**1. Introduction**

88 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

Wanyenze, R.K., Nawavvu, C., Namale, A.S., Mayanja, B., Bunnell, R., Abang, B., Amanyire,

Ward, V. & Mendelsohn, J. (2009). *Supporting the educational needs of HIV-positive learners in* 

World Health Organization [WHO], Joint United Nations Programme on HIV/AIDS

World Health Organization [WHO], Joint United Nations Programme on HIV/AIDS

*the World Health Organization*, 86(4):302-309.

UNICEF, Geneva.

UNICEF, Geneva.

G., Sewankambo, N.K., & Kamya, M.R. (2008). Acceptability of routine HIV counselling and testing, and HIV seroprevalence in Ugandan hospitals. *Bulletin of* 

*Namibia*. United Nations Educational, Scientific and Cultural Organization, Paris.

[UNAIDS], & United Nations Children's Fund [UNICEF]. (2010). *Towards universal access: Scaling up priority interventions in the health sector*. WHO, UNAIDS, &

[UNAIDS], & United Nations Children's Fund [UNICEF]. (2009). *Towards universal access: Scaling up priority interventions in the health sector*. WHO, UNAIDS, &

> The health systems context in rural South Africa presents significant challenges for addressing the intersecting problems of HIV/AIDS and Gender Based Violence (GBV). In KwaZulu-Natal Province, district level government responses to these issues are principally focused in urban, higher population areas. Rural health systems rely more heavily on nongovernmental organizations (NGOs), which have serious time limitations and insecure external funding. Weak management skills, and insufficient capacity to design and monitor services, are key problems. There is also a shortage of health personnel in rural areas, and high attrition rates due to poor work conditions, substandard accommodation environments, inadequate pay and benefits, and illness and stress resulting from to the high demands posed by the HIV/AIDS epidemic and other primary health care issues. Overall, the rural health structure is very under-developed, under-staffed, under-resourced and under-trained around issues of GBV and HIV/AIDS.

> There is a pressing need for rural health services to focus on health promotion and prevention - including violence prevention - and to develop new strategies for coordinating the activities of health professionals with voluntary associations and NGOs. This paper presents an institutional analysis of why access to GBV and HIV/AIDS services is low in rural KwaZulu-Natal, with a focus on understanding existing professional structures and community beliefs that act as barriers to health system development. Such an understanding can also reveal how existing strengths and resources may be harnessed to encourage changes in the cultural attitudes and structures that support the gender violence-HIV/AIDS nexus, and identify salient points of entry at which interventions can be designed.

#### **1.1 An institutional perspective on "Access"**

#### **1.1.1 The health system as "Institution"**

It is well recognized that the health sector faces certain institutional characteristics that distinguish it from other sectors of society [Jan et al., 2008; Mooney, 1994]. Specifically, these characteristics include the role of institutions in providing access to health benefits, or more exactly, preservation from ill health or health losses. In this view, institutions are not organizations per se, but are the 'rules' that govern the conduct of players, whether individuals or organizations, within society [North, 1993]. Thus, institutions include formal rules such as legislation concerning resource allocation to health and the regulation of professionals, and informal rules such as social customs and community norms that shape

An Institutional Analysis of Access to

funding and access to transport [Russel et al., 2000].

Testing (VCT) follow-up services to these same women.

can easily be discerned by onlookers [Senderowitz, 1999; Van Dyk, 2002].

better patient access.

GBV/HIV Services in Rural KwaZulu-Natal, South Africa 91

and retention. In rural areas, traditional socio-cultural norms, practices and beliefs at once inhibit women from seeking health care around GBV and HIV/AIDS, and can produce institutional resistance to the restructuring of health services in ways that might facilitate

Women in rural areas of South Africa may have considerable difficulty accessing public health clinics for several reasons. First, significant variability in access and availability of clinical services mean that some women must travel long distances to reach the nearest clinic. This is physically impossible for many women with disabilities, illness, or who are sick with HIV/AIDS, who may otherwise have reached the clinic by walking or other forms of transportation. Women without economic means cannot pay for the costs of transport, creating a key structural barrier to their ability to access free contraceptives, receive HIV/AIDS testing and counseling, or access treatment if they are HIV/AIDS infected. The nature of voluntary testing and counseling in public health clinics requires multiple visits: formerly in KwaZulu-Natal, HIV test results took an average of three weeks to be processed, for example, and many patients never returned to receive their results [Campbell et al. 2002]. Treatment and counseling may also require multiple visits, which means that women without physical and economic access to clinics may not attend initially or make return visits. Finally, some community-based service providers who would have provided home visits to isolated women have reported that they do not do so because of their own limited

