What Works for Women and Girls

al., 2000: 466). For example, a study in Uganda with 3,422 women ages 15 to 24 found thatwomen who always used condoms were less likely than those who never used condoms or usedthem inconsistently to report physical violence and sexual coercion (Zablotska et al., 2009).A study in the Central African Republic found that among both men and women ages 15–50,those whose sexual initiation was forced were between 1.77 and 2.47 times more likely to reportmultiple partners in adulthood, compared to those whose first sex was consensual (Sonse etal., 1993 cited in Jejeebhoy and Bott, 2003). Intimate partner violence tends to be consistentlyassociated with inconsistent condom use, having an unplanned pregnancy or induced abortion,and having an STI, including HIV (Coker, 2007).A review for the U.S. Institute of Medicine based on studies between 1998 and 2007found that “violence or fear of violence from an intimate partner is an impediment (to) or aconsequence of HIV testing” (Campbell et al., 2008b: 2). Many women do not disclose statusbased of fear of violence and abandonment. While some studies have shown that only a smallpercentage of women experienced negative responses after disclosure of their HIV status,there is some evidence that women are subjected to violence from their sexual partners as aconsequence of HIV testing and disclosure of results (Maman, 2001b). Women who discloseare more likely to be in secure relationships. [See also Chapter 6. HIV Testing and Counselingfor Women] Violence is also a barrier to adherence to treatment as spouses may require thatwomen share treatment if their partners do not want to be tested. Women may take HAART insecret. [See also Chapter 7. Treatment]Some evidence exists that violence prevention is effective, particularly by developingnurturing relationships between parents and children, by developing life skills in childrenand adolescents and by changing gender norms (WHO, 2009d). Programs and evaluations towork with men to reduce violence have been limited (Ricardo and Barker, 2008). More recentliterature indicates that abusive men are more likely to have other sexual partners unknown totheir wives (Campbell et al., 2008a). A 2003 study in Uganda found that those women whosehusband had another partner were more than twice as likely to have a higher risk of intimatepartner violence. The women expressed reluctance to test for HIV, disclose HIV results andrequest to use condoms because of fear of intimate partner violence (Karamagi et al., 2006).Sexual Abuse Puts Children at Risk for HIVChildren who are sexually abused are more at risk as adults of acquiring HIV (Slonim-Nevoand Mukuka, 2007). Pilot programs are beginning to successfully address the needs for postexposureprophylaxis by children who suffer from rape (Speight et al., 2006). “There is agrowing recognition that children in sub-Saharan Africa are vulnerable to HIV transmissionthrough sexual abuse and exploitation including incest, child rape, early (coerced) coitus,‘sugar daddies’ and transactional sex” (Lalor, 2008). Family, non-family, acquaintance, andnon-acquaintance perpetrators abuse young girls. Interventions are needed to reduce the incidenceof sexual abuse, as well as to address the consequences of abuse. Furthermore, education-relatedexposure to violence needs to be addressed. Research conducted by Human RightsWatch in Zambia in 2002 found that long commute times to and from school was a significant300 CHAPTER 11 STRENGTHENING THE ENABLING ENVIRONMENT