Gender-based Violence and HIV
Gender-based violence (GBV) is a major problem throughout the world, and the intersection between HIV and GBV is widely acknowledged. Because of the association between these two topics, reducing GBV is one of the five gender strategies promoted through the U.S. President’s Emergency Plan for AIDS Relief.
The purpose of this technical brief is to assist HIV program planners and implementers in designing, planning, and implementing activities that integrate GBV and HIV prevention, treatment and care, and support programs.
Visit our Technical Brief Series page to see other recent publications.
Gender-based violence (GBV) is a major problem throughout the world. It includes sexual, physical, emotional, and financial abuse; structural discrimination (institutional structures that result in disparities or stigmatization in services); state-sponsored violence (i.e., persecution of sex workers, men who have sex with men, women living with HIV); and trafficking of women and girls. GBV primarily affects women and girls, but men, boys, and gender minority communities are also impacted.The prevalence of GBV globally varies considerably. A 2005 multicountry study by the World health Organization (WHO) found prevalence of lifetime physical violence ranged from 13 percent in Japan (city statistics) to 61 percent in Peru (provincial statistics) (García-Moreno et al. 2005).
Reducing GBV is one of the five gender strategies promoted through the U.S. President's Emergency Plan for AIDS Relief. The purpose of this technical brief is to assist HIV program planners and implementers in designing, planning, and implementing activities that integrate GBV and HIV prevention, treatment and care, and support programs.
The intersection between HIV and gender-based violence (GBV) is widely acknowledged (Ertürk 2005; García-Moreno et al. 2005; Guedes 2004; Harvard School of Public Health 2006), with an increased risk of HIV for women experiencing GBV increasingly documented (Dunkle et al. 2004; Maman et al. 2002). However, there is a limited evidence base on GBV programs and services, and even less on those that integrate HIV and GBV.
The brief is informed by 1) a review of the most recent research findings on the intersection of GBV and HIV,(1) 2) promising practices documented in the program literature,(2) and 3) telephone interviews with select program implementers.(3) The GBV/HIV Program Implementer's Wheel(4) (Figure 1) is a model that summarizes the strategies and activities discussed most often in the literature as necessary for an effective response to mitigate GBV with particular attention to the context of HIV programs. It includes the following:
- Multi-sectorial approaches that integrate across justice, health, education, economic, social service, and other sectors (the two outer rings of the wheel)
- Strategies for multi-level impact at the individual, family, service provider/organization, community, and national levels, framed by an enabling environment that includes political will, financial commitment, capacity building, advocacy, changing gender norms, and challenging stigma (inner circles of the wheel)
- Multiple interventions (spokes of the wheel), including a human rights framework that includes developing laws, policies, and programming; promoting women's economic security; empowering girls and women; challenging gender norms, roles, and behaviors; providing life skills education; providing services for survivors of GBV; training health care workers, counselors, police, and others; using mass media; increasing community awareness, outreach, and mobilization; and providing face-to-face education.
The wheel uses an ecological model (Heise 1998) that considers multi-level causes of GBV (including individual, contextual, institutional, and macro-systemic) (Ellsberg et al. 2008; Ertürk 2005; Ferdinand 2009; Guedes 2004), theories about the central role gender constructs and power relationships play in perpetuating GBV (Connell 1987; Courtenay 2000), social cognitive theory that demonstrates the role of individual and collective efficacy (the ability to reach goals and create change) in achieving transformation of gender norms (Bandura 1997), and an understanding that multiple interventions are needed with more effective programs integrating more than one program component (Barker, Ricardo, and Nascimento 2007).
The GBV/HIV Program Implementer's Wheel can help program implementers identify strengths as well as gaps within a particular social context for addressing GBV and HIV. It can be used as a tool to guide local, regional, or national strategic planning, although it is not meant to be exhaustive or definitive for every situation. A situational analysis that includes stakeholder consultations should be conducted to learn what is currently working within a context, what gaps are most pressing, and what additional needs may be present. All stakeholders, including women and men, should be part of the analysis. To ensure that a concern for the safety and confidentiality of women and girls remains central to the approach, it is important to engage them in all aspects of program planning, implementation, and evaluation (see Box 1).
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Mechanisms to Affect Integration Across Sectors and Programs/Services
BOX 1: DO NO HARM
"Do no (further) harm" is a central mandate in work relating to GBV. Safety of those affected by violence is culturally and context-specific. Participatory planning approaches that engage women in planning, implementing, and evaluating interventions should be used to address these issues.
Mechanisms to affect integration of programs, services, and advocacy across sectors and among traditionally fragmented HIV or GBV programs and services include a wide range of activities.The evidence base for these activities includes higher numbers of women served, legislation, funding, and effective mobilization of social capital.
Promising practices include the use of coordinating councils, coalitions, and similar mechanisms that bring together broad spectrums of stakeholders and program implementers, including nongovernmental organizations (NGOs), community-based organizations, faith-based organizations, government agencies, health and legal/judicial providers, and others. In the United States, diverse coalitions worked to pass the initial Violence Against Women Act (VAWA) of 1994 (reauthorized in 2000 and 2006). VAWA of 1994 provided $1.6 billion in funding and institutionalized grassroots efforts across the justice, health, and service delivery sectors.
