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Trauma-informed care Integrating Trauma-Informed and Sexual and Reproductive Health Care in the Domestic HIV Response Sonia Rastogi U.S. Positive Women’s.

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Presentation on theme: "Trauma-informed care Integrating Trauma-Informed and Sexual and Reproductive Health Care in the Domestic HIV Response Sonia Rastogi U.S. Positive Women’s."— Presentation transcript:

1 Trauma-informed care Integrating Trauma-Informed and Sexual and Reproductive Health Care in the Domestic HIV Response Sonia Rastogi U.S. Positive Women’s Network Revitalizing the U.S. Domestic HIV Response, December 2012

2 Poorer health outcomes HIV-positive Black women have life expectancies that are approx. 6 years shorter than HIV-positive white men due to late initiation and early discontinuation of ART, and higher rates of concurrent health and psychosocial issues (2009)HIV-positive Black women have life expectancies that are approx. 6 years shorter than HIV-positive white men due to late initiation and early discontinuation of ART, and higher rates of concurrent health and psychosocial issues (2009) HIV-positive women have 20% higher death rates, higher rates of hospitalization, and twice as many HIV-related and AIDS defining illnesses per person than their male counterpartsHIV-positive women have 20% higher death rates, higher rates of hospitalization, and twice as many HIV-related and AIDS defining illnesses per person than their male counterparts Where is the data on trans women?Where is the data on trans women? Women and HIV Factsheet, July 2012, Kaiser Family Foundation

3 Why? Rate of Intimate Partner Violence : 55% among women living with HIV, double the national rate of 24.8% Rate of Intimate Partner Violence : 55% among women living with HIV, double the national rate of 24.8% Rates of Childhood Sexual Abuse and Childhood Physical Abuse : 39% and 42% respectively among women living with HIV, more than twice the national rates of 16.2% and 22.9% Rates of Childhood Sexual Abuse and Childhood Physical Abuse : 39% and 42% respectively among women living with HIV, more than twice the national rates of 16.2% and 22.9% Rate of Lifetime Sexual Abuse : 61% among women living with HIV, over 5 times the national rate of 12% Rate of Lifetime Sexual Abuse : 61% among women living with HIV, over 5 times the national rate of 12% Rate of Post-traumatic Stress Disorder : 30% among women living with HIV, almost 6 times the national rate of 5.2% Rate of Post-traumatic Stress Disorder : 30% among women living with HIV, almost 6 times the national rate of 5.2% Source: Machtinger et al., Psychological Trauma and PTSD in HIV-positive Women: a Meta-Analysis, November 2012, AIDS Behavior

4 “Convergence of forces” HIV criminalization lawsHIV criminalization laws Criminalizing the sexuality of women living with and at risk of HIVCriminalizing the sexuality of women living with and at risk of HIV Transphobia & HomophobiaTransphobia & Homophobia PovertyPoverty High rates of incarceration in communities of colorHigh rates of incarceration in communities of color Politically disenfranchised: lowest voter turnout, voter ID lawsPolitically disenfranchised: lowest voter turnout, voter ID laws

5 Impact Impaired sexual decision- makingImpaired sexual decision- making Four-fold increase in STIsFour-fold increase in STIs Higher likelihood of substance use in one’s lifetimeHigher likelihood of substance use in one’s lifetime Depression, PTSD, anxiety, chronic stressDepression, PTSD, anxiety, chronic stress

6 Impact: Compromised immunofunction Increased prevalence of stress, depression, and chronic anxietyIncreased prevalence of stress, depression, and chronic anxiety Reduced CD4 counts and other HIV biomarkers due to PTSD and depressionReduced CD4 counts and other HIV biomarkers due to PTSD and depression Associations between altered red blood cell and decreased T-cell functionAssociations between altered red blood cell and decreased T-cell function Associations between violence and hypothalamic-pituitary- adrenal axis functioning (greater occurrence of altered levels of cortisol and dehydroepiandrosterone)Associations between violence and hypothalamic-pituitary- adrenal axis functioning (greater occurrence of altered levels of cortisol and dehydroepiandrosterone) Altered neuropsychological functioning that can negatively impact immune responses to HSV infectionAltered neuropsychological functioning that can negatively impact immune responses to HSV infection Relationship between stress and other psychosocial factors with faster disease progression among people living with HIVRelationship between stress and other psychosocial factors with faster disease progression among people living with HIV Source: Campbell et al., The intersection of intimate partner violence against women and HIV/AIDS: a review, December 2008, International Journal of Injury Control and Safe Promotion

7 Health & Wellbeing Living with HIV is traumatic Institutional Violence : HIV criminalization laws, War on Women, employer discrimination, etc. Community-based Violence : homophobia, transphobia, stigma & discrimination when receiving services, etc. Intimate Partner Violence : stigma, disclosure, isolation, fear, isolation, depression, PTSD

8 UCSF Women’s HIV Program

9 Peer-based support: common threads Small group (8-12) HIV prevention training organized around intensive, interactive, skill- building sessionsSmall group (8-12) HIV prevention training organized around intensive, interactive, skill- building sessions Designed to enhance the ability of women living with HIV to understand and share life experiences including HIV and traumaDesigned to enhance the ability of women living with HIV to understand and share life experiences including HIV and trauma

10 Peer-based support: WORLD Phoenix Project: short pilot project in 2010 to re- engage/link women who had fallen out of carePhoenix Project: short pilot project in 2010 to re- engage/link women who had fallen out of care Identified 25 women out of care; successfully linked 17Identified 25 women out of care; successfully linked 17 BANPHBANPH Ryan White modelRyan White model

11 A Nationally recognized issue “The research needs of integrated care in mental health has moved past demonstration of efficacy to address issues of implementation, effectiveness, sustainability, utilization of technology to reduce costs, extension of the successful integrated care models to specialty mental health settings, and to clinical conditions beyond depression.”

