Why address gender-based violence in HIV response & what are effective strategies? Why address gender-based violence in HIV response & what are effective strategies? Avni Amin World Health Organization Integrating strategies to address gender-based violence and engage men and boys to advance gender equality through National Strategic Plans on HIV and AIDS November 2011, Istanbul, Turkey

Part 1: Why address gender-based violence in the HIV response? Review data:  How widespread is gender-based violence?  How is gender-based violence linked to HIV ?

Definition: gender-based violence (GBV) GBV: violence involving men & women; derived from unequal power relationships between men and women; includes physical, sexual & psychological harm:  acts of physical aggression  emotional, psychological abuse & controlling behaviours  coerced sex, sexual harassment, rape Violence against women (VAW): public or private act of gender- based violence that results, or likely to result in physical, sexual or psychological harm to women.

Different forms of GBV  Sexual, physical, or emotional violence by an intimate partner (intimate partner violence or IPV) & non partners;  Child sexual abuse  Sexual violence in conflict situations  Sexual harassment & abuse by authority figures (e.g teachers, police officers or employers etc),  Forced prostitution and sexual trafficking  Child marriage  Violence perpetrated or condoned by the state.  Homophobic violence  Violence against women and men living with HIV

Key Message 1 Gender-based violence is a widespread public health & human rights problem worldwide.

Source: Preventing HIV by preventing violence: the global prevalence of intimate partner violence against women and its links with HIV infection. Devries K et al Paper presented at the Vienna AIDS Conference. Forthcoming publication on the Global Burden of Disease.

Prevalence of IPV: select countries Source: UN women, March 2011, Violence against women Prevalence Data: Surveys by country

Violence against vulnerable groups  Prevalence of recent rape by clients among female sex workers (FSW)  32% in Mombasa, Kenya (2007)  31% in Karnataka, India (2005)  26% in Macau, China (2011)  In Vancouver, Canada IDU survey  68% of women & 19% of men lifetime history of sexual violence  Child sexual abuse 33% for women, and 13% for men  In the USA in 2 studies:  68% young MSM : threats or violence from either family or partners  25% threats or violence by both family & partners Sources: Shannon K et al. A systematic review of gender-based violence and links to HIV infection among sex workers. Forthcoming 2012; Braistein P et al 2003); Spratt, Kai Technical Brief: Integrating Gender into Programs with Most-at-Risk Populations. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.

Key Message 2 Gender-based violence is rooted in or a manifestation of gender inequality in society: Traditional gender norms perpetuate violence against women.

Women’s agreement that wife-beating justified for at least 1 reason Source: Preliminary results, PAHO/CDC (forthcoming) “Violence against women in 12 countries from LAC”

Key Message 3 Gender-based violence is both a risk factor for, and a potential consequence of being identified as having HIV

Gender-based violence & HIV Across all settings women who have experienced IPV are 2X more likely to be at risk of HIV/STI infection compared to those with no IPV Source: Preventing HIV by preventing violence: the global prevalence of intimate partner violence against women and its links with HIV infection. Devries K et al Paper presented at the Vienna AIDS Conference. Forthcoming publication on the Global Burden of Disease.

Gender-based violence & HIV  Longitudinal study, South Africa: HIV incidence in women with multiple episodes of intimate partner violence 9.6 per 100 person- years vs 5.2 per 100 person-years among those with one or none (aIRR =1.51); 12% of new HIV infections attributed to intimate partner violence.  Tanzania: women seeking HIV counseling and testing who had experienced violence were 2X more likely to be HIV positive  India, a study of 28,000 married women: those who experienced physical & sexual violence from intimate partners over 3 X more likely to be HIV-positive than those who had experienced no violence  Studies from India, South Africa & the USA: men who perpetrate violence more likely to engage in high-risk sexual behaviours Sources: Jewkes et al Lancet, Maman et al, 2002; Silverman et al, 2008; Raj et al 2006, Dunkle et al 2007, Jewkes et al 2006, Silverman et al 2007

Gender-based violence & HIV  Female Sex Workers, Thailand who experienced physical &/or sexual violence 31% more likely to report an STI symptom (2010)  Sex workers, China:  who experienced client violence - 32% more likely to report condom use failure compared to those who did not (2011).  who experienced high compared to low levels of client violence (2008) - 2X as likely to report condom use failure. Source: Shannon K et al. Forthcoming 2012;

Pathways linking GBV & HIV Source: Jewkes et al. 2010

Part 2: Key strategies to address GBV in the context of HIV/AIDS programming?

Objectives part 2: Identify:  Key principles & framework  Evidence-based interventions & strategies

Key Principles: Core values  A human rights approach  Promote gender equality  Non-discrimination  Meaningful participation  Safety first & confidentiality

Key Principles: Sound programming  Understand epidemiology of both HIV &GBV & links  Strategies that foster participatory learning  Use multiple entry points & approaches  Recognize needs of the most marginalized  Build competencies in understanding & responding to GBV  Partnerships with range of stakeholders  Rigorous monitoring & evaluation

Ecological framework for programming Couples & families Socio- economic conditions Laws & Policies Communities Countries Cultural & Social Gender Norms I ndividual Behaviour Choice in partner(s) Choice to have sex Partner reduction Condom use Drug use or non use

Address gender inequality as driver of GBV & HIV Individual Behaviour Choice in partner(s) Choice to have sex Partner reduction Condom use Drug use or non use Couples & families Socio- economic conditions Laws & Policies Communities Countries Cultural & Social Gender Norms Transforming harmful gender norms Soul City, Sexto Sentido Stepping Stones Empowering women: Microfinance, education, relationship skills, community mobilization IMAGE, Stepping Stones, Sex workers: Sonagachi Engaging men and boys Changing male norms & behaviours Program H, Yaari Dosti, One Man Can, Men As Partners Promoting GE laws& policies: Equal inheritance laws Laws against violence Training law enforcement National standards on post- rape care

Address GBV in HIV prevention, treatment & care Prevention: Behaviour Change Communication integrate: Violence & HIV risk messages Individual, Group, Peer Counselling: Combined risk-reduction & violence prevention: self-esteem, negotiation skills, partner communication, trauma counselling, HIV Testing & Counselling: Training HIV counsellors in identifying & appropriate response to GBV Safety planning, disclosure support PMTCT Couple Counselling & Testing Involving male partners Treatment Comprehensive Post-rape care including PEP Care & Support Peer & mediated disclosure support Key populations Sex Workers Substance abusers (IDU, drug & alcohol) MSM Survivors of GBV Women with prison history partners of substance abusers Adolescents

WHO Resources on GBV & HIV Links: alth/publications/violence/en/ Avni Amin