Recommendation: Promote zero tolerance of all forms of violence against women and girls

The Link Between Violence and HIV/AIDS
Violence against women is both a cause and a consequence of HIV/AIDS.
It is a fact of life for too many women in all countries, whether in peacetime, during conflict or post-conflict periods. The true extent of violence against women is unknown, but current research indicates that intimate partner violence ranges anywhere from 10 to 69 per cent, and one in four women may experience sexual violence by an intimate partner in her lifetime. (1) To truly understand the extent of violence against women, the number of women who experience violence at the hands of strangers must be added to the above figures.

Economic disruption, war or conflict also exacerbate genderbased violence in numerous ways. The experience of women like Khadija Bah, who was abducted by rebels in Sierra Leone (see Box, p. 49), is repeated many times over in conflict zones. In Rwanda, during the 1994 genocide, hundreds of thousands of women were raped, many by men who were HIV-positive. (2) Globally, up to two million women are trafficked every year, many of them at great risk of sexual abuse, and all at risk of HIV infection. (3) If their HIV-positive status is known, many women are in danger of being beaten, abandoned or thrown out of their homes.

Many are afraid to ask their partners to change their sexual behaviour or to use protection. In Botswana, women have admitted to health professionals that they are afraid of their partner’s reaction if he finds out they are HIV-positive. That fear has kept them from being tested, from returning for their results if they are tested, from participating in PMTCT and treatment programmes and, for those who agree to be treated, from adhering to the regimen because they are trying to hide their pills. (4)

While violence and the fear of violence make it hard for women to access prevention, treatment and care, the very fact that they are living with violence seems to increase their susceptibility to HIV.

According to a recent study, one of the first to show a firm link between violence and HIV, women who are beaten or dominated by their partners are much more likely to become infected by HIV than women who live in non-violent households. The research was carried out among 1,366 South African women who attended health centres in Soweto and agreed to be tested for HIV and interviewed about their home lives. After being adjusted for factors that could skew the outcome, such as whether interviewees had engaged in casual sex or sex work, the figures showed that women who were beaten by their husbands or boyfriends were 48 per cent more likely to become infected by HIV than those who were not. Those who were emotionally or financially dominated by their partner were 52 per cent more likely to be infected than those who were not dominated. (5)

A smaller study in Tanzania found that HIV-positive women were over two and a half times more likely to have experienced violence by their partner than HIV-negative women. (6)

This increased vulnerability is tied to several issues. One is lack of control. Male condoms or other protection are irrelevant when a woman is being beaten and raped. Another is physiological susceptibility.

WHO reports that during “forced vaginal penetration, abrasions and cuts commonly occur, thus facilitating the entry of the virus—when it is present—through the vaginal mucosa.” (7)

These conditions are magnified for young girls. Their reproductive tracts are not fully developed and are therefore prone to tearing during sexual activity. They are more likely to experience sexual coercion than adult women. In several studies around the world, up to one third of adolescent girls reported that their first sexual experience was coerced. Many are married at a young age to older men, and the power inequities inherent in these relationships can lead to violence or the threat of it. (8) Adolescent girls are also prime targets for traffickers or militia groups. Worldwide, it is estimated that 800,000 to 900,000 people—women, men, girls and boys—are trafficked every year into forced labour and sexual exploitation, a highly lucrative global industry controlled by powerful criminal organizations. (9) The UN Office on Drugs and Crime estimated that in 1997, these groups amassed some $7 billion a year while making use of the Internet to expand their networks in both industrialized and developing nations. (10)

The risk of violence and sexual abuse is high among girls who are orphaned by AIDS, many of whom face a heightened sense of hopelessness along with a lack of emotional and financial support.

In a study in Zambia, Human Rights Watch found that among girls who had been orphaned by AIDS, hundreds were being sexually assaulted by family members or guardians or forced into sex work to survive. (11)

Violence During Conflict
As difficult as it may be for women who experience violence during peacetime, the challenges during conflict are even greater, as police and judicial systems crumble and health infrastructure and other services decline. Both UN Security Council Resolutions 1325 on Women, Peace and Security and 1308 on HIV and Conflict note that women and girls are disproportionately vulnerable to HIV infection during conflict and post-conflict periods. This is not only because they are frequently sexually abused by various armed groups, but because they may be fleeing their homes, may have lost their families and their livelihood, and may have little or no access to health care. Along the eastern border of the Democratic Republic of the Congo, an ongoing civil war has destroyed lives, villages and livelihoods. Now the area is thought to be on the verge of a major HIV epidemic. Some 60 per cent of the militia who roam the countryside raping, torturing and mutilating thousands of women and girls are believed to be HIV-positive, and virtually none of the women have access to services and care. (12)

Ending Violence

A boy perches on his father’s shoulders during a men’s march to protest violence against women in Cape Town, 2001.

Gender-based violence is now one of the leading factors for HIV infection. (13) Unless the link between the two is broken, it will be hard to reverse the epidemic. While the challenges are daunting, there are many models already in place that use a variety of approaches: utilizing the health-care system, human rights protection, education, legal reform and working with community groups. When the rule of law has been eroded or has disappeared, as in conflict situations, efforts are being made to offer protection and prophylaxis through humanitarian agencies. One hopeful response is the involvement of men who are working in anti-violence projects, both because it is the right thing to do, and because they understand that changing behaviour is a way to safeguard their own health.

Involving Men
Men are both instigators of violence and essential to the solution a reality that is recognized by both men’s and women’s groups in many parts of the world. In particular, men are beginning to organize effectively against violence against women by examining their own attitudes and behaviours. This is a rapidly growing movement that has been most visible in sub-Saharan Africa. It has emerged out of a concern that violence against women puts both men and women, young and old, at tremendous risk.


