Women, HIV and Intimate Partner Transmission (Jul-Aug 2009)

Launch discussion on intimate partner transmission of HIV and its linkages with violence on the Joint Community of Practice on HIV, Human Rights and Gender in Asia and the Pacific (HIVAPCOP). The guest moderator of the inaugural discussion is Dr. Nafis Sadik, UN Special Envoy on HIV and AIDS in Asia and the Pacific

The 2008 Report of the Commission on AIDS in Asia illustrates the inextricable linkages between HIV, human rights and gender. Human rights violations and gender inequality are fuelling the epidemic and creating major obstacles in reaching our Universal Access goals and the MDG targets for HIV and AIDS.

Gender-related HIV challenges are deeply embedded in the fabric of society. Gender norms prevent girls from seeking information and services on sexual health and HIV, and deny women their say in sexual decisions. At the same time, gender norms encourage boys and men to engage in multiple sexual encounters and risky behaviour. Intimate partner violence is silencing women's voice, and preventing them from seeking help and taking measures to protect themselves from HIV infection. This is compounded by the shame and persistent stigma associated with HIV which creates powerful barriers to accessing basic HIV prevention and treatment services.

It is estimated that 50 million women in Asia are at risk of HIV infection from their intimate partners and urgent attention is needed for developing effective prevention strategies to reach them.

In the light of this, I am delighted to launch the inaugural virtual discussion on intimate partner transmission of HIV and its linkages with violence on the newly established HIVAPCOP. HIV and Intimate Partner Transmission raises questions related to intimate partner violence, giving agency to vulnerable women, engaging men in the response, and improving women's rights to inheritance and property as a way of addressing violence and providing coping mechanisms.

Please find a few key questions below to help kick start the discussion. The results of this e-discussion will feed into the multi partner (UNDP, UNAIDS, UNIFEM, UNFPA, WAPN+ and ICW) joint symposia on HIV and Intimate Partner Transmission at the 9th ICAAP in Bali, Indonesia.

HIV, Intimate Partner Transmission and Domestic Violence

In some parts of Asia, it can be said that marriage is a robust indicator of HIV vulnerability for women. To what extent does this hold to be true in your experiences?
Violence within marriage appears to be the norm rather than the exception in many of our communities. There is also substantial evidence that violence increases women and men's vulnerability to contracting HIV. What violence prevention efforts have been effective in empowering women and affecting HIV transmission rates?
Spousal violence involves at least two people, usually a male perpetrator and a female victim. What approaches have been used to work with men and boys to prevent violence within marriage and reduce HIV transmission?
For survivors of spousal violence who are also infected or affected by HIV/AIDS what kinds of support structures/mechanisms have been seen to be effective in helping them survive? To what extent do women's empowerment schemes provide enough support?

I look forward to your contribution and to a lively exchange of views.

Sincerely,

Dr. Nafis Sadik,
UN Special Envoy on HIV and AIDS in Asia and the Pacific
HIV-APCOP Guest Moderator

Comments:

Is violence within marriage the norm?
Wed, 2010-07-28 11:41 — Ione Lewis

I have completed a research study with 415 women in Papua New Guinea with 2 in country researchers in 2007. We found high rates of physical (58%), sexual (45%), emotional (56%) and financial(46%) abuse in relationships and use of social isolation as a form of control over wives (36%). This does mean physical violence is very common and yet 40% of relationships didn't have violence. We need to look at protective factors against violence.

Now interviews we are doing with men in Western Highlands of Papua New Guinea are revealing the high rates of violence and harsh treatment they are exposed to - as children by parents, brothers and teachers - the incidence of violence is high in social situations, on the street, in public transport, even in churches, and many report involvement in tribal warfare resulting in death, injuries and loss of property.

So it is violence in all social contexts which is very common - not just in marriage.

Ione Lewis

Consolidated Reply: Women, HIV and intimate partner transmission
Tue, 2009-08-25 13:42 — admin

(23 June- 10 July 2009)

Guest moderated by Dr. Nafis Sadik, UN Special Envoy on HIV and AIDS in Asia and the Pacific and prepared by Surabhi Kukke, HIV-APCOP facilitator.

________________________________________

Contributions were received, with many thanks, from:

Madhu Bala Nath, UNIFEM
Azrul Mohd Khalib, UNDP, Malaysia
Dr. Jean D’ Cunha, UNIFEM East & Southeast Asia
Anjani Bhattarai, UNDP, Nepal
Jay G. Silverman, Harvard School of Public Health
Nashida Sattar, UNDP, Regional Centre in Colombo
Niranjan Saggurti, Population Council Delhi
Vandana Mahajan, UNIFEM, South Asia
Ferdinand Strobel, UNDP, Pacific Center

________________________________________

Summary Response:

[Facilitator’s note: The HIV-APCOP received responses from members in India, Malaysia, Thailand, Nepal, USA, Sri Lanka and the Fiji Islands. For country examples, see attached]

Background
Findings from a recent study[1] on spousal and intimate partner transmission in sero discordant couples in Southeast Asia indicate that women are increasingly contracting HIV from their husbands and long term partners and they constitute the majority of new infections.

These findings also confirm that discrimination and violence against women/girls and the norms and standards of sexual engagement that condone or socially sanction violence in intimate partner relationships, render women vulnerable to HIV/AIDS. Cultural taboos, including the notion of sex being a “male right,” especially within marriage, often gives women little space to openly discuss and negotiate sexual relations within marriage, increasing their vulnerability to HIV infection. Positive women face disproportionate stigma and discrimination, which affects emotional well being, diminishes access to treatment and care, employment and a spectrum of other services. Finally, when a positive woman has to assume the additional responsibility of caring for family members suffering from HIV/AIDS, it increases emotional/physical stress, enhances time poverty, and may reduce her earning potential or push her to earn more.

Summary of Responses to Questions

In some parts of Asia, it can be said that marriage is a robust indicator of HIV vulnerability for women. To what extent does this hold to be true in your experiences?