Public health clinics are also very uneven in terms of resource and staff availability across the country, with rural areas suffering the most [Delius et al., 2002; Kelly et al., 2001]. In some rural areas of KwaZulu-Natal, voluntary counseling and testing is not available at all [Kelly et al., 2001]. Many primary health care clinics in rural KwaZulu-Natal are organized to render antenatal services to pregnant women on one specific day of the week, and 40-60 pregnant women often require services on that particular day [Ngidi et al., 2002]. These demands create major challenges in terms of offering adequate Voluntary Counseling and

The physical and organizational structure of clinics is also a component in the improvement of VCT services, as well as for increasing the likelihood that people will feel comfortable attending clinics for HIV/AIDS related reasons [Senderowitz, 1999]. Van Dyk's [Van Dyk, 2002] survey of over 1400 men and women found that 33% preferred to go to an unknown clinic (i.e., not in their community) for voluntary counseling and testing. Of these, 50% do "not trust health care workers to keep a secret", 30% prefer "total confidentiality" which they may not receive at their local clinic, and 13% "fear prejudice and rejection" from going to the local clinic. These fears are highly attributable to the public nature of many clinics, in which there is a lack of privacy and individuals' problems or reasons for coming to the clinic

Finally, state provision of free and/or low cost accessible services and drugs to HIV/AIDS patients has long been identified as a crucial step in the prevention and treatment effort [Joint Monitoring Committee on the Improvement of the Quality of Life and Status of Women, 2001a]. However, the roll-out of antiretroviral therapy (ART) is still far from even or universal, despite the fact that the government began providing it through the public health system in 2003. Rural areas continue to experience the least access to publicly-

**1.2.1 Location, mandate, resources and organization of public health clinics** 

health care practices. An institutionalist analysis views interventions as more than a simple balancing of inputs and outputs (or costs and benefits) and thus provides a more complete account of health decision-making. Such an analysis requires a coherent theory of how health services work in a specific context.

The development of health programs in areas of restricted resources often involves 'institution building' and this paper provides an analysis of how this occurs in the context of HIV/AIDS and gender violence in South Africa. Other recent institutional analyses that have focused on this problem expose implicit costs and values from the perspective of health economics [Jan et al., 2008]. Institutional development may also be concerned with issues of health service quality. However, the current analysis is focused on concepts of equity in access to these important health and social services.

#### **1.1.2 Institutional access**

Health systems research is increasingly focused on issues of inequity in access to underlying determinants of health, as well as to curative services. Access is understood to be amenable to policy decisions about the supply of health care. Access barriers deter, delay and minimize the search for health care solutions to HIV/AIDS and gender violence. However, it is important to note that access is also limited by demand-side factors that are less than optimal.

Gilson and Schneider [Gilson et al., 2007] have summarized three key dimensions in defining access, or the degree of fit between the health system and those it serves. These domains concern a dynamic process of interaction between health institutions and individuals or households. 'Availability', or physical access, refers to whether the appropriate health services are in the right place at the right time. 'Affordability', or financial access, refers to the relationship between the cost of health care and individuals' ability to pay. Finally, 'acceptability', or cultural access, refers to the social and cultural distance between health care systems and their users [Guilford et al., 2002; Delius et al., 2002]. Studies of how these dimensions interact with each other are particularly needed, as interventions to address single issues of access may be ineffective in reducing inequity. Within an access framework and from an institutional perspective, we examine the interactions of various material and operational, or procedural, barriers to accessing HIV/AIDS and gender based violence services in an under-resourced rural area in KwaZulu-Natal. This multi-dimensional analysis will hopefully provide the basis for multilevel interventions.

