The Effect of Gender Based Violence (GBV) on Mortality: a longitudinal study of US women with & at risk for HIV Kathleen M. Weber Steve R. Cole, Jane Burke-Miller, Denis Agniel, Rebecca Schwartz, Tracey Wilson, Mary Young, Elizabeth Golub, Kathryn Anastos & Mardge H. Cohen for the WIHS Collaborative Study Group

Background Gender based violence (GBV) is a human rights violation impacting the health of women globally. Gender based violence (GBV) is a human rights violation impacting the health of women globally. GBV increases risk for both HIV acquisition and transmission; HIV may increase risk for abuse. GBV increases risk for both HIV acquisition and transmission; HIV may increase risk for abuse. Prevalence of GBV is high (24-78%) among women with and at risk for HIV infection. Prevalence of GBV is high (24-78%) among women with and at risk for HIV infection. Psychosocial consequences of GBV ( unemployment, depression, substance abuse ) are associated with reduced adherence & poor outcomes. Psychosocial consequences of GBV ( unemployment, depression, substance abuse ) are associated with reduced adherence & poor outcomes. Cohen M 2000/2004; Wyatt G 2002; Gielen A 2007; Sareen 2009; Leserman 2007; Mugavero 2009

Study objectives To determine the prevalence of current abuse, including sexual, physical & domestic/emotional abuse, among women with a high background rate of violence exposure To determine the prevalence of current abuse, including sexual, physical & domestic/emotional abuse, among women with a high background rate of violence exposure To determine the effect of recent abuse on all cause mortality in HIV infected and at risk women To determine the effect of recent abuse on all cause mortality in HIV infected and at risk women

Study Design Longitudinal data from the Women’s Interagency HIV Study (WIHS), the largest ongoing US cohort of HIV+ & risk matched women seen q. 6 months Longitudinal data from the Women’s Interagency HIV Study (WIHS), the largest ongoing US cohort of HIV+ & risk matched women seen q. 6 months 2,222 ( 1642 HIV+/580 HIV-) women from the Chicago, DC, & New York City sites with abuse & mortality data between enrollment (1994 or 2001) through censoring (12/31/07) 2,222 ( 1642 HIV+/580 HIV-) women from the Chicago, DC, & New York City sites with abuse & mortality data between enrollment (1994 or 2001) through censoring (12/31/07) Median follow-up of 12 & 6 years; total 18,177 person years Median follow-up of 12 & 6 years; total 18,177 person years

Statistical Approach Marginal structural (pooled logistic regression) models were estimated using inverse probability weights & the same covariates as standard models to estimate survival function and mortality hazard ratio for recent abuse. Marginal structural (pooled logistic regression) models were estimated using inverse probability weights & the same covariates as standard models to estimate survival function and mortality hazard ratio for recent abuse. In longitudinal studies, MSM can account for the effect of abuse when it is confounded by covariates that are themselves affected by abuse. In longitudinal studies, MSM can account for the effect of abuse when it is confounded by covariates that are themselves affected by abuse. Cole SR 2008; Robins 2000

Study Measures Exposure: Recent (past year) self reported abuse including forced sexual contact, physical abuse/assault, or intimate partner violence (IPV) Exposure: Recent (past year) self reported abuse including forced sexual contact, physical abuse/assault, or intimate partner violence (IPV) IPV = domestic or emotional abuse including a partner threat to hurt or kill, prevent from leaving/entering home, making phone calls, meeting w/ friends, attending work/school, or getting needed medical care Outcome: All cause mortality & time to death confirmed by National Death Index registry matches Outcome: All cause mortality & time to death confirmed by National Death Index registry matches Covariates: Baseline & time varying behavioral, sociodemographic, & clinical factors known to be associated with mortality and/or abuse Covariates: Baseline & time varying behavioral, sociodemographic, & clinical factors known to be associated with mortality and/or abuse

Baseline Characteristics by Survival Status CharacteristicSurvivors (n= 1785) % (n) Deaths (n=437) % (n) p- value HIV+ Serostatus69 (1231)94 (411)<.001 Age, Median (IQR)34 (29, 39)39 (34, 43)<.001 Income < $18,000/yr65 (1169)76 (334)<.001 Education < HS35 (628)43 (187).003 Race.167 White18 (329)15 (66) African American67 (1202)72 (313) Other14 (254)13 (58) History of Pre-WIHS Abuse71 (1267)77 (335).020 Childhood Sexual Abuse (CSA) 22 (395)30 (129).002 Depressive symptoms47 (843)64 (280)<.001 Cognitive Function Score, Median (IQR) 90 (70, 100)80 (60, 95)<.001 Transactional Sex24 (423)40 (175)<.001

