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By Maegan McCane Violence against women and girls (VAWG) is an issue that continues to be perpetuated and reproduced worldwide. The United Nations (UN) defines VAWG as: '…as any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women and girls, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. Violence against women and girls encompasses, but is not limited to, physical, sexual and psychological violence occurring in the family or within the general community, and perpetrated or condoned by the State.' In the UK, VAWG’s definition covers crimes such as domestic abuse including homicide, sexual assault, stalking, sexual exploitation, child abuse, female genital mutilation (FGM), forced marriage, and harassment in work and public life. In the UK, there are about 2.3 million victims, aged 16 to 74, of domestic abuse each year (Elkin, 2022). Two-thirds of these are women. Women and girls from Black and minority ethnic communities (BME) experience higher levels of VAWG. (Siddiqui, 2018). Black Caribbean and Black African women and girls experience higher instances of domestic homicide and abuse-driven suicide, and they are more subject to culturally specific VAWG practices, such as FGM or forced marriage. Generally, experiencing VAWG comes with a host of health problems. The World Health Organization (2021) describes VAWG as taking the form of physical, mental, behavioral, and/or sexual and reproductive violence. Physical Sexual and reproductive • acute or immediate physical injuries, such as bruises, abrasions, lacerations, punctures, burns and bites, as well as fractures and broken bones or teeth • more serious injuries, which can lead to disabilities, including injuries to the head, • unintended/unwanted pregnancy • abortion/unsafe abortion • sexually transmitted infections, including HIV • pregnancy complications/miscarriage • vaginal bleeding or infections eyes, ears, chest and abdomen • gastrointestinal conditions, long-term health problems and poor health status, including chronic pain syndromes • death, including femicide and AIDS related death • chronic pelvic infection • urinary tract infections • fistula (a tear between the vagina and bladder, rectum, or both) • painful sexual intercourse • sexual dysfunction Mental Behavioral • depression • sleeping and eating disorders • stress and anxiety disorders (e.g. post- traumatic stress disorder) • self-harm and suicide attempts • poor self-esteem • harmful alcohol and substance use • multiple sexual partners • choosing abusive partners later in life • lower rates of contraceptive and condom use As we see, VAWG has significant and long-lasting impacts on one’s physical health. A woman or girl could be exposed to injury or other physical harm, unwanted pregnancy or pregnancy complications, sexually transmitted infections, or even death. VAWG is extremely detrimental for one’s mental health. Those experiencing any type of VAWG will often have mental health issues such as depression or anxiety and can be at higher risk for suicide. People experiencing sexual violence or sexual exploitation violence can deal with sexual dysfunction or have anxiety around sex and intimacy. These women and girls are at increased risk for urinary tract infections, incontinence, constant pain, pain during and difficulty having sex, repeated infections, which can lead to infertility bleeding, cysts, and abscesses, and problems during pregnancy, labor, and childbirth, which can be life threatening for mother and baby (National Health Service, 2022). How Can We Help Women and Girls Experiencing VAWG? Addressing VAWG requires an effort from multiple parts of society. First, we need to understand the impact VAWG has on the health and well-being of women and girls. We also need more empathetic and caring health workers who understand what is needed for a truly survivor-centred response. Many minority ethnic women and girls express the wish for services that are catered towards them. Creating those services and integrating them into existing health services will do nothing. Finally, from a logistics standpoint, addressing VAWG means having a set protocol in place, referral networks that actually work, and documentation, monitoring, and evaluation of existing services to see how they can be improved on. Not only will improving VAWG services help change the lives of those affected, it will be nothing but a net benefit to society as a whole. Economically, VAWG costs states millions of pounds a year, primarily in policing and social services; one in ten calls to the police are about domestic violence. The social impact of VAWG cannot possibly be measured economically, but instead can be measured in suffering, loss, pain, and trauma. Improving VAWG services can help to stop traumatic instances before they begin or further escalate. Targeted domestic violence policy, therefore, should be a top priority for the government. In 2021, the UK passed legislation that directly addresses and allocates more resources to VAWG. The Domestic Abuse Act of 2021 is a landmark piece of legislation and is a good first step, but as a society, we need to go further in our policy decisions that address VAWG.

