2011

Alcohol and Gender-based Violence in Latin America: Links with HIV and Implications for Action

July 26th, 2012

Floriza Gennari, MSc

PAHO

2011

Overview:

Linkages Between Alcohol, Gender-based Violence and HIV Latin American and Caribbean Context:

• HIV • Gender-based violence• Alcohol consumption

Implications for Action

2011

Why Alcohol and Gender-Based Violence?• To strengthen HIV prevention efforts,

interventions must address GBV and alcohol consumption, especially in men and women engaged in heavy episodic drinking

• HIV care and treatment also important and affected by alcohol and GBV

2011

Links Between Alcohol and Violence • There is a positive association between drinking and

severity of aggression• GENACIS study:

– Drinkers were more likely than abstainers to report physical intimate partner violence (IPV) towards their female partners

– Women who engaged in heavy episodic drinking (HED) more likely to be victims of IPV

• Violence Against Women in LAC study:– In all countries except Paraguay (2008), the most

commonly reported triggers for IPV was his drunkenness or drug use, reported by 29.8% of women in Guatemala 2008/9 and 53.4% of women in Ecuador 2004

2011

Links Between Alcohol and Violence (cont.)• Several small-scale, qualitative studies carried out

in indigenous communities found that:– Perception that alcohol consumption has

increased, particularly among young men (Health Canada 2005)

– In San Pablo, Nicaragua, both men and women consider intra-family violence as the main problem associated with alcohol (PAHO 2006)

– In Comarca Ngogbe-Bugle, Panama, wives report that husbands are physically violent towards them when they drink (PAHO 2006)

2011

• Clear association between:– Alcohol use and HIV prevalence (e.g. meta-

analysis of African studies cf. Fisher et al., 2007)

– Alcohol use (various measures) and HIV incidence (Baliunas et al., 2010)

– Alcohol use and unsafe sex in HIV-positive people (pathway to HIV; Shuper et al., 2009)

• Overall, alcohol consumption (esp. heavy consumption) is associated with HIV incidence and course of disease

Links Between Alcohol and HIV

2011

Links Between GBV and HIV• GBV both a cause and a consequence of HIV• Women who experience GBV or high level of gender

inequality in their sexual relationships are at an increased risk of HIV infection

• Women who are HIV+ more likely to experience GBV

• Men who use violence are more likely to engage in sexual risk-taking behavior, and are more likely to be HIV-infected (India, SA)

• Past exposure to sexual/IPV/controlling behavior is associated with high-risk sexual behavior in women

Addressing violence against women and HIV/AIDS: What works? UNAIDS, WHO, 2010

2011

Links between violence against women and HIV

Addressing violence against women and HIV/AIDS: What works? UNAIDS, WHO, 2010

2011

GBV, HIV, and Alcohol Consumption: What We Conclude1. Alcohol (especially HED) is associated with intimate

partner violence2. GBV/IPV/unequal sexual relationships are

associated with HIV3. Women, indigenous peoples, MSM, transgender,

are at greater risk GBV, HIV, and harmful alcohol consumption

4. HIV interventions must address socio-cultural context, structural factors in addition to individual behavior

2011

HIV, GBV, and Alcohol Consumption in Latin America and the Caribbean

2011

HIV in Latin America and the Caribbean (LAC)Latin America:• Concentrated among men who have sex with

men (MSM), transgender people, injecting drug users (IDU), and sex workers

• MSM: comprise 25% of HIV infections, and almost 1 in 3 have sex with both men and women

• Feminization of HIV: increase from 6% in 1994 to more than 30%

• Indigenous peoples: 5% of new infections in Central America have occurred in Garifuna living in Belize, Guatemala, Nicaragua and Honduras, (overall prevalence 4.5%). (Bastos, FI, et al, 2008)

“Challenges Posed by the HIV Epidemic in LAC” 2009, UNAIDS, PAHO, UNICEF

2011

HIV in Latin America and the Caribbean (LAC)The Caribbean:• 2nd highest HIV prevalence in the world, after Sub-

Saharan Africa (1.0% [0.9–1.1%]). (UNAIDS, 2009) • Women account for about 50% of all infections. In

Trinidad and Tobago, Guyana, and Belize nearly 60% of those infected are women

• High prevalence among sex workers: studies found 27% in Guyana, 24% in Suriname, and 9% in Jamaica

• HIV burden among MSM also high - 20% of MSM in Trinidad and Tobago and 31% of MSM in Jamaica Bastos, FI et al. (2008), UNAIDS 2009

2011

Barriers in Accessing HIV Testing, Care and Treatment

Sex/gender identity

Income/socio-economic status

Ethnic/cultural background

Cultural/linguistic barriersWomen suffer double discriminationMistreatment by health care workers

Men less likely to seek careWomen: GBV, exploitation/sexual traffickingLess access to services/information

Fear of rejection, stigma, and discrimination

Limited funds/time/transportation Lack of information

Sexual orientation

Multiple

Obstacles

2011

Physical partner violence against women, ever and past 12 month (DHS: current/most recent partner study)

Source: Preliminary results, PAHO/CDC (forthcoming) “Violence against women in LAC”

2011

Lifetime sexual violence by a partner and by any perpetrator:

Source: Preliminary results, PAHO/CDC (forthcoming) “Violence against women in LAC”

2011

Unwanted or Coerced First Sex

Source: WHO Multi-country Study (2005) and Preliminary results, PAHO/CDC (forthcoming) “Violence against women in 12 countries from LAC”

2011

Gender-based Violence and Ethnic Origin

Sources: 1) Ecuador: Source: CEPAR. Demographic and Maternal and Child Health Survey, ENDEMAIN 2004. Final Report. Quito, October 2005. (2) Guatemala: MSPAS/INE/UVG/CDC/USAID/ASDI/APRESAL/EU /UNDP/UNICEF/UNFPA/Project POLICY II/CARE. Encuesta Nacional de Salud Materno Infantil 2002 [National Maternal and child Health Survey 2002], Guatemala, October 2003.