12 A Nationally recognized issue

13

14 The memorandum calls for “integrating of sexual and reproductive health services, gender-based violence services, and HIV/AIDS services, where research demonstrates that doing so will result in improved and sustained health outcomes.”

15 At the end of the day… Trauma impacts everyone (similar and distinct traumas of queer and trans men)Trauma impacts everyone (similar and distinct traumas of queer and trans men) Trauma keeps people off their medications. Focus on the treatment cascade by first working through trauma and stigma.Trauma keeps people off their medications. Focus on the treatment cascade by first working through trauma and stigma. Violence against women and trauma are inextricably linked with sexual and reproductive health and justiceViolence against women and trauma are inextricably linked with sexual and reproductive health and justice The risk of higher costs if we do not address the glaring issues in the lives of people living with HIVThe risk of higher costs if we do not address the glaring issues in the lives of people living with HIV Beyond screening: trauma-informed care 2.0Beyond screening: trauma-informed care 2.0 Enthusiastically address structural, psychosocial, and behavioral factorsEnthusiastically address structural, psychosocial, and behavioral factors

16 Recommendations to amend the NHAS Identify, support, and resource trauma-informed demonstration projects that address violence against women and the impact of trauma in women’s livesIdentify, support, and resource trauma-informed demonstration projects that address violence against women and the impact of trauma in women’s lives Identify emerging and bolster existing advocacy and policy efforts that combat the structural root causes that put all women at risk for HIV in the first placeIdentify emerging and bolster existing advocacy and policy efforts that combat the structural root causes that put all women at risk for HIV in the first place Identify and craft strategic entry points into the ACA and Medicaid expansion for the Ryan White Care Model to be adapted into primary care and care for chronic diseasesIdentify and craft strategic entry points into the ACA and Medicaid expansion for the Ryan White Care Model to be adapted into primary care and care for chronic diseases Meaningful and thoughtful integration of peer services & interventionsMeaningful and thoughtful integration of peer services & interventions Training and capacity building to recognize, articulate, triage, and address traumaTraining and capacity building to recognize, articulate, triage, and address trauma Investing in researchInvesting in research Investment in female-initiated and female-controlled prevention optionsInvestment in female-initiated and female-controlled prevention options Investment in understanding the physiological impacts of traumaInvestment in understanding the physiological impacts of trauma Investment in understanding the hidden health care costs of stigma (how much are we spending on health care that does not recognize or address stigma)Investment in understanding the hidden health care costs of stigma (how much are we spending on health care that does not recognize or address stigma) Investment in operational science and implementation science (opportunity to build from the ground level)Investment in operational science and implementation science (opportunity to build from the ground level)

17 Sources Campbell et al., The intersection of intimate partner violence against women and HIV/AIDS: a review, December 2008, International Journal of Injury Control and Safe PromotionCampbell et al., The intersection of intimate partner violence against women and HIV/AIDS: a review, December 2008, International Journal of Injury Control and Safe Promotion Briefing Paper: Ending HIV-related Health Care Disparities for Women, March 2012, 30 for 30 CampaignBriefing Paper: Ending HIV-related Health Care Disparities for Women, March 2012, 30 for 30 Campaign Women and HIV Factsheet, December 2012, Kaiser Family FoundationWomen and HIV Factsheet, December 2012, Kaiser Family Foundation Violence Against Women and Trauma Factsheet, U.S. Positive Women’s Network, December 2012Violence Against Women and Trauma Factsheet, U.S. Positive Women’s Network, December 2012 Machtinger et al., Psychological Trauma and PTSD in HIV-positive Women: a Meta-Analysis, November 2012, AIDS BehaviorMachtinger et al., Psychological Trauma and PTSD in HIV-positive Women: a Meta-Analysis, November 2012, AIDS Behavior Fried, S. and Kelly, B., Gender, Race + Geography = Jeopardy: Marginalized Women, Human Rights and HIV in the U.S., July 2011, Women’s Health Issues: Special SupplementFried, S. and Kelly, B., Gender, Race + Geography = Jeopardy: Marginalized Women, Human Rights and HIV in the U.S., July 2011, Women’s Health Issues: Special Supplement Machtinger et al., Recent Trauma is Associated with Antiretroviral Failure and HIV Transmission Risk Behavior Among HIV-positive Women and Female-identified Transgenders, AIDS Behavior, November 2012Machtinger et al., Recent Trauma is Associated with Antiretroviral Failure and HIV Transmission Risk Behavior Among HIV-positive Women and Female-identified Transgenders, AIDS Behavior, November 2012 Losina et al., Racial and sex disparities in life expectancy losses among HIV-infected persons in the United States: impact of risk behavior, late initiation, and early discontinuation of antiretroviral therapy, Clinical Infectious Diseases: an official publication of the Infectious Diseases Society of America, October 2009Losina et al., Racial and sex disparities in life expectancy losses among HIV-infected persons in the United States: impact of risk behavior, late initiation, and early discontinuation of antiretroviral therapy, Clinical Infectious Diseases: an official publication of the Infectious Diseases Society of America, October 2009


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