Jennifer "Gigi" Blanchard MD of UC San Diego Owen Clinic presents "Hidden Lives: Women and Adolescents with HIV" at AIDS Clinical Rounds

1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS

2. Hidden Lives: Women &
Adolescents with HIV
Gigi Blanchard, MD
July 17, 2015

3. Maria
! Maria is a 39yo Latina here for f/u labs and
resistance testing. She is here with her 4yo son.
! 4/15 CD4 = 63(3%) VL = 11265
! She is on RIL/TDF/FTC
! Genotype from last month:
! M184V
! K103R, V179D and Y181C

4. Maria
! Diagnosed during pregnancy with both HIV and
syphilis
! Had trouble with adherence during her pregnancy,
but her son was born HIV negative
! Hospitalized for PCP a few years ago
! Misses a lot of appointments despite reminder
calls
! Vague about her adherence – no great explanation

5. My Response to Maria
! Dread her appointments
! I feel helpless to help her
! I feel like it’s a waste of time
! She’s really guarded and flat
! I wonder about her cognitive function
! I wonder about her ability as a mother
! Compassion fatigue

6. Maria
! Lives with her sister, who doesn’t know her
diagnosis
! She and her son sleep on the couch
! No car; no work
! Her ex-BF was verbally abusive of her when she
disclosed her status to him
! “Slut”
! “Horrible mother”
! She hears his voice in her head when she looks at the
meds

7. Frequently Seen Stressors
! Homelessness
! Gas & electric and
water interruptions
! Isolation
! Single Parenting
! Domestic Violence
! Substance Use
! Mental Illness
! Unemployment/
Underemployment
! Poverty
! Limited
Transportation
! Low Literacy
! Stigma

8. Marcus
! 19 yo here for routine f/u. He is on DRV/r + TRU
! 2/15 CD4 = 681 VL <20
! Has missed the last 2 appointments
! Admits to missing meds ~ 2x/week now for
unknown amount of time. No side effects – just
misses
! Has been clean and sober for ~ 1 yr
! Had unprotected sex last weekend with a man who
is also HIV+; doesn’t know if he’s on meds or not

9. What do you do next?
! After reminding him of the importance of adherence and the risk
of developing resistance you:
! A. Have him do an interactive computer program to reinforce this
education
! B. Discuss getting a pill box and setting an alarm on his phone
! C. Get a viral load and a genotype
! D. Refer him for therapy
! E. A, B and C
! E. C & D
! F. All of the above

10. Marcus – more history
! Foster care kid; Sexually and physically abused as
a kid
! Survival sex for food, clothing, and shelter
! At last visit, he was really proud of himself for
maintaining sobriety but admitted it felt “weird”
! Now admits to feelings of anger and depression
! His HIV meds remind him of his drug abuse and
prostitution
! He feels a lot of shame

11. Hidden Barriers to Health
! H/o childhood abuse
! They may not recognize that they were abused
! They don’t want to talk about it – may take years
! Pills are reminders of disease, of what led to the
disease
! Trigger feelings of anger and helplessness
! Medical visits are reminders of disease, of rejection
! May take months to get a patient into clinic
! Takes even more time to get them to come back

12. Question
! Childhood maltreatment is ass’d with which of the
following:
! Ischemic heart disease
! Cancer
! > 30 lifetime partners
! Low IQ
! A,B,C
! All of the above
! None of the above

14. Stress/Trauma
! Stress: when a person is challenged in their
emotional, mental or physical well-being to an
extent that exceeds their ability to cope
! Trauma: Any event that causes an unusually high
level of emotional stress and has a long lasting
negative effect on a person
! Depends on the subjective emotional experience of it

15. Stress/Trauma
! Personal
! Physical and Sexual Abuse
! Verbal Abuse
! Neglect
! Social deprivation
! Financial abuse – i.e.
withhold funds (for gas
money, etc)
! Usually multiple forms of
trauma
! i.e. physical/sexual abuse
usually accompanied by
neglect
! Household dysfunction
! Witnessing violence
! Criminal activity
! Parental separation
! Parental death or illness
! Poverty
! Substance abuse

16. Response to Stress/Trauma
! Big T Trauma: events that cause physical harm
and/or a threat to life or physical safety
! Little T Trauma: upsetting life experiences that are
more common but not thought of as trauma
! Simple traumas clear on their own
! Complex trauma take longer to heal and leave life-
long scars