While political will and financial commitment are required at the macro level, harmonization and programmatic integration are also required at the organizational level. Promising practices include joint training, budgeting, policies, programs, alliance building, and advocacy.
The Civil Resource Development and Documentation Center, a Nigerian NGO, in partnership with the Ministry of Women's Affairs and Social Development is implementing "Bridges to End Gender Based Violence—a Strategy for HIV/AIDS Prevention and Stigma Reduction" in two states with support from the U.N. Trust Fund to End Violence Against Women (U.N.Trust Fund). The project provides training, capacity building, and advocacy to key stakeholders in multiple sectors (including health, legal, justice, and mass media) to strengthen an understanding of the intersections of GBV and HIV, the rights of those impacted, obligations of the various sectors to meet women's needs, and the role each can make in creating social change.The project utilizes the "Mutapola Framework," a rights-based, woman-centered approach(5) that includes strengthening and building capacity and confidence among women to report cases with relevant legal sector actors, and to hold service providers accountable for their obligations with respect to violence against women (VAW). Service providers who have participated in the Mutapola training subsequently conduct training of trainers within local communities. combined capacity development workshops for women living with HIV, service providers, and community leaders foster responsibility and create an enabling environment for women to access meaningful HIV and VAW services.
SASA! A FILM ABOUT WOMEN, VIOLENCE, AND HIV/AIDS AND DISCUSSION
SASA is Kiswahili for "now."
Start--thinking about the connections between violence against women and HIV (use your power within)
Awareness--raise awareness (about men's power over women)
Support--women, men, and activists (join your power with others)
Action--take action (use your power to create change)
This 30-minute documentary (or short 6-minute version) is an education and advocacy tool to stimulate awareness, support, and action around the power imbalances that fuel gender inequity.
The guide provides discussion questions and specific Awareness, Support, and Action ideas for the following multi-sectoral audiences: teachers and parents, police, health care providers, religious leaders, counselors, NGOs, policymakers, and donors.
The film is one of many programs and tools produced by Raising Voices
Source: SASA! 2007
Integrating Gender-based Violence in Health Care Settings
While there has been little rigorous evaluation of efforts within health care settings (Ellsberg 2006), there is agreement that a systems approach should guide efforts to improve the health care response to GBV (Bott, Morrison, and Ellsberg 2005; Guedes, Bott, and Cuca 2002; Heise, Ellsberg, and Gottemoeller 1999; Interagency Gender Working Group of USAID 2002). A WHO multi-country study demonstrated a statistically significant connection between women who experience violence and compromised physical and mental health (García-Moreno et al. 2005). Studies also indicate that many women who experience GBV seek health care for injuries but do not report the abuse (Population Council 2006). Women who experience GBV are at increased risk of HIV (Dunkle et al. 2004; WHO 2006), making disclosure a significant issue for prevention. Primary health care, reproductive health, and HIV counseling and testing services are all entry points for responding to HIV and GBV.
A 2006 WHO consultation, “Addressing Violence Against Women in HIV Testing and Counseling,” concluded that awareness of the links between HIV and GBV must be increased at different levels—including health care providers, government health officials, counselors, and others. Additional recommendations are for further research and for tailoring counseling and testing strategies to needs of women in violent relationships (WhO 2006).
Integrating Responses to Gender-based Violence in Multiple Sectors
The Thohoyandou Victim Empowerment Programme (TVEP) is a rights-based program that works across justice, health, education, and social service sectors to address all forms of sexual assault, domestic violence, child abuse, and AIDS prevention and stigma mitigation in the Thulamela Municipality of South Africa. Among its many programs are two 24/7 Family Violence and Sexual Abuse Trauma Centres, located at a regional and at a district hospital. The hospital center works in partnership with the Thutuzela Care Centres, which staffs the program during regular business hours while TVEP staffs the program after-hours. The 24/7 centers provide access to police, counseling, medical exams and treatment, case management, court chaperones and on-site support to children, referrals to civil society, and transport subsidies. Among the achievements is a 65-75 percent completion rate of HIV post exposure prophylaxis (PEP), a result attributed to the follow-up provided through home visits conducted on the third day after the incident was reported, and the allocation of one victim advocate to “buddy” each client for the duration of the trial. (Click here for more information).
Mechanisms to Affect Multi-level Impact
A comprehensive strategy to address GBV and HIV includes mechanisms to bring about multilevel impact at the individual, family, service provider/organization, community, and national levels, affecting individual behavioral, as well as social and political structural change. Evidence indicates that it is the combined effect of impacting each level that brings about social change (Solórzano et al. 2008; Usdin et al. 2005).
Political will, financial commitment, advocacy, building capacity, challenging stigma, and changing gender norms are part of an enabling environment that drives and supports these impacts. The 2008 U.N. General Assembly Special Session on HIV/AIDS report states that while more than 80 percent of national governments report a focus on women as part of their multi-sectorial strategy for HIV, only 52 percent report that a budget is allocated for programs dedicated to women's issues (Ferdinand 2009).
