Gender inequality, gender-based violence and HIV: Connections & challenges in sub-Saharan Africa

Background: Gender-based violence and gender inequality play an important role in driving the HIV pandemic, however empirical research linking violence and inequality to HIV serostatus remains limited. Most available evidence comes from sub-Saharan Africa, which is also home to most of the world's HIV positive women. Synthesizing this evidence is crucial for developing effective prevention policy and programs.

Methods: We reviewed studies from sub-Saharan Africa which link data on gender-based violence and gender inequality to HIV serostatus.

Results: Multiple pathways link gender-based violence and inequality to HIV infection among women: direct infection during sexual assault, reduction in women's power to determine the timing and circumstances of sex, and increased sexual risk as a consequence of violence. Gender power inequalities in the absence of overt violence are also associated with increased HIV infection among women. Men who perpetrate violence engage in higher levels of HIV risk behavior than non-perpetrators, and may be at higher risk for both acquiring and transmitting HIV. Interventions jointly targeting HIV risk taking and violence perpetration among men show preliminary evidence of efficacy.

Conclusions: Emerging evidence supports multiple pathways between gender-based violence, gender inequality, and HIV risk for both women and men in sub-Saharan Africa. The constraints placed on women's sexuality strongly suggest that men must be kept central in strategies for HIV prevention. We advocate a shift in focus to “gender transformative” policies and programs which move beyond acknowledging the status quo of violence and inequality in women's lives and actively seek to transform gender roles.