#### **1.2 Literature review**

The issue of gender violence and its links to HIV/AIDS in rural settings has not been addressed in a substantive way. There are several complex issues in rural health systems that interact to present significant institutional problems to health and safety. Material barriers to health for poor rural women have been noted to include lack of physical access to public health clinics, low levels of resources and staff in existing clinics, and the high costs of treatment [Delius et al., 2002]. Further, considerable operational or procedural problems exist in terms of staff awareness and training around GBV and HIV/AIDS issues, as well as negative attitudes and gendered discrimination against women seeking contraceptives, HIV/AIDS tests, or HIV/AIDS treatment [MacPhail et al., 2001]. These general structural and operational problems are exacerbated in rural locations, which also have problems of inattention by the government, lack of training and resources, and poor staff recruitment

health care practices. An institutionalist analysis views interventions as more than a simple balancing of inputs and outputs (or costs and benefits) and thus provides a more complete account of health decision-making. Such an analysis requires a coherent theory of how

The development of health programs in areas of restricted resources often involves 'institution building' and this paper provides an analysis of how this occurs in the context of HIV/AIDS and gender violence in South Africa. Other recent institutional analyses that have focused on this problem expose implicit costs and values from the perspective of health economics [Jan et al., 2008]. Institutional development may also be concerned with issues of health service quality. However, the current analysis is focused on concepts of

Health systems research is increasingly focused on issues of inequity in access to underlying determinants of health, as well as to curative services. Access is understood to be amenable to policy decisions about the supply of health care. Access barriers deter, delay and minimize the search for health care solutions to HIV/AIDS and gender violence. However, it is important to note that access is also limited by demand-side factors that are less than

Gilson and Schneider [Gilson et al., 2007] have summarized three key dimensions in defining access, or the degree of fit between the health system and those it serves. These domains concern a dynamic process of interaction between health institutions and individuals or households. 'Availability', or physical access, refers to whether the appropriate health services are in the right place at the right time. 'Affordability', or financial access, refers to the relationship between the cost of health care and individuals' ability to pay. Finally, 'acceptability', or cultural access, refers to the social and cultural distance between health care systems and their users [Guilford et al., 2002; Delius et al., 2002]. Studies of how these dimensions interact with each other are particularly needed, as interventions to address single issues of access may be ineffective in reducing inequity. Within an access framework and from an institutional perspective, we examine the interactions of various material and operational, or procedural, barriers to accessing HIV/AIDS and gender based violence services in an under-resourced rural area in KwaZulu-Natal. This multi-dimensional analysis will hopefully provide the basis for multi-

The issue of gender violence and its links to HIV/AIDS in rural settings has not been addressed in a substantive way. There are several complex issues in rural health systems that interact to present significant institutional problems to health and safety. Material barriers to health for poor rural women have been noted to include lack of physical access to public health clinics, low levels of resources and staff in existing clinics, and the high costs of treatment [Delius et al., 2002]. Further, considerable operational or procedural problems exist in terms of staff awareness and training around GBV and HIV/AIDS issues, as well as negative attitudes and gendered discrimination against women seeking contraceptives, HIV/AIDS tests, or HIV/AIDS treatment [MacPhail et al., 2001]. These general structural and operational problems are exacerbated in rural locations, which also have problems of inattention by the government, lack of training and resources, and poor staff recruitment

health services work in a specific context.

**1.1.2 Institutional access** 

optimal.

level interventions.

**1.2 Literature review** 

equity in access to these important health and social services.

and retention. In rural areas, traditional socio-cultural norms, practices and beliefs at once inhibit women from seeking health care around GBV and HIV/AIDS, and can produce institutional resistance to the restructuring of health services in ways that might facilitate better patient access.

#### **1.2.1 Location, mandate, resources and organization of public health clinics**

Women in rural areas of South Africa may have considerable difficulty accessing public health clinics for several reasons. First, significant variability in access and availability of clinical services mean that some women must travel long distances to reach the nearest clinic. This is physically impossible for many women with disabilities, illness, or who are sick with HIV/AIDS, who may otherwise have reached the clinic by walking or other forms of transportation. Women without economic means cannot pay for the costs of transport, creating a key structural barrier to their ability to access free contraceptives, receive HIV/AIDS testing and counseling, or access treatment if they are HIV/AIDS infected. The nature of voluntary testing and counseling in public health clinics requires multiple visits: formerly in KwaZulu-Natal, HIV test results took an average of three weeks to be processed, for example, and many patients never returned to receive their results [Campbell et al. 2002]. Treatment and counseling may also require multiple visits, which means that women without physical and economic access to clinics may not attend initially or make return visits. Finally, some community-based service providers who would have provided home visits to isolated women have reported that they do not do so because of their own limited funding and access to transport [Russel et al., 2000].

