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Gender-Based Violence, Health, and HIV
Intersections and Implications for HIV Clinicians
Poll: Who is on the call today?
1. Local or State DV/SA Program
2. Health care provider (Primary, Women’s
Health, etc.)
3. HIV Testing, Treatment and Care
Provider
4. Other
Making the Connection:
Gender-Based Violence
and HIV
4
Learning
Objectives
As a result of this activity, learners will be
better able to:
1.
Describe the intersection between gender-based
violence and STIs/HIV.
2.
Describe how gender-based violence can affect health
and treatment outcomes for people living with
STIs/HIV.
3.
Identify strategies to assess for gender-based violence
and respond appropriately to disclosures
4.
List harm reduction strategies for partner HIV
notification
5.
Identify options for HIV prevention and risk reduction
in the context of GBV
“
Research shows us that
violence is both a significant cause
and a significant consequence of
HIV infection among women.
“
Judy Auerbach
American Foundation for AIDS Research (AmfAR)
6
Understanding the Problem
• Gender-based violence increases the chance of
becoming infected with HIV.
• Women are 2-5 times more likely than men to
contract HIV from during heterosexual sexual
intercourse.
Can anyone tell me why?
7
Victims of GBV are More Likely to be Infected
• Women and girls who are victims of GBV
are 4 times more likely to become
infected with STIs including HIV.
• Women who were beaten or dominated by
their partners were 48% more likely to
become infected with HIV than women in
non-violent relationships.
(Decker et al, 2009; Gielen et al, 2007; Decker et al, 2005;
Wingood et al, 2000; Campbell &Soeken, 1999)
8
Women disclosing
physical abuse
were
Women disclosing
psychological abuse
were
3 TIMES
2 TIMES
more likely to
more likely to
experience an STI. experience an STI.
(Coker et al, 2000)
Men and Health Impact of IPV
• Men who have sex with men (MSM) are at higher
risk for experiencing both HIV and intimate partner
violence.
• Among men who had experienced intimate partner
violence, there were higher rates of depression.
http://www.ncbi.nlm.nih.gov/pubmed/26222752
http://www.ajpmonline.org/article/S07493797(08)00224-9/abstract
10
GBV and HIV Status Disclosure
24% of female patients
experienced physical abuse after
disclosing their HIV status and
45% feared such a reaction.
(Rothenberg K.H. et al, 1995)
11
Over half of women living with HIV
have experienced GBV, considerably
higher than the national prevalence
among women overall (55% vs. 36%).
(Machtinger, 2012; Black, 2011)
HIV AND GBV
Among women who are
experiencing GBV, women
who are HIV-positive
experience more severe
violence and more frequent
abuse compared to HIVnegative women.
Review study by Gielen et al, 2007
13
Among a small sample of HIV-positive men:
• 39% reported physical intimate partner violence by a
primary sexual partner
• 17% reported physical intimate partner violence by a
casual sexual partner
Shelton et al, 2005
14
Why do we
talk about
cooccurrence
of HIV and
GBV?
HIV is a social disease with clinical implications
•
The infection moves primarily through social
and sexual networks
•
Communities that are most marginalized by
stigma and discrimination are also most
vulnerable to HIV
•
Clinical outcomes also reflect the prevailing
inequities and health disparities
•
15
It’s not just viral load!
Violence is a driver of the HIV epidemic
Violence and the threat of violence:
interfere with women’s negotiating power
introduces elevated risk, through coerced sex
May increase risk taking behaviors, like transactional sex
may be a more immediate threat than HIV
May prevent access to treatment and care
Increased
vulnerability to
HIV/STI infection,
poor treatment
outcomes
16
RISK
REDUCING RISK REQUIRES AN INDIVIDUAL BEHAVIORAL
SOLUTION
VS.
VULNERABILITY
REDUCING VULNERABILITY REQUIRES STRUCTURAL
SOCIAL CHANGE
17
GBV increases the risk for HIV infection through:
• Sexual coercion/forced sex with an infected partner
• Limited or compromised negotiation of safer sex
practices
• Increased sexual risk-taking behaviors, including
survival and transactional sex
• Increased risk of mother-to-child HIV transmission
among abused pregnant women
• Increased risk of unsafe injecting practices and
coerced drug use
Maman, S. et al. 2000. The intersections of HIV and violence:
Directions for future research and interventions. Social Science
& Medicine 50(4):459-478.
