WHO issues new guidance on HIV self-testing ahead of World AIDS Day

From the WHO Website
News release
29 November 2016 | GENEVA - In advance of World AIDS Day, WHO has released new guidelines on HIV self-testing to improve access to and uptake of HIV diagnosis.
According to a new WHO progress report lack of an HIV diagnosis is a major obstacle to implementing the Organization’s recommendation that everyone with HIV should be offered antiretroviral therapy (ART).
The report reveals that more than 18 million people with HIV are currently taking ART, and a similar number is still unable to access treatment, the majority of which are unaware of their HIV positive status. Today, 40% of all people with HIV (over 14 million) remain unaware of their status. Many of these are people at higher risk of HIV infection who often find it difficult to access existing testing services.
"Millions of people with HIV are still missing out on life-saving treatment, which can also prevent HIV transmission to others," said Dr Margaret Chan, WHO Director-General. "HIV self-testing should open the door for many more people to know their HIV status and find out how to get treatment and access prevention services."
HIV self-testing means people can use oral fluid or blood- finger-pricks to discover their status in a private and convenient setting. Results are ready within 20 minutes or less. Those with positive results are advised to seek confirmatory tests at health clinics. WHO recommends they receive information and links to counselling as well as rapid referral to prevention, treatment and care services.
HIV self-testing is a way to reach more people with undiagnosed HIV and represents a step forward to empower individuals, diagnose people earlier before they become sick, bring services closer to where people live, and create demand for HIV testing. This is particularly important for those people facing barriers to accessing existing services.
Between 2005 and 2015 the proportion of people with HIV learning of their status increased from 12% to 60% globally. This increase in HIV testing uptake worldwide has led to more than 80% of all people diagnosed with HIV receiving ART.

Who misses out on HIV testing?

HIV testing coverage remains low among various population groups. For example, global coverage rates for all HIV testing, prevention, and treatment are lower among men than women.
Men account for only 30% of people who have tested for HIV. As a result, men with HIV are less likely to be diagnosed and put on antiretroviral treatment and are more likely to die of HIV-related causes than women.
But some women miss out too. Adolescent girls and young women in East and Southern Africa experience infection rates up to eight times higher than among their male peers. Fewer than one in every five girls (15–19 years of age) are aware of their HIV status.
Testing also remains low among "key populations" and their partners - particularly men who have sex with men, sex workers, transgender people, people who inject drugs, and people in prisons - who comprise approximately 44% of the 1.9 million new adult HIV infections that occur each year.
Up to 70 % of partners of people with HIV are also HIV positive. Many of those partners are not currently getting tested. The new WHO guidelines recommend ways to help HIV positive people notify their partners about their status, and also encourage them to get tested.
"By offering HIV self-testing, we can empower people to find out their own HIV status and also to notify their partners and encourage them to get tested as well," said Dr Gottfried Hirnschall, Director of WHO’s Department of HIV. "This should lead to more people knowing their status and being able to act upon it. Self-testing will be particularly relevant for those people who may find it difficult to access testing in clinical settings and might prefer self-testing as their method of choice."
Self-testing has been shown to nearly double the frequency of HIV testing among men who have sex with men, and recent studies in Kenya found that male partners of pregnant women had twice the uptake of HIV testing when offered self-testing compared with standard testing.
Twenty three countries currently have national policies that support HIV self-testing. Many other countries are developing policies, but wide-scale implementation of HIV self-testing remains limited. WHO supports free distribution of HIV self-test kits and other approaches that allow self-test kits to be bought at affordable prices. WHO is also working to reduce costs further to increase access. The new guidance aims to help countries scale up implementation.
WHO is supporting three countries in southern Africa which have started large scale implementation of self-testing through the UNITAID-funded STAR project and many more countries are considering this innovative approach to reaching those who are being left behind.

