1. Deadly Intersection for Women HIV/AIDS & Gender Based Violence: Program Implications Deadly Intersection for Women HIV/AIDS & Gender Based Violence: Program Implications Jacquelyn Campbell PhD, RN, FAAN Anna D. Wolf Chair & Professor The Johns Hopkins University School of Nursing Jacquelyn Campbell PhD, RN, FAAN Anna D. Wolf Chair & Professor The Johns Hopkins University School of Nursing

2. Violence Prevention in Low & Middle-Income Countries: Finding a Place on Global Agenda ‘07 State of science in violence prevention – US & Global National & International participants from health, criminal justice, public policy, economic development Identified specific opportunities for U.S. gov. & other leaders with resources to more effectively support prevention of violence. Need for integrated, science-based approach & agenda to support research, clinical practice, program development, policy analysis, & advocacy for violence prevention. US Senate Hearings – 6-08 – Planning Committee: Mark Rosenberg, Chair, James Mercy, Co-Chair Sir George Alleyne, Alexander Butchart, Jacquelyn Campbell, Darnell Hawkins IOM Staff: Kimberly Scott, Senior Program Officer and Rapporteur Patrick Kelley, Board Director Paper on HIV/AIDS & Violence against Women – Campbell, Baty et al http://www.iom.edu/CMS/3783/48783/50755.aspx

3. Global Definitions Gender Based Violence (UN): Acts of violence (physical, sexual, psychological) against women and girls including intimate partner violence & dating violence, rape and sexual assault, violence against domestic workers, childhood sexual abuse, forced sexual initiation, forced marriage Intimate Partner Violence (WHO): Any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship, includes: physical aggression, psychological abuse, forced intercourse & other forms of sexual coercion, various controlling behaviors (Krug et. al. ’03) Basic issue of control of female sexuality – 40- 45% of physically abused women forced into sex & continuum of “intimacy” of partners

4. New Face of HIV/AIDS – HIV/VAW interface recognized officially by UN ‘04 Around globe women are the fastest group contracting HIV and in many settings fastest group converting to AIDS – e.g. Uganda For each 100 HIV+ males – 160 females Adolescent girls particularly affected – 10% of girls 10-14 yo vs. 3% of boys in Botswana In US – poor African American women most affected – 69% of new cases in ‘07 In Africa – women are dying the most from AIDS – 3:1 ratios – Sub-Saharan Africa – girls: 75% HIV+15-19 yo

5. Studies Showing Direct HIV-IPV connection - Africa Tanzania: Women infected with HIV significantly more likely to report physical & sexual violence with current partner than HIV negative women (OR 2.42, 95% CI 1.20-4.87; OR 2.39, 95% CI 1.21- 4.73) [Maman et al. ‘02] South Africa: IPV (OR 1.48, 95% CI 1.15-1.89) associated with HIV seropositivity, after adjustment for age, current relationship status & women’s risk behavior. [Dunkle et al ‘04] Kenya: HIV positive women significantly more likely to have experienced physical partner violence in ifetime (OR 1.8 95% CI 1.1-2.8)[Fonck et al ‘05]

6. Studies Showing Direct HIV-IPV connection India – IPV as both risk factor and risk marker– Decker et al, J AIDS‘ ’09 – male perpetrators of IPV – increased HIV+ (AOR 1.94); wives of IPV perpetrators increased risk of HIV+ (AOR = 7.04) –adjusting for other risk behaviors US – National Survey – IPV increased HIV+ by AOR = 3.44 – General Hospital Psychiatry – ‘09

7. HIV/DV Connections – Etiology (Maman et al ’99; Campbell et al ‘08) Immune system suppression with stress – CD4 counts dropping? Trauma of forced sex increasing HIV transmission; anal sex Increased STD’s & untreated STD’s (Johnson ‘02) Impossible to negotiate safe sex if a battering relationship Women accused of infidelity if want to use safe sex Males have other partners unknown to women (WHO multicountry study ’04) Fear of being beaten for being tested; notifying partner of positive status; delay in treatment Substance abuse – self medication for PTSD

8. Accepted Best Practices for Prevention of AIDS A = Abstinence B = Be Faithful C = Use Condoms

9. Forced First Intercourse (WHO Multi- Country Study) WHO Multi-country study 3-30% sexual initiation physically forced – 11-45% among those whose sexual debut <15 years US – 12.4% - Stockman ‘08 25% of those sexually active <14yo MSM – Relf ’03 & high risk behavior

