Integrating Gender-Based Violence Services Into HIV Care: Insights From Malawi

BACKGROUND

Gender-based violence (GBV) is defined as violence that results or may result in physical, sexual, or psychological harm or suffering to individuals based on their gender.¹ GBV is not only a major public health problem but also a human rights issue, deeply rooted in structural, gender-based inequalities perpetuated by social and political forces.² The 4 main types of GBV—physical, sexual, emotional or psychological, and economic—are linked to a broad range of mental and physical health problems, including HIV.³

In Malawi, GBV remains pervasive, with all 4 types presenting in varying degrees.⁴ A 2013 survey found that 1 in 5 females and 1 in 7 males in Malawi have experienced at least 1 incident of sexual abuse before the age of 18 years.⁵ Given Malawi’s high HIV prevalence at 8.9% among adults,⁶ addressing the intersection of GBV and HIV/AIDS is particularly critical. Research shows that exposure to GBV is closely associated with poor health outcomes,⁷ including HIV acquisition and treatment interruption.⁸ GBV acts as a barrier to HIV prevention, testing, and treatment adherence, with fear of GBV inhibiting disclosure of HIV status to sexual partners.^9–11 In addition, HIV is associated with increased experience with GBV, where women living with HIV have reported violence after disclosing their status,¹² including reproductive coercion (forced or coerced sex, sabotage of contraception, or the forcible control of reproductive health by an abusive partner).^13–15

To support GBV survivors, the government of Malawi established one-stop centers (OSCs) in select hospitals, providing comprehensive post-GBV care, including clinical, psychosocial, and legal support.¹⁶ These OSCs house health care providers, social workers, and police in the same location to manage GBV cases. Despite the establishment of OSCs with designated space and staff to support GBV survivors, challenges persisted, including the lack of a comprehensive data collection tool, incomplete documentation, and staffing shortages that hindered consistent operations. In addition, some guardians hesitated to report sexual violence cases among minors if they perceived the encounter as consensual or if the perpetrator was someone they relied on financially. This highlights a critical gap in awareness and education around GBV.

Many GBV interventions focus on identifying and reducing partner violence in antenatal care or primary health care settings.^17,18 However, few studies have evaluated comprehensive GBV integration within HIV services across the care continuum.^19–22 Routine screening for GBV in health care settings is not recommended unless under certain circumstances.^7,23 However, some studies have shown that women are receptive to GBV screening, and it can help identify those at risk of violence.²⁴ Given that HIV increases the risk of GBV,²⁵ it is essential to integrate GBV services into HIV care to address the intersecting needs of individuals affected by both HIV and GBV.

Integrating GBV services into HIV care requires a coordinated approach that addresses both the health and psychological needs of survivors.⁷ Best practices for such integration in low-resource settings are limited, but lessons learned from integrating GBV response into HIV services can guide health care providers in effectively incorporating GBV screenings, referrals, and care into HIV services. These insights can shape protocols, inform training programs, and influence policy, ensuring comprehensive care for all GBV survivors.

In this article, we describe the integration of GBV services at the Lighthouse Trust HIV clinics in Malawi by analyzing routinely collected data. We detail the GBV screening process, documentation, intervention implementation, best practices, and lessons learned, as well as the uptake of GBV services. By examining this integration, we aim to contribute to the existing body of knowledge and inform future interventions and policies to address GBV effectively within HIV care.

METHODS

Integration of GBV Services Into Lighthouse Centers of Excellence

Lighthouse Trust began offering GBV services in January 2020. To ensure efficient delivery of GBV services, from October to December 2019, Lighthouse Trust conducted several activities as part of the integration, including engaging stakeholders, training health care providers, developing a standard operating procedure, enhancing referral for post-GBV care, and developing data collection tools.

Stakeholder Engagement

Key stakeholders, including health care providers, community leaders, police, and GBV survivors, were engaged to ensure the integration process was inclusive and addressed the multifaceted needs of survivors.