18
Sexual Coercion
A range of behaviors that a partner may use to pressure or
coerce a person to have sex without using physical force.
• Pressuring a partner to have sex when the partner does not
want to
• Forced or coerced non-condom use or not allowing other
prophylaxis use
• Intentionally exposing a partner to an STI or HIV
• Threatening to tell friends or loved ones about HIV diagnosis
• Threatening retaliation if notified of a positive HIV result
19
Knowledge Isn’t Enough
Women with high STI
knowledge who were
fearful of abuse were
less likely to
consistently use
condoms
than nonfearful women
with low STI knowledge.
(Raiford et al, 2009)
20
GBV and Increased Sexual Risk Behaviors
Women who have experienced
past or current GBV are more
likely to engage in high risk sexual
behavior:
• Have multiple sexual partners
• Have a past or current sexually
transmitted infection
• Report inconsistent use or
nonuse of condoms
• Have a partner with known HIV
risk factors
21
Wu et al, 2003
GBV and Increased Sexual Risk Behaviors
HIV-positive men and women who experienced GBV
were more likely to engage in
Bogart et al, 2005
22
Compromised Negotiation of Safe Sex
HIV-positive women who
experienced recent GBV
were more likely to report:
• Inconsistent condom use
• Unplanned pregnancy
• Abuse stemming from
requests for condom use
Lang et al, 2007
23
Anal Intercourse and HIV
Data show that where GBV is present, there is a higher
rate of unprotected anal sex.
Anal sex can be a part of a healthy sexual relationship,
but it can also be used to degrade an individual
particularly if they are not consenting to sexual activity.
24
Anal Intercourse and HIV Transmission
Unprotected anal intercourse is a highly efficient means
of HIV transmission
– 18x greater risk relative to vaginal intercourse
– Increased abrasions and lacerations that accompany anal
sex can facilitate transmission
– For people who engaging in anal sex in order to prevent
pregnancy or because they have concerns around virginity
and vaginal sex, the risk for HIV infection may be higher.
Baggaley, RF (2010)
Grulich AE, Zablostka I (2010) Laura Duberstein
Lindberg, Rachel Jones, and John S. Santelli, (July
2008
25
Perpetrator HIV risk
Abuse perpetrators are more likely to engage in greater
HIV risk behaviors:
• Condom non-use, including coercive condom non-use
• Sexual infidelity/concurrent partnerships
• More likely to have multiple sexual partners
• Injection drug use
• Unprotected anal intercourse
(Decker et al., 2009, Silverman et al., 2007; Dunkle et al., 2006)
26
Vulnerable Population: Sex Workers
• Sex work, transactional sex or economically
motivated sex is not inherently a form of GBV
• The power dynamic implicit in the exchange of sex
for money, drugs or necessities creates
disproportionate vulnerability to GBV
• GBV and violence from other perpetrators are
common among women involved in the sex industry,
including sexual exploitation and economically
motivated sex
27
GBV and sex work, sexual exploitation, and
economically motivated sex
Women involved in the sex industry, including those
trafficked for sexual exploitation, suffer a high burden of HIV.
• Abusive partners can pressure women into sex trade as a
means of control or obtaining scarce resources
• Sex trade as a means of escaping abusive relationships
• Violence from clients, police, and pimps is common, and
significantly associated with increased HIV risk behavior
and infection
• Lack of control around clients and condom use increases
risk of infection
28
Vulnerable Population: Intravenous Drug Users
• Studies have found that violence increases women’s risk
for initiation into injecting drug use, and the odds of
intimate partner aggression are 3X greater when drug
use is implicated.1
• ~16% of new HIV infections among women are attributed
to injection drug use2
• Substance use and violence are considered bidirectional3
• Vertical transmission rates among HIV positive women
who use drugs are significantly higher than among HIV
positive women without a history of drug use4
29
Violence, Injecting Drug Use and Sex work
• Significant overlap between women
who engage in injecting drug use and
sex work behaviors, particularly
street-level sex work1
• Many female IDU are engaged in sex
work regularly or occasionally, which
increases HIV transmission risk2
• Transactional sex: female IDU have
reported providing sex in exchange
for housing, food and protection1
30
Violence, Injecting Drug Use and Sex work
Female IDU sex workers are at heightened risk of sexually
acquired HIV due to:
• exposure to multiple sexual partners
• limited condom use (or forced non condom use) with
partners1
Female IDU sex workers are faced with significant health risks,
high threats of violence, and high social marginalization.1
31
Vulnerable Population: Men who have sex with men
• Approximately 26% of gay men report lifetime GBV1
• Recent studies have suggested that men who have sex
with men (MSM) who experience GBV are more likely to
be HIV positive than those not experiencing violence, and
are more likely to2:
– engage in substance use
– suffer from depressive symptoms
– engage in unprotected anal sex
• An Alabama study found that MSM who experience GBV
also report feeling unable to negotiate condom use3
32
Vulnerable Population: Transgender Communities
• Findings from a meta-analysis showed that 27.7% of
transgender women tested positive for HIV infection.