PRESS RELEASE Thursday 30 November 2023 World AIDS Day: “We can end inequalities by letting communities lead” says UNAIDS executive director Exemplifying the UNAIDS World AIDS Day theme of ‘Let Communities Lead’, National AIDS Trust and One Voice Network are proud to have hosted UNAIDS’ Executive Director Winnie Byanyima, to learn more about a pioneering partnership centering Black communities in HIV care. The Unheard Voices project is a collaboration between National AIDS Trust and One Voice Network, an independent collective of Black-led community organisations, seeking to improve the health and wellbeing of Black communities in the UK who are affected by HIV. The project aims to end structural inequalities by ensuring Black communities living with or at risk of HIV can hold decision-makers to account, influence actions, and become part of the decision-making process. According to figures from UKHSA, despite making up a smaller number of the overall London population, Black Africans represented 26% of all newly diagnosed London residents in 2021. Black Africans were more likely to be diagnosed late than the white population (57% and 32% respectively). “It is through enabling communities like those I met today that we will end HIV transmissions and end AIDS as a public health threat. You light the way,” said Winnie Byanyima, Executive Director of UNAIDS. “As a black woman, I have experienced how difficult it is to make our voices heard. Your determination inspires me. Racism, sexism and homophobia are bad for our health. It is vital to let communities lead to address systemic inequalities in all aspects of life. That is how we will make sure that everyone’s right to health and social services is realised.” By involving Black communities in decisions about their HIV care and commissioning, Unheard Voices aims to influence a health and support system which offers equitable standards of care, to reduce the disproportionate impact of HIV or HIV related stigma and discrimination. Reverend Jide Macaulay, One Voice Network chairperson and Founder and CEO of House Of Rainbow, said: “The United Kingdom has made significant strides in combatting HIV and achieving UNAIDS goals; however, it is evident that the quality of life for Black African communities is currently at a critical low. Urgent actions are needed to allocate resources and provide support to address this issue.” Oluwakemi Agunbiade, Policy and Campaigns Officer at National AIDS Trust, said: “When community voices are included throughout the journey of HIV service design, decision-makers benefit from a new perspective on how Black people impacted by HIV can be best supported. Without involving with Black communities, health care systems are missing out on vital information to understand how best to meet their HIV related needs. “Whilst our upcoming report on community involvement in London HIV commissioning does highlight that many commissioners are engaging with community leaders, much more needs to be done. We strongly encourage a shift towards coproduction where community members are stakeholders with a say in their own healthcare. To further guide decision-makers, the Unheard Voices Report will also include best practice on how to overcome the barriers to effective genuine community involvement when designing HIV services. “We’re so delighted to be able to let Winnie Byanyima know about the work of Unheard Voices and share UNAIDS vision of collaborative, community focussed interventions to improve the lives of people living with and affected by HIV.” Ahead of World AIDS Day, Winnie joined representatives from National AIDS Trust and the twelve London based organisations who make up the One Voice Network, to gain a greater understanding of the grassroots work being done to support Black people living with HIV. During the event, Winnie and attendees from within the HIV community were treated to a performance from the Joyful Noise choir. The choir, organised by One Voice Network organisation NAZ, are an inclusive, peer support group made up entirely of people living with HIV. The choir serves as a community for HIV-positive individuals, as well as an inspiring tool to help end the stigma associated with HIV. UNAIDS is the specialised agency within the United Nations that works towards ending the AIDS epidemic as a public health threat by 2030. For World AIDS Day 2023, UNAIDS are highlighting and uplifting the communities who are at the frontline of progress in the HIV response with their theme ‘Let Communities Lead’. To coincide with World AIDS Day, UNAIDS have further highlighted the impact that community based organisations have had on the response to HIV in their Let Communities Lead report30. Published this week, the report reveals how communities working to end AIDS are too often unrecognised, under-resourced and in some places even under attack. Further information about the Unheard Voices project can be found on the One Voice Network website. For more information on World AIDS Day visit National AIDS Trust’s dedicated website. Ends For more details please contact Joe Parry on joe.parry@nat.org.uk, 020 7814 6738 Notes to editors About National AIDS Trust We’re the UK’s HIV rights charity. We work to stop HIV from standing in the way of health, dignity and equality, and to end new HIV transmissions. Our expertise, research and advocacy secure lasting change to the lives of people living with and at risk of HIV. www.nat.org.uk