Members felt that marriage is not yet a ‘robust indicator’ of HIV in Asia but is increasingly emerging as a possible risk to contracting the virus. Framing the issue this way runs the risk of a range of conservative responses from non-acceptance and branding this position as anti-marriage to introduction of mandatory pre marriage testing. What might be more useful is to use data and analysis to establish the power dynamic - power exercised by and large by men over women in society as a whole, including in marriage - as a key cause. Interventions need to strike at this power dynamic in order to make any real difference in terms of halting or reversing the spread of HIV.

It is important to note that not all women in marriage are at risk for HIV; there are specific groups of married women who are at higher risk than other women. Research to date has characterized such groups of women by the behaviors of men and cultural practices in marital system within the South Asian context. For instance, married women who face Intimate Partner Violence (IPV), have husbands with hypermasculine attitudes or are heavy users of substance. These men are also more likely to engage in unprotected extra marital sexual relations and hence are at increased risk of HIV transmission. Female partners of migrant men or female migrants themselves as married partners are at risk of HIV due to lack of knowledge and skills to protect themselves and inaccessibility and lack of knowledge about quality services. This multi-factorial risk of HIV transmission in intimate partner relationships points to specific groups of married couples at higher risk rather than “marriage” itself being an indicator for risk of infection.

It is critical to invest heavily in helping women to assess their risk of HIV infection through self-administered questionnaires. These have been developed in the region but since they have to go through peer counselors and field workers, the assessment of self risk has to be done keeping the woman’s and man’s right to privacy in perspective.

Violence within marriage appears to be the norm rather than the exception in many of our communities. There is also substantial evidence that violence increases women and men’s vulnerability to contracting HIV. What violence prevention efforts have been effective in empowering women and affecting HIV transmission rates?

It was noted that we are rather far from operationalizing the established links between violence prevention efforts and HIV prevention rates in a cohesive, coordinated way in policies and programs as this is only just gaining gradual acceptance, in particular, among governments. As a result, we are even farther away from establishing quantitative links between violence prevention efforts and HIV transmission rates.

While the signs of progress in addressing violence against women are many, large scale efforts at violence prevention have not been very effective, until now.[2] They have either tried to create spaces for women in their own homes through acts like the Domestic Violence Act in India or they have moved into the economic empowerment model of creating incomes for the survivors of violence so that they can, at best, survive. However, members noted: neither of these initiatives directly help in HIV prevention.

Good macro data on (a) different forms of violence against women; (b) sex disaggregated data and gender statistics on the feminization of HIV/AIDS and spousal transmission is presently ‘work in progress”. One among many problem issues in data collection is poor reporting due to stigma and discrimination. This adds to the problem of establishing links between the efficacies of violence prevention efforts, women and preventing HIV transmission.

It is now becoming clear that to prevent HIV for women in violent relationships we need;
• Psychosocial interventions like trauma counseling and help in building self esteem along with access to women controlled technology for AIDS prevention, such as the female condom.
• Substantial work on lobbying with governments to make this affordable and accessible.
• Violence against women practitioners need to come together with HIV/AIDS practitioners, including related ministries and government departments, ministries of women’s empowerment, and health
ministries to facilitate the development of policies and programs that are focused and coordinated.

Spousal violence involves at least two people, usually a male perpetrator and a female victim. What approaches have been used to work with men and boys to prevent violence within marriage and reduce HIV transmission?

Members agreed that work with men and boys is absolutely critical to support men to redefine masculinity and deconstruct the concept of hegemonic (hyper) masculinity themselves. The UNDP project, Partners for Development, is beginning to gather speed on issues relating to masculinity and some networks on this issue are beginning to find their space in South Asia. They are however as yet nascent and are trying to gather evidence and research on men and GBV. There is considerable data on intimate partner violence however, not much of it is from the perspective of men. ICRW has just completed a study on why men are violent and how they feel after they are violent. The study points to the need for self esteem development of adolescents as well as the importance of trauma and guilt counseling to help adolescents living in violent homes to value non violence.

For survivors of spousal violence who are also infected or affected by HIV/AIDS what kinds of support structures/mechanisms have been seen to be effective in helping them survive? To what extent do women’s empowerment schemes provide enough support?

Members suggested a variety of empowerment mechanisms to support survivors of spousal violence who are also infected or affected by HIV/AIDS.
• Economic empowerment programs that are gender responsive and consistent with market demand.
• Gender responsive workplace, education policies that ensure that HIV positive people, including women do not lose their jobs and children/youth are retained in school/college.
• Effective trauma counseling that is not moralistic and that combines indigenous with western methods or is solely indigenous. The above kind of counseling needs to be developed for children and family members as well, but one it not aware of this, though it might exist.
• Community awareness raising to create community support that reduces stigma and discrimination and enhances service provision (community also involves local service providers in communities as well)
• Advocacy and pressure groups to reduce drug prices and enhance women’s access to treatment and care for both spousal violence and HIV, and the same for their children.
• Work with men and boys and other family members to care for HIV positive family members, including positive women family members to reduce women’s work burden.
• Support programs for children where both parents are positive or have expired. This is a huge emotional burden that women in particular tend to carry.

Final Note

Finally, one member felt that in the current HIV scenario in the region, the emphasis of focusing on certain population groups and communities and having a targeted approach, may lead to women being addressed essentially as spouses and partners of MARPS. This member suggested that the focus be broadened to address the issues of vulnerability to HIV and impact of violence for those women and young girls who are not wives or in any marital relationship. This ideological framework would bring in the political, social and economic agency of women and girls as human beings in their own right and not merely as wives, partners and spouses.