• Of transgender individuals, 34.6% reported lifetime physical
abuse by a partner and 64% reported experiencing sexual
assault.
Structural Inequity/Oppression -> Health Disparities
• Among newly diagnosed with HIV, 51% of trans women had
documentation in their medical records of some combination
of substance use, commercial sex work, homelessness,
incarceration, and/or sexual abuse as compared with 31% of
cisgender people.
http://www.cdc.gov/hiv/group/gender/transgender/
The Taskforce, 2014
33
Practice implications
for HIV testing and
counseling services
34
Implications for HIV Programs
GBV affects HIV prevention and risk reduction:
• Victims are often isolated and not exposed to HIV prevention information
• Abusers may prevent victims from receiving medical care, which could
negatively impact their health, limit their opportunities to receive
information about HIV, and increase their risk of contracting HIV
• Clients may not be able to negotiate safe sex or safer injection practices
with an abusive/coercive partner, which impedes ability to manage their
own risk
• IPV may be a more immediate threat to a client than a sexually
transmitted infection or HIV status
• IPV limits adherence to medication that might decrease viral load, which
might increase the chances of transmission to others.
35
Receiving medical care
decreased women’s risk
of further sexual
assault by an
intimate partner by
32%.
(McFarlane et al, 2005)
Your Role is Important - DOABLE
• Providers do not have to be DSV
experts to recognize and help
patients experiencing GBV
• Ability to partner with local DSV
agencies to support your work
• HIV testing and counseling offers a
confidential, private and unique
opportunity for education, early
identification, risk reduction and
intervention
37
Redefining screening
• NOT just a checklist, something that gets filled out
and goes in the chart
• IS a conversation
• IS how a clinic is set up
• IS how providers are trained
• Move away from screening questions to universal
education, assessment and brief counseling.
38
Getting Started: DO NO HARM
• Assessing for GBV can put your client in
danger—always assess patients alone
and not within earshot of a partner or
family member
• Always disclose the limits of
confidentiality before beginning any
assessment
• Never use a family member or friend as
an interpreter—use medically trained
interpreters only
• You violate HIPAA reporting laws if you
report something not mandated by law
39
Strategies for HIV Programs
Universal Education provides an
opportunity for clients to make the
connection between violence, health
problems, and risk behaviors
40
Simple
intervention
tool and
conversation
starter:
The Safety
Card
•
41
Safety cards can be ordered for a nominal shipping fee at:
www.futureswithoutviolence.org/health/hiv
This safety card
is an evidencebased simple
intervention and
can take
seconds to
share with a
patient.
42
• Help survivors of violence and sexual
coercion learn about risk, safety planning,
harm reduction strategies and support
services.
• Plant seeds for those who are experiencing
abuse but not yet ready to disclose.
• Provide primary prevention for patients
who have not been in this kind of
relationship—so they can identify signs of
an unhealthy relationship and ideally avoid
them or help a friend who is experiencing
abuse.
How to Introduce the Card:
• "We’ve started giving this card to all our patients so
they know how to get help for themselves or so
they can help others."
• (Unfold card and show it) "It's kind of like a
magazine or online quiz. It talks about respect, sex
and how those things are connected to STDs and
HIV."
43
After introducing
the safety card,
you can go over
it and ask
questions to
assess for GBV
and sexual
coercion
44
The safety card lists specific questions related to
condom negotiation and sexual coercion to help you
assess for GBV and risk of HIV—always ask your
patients if they feel afraid asking her partner to use
condoms.
45
46
47
48
49
50
Review the
Resources Panel
“On the back of
the card are
some phone
numbers and
websites, in
case you or a
friend ever
needs
information or
support”
51
Using the Safety Card
1. Disclose limits to confidentiality!
2. Universal Education – Everyone gets this!
Normalize activity: "I've started giving this
card to all of my patients”
3. Open the Card - Do a quick review: "It talks
about healthy sex and safe relationships"
4. Make the Connection - Create a sense of
empowerment: “We give this to everyone so
they know how to get help for themselves if
they were to need it and so they can help a
friend or family member.”
