Integrating Intimate Partner Violence “Screening” into HIV Clinical Settings

1. Integrating Intimate Partner Violence “Screening” into HIV Clinical Settings 25 October, 2018Joya BanerjeeSenior Technical Advisor, Gender

2. Objectives of this presentation • Understand why we should conduct routine enquiry for intimate partner violence in HIV clinical settings • Understand the difference between different types of enquiry • Understand the minimum requirements for conducting routine enquiry for IPV. • Learn when and how routine enquiry for IPV should take place • Learn what to do if a survivor discloses violence

3. Definition: Gender-Based Violence (GBV) • GBV is any form of violence against an individual based on biological sex, gender identity or expression, or perceived adherence to socially-defined expectations of what it means to be a man or woman, boy or girl. • GBV includes sexual assault, intimate partner violence, child sexual abuse, physical and psychological abuse, threats, coercion, arbitrary deprivation of liberty, and economic deprivation. • GBV is rooted in gender-related power differences, including social, economic and political inequalities. It is characterized by the use and abuse of physical, emotional, or financial power and control. Source: Adapted from USAID IGWG GBV Task Force

4. Definitions: Intimate Partner Violence (IPV) and Sexual Assault Intimate partner violence • Ongoing or past violence and abuse by an intimate partner or ex-partner, defined as a husband, boyfriend or lover, either current or past • The vast majority of IPV survivors are women. This presentation refers mainly to heterosexual women, but also applies to male and LGBTQI survivors • Women may suffer several types of violence by a male partner: physical violence, sexual violence, emotional/psychological abuse, financial violence and controlling behaviors Sexual assault • Forced sex or rape; it can be by someone a woman knows (partner, family member, friend or acquaintance) or, less often, by a stranger. Source: WHO Clinical Handbook 2014

5. Why should health providers enquire about IPV? Photo: Kate Holt, MCSP Liberia, 2016

6. Why are we here? • 1 in 3 women worldwide has been beaten, coerced into sex, or otherwise abused in her lifetime • Survivors of IPV have a right to safety, dignified care, and justice • Freedom from violence is a human right, and health is a human right. • Health providers may be the only person a survivor can turn to for support. Health workers are often respected, objective arbiters, and women often fear the police. • GBV has serious (and often fatal) consequences for women’s health. • It is the duty of health professionals to respond. Photo: Kate Holt/MCSP DRC 2017 Source: Adapted from WHO 2018 VAW Curriculum

7. Why are we here? (Continued) • Due to economic dependence on the perpetrator, safety issues, privacy concerns, victim blaming, and/or a lack of faith that they will be believed or receive help, survivors rarely report IPV in any part of of the world • In many countries, health care providers are screening for IPV without training and without meeting minimum requirements • If done well, screening can save lives, prevent poor health outcomes, and reduce violence To enquire and then offer no services/ poor quality services could re-traumatize the survivor, create a lack of trust in services, and falsely raise her hope for justice Source: Adapted from WHO 2018 VAW Curriculum

8. GBV and HIV Sexual Violence • GBV and HIV are mutually reinforcing epidemics. • Sexual violence increases the risk of HIV infection by 2-4x, and HIV disclosure can increase the risk of IPV • GBV is both a risk factor for HIV infection as well as a consequence of being infected with HIV. • Fear of violence may prevent some women from seeking an HIV test HIV Source: Adapted from WHO 2018 VAW Curriculum

9. For ethical consideration…. • Would you test someone for HIV if there were no treatment or care available? • Would you test someone for HIV in a public place? • Would you screen someone for IPV if there were no privacy, services or criminal justice system available? One of the public health criteria required for routine inquiry for IPV is the availability of an effective response. WHO recommends assessing the risk of IPV and discussing possible steps to ensure the physical safety of clients, particularly women, who are diagnosed HIV positive. (Sources: WHO Guidelines 2013 and WHO 2015 Consolidated Guidelines on HIV Testing Services p.28)

10. IPV Clinical Enquiry and Routine Enquiry (aka “Screening”) Photo: Vikram Raghuvanshi/ 2011

11. What is IPV “Screening”? Screening is a structured process used to detect a disorder or health condition. There are three main types of IPV “screening”: • Clinical Enquiry (CE, aka “case identification”) is asking questions about IPV to patients who either disclose they have experienced violence, or patients who show signs and symptoms of IPV (next slide). This should be done no matter what the condition of GBV services in order to provide appropriate and timely care. Source: Jhpiego/CDC/WHO GBV Quality Assurance Standards 2018

