Speaker Charlotte Watts, a professor at the London School of Hygiene and Tropical Medicine, explained that when thinking about the transmission of HIV and its link to violence most people assume the relationship exists in the realm of forced sex or sexual violence alone. However, the relationship is far more complex than this. Recent epidemiological data and studies prove that the spread of HIV and its connection to violence is multidirectional and results in multiple outcomes that exist on many levels.
Watts summarized a variety of studies in her presentation that highlight the current knowledge base and understanding of the intricate relationship between IPV and HIV. First she summarized a study from Rachel Jewkes at the Medical Research Council in South Africa. The evidence there showed that those women who have experienced violence have a significantly higher risk of contracting HIV than women who have not experienced violence. This trend holds true for women who are not necessarily experiencing violence but are in a highly unequal relationship (Jewkes et al., 2010). Watts explained that it is within this gender imbalance and unequal distribution of rights wherein partner violence and the increased risk of HIV coexist.
The next study Watts shared teased out different forms of violence and their relationship with HIV contraction. Using data collected in the city of Rakai, Uganda, researchers were able to echo the findings of the Jewkes paper in determining that women who experience violence face a significantly higher risk of contracting HIV (Kouyoumdjian et al., 2013). Researchers also analyzed the relationships between specific types of violence and HIV infection. Perhaps unsurprisingly, sexual violence showed a very significant relationship. However, the study also showed that physical
violence experienced without concurrent sexual violence showed a very similar relationship, meaning that it is not only sexual violence that increases a woman’s risk of becoming HIV positive. Using data from global studies, Watts explained that this trend is found throughout the world—not just in East Africa. Notably, the Rakai study showed that even verbal abuse had a smaller, but statistically significant relationship with HIV infection (Kouyoumdjian et al., 2013; WHO, 2005; Ying et al., 2013).
As many speakers echoed in their presentations, the reasons behind these complex relationships are not entirely known. However, Watts explained that violence prevention researchers speculate that the causes are complex and multidimensional. In the instances of sexual violence, there may be cases of unprotected forced sex, or instances of lacerations or abrasions that increase the likelihood of HIV transmission. But beyond this, the power imbalance between men and women indicates that women who live in fear of violence within a relationship may be unable to negotiate condom use or other preventive measures, such as microbicides, that can help mitigate the risk of HIV exposure and spread.
Looking at this relationship from another angle, it was explained that the men who perpetrate violence are shown to be more likely to engage in other risky behaviors that increase their chances of HIV infection. These behaviors include concurrent sexual partners and engaging in commercial sex. The male perpetrator’s increased risk trickles down to his female partner, thus increasing her overall risk of contracting HIV. Furthermore, the WHO Multi-country Study reported that Tanzanian women in violent relationships asked their partner to use a condom more often than women in nonviolent relationships; however, men in those same violent relationships are more likely to refuse condom usage than those in nonviolent relationships. Watts explained that this shows that not only are women in violent relationships aware of an increased risk of sexually transmitted infections, but also that the men in these relationships exert power over their partners in a multitude of ways—not only through the use of violence. Furthermore, this need to exert power in a relationship, she stated, points to a strong sense of masculinity and expectations that these men hold in relationships. Watts went on to posit that any effective HIV intervention or prevention programming would have to address physical, sexual, and verbal abuse, as well as concepts of gender equity and masculinity. The relationship between violence and HIV is so strong, that to attempt to tackle one without the other would be ineffective.
Many speakers pointed out that the dynamics in violent relationships may also cause a woman to ignore her HIV status due to a fear that she may be subjected to violence if she tests positive. As a result, the violence not only increases her likelihood of exposure to HIV, but it also decreases her likelihood of accessing treatment or care should she contract it. Speaker
Rose Apondi, a Public Health Specialist at the Centers for Disease Control and Prevention, also explained that gender-based violence is both a cause and effect of HIV. This bi-directional relationship is yet another indicator that both HIV- and IPV-prevention efforts could benefit from coordinated programming. The relationship appears to work in both directions, as keynote speaker Christine Ondoa, the Director General of the Uganda AIDS Commission, noted in citing preliminary results from the community-based SASA! intervention1 showing that reducing IPV in a community by 18 percent can reduce new HIV infections by 36 percent.
