HIV & Violence
      Rebecca J. Macy, PhD, ACSW, LCSW
Associate Professor, School of Social Work
University of North Carol...
 Healthcare providers: managing HIV as a
  chronic disease
 Among persons with HIV, high rates of
  exposure to violence...
   Prevalence of violence in North Carolina

   General health consequences of violence

   Connections between violenc...
   Child maltreatment: anonymous
    telephone survey to probabilities samples
    of North & South Carolina mothers (n=
...
   Child Physical Abuse        (Kaplan, Pelcovitz &
    Labruna, 1999)
    ◦ Suicidal behavior
    ◦ Mental health proble...
   25% of women reported experiencing
    physical/sexual violence in lifetime since
    turning 18
    ◦ For physical vi...
   Physical Health             Mental Health
    ◦ Injuries                   ◦ Depressive disorders
    ◦ Chronic pain ...
   Direct Pathways
    ◦ Example: Survivors’ chronic pain may result from
      injuries sustained during repeated violen...
   Survivors more likely (compared to those
    who have not experienced violent
    victimization) to:
    ◦   Have chro...
   Violent victimization may trigger
    pathways to HIV exposure

   Co-occurring risk factors: history of
    victimiz...
   Violent victimization undermines adaptive
    coping capacity
    ◦ Disrupts positive views of self, relationships, fu...
   Violence survivors challenged by HAART
    adherence…

   Distress & depression impedes adherence
   Violent trauma ...
   Violent victimization (past & current) may
    accelerate HIV disease progression:
    ◦ Psychological responses to vi...
Stigma



    Community               Burdened
     Crime &               Systems of
     Violence                 Care


...
   Assessment

   Trauma-Informed Approaches to
    Healthcare

   Mental Health Interventions for Violence
    Survivo...
 1992: Universal violence screening
  recommended by American Medical
  Association
 However, universal screening for vi...
   Continued call for universal screening
    given:
    ◦ Pervasiveness of violence, especially among
      those with H...
   Realize potential therapeutic effect of assessment
   Privacy & confidentiality
   Environmental considerations
   ...
   Domestic violence & sexual assault programs
    are located in most counties throughout
    North Carolina
   Service...
   Healthcare systems & practices are adapted
    to account for patient’s experiences of violent
    victimization

   ...
 Seeking Safety: co-occurring PTSD &
  substance abuse disorders
  (Najavitz, 2007)
 Prolonged Exposure for PTSD: repeat...
   Limited longitudinal research on relationships
    between violence & health
    ◦ Most findings from cross-sectional ...
Questions? Discussion?
Dr. Rebecca J. Macy
           School of Social Work
 University of North Carolina at Chapel Hill
      325 Pittsboro Stre...
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HIV & Violence

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

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  • Community with 10,000 children: 430 children victimized by harsh physical discipline & 110 children forced to have sex with adult/older child
  • Cytokines are regulators of host responses to infection, immune responses, inflammation, and trauma. Some cytokines act to make disease worse (proinflammatory), whereas others serve to reduce inflammation and promote healing (anti-inflammatory).
  • Interplay among violence, mental health problems, negative coping behaviors, substance misuse & medication adherence
  • Seeking Safety has the goal of helping clients to “attain safety from both PTSD and substance use disorders” (Najavitz, 2007, p. 143). The treatment was designed flexibly so that it could be delivered in multiple ways: either in a group or individual format; in various setting (inpatient clinics to community-based agencies); with men or women; and with various substance disorders and types of traumas. The treatment has “25 topics that address cognitive, behavioral, interpersonal and case management domains” (Najavitz, 2007, p. 143). The treatment provider can deliver as many or as few of the topics as possible in any order. In addition, the treatment can be effectively delivered by a range of providers, including paraprofessionals.Prolonged exposure is one of the most researched treatments for PTSD, and it has repeatedly demonstrated efficacy in the treatment of PTSD among individuals who have survived a variety of traumas, including women who have survived violent physical and sexual assaults (see for example, Foa et al., 2005). Prolonged exposure is usually delivered in 9-12 individual therapy sessions that are 1.5-2 hours in length. Prolonged exposure is most effectively implemented when (1) there is a strong therapeutic alliance between the therapist and the client; (2) the therapist has a provide a clear and thorough rationale for the treatment; (3) the therapist has successfully conveyed to the client the potential usefulness of prolonged exposure, as well as the therapist’s expertise in delivering the therapy; and (4) the treatment is individually tailored to the client’s unique situation and symptoms (Hembree, et al., 2003). In addition, prolonged exposure should be delivered to violence survivors who are not in danger and are living safe, violence-free lives.
  • HIV & Violence

    1. 1. HIV & Violence Rebecca J. Macy, PhD, ACSW, LCSW Associate Professor, School of Social Work University of North Carolina at Chapel Hill
    2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 14. Stigma Community Burdened Crime & Systems of Violence Care Poverty Oppression Connections between HIV & Violence: Importance of Context
    15. 15.  Assessment  Trauma-Informed Approaches to Healthcare  Mental Health Interventions for Violence Survivors Healthcare Strategies for Addressing Violence
    16. 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. 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. 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. 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. 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. 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. 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. 23. Questions? Discussion?
    24. 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…

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