Greentree white paper: sexual violence, genitoanal injury, and HIV: priorities for research, policy, and practice

A Multi-Methodological Exploration of Persecution Experiences and Related Injuries of Sexually Minoritized Asylum Seekers and Refugees in Nairobi, Kenya

Introduction: Sexually minoritized men in the East, Horn, and Central Africa continue to flee from their countries, because of actual or feared persecution, to neighboring Kenya to seek protection and safety. However, there is limited research on their experiences and needs. Therefore, this study aimed to describe the persecution experiences of gay and bisexual asylum seekers and refugees in the Nairobi Metropolitan Area. Methods: We adapted McAdam’s Life-Story Interview (LSI) to develop a semi-structured interview guide. We used the interview guide to conduct one-time anonymous in-depth interviews with 19 gay and bisexual men recruited by purposive sampling. The study also included a photovoice component and written reflections. We transcribed the interviews verbatim, uploaded them to NVivo 12 plus, and analyzed the data using Braun and Clarke’s six-step thematic analysis framework. Results: The mean age of the participants was 26, with the largest age group being 18–24 (n = 9, 47%). We found six major themes: (1) The Anti-Homosexuality Act, (2) death punishment, (3) physical abuse, (4) sexual violence, (5) discrimination, and (6) injuries. Conclusions: Continued multi-layered discrimination across borders may have adverse physical health outcomes for gay and bisexual asylum seekers and refugees in the Nairobi Metropolitan Area. Further collaborative strategies may help to understand and develop culturally sensitive interventions to improve their health and well-being.

The Penis, the Vagina and HIV Risk: Key Differences (Aside from the Obvious)

Globally, most Human Immunodeficiency Virus type 1 (HIV) transmission occurs through vaginal–penile sex (heterosexual transmission). The local immune environment at the site of HIV exposure is an important determinant of whether exposure during sex will lead to productive infection, and the vaginal and penile immune milieus are each critically shaped by the local microbiome. However, there are key differences in the microbial drivers of inflammation and immune quiescence at these tissue sites. In both, a high abundance of anaerobic taxa (e.g., Prevotella) is associated with an increased local density of HIV target cells and an increased risk of acquiring HIV through sex. However, the taxa that have been associated to date with increased risk in the vagina and penis are not identical. Just as importantly, the microbiota associated with comparatively less inflammation and HIV risk—i.e., the optimal microbiota—are very different at the two sites. In the vagina, Lactobacillus spp. are immunoregulatory and may protect against HIV acquisition, whereas on the penis, “skin type” flora such as Corynebacterium are associated with reduced inflammation. Compared to its vaginal counterpart, much less is known about the dynamics of the penile microbiome, the ability of clinical interventions to alter the penile microbiome, or the impact of natural/induced microbiome alterations on penile immunology and HIV risk.

Recent sexual violence exposure is associated with immune biomarkers of HIV susceptibility in women

PROBLEM

HIV/AIDS and sexual violence act synergistically and compromise women's health. Yet, immuno-biological mechanisms linking sexual violence and increased HIV susceptibility are poorly understood.

METHODS

We conducted a cross-sectional pilot study of HIV-uninfected women, comparing 13 women exposed to forced vaginal penetration within the past 12 weeks (Exposed) with 25 Non-Exposed women. ELISA assays were conducted for 49 biomarkers associated with HIV pathogenesis in plasma and cervicovaginal lavage (CVL). Differences between Exposed and Non-Exposed were analyzed by linear and logistic regression, using propensity score weighting to control for age, race, socioeconomic status, menstrual cycle, and contraceptive use.

RESULTS

In CVL, Exposed women had significantly reduced chemokines MIP-3α (p < .01), MCP-1 (p < .01), and anti-HIV/wound-healing thrombospondin-1 (p = .03). They also had significantly increased inflammatory cytokine IL-1α (p < 0.01) and were more likely to have detectable wound-healing PDGF (p = .02). In plasma, Exposed women had reduced chemokines MIP-3α (p < .01) and IL-8 (p < .01), anti-inflammatory cytokine TGF-β (p = .02), anti-HIV/antimicrobial HBD-2 (p = .02), and wound-healing MMP-1 (p = 0.02). They also had increased thrombospondin-1 (p < .01) and Cathepsin B (p = .01). After applying the stringent method of false discovery rate adjustment, differences for IL-1α (p = .05) and MCP-1 (p = .03) in CVL and MIP-3α (p = .03) in plasma remained significant.

