1. 2011 Alcohol and Gender-based Violence in Latin America: Links with HIV and Implications for Action July 26 th, 2012 Floriza Gennari, MSc PAHO

2. 2011 Overview: Linkages Between Alcohol, Gender-based Violence and HIV Latin American and Caribbean Context: HIV Gender-based violence Alcohol consumption Implications for Action

3. 2011 Why Alcohol and Gender-Based Violence? To strengthen HIV prevention efforts, interventions must address GBV and alcohol consumption, especially in men and women engaged in heavy episodic drinking HIV care and treatment also important and affected by alcohol and GBV

4. 2011 Links Between Alcohol and Violence There is a positive association between drinking and severity of aggression GENACIS study: –Drinkers were more likely than abstainers to report physical intimate partner violence (IPV) towards their female partners –Women who engaged in heavy episodic drinking (HED) more likely to be victims of IPV Violence Against Women in LAC study: –In all countries except Paraguay (2008), the most commonly reported triggers for IPV was his drunkenness or drug use, reported by 29.8% of women in Guatemala 2008/9 and 53.4% of women in Ecuador 2004

5. 2011 Links Between Alcohol and Violence (cont.) Several small-scale, qualitative studies carried out in indigenous communities found that: –Perception that alcohol consumption has increased, particularly among young men (Health Canada 2005) –In San Pablo, Nicaragua, both men and women consider intra-family violence as the main problem associated with alcohol (PAHO 2006) –In Comarca Ngogbe-Bugle, Panama, wives report that husbands are physically violent towards them when they drink (PAHO 2006)

6. 2011 Clear association between: – Alcohol use and HIV prevalence (e.g. meta- analysis of African studies cf. Fisher et al., 2007) – Alcohol use (various measures) and HIV incidence (Baliunas et al., 2010) – Alcohol use and unsafe sex in HIV-positive people (pathway to HIV; Shuper et al., 2009) Overall, alcohol consumption (esp. heavy consumption) is associated with HIV incidence and course of disease Links Between Alcohol and HIV

7. 2011 Links Between GBV and HIV GBV both a cause and a consequence of HIV Women who experience GBV or high level of gender inequality in their sexual relationships are at an increased risk of HIV infection Women who are HIV+ more likely to experience GBV Men who use violence are more likely to engage in sexual risk-taking behavior, and are more likely to be HIV-infected (India, SA) Past exposure to sexual/IPV/controlling behavior is associated with high-risk sexual behavior in women Addressing violence against women and HIV/AIDS: What works? UNAIDS, WHO, 2010

8. 2011 Links between violence against women and HIV Addressing violence against women and HIV/AIDS: What works? UNAIDS, WHO, 2010

9. 2011 GBV, HIV, and Alcohol Consumption: What We Conclude 1.Alcohol (especially HED) is associated with intimate partner violence 2.GBV/IPV/unequal sexual relationships are associated with HIV 3.Women, indigenous peoples, MSM, transgender, are at greater risk GBV, HIV, and harmful alcohol consumption 4.HIV interventions must address socio-cultural context, structural factors in addition to individual behavior

10. 2011 HIV, GBV, and Alcohol Consumption in Latin America and the Caribbean

11. 2011 HIV in Latin America and the Caribbean (LAC) Latin America: Concentrated among men who have sex with men (MSM), transgender people, injecting drug users (IDU), and sex workers MSM: comprise 25% of HIV infections, and almost 1 in 3 have sex with both men and women Feminization of HIV: increase from 6% in 1994 to more than 30% Indigenous peoples: 5% of new infections in Central America have occurred in Garifuna living in Belize, Guatemala, Nicaragua and Honduras, (overall prevalence 4.5%). (Bastos, FI, et al, 2008) “Challenges Posed by the HIV Epidemic in LAC” 2009, UNAIDS, PAHO, UNICEF

12. 2011 HIV in Latin America and the Caribbean (LAC) The Caribbean: 2 nd highest HIV prevalence in the world, after Sub- Saharan Africa (1.0% [0.9–1.1%]). (UNAIDS, 2009) Women account for about 50% of all infections. In Trinidad and Tobago, Guyana, and Belize nearly 60% of those infected are women High prevalence among sex workers: studies found 27% in Guyana, 24% in Suriname, and 9% in Jamaica HIV burden among MSM also high - 20% of MSM in Trinidad and Tobago and 31% of MSM in Jamaica Bastos, FI et al. (2008), UNAIDS 2009

13. 2011 Barriers in Accessing HIV Testing, Care and Treatment Sex/gender identity Income/socio- economic status Ethnic/cultural background Cultural/linguistic barriers Women suffer double discrimination Mistreatment by health care workers Men less likely to seek care Women: GBV, exploitation/sexual trafficking Less access to services/information Fear of rejection, stigma, and discrimination Limited funds/time/ transportation Lack of information Sexual orientation Multiple Obstacles

