Review of evidence on the linkages between gbv and hiv
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Review of evidence on the linkages between GBV and HIV. Naeemah Abrahams Ph.D. Gender & Health Research Unit: South African Medical Research Council

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Review of evidence on the linkages between gbv and hiv

Review of evidence on the linkages between GBV and HIV

Naeemah Abrahams Ph.D.

Gender & Health Research Unit: South African Medical Research Council

On behalf of: Global Burden of Disease Injuries and Risk Factor Study2010 study expert group on Interpersonal Violence: chaired by Charlotte Watts1 and Claudia Garcia-Moreno 2 and co-ordinated by Karen DeVries1

1London School of Hygiene and Tropical Medicine

2World Health Organization



  • Recognition from quite early in AIDS epidemic that gender inequality and violence placed women at risk of HIV

    • High level endorsement: e.g. Ending VAW is among 9 priority areas in the UNAIDS Outcome Framework 2009-11

    • PEPFAR funding in Sub-Saharan Africa

    • UN Stop Rape Campaign

  • Many NSPs include interventions to address gender issues and reduce violence

  • Key question:

    • What is the evidence?

Many pathways through which ipv experiences increase risk of hiv

Many pathways through which IPV experiences increase risk of HIV

  • Forced sexual intercourse

  • Women in abusive relationships less likely to refuse and negotiate sex and condom use

  • Abusive men more risky behaviours (more likely to have multiple partners/ use alcohol/ visit sex workers / have STIs/

  • Child sexual abuse

  • Reverse causality – abuse/ abandoned because of HIV status

This presentation

This presentation

  • Results from a systematic review and meta analysis on associations between IPV and HIV/STIs

  • Non Partner sexual violence

  • Other evidence

    • Perpetration studies

    • Child abuse analysis

Aims methods of ipv and hiv sti review

Aims & methods of IPV and HIV/STI review


  • Compile existing epidemiological evidence on the association between exposure to intimate partner violence (IPV) and HIV/STI infection- focus on physical and sexual violence


  • Systematic review

  • Searches of Pubmed, Embase, Cinahl, other databases until Dec 1 2010- 20 electronic data bases screened as well as unpublished studies

  • > 3,000 abstracts screened

  • Identified all papers reporting associations with HIV/STI

  • Inclusion: any population, any definition of IPV, HIV/STI

  • Analysis stratified by study quality:

    • Prospective studies

    • High quality cross-sectional studies (biological outcome data, unexposed reference group)

  • Meta-analysis done to produce a pooled estimate



  • 35 papers, describing 41 datasets with 121,479 participants, reporting 115 estimates included

    • 5 prospective datasets

      • 3 large studies with biological outcomes

        • 2 incident HIV, 1 incident STIs

    • 3 case-control datasets

    • 35 cross-sectional datasets

      • With biological outcome data AND unexposed reference groups

        • HIV: 12 datasets, 25 estimates

        • STI: 6 datasets, 6 estimates

Quality considerations to assess confounding and bias

Quality considerations to assess confounding and bias

  • Best quality – prospective studies (exposure of violence precede the outcome – HIV)

  • Biological outcomes vs self reports

  • Misclassification of exposure to violence

    • Type of violence measured i.e. physical / sexual alone vs physical and or sexual

    • Current & past partner (DHS )vs any partner ever

  • Control of confounding

    • Male partner variables (alcohol use, concurrent partners)

    • Women’s concurrent partners

P rospective studies find associations

Prospective studies find associations

Review of evidence on the linkages between gbv and hiv

Different analyses of same cross-sectional data have different findings depending on restricting of analysis to current partner women only /controlling of variables/ us of weighted data

Review of evidence on the linkages between gbv and hiv

Cross sectional studies and different forms of IPV considered: Biological HIV outcome





Figure:. Cross-sectional studies. Pooled OR, biological data only, HIV outcome, where reference group is no physical or sexual violence

Non partner sexual violence hiv sti

Non Partner Sexual Violence & HIV/STI

  • Associations from 3 studies included – (US & SA)

    • 3 studies reported on association between HIV and NPSV

    • 1 longitudinal study (SA); 1 case control; 1 cross sectional (US veteran studies)

Girl children abused in childhood have a higher hiv incidence jewkes et al child abuse neglect 2010

Girl children abused in childhood have a higher HIV incidence: (Jewkes et al Child Abuse & Neglect, 2010)

Evidence from research with men

Evidence from research with men:

  • Survey of adult men in Eastern Cape and KZN: perpetration of physical IPV was associated with elevated HIV prevalence in young men (aged <25): (Jewkes et al 2009)

    • > 1 episode of physical IPV aOR2.08(1.07, 4.06)

  • Similar findings from India: Men who have perpetrated IPV have elevated HIV prevalence

    • aOR for 1.91 (95%CI 1.11, 3.27) (Decker et al 2009)

Review of evidence on the linkages between gbv and hiv

Incidence and relative incidence of HIV infection in women exposed to forms of violence and inequity: (analysis provided by R Jewkes- based on SA study )

Growing evidence of a clustering of risk behaviours

Growing evidence of a clustering of risk behaviours

  • Men who are abusive to their partners are also more likely to have:

    • Concurrent sexual partners

    • A sexually transmitted infection

    • Problematic use of alcohol

    • Refuse to use a condom

  • Clustering of risk linked to common underlying risk factors

Potential pathways of association between ipv women s risk of hiv

Gender inequality

& social norms condoning some use of violence

Poverty & economic


  • Social constructions

  • of masculinity

  • Problematic

  • alcohol use

Reduced access to info & HIV services

Low or inconsistent condom use

Increased probability partner has HIV and/or STI

Increased likelihood that woman is HIV infected

Potential pathways of association between IPV & women’s risk of HIV

  • Early experiences or witnessing of violence







Child abuse sexual /physical



Partner has concurrent sexual partners

Woman has concurrent sexual partners






  • Prospective studies show an association between physical and/or sexual IPV and incident HIV in South Africa

  • Prospective data also find association between sexual IPV & HIV in Uganda and sexual violence & STI in India

  • Cross-sectional data analysis find less consistent findings- but better quality studies show significant associations

  • Despite growing studies – quality of studies lead to mix results

    • Need Longitudinal studies – to answer causal questions

    • Measurement of exposure to violence

    • Control of confounding variables – male partner variables

  • Unclear how generalizable findings are across different epidemic settings

  • Pathways between IPV & HIV complex – need to be better understood to inform effective programmes

Priorities to improve evidence base

Priorities to improve evidence base…

Identify opportunities to collect additional evidence from longitudinal studies

  • Take advantage of opportunities within ongoing intervention trials with HIV outcomes

    Make best use of DHS & other population data collection

  • Address methodological issues in DHS such as collecting data on violence exposure from all partners

    Integrate questions on violence in HIV intervention research

  • Provide deeper understanding of how violence and the fear of violence may undermine effectiveness of proven HIV interventions

Review of evidence on the linkages between gbv and hiv

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