12. General Signs and Symptoms of IPV • Bruising, fractures, abrasions, and/or traumatic injury, particularly if repeated over time, with vague/ implausible explanations • Unexplained chronic gastrointestinal symptoms such as irritable bowel syndrome and chronic pain • Unexplained reproductive tract symptoms, such as pelvic pain, sexual dysfunction • Multiple unintended pregnancies and/or terminations, delayed pregnancy care, or adverse birth outcomes • Unexplained genital or anal injury, such as pain, sores, bleeding or discharge from the genitalia or anus • Unexplained genitourinary symptoms, such as pain during urination, frequent bladder or kidney infections

13. General Signs and Symptoms of IPV (continued) • Repeated vaginal or anal bleeding and sexually transmitted infections • Other unexplained chronic pain • Problems with the central nervous system – e.g., headaches, cognitive problems, hearing loss • Repeated health consultations with no clear diagnosis • Intrusive partner or spouse who insists on being present in consultations • Symptoms of depression, anxiety, PTSD, sleep disorders • Suicidal thoughts and/or behaviors, or other self-harm • Alcohol and other substance abuse • *Signs and Symptoms for children and adolescents are described in the Jhpiego/CDC/WHO/PEPFAR GBV Quality Assurance Facilitation Guide

14. What is IPV “Screening” (continued) 2. Routine enquiry (RE) is asking all patients in a particular setting (e.g. asking all ANC patients or all HIV patients). This should only be done in settings that meet the minimum requirements as per WHO guidelines. 3. Universal screening is asking all patients in all settings (patients are asked no matter what service they receive). Universal screening is not recommended anywhere in low-income settings.There is insufficient evidence that it leads to a decrease in IPV or health benefits. It may also overwhelm already over-burdened providers & health systems. Source: Jhpiego/CDC/WHO/PEPFAR GBV Quality Assurance Standards 2018

15. Objectives of IPV Clinical Enquiry and Routine Enquiry • Identify survivors of IPV • Support the survivor with brief empathetic first-line support (LIVES) • Refer survivors to minimum post-GBV care package: • HIV post-exposure prophylaxis (within 72 hours of sexual assault) • Emergency contraception (within 120 hours of sexual assault) • HIV testing, counseling and linkage to treatment • STI testing and treatment • Treatment of acute injuries • Basic psychosocial counseling • Referrals to other services as appropriate Photo: Kate Holt/MCSP Ethiopia 2017 Source: Adapted from WHO 2018 VAW Curriculum

16. Minimum Requirements for Conducting CE and RE A protocol/ SOP for the provision of post-GBV services A standard set of questions Providers are trained on how to ask about IPV or sexual violence Providers offer first-line support (LIVES) A system for referrals to post-GBV care services is in place Providers only ask about IPV in a private setting, confidentiality ensured Source: USAID, Office of HIV/AIDS, Gender and Sexual Diversity Branch

17. What clinical settings may be appropriate to enquire about IPV when minimum conditions are met? • Antenatal Care (Recommended as a key component of ANC by WHO 2016 Guidelines for a Positive Pregnancy Experience) • Family Planning Counseling • HIV Testing and Counseling (Recommended for clients who test positive for HIV, particularly women, in WHO’s 2015 HTS Guidelines) • HIV Care and Treatment

18. Minimum Requirement: Privacy • Patient cannot be seen or heard from outside the room • Survivors should not have to move from room to room in the health care setting to receive care, • Survivors should not be made to repeat the story to multiple providers, especially not to those not directly involved in care • Breaches in privacy can put patients AND providers at risk for violence • If a perpetrator learns that a survivor has come for services, he may become violent against the patient and provider • If a community member overhears the counseling session, or sees the patient in a health facility where post-GBV care is offered, s/he may tell the perpetrator Source: Adapted from WHO 2018 VAW Curriculum

19. Minimum Requirement: Confidentiality • Providers and staff are required to maintain health information and documents confidentially. • Includes confidentiality from family members (except in situations of mandatory reporting, e.g. for children) • Providers and staff need survivor’s consent to provide information to referral partners (legal, police, etc). • Health care professionals/staff have a responsibility to safely secure/store all survivors’ records (locked cabinet or room) Source: Adapted from WHO 2018 VAW Curriculum

20. When to ask about violence: strategies to preserve confidentiality • Talk about abuse only when you and she are alone. • No one older than age 2 should overhear your conversation. Even another woman could be the mother or sister of an abuser. • Never discuss it if her partner or other family members or anyone else who has accompanied her—even a friend—may be able to overhear. • You may need to think of an excuse to be able to see the woman alone • Send the extra person to do an errand or fill out a form • If her children are with her, ask a colleague to look after them while you talk. Source: Adapted from WHO 2018 VAW Curriculum

