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Deadly Intersection for Women
HIV/AIDS & Gender Based
Violence: Program Implications
Jacquelyn Campbell PhD, RN, FAAN
Anna D. Wolf Chair & Professor
The Johns Hopkins University
School of Nursing
Violence Prevention in Low & Middle-Income
Countries: Finding a Place on Global Agenda ‘07
• State of science in violence prevention – US & Global
• National & International participants from health, criminal justice,
public policy, economic development
• Identified specific opportunities for U.S. gov. & other leaders with
resources to more effectively support prevention of violence.
• Need for integrated, science-based approach & agenda to support
research, clinical practice, program development, policy analysis,
& advocacy for violence prevention.
• US Senate Hearings – 6-08 –
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Planning Committee: Mark Rosenberg, Chair, James Mercy, Co-Chair
Sir George Alleyne, Alexander Butchart, Jacquelyn Campbell, Darnell Hawkins
IOM Staff: Kimberly Scott, Senior Program Officer and Rapporteur
Patrick Kelley, Board Director
Paper on HIV/AIDS & Violence against Women – Campbell, Baty et al
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http://www.iom.edu/CMS/3783/48783/50755.aspx
Global Definitions
Gender Based Violence (UN): Acts of violence
(physical, sexual, psychological) against women and girls
including intimate partner violence & dating violence,
rape and sexual assault, violence against domestic
workers, childhood sexual abuse, forced sexual
initiation, forced marriage
Intimate Partner Violence (WHO): Any behavior within
an intimate relationship that causes physical,
psychological or sexual harm to those in the relationship,
includes: physical aggression, psychological abuse,
forced intercourse & other forms of sexual
coercion, various controlling behaviors (Krug et. al. ’03)
Basic issue of control of female sexuality – 4045% of physically abused women forced into sex
& continuum of “intimacy” of partners
New Face of HIV/AIDS – HIV/VAW
interface recognized officially by UN ‘04
Around globe women are the fastest group
contracting HIV and in many settings
fastest group converting to AIDS –e.g. Uganda
For each 100 HIV+ males – 160 females
Adolescent girls particularly affected –
10% of girls 10-14 yo vs. 3% of boys in
Botswana
In US – poor African American women
most affected – 69% of new cases in ‘07
In Africa – women are dying the most from
AIDS – 3:1 ratios –
Sub-Saharan Africa – girls: 75% HIV+15-19 yo
Studies Showing Direct HIV-IPV
connection - Africa
Tanzania: Women infected with HIV significantly
more likely to report physical & sexual violence
with current partner than HIV negative women (OR
2.42, 95% CI 1.20-4.87; OR 2.39, 95% CI 1.214.73) [Maman et al. ‘02]
South Africa: IPV (OR 1.48, 95% CI 1.15-1.89)
associated with HIV seropositivity, after
adjustment for age, current relationship status &
women’s risk behavior.
[Dunkle et al ‘04]
Kenya: HIV positive women significantly more
likely to have experienced physical partner violence
in ifetime (OR 1.8 95% CI 1.1-2.8)[Fonck et al ‘05]
Studies Showing Direct HIV-IPV
connection
India – IPV as both risk factor and risk marker–
Decker et al, J AIDS‘ ’09 – male perpetrators of
IPV – increased HIV+ (AOR 1.94); wives of IPV
perpetrators increased risk of HIV+ (AOR =
7.04) –adjusting for other risk behaviors
US – National Survey – IPV increased HIV+ by
AOR = 3.44 – General Hospital Psychiatry – ‘09
HIV/DV Connections – Etiology
(Maman et al ’99; Campbell et al ‘08)
Immune system suppression with stress – CD4
counts dropping?