Trained Health Care Providers

Providers underwent training to recognize subtle behaviors, health issues, physical and emotional signs, or services sought that might indicate the presence of GBV (Supplement 1). Three distinct training programs were implemented to enhance the capabilities of key health care providers, including nurses, clinicians, HIV diagnostic assistants, and psychosocial counselors. The first training was standardized training focused on GBV and the OSC function and conducted by facilitators from the Ministries of Gender, Health, and the Judiciary, and the police. The second training program was not standardized but addressed GBV and child protection and was conducted by the Police-Victim Support Unit. The third training was on using the LIVES (Listen, Inquire, Validate, Enhance safety, and Support)¹⁷ model, an initiative by WHO aimed to assist providers in identifying instances of violence within a clinical setting and providing initial support. This training was conducted by 2 Lighthouse Trust GBV team leads who were trained as trainers through a standardized U.S. Centers for Disease Control and Population training on LIVES. These comprehensive training sessions sought to equip health care providers with a holistic understanding of survivor management. The trainings included various topics, such as describing different forms of GBV, GBV screening using a tool adapted from Papua New Guinea,³⁰ offering initial support, guidelines for reporting incidents to the police, child rights, comprehensive health care packages, forensic examinations, courtroom testimony, and proper documentation in the GBV register. In total, 174 providers were trained across all COEs. Refresher training using the LIVES model was then conducted annually. Feedback from providers indicated that refresher training was essential to reinforce skills and update knowledge on new protocols.

Standard Operating Procedure and Intensified Screening

Based on WHO guidelines,⁸ Lighthouse Trust did not conduct universal screening for GBV. Screening was only conducted when providers identified GBV indications to a recipient of care. A GBV survivor could be identified at any service delivery point (e.g., clinic room, reception area, vitals area, or HIV testing room) through several means: self-description of assault/violence, a referral letter from police, or clinical suspicion (e.g., through complaints or excuses, identified only in clinic rooms). To ensure the accuracy and consistency of GBV screening procedures, Lighthouse Trust developed a detailed standard operating procedure used exclusively in Lighthouse Trust facilities (Supplement 2) that outlined the appropriate protocols for administering GBV screening. GBV screening was also introduced in all clinic service delivery points, including the front desk and guard stations, where health care workers used a standardized screening tool (Supplement 3) when they suspected potential signs and symptoms of GBV among clients.

Enhanced Referral for Post-GBV Care

All clients who were identified as having experienced GBV were referred to the appropriate provider for post-GBV care. Before making the referral, the client was given adequate time to decide whether to accept the referral. Providers did not exert pressure on clients who refused referral services but instead provided information on available post-GBV care and educated the client on the mental and physical health effects of GBV. Based on the type of GBV, Lighthouse Trust provided the following clinical services: HIV testing, post-exposure prophylaxis (PEP), syndromic sexually transmitted infections (STI) screening and treatment, psychosocial services (PSS) (Supplement 4), and provision of emergency contraception. In cases where the client had experienced severe physical violence, the client was referred to the central hospital for advanced medical care. Furthermore, the client was referred to the OSC, where a police officer provided judicial support. A follow-up visit was then scheduled for all clients if they were willing.

Data Collection Tools

The OSCs did not possess an official register to record GBV cases before the service integration. Instead, cases were documented in a hardcover notebook that was used for several years, resulting in a nearly torn cover. Furthermore, available data and information gaps, such as missing client data on types of GBV experienced and post-GBV services provided, indicated the need to enhance GBV documentation processes. To address this issue, Lighthouse Trust developed a comprehensive and user-friendly GBV register incorporating essential indicators for both the OSC and Lighthouse Trust (Figure 1).

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FIGURE 1

Register Used to Record Gender-Based Violence Cases in Services Integrated With HIV Services, Malawi

LESSONS LEARNED

Since 2020, Lighthouse Trust has integrated post-GBV care into its services, standardizing care through standard operating procedures and training health care providers to screen and care for GBV survivors in a manner that would not retraumatize GBV survivors, aligning with findings from similar settings.^18,22 The training also expanded providers’ recognition of emotional violence, leading to a more comprehensive approach to addressing all forms of GBV.