For more information please contact:

Tunga Namjilsuren
WHO Department of HIV, Global Hepatitis Programme
Telephone: +41 22 791 1073
Mobile: +41 79 203 3176
Email: namjilsurent@who.int
Gregory Härtl
Coordinator, Department of Communications
Mobile: +41 79 500 6552
Telephone: +41 22 791 4458
Email: hartlg@who.int

Violence against women

From WHO Website

Intimate partner and sexual violence against women

Fact sheet
Updated November 2016

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Key facts:

• Violence against women - particularly intimate partner violence and sexual violence - are major public health problems and violations of women's human rights.
• Global estimates published by WHO indicate that about 1 in 3 (35%) women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime.
• Most of this violence is intimate partner violence. Worldwide, almost one third (30%) of women who have been in a relationship report that they have experienced some form of physical and/or sexual violence by their intimate partner in their lifetime.
• Globally, as many as 38% of murders of women are committed by a male intimate partner.
• Violence can negatively affect women’s physical, mental, sexual and reproductive health, and may increase vulnerability to HIV.
• Factors associated with increased risk of perpetration of violence include low education, child maltreatment or exposure to violence in the family, harmful use of alcohol, attitudes accepting of violence and gender inequality.
• Factors associated with increased risk of experiencing intimate partner and sexual violence include low education, exposure to violence between parents, abuse during childhood, attitudes accepting violence and gender inequality.
• There is evidence from high-income settings that school-based programmes may be effective in preventing relationship violence (or dating violence) among young people.
• In low-income settings, strategies to increase women’s economic and social empowerment, such as microfinance combined with gender equality training and community-based initiatives that address gender inequality and relationship skills, have shown some effectiveness in reducing intimate partner violence.
• Situations of conflict, post conflict and displacement may exacerbate existing violence, such as by intimate partners, and present additional forms of violence against women.

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Introduction

The United Nations defines violence against women 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, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life."
Intimate partner violence refers to behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours.
Sexual violence is "any sexual act, attempt to obtain a sexual act, or other act directed against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part or object."

Scope of the problem

Population-level surveys based on reports from victims provide the most accurate estimates of the prevalence of intimate partner violence and sexual violence in non-conflict settings. The "WHO Multi-country study on women’s health and domestic violence against women" (2005) in 10 mainly low- and middle-income countries found that, among women aged 15-49:

• between 15% of women in Japan and 71% of women in Ethiopia reported physical and/or sexual violence by an intimate partner in their lifetime;
• between 0.3–11.5% of women reported sexual violence by someone other than a partner since the age of 15 years;
• the first sexual experience for many women was reported as forced – 17% of women in rural Tanzania, 24% in rural Peru, and 30% in rural Bangladesh reported that their first sexual experience was forced.

A 2013 analysis conduct by WHO with the London School of Hygiene and Tropical Medicine and the Medical Research Council, based on existing data from over 80 countries, found that worldwide, almost one third (30%) of all women who have been in a relationship have experienced physical and/or sexual violence by their intimate partner. The prevalence estimates range from 23.2% in high-income countries and 24.6% in the Western Pacific region to 37% in the WHO Eastern Mediterranean region, and 37.7% in the South-East Asia region. Furthermore, globally as many as 38% of all murders of women are committed by intimate partners. In addition to intimate partner violence, globally 7% of women report having been sexually assaulted by someone other than a partner, although data for this is more limited.
Intimate partner and sexual violence are mostly perpetrated by men against women. Child sexual abuse affects both boys and girls. International studies reveal that approximately 20% of women and 5–10% of men report being victims of sexual violence as children. Violence among young people, including dating violence, is also a major problem.

Risk factors

Factors associated with intimate partner and sexual violence occur at individual, family, community and wider society levels. Some factors are associated with being a perpetrator of violence, some are associated with experiencing violence and some are associated with both.
Risk factors for both intimate partner and sexual violence include:

• lower levels of education (perpetration of sexual violence and experience of sexual violence);
• exposure to child maltreatment (perpetration and experience);
• witnessing family violence (perpetration and experience);
• antisocial personality disorder (perpetration);
• harmful use of alcohol (perpetration and experience);
• having multiple partners or suspected by their partners of infidelity (perpetration); and
• attitudes that are accepting of violence and gender inequality (perpetration and experience).

Factors specifically associated with intimate partner violence include:

• past history of violence;
• marital discord and dissatisfaction;
• difficulties in communicating between partners.

