International HIV prevention efforts need to take much greater account of violence against women and sexual coercion if they are to be successful, say two US researchers in the May 1st edition of The Lancet. Their comments come in response to South African research published in the same edition that shows women reporting violence or a high degree of control from a sexual partner were almost 50% more likely to be HIV-positive.
Rachel Jewkes and colleagues from South Africa's Medical Research Council studied 1366 women who agreed to HIV testing while attending antenatal care at four health centres in Soweto, South Africa. Private face-to-face interviews included the assessment of sociodemographic characteristics, experience of gender-based violence, gender equality in their relationships and risky sexual practices.
Two factors were identified that were associated with a 50% higher prevalence of HIV-1 infection: receiving physical abuse from a male partner and being in a relationship where the male partner had excessive control of the relationship. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with increased HIV risk.
“Women with violent or controlling male partners are at increased risk of HIV infection,” said Dr Rachel Jewkes. “We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships and HIV risk behaviours in men, as well as effective interventions, are urgently needed.”
In an accompanying commentary article, Sandra Martin and Sian Curtis of the University of North Carolina department of Maternal and Child Health point out that approaches to HIV prevention based on abstinence, behaviour change and condoms – the ABC approach – will be of limited use unless wider cultural change is promoted.
“In light of research establishing links between gender-based violence and HIV infection… we believe an examination is necessary of the extent to which new global health initiatives for the prevention and treatment of HIV/AIDS incorporate strategies for stopping gender-based violence.”
Whilst praising the President’s Emergency Plan for AIDS Relief for its recognition that intimate partner violence, coercive sex and gender inequity play critical roles in perpetuating the epidemic, they question whether the Bush administration’s favoured approach to prevention – ABC – can be successful without first making substantial progress towards reducing levels of sexual violence and coercion.
“[A] strong emphasis on abstinence among the young will be of limited use in settings in which many young women are forced to have sex against their will,” they note.
“Women might not take advantage of voluntary HIV testing and counselling if they fear their partners will react violently to the news that they are HIV-positive.”
“The initiative’s highlighting of condom use for particular high-risk groups of people rather than for everyone could further stigmatise condoms and decrease their use. Moreover, we wonder whether some women, such as those in violent relationships, would really be able to successfully negotiate condom use with their partners, especially in settings in which men typically have much greater power than women.”
References
Dunkle KL et al. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The Lancet 363: 1415-21, 2004.
Martin SL, Curtis S. Gender-based violence and HIV/AIDS: recognising links and acting on evidence. The Lancet 363: 1410-1411, 2004.