The Lighthouse Trust model, characterized by its multidisciplinary team approach and survivor-centered care, proved effective in our setting and could serve as a replicable model for other clinics seeking to integrate GBV services. The key to its success lies in strong stakeholder collaboration and ongoing training and capacity-building. Police involvement in the clinic setting can be beneficial when handled sensitively. In addition, continued community sensitization will ensure increased awareness of GBV and access to post-GBV services.

Challenges in documenting multiple types of GBV, such as combined physical, sexual, and emotional violence, were noted, leading to potential underreporting or misreporting. Additionally, the GBV register’s focus was primarily on younger age groups, inadvertently resulting in the 30+ age group being grouped together without further disaggregation. Implementing an electronic data management system could effectively address documentation challenges by enabling accurate tracking of multiple GBV types, linking GBV care to HIV outcomes, and improving data capture across all age groups.

Furthermore, guardians sometimes hesitated to report sexual violence against child survivors to the police. In some cases, children were given money for sexual encounters with adults, mistakenly leading guardians to view the interactions as consensual, not considering the minors’ inability to consent legally. There were also cases where guardians were reluctant to report a child’s GBV experience if they were financially dependent on the perpetrator. This emphasizes an urgent need for increased community awareness about GBV affecting children.²² In addition, the lack of a safe house further complicated situations where child survivors could not be safely housed with relatives, highlighting the need for secure shelters for minors who are survivors of GBV.

Heavy workloads contributed to incomplete documentation, suggesting that the actual number of GBV cases may be higher than reported, as well as inconsistent proactive GBV screening and gaps in necessary support service referrals, with some cases prematurely reported to the police without the survivors first receiving health care intervention. Training staff to manage workloads more efficiently and emphasizing the importance of comprehensive documentation could help ensure no cases are overlooked. However, this would require additional resources, which may be difficult to secure in a resource-limited setting like Malawi.

Despite making strides in integrating GBV into routine care, we cannot attribute the impact of post-GBV services to ART retention, viral load suppression, or other HIV-related outcomes. Pre- and post-integration analysis of the survivors would also be a challenge as documentation tools for GBV and HIV do not have a linking identifier.

Community sensitization efforts and GBV screening at ART clinics have contributed to an increase in reported GBV cases, though some clients may not have received the complete post-GBV treatment package if they reported to the facility beyond the recommended time, particularly those who required PEP and emergency contraceptives.

The COVID-19 pandemic underscored the critical importance of maintaining adaptable and resilient service delivery models, particularly when OSCs were temporarily converted into COVID-19 isolation centers and survivors were compelled to seek help in overcrowded hospitals. This shift may have deterred some from accessing services, highlighting the need for contingency planning in public health crises. Despite these challenges, the continued increase in reported GBV cases during the pandemic emphasizes the persistent need for accessible, survivor-centered care, even under strained circumstances.

RECOMMENDATIONS

In conclusion, effective GBV care is vital for HIV clients, with provider training in LIVES enhancing the identification and support of GBV survivors. The large number of reported GBV cases in our findings highlights the need for such interventions. Though not explicitly analyzed here, the prevalence of GBV cases likely influences HIV outcomes among people living with HIV and those accessing HIV prevention services. Delivering comprehensive GBV care requires raising awareness among providers and the community and ensuring survivors receive comprehensive GBV care, with efforts made to ensure service accessibility, confidentiality, and safety. Collaboration within health facilities and across governmental ministries—such as health, gender, education, and judicial sectors, is essential for streamlined GBV awareness, prevention, care, and support, including the establishment of safe houses for GBV survivors (especially children) who experienced violence in their homes. Additionally, implementing an electronic medical records system specifically designed to capture GBV-related data linked with HIV reporting systems, comprehensive provider training, and a robust monitoring and evaluation framework will strengthen GBV services in ART clinics, fostering a culture prioritizing all clients’ safety and dignity.