To reach out to women in marriage who are at risk or are vulnerable, there is no getting away from addressing the underlying causes of gender inequality. This work needs to be embedded in the larger efforts taking place across the world by diverse groups of men and women to address VAW and other forms of gender based violence. A life cycle approach, which highlights her denial, deprivation and discrimination as a continuum of human rights violation, is needed to tackle the risks of HIV and violence for women in marriage.
________________________________________
[1]In 2008, the UNIFEM East and Southeast Asia, Regional Office Bangkok, conducted a study, entitled “Responding to the Feminization of HIV/AIDS: A Rapid Assessment of Spousal and Partner Transmission of HIV and Sero Discordant Couples” in four countries in Southeast Asia in partnership with UNAIDS, Asia Regional Office, Bangkok.

[2]There are, however, community based examples of how work on preventing discrimination and violence against women and HIV prevalence have been combined with good effect

________________________________________

Recommended Resources:

Women and HIV in the Asia-Pacific Region Guide
http://www2.undprcc.lk/resource_centre/pub_pdfs/P1103.pdf

Spousal transmission of HIV/AIDS in Sri Lanka
http://www.hivapcop.org/resources/pdf/SpousalTransmission_HIVinfection_f...

Draft of the Assessment on the Risks and Vulnerabilities of HIVTransmission to the Spouses of MARPs in Nepal
http://www.hivapcop.org/resources/pdf/raft_of_assessment_on_spousal_tran...

Intimate Partner Violence and HIV Infection Among Married Indian Women
http://www.hivapcop.org/resources/pdf/jama_8-13-2008_in_print.pdf

Intimate Partner Violence Functions as Both a Risk Marker and Risk Factor for Women’s HIV Infection: Findings From Indian Husband–Wife Dyads
http://www.hivapcop.org/resources/pdf/Decker_JAIDS_IPV-HIV_Couples.pdf

Country Example

Response from Ferdinand Strobel, UNDP, Fiji Islands
Tue, 2009-07-28 10:10 — admin

Friday, 10 July 2009

Dear Dr. Sadik,

Thank you for posting this e-discussion and raising thoughts provoking questions. Although essentially focused on Asia the discussion has also great relevance for the Pacific Islands where sufficient research has not yet been done to confirm whether this same phenomenon of at risk ‘married’ monogamous women has also emerged, perhaps among other trends as well.

In the Pacific, the epidemiological picture of HIV is much less clear than in Asia. Neither commercial sex work, nor injecting drug use are yet documented as being of significant importance. And, generally the major drivers of HIV infection in the Pacific are much less precisely known. Proxy indicators such as Sexually Transmitted Infections rates and unwanted pregnancies -both very high in most Pacific Islands Countries - suggest that high risk sexual behaviours, including low condom use and concurrent multiple sexual partners for both male and female are common.

There have, for example been some suggestions that in PNG, multiple sexual partners by both ‘married’ women and men may also be an emerging pattern of transmission that needs to be better understood.

Research on male – to –male sex also points out that not all male-to-male sex is associated with gender or sexual identity in the Pacific, in the same way it is in other regions. Many men who have sex with men in the Pacific are in fact married men (or men in long term relationships with women) and who also engage in situational same sex activity. This situation creates greater potential for bridging between a “most at risk group” to the general population that is not necessarily found in concentrated MSM epidemics such as found in the West or some parts of Asia.

Mobility and migration of a predominantly male workforce represent a known risk factor. Studies in Kiribati, Fiji, PNG and Tuvalu among sailors found that multiple sex partners and group sex were regarded as part of the “seafaring lifestyle’. There is also anecdotal evidence of predominantly husband to wife HIV and STI transmission in this particular sub population-group. High risk sexual behaviours and high levels of mobility and migration also tend to coincide in urban areas where commercial sex is concentrated and where women, including married women also engage in transactional sex for survival.

Gender based violence, most of which perpetrated by partners is highly prevalent in the Pacific islands (above 50% in a number of countries studied) and HIV transmission in ‘marriage’ and the intersection with violence is clearly one of these research gaps. However, some research available is quite revealing and also rich in nuances. For example: a recent PNG study showed that sexual abuse in relationships was strongly associated with HIV positive status while level of school education, post school education and paid employment were not found to influence rates at which women reported domestic violence. Another showed interestingly that the concern that men most often articulated about the consequences of extramarital ‘infidelity’ was possible violent retaliation for “stealing” another man’s wife. Therefore, divorced or separated women (or a widow) who exchange sex for money are considered to be “safe” partners.

Another feature of the region is its over-reliance on the “stronger A & B, weaker C” version of the ABC approach. Although it suits the prevailing cultural and religious Christian values, it is often at odd with the reality of diverse social constructions of marriage (and ‘infidelity’). Many Prevention messages are therefore often misunderstood or misinterpreted. In some cases it may even be that they are misleading or at least make acknowledging HIV risk more difficult (i.e marriage is a “sacred space”…). Not to mention the moral dimension that contributes to the often huge gaps observed between attitudes and practices and secrecy around extramarital sex.

The prevailing focus on identified ‘at risk groups’ in strategies and programme may also contribute to this and miss the point that transmission could be more frequent where most people do not expect it, or in social spaces considered “safe”. The influence of the context (social, economic, political…) on sexual behaviour, sexual codes and norms, but also power relations between gender roles within and outside marriage that put men at great risk and then in turn their female partners at even greater risk definitely needs more attention.

As noted by many researchers, interventions that basically scale up individual behaviour change to the population level -without addressing the context- are likely to fail. This clearly makes UNDP’s work on the context more relevant than ever.

Recently UNDP (in collaboration with UNIFEM and SPC) reviewed the available evidence on Gender and HIV in the Pacific Islands and identified 5 critical areas of work with a series of specific recommendations for the Pacific (not listed here):

Address the prevention of violence against women, children (both girls and boys) and sexual minorities as an integral part of preventing the spread of HIV
Mainstream gender equality into national and regional policies, strategies and programmes for HIV prevention and care and make them culturally relevant and human rights based
As an integral part of programmes to prevent the spread of HIV, promote measures to encourage positive models of masculinity among men and boys and increased awareness and exercise of rights among women and girls
Improve the legal framework for gender equality and human rights as an integral part of preventing the spread of HIV
Empower women and girls economically as an integral aspect of HIV prevention programmes.

