Gender-based violence and HIV in Asia and the Pacific November 2015 www.aidsdatahub.org HIV and AIDS Data Hub for Asia-Pacific Gender-based violence (GBV) and intimate partner violence (IPV) can increase the risk of HIV transmission Globally, studies have shown that IPV can increase the risk of HIV infection by around 50%. (3) In Thailand, FSW who experienced physical and/or sexual violence are 31% more likely to report an STI symptom. (2) In Asia, between 15-65% women experience violence by their intimate partner during their lifetime. (4) Globally, women exposed to IPV from husbands exposed to HIV through regular unprotected multiple partner sex have a 7-times higher HIV risk compared with women not exposed to intimate partner violence and whose husband did not have sex with multiple partners. (1) Sources: (1)Decker, M. R., Seage, G. R., Hemenway, D., Raj, A., Saggurti, N., Balaiah, D., & Silverman, J. G. (2009). Intimate Partner Violence Functions as both a Risk Marker and Risk Factor for Women’s HIV Infection: Findings from Indian Husband-Wife Dyads. Journal of Acquired Immune Deficiency Syndromes (1999), 51(5), 593–600. http://doi.org/10.1097/QAI.0b013e3181a255d6; (2) Decker, M. R., McCauley, H. L., Phuengsamran, D., Janyam, S., Seage, G. R., & Silverman, J. G. (2010). Violence Victimization, Sexual Risk and STI Symptoms Among a National Sample of FSWs in Thailand. Sexually Transmitted Infections, 86(3), 236–240. http://doi.org/10.1136/sti.2009.037846; (3) Watts, C., cited in Hale, F., Vasquez, M./Development Connections, International Community of Women Living with HIV/AIDS, UN Women. (2011). Violence Against Women Living with HIV/AIDS: A Background Paper. USA; (4) UNAIDS. (2009). HIV Transmission in Intimate Partner Relationship in Asia. Geneva. Violence against key populations www.aidsdatahub.org HIV and AIDS Data Hub for Asia-Pacific Key populations who were forced to have sex, 2008-2014 % 50 Last 6 months Last 12 months Ever 41 40 29 30 28 25 22 20 21 16 15 13 10 2 0 Herat, Afghanistan (2012) Lao PDR (2008) FSW FSW 16 Terai Port Dhaka, Port Dhaka, Kabul, Yangon, Highway Moresby, Bangladesh Moresby, Bangladesh Afghanistan Myanmar Districts, PNG (2010) (2013-14) PNG (2010) (2013-14) (2008) (2013-2014) Nepal (2012) MSW MSW TG TG Fiji (2010-11) MSM MSM Source: Prepared by www.aidsdatahub.org based on IBBS 2008 (Lao PDR); IBBS 2012 (Afghanistan); IBBS 2012 (Nepal); Kelly, A., Kupul, M., Man, W. Y. N., Nosi, S., et al. (2011). Askim Na Save (Ask and Understand): People Who Sell and Exchange Sex in Port Moresby; Bavinton, B., Singh, N., Naiker, D. S., et al. (2011). Secret Lives, Other Voices: A Community-Based Study Exploring Male-to-Male Sex, Gender Identity and HIV Transmission Risk in Fiji.; Khan S., et al., Rapid assessment of male vulnerabilities to HIV and sexual exploitation in Afghanistan, March 2009; UNESCO, & Ministry of Health, Myanmar. (2015). Multi-level Risk and Protective Factors and HIV-related Risk Behaviours among Young Men who Have Sex with Men (YMSM) in Myanmar; icddr,b. (2015). A Survey of HIV, syphilis and risk behaviors among males having sex with males, male sex workers and hijra. Global Fund Rolling Continuation Channel Project of icddr,b. HIV and AIDS Data Hub for Asia-Pacific Violence against key populations Thailand: TG and MSWs identified as female or gay and those who took on the anal receptive sex role in their relationships were significantly and independently associated (CI=95%) with experiencing coerced sex (1) Thailand (Pattaya):In a 2008 study, 89% and 69% of TG and MSM, respectively, reporting having experienced violence as a result of their sexual/gender identify and/or behavior. (2) 16% of female sex workers in Hunan, China, reported work-related violence (3) Bangladesh: 36% of MSM, 28% of TG people (Hijras), and 45% of MSWs reported having been raped or beaten in the previous year. (4) Sources: (1) Cited in Betron, M. and E. Gonzalez-Figueroa.