5. Hotline and/or Local Referral
52
Sample script to disclose the limits of
confidentiality before asking about GBV:
“Before I get started, I want you to know that everything
here is confidential, meaning I won’t talk to anyone else
about what is happening unless you tell me that you are
being hurt physically or sexually by someone or planning to
hurt yourself.”
53
Universal Education
GBV occurs in all communities and can be found in all
types of relationships.
• Although most reported victims of GBV are female,
clinicians should screen all clients regardless of
gender, age or other demographic characteristics,
the gender of their partner(s) or the relationship
between the potential victim and abuser.
54
Universal Education
Provider Tips
• Be sensitive to the fact that individuals who are GLBT
who are requesting HIV testing may be in an abusive
relationship
• Use gender neutral terminology when referring to
partners
• Recognize that individuals who are GLBT may not identify
or disclose as such
• Be aware of GLBT community resources
55
Opportunities to introduce a discussion of
GBV:
• At Intake/Pre-test Counseling
• During Risk Assessment
• During Sexual History Taking
• During Discussion of How Individual Might React to
Testing HIV Positive Whenever Partners are
Discussed
• During Safer Sex Discussions At Post-test Counseling
56
To begin asking about violence, normalize the
conversation
• Discussion of violence concerns should be introduced in a
general way, using simple statements such as:
"There are some questions that I ask all my patients
because some of them are in relationships where they are
afraid their partners may hurt them, or they know
someone who is in that kind of relationship.”
• This framing statement normalizes the conversation, a
critical step to making clients feel more comfortable.
57
Recommended Practice: Integrating GBV
assessment into HIV pre-test counseling
Providers are encouraged to begin discussions of violence
issues in pre-test counseling, as part of an overall
discussion of support systems and what the client might
anticipate if the test result is positive.
58
Post-test counseling: Another opportunity for
assessment
Post-test counseling provides an additional opportunity to talk about
GBV issues, regardless of the test result.
59
•
GBV screening can take place during post-test counseling, when you discuss partner
notification—but should take place before partner names are elicited.
•
"It is important to let your partners know they have been exposed to HIV so they can
learn their own status and we hope you will help with this. First, however, I want to
make sure that notifying your partners won't put you at risk. Nothing will happen to you
if you decide it is not safe for us to notify this person.”
•
“A next step would be to try to let your partner and other contacts know that they may
have been exposed to HIV. Of course, it is very important to try to stop the spread of HIV
and help people get health care as quickly as possible. When we make a notification, we
do not tell them who may have exposed them or even anything about the type of
exposure.”
Post-test counseling: Another opportunity for
Assessment
•
Assessment takes place on a partner-by-partner basis for any partners
voluntarily identified and for any additional partners or spouses known to the
provider:
– "What response would you anticipate from this partner/ex-partner if he/she were
notified of possible exposure to HIV?”
•
Follow-up questions to explore a history GBV and anticipated consequences of
HIV partner notification:
– “Have you ever felt afraid of your partner or ex-partner?”
– "Based on what you've just told me, do you think that the notification of this
partner will have a severe negative effect on your physical health and safety, or
that of your children or someone close to you?”
– "Are you afraid of what might happen to you or someone close to you if this
partner were notified?"
60
REMEMBER:
Disclosure is not
the goal, and,
Disclosures
Happen!
61
Responding appropriately to
disclosures of GBV and/or sexual
coercion
62
Listen and Validate
When a patient discloses that they are experiencing GBV,
sexual coercion, or is afraid to ask their partner to use
condoms, first validate their experience.
• Thank them for sharing this with you and
convey empathy
• Validate that GBV and sexual coercion are
health issues that you can help with
• Let them know you will support them
unconditionally and without judgment
63
Validating Statements:
• I’m glad you told me about this.
I’m so sorry this is happening. No
one deserves this.”
• “You’re not alone.”
• “Help is available.”
• “I’m concerned for your safety.”
Your recognition and validation of
the situation are invaluable.
64
Supporting survivors: What NOT to say
•
•
•
•
•
“you should call the police and make a report”
“You are definitely in an abusive relationship”
“That does not sound like rape to me…”
“Your partner is crazy, you need to break up with them”
“So what happened after that, and what happened after
that?”