Although not released yet, the study has already ‘triggered’ an SPC led regional programme looking at operationalising the second recommendation. UNDP with the support of PAF funding will pilot research on HIV transmission in intimate partner relationship. UNDP and UNIFEM and many other partners will continue supporting countries towards implementing the others. Obviously there remain yawning gaps in research, legislation and policies that need to be addressed. But foremost, it is endogenous innovative efforts, at the community and family levels that will bring about the positive social change and address harmful gender norms that need to be scaled up.

Vandana Mahajan, Programme Officer, UNIFEM
Tue, 2009-07-14 21:50 — admin

Dear Dr. Sadik,

Warm greetings from UNIFEM, South Asia!

Thanks and congratulations for raising these points for reflection.

I add my tiny bit to the healthy debate:

With regards to the four key questions that you have raised, the focus of inquiry is on female spouses in marital relations. This universe is hugely important and not for a moment I would like to diminish the importance of raising the issues of women‘s vulnerability to HIV in context of long term relations such as marriage. However, I feel that in the current HIV scenario in the region, the emphasis of focusing on certain populations groups and communities and having a targeted approach, will lead to women being addressed essentially as spouses and partners of MARPS. My submission is if this universe could be broadened to address the issues of vulnerability to HIV and impact of violence for those women and young girls who are not wives or in any martial relationship. This ideological framework would bring in the political, social and economic agency of women and girls as human beings in their own right and not as wives, partners and spouses.

The discussions so far on this COP has strongly iterated that it is the unequal power relations between men and women and among themselves which drive the risks and vulnerabilities to HIV and Violence. Therefore, any strategy to address spousal violence and reduce the risk of women in stable and martial relations of getting HIV infection from their male partners would need to factor in changing the gender norms, addressing the inequitable power relations, challenging the notions of hegemonic masculinity and subjugating femininity.

The risks of HIV and violence for women in marriage need to be seen and addressed from a life cycle approach from womb to tomb which highlights her denial, deprivation and discrimination as a continuum of human rights violation.

With warm regards
Vandana Mahajan

Nashida Sattar, Programme Analyst, UNDP RCC
Tue, 2009-07-14 21:50 — admin

Dear Dr. Sadik,

I would like to share with the group, the findings from the study conducted in Sri Lanka as part of the regional assessment on spousal transmission of HIV in the Asia Pacific region.

Findings of the study on intimate partner relationships in Sri Lanka:

In 2008, UNAIDS RST in collaboration with the UNDP Regional Centre in Colombo undertook a regional assessment on spousal transmission of HIV in the Asia Pacific region. Four countries in South Asia were chosen to be part of the regional assessment and Sri Lanka was one of them.

In Sri Lanka, two decade after the first case was reported (in 1987) the epidemic continues to be at a low level. Recent estimates suggest that the adult prevalence of HIV infection to be at 0.03% and the main mode of transmission is heterosexual.

The study demonstrated that 36% of HIV positive women were infected by their intimate and stable partner. For the great majority of them (94%) the male partner had reported acquiring the infection while employed outside the country. The study noted strong inter-linkages between women in intimate stable relationships and high risk groups. For example, it was highlighted that almost a quarter of the men who have sex with men have had sexual intercourse with a women, 14.7% of whom with a female long term partner. It noted that over 27% of male sex workers, working around the beaches (beach boys) were married. It also demonstrated that condom use within marriage was very rare (5.7%) even between sero disconcordant couples.

The study noted that separation of spouses related to overseas employment, low levels of knowledge in most population groups, the inadequacy of preventive interventions targeting most at risk populations both in quality and coverage, societal norms such as men initiating, dominating and controlling sexual decisions within marriage, high prevalence of alcoholic misuse, low condom use etc. were key vulnerability factors.

Although by no means comprehensive, the study does point to the HIV and STI vulnerabilities faced by married women in Sri Lanka and highlights the importance of targeted couple based intervention programmes. It points to the strong inter- linkages between intimate partner relationships and migration in Sri Lanka and given the increasing numbers of migrants from Sri Lanka the study strongly calls for couples based pre departure programmes for migrants.

Spousal transmission of HIV/AIDS in Sri Lanka

Thanks,

Nashida

Niranjan Saggurti, HIV and AIDS Program, Population Council
Tue, 2009-07-14 21:49 — admin

Dear Dr. Sadik,

Thank you for moderating this extremely important discussion on prevention of HIV in intimate partner relationships. Please see my response to the first three questions.

In some parts of Asia, it can be said that marriage is a robust indicator of HIV vulnerability for women. To what extent does this hold to be true in your experiences?

Having extensive field experience in India and desk research experience in other countries of South Asia, I would say ‘Marriage’ per se is not a robust indicator of HIV vulnerability for women. The gender roles, norms, cultural practices, life styles in marital relationships facilitate the risk of HIV for women. Marriage limits the women for her sexual negotiation and safe sex practices with partner even if she is aware that he has high risk behaviors. And not all women in marriage are at risk for HIV. For example, there are particular group of women in marital relationships who are at higher risk than other women. Research to date has identified such groups of women by the behaviors of men and cultural practices in marital system within South Asian context. They are:

• Women who face intimate partner violence (IPV) and sexual violence (SV) or men who perpetrate IPV are at increased risk for HIV infection. Research in countries of South Asia suggests that between 30-70% women in intimate partner relationships face violence.
• Women who have husbands’ with hypermasculinity attitudes, as those men are more likely to engage in extramarital sexual behaviors.
• Women who have husbands’ with heavy alcohol drinking, as they are more likely to engage in risk taking behaviours thereby increasing the risk of HIV transmission.
• Married female partners of men with high risk behaviors such as injecting drug use and MSM, as condom use is almost none within marriage by these men.
• Female partners of migrant men or female migrants themselves as married partners are at risk to HIV due to lack of knowledge and skills to protect themselves, inaccessibility and lack of knowledge about quality services; sociocultural norms and beliefs.

