Intersections between HIV and Sexual and Domestic Violence

Farah Nageer
Pan American Health Organization
Gender, Ethnicity and Health Unit
525 Twenty-third Street, NW
Washington, DC 20037
U.S.A
Phone: (202) 974-3125
www.paho.org/genderandhealth
www.paho.org/generoysalud

Background

Initial findings from global studies show that sexual and domestic violence (SDV) against women is an identifiable risk factor for HIV and, conversely, HIV is a risk factor for various types of violence against women, including sexual violence. SDV and HIV pose a double threat for communities around the world, including those in Latin America and the Caribbean (LA/C) where both public health problems persist with alarming force. This requires joint action within the LA/C region to address socio-cultural norms that condone violence against women and related factors that contribute to the continued growth of the HIV epidemic throughout this region.

Over the past ten years, LA/C has experienced an aggressive increase in HIV with the highest prevalence rates (2-4%) among young women between 15 to 25 years of age (Caribbean Epidemiological Center, 1998). The Caribbean, with over 330,000 people living with HIV, remains the region with the second highest prevalence rate (1.6%) following Sub-Saharan Africa (UNAIDS, 2006). These statistics reflect a dramatic feminization of the HIV epidemic in LA/C over the last 10 years. Women now comprise 51% of HIV-positive adults in the Caribbean and 30% in Latin America (UNAIDS, 2006). In addition to increased challenges posed by HIV to the health status of women across the region, the perpetuation of various forms of gender-based violence, specifically SDV, poses a significant health threat to women in the region. Research on how these two epidemics are connected is therefore necessary to understanding the linkages and developing strategies to address them.

“Women now comprise 51% of HIV positive adults in the Caribbean and 30% in Latin America”

Existing research in sub-Saharan Africa, the United States, and India, among other countries, has documented four key channels by which the intersections between HIV and SDV can be explained. These channels are: (1) forced sex; (2) violence as a limiting factor to women’s capacity to negotiate safe sex; (3) childhood abuse as a related factor for high-risk sexual behavior in adolescence and adulthood; and (4) HIV-positive status as a causal factor for violence by a partner and/or family members. The first three channels represent violence as a risk factor for contracting HIV while the fourth refers to an inverse relationship whereby being HIV-positive is a risk factor for SDV.

This article provides an overview of a pilot project entitled “Investigating the Intersections between HIV and Sexual and Domestic Violence in Central America and Exploring Strategies for an Integrated Model of Care and Treatment” that is jointly coordinated by the Gender, Ethnicity and Health (GE) and HIV Units of the Pan American Health Organization (PAHO). The initiative seeks to explore the first, second, and fourth channels of the intersection between SDV and HIV using a determined sample of women in Belize, Honduras, and Nicaragua comprised of survivors of SDV and women living with HIV.

This study adapts Lori Heise’s ecological framework for addressing violence against women (VAW) (1998) to include both SDV and HIV in a framework that examines different levels of factors to explain the cycle of sexual and domestic violence against women. Heise’s model identifies a group of factors associated with VAW at the societal, community, relational, and individual levels to describe various levels and types of violence within a continuum of violence against women. This model is combined with the four channels of intersection between SDV and HIV as mentioned earlier and serves as the point of departure for the development of a preliminary theoretical understanding of the pathways to HIV infection among women that are based in sexual and domestic violence. Given that no evidence exists in the region that jointly explores these two public health issues, this initiative will begin to fill the information gap that exists and explore opportunities for further research and joint action in this area.

The three main components of this initiative are: (1) descriptive, qualitative country studies that assess and analyze the situation of HIV and sexual and domestic violence; (2) supporting the revision and/or creation of new policies and tools to address access to treatment both for women survivors of sexual and domestic violence and women living with HIV; and (3) the validation and subsequent implementation of the World Health Organization's Guide for Incorporating Gender into HIV Testing and Counseling programs. Data collection for the project, which received funding from the 3x5 Initiative and the Women, Health, and Development Department of the World Health Organization (WHO), will be completed in 2006.

Research Description

The country studies are exploratory and descriptive in nature. The country studies have three primary objectives: (1) estimate the proportion of female SDV survivors using SDV services that are HIV-positive; (2) estimate the proportion of HIV-positive women using HIV health care services that have experienced SDV before and/or after being infected with HIV; and (3) explore the experiences, knowledge and perceptions of women with HIV who are also survivors of SDV to improve institutional responses to both problems.
The target population is women, between the ages of 18-49 years, who are users of public and private health services for care and support of SDV and women with HIV who are users of HIV health care services. The specific geographic area, racial and ethnic groups, and characteristics of the participants vary in each country. The sample size in each country will be determined with the help of an expert in this area.

The study utilizes both qualitative and quantitative methods to address its objectives. A questionnaire will be administered to all participants. The Census and Survey Processing System (CSPro) will be used to analyze the data. The HIV Rapid Test will be administered to consenting female victims of SDV and referrals to corresponding counseling and support services will be provided.

The study results will be used to formulate questions for future research and to increase awareness of possible intersections between SDV and HIV in the region. Furthermore, it is anticipated that the country study process will uncover some of the methodological challenges that are inherent in a project of this nature, and facilitate entry points into the three participating countries for further research and joint action on SDV and HIV.

Initial Observations

Some initial observations from the implementation of the project in Nicaragua allow us to gain a better understanding of particular considerations and challenges associated with a project that addresses two public health problems with major socio-cultural implications.

One key finding is the need to adapt the survey questions on SDV and HIV to accommodate the reality that both of these issues continue to be regarded as socially and/or culturally taboo. In Nicaragua, people living with HIV were identified to administer the questionnaire to participants in some of the regions where the study was undertaken. In Nicaragua and Honduras, careful consideration was given to the timing of when to approach women accessing participating service providers in order to not threaten their use and the effective delivery of these services.

Special considerations on how the study was conducted in the border regions of each participating country will be made available at the completion of the country study phase of this project. In the planning stages of this initiative, it was noted that the study’s implementation in some border areas where there was only one HIV testing clinic could be especially difficult due to the challenge of providing services to those in need when there are high levels of stigma and discrimination faced by women seen entering or leaving the facility.

Next Steps

Following the completion of the first phase of the study in July 2006, findings from each of the participating countries will be compiled, analyzed, and compared. A summary paper of the findings will be produced and next steps will be coordinated jointly by country stakeholders, funding agencies, and PAHO’s HIV and GE Units.

At the time this article was written, Farah Nageer, worked at the Gender, Ethnicity and Health Unit of the Pan American Health Organization.

References

Caribbean Epidemiological Center (CAREC). Annual report on HIV/AIDS infection rates in the Caribbean 1997/1998.