Crack, Cocaine, Heroin (CCH) Current 21 (373)35 (154)<.001 CCH Ever53 (952)77 (335)<.001 IDU Ever22 (393)51 (222)<.001 Current Smoking55 (974)70 (305)<.001 Smoking Ever68 (1205)83 (362)<.001 Hazardous Drinking15 (263)21 (90).003 Partnered38 (678)34 (150).168 Unstable Housing19 (335)17 (75).492 CD4 Count, Median (IQR) (284, 608)209 (52, 404)<.001 CD4 Nadir, Median (IQR) (169, 409)115 (16, 263)<.001 log Viral Load, Median (IQR) (7.6, 10.5)11.0 (9.3, 12.3)<.001 HAART Use 1* 19 (234)4 (15)<.001 ARV non-adherence 1* 12 (142)11 (47).998 CharacteristicSurvivors % (n) Deaths % (n) p- value Baseline Characteristics by Survival Status

Current abuse by HIV, study year, & pre-enrollment abuse HIV+ with h/o abuse HIV- with h/o abuse HIV+ no prior abuse HIV- no prior abuse Llalllllaljjtlh e aidiiiiiiiiiiiiiissllsllllsll slslllllllslllllsllllllllllllll lll

Survival Cumulative Probability

Association of recent abuse with mortalityCurrentAbuseDeaths Person- years HR a 95% CI a UnadjustedNo NA Yes , 1.60 Baseline-Adjusted b , 1.64 Fully-Adjusted c , 1.60 Weighted c , 2.57 Weighted, trimmed d , 2.02 a HR, hazard ratio; CI, confidence interval b Adjusted for baseline variables: Study Site, HIV Serostatus, Age, Race, Income, Education, History of Pre-WIHS Abuse, Childhood Sexual Abuse, Health Care Utilization, CES-D Score, Cognitive Function, Drug Use, Smoking Status, Having a Partner, Unstable Housing, Transactional Sex, Hazardous Drinking, Viral Load, CD4 Count, Nadir CD4 Count, HAART Use, Non-adherence c Adjusted (or weighted) for baseline and time varying variables: Study Site, HIV Serostatus, Age, Race, Income, Education, History of Pre-WIHS Abuse, Childhood Sexual Abuse, Health Care Utilization, CES-D Score, Cognitive Function, Drug Use, Smoking Status, Having a Partner, Unstable Housing, Transactional Sex, Hazardous Drinking, Viral Load, CD4 Count, Nadir CD4 Count, HAART Use, Non-adherence d Weighted trimmed at the 0.1 and 10

Association of recent abuse with mortality by HIV serostatus AbuseDeathsPYsHR95% CI HIV- (n=580)UnadjustedNo NA Yes , 8.78 Baseline- Adjusted b , 8.09 Fully-Adjusted c , 8.43 Weighted c , Weighted, trimmed d , HIV+ (n=1642)UnadjustedNo NA Yes , 1.49 Baseline- Adjusted b , 1.49 Fully-Adjusted c , 1.44 Weighted c , 2.47 Weighted, trimmed d , 1.89

Conclusions Women in our study had a very high (78%) lifetime prevalence of abuse; 36% reported recent abuse during the study Women in our study had a very high (78%) lifetime prevalence of abuse; 36% reported recent abuse during the study Women reporting recent abuse were twice as likely to die than those not experiencing abuse Women reporting recent abuse were twice as likely to die than those not experiencing abuse Stratified by HIV serostatus, HIV+ women reporting recent abuse were 42% more likely and HIV uninfected women 4x more likely to die Stratified by HIV serostatus, HIV+ women reporting recent abuse were 42% more likely and HIV uninfected women 4x more likely to die HIV related mortality likely masked the magnitude of abuse mortality hazard for HIV+ women HIV related mortality likely masked the magnitude of abuse mortality hazard for HIV+ women

Implications Identification of current abusive episodes and provision of interventions may improve survival. Identification of current abusive episodes and provision of interventions may improve survival. –Providing resources to design, test, and utilize innovative interventions are needed to prevent and treat those affected by GBV. Future research into the relationship of gender based violence, trauma, PTSD, & other stressful life events, on the neuroendocrine and immune regulatory systems may elucidate the way abuse impacts mortality Future research into the relationship of gender based violence, trauma, PTSD, & other stressful life events, on the neuroendocrine and immune regulatory systems may elucidate the way abuse impacts mortality

What is needed? Health care system integration of violence screening & referrals to keep women safe and alive Health care system integration of violence screening & referrals to keep women safe and alive A cultural shift toward a no tolerance approach to family & community violence A cultural shift toward a no tolerance approach to family & community violence Gender equity, reducing poverty, increasing education opportunities, and women’s empowerment to challenge current structural violence Gender equity, reducing poverty, increasing education opportunities, and women’s empowerment to challenge current structural violence