Most of these factors are inter-linked: for example, men with hypermasculinity attitudes are more likely to drink alcohol heavily and they are more likely to engage in extramarital sexual behaviour and perpetrate violence within marital relationships. This multi-factorial risk to HIV transmission in intimate partner relationships points to specific group of high risk married couples rather than ‘universal marriage’. However, it is true that in most countries of South Asia, marriage facilitates the risk of HIV transmission to wives in a way due to lack of sexual negotiation and condom use by the women who have ‘high risk (as per the above factors)’ husbands /intimate sexual partners.
Violence within marriage appears to be the norm rather than the exception in many of our communities. There is also substantial evidence that violence increases women and men's vulnerability to contracting HIV. What violence prevention efforts have been effective in empowering women and affecting HIV transmission rates?
Growing evidence from studies in South Asian context highlights the high rates of intimate partner violence and is considered a norm in most societies. Studies indicate that elevated rates of sexual risk behaviors (eg., extramarital and multiple sex partners, no or inconsistent condom use, and forced unprotected sex) are significantly higher among abusive men than among non abusive men. Similarly, women who face violence are at increased risk for HIV infection. No doubt that violence within marriage has significant linkages with vulnerability to contracting HIV.

There are hardly any evidence based preventive interventions in addressing violence to reduce the risk of HIV transmission in intimate partner relationships in South Asian context. The project that we have just initiated two projects in India: one that uses ‘women-only’ focused intervention to address the HIV risk from risky (defined as, women who experience violence from husbands) husbands. This strategy was initiated because men who perpetrate severe violence (they are most at risk for HIV) are the ones who do not even participate in preventive or curative interventions. So the ‘women-only’ focused intervention makes an attempt to build capacities for self-negotiations within marital relationships. The other project focuses on ‘couple-based’ interventions to improve marital communications to reduce violence and HIV risks within marriage. Besides these two experimental research projects (in progress), there are any evidence based programs in South Asian context.

There were few other programs focused on young men and women that have addressed masculinity attitudes, gender roles and responsibilities in India context that were proven to be effective (Population Council’s Horizons Program) in reducing violence and sexual risk behaviors. Still more work needs to be done in this area by identifying evidence-based interventions that were effective in other country-contexts and adapting the successful approaches.

There were few approaches tested in Indian context including school-based education programs. The most programs that I am aware were from the studies conducted at Population Council:

• Promoting gender-equitable norms among young men to reduce HIV risk and violence: A pilot intervention.
http://www.popcouncil.org/pdfs/horizons/yaaridostieng.pdf

• Reducing young men’s HIV risk and violence against women by promoting gender-equitable norms and behavior in India
http://www.popcouncil.org/horizons/projects/India_GenderNorms.htm

• Intervention to promote gender equity and empowerment among young women to reduce vulnerability to HIV and SRH risks.
http://www.popcouncil.org/pdfs/horizons/India_SakhiSaheli_Eng.pdf

• Exploring intergenerational dialogue on sexuality and HIV/AIDS: Building effective youth-adult partnerships to prevent HIV transmission
http://www.popcouncil.org/pdfs/IndiaUpdate/IndiaUpdate_Intergenerational...

Best regards,

Niranjan Saggurti
HIV and AIDS Program
Population Council
New Delhi.

Response from Jay G. Silverman
Tue, 2009-07-14 21:49 — admin

Dear Dr. Sadik,

Thank you so much for leading this extremely important discussion on how to best move forward regarding the links between husband and other male partner violence against women, and the transmission of HIV to wives and female partners. It is a very exciting advance to have such an effort recognize both the need to move beyond the traditional foci of HIV prevention and to better consider the impact of gender-based violence. I want to attach two publications of research that I and Dr. Michele Decker have conducted on this question in the Indian context. Both of these point to a conceptualization of the role of male partner violence in women's HIV infection involving both the higher levels of sexual risk found among abusive men, and the greater likelihood of abusive men (as compared to other men infected with HIV) to transmit HIV to a female partner. The evidence for both of these effects leads us to think of female partners of abusive men (whether in Asia, the PI or anywhere else on the globe) as being in 'double jeopardy' regarding their risk for HIV. They are both with a partner who is more likely to become HIV infected based on his behavior outside of the relationship, AND they are also at increased risk for having such infection transmitted to them, likely based on his abusive behavior inside the relationship (e.g., forced and coerced unprotected sex possibly leading to genital lesions).

In thinking about prevention, this type of model necessarily leads us to consider the likely common cause of both of these forms of gendered male behavior - norms, policies and structures that encourage boys' and men's entitlement to sexual access and control of women and girls (both within and outside of relationships), their entitlement to use of violence and coercion in gaining such access and control, and their placement of their own interests above concern for the infection of their female partners. Such approaches are currently being tested in Africa; initial evaluations indicate that they are partially successful. Perhaps we should consider adapting and optimizing such prevention models for use with our populations? Looking forward to hearing people's thoughts. Thank you, again, for initiating this very important dialogue, and I look forward to having the opportunity to continue it in-person with those able to come to ICAAP in August.

Intimate Partner Violence and HIV Infection Among Married Indian Women
Intimate Partner Violence Functions as Both a Risk Marker and Risk Factor for Women’s HIV Infection: Findings From Indian Husband–Wife Dyads

Very best,

Jay

Jay G. Silverman, Ph.D.
Associate Professor of Society, Human Development and Health
Director of Violence Against Women Prevention Research
Harvard School of Public Health
677 Huntington Avenue
Boston, MA 02115
Phone - 617-432-0081

Response from Anjani
Tue, 2009-07-14 21:48 — admin

Dear Dr. Sadik,

1. In some parts of Asia, it can be said that marriage is a robust indicator of HIV vulnerability for women. To what extent does this hold to be true in your experiences?

In the context of Nepal, as most-at-risk population (MARPs) are mostly men, unless otherwise research is conducted on the other vulnerability factors of women, marriage appears to be one of the key vulnerability factors for Nepali women, who generally are considered to be in the monogamous relationship. Reference in this regard is the recently conducted desk review on spousal transmission of HIV in Nepal (TOR of the review and initial draft report are attached for your information).

