Globally, one in three adolescent girls and young women experience physical, psychological or sexual intimate partner violence or sexual violence by a non-partner. Boys and young men experience gender-based violence too, but global data on this phenomenon are scarce.
Gender-based violence increases young people's vulnerability to HIV and those living with HIV are also more likely to experience gender-based violence.
There are a number of effective interventions to prevent gender-based violence among adult women and men at risk of HIV infection. But little is known about the effectiveness of these interventions in adolescents and young people.
We wanted to know what works to prevent gender-based violence among adolescents and young people living with or affected by HIV in low-and middle-income countries. We conducted a systematic review of all evaluated interventions with people aged between 10 and 24, who were living in an HIV endemic low-or middle-income country or came from key populations.
Key populations are people with a particularly high risk of HIV infection. These include people who inject drugs, men who have sex with men, transgender people, incarcerated people and sex workers. The evaluations had to contain a control group so that we could see if there were reductions in violence in the intervention group.
We chose to do a systematic review because it's the most robust method to bring together all of the available evidence to tell us whether interventions are effective. We excluded interventions that did not have a comparison group.
Our findings suggest that interventions to reduce exposure to gender-based violence (mostly reported by girls) need to combine a number of components. These include social empowerment, sexual health education, economic strengthening, self-defence and educating boys about gender equality.
What we found
We identified 18 studies with a total of 21 interventions to prevent or reduce gender-based violence. They included a total of 39,746 young people from areas with high HIV prevalence in Brazil, Ethiopia, Kenya, South Africa, Uganda and Zimbabwe. Despite our comprehensive search, we found no studies focusing specifically on young people living with HIV or from key populations. Of the studies we included, ten had only girl participants; two had only boy participants and six included both boys and girls.
We found three types of interventions that reduced exposure to gender-based violence:
1) Sexual health and social empowerment interventions that increase girls' skills and knowledge of HIV prevention, sexual and reproductive health and rights, gender equality and conflict resolution.
2) Sexual health, empowerment and economic strengthening interventions with added vocational training or financial literacy.
3) Self-defence interventions for girls together with gender equality training for boys. These interventions taught girls self-defence, de-escalation techniques and how to identify safe spaces in their communities. Boys learned about gender equality and how to de-escalate and intervene if they saw a girl being attacked.
We found two interventions that showed mixed but promising effects in reducing exposure to gender-based violence. These were gender equality education for boys without the self-defence component for girls, and cash transfers to girls and their families. These interventions showed some effectiveness but we only found a few studies.
Interventions to make schools safer didn't reduce exposure to gender-based violence. However, these interventions worked to reduce other types of violence such as corporal punishment. One reason may be that they weren't specifically focused on gender equality. Another intervention that didn't work was only providing savings accounts for girls.
Surprisingly, none of the interventions that aimed to lower perpetration of gender-based violence were effective. Boys who participated in these interventions didn't report lower rates of sexually or physically harming girls even though girls in the same intervention reported experiencing less violence and we don't know why that is. Overall, there was a lack of such evaluated interventions.
The studies we reviewed had a number of limitations.
First, only one study invited young people to co-create intervention content and only some involved young people in intervention planning. Involving target participants in the design is crucial to make interventions acceptable.
Second, there is a paucity of studies on what works to prevent violence against boys and gender non-conforming youth. Many studies asked girls to report their experience of gender-based violence; the same studies asked boys if and how often they had perpetrated gender-based violence. Few studies acknowledged that boys can also be victims.
Third, none of the studies explicitly addressed gender-based violence in young people living with HIV or key populations at risk of HIV.
Finally, while half of the studies were randomised controlled trials, the other half were non-randomised studies of poor quality. This means we can't establish, without reasonable doubt, if the intervention had an effect as differences in the intervention group may be due to other circumstances.
Despite these limitations we can glean some important insights into what works and what doesn't to prevent gender-based violence among young people living with or affected by HIV.
What must be done?
The results from this review are encouraging. But gender-based violence is a complex global health problem.
Researchers need to do more to see if these interventions are actually effective when rolled out to the general population. More must be done to include marginalised adolescents and young people in the design of interventions. Most importantly, interventions must be aimed at both boys and girls as well as at their broader communities.
Policy makers must invest more time and money in rolling out and evaluating promising interventions. This means investing in young people and their communities to be meaningfully involved.
Evidence shows that involving the whole community is critical to transform the harmful gender norms that fuel gender-based violence. This includes involving adolescents and young people who are living with HIV and from key populations, and moving away from the narrow view that gender-based violence only affects adolescent girls and young women.
Luisa Orza, Lead: HIV Technical (Gender) at Frontline AIDS, contributed to this article
Authors: Franziska Meinck - Lecturer in Social Work, University of Edinburgh | Heidi Stckl - Lecturer in Social Epidemiology, London School of Hygiene & Tropical Medicine | Marija Pantelic - Public health researcher, Brighton and Sussex Medical School