In South Africa, the Soul City Institute for Health and Development Communication developed a multimedia health promotion program featuring the use of primetime radio and television dramas (edutainment) and print information to create social change. Soul City 4, the fourth in an edutainment series, focused on domestic violence in partnership with the National Network on Violence Against Women. It is credited with promoting dialogue at the interpersonal and community level and creating an enabling environment that supports individual efficacy, as well as community action and advocacy, ultimately effecting passage of a national law on domestic violence. A rigorous evaluation demonstrated increase in knowledge, positive attitudes (10 percent increase in those who disagree that domestic violence is a private matter), shifts in social norms, and increases in women's sense of self-efficacy (Usdin et al. 2005).
Key Intervention Strategies
While contexts vary considerably by region and country, the literature suggests that the following strategies are significant in any plan to mitigate GBV. These are particularly relevant within the context of HIV prevention, treatment, and care and support programs. An individual program may address one or more of these areas, and multiple efforts are often required to achieve widespread impact relating to each component. Some evidence indicates that integrating multiple approaches to HIV prevention is more effective than single-approach strategies. This includes combining behavioral (i.e., building condom negotiation skills), biomedical (increasing access to emergency HIV prophylaxis), and structural (developing laws and policies that positively impact gender norms) approaches (Barker, Ricardo, and Nascimento 2007; Coates, Richter, and Caceres 2008). In addition, effecting both individual and collective efficacy through methods that generate interpersonal and community dialogue are aspects of many programs that achieve results.
A Human Rights Framework Including Laws, Policies, and Programming
A human rights framework includes underlying principles that all people have the right to live without stigma, discrimination, and violence, and with self-determination. This framework is significant in framing laws and policies to protect the legal rights of women and of people living with HIV, providing justice to those whose rights are violated, and guiding programming. Participating in international campaigns relating to HIV and GBV is an effective strategy for garnering broad support for a human rights framework, as well as promoting awareness and general knowledge. International Women's Day (March 8), International Women's Human Rights Defenders Day (November 29), the 16 Days of Activism against Gender Violence (November 25 to December 10), and World AIDS Day (December 1) are examples of campaigns that can highlight GBV and HIV.
Activities and programs to strengthen a human rights approach to HIV and GBV include:
- Developing and implementing laws, policies, and procedures for national, regional, and local levels that set minimum standards and impose penalties for failure to adhere to them
- Training police and members of judicial systems to provide knowledge and skills and to transform gender norms and attitudes that contribute to stigma and discrimination
- Raising awareness of laws and the rights of women and other marginalized groups
- Providing advocacy and support for those trying to navigate complicated justice systems
- Ensuring funding mechanisms and budgets to support implementation of laws and policies
- Supporting watchdog groups to report abuses within legal systems.
Women's Economic Security
Studies have shown that women who have economic independence have higher levels of agency, allowing them to leave a relationship if needed, to make financial decisions that can alleviate or prevent poverty, and to pay for health care and services for themselves and their families (Drimie 2002; Vyas and Watts 2008). A World Bank study used empirical data from the developing and developed world to demonstrate links between gender inequality, poverty, and higher HIV rates. The study concluded that gender equity is a core development issue that is associated with overall economic growth, productivity, and quality of life (King and Mason 2001).
A review of the evidence-based literature on how economic empowerment affects women's risk of GBV reveals a complex landscape. Published data from 41 locations in 22 countries indicated that ownership of household assets and women's higher education were generally protective; however, whether a woman's involvement in income-generation activities provided protection or added risk was context-specific (Vyas and Watts 2008). Findings support the need to build women's economic independence and security, as well as the importance of safety planning and services to address violence in participants' lives. Promoting women's economic security may also mean building both a woman's and her partner's capacity for income generation (see also AIDSTAR-One's Technical Brief on Microfinance and Economic Development).
An early ethnographic study that looked at whether microcredit programs for women in Bangladesh exacerbate VAW concluded that risk of violence could be both decreased and increased. Because of the pervasive nature of VAW in Bangladesh, the authors suggest that programs addressing economic security also offer good opportunities for interventions targeting the violence. In addition, they state that when women reached a high level of economic independence from men domestic violence tended to stop (Schuler, Hashemi, and Badal 1998). An interesting point is that women did not report wanting the microcredit program to stop because of increased violence, when this was the case.
Girls' and Women's Empowerment/Agency
Girls and women's empowerment is central to HIV and GBV prevention and mitigation. A woman's sense of agency influences her ability to ask a partner to use a condom, to avoid and leave violent relationships, to provide appropriate child care and support, and to seek health care and/or other services. Fundamental means of empowering girls and women include formal education, knowledge of legal rights and advocacy skills, representation in law-making and other decision-making bodies at all levels, and participation in the justice system.