(2009). Gender Identity, Violence, and HIV among MSM and TG: A Literature Review and a Call for Screening. Washington, DC: Futures Group International, USAID Health Policy Initiative, Task Order 1; (2) Cited in Betron, M. (2009). Screening for Violence against MSM and Transgenders: Report on a Pilot Project in Mexico and Thailand. Washington, DC: Futures Group, USAID Health Policy Initiative, Task Order 1; (3) Kelvin, E. A., Sun, X., Mantell, J. E., Zhou, J., Mao, J., & Peng, Y. (2013). Vulnerability to sexual violence and participation in sex work among high-end entertainment centre workers in Hunan Province, China. Sexual Health, 10(5), 391–399. http://doi.org/10.1071/SH13044; (4) FHI 360. (2013). Exploring Gender Based Violence Among Men Who Have Sex With Men (MSM), Male Sex Worker (MSW) and Transgender (TG) Communities in Bangladesh and Papua New Guinea. Washington, D.C. HIV and AIDS Data Hub for Asia-Pacific Proportion of female sex workers who were physically assaulted, 2006-2012 % last 3 months last 12 months 60 53 51 50 45 40 32 30 17 20 21 11 10 0 Luangnamtha 16 Terai Highway Districts Kathmandu Lao PDR (2008)* Nepal (2012) Nepal (2011)* Chittagong Fiji (2012) Dhaka Khulna Bangladesh (2006-2007)* * Street-based FSW Source: Prepared by www.aidsdatahub.org based on Behavioural Surveys and Integrated Biological and Behavioural Surveys HIV and AIDS Data Hub for Asia-Pacific Proportion of female sex workers who were physically assaulted or harassed by police or security personnel, 2010-2012 % 30 25 25 18 20 harassed in the last 12 months 13 15 10 5 4 physically assaulted in the last 6 months 0 6 Terai Highway Districts 22 Terai Highway Districts Nepal (2012) 16 Terai Highway Districts Papua New Guinea (2010) Source: Prepared by www.aidsdatahub.org based on Ministry of Health and Population, National Centre for AIDS and STD Control (NCASC). (2012). Integrated Biological and Behavioral Surveillance Survey among Female Sex Workers in 22 Terai Highway Districts of Nepal 2012 and Kelly, A., Kupul, M., Man, W. Y. N., Nosi, S., et al. (2011). Askim Na Save (Ask and Understand): People Who Sell and Exchange Sex in Port Moresby HIV and AIDS Data Hub for Asia-Pacific Proportion of female sex workers who have been forced to have sex, 2008-2012 6 months % 12 months Ever 80 64 60 40 20 18 21 24 26 21 22 21 29 7 13 Pakistan (2011) Nepal (2011) Nepal (2012) Source: Prepared by www.aidsdatahub.org based on Behavioural Surveys and Integrated Biological and Behavioural Surveys TimorLeste (2008) Herat Kabul 16 Terai Highway 22 Terai Highway Kathmandu Pokhara Cell phone-based Street-based Brothel-based Home-based 0 Afghanistan (2012) HIV and AIDS Data Hub for Asia-Pacific Proportion of FSW who were forced by clients for unprotected sex in the last 3 months, 2005-2008 Lao PDR (2008) 52 Luang Prabang, Lao PDR (2008) 67 Cambodia (2005) * 67 * Last week 0 20 Source: Prepared by www.aidsdatahub.org based on IBBS 2008 (Lao PDR) and STI Sentinel Survey 2005 (Cambodia) 40 60 % 80 HIV and AIDS Data Hub for Asia-Pacific Police and client violence against sex workers Police brutality may force sex workers into hiding, effectively excluding them from basic health and social care services. In an effort to not be identified as a sex worker and be a target of police corruption, many sex workers don’t carry condoms. Economic violence including extortion by police can prompt sex workers to take on riskier clients or sex acts to recover lost money. It can also reduce financial resources which in turn limits sex workers’ ability to afford medical treatment, increasing the risk of injuries going untreated and likelihood of HIV transmission. In a multi-country study, published