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Trauma-informed care

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. Poorer health outcomes.

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Trauma-informed care

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  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 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? 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% • 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 Post-traumatic Stress Disorder: 30% among women living with HIV, almost 6 times the national rate of 5.2% Source: Machtingeret al., Psychological Trauma and PTSD in HIV-positive Women: a Meta-Analysis, November 2012, AIDS Behavior

  4. “Convergence of forces” • HIV criminalization laws • Criminalizing the sexuality of women living with and at risk of HIV • Transphobia & Homophobia • Poverty • High rates of incarceration in communities of color • Politically disenfranchised: lowest voter turnout, voter ID laws

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

  6. Impact: Compromised immunofunction • Increased prevalence of stress, depression, and chronic anxiety • Reduced CD4 counts and other HIV biomarkers due to PTSD and depression • Associations 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) • Altered 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 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. UCSF Women’s HIV Program

  8. Peer-based support: common threads • Small 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 trauma

  9. Peer-based support: WORLD • Phoenix 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 17 • BANPH • Ryan White model

  10. 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.”

  11. A Nationally recognized issue

  12. A Nationally recognized issue

  13. A Nationally recognized issue 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.”

  14. At the end of the day… • 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. • Violence 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 HIV • Beyond screening: trauma-informed care 2.0 • Enthusiastically address structural, psychosocial, and behavioral factors

  15. 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 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 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 diseases • Meaningful and thoughtful integration of peer services & interventions • Training and capacity building to recognize, articulate, triage, and address trauma • Investing in research • Investment in female-initiated and female-controlled prevention options • Investment 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 operational science and implementation science (opportunity to build from the ground level)

  16. 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 Promotion • Briefing Paper: Ending HIV-related Health Care Disparities for Women, March 2012, 30 for 30 Campaign • Women and HIV Factsheet, December 2012, Kaiser Family Foundation • Violence Against Women and Trauma Factsheet, U.S. Positive Women’s Network, December 2012 • Machtingeret 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 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 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 2009

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