violence
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 (Caretta, 2008). 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). 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 Chapter 13. Structuring Health Services to Meet Women’s Needs]
Ensuring Rape Victims Have Access to PEP Is Essential
In many countries, there are few services for women who are subjected to violence – and fewer for girls. Rape victims need timely access to post-exposure prophylaxis (PEP). 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. “Although the South African government has developed national guidelines for PEP treatment of individuals 14 and older, there are no corresponding guidelines for children under fourteen. As a result, many health care providers lack basic information about how—and even in what circumstances—to provide PEP to children under fourteen,” despite reports of rape of children under the age of 14, including infants (HRW, 2003a: 70).
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. Blurred boundaries between forced and consensual sex emerged. 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. Additional evidence and resources for working with all sectors – health, police, justice, education, and in conflict settings are available at www.endvawnow.org (UNIFEM, 2010).