Reducing the Burden of the Violent Experience

By Linda-Gail Bekker, Deputy Director of the Desmond Tutu HIV Foundation

Women* have many gender-unique experiences. Some of these are biologically determined: falling pregnant, giving birth; others are cultural: the relief of taking off a bra and the pain of high heeled shoes.  Then there are situations that arise from gender inequality and patriarchal norms. This includes the experience of violence, which 1 in 3 women will experience at least once in their lives.
November 25 is the International Day for the Eradication of Violence against Women. This day recognizes the impact of gender-based violence (GBV), which goes beyond the mere physical damage. Mental health, economic self-sufficiency and resilience to disease are all affected. A strong, mutually-reinforcing association has been found between violence against women and elevated HIV risk (1).
In areas where high GBV and HIV prevalence intersects, such as in sub-Saharan Africa, adolescent girls and young women face often insurmountable challenges to leading safe and healthy lives. In the Gauteng province of South Africa alone, where HIV prevalence stands at 12.4%, 51% of women have experienced violence and 76% of men admitted to committing it, putting levels of GBV and HIV high above global averages. To women at high risk of GBV, HIV is just one more factor to the already heavy burden of violence.
The path from violence to HIV:
Women with a history of sexual abuse are 53% more likely to contract HIV. This risk increases with the severity and frequency of the violence (1). Violence against women is obviously enhancing their HIV risk, but how?
First is the direct association: HIV transmission through sexual violence, where the abuser is HIV-infected. This can be sexual assault, rape, or a subtler threat or fear of violence from an intimate partner that results in a forced reduction in safe sex behaviour, such as reduced condom use. Men with a history of being violent are found to be more likely to engage with sexually risky behaviour (multiple partners, concurrent partners, high STI prevalence), and as a result more likely to acquire HIV (2).  This places women in intimate relationships with violent men at higher risk of contracting HIV, independently of their own sexual risk behaviour (1).
Second is the indirect association: HIV risk driven by physical rather than sexual violence, where the woman shows an increase in sexually risky behaviour, as a result of the violent experience. This could occur because the women experience a reduced ability to negotiate the timing and consequences of intercourse, or because once victimised they have a higher chance of re-entering abusive relationships. The long-term psychological impact of violence, illustrated by the strong association with poor mental health, is likely to contribute to this.
The link with HIV is bi-directional: women who experience violence are more likely to contract HIV, and women who are HIV infected are more likely to experience violence. Fear of violence (can prevent women from disclosing their status, receiving treatment and accessing HIV prevention services. The intersection of HIV and violence against women must be tackled from both sides through strong HIV prevention with radical reductions in GBV.
Prevention of Violence:

GBV occurs within a broader social context of persistent gender inequality and patriarchal social norms, which are both a consequence and an enforcer of continued violence against women. Eradication will require a radical shift in mindset. A way to tackle this is through strong, evidence-based behavioural and social interventions, advocacy and public awareness.
In low income settings, the WHO recommends microfinancing combined with gender equity training and community-based initiatives. To find new interventions, global pilot studies have been launched by the “What Works Against Violence” Campaign (3). These projects are community-based, incorporating both men and women, and seek to find novel and effective means of preventing violence against women.
An example is the Right to Play project in Pakistan, which aims to encourage positive forms of masculinity and build girls’ confidence, leadership and resilience through engagement in sport and play.  Interventions that begin at a young age and work within a community and family context are hugely beneficial.
Primary prevention focuses on the social drivers of the violent experience; however, meeting the immediate needs of those that have experience violence and provision of psychological counselling to those already affected is equally critical. Enhancing knowledge and dismantling the stigma surrounding HIV can reduce violence associated with disclosure of HIV status. Social interventions are powerful tools, however they address issues that are slow moving and resistant to change. To accelerate this strong societal input and political will are needed.
Prevention of HIV:
If we can’t protect all women from violence right now, we need to at least protect them from HIV. Reducing transmission of HIV reduces the burden of the violent experience. We now have a comprehensive primary prevention toolkit, tailored to adolescent girls and women, that includes both biomedical hammers and social intervention spanners of known efficacy.
Of particular interest is PrEP: a daily pre-exposure prophylaxis pill that can be taken by HIV-uninfected people to protect them from HIV infection. PrEP has been shown to work in diverse populations, when adherence is high.
For young woman and girls, PrEP can provide a way to manage HIV risk without the need for a partner’s consent or knowledge, and help make safe sex a given, rather than a negotiation. PrEP pills are just one means of women-controlled HIV prevention. New developments in HIV prevention research could expand the PrEP formulations to include long-acting injectable and topical PrEP gels.
 
The day for the Eradication of Violence Against Women marks the beginning of 16 days of activism: a chance to take action, to push for prolonged and heightened awareness, and to encourage a culture of zero tolerance. In 2016, there is absolutely no reason why any women should be subjected gender-based violence, and, with current prevention tools available, HIV should never be a consequence of such violence.

*Caveat: Women here refers to both cis- and transgender individuals, as well as any person that identifies with the female gender.
 
References:

1. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004; 363: 1415-21.
2. Dunkle KL, Decker MR. Gender-based violence and HIV: Reviewing the evidence for links and casual pathways in the general population and high-risk groups. American Journal of Reproductive Immunology. 2012; 69(s1):20-26.
3. What Works to Prevent Violence. Innovation Projects. [Online] available: http://www.whatworks.co.za/about/global-programme/global-programme-projects/innovation-projects