65
Offer support and harm reduction counseling
that focuses on safety
• Give them a safety card to keep and
review if it is safe for her to do so
• Ask patient if they has immediate safety
concerns and discuss options
• Make a ‘warm referral’ to a local DSV
advocate or community resource
66
Providing a “Warm” Referral
When you can connect to a local program it makes all
the difference.
• “If you would like, I can put you on the phone right
now with [name of local advocate], and we can come
up with a plan for you to protect your safety.”
67
Harm Reduction: Safer Partner Notification
If patient has a positive test result, discuss strategies to
promote safety around partner HIV notification
•
Although there may not be previous incidents of severe violence, the
notification of HIV exposure may spark an abusive reaction
•
Notification may escalate serious verbal threats to physical violence or may
increase the severity of preexisting abuse
– Concern about escalation of violence as a result of partner notification might be a
higher priority than their HIV status
•
Other severe adverse outcomes may occur, such as loss of housing, withdrawal
of financial support, custody retaliation or withholding access to health care or
medications.
– Know your state’s specific laws regarding partner notification
– If the partner is in clinic with your patient today, assess for them for immediate
safety and staff safety—determine if partner notification deferral is appropriate
68
Harm Reduction: Screening of Partners/Contacts
Providers must be sensitive to a risk for violence
against a partner when that partner is notified
If it is learned that a partner may be experiencing GBV,
this information is crucial for protecting the partner
from risk of violence related to HIV partner notification,
and for deciding whether any public health follow-up in
relation to that partner should proceed.
69
Harm Reduction: Deferral of HIV Partner
Notification
Partner notification can be deferred
if there is risk of behavior toward the
HIV-infected individual which may
affect their physical health and
safety, his/her children, or someone
who is close to them or to a
partner/contact.
70
Harm Reduction: Confidentiality
HIV-infected individuals should always be assured that:
• The information provided will be kept strictly confidential
• The confidentiality of HIV-related GBV information is
protected by law and regulations
• That such protected information will be used only to help
make decisions about whether partner notification should
proceed and to offer referrals for domestic violence services
• In no cases are names of HIV-infected individuals provided to
partners by public health staff
71
Prevention of HIV: Risk Reduction
• Moving down the risk ladder—providers are uniquely
positioned to help patients evaluate risky behaviors
and lower their risk of HIV by:
– Educating patient on risky sexual behaviors and how they
increase the likelihood of HIV infection
– Educating patient on condom use and safe sex practices
– Connecting patient to community resources
When violence enters the picture, however, risk reduction
becomes more complex.
72
Violence is a barrier to
risk-reduction counseling,
and providers must
become more creative in
how they help patients
manage risk, safety, and
treatment plans
GBV and Risk Reduction
• Prioritize patient safety when assessing risky
behaviors and creating a risk reduction plan, and
always disclose limits of confidentiality
• Recognize that violence might be a more immediate
threat than risk of HIV
• Educate patient on alternative contraceptive options
other than the male condom
• Refer patient to local resources that will assist her in
reducing risk behaviors and staying safe
74
Risk Reduction and Safety Planning
If a patient is experiencing GBV, making a warm,
supported referral to a local DSV advocate provides the
opportunity to integrate a risk reduction plan with
safety planning
– Improves their ability to avoid HIV exposure
– Increases their physical safety when they use tactics to
avoid risky sexual behaviors
75
Pre-Exposure Prophylaxis (PrEP)
• PrEP is an antiretroviral therapy regimen that can
reduce the risk of HIV transmission before exposure
– Meant for people who are at high risk of infection
– Requires strict adherence – daily dosage
• Studies showed that the risk of contracting HIV was
92% lower for those who took the medicines
consistently than for those who didn’t.
• Covered by most insurance programs
76
Post- Exposure Prophylaxis (PEP)
• PEP is an antiretroviral therapy regimen that can
reduce risk for HIV after potential exposure
– Should be used within 72 hours of exposure
– Should not be used by people with frequently recurring
exposure
– Part of standard options for sexual assault survivors; less
applicable for women experiencing chronic abuse
• Can be covered by insurance or accessed through the
Office for Victims of Crime
77
Hotline
Referral
78
Offer patients the use of your office phone
to make the call
Online Resource on Health and IPV
www.healthcaresaboutipv.org
Offers policy memos, patient and
provider educational tools and
resources.
Contact Kate Vander Tuig:
[email protected]
Thank you!