DIFFICULTIES AND SOLUTIONS FOR DEVELOPING A COORDINATED IPV AND HIV PREVENTION APPROACH
Despite the success of SASA!, many workshop speakers explained that, overall, it has been difficult to identify the best ways to prevent both IPV and the spread of HIV within the region. This is caused by a variety of factors that were discussed by many speakers and public commentators. In her keynote address, Ondoa emphasized the need for a collaborative approach—for policy makers to work closely with academics and organizations like UNAS to develop effective, evidence-based programming to reduce the burden of IPV and HIV in the region. Apondi raised this point again, stating the need for a coordinated, multisector approach. She explained that the problem is not contained within any one ministry of the government or sector of society; instead it cuts across multiple ministries and sectors, thus demanding a complex and collaborative solution.
Speaker Samuel Likindikoki, a Lecturer and Medical Specialist at Muhimbili University, raised the issues found within current research and data that make it extremely difficult to develop a case for increased resources and funding streams—which are necessary to any successful intervention efforts. He worried that current data is conflicting, showing that advocacy, screening, and criminal justice efforts are ineffective. Watts pointed out that this is more than likely due to the poor quality of the studies, which results in unreliable data. Likindikoki reminded the audience that it is important to have clear and convincing data in order to produce effective, evidence-based programming in order to create and maintain prevention and intervention programming.
This call for data was echoed by many speakers and commentators across the entirety of the workshop. But as Mbwambo explained in her keynote address, these efforts will require resources, meaning that this
1 See Chapter 5 for more information regarding the SASA! intervention and approach to IPV and HIV prevention.
group needs to identify a clear message for their governing bodies to raise the necessary resources for programming.
Apondi reminded the audience that it is not only data or monetary resources that are lacking. Often times, health centers are extremely understaffed, resulting in a lack of capacity to perform effective screening efforts, much less intervention and prevention programs. She went on to reinforce a point made by Likindikoki in his presentation regarding economic analyses. Likindikoki suggested that operational research must be undertaken in order to put a dollar amount on both the current burden of IPV in the region and the potential costs of prevention and intervention efforts. It is this financial argument, Apondi claims, that will make the biggest impact with policy makers and provide the attention needed from crosscutting sectors of government. She also made the point that NGOs have a strong role to play with both research and policy efforts as well as community health initiatives. In fact, other speakers shared successful initiatives showing promise in regard to IPV and HIV specifically, but also toward IPV more generally—which, as noted earlier, can help reduce the overall burden of HIV within a community too.
Two such examples of successful interventions that were presented at the workshop are the SHARE model and the approach undertaken by LVCT Health.2
Workshop speaker Lina Digolo of LVCT Health explained that the Kenya-based NGO focuses on producing quality health research for the Kenyan government to build policies around. Its most recent work focuses on the intersection of IPV and HIV by assessing the prevalence, acceptability, and feasibility of IPV screening within its existing HIV testing and counseling (HTC) settings. Already, LVCT is seeing promising outcomes from the initial portion of a three-phase study. These promising results provide not only a strong basis for the next phases of intervention and prevention strategies within the study, but also help to develop the foundational evidence for why the Kenyan government should begin to fund health programs and interventions that seek to prevent IPV both and HIV simultaneously.
Speaker Jennifer Wagman of the Uganda-based SHARE program explained that the SHARE model uses a community mobilization approach to prevent and screen for IPV while reducing the associated risk factors that can lead to HIV infection. By building on existing infrastructures within the
2 More information regarding the LVCT and SHARE models and studies can be found in Chapter 5 of this summary.
region and using evidence-based methods developed by Raising Voices and the stepping stone approach, SHARE has been able to develop multiphased programming that is used in concurrence with existing HIV prevention and treatment efforts within the region. Results of their studies show that the program is effective in reducing women’s overall experiences of IPV while also decreasing overall HIV incidence rates. These promising results indicate that the SHARE model may be effective in other settings, too.
Jewkes, R., K. Dunkle, M. Nduna, and N. Shai. 2010. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: A cohort study. Lancet 376(9734):41–48.
Kouyoumdjian, F. G., L. M. Calzavara, S. J. Bondy, P. O’Campo, D. Serwadda, F. Nalugoda, J. Kaqaayi, G. Kigozi, M. Wawer, and R. Gray. 2013. Risk factors for intimate partner violence in women in the Rakai Community Cohort Study, Uganda, from 2000 to 2009. BMC Public Health 13:566.
WHO (World Health Organization). 2005. WHO multi-country study on women’s health and domestic violence against women: Summary report of initial results on prevalence, health outcomes and women’s responses. Geneva, Switzerland: WHO.
Ying, L., C. M. Marshall, H. C. Rees, A. Nunez, E. Ezeanolue, and J. Ehiri. 2013. Intimate partner violence and HIV infection among women: A systematic review and meta-analysis. Journal of the International AIDS Society 17:18845.
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