The connections between HIV and violent trauma (focusing on childhood abuse and intimate violence) are presented here.

1. HIV & Violence
Rebecca J. Macy, PhD, ACSW, LCSW
Associate Professor, School of Social Work
University of North Carolina at Chapel Hill

2.  Healthcare providers: managing HIV as a
chronic disease
 Among persons with HIV, high rates of
exposure to violence
 Persons with HIV who are also violence
survivors less likely to adhere to Highly
Active Antiretroviral Therapy (HAART)
 Brief & colleagues, 2004; Mugavero & colleagues,
2006; Whetten & colleagues, 2008; Wyatt &
colleagues, 2004
HIV & Violence: The Challenge

3.  Prevalence of violence in North Carolina
 General health consequences of violence
 Connections between violence & HIV
 Strategies for addressing violence in
context of healthcare
Presentation Overview

4.  Child maltreatment: anonymous
telephone survey to probabilities samples
of North & South Carolina mothers (n=
1435)
◦ Incidence of use of harsh physical discipline
ever was 43 cases per 1000 children
◦ 11 per 1000 had ever been forced to have
sex with adult/older child
 (Theodore & colleagues, 2005)
Child Maltreatment in Carolinas

5.  Child Physical Abuse (Kaplan, Pelcovitz &
Labruna, 1999)
◦ Suicidal behavior
◦ Mental health problems
◦ Psychobiological problems
 altered brain development, hormonal
changes, impaired sleep, gastrointestinal disorders
 Child Sexual Abuse (Putnam, 2003)
◦ Major depression & dysthymia
◦ Sexualized behaviors
 leading to increased risk for STD’s
◦ Psychophysiological reactivity & other
neurobiological sequelae
Health Problems & Child
Maltreatment

6.  25% of women reported experiencing
physical/sexual violence in lifetime since
turning 18
◦ For physical violence, 82% reported victimization
by partner
◦ For sexual violence, 69% reported victimization by
partner
 Statewide data from a representative sample
of women using NC Behavioral Risk Factor
Surveillance System
◦ Martin & colleagues, 2008
Adult Violence among North
Carolina Women

7.  Physical Health  Mental Health
◦ Injuries ◦ Depressive disorders
◦ Chronic pain ◦ Anxiety disorders
◦ Reproductive & ◦ PTSD
gynecologic health ◦ Suicidal thoughts &
problems behaviors
◦ Gastrointestinal ◦ Substance use &
problems abuse
◦ Sleep disturbance  Prescription drug
◦ Heart disease abuse
Health Problems & Partner Violence
(Campbell 2002; Logan & colleagues, 2002; Macy &
colleagues, 2009; Plichta, 2004)

8.  Direct Pathways
◦ Example: Survivors’ chronic pain may result from
injuries sustained during repeated violent assaults
 Indirect Pathways
◦ Survivors have increased chronic inflammation
(increased levels of pro-inflammatory cytokines);
chronic inflammation impairs survivors’ health
◦ Example: Gastrointestinal disorders may be due to
chronic stress of living with a violent partner &
associated physical changes
 (Campbell, 2002; Kendall-Tackett, 2007)
How Does Violent Victimization
Lead to Health Problems?

9.  Survivors more likely (compared to those
who have not experienced violent
victimization) to:
◦ Have chronic & serious health problems
◦ Seek healthcare services
◦ Be dissatisfied with healthcare services
◦ (Campbell, 2002; Plichta, 2007)
 Survivors often have co-occurring physical
& mental health problems
Violence & Health: Key Points

10.  Violent victimization may trigger
pathways to HIV exposure
 Co-occurring risk factors: history of
victimization, risky sexual behaviors,
substance misuse, & needle sharing
◦ Brief & colleagues, 2004; Whetten &
colleagues, 2008
Connections between HIV &
Violence (1)

11.  Violent victimization undermines adaptive
coping capacity
◦ Disrupts positive views of self, relationships, future
◦ Coping efforts required to survive violent
victimization may leave a person with few internal
coping resources
◦ Maladaptive behavioral efforts to minimize the
cognitive & emotional consequences of violence
(substance misuse, sexual behaviors)
◦ Macy, 2007
Connections among HIV Risks:
Maladaptive Coping