Public health clinics are also very uneven in terms of resource and staff availability across the country, with rural areas suffering the most [Delius et al., 2002; Kelly et al., 2001]. In some rural areas of KwaZulu-Natal, voluntary counseling and testing is not available at all [Kelly et al., 2001]. Many primary health care clinics in rural KwaZulu-Natal are organized to render antenatal services to pregnant women on one specific day of the week, and 40-60 pregnant women often require services on that particular day [Ngidi et al., 2002]. These demands create major challenges in terms of offering adequate Voluntary Counseling and Testing (VCT) follow-up services to these same women.

The physical and organizational structure of clinics is also a component in the improvement of VCT services, as well as for increasing the likelihood that people will feel comfortable attending clinics for HIV/AIDS related reasons [Senderowitz, 1999]. Van Dyk's [Van Dyk, 2002] survey of over 1400 men and women found that 33% preferred to go to an unknown clinic (i.e., not in their community) for voluntary counseling and testing. Of these, 50% do "not trust health care workers to keep a secret", 30% prefer "total confidentiality" which they may not receive at their local clinic, and 13% "fear prejudice and rejection" from going to the local clinic. These fears are highly attributable to the public nature of many clinics, in which there is a lack of privacy and individuals' problems or reasons for coming to the clinic can easily be discerned by onlookers [Senderowitz, 1999; Van Dyk, 2002].

Finally, state provision of free and/or low cost accessible services and drugs to HIV/AIDS patients has long been identified as a crucial step in the prevention and treatment effort [Joint Monitoring Committee on the Improvement of the Quality of Life and Status of Women, 2001a]. However, the roll-out of antiretroviral therapy (ART) is still far from even or universal, despite the fact that the government began providing it through the public health system in 2003. Rural areas continue to experience the least access to publicly-

An Institutional Analysis of Access to

perpetuated as a result of the new Bill.

PEP, or provide counseling around HIV and PEP.

gender violence and HIV/AIDS nexus?

long-established tradition of migrant labour.

**1.3 Research question** 

**2. Methods** 

GBV/HIV Services in Rural KwaZulu-Natal, South Africa 93

the requirement that women report to police will influence women's access. The Bill at once requires coordination between police and health services while eliminating the need for collaboration between health services and voluntary organizations or NGOs that provide other supports. Women who fear further violence from perpetrators or who do not want to go "public" about the rape for fear of stigma, will choose not to file charges and so will be denied access to PEP. It will also be less likely that health professionals will be compelled to refer them to support services or counseling. Pre-existing inefficiencies with service coordination, and gender-blind aspects of post-sexual assault care in rural areas, may be

Many researchers argue that a gap clearly exists in public health clinics and VCT programs in terms of staff training, awareness, attitudes, and overall handling of violence against women in the context of HIV/AIDS; conversely, HIV services have not been adequately integrated into public services provided to survivors of sexual violence [Vetten et al., 2001; Joint Monitoring Committee on the Improvement of the Quality of Life and Status of Women, 2001b; France et al., 2000]. This lack of integration works as a barrier to HIV/AIDS prevention and treatment for survivors of rape, and may put HIV/AIDS infected women at increased risk for violence. For example, non-governmental rape crisis centres and women's shelters require more resources and training around the issues of HIV/AIDS. Shelters for abused women are not always accessible to HIV/AIDS infected women: many of these shelters will not allow HIV/AIDS infected women to reside there, which puts women at risk of more violence at the hands of their partners. Women's shelters and clinics that do address issues of HIV/AIDS are often poorly resourced to do so. Non-governmental rape crisis centres often do not have the resources, knowledge or capacity to give HIV tests, administer

Overall, there are significant barriers documented regarding access to the health system response to GBV and HIV/AIDS. How do these material and procedural barriers to availability, affordability and acceptability interact together in rural areas to aggravate the

The Health District Sisonke (DC43) in KwaZulu-Natal was the site for this study. Located in the foothills of the southern Drakensberg mountains, about 90 kms from Pietermaritzburg, this area has a demographic profile with a variety of rural communities broadly representative of the country as a whole. It also has a history of public health involvement and innovation dating back to the 1940s [Jeeves, 1998]. The legacy of apartheid has created a highly uneven landscape, with marked inequalities in access to land, resources, employment, income and services. Migration remains a commonly practiced response to extreme poverty and unemployment in large parts of the district under study, continuing a