A World Bank publication dedicated to measuring empowerment includes a framework that can be used to develop context-specific indicators of women's empowerment (see Resources section). The framework addresses multi-level aspects (household, community, and broader arenas) for economic, social and cultural, legal, political, and psychological components of women's empowerment (Malhotra and Schuler 2005).
Challenging Gender Norms, Roles, and Behaviors
BOX 2: RATING PROGRAMS BY THEIR ATTENTION TO GENDER
Gender Transformative--seeks to transform gender roles and create gender equity in relationships.
Gender Sensitive--recognizes that gender is socially-constructed and is attentive to special needs based on gender.
Gender Neutral--does not address gender; in a positive or negative way.
Source: Barker; Ricardo; and Nascimento.
There is increasing and overwhelming evidence that challenging and transforming gender norms, roles, and behaviors is an essential aspect of addressing HIV and GBV and requires the active engagement of men and boys (Barker, Ricardo, and Nascimento 2007).
A review was conducted of 58 evaluation studies of interventions with men and boys addressing sexual and reproductive health/HIV; fatherhood; GBV; maternal, newborn, and child health; and gender socialization. Gender-transformative interventions (see Box 2) had a higher rate of effectiveness (41 percent of the 27 programs meeting this criterion were rated effective versus 29 percent of the total of 58 interventions studied) (Barker, Ricardo, and Nascimento 2007).
Programs were divided into the types of intervention activities used including group education; service-based (health or social services); community outreach, mobilization, and mass-media campaigns; and integrated (use two strategies). Of the 17 programs rated "effective" in producing behavior change, 47 percent used integrated approaches; 30 percent used community outreach, mobilization, and mass-media campaigns; 12 percent used group education; and 12 percent were service-based (Barker, Ricardo, and Nascimento 2007).
Sonke Gender Justice Network (Sonke) has programs throughout Africa to strengthen government, civil society, and citizen capacity to support men and boys to promote gender equality, prevent domestic and sexual violence, and reduce the spread and impact of HIV and AIDS. Sonke programs use multiple approaches, reach multiple levels, and work across sectors. An example of a Sonke project is "Brothers for Life," featured in Box 3.
BOX 3: BROTHERS FOR LIFE CAMPAIGN
A national campaign in South Africa engages men over 30 years of age to become positive influences in their communities as men, partners, parents, and leaders, addressing issues that put men at risk for HIV.
The campaign uses:
- Mass media, including print media, television, radio, dramas, talk shows, and text messaging.
- Community mobilization, using community events, entertainment venues, sports activities, places of worship, and workplaces for dialogue, education, and role modeling.
- Multi-level approaches, including community dialogues, face-to-face education, awareness raising activities, and advocacy.
Multi-sectoral partners include:
- Johns Hopkins Health and Education in South Africa
- South African National AIDS Council
- Sonke Gender Justice
- The Department of Health, USAID/PEPFAR
- The U.N. System in South Africa
- University of Pretoria Centre for the Study of AIDS and RHRU: Reproductive Health and HIV Research Unit of the University of Witswaterand
- Over 20 civil society partners.
Source: Brothers for Life
BOX 4: STEPPING STONES: A GENDER TRANSFORMATIVE HIV PREVENTION INTERVENTION
Focused on improving health by developing more gender-equitable relationships with better communication between partners, Stepping Stones is replicated in over 40 countries and translated into at least 13 languages.
The program's key strategies include:
- Participatory learning approaches (role play, drama, critical reflection)
- Peer facilitators who are the same sex and slightly older
- Thirteen three-hour sessions
- Three peer group meetings on a range of life-skills topics
- Delivery primarily in schools to groups over several weeks
- Community involvement.
An impact evaluation demonstrated that Stepping Stones was effective in improving knowledge, skills, attitudes, and self-efficacy in areas related to risk reduction and in male gender norms and behaviors associated with GBV.
Life skills, including goal-setting, decision-making, communication, assertiveness, and negotiation skills, can prevent and mitigate relationship violence and promote safe sex. Good practices for life skills emphasize the use of participatory methods that encourage reflection and dialogue as critical aspects of behavior change. Life-skills training should acknowledge the power dynamics that may make it difficult or impossible for girls and women to use these skills in protecting themselves in some situations.
Stepping Stones (featured in Box 4) is a life-skills intervention that was determined effective after rigorous evaluation. Developed in Uganda, Stepping Stones is now replicated around the world (Jewkes et al. 2007).
More research is needed to understand how women who remain in violent relationships can protect themselves from HIV. A program that has demonstrated some success is Project Future Is Ours, a life-skills intervention that promotes condom usage. In the formative research phase for the intervention, a group of women who had experienced physical abuse in the previous year were identified and provided a targeted life skills intervention. The program featured eight two-hour participatory sessions where women had opportunities to share relationship experiences, values, and feelings. A two-hour booster session was provided seven months later. Five months post-booster, women reported significantly fewer unprotected vaginal or anal intercourse occasions and a greater proportion of condom-protected occasions than women in the control group. There was no impact (positively or negatively) on the abuse among women who were able to negotiate safer sex (Melendez et al. 2003).
