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  • Searches of Pubmed, Embase, Cinahl, other databases until Dec 1 2010- 20 electronic data bases screened as well as unpublished studies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

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


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)

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