Gender inequality and domestic violence: implications for human immunodeficiency virus (HIV) prevention

Abstract

Domestic violence and human immunodeficiency virus (HIV) infection are problems of great public health worldwide, especially sub-Saharan Africa and much of the developing countries. This is due to their far reaching social, economic and public health consequences. The two problems have gender inequality and gender power imbalances as the driving force behind the “epidemics”. HIV infection is mainly acquired through heterosexual relations, which themselves are greatly influenced by socio-cultural factors, underlying which are gender power imbalances. Unfortunately gender relations, and gender issues in general, have not been given much emphasis in the medical perspective, especially in efforts for prevention and control of HIV infection. There is thus a need to mainstream gender relations in reproductive health. This article aims at emphasizing the intersection between domestic violence, gender inequality and HIV infection.

Introduction

The United Nations Declaration on Elimination of Violence against Women (1993) defines violence against women as “any act of gender-based violence that results in, or is likely to result in, physical, psychological or sexual harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life”. These acts include domestic violence, spousal battering, sexual abuse of female children, rape and sexual assault (including marital rape), traditional practices harmful to women (such as female genital mutilation), forced prostitution, intimidation or sexual harassment. Domestic violence is defined by the World Health Organization¹ as “the range of sexually, psychologically and physically coercive acts used against adult and adolescent women by current or former male intimate partners”

Worldwide, the majority of people infected with the human immunodeficiency virus (HIV) infection come from sub-Saharan Africa, most of infections result from unprotected sex occurring in heterosexual relationships, and women are 6 times more likely be infected than men.² Unequal power relationships render women into a subordinate position than makes them socially and financially dependent on men, with limited access to resources, finances, employment, education and healthcare.³ Where they exist, cultural, socio-economic, structural and institutional barriers reinforce marginalization of women and any co-existing gender inequality.³ Such unequal power relations increase women's risks and vulnerability to exploitation and therefore acquisition of HIV infection.⁴

The global epidemiological statistics on HIV infection point out some factors that are associated with the infection.² These include lack of financial autonomy, education or gainful employment, which force women into early sex or early marriages, at a time when the genital mucosa is at the highest risk of trauma. Others are socio-cultural beliefs and practices, such as wife inheritance and wife sharing, and masculinity, which may be associated with risk-taking social and sexual behaviour.

Poverty, which is also a risk factor for violence against women¹, is associated with HIV infection through proximate determinants, such as casual sex, multiple sexual partners and sexually transmitted infections.^2,4–6 Other risk factors for domestic violence are low socio-economic status, young age, staying with relatives or in-laws and lack of education.⁷ Interventions to control sexually acquired HIV infection have involved 3 overlapping phases.^4–6 These are mass education campaigns for populations at high risk of HIV infection, comprehensive biomedical approaches (such as treatment of sexually transmitted infections and antiretroviral therapy), and recognition of the role of contextual factors in shaping behaviour. There is a complex interrelationship of the proximate determinants of vulnerability to HIV infection.^4–6

The objective of this review of the literature was to examine the relationship between gender inequality, domestic violence and HIV infection.

Methods

Data for the review was obtained from AIDSLINE and Medline Databases, from articles published in the English language. There are 4 major areas which were investigated are represented by 4 questions:

a)	Are women with HIV infection at higher risk of domestic violence than the general population?
b)	Do women with HIV infection have higher risk factors (demographic or behavioral) for domestic violence than the general population?
c)	Is domestic violence a risk factor for HIV infection? Does domestic violence increase women's risk of HIV acquisition?
d)	Does acquisition of HIV infection or disclosure of HIV sero-status increase risk of domestic violence?

1 Are women with HIV infection at higher risk of domestic violence than the women in the general population?

The risk of domestic violence is higher among women with HIV infection than women in the general population.^8–10 Women at risk of HIV infection (where the spouse is HIV positive) or who perceive themselves to be at high risk of acquiring HIV infection from the spouse) may have higher levels of violence than the general population. Such women may be unwilling to have sexual relations with their partners, who may retaliate with physical violence or sexual coercion. Therefore a risk assessment for HIV infection should include questions on prior sexual abuse in childhood and co-existing domestic violence.