in 2015, police personnel and clients were the most commonly cited people who used violence against sex workers, across study sites in Indonesia, Myanmar, Nepal and Sri Lanka and across gender categories. Sources: Open Society Institute. (2006). Fostering Enabling Legal and Policy Environments to Protect the Health and Human Rights of Sex Workers. Johannesburg, South Africa; UNFPA. (2015). Policy Brief. Sex Work, Violence and HIV – From Evidence to Safety. Bangkok; Bhattacharjya, M., Fulu, E. and Murthy, L. with Seshu, M.S., Cabassi, J. and VallejoMestres, M. (2015). The Right(s) Evidence – Sex Work, Violence and HIV in Asia: A Multi-Country Qualitative Study. Bangkok: UNFPA, UNDP and APNSW (CASAM). HIV and AIDS Data Hub for Asia-Pacific State-level violence against sex workers Fiji: A 2009 study revealed that police surveillance and the threat of criminal sanction affects the ability of sex workers to safely negotiate prices and condom usage with clients. (1) China: A 2010 study demonstrated that median syphilis prevalence in incarcerated sex workers was twelve-times higher than sex workers who were not incarcerated. (2) China: Based on 31 qualitative interviews, sex workers felt compelled to pay large bribes to the arresting officers to avoid detention.(3) Thailand: FSW reported giving up to 10-17% of their earnings as bribed to police (Migrants FSW from Lao PDR, Cambodia, Myanmar). (4) India: A 2011 study indicated that sex workers who have experienced a police raid are threetimes more likely to report an STI and four-times more likely to report client violence. (5) PNG:15% of FSW and 21% pf TGSW surveyed reported being forced to have sex by police in the last 6 months. (6) Sources: (1) McMillan K., and H. Worth (2010) Risky Business: Sex work and HIV prevention in Fiji. International HIV Research Group, UNSW, Sydney; (2) Tucker, J., Ren, Xi., Sapio, F. (2010), “Incarcerated sex workers and HIV prevention in China: Social suffering and social justice countermeasures,” Social Science & Medicine, vol. 70 no. 1: 121-129; (3) Asia Catalyst 2013: asiacatalyst.org/blog/AsiaCatalyst_CustodyEducation2013-12-EN.pdf; (4) EMPOWER Foundation (2012). Hit and Run: The Impact of Anti Trafficking Policy and Practice on Sex Worker’s Human Rights in Thailand. Bangkok: RATS-W Team EMPOWER Foundation; (5) Erausquin, J.T., Reed, E., Blankenship, K.M. (2011), Police-Related Experiences and HIV Risk Among Female Sex Workers in Andhra Pradesh, India, Journal of Infectious Diseases, vol. 204 (Suppl. 5):1223–1228; (6) Kelly, A., Kupul, M., Man, W.Y.N., Nosi, S., Lote, N., Rawstorne, P., Halim, G., Ryan, C. & Worth, H. (2011) Askim na save (Ask and understand): People who sell and/or exchange sex in Port Moresby. Key Quantitative Findings. Papua New Guinea Institute of Medical Research and the University of New South Wales: Sydney, Australia; HIV and AIDS Data Hub for Asia-Pacific Violence and impunity Early age of perpetration of violence 23% of men who raped in Bougainville, PNG, and 16% in Cambodia were 14 years or younger when they first committed this crime. (2) Inclusion of boys and men in all responses to eliminate gender-based violence and abuse is crucial. Making sure that key populations know their rights is not sufficient, they also need to know where to seek help without facing stigma and discrimination. In Cambodia 67% of PLHIV who had their rights violated had attempted to access legal assistance but only 6% knew about any legal services or human rights organizations to approach for help. (1) Between 72-97% of the respondents who had perpetrated rape did so in complete impunity. (2) Sources: (1) Cambodian People Living with HIV Network (CPN+) (2010). People Living with HIV Stigma Index. Phnom Penh. (2) Fulu, E., Warner, X., Miedema, S., Jewkes