Why address genderbased violence in HIV response what

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 14 -16 November 2011, Istanbul, Turkey

Part 1: Why address gender-based violence in the HIV response? Review data: v How widespread is gender-based violence? v 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: vacts of physical aggression vemotional, psychological abuse & controlling behaviours vcoerced sex, sexual harassment, rape Violence against women (VAW): public or private act of genderbased violence that results, or likely to result in physical, sexual or psychological harm to women.

Different forms of GBV v. Sexual, physical, or emotional violence by an intimate partner (intimate partner violence or IPV) & non partners; v. Child sexual abuse v. Sexual violence in conflict situations v. Sexual harassment & abuse by authority figures (e. g teachers, police officers or employers etc), v. Forced prostitution and sexual trafficking v. Child marriage v. Violence perpetrated or condoned by the state. v. Homophobic violence v. 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 2010. 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 v. Prevalence of recent rape by clients among female sex workers (FSW) v 32% in Mombasa, Kenya (2007) v 31% in Karnataka, India (2005) v 26% in Macau, China (2011) v. In Vancouver, Canada IDU survey v 68% of women & 19% of men lifetime history of sexual violence v Child sexual abuse 33% for women, and 13% for men v. In the USA in 2 studies: v 68% young MSM : threats or violence from either family or partners v 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. 2010. 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 2 X 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 2010. Paper presented at the Vienna AIDS Conference. Forthcoming publication on the Global Burden of Disease.

Gender-based violence & HIV v Longitudinal study, South Africa: HIV incidence in women with multiple episodes of intimate partner violence 9. 6 per 100 personyears vs 5. 2 per 100 person-years among those with one or none (a. IRR =1. 51); 12% of new HIV infections attributed to intimate partner violence. v Tanzania: women seeking HIV counseling and testing who had experienced violence were 2 X more likely to be HIV positive v 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 v Studies from India, South Africa & the USA: men who perpetrate violence more likely to engage in high-risk sexual behaviours Sources: Jewkes et al 2010. 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 v. Female Sex Workers, Thailand who experienced physical &/or sexual violence 31% more likely to report an STI symptom (2010) v. Sex workers, China: vwho experienced client violence - 32% more likely to report condom use failure compared to those who did not (2011). vwho experienced high compared to low levels of client violence (2008) - 2 X 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: v Key principles & framework v Evidence-based interventions & strategies

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

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

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

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

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 Treatment Care & Support Couple Counselling & Testing Involving male partners Comprehensive Post-rape care including PEP 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: www. who. int/gender www. who. int/reproductivehe alth/publications/violence/en/ Email Avni Amin amina@who. int