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Stepping Stone

Overcoming sexual violence in the context of HIV

Von Nell Osborne & Alice Welbourn

"So why is there so little recognition of sexual and other violence against women in global HIV policies?," asks Alice Welbourn in her contribution to the aidsfocus conference. We document her presentation.

Overcoming sexual violence in the context of HIV

I have recently returned from the 20th International AIDS Conference in Melbourne where, in many areas, these links between Violence against Women and HIV are only beginning to creep up into the presentations of academics and policy makers – despite decades of activism. This is because whilst the formal evidence base for violence against women as a cause of HIV has been emerging since 2010 (Defries et al, IAS 2010), it is still not widely recognized that violence is also experienced widely by women as a consequence of their HIV diagnosis.

It has taken many years of collaboration to reach the point we now inhabit, a consensus that the links between HIV and violence against women are systemic, multidirectional and wide spread.

Little Recognition of Sexual Violence against Women in global HIV Policies

So why is there so little recognition of sexual and other violence against women in global HIV policies? In part because there is still insufficient formal “evidence base” for its widespread existence in healthcare settings as well as from partners. The formal “medical evidence base” is lagging behind widespread “anecdotal” narratives of abuse. And because a lot of policy has evolved without pausing to fully understand the reality of women’s lives. Yet, “absence of evidence” of such rights violations still does not mean “evidence of absence.”

Violence against Women and HIV
Violence against Women comes in many different forms and it happens in every country in the world – endemically. Statistically, violence has been found to affect 1 in 3 women during their lifetime, worldwide: 25% of the women in Europe. The cumulative impact of this violence is predictably vast and far-reaching. 38% of murders of women globally were reported as being committed by their intimate partners. Women who have been exposed to intimate partner violence (IPV) are twice as likely to experience depression and to have alcohol use disorders. In the context of HIV, women who have experienced intimate partner violence are 1.5 times more likely to acquire HIV. Sexual violence does not happen in a vacuum. Alongside it, women normally experience physical violence as well as often life-long psychological trauma.

Sex workers with HIV get beaten by their clients in Senegal for refusing condomless sex. South African women ensure their daughters have hormonal contraceptives to ensure that when they are raped they won’t get pregnant.  42% of women living with men who inject drugs in Georgia have been physically abused by their partners. And many women, who are unable to negotiate condom use with their partners, experience daily sexual violence of state-sanctioned “marital” rape. Yet this too is sexual violence, often offering the risk of unwanted pregnancy, STIs and/or HIV - though hardly ever recognised as such.

Understanding the links between gender-based violence and HIV is vital and this means understanding the prevalence of violence, including sexual violence, against women as a result of their HIV diagnosis. There are increasingly widespread reports of anxiety and depression amongst women as a result of their HIV diagnosis. A baseline study by COWLHA Malawi (2012) clearly showed strong links between gender-based violence (GBV), anxiety and depression, and a resultant lack of adherence to Anti-Retroviral Therapy (ART). The consequences of GBV numbered, firstly, refusal to continue ART. Next there was inconsistency in following ART guidelines, which renders ARTs ineffective and can enable both resistance to the medication and drug-resistant strains of HIV to develop. Further consequence included poor management of opportunistic infections, leading to further illness, unplanned pregnancies and extra-marital sexual relationships (COWLHA 2012, 23-24). In one community in Malawi, men reported abusing their wives because they were going to hospital to access ARVs.

 Stepping Stones (Film Stil)

"I used to abuse my wife when she went to the hospital to collect her ARV treatment because she used to come back late at night and I didn't like it.”  Village headman, Malawi (Film: Salamander Trust and COWLHA, 2013).


Access to HIV care, support and treatment remains deeply affected by gendered power inequalities. By ignoring the experiences of women living with HIV we are also failing to implement successful HIV policies and health services.

Glimmers of Hope

There are however some glimmers of hope that we are beginning to think more holistically about the links between HIV and Violence against Women. Ironically, it is the rapidly increasing prevalence of HIV among women (now numbering 50% of people living with HIV worldwide) that has drawn new attention to the various and pervasive forms of Violence Against Women.

WHO Department for Reproductive Health and Research recently issued new guidelines (WHO, 2014), “Ensuring human rights in the provision of contraceptive services and information”, which recognise publically at last the limitations of the current formal research process to address the complex non-linear, socio-economic and political determinants which shape the lives of most of us: and which most certainly fuel and fan this HIV pandemic for women. These new Guidelines on contraception state: “Given that the realization of human rights within contraceptive information and services is not a research area that lends itself to randomized controlled trials or comparative observational studies, much of the evidence available for the priority topics could not be readily synthesized using the GRADE approach [which grades the strength of evidence].” 