R., Roselli, T., Lang, J. (2013). Why Do Some Men Use Violence Against Women and How Can We Prevent It? Quantitative Findings from the United Nations Multi-country Study on Men and Violence in Asia and the Pacific. Bangkok: UNDP, UNFPA, UN Women and UNV. HIV and AIDS Data Hub for Asia-Pacific Intimate partner violence (IPV) Studies have shown that key populations in Asia and the Pacific experience intimate partner violence In Pakistan, up to 66% of FSW faced physical violence and 34% faced sexual violence from their intimate partners. (1) In PNG 29% of TGSW were physically assaulted by a family member. (3) In China 55% of FSW reported emotional violence, 20% reported physical violence, and 16% reported sexual violence. (2) Violence against MSM and TG is used as a way to subordinate them to inferior feminine roles. (4) Sources: (1) Hawkes, S., et al. (2009). “HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: A cross-sectional prevalence survey,” Sexually Transmitted Infections, vol. 85;Suppl. 2:8–16; (2) Zhang, C., Li, X., Hong, Y., Chen, Y., Liu, W., Zhou, Y. Partner violence and HIV risk among female sex workers in China. AIDS Behav. 2012 May;16(4):1020-30. doi: 10.1007/s10461-011-9967-0; (3) Kelly, A., Kupul, M., Man, W.Y.N., Nosi, S., Lote, N., Rawstorne, P., Halim, G., Ryan, C. & Worth, H. (2011) Askim na save (Ask and understand): People who sell and/or exchange sex in Port Moresby. Key Quantitative Findings. Papua New Guinea Institute of Medical Research and the University of New South Wales: Sydney, Australia; (4) Cited in Betron, M. and E. Gonzalez-Figueroa. Task Order 1. (2009). Gender Identity, Violence, and HIV among MSM and TG: A Literature Review and a Call for Screening. Washington, DC: Futures Group International, USAID |Health Policy Initiative, Task Order 1. Gender-based violence against women and girls living with HIV www.aidsdatahub.org HIV and AIDS Data Hub for Asia-Pacific Proportion of women living with HIV who had a desire to have children reported being coerced to undergo sterilization, 2012-2013 35% 30% 25% 20% 33% 15% 22% 10% 5% 11% 11% Indonesia (2012-2013) Philippines (2012-2013) 5% 0% Lao PDR (2013) Source: Prepared by www.aidsdatahub.org based on http://apnmata.org/country-profiles/ Pakistan (2012-2013) Nepal (2012-2013) HIV and AIDS Data Hub for Asia-Pacific Proportion of surveyed HIV-positive pregnant women who were asked to undergo sterilization, 2011 50% 40% 30% 20% 10% 35% 15% 15% 18% Nepal Bangladesh Viet Nam 39% 40% India Indonesia 0% Cambodia Source: Prepared by www.aidsdatahub.org based on Women of the Asia Pacific Network of People Living with HIV (APN+). (2012). Positive and Pregnant. How Dare You. A study on access to reproductive and maternal health care for women living with HIV in Asia. Bangkok. HIV and AIDS Data Hub for Asia-Pacific Number of HIV-positive pregnant women who were asked to undergo sterilization and had the option to decline, 2011 Number of HIV-positive pregnant women 80 70 70 67 60 50 40 34 39 44 39 36 25 30 20 10 Asked to undergo sterilisation 5 2 6 1 Had the option to decline 0 Source: Prepared by www.aidsdatahub.org based on Women of the Asia Pacific Network of People Living with HIV. (2012). ‘Positive and Pregnant. How Dare You. A study on access to reproductive and maternal health care for women living with HIV in Asia. Bangkok. HIV and AIDS Data Hub for Asia-Pacific Violence as a consequence of HIV The People Living with HIV Stigma Index shows that women living with HIV in Asia and the Pacific are more likely than men living with HIV in the to be the target of verbal abuse and physical violence as a direct result of their HIV status. (1) The People Living with HIV Stigma Index report for Fiji revealed that 13% of respondents had experienced forced disclosure of HIV status to sexual partners. Forced disclosure