CATIE News

• Interpersonal violence (IPersV) can be physical, psychological or sexual
• A Calgary study found that 36% of 1,064 HIV-positive people reported IPersV
• People who reported IPersV, particularly childhood IPersV, had poorer health and survival over the long-term

The effect of HIV treatment (ART) is so transformative that scientists increasingly expect that many ART users will have near-normal life expectancy. However, there are factors that can undermine a person’s ability to take ART exactly as prescribed, maintain regular clinic and laboratory visits, and engage in healthy behaviours. One of these factors is mental health. A person’s mental health can be affected by biological, social and structural factors as well as past or current events that cause psychological distress and trauma.

Focus on interpersonal violence

According to a team of researchers at the Southern Alberta HIV Clinic in Calgary, interpersonal violence (IPersV) “includes violence between intimate partners, family members, friends and acquaintances.” The research team screened more than 1,000 HIV-positive people for IPersV. Those who disclosed IPersV were referred to social workers for counselling. The researchers monitored people for nine years after IPersV screening.

A total of 36% of participants disclosed IPersV. The researchers found that despite receiving counselling these people were at heightened risk for numerous indicators of poor health, including decreased CD4+ cell counts, persistently detectable HIV viral loads and reduced survival compared to HIV-positive people who did not disclose IPersV.

In their report, in press in the journal AIDS, the researchers outline their algorithm for helping people with IPersV. They encourage other HIV clinics to engage in similar screening and to provide offers of treatment if social workers are available in clinic or referrals for out-of-clinic psychosocial support.

Study details

In June 2009, researchers began screening participants for a history of IPersV. Participants were monitored for nine years after this screening.

Results

More than one-third of participants (36%) disclosed experience(s) of IPersV, distributed as follows:

• IPersV in childhood only – 21%
• IPersV in adulthood only – 15%

Gender

Women (46%) were more likely than men (33%) to disclose IPersV. Women were also more likely to disclose IPersV restricted to adulthood (25%) than men (12%).

Ethno-racial groups

Indigenous people were more likely to disclose IPersV (71%) than white people (38%) and people of African, Caribbean or Black ancestry (20%).

Co-existing health conditions

There were no differences in rates of certain co-existing health conditions, such as cardiovascular disease, cancer, diabetes, gastrointestinal issues or nerve injury, between people with and without IPersV.

However, researchers found that people who disclosed IPersV were significantly more likely to have the following:

• problematic substance use (this included methamphetamine, cocaine/crack and/or heroin/opioids)
• co-infection with hepatitis C virus
• thoughts of self-harm or engagement in acts of self-harm
• mental health conditions

Dropping out of care

Over the course of the study, the researchers found that people who disclosed childhood IPersV were significantly more likely (40%) to fall out of HIV care compared to people who reported IPersV in adulthood only (26%) or who never reported any IPersV (27%).

Rates of discontinuing care due to moving away from southern Alberta were similar regardless of whether or not IPersV was disclosed.

Impact on survival

The researchers found that people who disclosed childhood IPersV were nearly twice as likely (16%) to die prematurely compared to people who reported adulthood IPersV or no IPersV (about 8%). The researchers stated that deaths among people who disclosed childhood IPersV were “often related to mental health and addiction problems (drug overdose, violence, suicide) or HIV/AIDS-related complications.”

Several measures of behaviour and health

According to the researchers, throughout the study individuals who reported any IPersV had the following poor outcomes compared to people who did not disclose IPersV:

• 36% more likely to discontinue care
• 81% more likely to experience an elevated viral load, defined as 500 copies/mL or greater
• 47% more likely to experience a drop in CD4+ counts below the 200 cell/mm³ threshold
• 65% more likely to die

These trends were similar regardless of gender, ethno-racial group or level of education.

Bear in mind

The research team noted that “for victims of abuse, missed clinic appointments, healthcare discontinuation [and poor adherence] often reflected histories of trauma and stigmatization.”

What is being done?

According to the researchers, “opening a dialogue with [HIV-positive people] about their IPersV histories is crucial. In a previous study also conducted at the Southern Alberta HIV Clinic, individuals were receptive to IPersV screening, given that a trusting relationship existed between them and their healthcare providers. Screening individuals provided an opportunity for referral to a social worker specializing in domestic/interpersonal violence and abuse. The Southern Alberta HIV Clinic aims to screen each individual for IPersV and offer those disclosing IPersV the opportunity to speak with [the clinic’s] social workers. Social workers enable individuals to speak about their trauma and can develop safety plans to help patients access additional support.”

A legacy of violence

The Alberta study underscores the lingering impact of childhood IPersV on the health of adults. The precise mechanism by which childhood IPersV leads to poorer health is unclear but is likely a mix of interacting psychological and biological effects. The Calgary researchers noted other studies that found that abnormal changes to hormones and chemical signals involved in responses to stress have been linked to an increased risk for post-traumatic stress disorder (PTSD) and depression.

The current study is important and adds to the growing body of evidence of the harm of IPersV, particularly childhood IPersV. The research team’s work underscores the importance of helping vulnerable populations achieve better overall and long-term health.

—Sean R. Hosein

Resources

Intimate partner violence linked to poor health outcomes among women with HIV – CATIE News

The link between intimate partner violence and HIV – Prevention in Focus

REFERENCES:

1. Budd A, Krentz HB, Rubin LH, et al. Long-term consequences of interpersonal violence experiences on treatment engagement and health status in people living with HIV. AIDS. 2021; in press.
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6. Trickett PK, Noll JG, Susman EJ, et al. Attenuation of cortisol across development for victims of sexual abuse. Development and Psychopathology. 2010 Winter;22(1):165-75.