Factors specifically associated with sexual violence perpetration include:

• beliefs in family honour and sexual purity
• ideologies of male sexual entitlement and
• weak legal sanctions for sexual violence.

The unequal position of women relative to men and the normative use of violence to resolve conflict are strongly associated with both intimate partner violence and non-partner sexual violence.

Health consequences

Intimate partner and sexual violence have serious short- and long-term physical, mental, sexual and reproductive health problems for survivors and for their children, and lead to high social and economic costs.

• Violence against women can have fatal outcomes like homicide or suicide.
• It can lead to injuries, with 42% of women who experience intimate partner violence reporting an injury as a consequence of this violence.
• Intimate partner violence and sexual violence can lead to unintended pregnancies, induced abortions, gynaecological problems, and sexually transmitted infections, including HIV. The 2013 analysis found that women who had been physically or sexually abused were 1.5 times more likely to have a sexually transmitted infection and, in some regions, HIV, compared to women who had not experienced partner violence. They are also twice as likely to have an abortion.
• Intimate partner violence in pregnancy also increases the likelihood of miscarriage, stillbirth, pre-term delivery and low birth weight babies.
• These forms of violence can lead to depression, post-traumatic stress and other anxiety disorders, sleep difficulties, eating disorders, and suicide attempts. The same study found that women who have experienced intimate partner violence were almost twice as likely to experience depression and problem drinking. The rate was even higher for women who had experienced non partner sexual violence.
• Health effects can also include headaches, back pain, abdominal pain, fibromyalgia, gastrointestinal disorders, limited mobility and poor overall health.
• Sexual violence, particularly during childhood, can lead to increased smoking, drug and alcohol misuse, and risky sexual behaviours in later life. It is also associated with perpetration of violence (for males) and being a victim of violence (for females).

Impact on children

• Children who grow up in families where there is violence may suffer a range of behavioural and emotional disturbances. These can also be associated with perpetrating or experiencing violence later in life.
• Intimate partner violence has also been associated with higher rates of infant and child mortality and morbidity (e.g. diarrhoeal disease, malnutrition).

Social and economic costs

The social and economic costs of intimate partner and sexual violence are enormous and have ripple effects throughout society. Women may suffer isolation, inability to work, loss of wages, lack of participation in regular activities and limited ability to care for themselves and their children.

Prevention and response

There are a growing number of well-designed studies looking at the effectiveness of prevention and response programmes. More resources are needed to strengthen the prevention of and response to intimate partner and sexual violence, including primary prevention, i.e. stopping it from happening in the first place.
Regarding primary prevention, there is some evidence from high-income countries that school-based programmes to prevent violence within dating relationships have shown effectiveness. However, these have yet to be assessed for use in resource-poor settings. Several other primary prevention strategies: those that combine economic empowerment of women with gender equality training; that promote communication and relationship skills within couples and communities; that reduce access to, and harmful use of alcohol; and that change cultural gender norms, have shown some promise but need to be evaluated further.
To achieve lasting change, it is important to enact legislation and develop policies that:

• address discrimination against women;
• promote gender equality;
• support women; and
• help to move towards more peaceful cultural norms.

An appropriate response from the health sector can play an important role in the prevention of violence. Sensitization and education of health and other service providers is therefore another important strategy. To address fully the consequences of violence and the needs of victims/survivors requires a multi-sectoral response.

WHO response

WHO, in collaboration with partners, is:

• Building the evidence base on the size and nature of violence against women in different settings and supporting countries' efforts to document and measure this violence and its consequences, including improving the methods for measuring violence against women in the context of SDG monitoring. This is central to understanding the magnitude and nature of the problem at a global level and to initiating action in countries.
• Strengthening research and research capacity to assess interventions to address partner violence.
• Undertaking interventions research to test and identify effective health sector interventions to address violence against women.
• Developing technical guidance for evidence-based intimate partner and sexual violence prevention and for strengthening the health sector responses to such violence.
• Disseminating information and supporting national efforts to advance women's health and rights and the prevention of and response to violence against women.
• Supporting countries’ to strengthen the health sector response to violence against women, including the implementation of WHO tools and guidelines.
• Collaborating with international agencies and organizations to reduce and eliminate violence globally.