Council Commentary

Gender-based Violence: A Neglected Barrier to Women’s Engagement in HIV Services

Today, there is widespread recognition that gender-based violence (GBV) is a human rights violation and pervasive global health challenge with many consequences for women and girls including physical injury, psychological trauma, unwanted pregnancy, and sexually transmitted infections, including HIV.  

But we also need to take stock of emerging evidence which shows that GBV has a significant impact on women’s use of HIV services, including HIV testing, and care and treatment for those living with HIV. Women’s decreased use of HIV services jeopardizes their own health and well- being as well as broader public health aims, namely UNAIDS 90-90-90 goals for ending the AIDS epidemic through increased uptake of HIV testing, and greater initiation and adherence to anti-retroviral therapy (ART), and viral suppression.   

Looking ahead, policymakers and donors must recognize the additional role GBV plays as a barrier to women’s engagement in critical HIV services, and support efforts to stop violence and mitigate its damaging effects on women and girls.1 

Under the Population Council’s Project SOAR2, which uses science, research expertise, and state-of-the-art methodologies to generate critical evidence to improve HIV policies and programs, researchers recently synthesized the growing evidence of GBV’s impact on HIV outcomes among women, particularly their engagement in the HIV care continuum.3 They found that GBV plays a detrimental role in many contexts:

  • Violence—physical, sexual, and/or emotional—impedes women’s uptake of HIV testing,1-8 and if they test positive, engagement in HIV care and treatment,1,4,5,9-17 and adherence to ART.17–31
  • Violence and fear of violence has been shown to reduce adherence to HIV prevention technologies: pre-exposure prophylaxis (PrEP) for women not living with HIV,32, 33 post-exposure prophylaxis (PEP) for women possibly exposed to HIV,34-36 and microbicides as part of clinical trials.37
  • For women living with HIV, access to and engagement in care and treatment is negatively affected by verbal abuse and disrespectful treatment from health care providers.38-40

Project SOAR also identified several cutting-edge approaches to address violence using HIV platforms. These include:

  • Integrating intimate partner violence (IPV) screening and counseling into hospital HIV services.41
  • Counseling couples on relationship dynamics (e.g. communication, intimacy) to promote couples HIV testing (unpublished); and nurse-led IPV counseling in antenatal clinics.42,43
  • Introducing multi-level interventions (counseling, peer support, health provider training, and community mobilization) for sex workers living with HIV who face violence from clients and partners.44 

Evidence from newly completed and ongoing studies was reviewed and discussed with 50 HIV and violence experts, including researchers, practitioners, women’s advocates, and policymakers at a meeting Project SOAR convened in early June 2017.  The meeting included representatives from the International Community of Women Living with HIV and Salamander Trust who spoke about their own personal experiences with HIV and violence and the need for a rights-based and empowerment approach when conducting research and programs.  

Recommendations

Experts agreed that there is a pressing need to better understand how we can address GBV as a barrier to HIV programs and services, highlighting the challenge that only a relatively small body of work conducted in a limited number of countries and among certain populations exists to draw on.  Together they prioritized further research in three broad areas and highlighted research questions within those areas that if answered, would fill important knowledge gaps and move the field forward.   

Populations

Women living with HIV: What are the priorities of women living with both HIV and violence in ensuring their safety, dignity, and enhancing their resilience in order to improve their health and well-being? How can researchers / practitioners better integrate the perspectives of women in research and programs?   

Key populations:  What is the relationship between violence and key populations’ linkage to and retention in HIV care and ART adherence?  What are the particular realities and needs of transgender women?

Couples: How can programs address conflict, violence, and HIV among couples and what are the implications for engagement in the HIV care continuum and other outcomes, such as intergenerational violence?

Programs and Services

Integrating HIV and violence responses: What are most effective components of integrated HIV and violence interventions for women living with HIV, including key populations, which should be taken to scale?  Addressing violence during HIV testing is a start, but it needs to be more interwoven into HIV care and treatment. What works at different service delivery points along the HIV care continuum? Using implementation science how can we best deliver these integrated interventions?

Stigma and abuse reduction programs for health providers:  What effect does a stigma and abuse reduction program for health providers have on women’s linkage to care and adherence to treatment?

Mental health services: What is the content of psychosocial support for women living with HIV and experiencing violence? What services are being delivered and how? What is the effect of psychosocial support on HIV, violence, and mental health outcomes? How do we offer integrated HIV/violence/mental health services to women living with HIV? 

Measurement  

Resilience: How do we define and measure resilience in the context of violence and HIV prevention and care among adolescent girls and adult women? 

As the HIV/AIDS and violence communities confront GBV as a barrier to women’s engagement in the HIV care continuum, we must continue to fill the research gaps that lead to better programs, services, and policies for women living with HIV and experiencing violence in ways that protect their health and rights.45 And we must ensure that women living with HIV be engaged as equal partners in research that affects their lives.

 

1. While this blog focuses on women, we recognize that men are also affected by violence, including men who have sex with men.

2. Project SOAR (Cooperative Agreement AID-OAA-14-00060) is made possible by the generous support of the American people through the President’s Emergency Plan for AIDS Relief and the United States Agency for International Development (USAID). The contents of this blog are the sole responsibility of Project SOAR and the Population Council and do not necessarily reflect the views of USAID or the United States Government. Led by the Population Council, Project SOAR is implemented in collaboration with Avenir Health, Elizabeth Glaser Pediatric AIDS Foundation, Johns Hopkins University, Palladium, and The University of North Carolina.

3. The HIV care continuum is a series of steps a person with HIV takes from initial diagnosis through their successful treatment with HIV medication.

The full list of references can be viewed here.