(September 2010) Women with an abusive sexual partner are at greater risk of HIV infection than other women. Several studies have shown this association between HIV and gender-based violence, but the link has now been further documented and examined in a study that followed a group of nearly 1,100 young South African women for two years.1 The women had an average age of 18 years at the start of the study, and most were enrolled in school.
None of the women were HIV-positive at the start of the study, but those in abusive relationships were more likely to test positive for HIV at 12- or 24-month follow-up exams. Study participants rated as having a low sense of power in their relationships were also more likely to become infected. Their "relationship power equity" was measured through responses to questions such as whether they felt they could refuse their boyfriends' sexual advances.
In the South Africa study, published in The Lancet, researcher Rachel Jewkes and her colleagues reported the higher risk of HIV infection for women who were in a chronically abusive relationship or were previously exposed to violence or excessively controlling behavior—even in childhood.2 The association between HIV infection and violent or controlling behavior partly results from psychological effects that may affect women for years after the event. Emotional stress and low self-esteem might lead them to engage in riskier sex. "Thus, there is a vicious cycle, with abuse enhancing risks of HIV infection and further abuse."
South Africa has the greatest number of people infected with HIV/AIDS in the world—estimated at 5.7 million in 2009. Prevalence is highest among women: One in three women ages 25 to 29 is HIV-positive. Although more people living with HIV/AIDS are benefiting from life-prolonging antiretroviral treatment, new infections continue to occur at an alarming rate, especially among young women. This highlights the need to understand the risk factors for young people, such as the group included in this study, and how to address them.
Strategies to Stem the Violence
There is a growing body of evidence that shows that carefully targeted and designed intervention programs can change risky behavior. Intervention programs usually try to enable women to protect themselves from HIV and other sexually transmitted infections by asserting more control in their relationships, and by introducing gender equity concepts to men. Although such programs have had limited success in reducing HIV-infection rates so far, some researchers are optimistic that they can eventually create effective programs based on lessons learned from past attempts.3
Two promising programs mentioned in The Lancet article that address gender-based violence and HIV transmission are Stepping Stones, implemented in countries throughout the developing world, and Somos Diferentes, Somos Iguales ("We're Different, We're Equal"), created in Nicaragua and exported to several other Spanish-speaking countries. These programs rely on different approaches, but both have made inroads in promoting gender equity—crucial for reducing HIV transmission.
'Stepping Stones' to Gender Equity
Stepping Stones is a widely known participatory intervention program aimed at young men and women. First developed in the 1990s to combat rampant HIV-infection rates in Uganda, it has been translated and adapted for use in many other countries. Stepping Stones is now not only used throughout Africa, but also in Eastern Europe, Latin America and the Caribbean, and in India and Bangladesh.
One-half of the young women in the study reported in the The Lancet had participated in a Stepping Stones program administered in rural South Africa. They, along with young men from the same communities, had 13 three-hour sessions featuring sex education; role playing; self-reflection; and discussion related to HIV, gender roles, gender-based violence, and reproductive health. Men and women met in separate groups, usually on school grounds, and then jointly for a final community meeting. The other half of the young women in the study had received a three-hour course on HIV and safe sex. Twelve months later, and again at 24 months, all participants were tested for the HIV and herpes simplex viruses (HSV-2).
The Stepping Stones program was not linked to lower HIV-infection rates for participants. However, it was associated with significantly lower rates of HSV-2, a risk factor for HIV, suggesting that the program prompted behavior change that reduced sexually transmitted infections.
Another promising finding: The young men completing the program reported significant declines in violence against women, including rape. The changes were even greater after 24 months than at 12 months, illustrating that the program has a long-term effect on men's attitudes and behavior. This encouraging result adds to evidence provided by previous evaluations of Stepping Stones programs.
Nicaragua Program to Reduce Gender Bias
An intervention program in Nicaragua followed a different model, delivering its messages through the mass media. Although HIV prevalence is much lower in Nicaragua than in South Africa, the risk for transmission among young people is heightened there by unsafe sexual activity among many young people and a tradition of male dominance and irresponsible male sexual behavior. The program, Somos Diferentes, Somos Iguales (SDSI), carried out between 2002 and 2005, aimed to raise awareness among young Nicaraguans of the risks of HIV infection and gender-based violence, lessen the stigma against people with HIV, and encourage responsible sex and more equitable gender norms and behaviors.4 Elements of the program have been introduced in Guatemala and elsewhere.
SDSI messages were conveyed through television and radio programming. A weekly TV drama aimed at young people included HIV-positive characters and explored gender bias in everyday situations. Popular cast members made appearances at high schools to discuss HIV, gender equity, and related topics. An SDSI radio call-in show hosted by young adults encouraged debate about sexuality and gender issues.
An analysis of the program in three cities showed that young people were tuning in to the programs and were beginning to change their attitudes and behaviors. For example, compared with others, young people who watched or listened to the SDSI programs were more likely to say that men should share in housework, that a husband never has the right to hit his wife, and that they would be willing to be friends with someone with HIV/AIDS.5
Stepping Stones, SDSI, and similar programs around the world contribute toward efforts to reduce gender-based violence and promote gender equity. If these concepts and behaviors take hold in a society, women will be more empowered to protect themselves against abusive or controlling sexual partners and break the vicious cycle of abuse and HIV infection that plague so many women around the world.
Mary Mederios Kent is senior demographic writer at the Population Reference Bureau.
- Rachel K. Jewkes et al., "Intimate Partner Violence, Relationship Power Inequity, and Incidence of HIV Infection in Young Women in South Africa: A Cohort Study," The Lancet 376, no. 9734 (2010): 41-48; and Jay G. Silverman, "Key to Prevent HIV in Women: Reduce Gender-Based Violence," The Lancet 376, no. 9734 (2010): 6-7.
- Jewkes et al., "Intimate Partner Violence, Relationship Power Inequity, and Incidence of HIV Infection in Young Women in South Africa."
- Rachel K. Jewkes et al., "Impact of Stepping Stones on Incidence of HIV and HSV-2 and Sexual Behaviour in Rural South Africa: Cluster Randomised Controlled Trial," BMJ 337, no. a506 (2008), accessed at www.bmj.com/content/337/bmj.a506.full.pdf, on Sept. 7, 2010.
- Henry Espinoza, "Using Edutainment and Social Activities to Challenge Machismo in Nicaragua: The Example of Somos Diferentes, Somos Iguales," Sexual Health Exchange 2 (2005): 9-10, accessed at www.kit.nl/exchange/html/2005-2_using_edu.asp, on Sept. 7, 2010.
- Irela Solorzano et al., "Positive Impact of an HIV Prevention Communication for Social Change Program on Youth in Nicaragua" (2006), accessed at www.globalhealth.org/images/pdf/conf_2006/presentations/a1_pulerwitz.pdf, on Sept. 7, 2010.