Examining violence against women and the intersecting HIV epidemic in Brazil

VIOLENCE AGAINST WOMEN

Violence against women is a worldwide epidemic, with one in three women experiencing physical or sexual violence in their lifetime. The United Nations states that “violence against women and girls is one of the most widespread, persistent, and devastating human rights violations in our world today”.

Brazil is the fifth most violent country in the world for women, where every 15 seconds a woman experiences violence and every 2 hours a woman is killed by a man. According to a 2017 survey, 29% of Brazilian women report suffering verbal, physical or psychological violence in the past year and 52% of women did nothing about the violence. Although violence against women is a critical public health problem in Brazil, less is known about the life course timing of violence, who perpetrates violence against women, and the types of violence women endure. Understanding the violence profiles experienced by women would inform more targeted violence screening initiatives and tailored care services.

VIOLENCE AND HIV

Violence against women is associated with a two- to eight-fold increased risk for HIV infection. Less work has aimed to examine the violence profiles of women who are infected with HIV.

Brazil has the greatest number of people infected with HIV (n=830,000) in Latin America and the Caribbean. Despite Brazil’s socialized healthcare system that provides free HIV care and antiretroviral medication, there are persistent regional disparities in HIV. Specifically, the southeastern and southern regions of Brazil have the highest HIV prevalence, respectively accounting for 56% and 20% of all people infected with HIV since 2013 (Figure 1).

STUDY OBJECTIVES

We examined violence profiles across women’s life course in São Paulo (southeast) and Porto Alegre (south), Brazil and contrasted violence profiles by HIV status.

STUDY DESIGN

Cross-sectional data were merged and analyzed from two studies with similar designs: 1) the GENIH study (São Paulo) and 2) Women’s Sexual and Reproductive Health in the Context of HIV/AIDS study (Porto Alegre). In each region, women were randomly selected from a list of scheduled and walk-in appointments at primary health care centers (n=27 Porto Alegre, n=38 São Paulo) and specialized HIV clinics (n=7 Porto Alegre, n=18 São Paulo) (Figure 2).

MEASURES OF VIOLENCE

Our study investigated the frequency, life course timing, and perpetrator of two types of violence, defined as:

Physical Violence: Intentional use of physical force to hurt a person
Sexual Violence: Forced sex through threats or fear of attack

STATISTICAL ANALYSIS

We used Latent Class Analysis, a methodological technique that uses a person-centered approach, to identify profiles of violence experienced by women. Using detailed information about the frequency, life course timing, and perpetrators of physical and sexual violence experienced by women in São Paulo and Porto Alegre, Brazil, HIV+ and HIV- women in each location were sorted into profiles, also known as latent classes.

VIOLENCE PROFILES AMONG WOMEN IN BRAZIL BY HIV STATUS

Women in Porto Alegre (POA) and São Paulo (SP) were sorted into four distinct violence profiles (Figure 3): 1) No violence at all; 2) Physical violence only; 3) Sexual violence only; and 4) Both physical and sexual violence.

Our results revealed a critical disparity in the violence by HIV-status. In both regions, HIV+ women experienced more physical, sexual violence, and combined violence than HIV- women.

In terms of profiles, HIV+ women in SP who experienced both physical and sexual violence endured physical violence several times during childhood/adolescence, and sexual violence either a few or many times during adulthood but not within the past 12 months. HIV+ women in Porto Alegre who experienced both physical and sexual violence endured physical violence several times during childhood/adolescence or adulthood but not within the past 12 months, and sexual violence a few times either during childhood/adolescence or adulthood but not within the past 12 months.

Additionally, in POA, we found that HIV+ women reported more physical violence perpetrated by an intimate partner than HIV- women. Sexual violence was more likely to be perpetrated by a stranger in POA than in SP. Finally, there were no pronounced differences by region or HIV-status in terms of life course timing of physical or sexual violence.

STUDY IMPLICATIONS

Women experience violence at multiple points during their life course, providing ample opportunity for health care providers to help them. By understanding the context, life course timing, perpetrators, and type of violence women experience, we are more equipped to identify women who experience violence, intervene, and prevent trauma from the violence while accounting for HIV status.

Specifically, through multi-component interventions, we can:

Implement screening for violence in Brazil’s National Health Care System (SUS) for girls and women
Integrate violence assessments in HIV Specialized Care Service clinics
Administer safety planning for abused women in HIV Specialized Care Service clinics
Provide education about gender-based violence in intimate relationships
Provide education to HIV positive women about violence in the context of HIV disclosure
Shift social norms around gender relations, masculinities & use of violence
Improve communication between intimate partners
Facilitate reporting of violence for women
Improve the justice sector response to violence
Target community efforts to reduce violence by implementing bystander intervention programs