of HIV status and breach of patient confidentiality by healthcare providers has the potential of increasing women’s – as well as men’s – risk of violence, including IPV. (4) In a survey of 757 women living with HIV in Asia, 30% reported having been advised to undergo sterilisation. Many stated they did not feel they had the right to refuse the recommendation. More than half (61%) indicated these recommendations came from gynaecologists and HIV clinicians on the basis of the women’s HIV-positive status. (2) The People Living with HIV Stigma Index report for Pakistan found that 37% of the 228 female respondents felt they had been coerced by a healthcare professional into an abortion. (3) Sources: (1) GNP+, ICW, IPPF, UNAIDS. (2011). People Living with HIV Stigma Index: Asia Pacific Regional Analysis 2011. Bangkok; (2) Asia Pacific Network of People Living with HIV (APN+) (2012). Positive and Pregnant: How Dare You. A study on access to reproductive and maternal health care for women living with HIV in Asia. Bangkok; (3) The Association of People living with HIV and AIDS (APLHIV). (2012) The People Living with HIV Stigma Index: An index to measure the stigma and discrimination experienced by people living with HIV in Pakistan 2009-10. Islamabad; (4) The Fiji Network for People Living with HIV AIDS (2010). People Living with HIV Stigma Index – Fiji Islands. Suva. Violence against women in the general population www.aidsdatahub.org HIV and AIDS Data Hub for Asia-Pacific Proportion of women (15-49) who have experienced physical violence during pregnancy, 2005-2014 Maldives (2006) 6 Nepal (2011) 6 Viet Nam (2009) 5 Thailand (2005) 4 Bangladesh (2006) 4 Philippines (2013) 4 Cambodia (2014) 4 Timor Leste (2009-2010) 4 0 2 4 6 8 % Sources: Prepared by www.aidsdatahub.org based on Demographic and Health Surveys; Viet Nam General Statistics Office .(2010). ‘Keeping Silent Is Dying’ Results from the National Study on Domestic Violence against Women in Viet Nam; Ministry of Gender and Family. Ministry of Gender and Family. (2007). The Maldives Study on Women’s Health and Life Experiences: Initial results on prevalence, health outcomes and women’s responses to violence. Malé.; Garcia-Moreno, C., Jansen, H., Ellsberg, M., Heise, L. and Watts, C. (2005). WHO Multi-country Study on Women's Health and Domestic Violence against Women. World Health Organization. Geneva. HIV and AIDS Data Hub for Asia-Pacific Proportion of women (15-49) who have ever experienced physical or sexual violence, 2005-2014 100 physical violence % sexual violence 80 60 49 6 6 Rural Total Urban 10 9 20 19 6 7 6 4 3 3 Total 6 20 12 Rural 6 13 11 28 22 Urban 22 19 38 35 32 Total 20 34 Rural 28 20 18 Urban 20 34 Urban 36 40 Cambodia (2014) India (2005-06) Nepal (2011) Source: Prepared by www.aidsdatahub.org based on Demographic and Health Surveys Total Rural Urban Total Rural Urban Total Rural 0 Pakistan (2012-13) Philippines (2013) Timor Leste (2009) HIV and AIDS Data Hub for Asia-Pacific Proportion of women (15-49) who have experienced physical violence in the last 12 months, 2006-2014 % 100 80 60 40 29 19 20 6 8 8 9 Philippines (2013) Bangladesh (2006) Cambodia (2014) Nepal (2011) 0 Source: Prepared by www.aidsdatahub.org based on Demographic and Health Surveys India (2005-2006) Timor Leste (2009-2010) HIV and AIDS Data Hub for Asia-Pacific Proportion of women who have experienced sexual violence by spouse or intimate partner, 2005-2014 20 % Last 12 months 18 18 Ever 16 14 14 12 8 2 7 7 5 6 4 10 10 10 8 6 4 2 3 2 3 2 0 Bangladesh Timor Leste Philippines (2006) (2009-2010) (2013) Cambodia (2014) Maldives (2006) Viet Nam (2009) India (2005-2006) Nepal (2011) Pakistan (2013)* * Physical or sexual violence Source: Prepared by www.aidsdatahub.org based on Demographic and Health Surveys;Viet Nam General Statistics