The study setting is a traditional tribal area with poor secondary roads and almost complete lack of public/private transport. There are health clinics at Pholela, Bulwer, Underberg and Ixopo, a district mission hospital at Centacow, as well as a larger referral hospital in the

provided ART [Human Rights Watch, 2008]. In areas where clinics do not offer ART, many people cannot afford the cost of accessing treatment privately. Poor rural women with HIV/AIDS are unlikely to access these drugs for a variety of reasons, including lack of transportation to clinics offering ART, fear of stigma, inability to maintain the level of health (nutrition, clean water, adequate rest) required to take the drugs as prescribed, and a lack of other services or support in the community to help them comply with their medication regimen. Although ART was not available in the public health system when this study was conducted, the same issues around uneven provision of ART by clinics, and lack of training, expertise, equipment and attention to guidelines among health professionals, are still very relevant today.

#### **1.2.2 Community, legal and public health handling of violence against women**

Vetten & Bhana [Vetten et al., 2001] outline several problematic and gender-blind aspects of traditional VCT models. VCT and mother-to-child-transmission (MTCT) programmes usually promote partner-notification when a woman tests positive for HIV/AIDS. Such disclosure is encouraged to promote safer sex practices and partner testing. The potential for violent partner reactions to women's disclosure is rarely taken into account; similarly, VCT counselors may suggest couple counseling which may also trigger male violence and abuse. VCT/MTCT counselors or nurses may have little knowledge of domestic violence or expertise in determining if certain patients come from abusive relationships which will place them at even greater risk for abuse upon disclosure. Finally, HIV/AIDS testing is often done in public antenatal clinics without the patients' consent. Patients are often informed of their HIV/AIDS status in non-private settings, where the likelihood of others hearing is high.

Vetten & Bhana also argue that rape crisis centres in public hospitals and/or nurses and counselors on staff who deal with rape victims - are similarly lacking in training on the links between rape and HIV/AIDS. Rape victims are not always referred to HIV/AIDS counseling and testing centres, and nurses are often ill-equipped to counsel the women themselves, as they do not have the proper information or knowledge about the risk of HIV/AIDS following rape (i.e., when can the victim be tested, how long does HIV/AIDS take to incubate) [Vetten et al., 2001; Gernholtz, 2002]. At the time of this study, most clinics in rural KwaZulu Natal were not providing post-exposure prophylaxis (PEP) to rape survivors, and most women faced barriers of lack of transportation, stigma, discrimination and negative attitudes by health professionals, among others, when it came to accessing this life-saving drug. In 2002, the South African government committed to providing postexposure prophylaxis (PEP) to rape survivors through the public health system. Like ART, however, this roll-out has been slower than desired and uneven, with rural areas being slower to offer PEP to rape survivors (Human Rights Watch, 2008]. A corresponding protocol was released by the Department of Health [Department of Health, South Africa, 2003], which requires that all rape survivors be provided with counseling around HIV and PEP, and that referral systems be in place so that survivors of rape can access longer-term counseling. However, preliminary findings have shown that there is a lack of coordination among service providers and poor knowledge among health professionals of PEP guidelines [Birdsall et al., 2004]. A recent Bill [Republic of South Africa, 2007] legislated the provision of PEP to sexual assault providers, but added the requirement that a woman press criminal charges in order to access the life-saving drugs. No references to other treatment or counseling for rape survivors were made in the Bill. It has yet to be seen how these gaps and

provided ART [Human Rights Watch, 2008]. In areas where clinics do not offer ART, many people cannot afford the cost of accessing treatment privately. Poor rural women with HIV/AIDS are unlikely to access these drugs for a variety of reasons, including lack of transportation to clinics offering ART, fear of stigma, inability to maintain the level of health (nutrition, clean water, adequate rest) required to take the drugs as prescribed, and a lack of other services or support in the community to help them comply with their medication regimen. Although ART was not available in the public health system when this study was conducted, the same issues around uneven provision of ART by clinics, and lack of training, expertise, equipment and attention to guidelines among health professionals, are still very