In Kenya, men are organizing with the support of FEMNET, a regional women’s network. In November and December 2003, under the banner ‘Men Working to Stop the Spread of HIV/AIDS’, Men’s Travelling Conferences were organized through urban and rural areas of Ethiopia, Kenya, Malawi and Zambia. Travelling in buses through the region, men stopped in towns and villages to lead debates, and discussions about how to change attitudes and behaviours. The conferences culminated in Malawi on World AIDS Day, with a commitment to expand the work into the coming months and years. (14)

In South Africa, ‘Men as Partners’ (MaP), initiated by EngenderHealth, an NGO based in New York, uses workshops to discuss gender roles and to train peer leaders. (15) The programme has expanded throughout the country and is now being used in trade unions and the South African Defence Force. MaP urges men to challenge unequal gender roles and relationships within the household. “I realized it was impossible to work around issues of gender when you haven’t started with yourself,” said one peer leader. “I started becoming a counsellor to abusive men when I was actually getting assistance for myself. It is impossible to talk about HIV/AIDS when you are not talking about domestic and sexual violence.”

Similarly in South America, several NGOs are trying to confront a subculture of male aggressiveness head on. Instituto Promundo, a Brazilian NGO based in Rio de Janeiro, identifies young men in low-income communities who are ‘more gender-equitable’ than most and trains them to become group leaders. Working with three other NGOs (ECOS and PAPAI based in other cities in Brazil, and Salud y Género in Mexico), they developed training manuals for community interventions on sexual and reproductive health, mental health, violence prevention, fatherhood and care-giving, and HIV/AIDS. The manuals have been used in workshops where the young men lead discussions on male ‘honour’, condom negotiation and sexual coercion. (16)

Expanding Health Care

Many countries, spurred by women’s rights activists, are using the health-care system as a major entry point for ending violence. When obstetricians in Nigeria were surveyed on violence against women among their patients, 99 per cent said they had managed a case of violence at some point. They estimated that about 7 per cent of their patients annually were women who had been abused, with the majority of cases involving pregnant women. In 70 per cent of the cases, the assailant was the husband. (17)

In several countries, health workers are being trained to recognize signs of gender-based violence and to provide medical care as well as counselling and referral services. Some clinics are able to offer postexposure prophylaxis (PEP).

In Brazil, health centres are a source of referrals to shelters and to peer groups such as the one run by Promundo. Médecins Sans Frontières added a rape clinic to their HIV prevention and treatment centre in Khayelitsha, South Africa (see p. 26) as a way to help their patients cope with the high levels of violence against women in the country. Within six months, 105 girls and women who had been raped visited the clinic; 75 were under 14 years of age and 37 required PEP treatment to prevent HIV infection. (18)

In many countries, health centres have been developed that offer medical attention to survivors of violence, along with counselling and legal referrals, all in one setting.

Although still small in number, they could become an important source of HIV education and treatment in the coming years.

Promoting Women’s Legal Rights

Gender-based violence is commonplace in all regions. As a result, activists over the last few decades have turned to the courts and legal system to address it. Due to their advocacy in various countries, trials and convictions for rapists have become more common, domestic violence has been criminalized, health professionals have been obligated to report violence and the police have begun to treat it as a crime. Many countries now have laws that recognize the rights of women who have been trafficked. In a few countries, marital rape has also been recognized as a crime.

These legal reforms have been supported by a human rights agenda based on a series of international conventions and agreements that recognize women’s right to live free of violence.

General Recommendation 12 of the Committee that monitors implementation of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), which had been ratified by 175 nations as of January 2004, requires signatories to take all appropriate measures to eliminate gender-based violence. These measures can include actions to end trafficking, to provide training for armed forces and police on women’s rights or to protect children from sexual abuse.

Addressing Gender Violence in Conflicts

In most conflict settings, the rule of law is virtually nonexistent.
But even under violent conditions, it is possible to provide at least a modicum of protection. International entities and NGOs are attempting to distribute emergency health kits to women in conflict zones that contain post-exposure prophylaxis, condoms and other medications that are a small but critical part of women’s health-care needs.

Refugee camps and centres for the internally displaced are also becoming sites for education and services relating to HIV. As more women take on leadership roles in camps, they have also been able to bring about changes that make the camps safer for women. Peacekeepers are also being used to provide education and raise awareness. In Sierra Leone, one of the first programmes to acknowledge the critical role peacekeepers can play in preventing HIV/AIDS and protecting women’s rights, UN peacekeepers are trained in HIV/AIDS prevention, gender awareness and peer communication. (19)

The challenge of repairing the devastation caused by violence continues long after the fighting stops. In Rwanda, ten years after the genocide, women’s support groups are the glue helping to hold shattered communities together. One of the best known of these organizations is AVEGA, which was started to serve widows of the genocide. In the early years, members were dealing with memories of rape and torture and haunted by visions of their families being slaughtered while they watched. It was only the need to support their remaining children that kept many alive. AVEGA helped them get job training, acquire land and build houses. But with time, a new crisis emerged as HIV began to appear among the widows. In one survey of 1,125 women who had survived rape during the genocide, 70 per cent tested positive. (20) Now AVEGA devotes a substantial amount of time and resources to helping women get medical support for opportunistic diseases and counselling to prepare families for the ravages of HIV. “They have such courage,” said one AVEGA officer. “The women have challenged everybody and everything.
It is the challenge of life over death.”