2. Violence within marriage appears to be the norm rather than the exception in many of our communities. There is also substantial evidence that violence increases women and men's vulnerability to contracting HIV. What violence prevention efforts have been effective in empowering women and affecting HIV transmission rates?

Violence prevention efforts should start from addressing the root causes of violence, in parallel to economic empowerment of women. In the short term, most significant approach would be in providing space for women to come out of the violent situation so that they can have a choice.

3. Spousal violence involves at least two people, usually a male perpetrator and a female victim. What approaches have been used to work with men and boys to prevent violence within marriage and reduce HIV transmission?

Spousal transmission is an outcome of many interlinked factors. While it is crucial to work with men and boys for changing the stereotypical roles influenced by the patriarchal mind-set there is also a need to change the culturally accepted masculinity norm that encourages boys and men to be violent. In Nepal, women’s rights movement has included men as equal partner, and its result is positive; however, this movement is not directly linked with HIV related interventions.

4. For survivors of spousal violence who are also infected or affected by HIV/AIDS what kinds of support structures/mechanisms have been seen to be effective in helping them survive? To what extent do women’s empowerment schemes provide enough support?

Providing rehabilitation centers for women with HIV are found quite effective. In Nepal, HIV positive women are generally involved in advocacy for HIV prevention programmes. Not much initiative is taken in regard to economically empower them through other means, except small scale income generating activities.

TOR for Assessment on the spousal transmission of HIV in Nepal
Draft of the Assessment on the Risks and Vulnerabilities of HIV Transmission to the Spouses of MARPs in Nepal

Best regards,

Anjani with support from Purna Shrestha, Chief Researcher, Study on Spousal Transmission

Anjani Bhattarai
Social Development Officer
UNDP, Nepal
http://www.undp.org.np
Tel : +977-1-5523200 Ext 1012
Fax : +977-1-5523991/552398

Response from Dr. Jean D' Cunha
Tue, 2009-07-14 21:47 — admin

1. In some parts of Asia , it can be said that marriage is a robust indicator of HIV vulnerability for women. To what extent does this hold to be true in your experiences?

In 2008, the United Nations Development Fund for Women (UNIFEM) East and Southeast Asia, Regional Office Bangkok, conducted a study, entitled “Responding to the Feminization of HIV/AIDS: A Rapid Assessment of Spousal and Partner Transmission of HIV and Sero Discordant Couples” in 4 countries in Southeast Asia in partnership with UN AIDS, Asia Regional Office, Bangkok. Important findings are that, (a) the pandemic is increasingly assuming a woman’s face; In 2006 in Laos , men constituted 57% and women 43% of the people living with HIV/AIDS. In Cambodia , over half of those living with HIV are women – an increase from 38% in 1997, to a current 52%. (b) that women contracting HIV from spouses and partners are increasingly constituting the majority of new infections. According to the UNIFEM study, in Thailand , for instance, 38.7 % of new infections in 2007 were those of women infected by partners/spouses - an increase from 37% in 2005. By contrast only 9.6% of men were infected by partners/wives in 2007.

This is not surprising as discrimination and violence against women/girls and the double standards of male sexual morality, render women vulnerable to HIV/AIDS. In androcentric (male-centered) contexts, the institution of marriage/family is also patriarchal and bears the above markers – discrimination and violence against women. The following testify to this:
(a) womens’ and girls’ greater lack of access than men and boys to information and education on sex, sexuality, sexually transmitted diseases, HIV/AIDS because of cultural taboos surrounding sex and sexuality and because of gendered norms of conduct that deem it inappropriate for women and girls to show interest in and discuss these issues openly. This reduces women’s ability to protect themselves;
(b) unequal relations in marriage and cultural taboos surrounding sex and sexuality pre-empt open discussions between partners and spouses which may be a reason for non-disclosure of HIV status by male partners and spouses.. This renders women vulnerable to HIV. Alternately partners may be unaware of their HIV status and inadvertently transmit the infection;
(c) the notion of “sex being a male right”, especially within marriage, often gives women little space to openly discuss and negotiate sexual relations within marriage. Many women have also internalized the idea that submission is their conjugal duty, regardless of the nature of sexual demands being made on them; many fear violence if they speak openly about the way they experience sex and a sexual relationship or refuse to submit; within the above context, many women are unable to negotiate safe sex as they would be viewed as too forward or as this may cast doubts about the woman’s fidelity, as has been often reported;
(d) double standards of male sexual morality allow men to engage with several sexual partners – often unprotected, because men believe this enhances sexual experience. This may cause men to contract HIV which they may knowingly or unknowingly transmit to monogamous partners or spouses;
(e) positive women face disproportionate stigma and discrimination because of the general stigma attached to HIV/AIDS as sexually transmitted, and because women are perceived to have transgressed the boundaries of sexual conduct deemed socially appropriate for women. This affects emotional well being, diminishes access to treatment and care, employment and a spectrum of other services
(f) the relegation of women to domesticity and the inequities in intra family/household resource distribution compel women to often be the sole care givers for family members suffering from HIV/AIDS. This increases a woman’s work burden, increases emotional/physical stress, enhances time poverty, may reduce her earning potential or push her to earn more. When a positive woman has to additionally assume this burden, the effects are disastrous for herself, the children and family.

While for all the above reasons women are increasingly contracting HIV from partners and spouses, framing the issue as ” marriage is a robust indicator of HIV vulnerability for women”, runs the risk of a range of conservative responses - non-acceptance and branding this position as anti-marriage; introduction of mandatory pre marriage testing etc; What might be more useful is to use data and analysis to establish the power dynamic - power exercised by and large by men over women in society as a whole, including in marriage - as a key cause. Interventions need to strike at this power dynamic if we really need to make any real difference in terms of halting or reversing the spread of HIV.

