Will there be an AIDS-free generation?

A South African Perspective on Gender Inequality, Violence, Sexual Health and HIV


Rachel Jewkes, Director, Gender & Health Unit , South African Medical Research Council

Research emerging over the last two decades has demonstrated the critical impact of women's subordination to men and exposure to violence on their risk of HIV [1]. This heightened risk pertains in both adult women and girls. Critical evidence stems from research with adolescents in South Africa. This shows that those who have experienced intimate partner violence or who are in relationships with low equality are at greater risk of incident HIV infections, compared to those who do not. Nearly one in seven new HIV infections could be prevented if young women were not subjected to physical or sexual abuse and a similar proportion if they did not experience the greatest relationship power inequalities [2]. Research also shows that young women who have experienced sexual abuse in childhood and are not infected from the sexual acts are at greater risk of subsequent HIV infections as adolescents [3].

These findings are of huge importance in programming around HIV prevention and sexual health promotion for women of all ages. It is important to recognise that there is no direct biological connection, and this also means that the relative importance of exposure to violence may differ somewhat between populations. South African research suggests that severe violence exposure (more than one episode of physical or sexual intimate partner violence) is critical here, rather than any violence exposure.

The two most important intersections between violence, gender inequity and heightened HIV risk find expression in ideas about appropriate behaviour of men and women. In particular, these relate to the notion that men should be dominant over and in control of women, they should be heterosexual and should demonstrate their fearlessness, emotional resilience and heterosexuality through having many partners, buying sex if necessary, heavy drinking and care-freeness with respect to HIV risks [4].

Parallel expectations from women are that they will submit and treat their man ‘like a father' and not challenge his behaviour and control [5]. The use of violence is of course just one way in which control of female partners is achieved; women who submit to their male partner may not experience violence, but may none the less be at risk. Not all women do submit yet the context of resistance may also lead to violence, as in South Africa violence, especially rape, is often used to impose norms that women may have otherwise resisted. So women who position themselves as independent, whether by resisting men's advances or by adopting lifestyles that are more akin to those accepted for men, for example through seeking transactional sex, engaging in sex work, or having multiple partners, are more likely to experience violence from men, as well as having greater HIV risks associated with these practices. Such gender positions of submission and resistance on the part of women are fluid and women may submit in some relationships but not others, or at different times in their lives.

Most of the critical South African-based understandings of gender and HIV come from research with young women and men, mainly teenagers, and for them this is a critical formative stage in development. Research shows that teenagers tend to be more socially conservative with respect to gender roles than older men and women. This undoubtedly influences the high HIV incidence among teenage girls. Addressing their vulnerability requires working through the issues surrounding gender, and will not be achieved through attempts to change behaviour in isolation from the broader social and relational context.

Men mostly control sexual encounters, and it is tempting to think that programmes targeting them and their self-interest will be enough but, apart from the obvious exclusion of women, this is short sighted. Understandings from gender theory indicate that the impact on men will be limited by ideals of masculinity emphasising the demonstration of their manliness, with related sexually risky practices, unless interventions set out to change these. Evidence from the Stepping Stones programme evaluation shows that men can change in response to interventions that address gender issues, even among impoverished, relatively disempowered rural men, and that the incremental changes that made men a little less violent and more caring translated into a lower risk of genital herpes infections [6].

Discussion of gender and HIV is incomplete without reflecting on the risks for women in sex work and their clients. Whilst there has been a dominant focus on protecting individual sex acts, the broader understanding of how young women come to be in sex work and the multiple risks therein are often ignored. There is a particularly well established trajectory between early sexual abuse and engagement in sex work, which makes the practice inherently deeply interwoven with gender equity issues.

Furthermore women in sex work are perceived as subordinated by both their gender and by stigmatised sexual practices, rendering them particularly vulnerable to physical and sexual violence from their male clients, partners and others, such as the police. The gender inequity, violence and sex work nexus is further explicated by research that shows that men who engaged sexually with female sex workers, such as those who have transactional sex and relationships, are particularly prone to violence, criminal engagement and sexual risk taking [7].

In 2012 there is no lack of scientific evidence supporting the need for programming on gender equity and prevention of violence, and its critical role in reducing HIV risk. Developing means to effectively translate the evidence into programming is essential. Core elements involve a recognition that efforts need to be directed at both men and women, and that for adolescents, HIV prevention and reproductive health promotion need to be co-programmed with gender equity as they have common roots.

Recent reviews of what works in the prevention of sexual and intimate partner violence, published by the WHO, show that some of the interventions that have been evaluated have proven to be effective in violence prevention and can form key parts of HIV prevention programming. Of course further research into interventions is needed, but the central challenge is to develop mechanisms for programming what is now known to work whilst further developing the evidence base.

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References

1. Jewkes R (2010) Gender inequities must be addressed in HIV prevention. Science 329: 145-147.
2. Jewkes R, Dunkle K, Nduna M, Shai N (2010) Intimate partner violence, relationship gender power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. The Lancet 367: 41-48.
3. Jewkes R, Dunkle K, Nduna M, Jama N, Puren A (2010) Associations between childhood adversity and depression, substance abuse & HIV & HSV2 in rural South African youth. Child Abuse and Neglect 34: 833-841.
4. Jewkes R, Morrell R (2010) Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. . Journal of the International AIDS Society 13: (9 February 2010).
5. Jewkes R, Morrell R (2012) Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practices. Social Science & Medicine 74: 1729-1737.
6. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, et al. (2008) Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 337: a506.
7. Jewkes R, Sikweyiya Y, Morrell R, Dunkle K, Penn-Kekana L (2012) Men, prostitution and the provider role: understanding the intersections of economic exchange, sex, crime and violence in South Africa. PLoS One.