It is imperative that a safety planning component be part of any intervention working with women in abusive relationships.
Services for Victims/Survivors
Services for victims/survivors of GBV may include safety planning, crisis intervention (shelter and hotline), legal services, support groups, counseling, transitional housing, and advocacy services to assist women in accessing community-based services.
A "minimum package of services" for victims/survivors has not been defined in the global arena; however, there is a growing demand for such a definition. In addition, there is little research outside of the United States about the effectiveness of service-provision.
In many countries, women's abilities to use services such as hotlines or shelters are limited. A situational analysis, conducted in partnership with women, will help identify services that are most needed and appropriate. Findings from projects such as the International Planned Parenthood Federation, Western Hemisphere Region (IPPF/WHR) indicate that low-cost services such as support groups can be helpful to women even when specialized services are not available (Bott et al. 2004).
Training for Health Care Workers, Counselors, Police, Courts, and Others
BOX 5: PROFAMILIA IN THE DOMINICAN REPUBLIC, INPPARES IN PERU, AND PLAFAM IN VENEZUELA
Launched in 1999 by Latin American affiliates of IPPF/WHR to integrate GBV into sexual and reproductive health searvices.
- The number of providers who felt sufficiently prepared to support clients rose significantly:
- Talk about violence (from 19 to 61 percent)
- Identify physical violence (from 47 to 80 percent)
- Identify childhood sexual violence (28 to 48 percent)
- Attend cases of GBV (20 to 57 percent)
- Counsel about emergency contraception (NA to 96 percent).
- Reduction of barriers to asking women about violence:
- Cultural divide between client and provider (61 to 32 percent)
- Fear of offending client (53 to 29 percent)
- Not enough community resources (51 to 34 percent)
- Private space (34 to 13 percent)
- Can do little to help (30 to 20 percent)
- Time constraints (30 to 27 percent)
- Other priorities more important (20 to 8 percent)
- Significant changes in attitudes that blame victims rather than perpetrators.
Source: Bott et al. 2004
Targeted training of professionals who interact with those impacted by GBV and HIV has been a critical aspect of engendering social change. Training generally provides information, knowledge, and sensitization as a first step in changing norms, attitudes, and behavior, as well as the technical skills needed to implement a range of services and support to women. Key elements of training to integrate GBV and HIV include:
- Using participatory, interactive, experiential approaches with opportunities for reflection
- Using cross-training on GBV and HIV
- Engaging survivors of GBV and people living with HIV
- Being relevant to the local context
- Using peers where possible for training, mentoring, and/or coaching
- Using a pre-assessment of knowledge, skills, and attitudes to finalize the training content.
Latin American affiliates of the IPPF have integrated GBV into reproductive health services in targeted countries (see Box 5). The project design features two days of sensitization training for every employee, and three days of skills training for all professional staff. An essential component of training is role-plays to help providers overcome fears of raising issues that cannot be "fixed." Other important components include the development and use of a GBV screening tool; development of a GBV referral network; revision of service protocols to address patient confidentiality; and the provision of at least basic services in-house (crisis intervention, legal, counseling, support groups) to complement referrals. Connections with community advocacy efforts give health care workers a vehicle to create institutional changes, even when, at times, there is little they can do for patients. Institutional transformation and commitment is essential, as is monitoring and evaluation to provide input for continual improvement of the program (Bott et al. 2004; Guedes, Bott, and Cuca 2002; Population Council 2006).
Community Awareness, Outreach, and Mobilization
Community awareness, outreach, and mobilization efforts include a broad range of activities, from local awareness events to edutainment using primetime television and radio. While information-only interventions may be limited in effectiveness, efforts that engage individuals emotionally as well as intellectually, while promoting broad social change at the community level, are among the most effective strategies. The following are aspects of promising community awareness and mobilization program practices that have been effective in changing gender norms (Barker, Ricardo, and Nascimento 2007):
- Use positive, affirmative messages showing that change was possible and what was needed to make change
- Use extensive formative research to develop and test messages and to identify effective and relevant media in consultation with target populations
- Include those who have influence and/or power in communities, including celebrities, religious leaders, and sports figures who already made desired attitudinal and behavior changes
- Conduct campaigns that last at least four to six months.
Edutainment is the core component of interventions such as Somos Differentes, Somos Iguales (SDSI), profiled in Box 6, and Soul City; both used evidence-based practices addressing GBV and HIV (Solórzano et al. 2008; Usdin et al. 2005).
Additional key elements of mass media approaches include(6):
- Production quality meets local standards.
- Broadcast medium and timing are well thought-out and context-specific. For example, a serial radio show targeting fathers has to be on a station at a time fathers are likely to be listening.
- Sensitive information is presented in a way that breaks the silence on taboo topics, while keeping the viewing audience engaged.
- Messages engage individuals at a personal level first, working outward to promote social change.