While the signs of progress in addressing violence against women are many, (although it continues to exist for a variety of reasons), it is difficult to quantitatively establish at macro levels, links between violence prevention efforts and HIV transmission rates. This is firstly because while conceptual links between discrimination and violence against women and vulnerability to contracting HIV are being made, this is only just gaining gradual acceptance among governments in particular. We are rather far from operationalizing these links in a cohesive, co-ordinated way in policies and programs and consequently even farther away from establishing quantitative links between violence prevention efforts and HIV transmission rates.

Besides good macro data on (a) different forms of violence against women; (b) sex disaggregated data and gender statistics on the feminization of HIV/AIDS and spousal transmission is presently ‘work in progress”. One among many problem issues in data collection is poor reporting due to stigma and discrimination. This adds to the problem of establishing links between the efficacy of violence prevention efforts women and preventing HIV transmission.

There is need therefore for violence against women practitioners to come together with HIV/AIDS practitioners (this includes related ministries and government departments, ministries of women’s empowerment, health ministries etc) to facilitate the development of policies and programs that in a very focused and co-ordinated way help operationalize links between EVAW and HIV in VAW and HIV policies and programs. However having said this, there are community based examples cited below of how work on preventing discrimination and violence against women and HIV prevalence have been combined with good effect.

(a). I have read about the Stepping Stones Project in South Africa – a community based project for HIV prevention that improved sexual health by building more equitable gender relations. The project worked with local communities of young men and women using participatory learning approaches. Consciousness raising sessions were conducted over 6-8 weeks for a total of 50 hours, with single sex groups that were then brought together in mixed group meetings to build communication.

Evaluations of the project highlighted the following results:

Marked improvements in communication with partners, including on sexuality. The project had taught participants to express their opinions and feelings clearly, listen to each other and to discuss issues rather than remain quiet and bottle up feelings.
Realization by men that violence against women and girls was wrong
Awareness of sexual risk and the need to use condoms, followed by an acceptance and decision to use condoms.

There was evidence of behavior change: sexual engagement with fewer partners, increased condom usage, less transactional sex and less perpetration of severe intimate partner violence, as well as less substance use and more communication.

According to project assessments, these indicators taken as a group provide evidence of the positive impact of the intervention on men and are somewhat supported by the suggestion of a lower incidence of genital herpes among men. The set of male behaviours changed by the intervention overlaps closely with those associated with perpetration of intimate partner violence, rape, engaging in transactional sex, reflecting dominant notions of a hegemonic masculinity.

One of the key reasons for the success of this project is that it strikes at the power dynamic between men and women, (weighted in favour of the former) thus reducing the prevalence of HIV/AIDS.

(b) The UNDP-UNIFEM-UNFPA Joint program (South and Southeast Asia ) on Partners for Prevention works with men and boys to end discrimination and violence against women. The UNIFEM Program targeting middle and high school students focuses on eliminating discrimination against women and girls in school and student community contexts. But these are in an early stage, making it difficult to guage impact just yet.

The kinds of support structures/mechanisms that have been seen to be effective in helping survivors of spousal violence who are also infected or affected by HIV/AIDS survive are the following:

· Economic empowerment programs that are gender responsive and consistent with market demand

· Gender responsive workplace, education policies that ensure that HIV positive people, including women do not lose their jobs and children/youth are retained in school/college

· Effective trauma counseling that is not moralistic and that combines indigenous with western methods or is solely indigenous. The above kind of counseling needs t be developed for children and family members as well, but one it not aware of this, though it might exist.

Community awareness raising to create community support that reduce stigma and discrimination and enhances service provision (community also involves local service providers in communities as well)
Advocacy and pressure groups to reduce drug prices and enhance women’s access to treatment and care for both spousal violence and HIV, and the same for their children.
Work with men and boys and other family members to care for HIV positive family members, including positive women family members to reduce women’s work burden.
Support programs for children where both parents are positive or have expired. This is a huge emotional burden that women in particular tend to carry.

Dr. Jean D' Cunha,
Regional Programme Director, UNIFEM East & Southeast Asia

(Facilitator's note: This discussion is cross posted on the AP Gender COP and the AP-A2J networks)

Response from Azrul Mohd Khalib
Tue, 2009-07-14 21:47 — admin

Dear Colleagues,

I would like to respond to Madhu Bala Nath’s point by sharing the experience of Malaysia implementing mandatory premarital HIV testing as well as to attempt to contribute to whether marriage would be an indicator of HIV vulnerability for women.

In December 2008, the then Deputy Prime Minister Najib Abdul Razak (he is now the Prime Minister) announced that all states in Malaysia would begin implementation of mandatory premarital HIV testing for Muslim couples wanting to get married. This ruling, implemented as a form of HIV prevention and early detection of the disease, had actually been in effect for a number of years in all but two of the 13 states. The announcement was made to ensure uniform compliance by all states to implement the measure as a requirement to legalise marriage as a number of state governments had shown reluctance to make it a compulsory procedure.

When first introduced by the Johor state government in 2001, the ruling to conduct mandatory premarital HIV testing on all Muslim couples was actually issued by the state’s religious department via a fatwa (religious edict) which stated that Muslim marriages could only be solemnised after a mandatory HIV screening. This measure, strongly supported by the state government and its health department, was a reaction to a realisation that the majority of female HIV cases in Johor were found to be housewives. As the conventional understanding of Malaysia’s epidemic is that the majority of HIV cases are among injecting drug users, it was felt and speculated (without any real documented evidence) that these women were in fact being infected by their husbands and that they were all victims of the latter. Therefore, as a move to protect women from being infected with HIV, it was decided that screening people for HIV before marriage was necessary and thus made compulsory. Despite the protests of NGOs, the Ministry of Health (at the federal level) and the Malaysian Medical Association at the time, the measure became part of the religious procedure to be married in the state of Johor. As Islam as a religion under the Constitution is a state affair and not federal, the government in Kuala Lumpur has had their hands tied and was even forced to allow the state health department to support the ruling as it was a religious directive.

