1. The Intersection of Intimate Partner Violence and HIV Jennifer Marshall, Assistant Director Memphis Center for Reproductive Health August 2011

2. Special Thank You to… This presentation has been adapted from an original presentation by: ManChui Leung HIV Program Director Asian & Pacific Islander American Health Forum March 2008 This presentation was made possible by the.

3. Objectives After this session, participants will: – Understand how intimate partner violence can increase a person’s risk for being infected with HIV – Understand how being infected with HIV may increase a person’s risk for experiencing intimate partner violence – Have tools to screen for intimate partner violence among people living with HIV – Know about local intimate partner violence resources

4. Intimate partner violence can happen to anyone anywhere.

5. What is intimate partner violence? Intimate partner violence occurs when a person you are dating, living with, or married to physically, sexually, or emotionally injures you. Intimate partner violence is often used to establish and keep control. Intimate partner violence happens to women, men, adolescents, same sex partners- anyone.

6. What is intimate partner violence? Mild physical harm– like pulling hair or twisting flesh Verbal abuse (using words to make someone feel bad), threats or constant blame Violent actions that leave marks – like hitting, slapping, or beating Extreme violence using knives or guns Rape or sexual assault

7. How prevalent is IPV? Each year, – women experience about 4.8 million intimate partner related physical assaults and rapes. – Men are the victims of about 2.9 million intimate partner related physical assaults. 2,340 deaths in 2007. Of these deaths, – 70% were females, and – 30% were males. Understanding Intimate Partner Violence Fact Sheet. Centers for Disease Control and Detection Division of Violence Prevention. 2011. http://www.cdc.gov/ViolencePrevention/pdf/IPV_factsheet-a.pdfhttp://www.cdc.gov/ViolencePrevention/pdf/IPV_factsheet-a.pdf

8. How prevalent is IPV? A national study found that 29% of women and 23% of men had experienced intimate partner violence during their lifetime. (Coker et al., 2002). A review of representative samples found that between 9-28% of women have experienced child sexual abuse. (Vogeltanz et al., 1999) Coker AL, Davis KE, Arias I, Desai S, Sanderson M, Brandt HM, et al. Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine 2002;23(4):260. Vogeltanz, N.D., et al., Prevalence and risk factors for childhood sexual abuse in women: National survey findings., in Child Abuse & Neglect. 1999, Elsevier Science. p. 579-592.

9. How prevalent is IPV among PLWHAs? Prevalence of violence among women living with HIV or at risk for HIV may be as high as 67%. (Cohen et al., 2000) – DISPROPORTIONATED IMPACT: Compared to 29% of women overall. Prevalence of child sexual abuse among women living with HIV ranges from 31%-53%. (Koenig & Clark, 2004) – DISPROPORTIONATED IMPACT: Compared to 9- 28% of women overall. Cohen, M. et al. Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV. American Journal of Public Health. 2000 April; 90(4): 560-565. Koenig LJ, Clark H. Sexual abuse of girls and HIV infection among women: Are they related? In: Koenig LJ, Doll LS, O’Leary A, Pequegnat W, editors. From child sexual abuse to adult sexual risk: Trauma, revictimization, and intervention. American Psychological Association; Washington, DC: 2004. pp. 69–92.

10. INTERSECTION of Violence and HIV VIOLENCE CAN BE A BARRIER TO ENGAGING IN HIV RISK REDUCTION BEHAVIORS Violence limits a person’s ability to access and engage in HIV preventative behaviors, such as condom-use, monogamy, and pregnancy planning and prevention

11. Violence & Risk Reduction Women in abusive relationships: Are more likely to never use a condom (Hamburger et al., 2004) Report escalation of abuse when asking their partner to use a condom (Crosby, et al., 2002) Experience depression, anxiety, substance use, suicide ideation (Tjaden and Thoennes, 2000) Hamburger, ME, et al. Persistence of inconsistent condom use: relation to abuse history and HIV serostatus. AIDS Behavior. 2004 Sep; 8(3): 333-344. Crosby, RA, et al. HIV/STD prevention benefits of living in supportive families: A prospective analysis of high risk African- American female teens. American Journal of Health Promotion. 2002 Jan-Feb; 16(3): 142-145. Tjaden, P. and Thoennes, N. Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey. US Department of Justice. 2000 Nov.

12. INTERSECTION of Violence and HIV PARTNERS WITH HIGHER RISK OF HIV INFECTION Women who experience violence are more likely to be in partnerships with men who are at high risk for HIV from substance use and multiple partners.

