Part 1: Why address gender-based violence in the HIV response?

1. Why address gender-based violence in HIV response & what are effective strategies?Avni AminWorld Health OrganizationIntegrating strategies to address gender-based violence and engage men and boys to advance gender equality through National Strategic Plans on HIV and AIDS14-16 November 2011, Istanbul, Turkey

2. Part 1: Why address gender-based violence in the HIV response? • Review data: • How widespread is gender-based violence? • How is gender-based violence linked to HIV ?

3. Definition: gender-based violence (GBV) • GBV: violence involving men & women; derived from unequal power relationships between men and women; includes physical, sexual & psychological harm: • acts of physical aggression • emotional, psychological abuse & controlling behaviours • coerced sex, sexual harassment, rape   • Violence against women (VAW): public or private act of gender-based violence that results, or likely to result in physical, sexual or psychological harm to women.

4. Different forms of GBV • Sexual, physical, or emotional violence by an intimate partner (intimate partner violence or IPV) & non partners; • Child sexual abuse • Sexual violence in conflict situations • Sexual harassment & abuse by authority figures (e.g teachers, police officers or employers etc), • Forced prostitution and sexual trafficking • Child marriage • Violence perpetrated or condoned by the state. • Homophobic violence • Violence against women and men living with HIV

5. Key Message 1 Gender-based violence is a widespread public health & human rights problem worldwide.

6. 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.

7. Prevalence of IPV: select countries Source: UN women , March 2011, Violence against women Prevalence Data: Surveys by country

8. Violence against vulnerable groups • Prevalence of recent rape by clients among female sex workers (FSW) • 32% in Mombasa, Kenya (2007) • 31% in Karnataka, India (2005) • 26% in Macau, China (2011) • In Vancouver, Canada IDU survey • 68% of women & 19% of men lifetime history of sexual violence • Child sexual abuse 33% for women, and 13% for men • In the USA in 2 studies: • 68% young MSM : threats or violence from either family or partners • 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.

9. Key Message 2 Gender-based violence is rooted in or a manifestation of gender inequality in society: Traditional gender norms perpetuate violence against women .

10. 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”

11. Key Message 3 Gender-based violence is both a risk factor for, and a potential consequence of being identified as having HIV

12. Gender-based violence & HIV Across all settings women who have experienced IPV are 2X 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.

13. Gender-based violence & HIV • Longitudinal study, South Africa: HIV incidence in women with multiple episodes of intimate partner violence 9.6 per 100 person-years vs 5.2 per 100 person-years among those with one or none (aIRR =1.51); 12% of new HIV infections attributed to intimate partner violence. • Tanzania: women seeking HIV counseling and testing who had experienced violence were 2X more likely to be HIV positive • 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 • 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

14. Gender-based violence & HIV • Female Sex Workers, Thailand who experienced physical &/or sexual violence 31% more likely to report an STI symptom (2010) • Sex workers, China: • who experienced client violence - 32% more likely to report condom use failure compared to those who did not (2011). • who experienced high compared to low levels of client violence (2008) - 2X as likely to report condom use failure. Source: Shannon K et al. Forthcoming 2012;

15. Pathways linking GBV & HIV Source: Jewkes et al. 2010

16. Part 2: Key strategies to address GBV in the context of HIV/AIDS programming?

17. Objectives part 2: Identify: • Key principles & framework • Evidence-based interventions & strategies

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

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

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

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

22. 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 Key populationsSex Workers Substance abusers (IDU, drug & alcohol) MSM Survivors of GBV Women with prison history partners of substance abusers Adolescents PMTCT Couple Counselling & Testing Involving male partners Treatment Comprehensive Post-rape care including PEP Care & Support Peer & mediated disclosure support

23. Links: www.who.int/gender www.who.int/reproductivehealth/publications/violence/en/ Email Avni Amin amina@who.int WHO Resources on GBV & HIV