Gender inequality and violence against women and girls Professor Charlotte Watts FMedSci

Globally 1 in 3 women (30%) will experience physical and/or sexual violence by an intimate partner

Past year levels of intimate partner violence vary widely

Early and first sex is often forced or coerced Note: Zimbabwe1 data only available for 18-24 year olds Source: Violence Against Children Surveys

Sexual and other forms of violence are common Note: Zimbabwe1 data only available for 18-24 year olds Source: Violence Against Children Surveys

Sexual and other forms of violence are common Sexual violence against girls is often perpetrated by a boyfriend or husband Note: Zimbabwe1 data only available for 18-24 year olds Source: Violence Against Children Surveys

3 cohort studies find exposure to violence is associated with new HIV infections: Meta-analysis RR of 1.28 (1.00-1.64 95%CI) Li et al, J. Int. AIDS 2014 In east and southern Africa, percentage of HIV among women due to IPV estimated to be between 12% and 22% Existing evidence from cohort studies is sufficient to confirm that there is an association between experiencing partner violence and enhanced risk of acquiring HIV – at least for some individuals in some setting. Jewkes strongest study, demonstrates a rate ration of 1.65 in adjusted analysis for wome who have experience more than 1 episode of physical or sexual partner violence Meta analysis of cohort studies by Li, and published in Journal of the International AIDS Society While the degree of increased risk is modest, IPV can nonetheless have a substantial impact on population levels of HIV because the practice is highly prevalent. Existing studies estimate the attributable fraction of HIV due to IPV as between 12% and 22%. Jewkes et al, The Lancet, 2010 LI meta-analysis includes 16 countries showed the IPV was significantly associated with HIV infection [12]and the overall incidence of IPV was even higher if US data were removed, supporting a greater magnitude of IPV and sexual violence for women and girls outside the US, which via direct and indirect effects could predispose these women and girls to HIV infection.

Gender inequality & violence undermine 90-90-90 in equality, social norms that condone violence High prevalence of physical and/or sexual violence (women, HIV+ women, sex workers, transgenders, orphans) Physical violence, emotional abuse, fear of violence Difficulty negotiating sex or condom use Limited or no condom use Increased risk of HIV acquisition / transmission Reduced uptake and adherence to PMTCT Vertical HIV transmission Experience/fear of violence or other negative repercussions if HIV+ status becomes known to others Barriers to HIV testing & disclosure Barriers to accessing care & HIV treatment Delayed uptake / reduced adherence to treatment Increased morbidity & mortality

VIOLENCE IS PREVENTABLE

Small Enterprise Foundation The Intervention with Microfinance for AIDS & Gender Equity (IMAGE Study) Paul Pronyk, Julia Kim, Tanya Abramsky, Godfrey Phetla, James Hargreaves, Linda Morison, Charlotte Watts, Joanna Busza, John Porter SEF Small Enterprise Foundation

SASA!: Uganda Action Awareness Support Start Awareness Support Action Learning about the community Selecting Community Activists Fostering ‘power within’ staff and community activists Helping activists gain confidence Informal activities Encouraging critical thinking about men’s ‘power over’ women Strengthening skills and connections between community members Joining ‘power with’ others to support change Trying new behaviors, celebrating change Fostering the ‘power to’ make positive change Start Awareness Support Action Action Awareness Support involving community members, leaders and institutions to build critical mass

Common elements of successful interventions Multiple, mutually reinforcing components Derived from well conceptualised theory of change Engages both men and women (either together or sequentially) Includes skills building elements and opportunities to practice them Incorporates diffusion strategies