Addressing Gender-Based Violence and HIV/AIDS: The PEPFAR Initiative in Tanzania

Janet Fleischman
Senior Associate, Global Health Policy Center

The dual global epidemics of HIV/AIDS and gender-based violence (GBV) exert a destructive and disproportionate impact on women and girls, especially in high HIV prevalence countries in Africa. Despite bipartisan political consensus on the intersection of HIV and GBV, efforts to address this area have not attracted the necessary attention and resources to drive the program innovation that could demonstrate progress. That may now be beginning to change, with new momentum being brought to this agenda by the President’s Emergency Plan for AIDS Reliefs (PEPFAR) GBV initiative.

In April, I traveled to Tanzania to examine how the GBV initiative is being implemented. I found that, although still early in implementation and facing many challenges, the GBV initiative has the potential to yield important lessons about synergies in reducing GBV and HIV, with clear implications for U.S. global health investments.

The GBV Initiative, which focuses on Tanzania, Mozambique, and the Democratic Republic of Congo (DRC), is a U.S. government interagency effort to integrate activities to address GBV into existing HIV programs at the health facility and community levels, as well as at the national policy level. The initiative stems from a global body of research showing a strong and complex set of linkages between GBV and HIV, with violence being both a risk factor for HIV acquisition as well as a consequence of being HIV-infected. Recent country-level studies reveal that women who experience violence in relationships face a four-fold higher risk of HIV and sexually transmitted infections, emphasizing the urgency of addressing these mutually reinforcing epidemics.

However, the challenges ahead are daunting. At the country level, these include widespread gender inequalities that fuel GBV and contribute to under-reporting of cases, weak national health systems (and legal, police, and social welfare systems) with severe human resource constraints, and limited or nonexistent community referral networks. From the U.S. government side, the challenges involve the varying capacity of PEPFAR’s implementing partners to implement GBV programs, ongoing issues of U.S. government interagency collaboration and the accompanying tensions, and limited resources and short timeframes for tackling deep-rooted problems. To be sure, GBV is a sensitive and complicated issue, which many national and international officials, donors, and implementers are wary of addressing.

The new CSIS report describes the importance of the GBV initiative for the work of PEPFAR and the Global Health Initiative. To demonstrate success, the report says that the GBV initiative will have to show:

  • That the national government has made GBV a national policy priority;
  • That integrating GBV into HIV platforms produces constructive outcomes in prevention and access to services at the clinical level, and in the development of support structures and referral networks at the community level;
  • That these programs are sustainable over the longer term, by becoming part and parcel of public sector health services and training;
  • That high level leadership is sustained at the country level and in Washington, including that bipartisan support in the U.S. can be maintained and expanded.

Important questions remain about whether the GBV initiative will get traction beyond the short life of its PEPFAR funding and whether the initiative will serve as a vehicle for a more sustainable response. But this is undeniably a moment of opportunity in Tanzania and more broadly for U.S. policy.  As Secretary Clinton said, “We cannot stop the epidemic of HIV unless we also address the epidemic of violence against women.”

Click here to download the full report.  As always, I welcome your questions and comments. Please leave your thoughts below.

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