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Photo: Simone D. McCourtie/World Bank

Violence as an Epidemic

I sat with Maya* in a dimly-lit restaurant in Kathmandu, Nepal, in a private corner away from the other dining patrons. She spoke softly but her eyes intensely held mine throughout her story. Her husband had disapproved of her advocacy involvement with a local Nepali women’s rights group and began abusing her at home. His violence had progressively worsened after she became pregnant with a child, not the son he wanted but a girl. The violence finally culminated in a fight in which he doused Maya in kerosene and lit her on fire. She only broke my gaze at the end of the story as she unwrapped her arm from the colorful scarf draped across her shoulders to reveal where her right hand had once been. Her demeanor and expressions conveyed a very different emotion than the smiling young woman I would come to know through aid distributions following the earthquake. It was shame.

Maya’s experience is not an isolated incident. The World Health Organization (WHO) estimates that 1 in 3 (35%) women globally have experienced some form of physical or sexual violence in their lifetime.1 Nationally representative household survey data across multiple countries reveals approximately 25% of females and 10% of males experiencing sexual abuse prior to age 18. Despite staggering statistics of violence, few survivors seek post-violence care services while many of those who do seek services do not receive them.2

Gender-based violence (GBV) is broadly defined as any form of violence against an individual based on that person’s biological sex, gender identity/expression, or perceived adherence to socially-defined expectations of what it means to be a man or woman, boy or girl. There are many forms of GBV; it affects all populations, across all age bands, across the world. GBV is directly and indirectly linked to HIV; violence is not only a direct means of transmission but also affects access to health services and experiencing violence has even been correlated with sexual risk behaviors.3 Because of this link, the HIV epidemic cannot be controlled without concentrated efforts to prevent and respond to GBV.

The GBV QA Tool for Violence Response

Beneath these staggering statistics are individuals deserving of care and support. Although Maya bears the physical scars of her abuse, many survivors carry unseen emotional, spiritual, and mental scars resulting from violence. It is not enough to simply have services in place for survivors needing care – services must also be of the highest quality possible. The Gender-Based Violence Quality Assurance Tool (GBV QA Tool) is an adaptable resource for health providers, facility managers, and program planners to assess, improve, and ensure the highest quality of post-violence clinical care in health facilities. The tool is closely aligned with World Health Organization (WHO), President’s Emergency Plan for AIDS Relief (PEPFAR), and US Agency for International Development (USAID) guidelines and technical considerations, and can be used to initiate post-GBV care services, as well as to assess existing post-GBV care. The final version, available in English and French, covers 28 standards that are organized into 10 different sections by area of service delivery (e.g., facility readiness, clinical care). The GBV QA Tool seeks to ensure that post-GBV care is accessible and available; essential infrastructure, equipment and services are in place; providers deliver respectful, high-quality, appropriate and timely care; patients needing care are appropriately identified and tracked; relevant policies and procedures are followed; and staff have appropriate training and skills to deliver care.

Moving Forward

My involvement with the development of the tool began after it had been piloted and was ready to enter the next stages of development. I am honored to continue my role in seeing this tool and package rolled out across PEPFAR-supported facilities to stand up and strengthen quality services for survivors. While I am preparing to support programs in the initial adoption of the tool, the final goal is to have countries assume ownership and move towards a country-led, internal process. As we prepare for our first U.S.-based and Africa regional trainings for assessors, I am reminded of the incredible responsibility we as public health professionals have to the populations we serve across the globe. There has been a renewed global call to address violence, ranging from the #MeToo movement to political will across the globe. In recognizing the progress and shared responsibility to end the HIV epidemic, I look forward to contributing to the momentum of ending violence in all forms.

To learn more about the tool, you can watch an informational webinar here: https://youtu.be/SACFcmwCm5I

To view the materials, please visit: http://www.who.int/reproductivehealth/publications/post-violence-care-in-health-facilities/en/

*The name Maya is used to protect the individual’s identity and right to privacy


  1. Preventing intimate partner violence and sexual violence against women. Taking action and generating evidence. Geneva, World Health Organization, 2010.
  2. Sumner S, Mercy J, Saul J, Motsa-Nzuza N, Kwesigabo G, Buluma R, et al. Prevalence of Sexual Violence Against Children and Social Services Utilization – Seven Countries, 2007–2013. MMWR Morb Mortal Wkly Rep 2015;64:565-9
  3. Ministry of Health, Malawi. Malawi Population-based HIV Impact Assessment (MPHIA) 2015-16: First Report. Lilongwe, Ministry of Health. November 2017.


Written by Meagan Cain
Meagan is a PHI/CDC Global Health HIV Prevention Fellow for CDC Atlanta.