CONCLUSIONS

We report systemic and mucosal immune dysregulation in women exposed to sexual violence. As these biomarkers have been associated with HIV pathogenesis, dysregulation may increase HIV susceptibility.

HIV Pathogenesis in the Human Female Reproductive Tract

PURPOSE OF REVIEW

Women remain disproportionately affected by the HIV/AIDS pandemic. The primary mechanism for HIV acquisition in women is sexual transmission, yet the immunobiological factors that contribute to HIV susceptibility remain poorly characterized. Here, we review current knowledge on HIV pathogenesis in women, focusing on infection and immune responses in the female reproductive tract (FRT).

RECENT FINDINGS

We describe recent findings on innate immune protection and HIV target cell distribution in the FRT. We also review multiple factors that modify susceptibility to infection, including sex hormones, microbiome, trauma, and how HIV risk changes during women's life cycle. Finally, we review current strategies for HIV prevention and identify barriers for research in HIV infection and pathogenesis in women. A complex network of interrelated biological and sociocultural factors contributes to HIV risk in women and impairs prevention and cure strategies. Understanding how HIV establishes infection in the FRT can provide clues to develop novel interventions to prevent HIV acquisition in women.

The Role of Stress and Genital Immunity in Sexual Trauma and HIV Susceptibility Among Adolescent Girls and Adult Women (The THRIVE Study): Protocol for a Longitudinal Case-Control Study

BACKGROUND

The relationship between sexual violence and HIV risk has been extensively documented through social and behavioral research; however, the underlying biological mechanisms are poorly understood.

OBJECTIVE

The purpose of the THRIVE (Trauma and HIV Risk: Investigating Stress and the Immune Disruption of the Vaginal Environment) Study is to examine the impact of sexual trauma due to sexual violence on HIV susceptibility through dysregulation of soluble inflammatory and anti-inflammatory and anti-HIV biomarkers in the female genital tract and dysregulation of the hypothalamic-pituitary-adrenal axis among adolescent girls and adult women.

METHODS

The THRIVE Study is a longitudinal case-control study conducted in San Diego, CA, among a racially diverse sample. Cases are adolescent girls (aged 14-19 years) or adult women (aged 20-45 years) who have experienced forced vaginal penetration by a phallus perpetrated by a man within the past 15 days. Controls are adolescent girls or adult women who have engaged in consensual vaginal sex with a man within the past 15 days. At baseline and 1- and 3-month follow-up study visits, participants undergo a urine-based pregnancy test; venipuncture blood draw for HIV, C-reactive protein, adrenocorticotropic hormone, and progesterone testing; a 45-min interviewer-administered computer survey; and cervicovaginal lavage to measure proinflammatory and anti-inflammatory and anti-HIV soluble immune biomarkers. After each study visit, participants self-collect saliva specimens (upon waking, 30 min after waking, and 45 min after waking) at home for 3 consecutive days, which are later assayed for cortisol and dehydroepiandrosterone sulfate. Participants receive compensation at each study visit and for the return of saliva specimens, and a list of local medical and support services. Study procedures use trauma-informed care methods, given the sensitive nature of the study and enrollment of women in the acute phase after sexual trauma. All research staff and investigators adhere to ethical principles and guidelines in the conduct of research activities. Data will be analyzed for descriptive and inferential analyses.

RESULTS

The recruitment of participants is ongoing. The publication of the first results is expected by late 2021.

CONCLUSIONS

The THRIVE Study will provide foundational knowledge on how sexual trauma due to sexual violence increases susceptibility to HIV acquisition via alterations in cervicovaginal immune regulation and the psychobiology of the stress responses. These findings will inform future research on mechanistic models of in vitro and in vivo injury and cervicovaginal wound healing processes, which may lead to the development of nonvaccine biomedical HIV prevention products for girls and women.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18190.