**1.2.2 Community, legal and public health handling of violence against women** 

Vetten & Bhana [Vetten et al., 2001] outline several problematic and gender-blind aspects of traditional VCT models. VCT and mother-to-child-transmission (MTCT) programmes usually promote partner-notification when a woman tests positive for HIV/AIDS. Such disclosure is encouraged to promote safer sex practices and partner testing. The potential for violent partner reactions to women's disclosure is rarely taken into account; similarly, VCT counselors may suggest couple counseling which may also trigger male violence and abuse. VCT/MTCT counselors or nurses may have little knowledge of domestic violence or expertise in determining if certain patients come from abusive relationships which will place them at even greater risk for abuse upon disclosure. Finally, HIV/AIDS testing is often done in public antenatal clinics without the patients' consent. Patients are often informed of their HIV/AIDS status in non-private settings, where the likelihood of others hearing is high. Vetten & Bhana also argue that rape crisis centres in public hospitals and/or nurses and counselors on staff who deal with rape victims - are similarly lacking in training on the links between rape and HIV/AIDS. Rape victims are not always referred to HIV/AIDS counseling and testing centres, and nurses are often ill-equipped to counsel the women themselves, as they do not have the proper information or knowledge about the risk of HIV/AIDS following rape (i.e., when can the victim be tested, how long does HIV/AIDS take to incubate) [Vetten et al., 2001; Gernholtz, 2002]. At the time of this study, most clinics in rural KwaZulu Natal were not providing post-exposure prophylaxis (PEP) to rape survivors, and most women faced barriers of lack of transportation, stigma, discrimination and negative attitudes by health professionals, among others, when it came to accessing this life-saving drug. In 2002, the South African government committed to providing postexposure prophylaxis (PEP) to rape survivors through the public health system. Like ART, however, this roll-out has been slower than desired and uneven, with rural areas being slower to offer PEP to rape survivors (Human Rights Watch, 2008]. A corresponding protocol was released by the Department of Health [Department of Health, South Africa, 2003], which requires that all rape survivors be provided with counseling around HIV and PEP, and that referral systems be in place so that survivors of rape can access longer-term counseling. However, preliminary findings have shown that there is a lack of coordination among service providers and poor knowledge among health professionals of PEP guidelines [Birdsall et al., 2004]. A recent Bill [Republic of South Africa, 2007] legislated the provision of PEP to sexual assault providers, but added the requirement that a woman press criminal charges in order to access the life-saving drugs. No references to other treatment or counseling for rape survivors were made in the Bill. It has yet to be seen how these gaps and

relevant today.

the requirement that women report to police will influence women's access. The Bill at once requires coordination between police and health services while eliminating the need for collaboration between health services and voluntary organizations or NGOs that provide other supports. Women who fear further violence from perpetrators or who do not want to go "public" about the rape for fear of stigma, will choose not to file charges and so will be denied access to PEP. It will also be less likely that health professionals will be compelled to refer them to support services or counseling. Pre-existing inefficiencies with service coordination, and gender-blind aspects of post-sexual assault care in rural areas, may be perpetuated as a result of the new Bill.

Many researchers argue that a gap clearly exists in public health clinics and VCT programs in terms of staff training, awareness, attitudes, and overall handling of violence against women in the context of HIV/AIDS; conversely, HIV services have not been adequately integrated into public services provided to survivors of sexual violence [Vetten et al., 2001; Joint Monitoring Committee on the Improvement of the Quality of Life and Status of Women, 2001b; France et al., 2000]. This lack of integration works as a barrier to HIV/AIDS prevention and treatment for survivors of rape, and may put HIV/AIDS infected women at increased risk for violence. For example, non-governmental rape crisis centres and women's shelters require more resources and training around the issues of HIV/AIDS. Shelters for abused women are not always accessible to HIV/AIDS infected women: many of these shelters will not allow HIV/AIDS infected women to reside there, which puts women at risk of more violence at the hands of their partners. Women's shelters and clinics that do address issues of HIV/AIDS are often poorly resourced to do so. Non-governmental rape crisis centres often do not have the resources, knowledge or capacity to give HIV tests, administer PEP, or provide counseling around HIV and PEP.

#### **1.3 Research question**

Overall, there are significant barriers documented regarding access to the health system response to GBV and HIV/AIDS. How do these material and procedural barriers to availability, affordability and acceptability interact together in rural areas to aggravate the gender violence and HIV/AIDS nexus?