Trauma of forced sex increasing HIV
transmission; anal sex
Increased STD’s & untreated STD’s (Johnson ‘02)
Impossible to negotiate safe sex if a battering
relationship
Women accused of infidelity if want to use safe
sex
Males have other partners unknown to women
(WHO multicountry study ’04)
Fear of being beaten for being tested; notifying
partner of positive status; delay in treatment
Substance abuse – self medication for PTSD
Accepted Best Practices for Prevention
of AIDS
A = Abstinence
B = Be Faithful
C = Use Condoms
Forced First Intercourse (WHO MultiCountry Study)
WHO Multi-country study 3-30% sexual
initiation physically forced –
11-45% among those whose sexual debut <15
years
US – 12.4% - Stockman ‘08
25% of those sexually active <14yo
MSM – Relf ’03 & high risk behavior
B. “Be Faithful”
Women at risk – heterosexual married
women with no behavioral risk factors
Issues of forced anal sex – stigma & shame but
increasing trauma and risk of transmission
Husbands are
• Having sex with other women without wives’
knowledge
• Forcing them to have unprotected sex –
women trying to refuse b/c know they have
other partners &/or perceive them to be at
high risk for HIV (Koenig et al ’04- 24% of
women in Uganda - forced sex from partner)
Evidence of HIV/VAW Intersection
US studies showing IPV & more HIV risk
behavior (Cohen ’00; Gielen et.al.’02;
Burke ’05)
or victim of CSA
Women: Wyatt ‘00; Laughon ’01; Whetten ‘06
Men: Greenwood, Relf et. al. AJPH ‘03
Qualitative studies - Near impossibility of
negotiation of condom use with abusive
partner (Champion & Shain ’98; Davilla &
Brackley ’98; Laughon, in press; Stevens &
Richards 98’; Zierler & Krieger ‘97)
Adolescents – GBV & HIV risk
Adolescent girls saying they are afraid to insist on
using a condom – “He’ll either hit me or quit me”
(Loretta Sweet Jemmott, ‘08)
Girls “taking the pledge” but thinking that oral
and anal sex – “not sex”
6 US studies of adolescents – less or inconsistent
use with IPV (Teitelman et al – J of HIV/AIDS
Prev in Child & Youth ‘07)
In SA - national survey – 15-24 yo women who
experienced forced sex – inconsistent condom use
(X6) (Pettifor et al ‘04 ).
IMMUNE SYSTEM EFFECTS
HPA axis – hypothalmic – pituitary – adrenal gland
interactions
Stress of abuse, multiplied by poverty, other
stressors – but even separate from other stressors activates HPA & produces corticosteroids &
catecholamines
Suppresses T1 cell cytokines (fights bacteria &
viruses) production
Depression has same effects on immune system
 Total Mitogen Response with  depression in battered
women (Constantino, et al., 2000)
Lowered immunity to HIV? Or quicker reduction of
CD4 counts? – some evidence in Uganda – even non
pregnant women (Gray et al ‘09)
In Spite of Evidence – Need for
Collaborative Research
Most HIV research does not measure IPV
Or measures IPV incompletely – DHS vs. WHO
protocol
Or does not address physiological issues
related to GBV
Most IPV research does not address forced
sex separately & lacks context around
forced sex
Continued mystery as to why women
infected more than men in official policy
circles
Issues with CD4 count poorly understood
Girls often left out of discussion – focus on
Even with all the evidence
Most HIV prevention programs do not include
addressing IPV – men & women &/or evidence
lacking – EXCEPT (& situation improving!)
Sweet-Jemmott – adolescent girls – “Sisters
Saving Sisters” & “Sister to Sister” – 20 min
for adult women – but IPV not explicit or
measured (afraid “he will hit me or leave me”)
Wingood & DiClemente ’06 – but not explicit
content & no IPV measurement - Teitleman
Stepping Stones – Jewkes et al ’06 – South
Africa - significant improvement in IPV
reduction but not in HIV prevention – but
male IPV & hi risk sex related
El Bessel & colleagues – NYC – substance
abusers – male & female
Maman intervention for young men - Tanzania
Issues with PEP – Protocols &
Adherence
Transmission rates from rape unknown –
guidelines in US problematic – PEP not being
offered
Promising telephone intervention post rape –
Abrahams ‘09 in SA
Encouraging women through side effects
Rape trauma processing
Develop evidence base for PEP protocols – 3 day
starter pack w/follow up Thuthuzela Center in CT, SA
Other Promising Interventions in HIV
& Violence Prevention - & Issues
IMAGE microfinance & IPV prevention program –
including mobilization of women (Pronyk….Watts et
al’06)
In some locales may increase violence against women (e.g.
Pakistan – Koenig)
Needs to include HIV prevention & violence prevention
content
CHAMP program in US & SA – Bhana & Bell –
community protective, increasing resilience for HIV &
violence prevention – but VAW specific component
missing
“Raising Voices” – community programs to change
norms around gender & IPV – Uganda
Interventions for Abused Women
Remember most abused women still want the
relationship - & may want to get pregnant
Prenatal care – “window of opportunity”
Need to address physical and mental health
(beyond immediate injury/crisis) as well as
providing justice, empowerment, violence
reduction & HIV prevention or treatment
Healing from trauma – truth & reconciliation type
processes – Rwanda – Native American –
community justice type approaches – Koss
Physical health interventions to address immune
system compromise – anti-inflammatory agents?
Changing Norms - Getting Men Involved
(“Masculinities”) (www.endabuse.org)
“White Ribbon Campaign” – Canada
HIV testing & counseling programs for
men – Tanzania - Maman
Teaching recruits in the military –
“Tough Guise” Jackson Katz
Prisoner re-entry programs – Oliver
Williams
“Soul City” & Sonke Gender Justice –
“One Man” campaign Dean Peacock –
South Africa - FIFA
Promundo – Brazil – Gary Barker