Office . (2010). ‘Keeping Silent Is Dying’ Results from the National Study on Domestic Violence against Women in Viet Nam. Ministry of Gender and Family; Ministry of Gender and Family. (2007). The Maldives Study on Women’s Health and Life Experiences: Initial results on prevalence, health outcomes and women’s responses to violence. Malé. HIV and AIDS Data Hub for Asia-Pacific Proportion of women who have experienced intimate partner violence in the last 12 months, Pacific Island Countries and Territories, 2007-2009 % 40 35 30 physical violence 25 20 15 10 sexual violence 5 0 Marshall Islands (2007) Tuvalu (2007) Kiribati (2008) Vanuatu (2009) Source: Prepared by www.aidsdatahub.org based on Demographic and Health Surveys; Vanuatu Women’s Centre. (2011). The Vanuatu National Survey on Women’s Lives and Family Relationships. VWC. Port Vila.; Secretariat of the Pacific Community for Ministry of Internal and Social Affairs. (2010). Kiribati Family Health and Support Study: A study on violence against women and children. Ministry of Internal and Social Affairs, South Tarawa. HIV and AIDS Data Hub for Asia-Pacific Prevalence of men’s lifetime perpetration of physical and/or sexual partner violence, by site, 2010-2013 % of men reporting Bangladesh (rural) 42 Bangladesh (urban) Cambodia (national) 10 5 45 12 5 8 3 17 Physical violence only China (urban/rural) 32 Indonesia (rural) 7 4 Indonesia (urban) 6 6 Indonesia (Papua) 16 PNG (Bougainville) Sri Lanka (national) 13 14 Both physical and sexual violence 18 21 21 17 7 41 7 Sexual violence 22 18 9 Source: Fulu, E., Warner, X., Miedema, S., Jewkes R., Roselli, T., Lang, J. (2013). Why Do Some Men Use Violence Against Women and How Can We Prevent It? Quantitative Findings from the United Nations Multi-country Study on Men and Violence in Asia and the Pacific. Bangkok: UNDP, UNFPA, UN Women and UNV. HIV and AIDS Data Hub for Asia-Pacific Sexual violence against women Source: Fulu, E., Warner, X., Miedema, S., Jewkes R., Roselli, T., Lang, J. (2013). Why Do Some Men Use Violence Against Women and How Can We Prevent It? Quantitative Findings from the United Nations Multi-country Study on Men and Violence in Asia and the Pacific. Bangkok: UNDP, UNFPA, UN Women and UNV. HIV and AIDS Data Hub for Asia-Pacific Proportion of men (15-49) who agree that a husband is justified in hitting or beating his wife if she refuses to have sexual intercourse with him, 2005-2014 % 50 40 Urban 30 30 27 20 20 16 16 10 2 4 4 5 10 8 9 4 3 2 7 4 5 Total 0 Cambodia (2014) India (2005-06) Indonesia (2012) Source: Prepared by www.aidsdatahub.org based on Demographic and Health Surveys Pakistan (2012-13) Samoa (2009) Rural Timor-Leste (2009-10) HIV and AIDS Data Hub for Asia-Pacific Acceptance of violence prevents women from reporting violence Reported prevalence of physical and/or sexual intimate partner violence by site, comparison of men (perpetrated) and women (experienced) reports Sri Lanka (national) 28 33 68 PNG (Bougainville) 80 Cambodia (national) Bangladesh (urban) Bangladesh (rural) Women 39 China (urban/rural) 52 25 Men 33 53 55 62 57 Source: Fulu, E., Warner, X., Miedema, S., Jewkes R., Roselli, T., Lang, J. (2013). Why Do Some Men Use Violence Against Women and How Can We Prevent It? Quantitative Findings from the United Nations Multi-country Study on Men and Violence in Asia and the Pacific. Bangkok: UNDP, UNFPA, UN Women and UNV. HIV and AIDS Data Hub for Asia-Pacific THANK YOU slides compiled by www.aidsdatahub.org and UNAIDS Regional Support Team for Asia and the Pacific Data shown in this slide set are comprehensive to the extent they are available from country reports. Please inform us if you know of sources where more recent data can be used. Please acknowledge www.aidsdatahub.org if slides are lifted directly from this site.