17. Trauma and HIV
! Increased HIV risk behavior leading to increased
acquisition and transmission of HIV
! Poor adherence to treatment
! Poor HIV-related outcomes

18. Response to Stress/Trauma
! Depends on the sex of the person
! Fight or Flight
! Tend and Befriend
! Seen more in women
! In response to a threat, it refers to protection of off-
spring (tending) and seeking out the social group for
mutual defense (befriending).
! Depends on age/development of the brain
! Early life stress is ass’d with emotional disorders and
attention regulation

19. Question
Childhood sexual and physical abuse predict worse
performance on assessments of executive function,
problem solving and non-verbal reasoning in
adulthood (i.e. 40s).
True
False

20. The Adverse Childhood
Experiences Study

21. The Adverse Childhood
Experiences Study
! On going collaborative research between CDC and
Kaiser in San Diego
! Over 17,000 patients undergoing routine health
care volunteered to give detailed information about
their childhood experience of abuse, neglect and
family dysfunction
! Examined relationship between these experiences
and adult disease, health status and risk behavior

22. The Adverse Childhood
Experiences Study
Personal Abuse
! Physical Abuse
! Verbal Abuse
! Sexual Abuse
! Physical neglect
! Emotional neglect
Household Dysfunction
! Separation from parent
! Substance Abuse
! Domestic Violence
! Incarceration
! Mental Illness

23. ACE Study Results

24. ACE Study Outcomes
! Dose-response relationship between # of adverse
childhood exposures and the following:
! Ischemic heart disease
! Any cancer
! Stroke
! COPD
! Diabetes

25. ACE Study Demographics
! Female 54%
! White 75%
! Hispanic 11%
! High School Grad 93%
! College Grad 40%

28. Question
! Living with someone who is depressed or mentally
ill during the first 18 years of your life is ass’d with
! A. Having more than 30 lifetime sexual partners
! B. Ischemic heart disease
! C. Cancer

29. What’s Going On?
Why does this happen?

30. The Science of Stress
! Sympathetic nervous
system is activated
! Hypothalamic-pituitary axis
leads to the release of
ACTH, cortisol and
catecholamines from the
pituitary, adrenal cortex
and adrenal medulla
! Cortisol negative feedback
restores stress-related
reactions back to baseline

31. Limbic System
! The set of evolutionarily
primitive brain structures
located on top of the
brainstem and buried
under the cortex
! Involved in our emotions
and motivations, esp those
that are related to survival.
! Fear and anger
! Pleasure from eating
! Emotions related to sexual
behavior.

32. Limbic System
! Amygdala: essential for decoding stimuli that are
threatening to the organism; Fear processing
! Hippocampus: sends memories out to cortex for long-
term storage and then retrieves them; provides context
! Thalamus: relays sensory signals to and from the spinal
cord to the cortex
! Hypothalamus: vegetative and endocrine functions;
regulates hormones, body temperature, etc
! Prefrontal Cortex: planning, evaluating, decision
making, etc - higher order brain functions

33. Amygdala
! One of it’s main functions is
to protect us from a threat
! The integrative center for
attention, emotions,
emotional behavior and
motivation
! Important in face
perception; social
processing
! Receives input from all
senses and visceral inputs
! It’s size correlates with
aggressive behavior in all
species

34. Amygdala
! The link between prefrontal cortex, hypothalamus,
and amygdala creates emotion.
! Visceral input gives us our gut feelings, those
subjective feelings about what is good and what is
bad.
! Destruction of the amygdala leads to fearlessness
and a flat affect and inability to recognize emotion
in others
! Injury of the amygdala leads to trustworthiness
confusion

35. Startle Response
! All sensory info goes to the
thalamus
! Then goes straight to the
amygdala
! Then to the brainstem (w/
in hundredths of a second)
! React before you’ve even
had a chance to think
about it

36. A Thoughtful Response

37. Amygdala Hijack
! An immediate and overwhelming emotional
response out of proportion to the stimulus because
it has triggered a more significant emotional
response
! In low to moderate stress, the prefrontal cortex can
inhibit the amygdala
! In extreme stress, the amygdala shuts down the
cortex
! Evolutionary response - there is no time for thinking