10.3

13.2

9.9

8.4

16.6

8.6

11.4

7.3

15.3

19.5

14.8

14.5

20.4

25.2

33.0

21.8

3.8

4.6

3.8

2.1

5.1

3.5

3.9

3.3

0 10 20 30 40

Total

Indigenouspopulation

Mestizo

White

Other

Total

Indigenouspopulation

Ladino

Ecu

ador

(200

4)G

uate

mal

a (2

002)

Percentage

Physical Psychological Sexual

Women 15-49 who experienced intimate partner violence (IPV) in last year, by type and ethnic origin.Ecuador 2004, Guatemala 2003

2011

Prevalence of Heavy Episodic Drinking Among Men and Women

COUNTRY MEN (%) WOMEN (%)Argentina 55.5 9.6

Belize 38.2 8.9

Brazil 36.1 18.5

Canada 63.4 36.6

Costa Rica 34.0 11.3

Mexico 56.6 9.0

Nicaragua 40.2 6.6

Peru 59.1 26.1

Uruguay 36.7 7.4

USA 37.9 16.8

Unhappy Hours: Alcohol and Partner Aggression in the Americas, PAHO Multicentric Study, 2008

2011

Male Physical Aggression by Past-12-Month Heavy Episodic Drinking(HED)

0%

2%

4%

6%

8%

10%

12%

14%

Arg

entin

a

Bel

ize

Bra

zil

Can

ada

Cos

taR

ica

Mex

ico

Nic

arag

ua

Peru

USA

Uru

guay

No HEDHED

Source: Graham, Bernards, Munné, & Wilsnack, 2008, 2010.

2011

PAHO Interventions and Implications for Action

2011

PAHO InterventionsRelated to HIV and Gender:• Country-level support: In collaboration with USAID

supported recent Jamaica Health Systems Evaluation of the HIV Response in the area of Gender and GBV

• Capacity-building/training: With UN Women, development of a manual on HIV, Gender, and Human Rights, which incorporates the needs of specific groups such as MSM and transgender

• Evidence/guidelines: Development of a “Blueprint for the Provision of Comprehensive Care to Gay Men and Other Men Who Have Sex with Men (MSM) in Latin America and the Caribbean” as a guide for clinicians and health administrators in LAC

2011

WHO Global Strategy (2010)10 target areas:1. Leadership, awareness2. Health services response3. Community action4. Drink-driving policies5. Availability of alcohol6. Marketing of alcohol beverages7. Pricing policies8. Reducing the negative

consequences of drinking and alcohol intoxication

9. Reducing the public health impact of illicit alcohol and informally produced alcohol

10.Monitoring and surveillancePan AmericanHealthOrganization

2011

PAHO InterventionsRelated to Human Rights:• Capacity building on HIV and Human Rights for health

workers, judges and civil society (Central America, Dominican Republic, Jamaica and Belize)

• Review of national HIV law (Guatemala and El Salvador) and Ombudsperson’s report on HIV and human rights

• Evaluation of the response of the health system to HIV and STIs (El Salvador).

• Technical opinions and hearings before Inter-American Commission on Human Rights (Central America and Caribbean)

• Regional and sub-regional capacity building for LGTBI groups and sex workers (Central American and Southern Cone)

2011

PAHO InterventionsRelated to GBV:1. Evidence - Sexual violence in Latin

America and the Caribbean: A desk-review (2010) (with SVRI, UNFPA, Ipas) Comparison of population-based prevalence data on intimate partner and sexual violence from 12 countries in the region (partnership with CDC)

2. Prevention/capacity-building – 3-day training module on primary prevention of IPV/sexual violence, national workshops

3. Services - ‘Improving the health care sector response to GBV’ (with IPPF/WHR), Capacity building workshop on M&E in violence against women (with ICRW, Path, InterCambios)

2011

Implications for ActionLegal/policy reform• Implement WHO Global Strategy measures to reduce

harmful use of alcohol• Review/reform national policies and programs to ensure

their conformity with international human rights norms• Establish appropriate/culturally-sensitive health careMulti-sectoral Coordination/Capacity-Building• Coordinate a referral network between victims of GBV,

alcohol abuse and HIV services• Cross-training of clinical staff, sensitization of police,

judges on international human rights norms and standards

• Empower community-lead initiativesEvidence Building/Research• Research directly linking harmful alcohol with GBV and

HIV in LAC, more data on vulnerable groups

2011

Thank you!Acknowledgements:Dr. Maristela MonteiroDr. Alessandra Guedes

Dr. Sonja CaffeMs. Genevieve Grabman

Contact: Floriza Gennarigennarif@paho.org