A recent study suggests that intimate partner violence (IPV) increases the risk of HIV beyond what is expected for women living in sub-Saharan Africa who have male partners living with HIV. Women aged 15-24 had a 3% increase in risk when they had a partner living with HIV who perpetrated IPV, compared to women whose partner just had HIV. Men who perpetrate IPV were also shown to have higher rates of HIV. In Sub-Saharan Africa, one in three women between 15-49 report IPV at some point in their lifetime. Thus, the importance of tackling IPV to decrease HIV must not be underestimated. The study conducted by Salome Kuchukhidze of McGill University and colleagues which pooled data from several sub-Saharan countries was published in PLOS Global Public Health. Increased alcohol use, acceptance of IPV and stereotypes of male dominance contributed to violence against women. Perpetrators of IPV were more likely to engage in behaviours associated with an increase in HIV risk, which may be part of the reason why they had higher HIV rates. The researchers analysed data from 27 different countries between 2000 and 2020. The data was all taken from nationally representative household surveys which were all anonymised. There were 111,659 heterosexual couples that were reported to be married or co-habiting, aged over 15 years old. Of these couples, 79,325 had data on HIV available. IPV was detected by the female partner reporting sexual or physical violence within the last year in the survey, and the perpetrator was assumed to be her current partner. A separate analysis to assess if IPV increased the risk of HIV included only women aged 15-24 years old, to decrease the chance of pre-existing HIV before their current partner. Women aged 15-24 also have the highest risk of IPV and greatest incidence of HIV, making it the best group to estimate the additional risk of HIV in the context of IPV. Overall, 21% women reported IPV. Unsurprisingly, women who were younger, poorly educated, less likely to have a say in household decisions and less wealthy were more likely to report IPV. Women earning more than their partner were more likely to experience IPV, which may be due to the challenge this poses to gender stereotypes, leaving the male partner feeling threatened. These women may be more likely to refuse sex and negotiate condom use which would reduce their HIV risk but may increase their IPV risk. After adjustments for other factors, men who perpetrated IPV were 9% more likely to be living with HIV than those that didn’t. These men were slightly more likely to report paying for sex and having multiple partners in the previous year, which may contribute to the increased rates of HIV. Men who had more accepting attitudes towards IPV and who drank more alcohol were also more likely to be perpetrators. The researchers suggested that underlying attitudes around dominance over women could be driving higher rates of HIV in perpetrators of IPV due to these attitudes, leading to behaviours that increase the risk of HIV. When looking at women aged 15-24, the risk of HIV was 26.6% higher when their partner was living with HIV and 0.4% higher if they reported IPV. Combining these values, one might expect that the risk of HIV would be 27% greater for women who had a partner living with HIV and experienced IPV. However, women who reported IPV and had a partner with HIV were found to have a 30.1% increased risk of HIV, showing a joint effect of IPV with HIV which increased the risk of HIV by a further 3.1%. This may be explained by the finding that men living with HIV who perpetrated IPV were less likely to be on ART and virally suppressed compared to men who didn’t perpetrate IPV, although the sample size was too small to be conclusive on this point. However, other studies have shown higher rates of unsuppressed viral loads for men living with HIV who commit IPV compared to men who do not commit IPV. Other factors that the researchers suggest could increase the risk of HIV for those experiencing IPV were the effects of IPV on mental health and sexual behaviours which could increase risk factors for HIV acquisition like substance misuse, transactional sex and coerced anal sex. Important limitations to this study are that the timings of IPV perpetration and HIV acquisition are not available, making it impossible to be sure about whether IPV or HIV came first. It is also important to note that IPV and sexual behaviours may have been underreported due to their sensitive nature. However, neither of these limitations diminish the importance of trying to tackle IPV when trying to decrease HIV transmission. Given that this study was conducted over 27 different countries, the cultural and structural practices underlying the high rate of IPV are varied and complex. Efforts to decrease violence against women and girls must be tailored and specific. Further research to assess the causality of the increase in HIV amongst women subjected to IPV must be undertaken, which will inform efforts to reduce both IPV and HIV. “The impacts of violence and HIV are profound and have long-lasting effects on the well-being of millions of women and girls globally,” the researchers note. “Actions to eliminate violence and end AIDS must be accelerated.” References Kuchukhidze S et al. Characteristics of male perpetrators of intimate partner violence and implications for women’s HIV status: A pooled analysis of cohabiting couples from 27 countries in Africa (2000–2020). PLOS Global Public Health 3: e0002146, 2023 (open access). https://doi.org/10.1371/journal.pgph.0002146 Source: https://www.aidsmap.com/news/nov-2023/intimate-partner-violence-increases-womans-risk-acquiring-hiv

“Find Your Four is a campaign that aims to support people living with HIV to think about the four elements of their broader health and wellbeing that are most important to them and help them to be ready to talk to their HIV doctor, nurse or support group about why they matter. For more information and a range of resources to support those with HIV to live well, visit https://www.hivfindyourfour.co.uk. The Find Your Four campaign has been developed and funded by Gilead Sciences in collaboration with the HIV community.”