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In the June 2007 issue of Sexually Transmitted Infections, Dunkle and Jewkes make a much needed case for increased attention to the role of gender‐based violence (GBV) in fuelling the HIV pandemic. Referring to an article published in the same issue regarding GBV and STI risk in Bangladesh,1 they find mounting evidence for national generalizability across a range of cultural settings “supporting the link between perpetration of GBV and STI/HIV risk”. While agreeing with the spirit of their editorial, I question the logic they use to derive their recommendations and propose an alternative method for analysing the relationship among social ideals of masculinity, GBV and HIV/STI transmission using an ecological and comparative framework to explain population‐level variations in GBV and HIV prevalence.
Dunkle and Jewkes accurately point to the growing body of evidence that demonstrates unequivocally that women who experience GBV are at greater risk of HIV at the individual level. However, at the ecological level, it does not necessarily hold that countries with high rates of GBV/gender inequality experience heightened rates of HIV/STIs. For instance, although the WHO multi‐country study on GBV has found that Bangladesh has among the highest rates of GBV of the countries studied2,3 (findings reinforced in the Silverman et al study), Bangladesh has a negligible national HIV prevalence rate of <0.1%. Evidence suggests that Muslim societies, though often endorsing highly repressive gender norms, have extremely low rates of HIV/STIs.4 Likewise, the WHO multi‐country study found Ethiopia's and Peru's prevalence of intimate partner violence to be the highest of the 10 countries under study respectively; yet, adult HIV prevalence was estimated at 4.4% in Ethiopia and 0.6% in Peru. Countries with higher national HIV prevalence rates, including Namibia (19.6%) and Tanzania (6.5%), exhibited relatively lower rates of GBV.
In essence, Dunkle and Jewkes' comment commits the atomistic fallacy, or incorrectly generalising an individual‐level association to the group level.5 In order to assess the contribution of GBV to HIV at the ecological level, studies must move from thinking about the replication of findings in different settings to a comparative, population‐level framework. In his classic piece “Sick Individuals and Sick Populations”, epidemiologist Geoffrey Rose6 reminds us that the question, “‘Why do individuals have hypertension?' is a quite different question from ‘why do some populations have much hypertension, whilst in others it is rare?'”. In order to address this second question, Rose argues that “what distinguishes the two groups is nothing to do with the characteristics of individuals, it is rather a shift of the whole distribution”.
In the case of HIV, it remains somewhat of a mystery how individual HIV risk factors link up to population risk. Ultimately, due to the limited number of transmission routes, some variation in behaviour between populations, coupled with a tipping point and possible biomedical transmissible cofactors must be responsible for the heightened rate of HIV in certain populations. More evidence is needed to explain under what conditions gender inequitable beliefs link up with population‐level GBV and HIV risk.
This comment is in solidarity with Dunkle and Jewkes' contention that “socially transformative programs that promote gender equality and discourage perpetration of gender‐based violence are needed to combat the global HIV pandemic”. However, the modes by which to generate social transformation must stem from an understanding of the macro‐level causes of social phenomena across populations. Dunkle and Jewkes point to microbicides as a gender‐sensitive technology but one that fails to address the “underlying social constructions of gender”. To this, I would add male circumcision, an anti‐HIV intervention increasingly gaining in prominence that has the potential to reinforce entrenched gender norms and male power. Public health interventions that reinforce gendered power relations should be eschewed in favour of gender transformative interventions that proceed at the population level.
GBV, gender‐based violence