This is a critical watershed statement in that it recognizes that current methods to create the formal “evidence base” on which policy makers and implementers wish to base their programmes are just not fit for purpose when it comes to women’s sexual and reproductive health and rights. Assessing any social intervention programme – which should by definition have human rights at its heart – by using methods used for lab-based research is just not going to be appropriate. This statement is a significant breakthrough. It valorizes two points that many of us have made for some time. Firstly, some of the amazing community-based work that is happening to address Violence against Women, in the context of HIV, may not be recognized because organisations have not been able to afford to evaluate their work through a highly expensive Randomized Control Trial (RCT) that would “prove their efficacy” in terms of a “formal evidence base.” Secondly, this statement makes it clear that such formal RCT processes may not be appropriate for community-based social interventions in any case. With this statement, we hope there may come possibilities for finding better, faster and more holistic ways of evaluating programmes which respond to the complexity of the parallel pandemics of Violence against Women and HIV. And funding to roll them out.

Gender Communication

“Stepping Stones” is a training programme on gender HIV communication and relationship skills that I wrote in the mid-1990s, as a consequence of my own HIV diagnosis (Welbourn 1995). “Stepping Stones” has been implemented by the Coalition of Women Living with HIV and AIDS in Malawi (COWLHA) – whose baseline study I referred to earlier - to reduce gender-based violence among women living with HIV. A short video, commissioned by Salamander Trust, highlights the changes, which have taken place in communities where COWLHA members live as a consequence. The community members talk to camera about less quarrelling and other forms of violence and greater harmony between partners. Other notable changes include greater shared decision-making around income and expenditure in households, a happier environment for children and increased condom use. With the reduction in GBV in these communities, many positive changes have also emerged. Similar positive changes have been experienced in communities in many different contexts and cultures around the world where the programme has been well adapted. These include the Gambia, DRC, Uganda, Kenya, Tanzania, South Africa, India, Fiji, Mozambique, Angola and many other countries also.

In conclusion, despite the ever-increasing, and no doubt well-intentioned, push to roll out medication for all with HIV, one thing at least remains certain. Unless there is a concomitant push to end to sexual violence in all its forms, we are a long long long way from achieving the end to AIDS which is sought by us all.


Alice Welbourn, 22 April 2014  HIV: Violations or investments in women’s rights? 

Bewley S, Welch J (ed.) 2014 ABC of Domestic and Sexual Violence

COWLHA 2012 Baseline Report on Intimate Partner Violence Amongst People Living with HIV Coalition of Women living with HIV and AIDS Malawi

Devries K., L. Bacchus, J. Mak, J. Child, G. Falder, C. Pallitto, C. Garcia-Moreno, C. Watts 2010 Preventing HIV by preventing violence: global prevalence of intimate partner violence and childhood sexual abuse. Oral Abstract 13616, International AIDS Conference, Vienna

Hale F.  MJ and Vazquez 2011 Violence against women living with HIV: a background paper

Salamander Trust and COWLHA 2013 Seeking Safety: Stepping Stones in Malawi film

UNAIDS 2014 Unite with women, unite against violence and HIV

UNAIDS and ATHENA 2011   Community Innovation: Achieving SRH&R for Women and Girls through the HIV Response

Welbourn A 1995 Stepping Stones training programme on gender, HIV, communication and relationship skills Strategies for Hope, Oxford

WHO 2013 Infographic on global prevalence of violence against women, Geneva

WHO 2014 Ensuring Human Rights in the Provision of Contraceptive Information and Services, Geneva

Nell Osborne & Alice Welbourn

Alice Welbourn is a trainer, writer and activist and has worked on international gender, community participation, gender-based violence, HIV and accountability issues for nearly 30 years. She is the Founding Director of Salamander Trust. Diagnosed HIV positive in 1992, she wrote a training package on gender, HIV, communication and relationship skills called “Stepping Stones” (, now widely used across Africa, Asia, the Pacific, Latin America and beyond. Alice is a former international chair of the International Community of Women Living with HIV/AIDS ( and a former member of the Leadership Council of the Global Coalition on Women and AIDS. She is currently a member of the UNESCO Global Advisory Group for sex, relationships and HIV education, and she is one of 14 women to be honoured by the World YWCA in July 2007 with an award for innovative leadership in the global response to HIV. Contact:

Nell Osborne has worked as a consultant with several non governmental organisations, specializing in digital communications. She is currently employed with the Salamander Trust, co-ordinating the global Community of Practice for Stepping Stones Feedback. She also works in production for film and video. Contact:

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