21. Asking about violence: how to raise the subject carefully • Remember, support, not diagnosis, is your most important role. • “Many women experience problems with their husband or partner, or someone else they live with.” • “I have seen women with problems like yours who have been experiencing trouble at home.” • How are things at home? How is your relationship? • Sometimes the people we care about hurt us. Has that happened to you? • I am a safe person you can talk to if things are not all right at home. Source: Adapted from WHO Clinical Handbook 2014

22. Asking about violence: direct questions • Direct questions (if patient responds “yes” to any, offer 1st line support/ LIVES) • Are you afraid of your partner? • Has your partner or someone else at home ever threatened to hurt you or physically harm you in some way? If so, when has it happened? • Does your partner bully you or insult you? • Does your partner try to control you, for example not letting you have money or go out of the house? • Has your partner forced you into sex or forced you to have any sexual contact you did not want? • Has your partner threatened to kill you? Source: Adapted from WHO 2018 VAW Curriculum

23. Remember – you should not: • Try to persuade her to leave a violent relationship • Convince her to seek other services, such as police or legal system • Believe you know better how to solve her problems • Ask detailed questions that force her to relive painful events or analyze what happened or why. • Look at your watch, speak rapidly, or write while she is speaking • Invalidate her experiences or use statements expressing pity such as “You shouldn’t feel that way” or “Poor you” • Rush her or pressure her to tell her story • Interrupt. Wait until she has finished before asking questions. • Try to finish her thoughts for her. Source: Adapted from WHO 2018 VAW Curriculum

24. Counselling women on whether HIV disclosure is safe Is your partner aware that you have been tested for HIV and are receiving your HIV test results? If you told your partner you tested positive for HIV do you think he would react supportively? Are you afraid your safety would be at risk if you share your HIV test results with your partner? Do you think that your partner may harm you if you tell him that you have tested for HIV and your HIV test results are positive? Partner notification should only occur with the express consent of the HIV-positive client, be made to her partner(s) alone, and to nobody else. In some cases where the woman’s safety is at risk, partner notification should not be conducted. Source: Adapted from WHO 2018 VAW Curriculum

25. Planning for safer HIV disclosure in the context of violence Timing: Try to find a time where the partner is not tired, under the influence of alcohol or other substances, or stressed due to other factors such as a job. Location: Encourage women to finding a place that will provide some privacy but where there are other adults within close distance is important. Others present: Consider having another trusted adult present who is already aware of the woman’s HIV status to help support her, observe & listen You as the provider can offer to be accompany her during disclosure, or offer to confidentially contact the partner directly Find a space without children present– disclosing in front of children may be traumatic. Source: Adapted from WHO 2018 VAW Curriculum

26. Planning for safer HIV disclosure in the context of violence (continued) Finding the words and role playing: Help her find words that are direct without too much explanation, and without any accusations of blame against a partner. You can also encourage the woman to tell the partner that HIV treatment is available, and is effective at helping people live a long healthy life. “I have something important to tell you.” Safe exit strategy if things escalate: Help woman develop an exit plan with women if tension escalates during disclosure. Locating herself in a room where she can easily exit she need to leave quickly is important. E.g. avoid the kitchen where knives could be used as a weapon Source: Adapted from WHO 2018 VAW Curriculum

27. Example of Pathway for Care for IPV AND Violence suspected but not acknowledged/disclosed Refer for other health care as needed Refer to available community support services Violence identified or disclosed* *Some women may need emergency care for injury. Follow standard emergency procedures. • Tell her about services • Offer information on effect of violence on health and children • Offer follow-up visit Specific mental health conditions? YES First-line Support Listen Inquire Validate Enhance safety Support Source: USAID, Office of HIV/AIDS, Gender and Sexual Diversity Branch Treat or, if possible, refer for specific treatment Care for the conditions that brought her there

28. What should I do if she discloses violence? Photo: Dmitri Markine 2016

29. First-Line Support *First-Line support is not the same as post-GBV care/ services, which include treatment of injuries; HIV PEP; EC; HIV testing, counseling and linkage to treatment; STI testing and treatment; basic psychosocial counseling; and referrals

30. Goals of first line support • Identify her needs and concerns • Speak to her respectfully with kindness and empathy • Listen to and validate her concerns and experiences • Help her to feel connected to others, calm, and hopeful • Empower her to feel able to help herself or ask for support • Explore her options and respect her wishes • Give her the power to continue talking if she wishes (“Do you want to say more about that?”). Photo: Kate Holt/MCSP Ghana 2017 Source: WHO Clinical Handbook 2014

