Ian Askew PhD Director, Reproductive Health Services and Research, Nairobi, Kenya

1. State of the evidence:What are the gaps and priorities for strengthening linkages between GBV and HIV in sub-Saharan Africa? Ian Askew PhD Director, Reproductive Health Services and Research, Nairobi, Kenya

2. What evidence is needed? • Why link HIV and GBV programming? • GBV and HIV acquisition and transmission • HIV status and GBV • What factors contribute to linkages between GBV and HIV? • How can GBV and HIV programming be linked? • Feasibly, acceptably, effectively, affordably, and at scale

3. 1. Rationale for linking HIV and GBV programming • Sexual violence increases likelihood of HIV/STI acquisition and transmission during sex • Plausible increase in individual HIV risk (RR=2.4-27.1), due to genital injury and likelihood of perpetrator(s) being HIV+ • Mixed epidemiological evidence of effect on HIV prevalence at community / population level • In conflict settings, HIV incidence could increase by up to 10%, especially where HIV prevalence is low Charlotte Watts et al. 2010. “Sexual violence and conflict in Africa: prevalence and potential impact on HIV incidence”, Sex Transm Infect, 86: iii93-iii99

4. 1. Rationale for linking HIV and GBV programming • Common structural determinants of both • Actual or perceived HIV status can increase likelihood of suffering SGBV • Role of non-sexual GBV for HIV risk • Economic deprivation and exploitation • Social practices, especially: • FGM/C • Early marriage

5. In high HIV prevalence settings, married girls aged 15-19 years are much more likely than unmarried girls to have HIV infection • Marriage: • Increases frequency of sex • Decreases condom use • Eliminates ability to abstain • Older partners more likely to be infected Clark, S. 2004. Early Marriage and HIV Risks in Sub-Saharan Africa, Studies in Family Planning, 35[3]: 149–160

6. 2. Factors contributing to GBV– Do these affect HIV risk? • Most GBV occurs within the family or with a known perpetrator Heise, Lori L. 2011. What works to prevent partner violence? An evidence overview. Report for the UK Department for International Development.

7. Gender norms related to male authority, acceptance of wife beating and female obedience Pathways through which gender-based violence and gender and relationship power inequity might place women at risk of HIV infection Jewkes et al. 2010. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study, The Lancet

8. 2. Factors contributing to GBV– Do these also affect HIV risk? Perpetrators: • Exposure to violence in childhood • Boys subjected to harsh punishment, who are physically abused, or who witness their mothers being beaten • Excessive alcohol use, especially binge drinking, increases frequency and severity • Excessive drinking by men has been strongly associated with partner violence in nearly every setting Heise, Lori L. 2011. What works to prevent partner violence? An evidence overview. Report for the UK Department for International Development.

9. 3. How can GBV and HIV programming be linked? - Primary prevention • GBV prevention interventions evaluated with HIV outcomes • Stepping Stones • Self-reported reduction by perpetrators • No change in girls’ and women’s experiences or behaviours • No effect on HIV acquisition (reduction in HSV-2) • IMAGE • Reductions in reported IPV • No effect on HIV acquisition • On-going evaluations........

10. 3. How can GBV and HIV programming be linked? HIV GBV programmes Medical response Criminal-Justice System Community engagement

11. 3. How can GBV and HIV programming be linked? GBV HIV programmes

12. 3. How can GBV and HIV programming be linked? – Gaps in evidence • Implementing at scale • Addressing mental health of survivors, especially for those infected through sexual violence, and perpetrators • Supporting male and transgender survivors • Institutionalized, MSM, sex workers • Supporting child and adolescent survivors, including boys • Screening and treatment through health systems • Prevention and response interventions in educational institutions • Safe abortion services following rape • Services for perpetrators • Integrating GBV prevention and treatment into HIV programmes

13. Priorities for the future • Clearer interpretation of associations between types of violence and risk of HIV acquisition • A single act of rape has a low risk of HIV • Repeated unprotected exposure to an HIV-infected partner(s) increases risk • Violence increases risky sex • Violence reduces ability to protect • Evidence needed on GBV prevention interventions that: • Reduce gender inequities • Reduce early marriage • Increase economic empowerment • Reduce other factors associated with perpetration: • Childhood exposure to violence, especially among boys • Alcohol/substance abuse • Operations research to test HIV programming that reduces or mitigates GBV associated with stigma • Operations research to inform scaling up comprehensive GBV-HIV response programmes • Especially but not only in high prevalence settings