In a study conducted among 340 women who had received voluntary counseling and testing for HIV (VCCT), in which correlates of violence were estimated 3 months after the test, ¹⁰ the odds of reporting at least on violent event was significantly higher among HIV positive women than among HIV negative women (sexual violence OR = 2.39; 95%CI 1.21, 4.73; physical violence OR = 2.63, 95%CI 1.23, 5.63). Odds of reporting violence was 10 times higher among women less than 30 years.

2 Do women with HIV infection have more risk factors (demographic or behavioral) for domestic violence than the general population?

Risk factors for domestic violence and HIV infection intersect and overlap. Factors associated with domestic violence include poverty, polygamous relationships, partners' other relationships (serial or concurrent), shorter duration of the relationship, multiple sexual partners and homelessness.^1,3,7 Some of these are also risk factors for HIV infection.^2,5,6,8 Lack of autonomy, economic freedom or independence reduces women's power to negotiate safe sexual practices or even sexual relations.³ Demographic and behavioral factors associated with HIV infection (such as fear of and avoidance of sex), also increases women's exposure to violence.^8–11

3 Is domestic violence a risk factor for HIV infection? Does domestic violence increase survivors' risk of HIV acquisition?

The epidemics of violence against women and HIV tend to overlap in the social context of women's lives. Therefore, violence may be a risk factor for HIV infection.^12–16

Domestic violence may increase women's risk of HIV acquisition through forced sex, coercive sexual practices, and limiting women's ability to negotiate safer sexual practices (such as condom use).^3,17,18 Sexual violence often involves trauma to the genital tissues or anal sex, which increases infection risk. For many females, the initiation of coitus (coitarche) involves sexual coercion. Physical and sexual violence in childhood is associated with high risk sexual behaviour in adolescence or adulthood.

In the study by Maman et al,¹⁰ of 340 women attending the voluntary counseling and testing clinic in Dar es Salaam, Tanzania, the odds of having sexual or physical violence was higher among the HIV positive than among the HIV negative women, and was 10 times higher for women under 30 years. The authors concluded that violence is a risk factor for HIV infection.

4 Does acquisition of HIV infection or disclosure of HIV sero-status increase risk of domestic violence?

Some studies have shown that one of the major barriers to voluntary counseling and testing for HIV infection among pregnant women is the fear of the partner's reaction to the results, especially a positive test. Some women are subjected to domestic violence (physical or psychological) after disclosure. There is substantial evidence that acquisition of HIV infection or disclosure of positive HIV sero-status may be the trigger for violence, or may worsen co-existing violence.^19–24 Such violence is common where there is prior violence, drug abuse, poverty, discordant results and where women are younger.^19–24 The risk of violence after disclosure of positive sero-status is greatest where the partner's sero-status is negative or unknown, and where violence existed before.

Domestic violence has serious implications for prevention of mother-to-child HIV transmission (MTCT). Perceived risk of or existing violence may influence disclosure or partner notification by HIV positive women. It may also influence use of preventive measures for re-infection (such as negotiating use of barrier methods or abstinence), or choice between breastfeeding and formula feed options.^22–24 In a study from Kenya²⁵ only a third of 290 HIV infected women in an intervention study conducted to reduce MTCT in Mombasa, informed partners of their results despite prior discussion of advantages and risks. Despite counseling, 10% experienced violence or disruption of relationships.

Behavioral modifications after knowing one's HIV sero-status include abstinence, use of barrier methods, avoidance of some sexual practices (such as dry sex) and non-breastfeeding of the child (or use of formula feeds) after birth. These may increase the risk of violence for women especially where there is poor couple communication or failed negotiation.

Conclusion

Domestic violence and HIV infection are closely related. There is therefore need to:

1. Include counseling on domestic violence on the agenda of Voluntary Counseling and Testing and other HIV prevention efforts. Identification of HIV positive women at risk of abuse as routine part of counseling is likely to increase both rates of testing and compliance with recommended measures to prevent vertical HIV transmission. Counseling should include skills to avoid violence.

2. Raise awareness about domestic violence and its intersection with HIV infection. Sexual and reproductive health education often lacks discussions on gender inequalities and how these affect sexual attitudes, practices and behaviour. This gender inequality, through domestic violence, increases conditions for the spread of HIV infection and leads to barriers to client management.

3. Mainstream gender issues in Sexual and Reproductive Health and Rights training, research and interventions, as they are proximate determinants for reproductive ill-health