14. 2011 Physical partner violence against women, ever and past 12 month (DHS: current/most recent partner study) Source: Preliminary results, PAHO/CDC (forthcoming) “Violence against women in LAC”

15. 2011

16. Unwanted or Coerced First Sex Source: WHO Multi-country Study (2005) and Preliminary results, PAHO/CDC (forthcoming) “Violence against women in 12 countries from LAC”

17. 2011 Gender-based Violence and Ethnic Origin Sources: 1) Ecuador: Source: CEPAR. Demographic and Maternal and Child Health Survey, ENDEMAIN 2004. Final Report. Quito, October 2005. (2) Guatemala: MSPAS/INE/UVG/CDC/USAID/ASDI/APRESAL/EU /UNDP/UNICEF/UNFPA/Project POLICY II/CARE. Encuesta Nacional de Salud Materno Infantil 2002 [National Maternal and child Health Survey 2002], Guatemala, October 2003. Women 15-49 who experienced intimate partner violence (IPV) in last year, by type and ethnic origin. Ecuador 2004, Guatemala 2003

18. 2011 Prevalence of Heavy Episodic Drinking Among Men and Women COUNTRYMEN (%)WOMEN (%) Argentina55.59.6 Belize38.28.9 Brazil36.118.5 Canada63.436.6 Costa Rica34.011.3 Mexico56.69.0 Nicaragua40.26.6 Peru59.126.1 Uruguay36.77.4 USA37.916.8 Unhappy Hours: Alcohol and Partner Aggression in the Americas, PAHO Multicentric Study, 2008

19. 2011 Male Physical Aggression by Past-12- Month Heavy Episodic Drinking (HED) Source: Graham, Bernards, Munné, & Wilsnack, 2008, 2010.

20. 2011 PAHO Interventions and Implications for Action

21. 2011 PAHO Interventions Related to HIV and Gender: Country-level support: In collaboration with USAID supported recent Jamaica Health Systems Evaluation of the HIV Response in the area of Gender and GBV Capacity-building/training: With UN Women, development of a manual on HIV, Gender, and Human Rights, which incorporates the needs of specific groups such as MSM and transgender Evidence/guidelines: Development of a “Blueprint for the Provision of Comprehensive Care to Gay Men and Other Men Who Have Sex with Men (MSM) in Latin America and the Caribbean” as a guide for clinicians and health administrators in LAC

22. 2011 WHO Global Strategy (2010) 10 target areas: 1.Leadership, awareness 2.Health services response 3.Community action 4.Drink-driving policies 5.Availability of alcohol 6.Marketing of alcohol beverages 7.Pricing policies 8.Reducing the negative consequences of drinking and alcohol intoxication 9.Reducing the public health impact of illicit alcohol and informally produced alcohol 10.Monitoring and surveillance Pan American Health Organization

23. 2011 PAHO Interventions Related to Human Rights: Capacity building on HIV and Human Rights for health workers, judges and civil society (Central America, Dominican Republic, Jamaica and Belize) Review of national HIV law (Guatemala and El Salvador) and Ombudsperson’s report on HIV and human rights Evaluation of the response of the health system to HIV and STIs (El Salvador). Technical opinions and hearings before Inter- American Commission on Human Rights (Central America and Caribbean) Regional and sub-regional capacity building for LGTBI groups and sex workers (Central American and Southern Cone)

24. 2011 PAHO Interventions Related to GBV: 1.Evidence - Sexual violence in Latin America and the Caribbean: A desk-review (2010) (with SVRI, UNFPA, Ipas) Comparison of population-based prevalence data on intimate partner and sexual violence from 12 countries in the region (partnership with CDC) 2.Prevention/capacity-building – 3-day training module on primary prevention of IPV/sexual violence, national workshops 3.Services - ‘Improving the health care sector response to GBV’ (with IPPF/WHR), Capacity building workshop on M&E in violence against women (with ICRW, Path, InterCambios)

25. 2011 Implications for Action Legal/policy reform Implement WHO Global Strategy measures to reduce harmful use of alcohol Review/reform national policies and programs to ensure their conformity with international human rights norms Establish appropriate/culturally-sensitive health care Multi-sectoral Coordination/Capacity-Building Coordinate a referral network between victims of GBV, alcohol abuse and HIV services Cross-training of clinical staff, sensitization of police, judges on international human rights norms and standards Empower community-lead initiatives Evidence Building/Research Research directly linking harmful alcohol with GBV and HIV in LAC, more data on vulnerable groups

26. 2011 Thank you! Acknowledgements: Dr. Maristela Monteiro Dr. Alessandra Guedes Dr. Sonja Caffe Ms. Genevieve Grabman Contact: Floriza Gennari gennarif@paho.org