38. The Limbic System in
Action
! Amygdala - excitatory
control of hypothalamus
! Heightened response to
stimulus
! Hippocampus - inhibitory
control
! Cortisol binds to receptors
here
Hypothalamus

39. Depressive Response
! VMPF cortex regulates fear
output from the amygdala
! Depression is ass’d with
abnl VMPF activity
! Unable to suppress
negative emotions when
it’s compromised
! Rational long term
decisions and moral
judgments are
compromised
Anterior Cingulate Cortex
Limbic System
Orbital Frontal
Cortex Ventromedial
Cortex

40. Anterior Cingulate Cortex
Prefrontal
Cortex
Orbital Frontal
Cortex
Limbic System
Ventromedial
Cortex Amygdala
Hippocampus
↵
↵

41. Trauma and the Brain
! During periods of trauma there is adrenergic overload,
and the frontal lobe can not be accessed because the
amygdala is in control
! If a person is triggered at the limbic level, the quickest
way to alleviate the pain is to feed the pleasure
principal- alcohol, drugs, sex, food, gambling, hoarding.
! Traumatized individuals are often stuck in survival mode
because the individual is not able to link the limbic
activation to the frontal lobe.
! Thus, cognitive processing is impacted.

42. Trauma and the Developing
Brain
! Timing of trauma/stress
affects those brain regions
undergoing growth spurts
at that time
! Brain regions with
extended post-natal
development are most
vulnerable to long term
sequelae of stress
! Amygdala is fully formed
at birth
! Frontal lobe is the last to
develop
BRAINSTEM

43. The Limbic System
! The interface between the
primitive brainstem and
the rational cortex
! Emotions
! Attention
! Memory
! Motivation
! Attachmen

45. Emotions
! Input from all the senses and visceral inputs
become emotions in the limbic system
! This subcortical input is what gives us our “gut
feelings” or perceptions
! Nonverbal signals
! Non-rational since it’s subcortical
!

46. Attention/Meaning
! Prefrontal Cortex
! Anterior Cingulate Cortex
! Orbitofrontal region
! Integrates subcortical input with cortical
processing
! Determines importance - Is it worth paying
attention to

47. Memory
! Implicit Memory
! A type of memory in which previous experiences aid the
performance of a task without conscious awareness of
these previous experiences
! Didn’t require focal attention to be encoded or retrieved
! Fear - amygdala
! Explicit Memory
! Conscious, intentional recollection of previous experiences
and information
! Requires focal attention to be encoded
! Impaired when there is excessive catecholamines and
cortisol
! Hippocampus

48. Motivation
! Animal instincts
! Survival: finding food, desire to reproduce
Attachment
! Attachment to a caregiver – that natural bond

49. Amygdala
! Located deep within the temporal lobe
! Activates the HPA axis and autonomic responses
associated with fear and hormonal secretion
! It is responsible for fear conditioning
! an associative learning process by which we learn
through repeated experiences to fear something
! For example, when we hear an unpleasant sound, the
amygdala heightens our perception of the sound and
triggers the autonomic system for a fight or flight
response

50. Limbic System
! Plays a huge role in memory
! Interprets our emotional responses
! Stores memories
! Regulates hormones
! Involved with sensory perception, motor function
and olfaction

51. Hippocampus
! Memory center
! Provides contextual information
! Cortisol helps encode memories to the
hippocampus more effectively

52. Anterior Cingulate Cortex
! Governs attention

53. Effects of Early Life Stress
! Usually multiple forms of abuse
! Neglect/rejection is most frequent form of
maltreatment
! High or chronic levels of stress disturb brain
development which then affects mental health
! See functional and structural changes

54. ELS
! Hidden regulators in healthy parent-offspring
relationships
! Serotonin receptors in the hippocampus may be one
! Serotonin stimulation triggers increased
glucocorticoid receptors in the hippocampus
! Neglect/maternal rejection is one the most potent
stressors early in life
! Rhesus infants: the frequency of rejection
correlates with decreased CSF serotonin

55. Developmental Timing
! Timing of trauma/stress affects those brain regions
undergoing growth spurts at that time
! Brain regions with extended post-natal development
are most vulnerable to long term sequelae of stress
! Amygdala is fully formed at birth
! Frontal lobe is the last to develop