12.  Violence survivors challenged by HAART
adherence…
 Distress & depression impedes adherence
 Violent trauma inhibits patient’s capacity to
develop trusting relationships with providers
 Substance use disorders impede survivors’
capacity to engage in treatment
 Brief & colleagues, 2004; Mugavero &
colleagues, 2006
Connections between HIV &
Violence (2)

13.  Violent victimization (past & current) may
accelerate HIV disease progression:
◦ Psychological responses to violent trauma
affect immune functioning
◦ Substance use (alcohol) erodes immune
functioning
 Brief & colleagues, 2004; Whetten &
colleagues, 2008
Connections between HIV &
Violence (3)

14. Stigma
Community Burdened
Crime & Systems of
Violence Care
Poverty Oppression
Connections between HIV &
Violence: Importance of Context

15.  Assessment
 Trauma-Informed Approaches to
Healthcare
 Mental Health Interventions for Violence
Survivors
Healthcare Strategies for
Addressing Violence

16.  1992: Universal violence screening
recommended by American Medical
Association
 However, universal screening for violence
became controversial topic
 U.S. Preventative Task Force’s conclusion:
Insufficient evidence to recommend
routine screening in primary care
 (Plichta, 2007; Spangaro & colleagues 2009)
Assessing for Violence: The
Controversy

17.  Continued call for universal screening
given:
◦ Pervasiveness of violence, especially among
those with HIV
◦ Health implications of violence
◦ Women welcome providers inquiry about
violence
◦ Importance of accounting for violence when
treating health problems
◦ Violence goes undetected without active
assessment by providers
◦ (Plichta, 2007; Spangaro & colleagues 2009)
Assessing for Violence: The
Rationale

18.  Realize potential therapeutic effect of assessment
 Privacy & confidentiality
 Environmental considerations
 Validate patient’s positive response to violence
 Be able to explain how violence affects patient’s health
 Never pressure survivor into a specific course of action
 Be ready with useful information about how & where
survivors can access help
 Compendium of partner & sexual violence assessment
instruments for use in healthcare settings available from
Centers for Disease Control (Basile, Hertz, & Back, 2007)
Best Practices: Assessing for
Violence in Healthcare Settings

19.  Domestic violence & sexual assault programs
are located in most counties throughout
North Carolina
 Service provision is not standard, but
generally offer:
◦ Advocacy, shelter, individual counseling, support
groups
 To find a local program:
◦ North Carolina Coalition Against Domestic
Violence
◦ North Carolina Coalition Against Sexual
Assault
Community-Based Domestic
Violence & Sexual Assault Services

20.  Healthcare systems & practices are adapted
to account for patient’s experiences of violent
victimization
 Such adaptations will facilitate survivors’
engagement & participation in healthcare
services
 Please see detailed table included in
handouts for information about trauma-
informed service strategies
Trauma-Informed Healthcare

21.  Seeking Safety: co-occurring PTSD &
substance abuse disorders
(Najavitz, 2007)
 Prolonged Exposure for PTSD: repeated
imaginable exposure to the traumatic
memory (trauma reliving) & repeated in-
vivo exposures to safe situations that are
avoided (Hembree, Rauch & Foa, 2003)
Evidence-Based Mental Health
Practices for Violence/Trauma

22.  Limited longitudinal research on relationships
between violence & health
◦ Most findings from cross-sectional research
 Research on violence predominantly focuses
on women
◦ Know much less about how best to help male
survivors
 Limited research on violence & HIV
 Treatment research focused on persons
without HIV
◦ HIV is another trauma that may complicate
treatment
◦ EBP may need to be adapted for persons’ with HIV
Caveats

23. Questions? Discussion?

24. Dr. Rebecca J. Macy
School of Social Work
University of North Carolina at Chapel Hill
325 Pittsboro Street, CB #3550
Chapel Hill, NC 27599
919-843-2435
rjmacy@email.unc.edu
http://rebeccajmacy.blogspot.com/
http://www.linkedin.com/in/rebeccajmacy
How to contact me…