13. Violence & Higher Risk Partners Women with a history of abuse are 4 times more likely to engage in sex with a high risk partner (Beadnell et al., 2000). Women, even in high risk and violent relationships, are often unable to label sexual abuse as rape (El-Bassel et al., 2000). Beadnell, B., et al. HIV/STD Risk Factors for Women with Violent Male Partners. Sex Roles. 2000 April: 42(7-8), 661-689. El-Bassel, N., et al. Fear and Violence: Raising the HIV Stakes. AIDS Education and Prevention. 2000 April: 12(2), 154-170.

14. INTERSECTION of Violence and HIV VIOLENCE CAN BE A BARRIER TO ACCESSING HIV TESTING AND CARE SERVICES Fear of violence and other negative outcomes are controlling factors that serve as a barrier to a woman’s ability to access HIV testing and other health and human services.

15. Violence & HIV Testing and Care Women in violent relationships often have limited decision making authority with regard to accessing healthcare for themselves and their children (Tjaden & Thoennes, 2000). Most common barriers to disclosure are fear of abandonment, rejection, further violence from partner and family (Gielen, et al., 1997). Women living with HIV in violent relationships report a reluctance to keep appointments because of fear, depression and feeling “worn down”. – Abusive partners can also sabotage efforts to keep appointments or take medications (Lichtenstein, 2006). Tjaden, P. and Thoennes, N. Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against Women Survey. US Department of Justice. 2000 Nov. Gielen, AC, et al. Women’s disclosure of HIV status: experiences of mistreatment and violence in an urban setting. Women Health. 1997; 25(3): 19-31. Lichtenstein, B. AIDS Patient Care and STDs. February 2006, 20(2): 122-132.

16. INTERSECTION of Violence and HIV EXPERIENCE OF EARLY SEXUAL ABUSE The experience of early sexual abuse as a child or adolescent correlates with high risk behaviors and a limited ability to engage in risk reduction strategies

17. HIV, Child Sexual Abuse & High Risk Behaviors Women with a history of sexual abuse and violence: Have a 7-fold increase of HIV risk behaviors and other markers of risk (Wyatt, 2000). Are 14 times more likely to report an STD (Wingood & DiClemente, 1997). Tend to have more partners (Cohen et al., 2000), and high risk partners (Beadnell et al., 2000). Wyatt, GE, et al. Examining Patterns of Vulnerability to Domestic Violence Among African American Women. Violence Against Women. 2000 July; 6(5), 495-514. Wingood, GM and DiClemente, RJ. The effects of an abusive primary partner on the condom use and sexual negotation practices of African-American women. American Journal of Public Health. 1997; 87(6): 1016-1018. Cohen, M. et al. Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV. American Journal of Public Health. 2000 April; 90(4): 560-565. Beadnell, B., et al. HIV/STD Risk Factors for Women with Violent Male Partners. Sex Roles. 2000 April: 42(7-8), 661-689.

18. HIV, Child Sexual Abuse & High Risk Behaviors Substance use (Wilsnack, 2003) Victims of child sexual abuse are more likely to be re-victimized as adults (Wyatt, 2000). Men of color compared to white men, and gay/bisexual men compared to heterosexual men have a higher prevalence of child sexual abuse (Koenig, et al., 2003). Wilsnack, SC, et al. Child sexual abuse and alcohol use among women: Setting the stage for risky sexual behavior. In L. J. Koenig, L. S. Doll, A. O’Leary, & W. Pequegnat (Eds.), Child sexual abuse to adult sexual risk: Trauma, revictimization, and intervention (pp. 181–200). 2003. Wyatt, GE, et al. Examining Patterns of Vulnerability to Domestic Violence Among African American Women. Violence Against Women. 2000 July; 6(5), 495-514. Koenig, LS, et al. Child sexual abuse to adult sexual risk: Trauma, revictimization, and intervention. 2003

19. DISCUSSION Why might routine screening for violence be important for people living with HIV? Would you feel comfortable screening your patients/clients for violence?

20. Tools to Screen for Violence Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings http://www.cdc.gov/NCIPC/pub- res/images/IPVandSVscreening.pdf

21. Tools to Screen for Violence Have you ever been emotionally or physically abused by your partner or someone important to you? Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone? Within the last year, has anyone forced you to have sexual activities?

22. Local Resources YWCA of Greater Memphis Abused Women’s Services 901-725-4277 Shelby County Sexual Assault Resource Center 901-222-9960 LGBTQ Resource? Resource for Men?

23. Upcoming Lunch & Learns Clinic and Community Partner Updates October 20 th Parenting Options for HIV Positive Men November 17th Integrating Reproductive Health & HIV Testing January 12th Microbicides and other Special Topics February 16th