BOX 6: SOMOS DIFFERENTES, SOMOS IGUALES (SDSI)
A program of Puntos de Encuentros in Nicaragua
The program features multiple program-related components including a human rights framework; extensive use of mass media through edutainment; face-to-face education including group and peer education; community outreach, awareness, and mobilization; training; empowering women and youth; and changing gender norms. Elements include:
- Sexto Sentido, a weekly "social soap" television series that introduces sensitive topics into the home, and Sexto Sentido Radio, a lively nightly radio call-in show hat discusses and debates issues from the TV series
- Youth leadership training and capacity building that promote skills and alliance-building across different groups
- Participation in and coordination with national and local youth groups and coalitions
- Coordination with national and local journalists and media outlets and with young communicators
- Development and distribution of support materials, resource packs, and thematic campaigns
- Coordination with youth organizations and leaders in other Central American countries
- Ongoing monitoring and evaluation.
- Increased interpersonal communication on SDSI issues (including HIV and GBV), equitable gender norms, knowledge about HIV, use of HIV services, and reduced stigma
- Strengthened leadership, increased alliances, and increased open dialogue on taboo subjects
- Increased collective efficacy (meaning confidence that friends, family, and immediate community can organize and take action) related to domestic violence and HIV.
Source: Solórzano et al. 2008.
Face-to-face education, including small group education and peer education, is another component of many effective interventions. Small group education uses principles similar to those applied in life skills and training. Key elements of peer education include the following (Population Council 1999):
- Integrates with other interventions, including services that will be needed (i.e., for condoms, counseling and testing, and other health services)
- Carefully selects, trains, and re-trains peer educators
- Addresses gender differences and inequalities that affect sexuality and HIV transmission and mitigation
- Sets realistic behavior change goals that reflect challenges faced by participants and meets participants where they are in the process of change
- Involves key stakeholders
- Plans for sustainability—peer educator programs can be expensive to maintain training, supervision, and support for activities.
Men as Partners (MAP), a joint project initiated by EngenderHealth and Planned Parenthood Association of South Africa, works around the world addressing gender inequity using a range of approaches. Group education (workshops of 20 participants, lasting four to five days for a total 35 hours) is a core activity to engage men in reducing GBV in connection with sexual and reproductive health, including HIV. Workshops are facilitated by carefully trained facilitators using participatory techniques to explore gender norms. Collaborations with NGOs and engagement by participants in community action teams are significant aspects of supporting and sustaining individual change in knowledge, attitudes, and behaviors achieved in workshops. In 2002, a quantitative evaluation was conducted to measure the impact of this workshop methodology on men's reproductive health knowledge, attitudes, and behaviors. The study showed that MaP was effective three months post-intervention in several arenas. Knowledge about how HIV is transmitted increased from 26 percent pre-workshop to 45 percent three months after the workshop. Positive attitudinal changes related to male and female gender roles and sexual violence included a change from 61 percent of participants before the workshop who agreed that women's "sexy" dress invites rape, to 82 percent of participants who disagreed with this statement three months after the workshop (Peacock and Levack 2004).
There are many challenges in integrating activities to mitigate GBV within the context of HIV prevention, treatment, and care and support programs. As noted above, while gender is widely discussed as an important consideration in national and local planning, there is limited political will or commitment compared to what is needed to operationalize and adequately fund many of the strategic plans that already exist. Gender analysis of the impact of programs and program activities before or during program implementation is still relatively rare.
Needs include organizational capacity building, infrastructure development, expansion of services, and training. Monitoring and evaluation is needed to document promising practices appropriate for scale-up and replication in other settings, and replicated practices need to be studied in new settings to determine whether they remain effective.
Questions for future research include:
- How can access to HIV prevention, treatment, and care and support programs best be provided for women experiencing violence in their relationships without increasing women’s risk of GBV?
- What indicators can best measure effective program activities that reduce GBV among women participating in HIV programs? A set of standardized indicators is needed across programs and should include indicators that monitor changes in self-reported attitudes and behaviors and that triangulate data provided by men, for example, with women partners (Barker, Ricardo, and Nascimento 2007).
- Given the context-specific nature of GBV, can effective activities be successfully replicated regionally and/or globally? Among the challenges for this research is the costly nature of rigorous evaluation. Programs that have invested in these evaluations during their pilot stages will need funding to replicate the research as well as the intervention in additional locations.
- What additional community entry points can be identified to transform gender norms and roles? The growth of programs to engage boys and men at the community level is encouraging. Further research is needed to identify approaches to address the institutionalized gender norms that perpetuate gender bias at political, institutional, and organizational levels.
Manuals andTools for Integrating HIV/Health and GBV
- The ACQUIRE Project/EngenderHealth and Promundo. 2008. Engaging Boys and Men in Gender Transformation: The Group Education Manual, Engaging Men in HIV and AIDS at the Service Delivery Level: A Manual for Service Providers, and Engaging Men at the Community Level.
- The Interagency Gender Working Group of USAID. 2006. Addressing Gender-based Violence through USAID’s Health Programs: A Guide for Health Sector Program Officers. Washington, DC: USAID.
- Bott, S., et al. 2002. Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health.
- International Planned Parenthood Federation. 2000. Tools for Service Providers Working with Victims of Gender-Based Violence.