A new approach to assess the capability of health facilities to provide clinical care for sexual violence against women: a pilot study

Several tools have been developed to collect information on health facility preparedness to provide sexual violence response services; however, little guidance exists on how this information can be used to better understand which functions a facility can perform. Our study therefore aims to propose a set of signal functions that provide a framework for monitoring the availability of clinical sexual violence services. To illustrate the potential insights that can be gained from using our proposed signal functions, we used the framework to analyse data from a health facility census conducted in Central Province, Zambia. We collected the geographic coordinates of health facilities and police stations to assess women's proximity to multi-sectoral sexual violence response services. We defined three key domains of clinical sexual violence response services, based on the timing of the visit to the health facility in relation to the most recent sexual assault: (1) core services, (2) immediate care, and (3) delayed and follow-up care. Combining information from all three domains, we estimate that just 3% of facilities were able to provide a comprehensive response to sexual violence, and only 16% could provide time-sensitive immediate care services such as HIV post-exposure prophylaxis and emergency contraception. Services were concentrated in hospitals, with few health centres and no health posts fulfilling the signal functions for any of the three domains. Only 23% of women lived within 15 km of comprehensive clinical sexual violence health services, and 38% lived within 15 km of immediate care. These findings point to a need to develop clear strategies for decentralizing sexual violence services to maximize coverage and ensure equity in access. Overall, our findings suggest that our proposed signal functions could be a simple and valuable approach for assessing the availability of clinical sexual violence response services, identifying areas for improvement and tracking improvements over time.

Impact of chronic sexual abuse and depression on inflammation and wound healing in the female reproductive tract of HIV-uninfected and HIV-infected women

Sexual violence is associated with increased risk of HIV acquisition/transmission in women. Forced sex can result in physical trauma to the reproductive tract as well as severe psychological distress. However, immuno-biological mechanisms linking sexual violence and HIV susceptibility are incompletely understood. Using the Women’s Interagency HIV Study repository, a total of 77 women were selected to form 4 groups, stratified by HIV serostatus, in the following categories: 1) no sexual abuse history and low depressive symptom score (below clinically significant cut-off, scores <16) (Control); 2) no sexual abuse history but high depressive symptom score, ≥16 (Depression); 3) chronic sexual abuse exposure and low depressive symptom score (Abuse); 4) chronic sexual abuse exposure and high depressive symptom score (Abuse+Depression). Inflammation-associated cytokines/chemokines/proteases (TNF-α, IL-6, IL-1α, IL-1β, TGF-β MIP-3α, IP-10, MCP-1, Cathepsin B), anti-inflammatory/anti-HIV mediators (Secretory leukocyte protease inhibitor (SLPI), Elafin, beta defensin 2 (HBD2), alpha defensins (HNP 1–3), Thrombospondin (TSP-1), Serpin A1, A5, Cystatin A, B), and wound-healing mediators (Gro-α, VEGF, PDGF, EGF, FGF, IGF), were measured in cervical-vaginal lavage (CVL) using ELISA. Linear regression was used to model association of biomarkers with depression and abuse as predictor variables; the interaction between depression and abuse was also tested. Anti-HIV activity in CVL was tested using TZM-bl indicator cell line. In HIV-uninfected women, median levels of IL-6 (p = 0.04), IL-1α (p<0.01), TGF-β (p = 0.01), IP-10 (p = <0.01), PDGF (p<0.01) and FGF (p<0.01), differed significantly between groups. Specifically, an association was found between chronic sexual abuse and increased IL-1α (p<0.01), MIP-3α (p = 0.04), IP-10 (p<0.01), Serpin B1 (p = 0.01), FGF (p = 0.04) and decreased TGF-β (p<0.01), MCP-1 (p = 0.02), PDGF (p<0.01). Further, there was evidence of significant interactions between chronic sexual abuse and current depression for IL-1α, IP-10, Serpin A1, Cystatin B, and FGF. In HIV-infected women, median levels of TNF-α (p<0.01), IL-6 (p = 0.05), MIP-3α (p<0.01), and MCP-1 (p = 0.01), differed significantly between groups. Specifically, an association was found between chronic sexual abuse and increased MCP-1 (p = 0.03), Gro-α (p = 0.01) and decreased TNF-α (p<0.01), IL-1α (p = 0.02), MIP-3α (p<0.01) and Cathepsin B (p = 0.03). Current depressive symptoms were associated with significantly decreased MIP-3α (p<0.01). There was evidence of significant interactions between chronic sexual abuse and current depression for MCP-1 and FGF. No significant differences were observed in anti-HIV activity among all eight groups. Heat-map analyses revealed distinct immune network patterns, particularly in the Abuse groups for both HIV-infected and uninfected women. Our data indicates a complex relationship between chronic sexual abuse exposure, depressive symptoms, and FRT immune mediators that are also affected by HIV status. Association of chronic sexual abuse with increase in inflammation-associated cytokine/chemokine expression, along with impaired wound-healing associated growth-factors can create a microenvironment that can facilitate HIV infection. Evaluation of longitudinal changes in exposures and biomarkers are needed to untangle the immuno-biological mechanisms that may put women who endure life-long sexual abuse at increased risk for HIV.

