Monday, May 25, 2009

HIV & Violence

I was recently invited to give a presentation on the connections between HIV and violent trauma. (You can find the power point presentation here.)

While putting this presentation together, I found that the latest research on HIV holds critically important information for those of working in the violence field. Overall, there are three connections between HIV and violent trauma.

First, violent victimization may trigger a risk pathway leading to HIV exposure. Though the precise risk mechanism is not known, there is a cluster of co-occurring risk factors for HIV, including victimization, risky sexual behaviors, and substance misuse (alcohol, drug).

Why are survivors of violence more likely to engage in risky sex and substance misuse? Those of working with survivors should always keep in mind that victimization often undermines a person's ability to cope with this trauma in helpful ways. Violent victimization may damage a survivor's ability to view the world in a positive way, to trust others, and to feel good about him or herself.

Once these positive views of the self, others and the world are taken away, a survivor may be less likely to use helpful ways of coping, such as seeking out the support of friends and family, or seeking help from healthcare providers or counselors. With fewer positive ways of coping available, a survivor may be more likely to use risky ways to manage the feelings and thoughts from the violence, such as substance misuse.

Second, survivors with HIV are challenged by Highly Active Antiretroviral Therapy (HAART) adherence. The "fallout" effects of violent victimization, including depression, anxiety, substance misuse, can get in the way of a survivor's ability to keep medical appointments and adhere to a medication regime. Also, survivors may be less likely to engage with health care providers because victimization undermines their positive views of others- including doctors, nurses, counselors and other providers- as helpful and trustworthy.

Third, violent victimization may accelerate HIV diesease progression because the psychological responses to violence affect survivors' immune functioning. Also, if a survivor is misusing alcohol and drugs, these substances may also erode immune functioning.

To best help survivors, we should be mindful of the context in which violence and HIV occur. As an example, the stigma of HIV is another stressor that survivors must manage. Also, survivors may be dealing with other forms of oppression (heterosexism, ablism, racism, gender discrimination). Some surviviors with HIV may also be struggling with poverty. Finally, most surviviors are trying to access HIV treatment from healthcare systems that are overburdened and overwhlemed.

How can violence advocates help surviviors with HIV? First, we should call for universal screening of violent victimization in healthcare settings. When violence survivors are identified, healthcare providers should be prepared to coordinate their services with their local domestic violence and/or sexual assault program. Here in my state of North Carolina these programs can be found through the North Carolina Coalition Againist Domestic Violence and the North Carolina Coalition Againist Sexual Assault.

Second, we should call for greater use of trauma-informed healthcare practices. Trauma-informed care means that healthcare systems and practices are adapted to account for patients' experiences of violence and trauma to help surviviors better engage with and fully benefit from their healthcare. Rather than expecting surviviors to adapt to traditional healthcare structures and practices, trauma-informed services are welcoming, accessible and managable for survivors. Such practices may significantly help survivors with HAART adherence, for example.

Third, we should encourage the use of evidence-based practices for violence surviviors, such as Seeking Safety and Prolonged Exposure Therapy wherever appropriate and relevent.

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