This device (using the religious approach i.e. the use of fatwa, and amendments to the marriage solemnisation procedures by the religious department) was used repeatedly in almost every state to overcome arguments of unethical medical practice, unproven value of testing as a form of prevention, lack of cost effectiveness, etc. Basically religious ideology flies higher and has greater leverage. As a result, by early 2008, most states had implemented mandatory premarital HIV testing for all Muslims. In 2007, almost 150 000 people nationwide had been screened in this manner, with 0.06% found to be with HIV. The official position of the government doctors in the programme is that this procedure contributes to public awareness against HIV and provides another option in early detection of the disease. Success of this policy is measured by how many persons screened and are found to be positive. Persons who are found to be with HIV are not prevented from marrying but are subjected to a 3 month counselling session. 13% do proceed with marriage.

In every public survey conducted on this subject, more than 60% of Malaysians support mandatory premarital HIV testing and at least 50% believe that it should also be conducted for non-Muslims.Confidentiality is also frequently violated resulting in not only the religious official (who is procedurally required to know the test results) officiating the marriage being a party to the test results but also whole families. The consent of the woman’s father is also required before a marriage can be solemnised. It is increasingly common to hear of fathers demanding to know the HIV test results of both partners before consent is given.

The issue of applying to everyone (Muslims and non-Muslims) wanting to get married was discussed, agreed upon and accidently announced at the DPM’s 2008 press conference. However, the announcement (but not the decision) was later withdrawn and was blamed on media misquoting the DPM. He later backtracked by saying that a study was needed on whether to make pre-marital HIV screening mandatory for non-Muslims. However, the implementation of this policy is still going ahead.

The fact that most female HIV cases as a result of intimate partner transmission are during marriage i.e. from a spouse is neither truly acknowledged nor addressed in any way. What happens later to the persons who are tested positive and do not marry is not addressed. Counselling is not provided and considered unnecessary for those who test negative. A 2007 study of married Malay Muslim women living with HIV in Kelantan (another Malaysian state) indicated that despite having increased economic power within a marriage (women in Kelantan are known to be independent and excellent business entrepreneurs), they continued to experience power disparity due to cultural and religious factors which prevented them from seeking information on STDs, use condoms, refuse sex and also experienced sexual violence. Though a fatwa was issued a few years ago ruling that a woman may refuse sexual intercourse with a husband who has HIV, the reality is much different. Refusal to have sex exposes her to sexual violence, marital rape (not recognised in Malaysia), separation, polygamy (him taking another wife) and divorce. In many ways, a married Muslim woman in Malaysia may have less opportunity and fewer options to protect herself from HIV infection as opposed to a female sex worker.

Best regards,

Azrul Mohd Khalib,
UN HIV and AIDS Coordinator, Malaysia

(Facilitator's note: This discussion is cross posted on the AP Gender COP and the AP-A2J networks)

Response from Madhu Bala Nath
Tue, 2009-07-14 21:46 — admin

Dear Nafis ji,

we are delighted that you have agreed to moderate this first session. The questions you have raised are just so pertinent and I must confess I have been thinking over them and want to begin by saying that in development we at times have no answers but yes there are discoveries all the time. I will venture to share with you some of these discoveries.

In response to the first question, marriage is essentially not yet a robust indicator of HIV in Asia. But yes increasingly it is emerging as a possible risk to the virus. In fact I fear that if any ill informed administrator picks up this as even a remote possibility (that marriage is an indicator of HIV)then we may again have to fight proposals put up for legislation that propose that all young people go through an HIV test before marriage. So yes we need to invest heavily in helping women to assess their risk to HIV through self administered questionnaires that we have developed in the region but these have to go through peer counselors and field workers and the assessment of self risk has to be done keeping the woman's and man's right to privacy in view.

The second area of discussion is also quite challenging. I feel that our efforts at violence prevention have upto now not been very effective. WE have either tried to create spaces for women in their own homes through acts like the domestic violence act in India which in fact is not reducing her fear of violence in any way and is at times pushing her back into a relationship that just moves from being physically violent to emotionally violent. The spirit of the act is to keep her in her home and really does not explore the root cause of violence that she is facing. Other efforts at violence prevention have moved into the economic empowerment mode of creating incomes for the survivors of violence so that they can at best survive. Neither of these initiatives help in HIV prevention. It is now becoming clear that to prevent HIV for women in violent relationships we need psychosocial interventions like trauma counseling and help in building self esteem along with access to women controlled technology for AIDS prevention. I am referring to the female condom here. A lot of work on lobbying with governments is needed to make this affordable and accessible. There are no doubt political interests that are not letting the prices come down and no subsidy is being negotiated anywhere in the world on the female condom.

The work on men and boys is absolutely critical and we need men to redefine masculinity and break the concept of hegemonic masculinity themselves. The UNDP project on partners for development is beginning to gather speed on issues relating to masculinity and some networks on this issue are beginning to find their space in South Asia. They are however as yet nascent and are trying to gather evidence and research on men and GBV. Somehow we forgot to look at men and their behaviours inspite of believing that we understood gender! Today a lot of data on women in violent relationships is available but not that much on men. ICRW has just completed a study on why men are violent and how they feel after they are violent. There are interesting revelations there. Work on self esteem development of adolescents as well as on trauma and guilt counseling is critical to help adolescents living in violent homes to value non violence. This work is also just beginning in Asia.

I look forward to this discussion gaining momentum.

Warm regards,
Madhu Bala Nath
Technical Advisor on HIV, GBV and Anti Trafficking
UNIFEM

Resource mentioned in text:

GENDER-BASED VIOLENCE, MEN AND MASCULINITIES IN PEACE AND WAR, Some Reflections
http://www.hivapcop.org/resources/pdf/links/Barker_June_8_comments.ppt

Created: 07/02/2011 16:13:19
Updated: 10/02/2011 15:28:48

Women, HIV and Intimate Partner Transmission (Jul-Aug 2009)

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