How does violence increase women’s vulnerability to HIV? Charlotte Watts Gender, Violence & Health Centre London School of Hygiene & Tropical Medicine

Many forms of violence, many forms of risk Direct transmission through sexual violence Including potential increases in transmission associated with genital trauma Lack of control of sexual relations Difficulties to negotiate condom use / safe injection Child sexual abuse leading to later high risk behaviours Difficulties accessing testing, treatment and care services Child sexual abuse Sexual violence Intimate partner violence Physical abuse Psychological abuse Economic abuse Violence against sex workers, IDUs Trafficking into sex work

Biological evidence of linkages between violence and HIV infection South Africa - women with violent partners more than 50% more likely to be HIV infected than other women Tanzania - the odds of reporting violence are 10 times higher for young, HIV-positive women compared to young, HIV-negative women Goa, India – among married women, the risk of incident STI was 3 times higher than married women whose partners had not been violent. Rakai, Uganda - girls who reported forced/coerced sex had a higher risk of HIV infection Estimates of disclosure-related violence 0.4%-4% in U.S. 3.5%-14.6% in SSA

Percentage sexually experienced women reporting forced first sex Source: Who Multi-Country Study on Domestic Violence and Women’s Health 2005

Prevalence of sexual violence against women Source: Who Multi-Country Study on Domestic Violence and Women’s Health 2005

Clustering of risk behaviours Men - growing evidence that men who are abusive to their partners are also more likely to: Have more sexual partners Have an STI Have problematic use of alcohol Refuse to use a condom

Violence against sex workers & other vulnerable groups common Source: Jenkins 1996

Violence against women fundamentally undermines current HIV response Abstinence / monogamy coerced first sex common, particularly for early first sex coercion in primary partnerships common Behaviour change / delay starting sex sexual violence is widespread many women not able to influence partners sexual behaviour fear of violence and social norms condoning forced sex undermines possibility of negotiation Condom use Women experiencing or fearing violence may find impossible to negotiate HIV testing, treatment & care Fear of & experiences of violence undermine women’s ability to benefit