10. B. “Be Faithful” Women at risk – heterosexual married women with no behavioral risk factors Issues of forced anal sex – stigma & shame but increasing trauma and risk of transmission Husbands are Having sex with other women without wives’ knowledge Forcing them to have unprotected sex – women trying to refuse b/c know they have other partners &/or perceive them to be at high risk for HIV (Koenig et al ’04- 24% of women in Uganda - forced sex from partner)

11. Evidence of HIV/VAW Intersection US studies showing IPV & more HIV risk behavior (Cohen ’00; Gielen et.al.’02; Burke ’05) or victim of CSA Women: Wyatt ‘00; Laughon ’01; Whetten ‘06 Men: Greenwood, Relf et. al. AJPH ‘03 Qualitative studies - Near impossibility of negotiation of condom use with abusive partner (Champion & Shain ’98; Davilla & Brackley ’98; Laughon, in press; Stevens & Richards 98’; Zierler & Krieger ‘97)

12. Adolescents – GBV & HIV risk Adolescent girls saying they are afraid to insist on using a condom – “He’ll either hit me or quit me” (Loretta Sweet Jemmott, ‘08) Girls “taking the pledge” but thinking that oral and anal sex – “not sex” 6 US studies of adolescents – less or inconsistent use with IPV (Teitelman et al – J of HIV/AIDS Prev in Child & Youth ‘07) In SA - national survey – 15-24 yo women who experienced forced sex – inconsistent condom use (X6) (Pettifor et al ‘04 ).

13. IMMUNE SYSTEM EFFECTS HPA axis – hypothalmic – pituitary – adrenal gland interactions Stress of abuse, multiplied by poverty, other stressors – but even separate from other stressors - activates HPA & produces corticosteroids & catecholamines Suppresses T1 cell cytokines (fights bacteria & viruses) production Depression has same effects on immune system  Total Mitogen Response with  depression in battered women (Constantino, et al., 2000) Lowered immunity to HIV? Or quicker reduction of CD4 counts? – some evidence in Uganda – even non pregnant women (Gray et al ‘09)

14. In Spite of Evidence – Need for Collaborative Research Most HIV research does not measure IPV Or measures IPV incompletely – DHS vs. WHO protocol Or does not address physiological issues related to GBV M ost IPV research does not address forced sex separately & lacks context around forced sex Continued mystery as to why women infected more than men in official policy circles Issues with CD4 count poorly understood Girls often left out of discussion – focus on adult women

15. Even with all the evidence Most HIV prevention programs do not include addressing IPV – men & women &/or evidence lacking – EXCEPT (& situation improving!) Sweet-Jemmott – adolescent girls – “Sisters Saving Sisters” & “Sister to Sister” – 20 min for adult women – but IPV not explicit or measured (afraid “he will hit me or leave me”) Wingood & DiClemente ’06 – but not explicit content & no IPV measurement - Teitleman Stepping Stones – Jewkes et al ’06 – South Africa - significant improvement in IPV reduction but not in HIV prevention – but male IPV & hi risk sex related El Bessel & colleagues – NYC – substance abusers – male & female Maman intervention for young men - Tanzania

16. Issues with PEP – Protocols & Adherence Transmission rates from rape unknown – guidelines in US problematic – PEP not being offered Promising telephone intervention post rape – Abrahams ‘09 in SA Encouraging women through side effects Rape trauma processing Develop evidence base for PEP protocols – 3 day starter pack w/follow up Thuthuzela Center in CT, SA

17. Other Promising Interventions in HIV & Violence Prevention - & Issues IMAGE microfinance & IPV prevention program – including mobilization of women (Pronyk….Watts et al’06) In some locales may increase violence against women (e.g. Pakistan – Koenig) Needs to include HIV prevention & violence prevention content CHAMP program in US & SA – Bhana & Bell – community protective, increasing resilience for HIV & violence prevention – but VAW specific component missing “Raising Voices” – community programs to change norms around gender & IPV – Uganda

18. Interventions for Abused Women Remember most abused women still want the relationship - & may want to get pregnant Prenatal care – “window of opportunity” Need to address physical and mental health (beyond immediate injury/crisis) as well as providing justice, empowerment, violence reduction & HIV prevention or treatment Healing from trauma – truth & reconciliation type processes – Rwanda – Native American – community justice type approaches – Koss Physical health interventions to address immune system compromise – anti-inflammatory agents?

19. Changing Norms - Getting Men Involved (“Masculinities”) (www.endabuse.org) “White Ribbon Campaign” – Canada HIV testing & counseling programs for men – Tanzania - Maman Teaching recruits in the military – “Tough Guise” Jackson Katz Prisoner re-entry programs – Oliver Williams “Soul City” & Sonke Gender Justice – “One Man” campaign Dean Peacock – South Africa - FIFA Promundo – Brazil – Gary Barker