- Promundo. Program H Kit: Manual & Video for Working with Young Men.
- Raising Voices, SASA! An Activist Kit.
- Raising Voices, SASA! 2007. Film and Screening Guide.
- Soul City Institute.
- Stepping Stones, “A Training Package on Gender, Communication and HIV.”
- UNIFEM. 2008. Development Connections: A Manual for Integrating the Programmes and Services of HIV and Violence Against Women.
Women’s Empowerment: Framework for Measurement
- Malhotra, A., and S. R. Schuler. 2005. “Women’s Empowerment as a Variable in International Development.” In Measuring Empowerment: Cross-Disciplinary Perspectives, Ed. D. Narayan, 71–88. Washington, DC: The World Bank.
Reviews and Analyses of Interventions
- AIDSTAR-ONE. Good and Promising Programmatic Practices (G3Ps).
- Barker, G., C. Ricardo, and M. Nascimento. 2007. Engaging Men and Boys in Changing Gender-based Inequity in Health: Evidence from Programme Interventions. Geneva: World Health Organization, Promundo.
- Guedes, A. 2004. Addressing Gender-Based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis. Washington, DC: LTG Associates, Inc. and Social & Scientific Systems, Inc. for USAID Interagency Gender Working Group (IGWG).
- Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. 2008 Compendium of Evidence-Based HIV Prevention Interventions. DevTech Systems, Inc. & Centre for Educational Research and Training.
- USAID. 2006. The Safe Schools Program: Quantitative Research Instrument to Measure School-Related Gender-Based Violence.
- International Center for Research on Women, Integrating Multiple Gender Strategies to Improve HIV and AIDS Interventions: A Compendium of Programs in Africa, 2009.
- Rottach, E., S. R. Schuler, and K. Hardee. 2009. Gender Perspectives Improve Reproductive Health Outcomes: New Evidence.
Effective and Replicable Practices
These programs have had rigorous evaluations demonstrating positive results, impact, and replicability. each offers materials that can be used, some for purchase and others at no cost.
- The ACQUIRE Project/EngenderHealth and Promundo. 2008. Engaging Boys and Men in Gender Transformation: The Group Education Manual.
- Promundo. Program H Kit: Manual & Video for Working with Young Men.
- Raising Voices, SASA! An Activist Kit.
- Raising Voices, SASA! 2007. Film and Screening Guide.
- Soul City Institute.
- Stepping Stones, “A Training Package on Gender, Communication and HIV.”
Agencies and Organizations
Bandura, A. 1997. Social Learning Theory. Englewood Cliffs, NJ: Prentice hall.
Barker, G., C. Ricardo, and M. Nascimento. 2007. Engaging Men and Boys in Changing Gender Based Inequity in Health: Evidence from Programme Interventions. Geneva: World Health Organization, Promundo.
Bott, S., A. Guedes, M. C. Claramunt, and A. Guezmes. 2004."Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals in Developing Countries." London, England: International Planned Parenthood Federation.
Bott, S., A. Morrison, and M. Ellsberg. 2005. "Preventing and Responding to Gender-based Violence in Middle and Low-income Countries: A Global Review and Analysis," World Bank Policy Research Working Paper 3618. Washington, DC: World Bank.
Coates, T. J., L. Richter, and C. Caceres. 2008. "Behavioural Strategies to reduce HIV Transmission: How to Make Them Work Better." The Lancet 372:669–84.
Connell, r. 1987. Gender and Power. Stanford, ca: Stanford University Press.
Courtenay, W.H. 2000. "Constructions of Masculinity and Their Influence on Men's Well-being: A Theory of Gender and Health." Social Science & Medicine 50(10):1385–1401.
Drimie, S. 2002. The impact of HIV/AIDS on rural households and land issues in Southern and Eastern Africa. Rome, Italy: Food and Agriculture Organization of the United States (FAO) Sub Regional Office for Southern and Eastern africa.
Dunkle, K. L., R. K. Jewkes, H. C. Brown, G. E. Gray, J. A. Mcintryre, and S.D. Harlow. 2004. "Gender-based Violence, Relationship Power, and Risk of HIV Infection in Women Attending Antenatal Clinics in South Africa," The Lancet 363:1415–21.
Ellsberg, M. "Violence Against Women and the Millennium Development Goals: Facilitating Women's Access to Support." International Journal of Gynecology and Obstetrics 94:325–32.
Ellsberg, M., C. Bradley, A. Egan, and A. Haddad. 2008. Violence Against Women in Melanesia and East Timor: Building on Global and Regional Promising Approaches. Canberra, Australia: Australian Government/AUSAID.
Ertürk, Y. 2005. "Integration of the Human Rights of Women and the Gender Perspective: Violence Against Women." Intersections of Violence Against Women and HIV/AIDS, Report of the Special Rapporteur on Violence Against Women, Its Causes and Consequences. Geneva: United Nations, Commission on Human Rights.
Ferdinand, D. L. 2009. A Manual for Integrating the Programmes and Services of HIV and Violence Against Women. Washington, DC: UNIFEM, Development Connections.