Anal Intercourse Among Female Sex Workers in Côte d'Ivoire: Prevalence, Determinants, and Model-Based Estimates of the Population-Level Impact on HIV Transmission

Current evidence suggests that anal intercourse (AI) during sex work is common in sub-Saharan Africa, but there have been few studies in which the contribution of heterosexual AI to human immunodeficiency virus (HIV) epidemics has been investigated. Using a respondent-driven sampling survey of female sex workers (FSWs; n = 466) in Abidjan, Côte d'Ivoire, in 2014, we estimated AI prevalence and frequency. Poisson regressions were used to identify AI determinants. Approximately 20% of FSWs engaged in AI during a normal week (95% confidence interval: 15, 26). Women who performed AI were generally younger, had been selling sex for longer, were born in Côte d'Ivoire, and reported higher sex-work income, more frequent sex in public places, and violence from clients than women not reporting AI. Condom use was lower, condom breakage/slippage more frequent, and use of water-based lubricants was less frequently reported for AI than for vaginal intercourse. Using a dynamic transmission model, we estimated that 22% (95% credible interval: 11, 37% of new HIV infections could have been averted among FSWs during 2000-2015 if AI had been substituted for vaginal intercourse. Despite representing a small fraction of all sex acts, AI is an underestimated source of HIV transmission. Increasing availability and uptake of condoms, lubricants, and pre-exposure prophylaxis for women engaging in AI could help mitigate HIV risk.

Understanding the Intersection of Young Age, Mucosal Injury, and HIV Susceptibility

Adolescent boys and girls are disproportionately affected in the current HIV epidemic. Numerous sociobehavioral studies have addressed the indirect drivers surrounding this vulnerability-for example, socioeconomic, geographical locale, and all forms of violence. However, the direct factors that may influence infection, such as the anatomical and physiological maturation of the anogenital tracts of adolescents or the trauma and wound-healing processes of injured mucosal tissue, are understudied and represent a gap within the HIV prevention field. This article reviews the epidemiology of HIV infection and violence in adolescents and the available basic science knowledge attending this research area. More importantly, this review highlights the most critical gaps that need to be addressed to design preventive interventions that are safe and effective for this population, which is key to ending the HIV pandemic.

Impact of Sexual Trauma on HIV Care Engagement: Perspectives of Female Patients with Trauma Histories in Cape Town, South Africa

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no women had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Challenges in conducting research on sexual violence and HIV and approaches to overcome them

Studies have implicated sexual violence as a strong correlate of HIV acquisition in women. Characterizing how such violence affects the female immune system may provide insight into the biological mechanisms of HIV transmission and ultimately improve global HIV prevention strategies. Little research has been carried out in this domain, and the obstacles to investigation can be daunting. Here, we describe methodological challenges encountered and solutions explored while implementing a study of dysregulation of immune biomarkers potentially indicative of increased HIV susceptibility in women following sexual assault. Challenges included accessing sexual assault survivors and defining sexual assault, promoting study participant well-being during research engagement, reducing selection and information bias, collecting and processing biological samples, and adjusting for confounders such as reproductive tract infections and emotional and physical abuse. We found that many survivors of sexual assault welcomed the attention from study staff and felt empowered by the opportunity to help other women at risk for violence. Well-trained research staff and well-articulated community and medical partnerships were key methods to overcoming challenges while promoting the safety and welfare of vulnerable study participants.

Exploring Genitoanal Injury and HIV Risk Among Women: Menstrual Phase, Hormonal Birth Control, and Injury Frequency and Prevalence

BACKGROUND

Genital, anal, and oral injuries sustained from sexual intercourse may explain HIV transmission among women. We determined the variability in genitoanal injury frequency and prevalence in women after consensual sexual intercourse, exploring the role of menstrual phase and hormonal birth control.