31. Listen • The purpose is to give the woman a chance to share her experiences in a safe and private place. • This is important to her emotional recovery! • Let her know you’re listening through verbal and non-verbal cues. Ex: nod your head • Acknowledge how she is feeling • Let her tell her story at her own pace • Let her say what she wants. Ask “How can we help?” • Encourage her to keep talking if she wants through open ended questions. “Would you like to tell me more?” • Allow for silence. Give her time to think. • Stay focused on her experience • Acknowledge her needs and respect her wishes Source: WHO Clinical Handbook 2014

32. Inquire about needs and concerns • The purpose is to learn what is most important for the woman. • Phrase your questions as invitations to speak • Ask open-ended questions that encourage her to talk • Verify your understanding by restating what she says • Reflect back to her feelings she expresses • Explore as needed • Ask for clarification if you don’t understand • Help her identify and express needs and concerns • Summarize what she expressed Source: WHO Clinical Handbook 2014

33. Validate • The purpose is to let her know that her feelings are normal, that it is safe to express them, and that she has a right to live without violence. • Examples: • It’s not your fault. You are not to blame. • You did the most important thing you could do: you survived. • No one deserves to be hurt by their partner. • You are not alone. Unfortunately many other women face this problem. • Your life and your health are of value. • Everybody deserves to feel safe at home. • I am concerned this may be affecting your health. Source: Adapted from WHO Clinical Handbook 2014

34. Enhance safety • The purpose is to show her that you understand and believe her. • Assure her that she is not to blame. • Help assess her situation and make a plan for her future safety. • Many women who have been subjected to violence have legitimate fears about their safety. • Other women may not think they need a safety plan because they do not expect that the violence will happen again. • Assessing and planning for safety is an ongoing process – it is not just a one-time conversation. Source: WHO Clinical Handbook 2014

36. Source: WHO Clinical Handbook 2014

37. Support (through referrals) • The goal is to support women to connect with other resources for her health, safety, and social support. • Women’s needs are generally beyond what you can provide in the clinic. • Remember: women face multiple barriers to reaching out for help. • Your voice is important in encouraging her to seek support. • Discuss the woman’s needs with her, and share sources of help. • If you offer a referral, also offer to help make a call on patient’s behalf if it would be more comfortable for her Source: WHO Clinical Handbook 2014

38. Documentation • The provider should endeavor to document all key information the patient tells her/him, particularly to ensure that the survivor does not have to repeat her story again and again (leading to revictimization) • We recommend that providers use a GBV register and medico-legal form. There are standard forms available in the facilitation guide of the GBV Quality Assurance Facilitation Guide, available athttp://resources.jhpiego.org/resources/GBV-QA-tool

39. Know your setting! Referral networks & policy context Photo: Kate Holt/ MCSP Liberia 2017

40. Establishing referral pathways Identify, map and confirm (via a phone call or visit) available services such as: Police/Law enforcement Justice services Social Services Emergency shelter Economic/Livelihood support Child protection services Create a referral directory to keep track of community resources (job aid available) Establish informal or formal agreements an personal contacts with service providers Specify how you will find out if the woman reaches the referral resource Monitor referrals and coordination mechanisms Source: WHO Clinical Handbook 2014

41. Offer her a warm referral • Reduce barriers to women accessing services (e.g. help her identify a means of transport) • Explain why the service can be helpful for the patient’s specific need • Actively help women access the referral • Offer to make a call on her behalf • Offer to make a call with her • Offer private office space for her to make the call Source: Adapted from WHO 2018 VAW Curriculum

42. Additional Resources • WHO Clinical Handbook: Care for Women Subjected to Intimate Partner Violence and Sexual Violence (2014) • WHO Clinical and Policy Guidelines: Responding to Intimate Partner Violence and Sexual Violence Against Women (2013) • Jhpiego/CDC/WHO/PEPFAR GBV Quality Assurance Standards and Facilitation Guide (2018) • USAID Step by Step Guide to Strengthening Sexual Violence Services in Public Health Services (2010) • USAID The Clinical Management of Children and Adolescents Who Have Experienced Sexual Violence: Technical Considerations for PEPFAR Programs (2013) • WHO Violence Against Women Training Curriculum (2018, forthcoming)

43. Joya.Banerjee@Jhpiego.org Photo: Kate Holt/ MCSP Nigeria 2018