56. Brain Development
! Love and nurture increases serotonin tone in the
brain and stimulates 5-HT7 receptor in the
hippocampus
! Serotonin stimulation triggers increased
glucocorticoid receptors in the hippocampus
! Leads to permanent increase in glucocorticoid
expression in the hippocampus – more sensitive to
negative feedback of cortisol
! Neglected Rhesus babies have decreased CSF 5-HT

57. Physiologic Changes
! Chronic stress actually results in low AM cortisol
and blunted ACTH and cortisol responses
! Seen in infants in foster care but not in infants of
similar socio-economic standing
! Kids in foster care d/t neglect have markedly atypical
cortisol diurnal rhythms
! Low basal cortisol production causes increased
sensitivity of the amygdala
! Severe adversity in childhood is linked to markedly
increased reactivity of the autonomic nervous
system and the HPA axis to stress

58. Structural Changes
! Autopsy study of suicide victims with and w/o a
history of abuse and controls who had died
suddenly
! Found reduced total glucocorticoid receptor
expression in the hippocampus in suicide victims
who had been abused but not in suicide victims
who had not been abused
! Also found decreased expression of exon of NR3C1
gene which is linked to glucocorticoid receptor
expression

59. Brain Development
Cortex
Limbic System
Brainstem

60. Cortical Development:
Back to Front

61. ELS and Development
! Monkeys reared in isolation have deficits on
executive tasks – correlated with reduced white
matter tracks in the prefrontal cortex and the
anterior cingulate cortex
! Abnormal EEGs

62. Early Life Stress
! Glucocorticoids impair neural plasticity
! Prefrontal cortex and the hippocampus have a high
density of glucocorticoid receptors
! Prolonged exposure to cortisol leads to more
damage to these areas
! Structural and functional changes

63. The Results
! Impaired executive function
! Difficulty paying attention ! Trouble following
directions, i.e. take pills with food or without
! Poor working memory ! missed appointments,
missed doses
! Impaired reasoning
! Impaired problem solving and flexibility ! huge
problems with insurance or other snafus
! Impaired planning, decision making and execution

64. The Results
! Impaired affective regulation
! Impaired processing of social stimuli ! overreact
! Impaired emotion regulation ! get upset easily
! Poor impulse control ! abuse drugs, have unsafe sex,
etc
! Poor inhibition of inappropriate responses !
disruptive at the clinic; trouble with police
! Impaired reward processing

65. Alma
! 21yo Latina here for routine f/u.
! 4/15 CD4 = 63(1) and VL = 20,763
! She is on RIL/FTC/3TC and admits to missing
about twice/week.
! Reason for missed doses: “Just has a mental block
about HIV meds”
! Vague about whether or not she is taking it with food:
sometimes eats chips or fast food

66. Alma
! Sexually abused as a child
! Ran away and began using drugs at age 13
! Forced into rehab in Mexico –
! Abducted in the middle of the night and held against
her will
! Beaten; tied up
! Forced to take cold showers
! Father of her baby is 44yo and is incarcerated
! She has relapsed on meth

67. Alma
! Diagnosed with TB with a cavity – hospitalization
triggered her PTSD
! Involuntary admission
! Put in isolation
! Forced to take meds
! Not allowed to leave
! IV placement was very traumatizing

68. Estimates of PTSD in
women with HIV
! <25%
! 25-50%
! 50-75%
! >75%

69. Estimates of PTSD and
Trauma
! PTSD is estimated to be 30% among women with
HIV
! 5x higher than the national average
! Estimated rate of intimate partner violence is 55%
! Twice the national average

70. PTSD
! Persistently re-experience traumatic events
! Intrusive thoughts and flashbacks
! Nightmares and difficulty sleeping
! Hyperarousal
! Physiologic reactivity when exposed to reminders of
the event
! Pts usually try to avoid reminders of the event

71. Physiology of PTSD
! Elevated catecholamines
! Low cortisol levels
! There is increased blood flow to the amygdala with
anxiety and during panic attacks
! fMRI shows exaggerated amygdala responses and
diminished prefrontal cortex responses
! During symptomatic periods
! When shown happy vs fearful faces

72. Going to an appointment

73. Traumatic MD Visits
! Waiting room
! Lack of privacy walking into it - Seeing the man who
infected them in the waiting room can trigger them
! Unwanted advances - getting hit on
! Retelling the history repeatedly
! Re-live the trauma
! Insensitive or invasive procedures may trigger i.e.
pap smears, etc