METHODS

We used a longitudinal observational design with a convenience sample of 393 women aged 21 years and older. Participants had a baseline interview with gynecological examination, followed by consensual sexual intercourse with a male partner and a second gynecological examination. We analyzed injury prevalence with logistic regression and injury frequency with negative binomial regression among women who were (1) menstrual, not using hormonal birth control, (2) menstrual, using hormonal birth control, or (3) menopausal. We also compared injury among menstrual women in the follicular, ovulatory, and luteal phases.

FINDINGS

Women using hormonal birth control had 38% more external genitalia injuries [adjusted rate ratio (ARR) = 1.38, P = 0.030] and more than twice the anal injuries (ARR = 2.67, P = 0.005) as the nonhormonal birth control menstruating group. Menopausal women had more than 3 times the anal injuries (ARR = 3.36, P = 0.020) than those in the nonhormonal menstrual group. Among menstrual women, those in the follicular phase had a greater prevalence and frequency of external genitalia injuries than those in other phases.

INTERPRETATION

Increased rates of postcoital genitoanal injuries are noted among women using hormonal birth control and/or in the follicular phase of menstruation. Biological factors that influence women's risk for HIV warrant further investigation.

Nonoccupational Postexposure Human Immunodeficiency Virus Prophylaxis: Acceptance Following Sexual Assault

BACKGROUND

Nonoccupational postexposure prophylaxis (nPEP) for HIV following sexual assault may decrease the likelihood of HIV transmission.

OBJECTIVE

The purpose of this exploratory chart review study was to examine factors associated with patients accepting post-sexual assault nPEP at three forensic nurse examiner programs in urban settings.

METHODS

Forensic nursing charts of patients presenting for acute sexual assault care were reviewed as part of a mixed-methods study.

RESULTS

Patients assaulted by more than one or an unknown number of assailants were over 12 times more likely to accept the offer of nPEP (adjusted odds ratio [aOR] = 12.66, 95% CI [2.77, 57.82]). In cases where no condom was used (aOR = 8.57, 95% CI [1.59, 46.10]) or when any injury to the anus or genitalia was noted (aOR = 4.10, 95% CI [1.57, 10.75]), patients were more likely to accept nPEP. Patients with any injury to the face or head were less likely to initiate nPEP (aOR = 0.32, 95% CI [0.11, 0.97]).

DISCUSSION

This study is an important first step in understanding factors associated with nPEP acceptance after sexual assault.

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

An Electronic Daily Diary Study of Anal Intercourse in Drug-Using Women

Women (N = 138) with histories of illicit drug use were recruited into an electronic diary study that used Android smartphones for data collection. The diary was to be completed each day for 12 weeks using an "app" created in HTML5 and accessed over the Internet via smartphone. Data collection included information on sexual behaviors with up to 10 partners per day and contextual factors surrounding sexual behavior such as drug use before/after, type of sexual behavior (oral, vaginal, anal), and other activities such as using condoms for vaginal and anal intercourse and use of sexual lubricants. The sample was predominantly African American (58 %); 20 % Latina, 20 % White and 2 % reported as Other. Most women reported either less than a high school education (33 %) or having a high school diploma (33 %). The mean age was 39 years (SD = 11.78). Anal intercourse occurred on days when women also reported using illicit drugs, specifically methamphetamine and cocaine. Anal intercourse was not an isolated sexual activity, but took place on days when vaginal intercourse and giving and receiving oral sex also occurred along with illicit drug use. Anal intercourse also occurred on days when women reported they wanted sex. HIV prevention interventions must address the risks of anal intercourse for women, taking into account concurrent drug use and sexual pleasure that may reduce individual harm-reduction behaviors.

The syndemic illness of HIV and trauma: implications for a trauma-informed model of care

BACKGROUND

People living with HIV infection are disproportionately burdened by trauma and the resultant negative health consequences, making the combination of HIV infection and trauma a syndemic illness. Despite the high co-occurrence and negative influence on health, trauma and posttraumatic sequelae in people living with HIV infection often go unrecognized and untreated because of the current gaps in medical training and lack of practice guidelines.