García-Moreno, C., A. F. M. Jansen, M. Ellsberg, L. Heise, and C. Watts. 2005 WHO Multi-country Study on Women's health and Domestic Violence Against Women: Initial Results on Prevalence, Health Outcomes and Women's Responses. Geneva: World Health Organization.
Guedes, A. 2004. Addressing Gender-Based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis. Washington, DC: LTG Associates, Inc. and Social & Scientific Systems, Inc. for USAID Interagency Gender Working Group (IGWG).
Guedes, A., S. Bott, and Y. Cuca. 2002. "Integrating Systematic Screening for Gender-based Violence into Sexual and Reproductive Health Services: Results of a Baseline Study by the International Planned Parenthood Federation, Western Hemisphere Region." International Journal of Gynecology and Obstetrics 78(Supplement 1):S57–S63.
Harvard School of Public health, Program on International Health and Human Rights, Center for Women's Global Leadership. 2006. "Meeting Report : Action on Gender Based Violence and HIV/AIDS: Bringing Together Research, Policy, Programming and Advocacy," Toronto, August 9–10.
Heise, L. L. 1998. "Violence Against Women: An Integrated, Ecological Framework." Violence Against Women 4(3):262–90.
Heise, L. L., M. Ellsberg, and M. Gottemoeller. 1999. "Ending Violence Against Women." Population Reports, Series l, No. 11. Baltimore: Johns Hopkins University School of Public health, Population Information Program.
Interagency Gender Working Group of USAID. 2002. "Gender-Based Violence and Reproductive Health & HIV/AIDS: Summary of a Technical Update." Available at http://www.prb.org/pdf/Genderbasedviolence.pdf (accessed July 21, 2010)
Jewkes, R., M. Nduna, J. Levin, N. Jama, K. Dunkle, K. Wood, M. Koss, a. Puren, and n. Duvvury. 2007. "Evaluation of Stepping Stones: A Gender Transformative HIV Prevention Intervention, Policy Brief." Cape Town, South Africa: Medical Research Council.
King, E. M., and A. D. Mason. 2001. "Engendering Development through Gender Equality in Rights, Resources, and Voice." In a World Bank Policy Research Report Washington, DC: The World Bank.
Malhotra, A., and S. R. Schuler. 2005. "Women's Empowerment as a Variable in International Development." In Measuring Empowerment: Cross-Disciplinary Perspectives, Ed. D. Narayan. Washington, DC: The World Bank.
Maman, S., J. K. Mbwambo, N. M. Hogan., G. P. Kilonzo, J. C. Campbell, E. Weiss, and M. D. Sweat. 2002. "HIV-positive Women Report More Lifetime Partner Violence: Findings from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania." American Journal of Public Health 92(8):1331–7.
Melendez, R. M., S. Hoffman, T. Exner, C. Leu, and A. A. Ehrhardt. 2003. "Intimate Partner Violence and Safer Sex Negotiation: Effects of a Gender-specific Intervention." Archives of Sexual Behavior 32:499–511.
Peacock, D., and A. Levack. 2004. "The Men as Partners Program in South Africa: Reaching Men to End Gender-Based Violence and Promote Sexual and Reproductive Health." International Journal of Men's Health 3(3):173–88.
Population Council. 2006. "Living Up to Their Name: Profamilia Takes on Gender-based Violence." Quality/Calidad/Qualité 18:5–31.
Population Council. 1999. Peer Education and HIV/AIDS: Past Experience, Future Directions. New York: The Population Council. Available at http://www.popcouncil.org/pdfs/peer_ed.pdf (accessed July 21, 2010)
SaSa! 2007. Screening Guide. Available at http://www.raisingvoices.org/files/Screening%20Guide%20SaSa.pdf (accessed July 21, 2010)
Schuler, S. r., S. M. Hashemi, S. H. Badal. 1998. "Men's Violence against Women in Rural Bangladesh: Undermined or Exacerbated by Microcredit Programmes?" Development in Practice 8(2):148–57.
Solórzano, I., A. Bank, R. Peña, H. Espinoza, M. Ellsberg, and J. Pulerwitz. 2008. Catalyzing Individual and Social Change around Gender, Sexuality, and HIV: Impact Evaluation of Puntos de Encuentro´s Communication Strategy in Nicaragua. In Horizons Final Report. Washington, DC: Population Council.
Usdin, S., E. Scheepers, S. Goldstein, and G. Japhet. 2005. "Achieving Social Change on Gender-based Violence: A Report on the Impact Evaluation of Soul City's Fourth Series," Social Science & Medicine 61:2434–45.
Vyas, S., and C. Watts. 2008. "How Does Economic Empowerment Affect Women's Risk of Intimate Partner Violence in Low and Middle Income Countries? A Systematic Review of Published Evidence," Journal of International Development 21(5):577–602.
World Health Organization, Department of Gender, Women and Health (GWH), and Department of HIV/AIDS (HIV). 2006. Addressing Violence Against Women in HIV Testing and Counselling: A Meeting Report. Geneva: World Health Organization.