74. Don’t Ask, Don’t Tell:
Hidden Trauma
! Pts have buried this – don’t want to deal
! They may not recognize it as trauma
! They don’t tell their partners; they don’t tell their
families
! May take years of building trust before they might
disclose anything
! Will likely tell 1 part to 1 person and another part
to another person ! collaboration is key

75. What You Will Hear
! Drug and Alcohol Abuse
! Prostitution or promiscuity
! Inability to negotiate safe sex
! Depression and withdrawal
! Hypereactivity and stimulus seeking

76. What you will see when
these patients do show up
! Flat affect
! Borderline behaviors
! Splitting – playing staff off each other
! Denial
! Projection
! Provider is an authority figure and there is an
inherent power difference
! They feel vulnerable

77. What you will see
! Lying and Lip Service
! Some feel a lot of shame about not taking meds or other
behavior
! Survivors may have learned compliance to abusive
authority to avoid more abuse
! Self-destructive behavior
! Repetition Compulsion: expose themselves repeatedly to
situations reminiscent of the original trauma
! May be punishing themselves
! May be what they learned
! Catastrophic Thinking

78. How to Respond

79. Trauma Informed Care
! Realizes the widespread impact of trauma and
understands potential paths for recovery;
! Recognizes how trauma affects all individuals
involved with the program, organization or system,
including it’s own workforce
! Responds by fully integrating knowledge about
trauma into policies, procedures, and practices;
and
! Seeks to actively resist re-traumatization.”
Substance Abuse and Mental Health Services Administration

80. Principles of Trauma
Informed Care
! Safety: physical and psychological
! Trustworthiness and Transparency
! Peer support
! Collaboration and mutuality: recognition that healing
happens in relationships and in the meaningful sharing
of power and decision-making
! Empowerment, voice and choice:
! The individual’s autonomy is supported
! Individual’s strengths are recognized, validated & built up
! Cultural, Historical, and Gender Issues

81. Trauma Informed Visits
! Safety/Privacy
! Off site clinic for the most fragile patients
! Trustworthiness and Transparency: Therapeutic
relationships develop safety and trust
! R – respect
! I – information
! C – connection
! H – hope
! Boundaries - Balance questioning against invasion of
privacy

82. Trauma Informed Care
! Peer Support
! Choices and Control
! Educate patients, not dictate
! Inform them that they have a right to refuse to answer
a question
! Emphasize the patient’s right to refuse treatment
! “you don’t have to anything you don’t want to, but it is
recommended that you have a pap smear..”

83. Trauma Informed Care
! Emphasize Strength and Resilience of Patient
! Medical model highlights pathology
! Medical terminology implies something is wrong with
the person rather than something was done to them
and they survived
! i.e. Rape Victim vs Trauma Survivor
! Approach to behaviors/symptoms
! Maladaptive behaviors and coping mechanisms reflect
that the patient was doing the best that they could with
the skills they had to survive.
! Reduces patient’s guilt and shame
! Decreases providers frustration

84. Trauma Informed Care
Part 2 is coming in 2016 with data from our program

85. Thank You!!
! Jennifer Lewis, LCSW, PhD
! Gila Cohen, LCSW
! Nicole Pepper, MSW
! Maria Huerta, LCSW
! Adriana Gonzales, MSW
! Karina Valdez, Parenting
Coach
! Patricia Zepeda, case
worker
! Jill Blumenthal, MD
! Lisa Stangl, NP
! AJ Johnson, SW
! Joe Mora SW
! Chris Mueller, LCSW
! Rachel Gasca, MSW
! Karla Pardo, MSW
! Kristyn Pellechia, NP
! Ami Roeschlein, LMFT
! Larry Friedman, MD

86. Katie
! Diagnosed at 13 yo when she presented with ITP
! Her diagnosis led to her mother’s diagnosis
! Which led to her parents’ divorce
! Senior year missed her prom d/t severe cryptococcal
meningitis
! Shunt placed – she only remembers her head being
shaved
! Developed shunt infection with peritonitis
! Furious with team members who would palpate her
abdomen w/o warning

87. ! Help with transportation

98. Limbic System
! The set of evolutionarily
primitive brain structures
located on top of the
brainstem and buried
under the cortex
! Involved in many of our
emotions and motivations,
particularly those that are
related to survival.
! Pleasure from eating
! Fear and anger
! Emotions related to sexual
behavior.