OBJECTIVE

We set out to review the current literature on HIV infection and trauma and propose a trauma-informed model of care to target this syndemic illness.

METHODS

We searched PubMed, PsycINFO, and Cochrane review databases for articles that contained the following search terms: HIV AND either trauma (specifically violent trauma), PTSD, intimate partner violence (IPV), abuse, or trauma-informed care. Articles were limited to primary clinical research or metanalyses published in English. Articles were excluded if they referred to HIV-associated posttraumatic stress disorder or HIV-associated posttraumatic growth.

RESULTS

We confirm high, but variable, rates of trauma in people living with HIV infection demonstrated in multiple studies, ranging from 10%-90%. Trauma is associated with (1) increased HIV-risk behavior, contributing to transmission and acquisition of the virus; (2) negative internal and external mediators also associated with poor health and high-risk HIV behavior; (3) poor adherence to treatment; (4) poor HIV-related and other health outcomes; and (5) particularly vulnerable special populations.

CONCLUSIONS

Clinicians should consider using a model of trauma-informed care in the treatment of people living with HIV infection. Its adoption in different settings needs to be matched to available resources.

HIV-1 infection: the role of the gastrointestinal tract

The intestinal mucosa has an important role as portal of entry during mother-to-child transmission of HIV-1 and during sexual transmission. Tissue morphology and integrity, as well as distribution of relevant cell types within the mucosa, spanning from the oropharynx to the rectum, can greatly influence viral infection, replication, presentation, and persistence. The relative contribution to transmission by cell-associated or cell-free virus is still not defined for the different routes of transmission. Although the main target cells for HIV-1 replication are the CD4+ T lymphocytes, which are rapidly depleted both in the periphery and in the mucosal tissues, dendritic cells, Langerhans' cells, and macrophages are players in each of these processes. The predominant cells involved may differ according to the tract of the gut and the route of transmission. The microenvironment of the intestinal mucosa, including mucus, antibodies, or chemo-cytokines, can as well influence infection and replication of the virus: their role is still under investigation. The understanding of these processes may help in developing efficient prevention strategies.

Preventing HIV infection in women

Although the number of new infections has declined recently, women still constitute almost half of the world's 34 million people with HIV infection, and HIV remains the leading cause of death among women of reproductive age. Prevention research has made considerable progress during the past few years in addressing the biological, behavioral, and social factors that influence women's vulnerability to HIV infection. Nevertheless, substantial work still must be performed to implement scientific advancements and to resolve many questions that remain. This article highlights some of the recent advances and persistent gaps in HIV prevention research for women and outlines key research and policy priorities.

Sexual violence and HIV transmission: summary proceedings of a scientific research planning meeting

This summarizes proceedings of a Scientific Research Planning Meeting on Sexual Violence and HIV transmission, convened by the Social Science Research Council on 19–20 March 2012 at the Greentree Foundation in New York. The Meeting brought together an interdisciplinary group of basic, clinical, epidemiological and social science researchers and policy makers with the aim of: (1) examining what is known about the physiology of sexual violence and its role in HIV transmission, acquisition and pathogenesis; (2) specifying factors that distinguish risks throughout the maturation of the female genital tract, the reproductive cycle and among post-menopausal women; and (3) developing a research agenda to explore unanswered questions. The Meeting resulted in a consensus Research Agenda and White Paper that identify priorities for HIV research, policy and practice as it pertains to the role of sexual violence and genital injury in HIV transmission, acquisition and pathogenesis, particularly among women and girls.

The physiology of sexual violence, genito-anal injury and HIV: opportunities for improving risk estimation

Increased understanding about the relative contribution of genito-anal injury to HIV transmission may improve epidemic model estimates of the distribution of risk among and across different subpopulations. Better understanding about the distribution of HIV among subpopulations that are at highest risk of sexual violence can also improve the design and prioritization of combination prevention interventions that are most likely to reduce the risk of sexual violence and its potential contribution to HIV transmission. The effective incorporation of physiological and social variables into epidemic modelling will likely require new research approaches that can help communicate the level of risk associated with different types of 'heterosexual' transmission. Reference models that reflect the potential impact of sexual violence and genital injury can help direct attention toward key variables and uncertainties. For further research that clarifies these relationships will require multidisciplinary collaboration among groups with expertise in epidemiology, social science, public health, and clinical and basic science.