Kathleen M. Weber Steve R. Cole, Jane Burke-Miller, Denis Agniel ,

1. 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

2. Background 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. 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. Cohen M 2000/2004; Wyatt G 2002; Gielen A 2007; Sareen 2009; Leserman 2007; Mugavero 2009

3. 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 effect of recent abuse on all cause mortality in HIV infected and at risk women

4. 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 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

5. 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. • 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

6. Study Measures 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 Covariates: Baseline & time varying behavioral, sociodemographic, & clinical factors known to be associated with mortality and/or abuse

7. Baseline Characteristics by Survival Status

8. Baseline Characteristics by Survival Status

9. Current abuse by HIV, study year, & pre-enrollment abuse Llalllllaljjtlh e aidiiiiiiiiiiiiiissllsllllsllslslllllllslllllslllllllllllllllll HIV+ with h/o abuse HIV- with h/o abuse HIV+ no prior abuse HIV- no prior abuse 2,450 abuse episodes reported by 794 (36%) women 2,450 abuse episodes reported by 794 (36%) of women between 1994-2007

10. Survival Cumulative Probability

11. Association of recent abuse with mortality a HR, hazard ratio; CI, confidence interval bAdjusted 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

12. Association of recent abuse with mortality by HIV serostatus

13. Conclusions 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 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

14. Implications 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

15. What is needed? • 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 • Gender equity, reducing poverty, increasing education opportunities, and women’s empowerment to challenge current structural violence