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Vulnerability and Empowerment: At the International AIDS Conference, an Examination of Sexual Abuse and Violence Against Women -- and Men

By Enid Vázquez

November/December 2012

A history of recent abuse increases the risk of death by 40% in HIV-positive women, U.S. researchers reported at the 19th International AIDS Conference, held in Washington, D.C. in July.

Of note, men were also discussed in the session "Reducing Women's Vulnerability and Reinforcing Empowerment Opportunities," which examined both risks for HIV and potential strategies for reducing them. A South African study looked at sexual assault against men and a study from Pakistan looked at working with HIV-positive men to prevent transmission to their wives.

Another presentation, from the U.S., explained the concept of "critical consciousness," a strategy for taking power in your life, and two reports discussed gender-based experiences in HIV care in Zambia and South Africa, in both men and women.

"Sex is biological," explained co-facilitator Changu Mannathoko from UNICEF as she opened the session. "Gender is social, but it is very, very complicated."


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Abuse and Mortality

Kathleen M. Weber, R.N., of the Cook County [Chicago area] Health and Hospital Systems presented "The Effect of Gender-Based Violence (GBV) on Mortality: A Longitudinal Study of U.S. Women With and At Risk for HIV." Overall, women reporting a history of recent abuse were twice as likely to die in the timeframe of the study (1994-2007).

The findings arose from the Chicago unit of the Women's Interagency HIV Study (WIHS) cohort (basically, a research group of people with similar characteristics). The WIHS (pronounced "wise") cohort, which provides clinical care along with research, includes a group of HIV-negative women at high risk of infection for comparison. As could be predicted based on other research, all of these women had a high rate of lifetime abuse and violence, especially in childhood. The rate for lifetime history of abuse in the WIHS cohort is 72%.

When WIHS providers noted, however, a high rate of recent abuse, they decided to look at this and try to determine its impact on survival.

Weber said it's not surprising that women with a history of abuse would experience continuing or episodic abuse, pointing to well-established research findings showing just such a link, but the researchers were surprised to find that violence remained a constant in more than a full third of this group (36%). Moreover, the findings suggest that the background effect of violence on mortality may be hidden (or "masked," in statistical jargon) by the presence of HIV.

The study looked at 2,222 women (1,642 women with HIV and 580 HIV-negative) from the Chicago, New York City (Bronx and Brooklyn), and Washington, D.C. sites of WIHS. (The other two sites are Los Angeles and San Francisco.) Of the women in this study, 78% had a history of abuse at some point in their life.

Taking into consideration other risk factors such as smoking, depression, HIV infection, and lack of HIV therapy in the positive women, a history of gender-based violence remained a statistically significant risk factor for death. The HIV-negative women also had a higher risk of death if there was GBV, four times higher (or 400%). The number of deaths in this group, however, was only seven. "Still, abuse increased mortality," Weber said.

In her presentation, Weber noted the known connection between trauma and a host of negative health effects, such as depression, chemical addiction, and undesirable biological changes (including the production of the stress hormone cortisol and damage to the neuroendocrine and immune systems), arguing for continuing research into "possible biologic pathways underlying abuse-related sequelae [conditions resulting from previous disease]."

As background information, the WIHS study noted that, "Gender-based violence (GBV) is a human rights violation impacting the health of women globally. GBV increases risk for both HIV acquisition and transmission; HIV may increase risk for abuse. Prevalence of GBV is high (24-72%) among women with and at risk for HIV infection. Psychosocial consequences of GBV (unemployment, depression, and substance abuse) are associated with reduced adherence [to medication] and poor [health] outcomes."

The more recent abuse (in the previous year) experienced by the women reporting it included forced sexual contact, physical abuse or assault, or intimate partner violence (threatening to hurt or kill them and preventing them from: leaving or entering their home, meeting friends, making phone calls, attending school or work, or getting medical care).

Weber presented several strategies for turning the tide together on this violence. First, survival may improve with identification of current abusive episodes and interventions. Second, as stated above, continued research into the relationship of gender-based violence, trauma, post-traumatic stress disorder (PTSD), and other stressful life events on the neuroendocrine and immune systems and the resulting impact on mortality. Third, health care providers can screen for violence and provide referrals "to keep women safe and alive." Fourth, a cultural shift toward a zero tolerance approach to family and community violence. Lastly, but even more ambitious, "gender equity, reducing poverty, increasing educational opportunities, and women's empowerment to challenge structural violence." ("Structural violence" refers to such problems as the high prevalence of rape both here and around the world, intimate partner violence, etc.)

Although the WIHS research summary included in its conclusions screening and referrals by health care providers, the solution may not be that simple. Weber noted during her talk that the women often don't follow up with referrals from WIHS to get help in dealing with the violence in their life.

Read an interview with Kathleen M. Weber, R.N., here.
See the abstract and slides on "The Effect of Gender-Based Violence (GBV) on Mortality: A Longitudinal Study of U.S. Women With and At Risk for HIV."
See "Domestic Violence Doubles Risk of Death for HIV-Positive Women" from AIDSmeds.com here.

Critical Consciousness

Doctoral psychology student Gwendolyn Kelso of Boston University presented on the concept of critical consciousness, the "capacity to critically reflect and act upon one's sociopolitical environment." She reported specifically on African American women in the Chicago WIHS unit.

She and her colleagues surveyed 73 HIV-positive and 25 HIV-negative women. They found that the HIV-positive women with higher levels of critical consciousness had higher CD4+ T-cell counts and lower viral loads.

According to the presentation, African American women's vulnerability to the virus is shown in racial disparities in HIV and mortality; in structural factors creating vulnerability, namely racial and gender discrimination related to illicit drug use and depression; and in illicit drug use, depression, race, and HIV-related outcomes.

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The flip side to vulnerability is empowerment, namely, critical consciousness and its capacity to empower an individual by enabling them to think critically about their place in their world and act upon the realities of their sociopolitical environment by identifying areas where change is desirable and working towards that change. Empowerment is both personal, with individual coping and resilience, and political, with an aim to social change. Empowerment has been shown to be related to higher levels of education, decreased likelihood of cigarette smoking, longevity, physical and mental well-being, and commitment to a career and a future. Social change could be as simple as registering to vote and going to the polls, but in this concept, is connected to people uniting as a group to effect positive change in their lives (for example, coming together to advocate for better working conditions or to lobby legislators).

In short, if people can understand the social forces working against them, they're in a better position to deal with those forces effectively. This study affirmed other research showing that awareness of racism can improve a person's health outcomes (see the link to her slides below for references).

Read an interview with Gwendolyn Kelso, M.A., here.
See the abstract and study slides on "Critical Consciousness, Perceived Racial Discrimination, and Perceived Gender Discrimination in Relation to Demographics and HIV Status in African-American Women."

Read the full-text study, "Medically Eligible Women Who Do Not Use HAART: The Importance of Abuse, Drug Use, and Race."

The full-text study, "Causes of Death among Women with Human Immunodeficiency Virus Infection in the Era of Combination Antiretroviral Therapy," is available here.

See the abstract on "Perceived Racism and Self and System Blame Attribution: Consequences for Longevity."


Men, Women and Gender

Kristin Dunkle, M.P.H., Ph.D. of Emory University noted that while research has found a link between sexual abuse of women and of men who have sex with men (MSM) and a higher risk of HIV infection, there is much less data on the connection for other populations of men and almost none from developing countries. She and her colleagues found increased HIV risk for both male victims and perpetrators in South Africa. See their and other abstracts for presentations in this session.


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