Intimate Partner Violence and Sexually Transmitted Infections/HIV

1. Intimate Partner Violence and Sexually Transmitted Infections/HIV Michele R. Decker, ScD Assistant Professor Department of Population, Family & Reproductive Health Johns Hopkins Bloomberg School of Public Health mdecker@jhsph.edu

2. IPV and HIV: Overview • HIV and other sexually transmitted infections (STIs) in the US • How does IPV create risk for HIV and other STIs? • Violence, HIV and the sex industry: what do violence providers need to know? • How can advocates support women at risk and infected?

3. HIV and STI among women in the US • HIV among women and girls • Women account for 25% of adults living with an HIV diagnosis, and account for 20% of new HIV infections • Approximately 300,000 women were living with HIV in 2013 • Young adults ages 25 to 44 account for the majority of new HIV infections among women • Women and girls are also vulnerable to sexually transmitted infections (STIs) • Chlamydia, gonorrhea, syphilis, hepatitis B, trichomoniasis, HSV 2, HPV • 60 million women affected by new and existing STIs in 2013 CDC, 2010; 2013

4. IPV and HIV among US Women ORAdj. 3.44 (1.28, 9.22) (Sareen et al., 2009)

5. IPV & HIV among Indian women: DHS ORAdj. 3.92 (1.41, 10.92) (Silverman, Decker et al., 2008, JAMA)

6. Dating Violence & STI/HIV: MA YRBS ORAdj. 2.59 (1.05, 6.35) (Decker et al., 2005: Pediatrics.)

7. IPV and STI/HIV • These graphs illustrate just a few examples of a large literature linking IPV with STI/HIV risk and infection (e.g., Hess et al., 2012; Maman et al, 2000; Gielen et al, 2007; Campbell et al, 2008; Wu et al, 2003; Sareen et al, 2009) • Much of the research is cross-sectional, so the causation is unclear • In prospective research, IPV is associated with incident STI, including HIV (Weiss et al., 2008; Allsworth et al., 2009; Jewkes et al., 2010; Kouyoumdjian  et al., 2013) • More frequent and severe IPV among HIV positive women (Gielen et al, 2002; McDonnell et al, 2003; Wyatt et al, 2002)

8. Mechanisms: IPV and STI/HIV • Compromised sexual negotiation • inability to refuse sex, or certain kinds of sex • anal sex increasingly important – 16x transmission efficiency • Coerced and forced sex • usually unprotected • may result in physical trauma and facilitate transmission • Compromised condom negotiation • inability to ensure condom use, perpetrator condom refusal and condom removal • Greater risk introduced by male violence perpetrators • engage in greater sexual risk behavior, more likely infected

9. Perpetrator Condom Refusal Leading to STD “I told him to put a condom on, he didn't. ..I went to a clinic, and they were like, "Oh, he gave you Chlamydia." [H]e said it was me messin' around with some other guy, and that's not true, 'cause I was like, "You were the only guy I was with." And he's like, "Oh, that's you, you're messin' around," he's like, “fuck you, I thought you loved me." Miller, Silverman, Decker et al., qualitative interviews

10. Perpetrator Condom Refusal Leading to Pregnancy and STD “ He would never listen. … I’m like, don’t you think you should wear condoms you know I might get pregnant. And he’s like, next time. I’m scared of him. I’m really scared. Like I feel like he’s going to hurt me. I feel it. You just, I don’t know. Just like he’s going to hurt me.” Miller, Silverman, Decker et al., qualitative interviews

11. Recent IPV and coercive sexual/condom dynamics ORAdj. 1.97 ORAdj 4.36 ORAdj 11.39 (1.61, 2.42) (2.91, 6.52) (7.15, 18.16) Decker et al., 2013; n=3539 women in family planning clinics

12. Anal Intercourse and HIV • Anal intercourse: an underappreciated HIV risk factor • Unprotected anal intercourse is a highly efficient means of HIV transmission • ~16 fold greater risk relative to vaginal intercourse • IPV linked with anal intercourse, often unprotected (Silverman et al., 2011; Stockman et al., 2012; Hess et al.; Decker et al.2013,) • Abrasions and lacerations that accompany unwanted sex can facilitate transmission.

13. Recent IPV and recent anal sex ORAdj 2.13 (1.46, 5.10) ORAdj 2.26 (1.53, 3.33)

14. Perpetrator STI/HIV Risk • Male perpetrators of abuse engage in greater risk behavior • Sexual infidelity/concurrent partnerships • Injection drug use • Anal intercourse • Coercive condom nonuse • Sex with high risk partners (female sex workers) • Abuse perpetrators are more likely to be infected! (Decker et al., 2009, Silverman et al., 2007; Dunkle et al., 2006)

15. IPV Perpetration & Husband’s HIV:Husband-wife Dyads in India OR*adj 1.90 (1.11, 3.26) Decker et al., 2009

16. How does IPV relate to HIV? • Women victimized by IPV face “double jeopardy” • High risk male partner more likely to be infected • IPV as a risk marker for an infected male partner • Limited control over sex and other aspects of violent relationships may facilitate transmission • IPV as a risk factor for transmission in the presence of men’s infection • IPV may enhance or facilitate transmission

17. Violence and STI/HIV disclosure • STI/HIV disclosure can be a trigger or context for abuse (Gielen et al, 2000; Zierler et al, 2000; Zoenig et al, 2002; Medly et al, 2004; Maman et al, 2002; Kiarie et al, 2006) • Fear of IPV could be barrier for HIV-positive women to seek health care (Lichtenstein, 2005) • Need to prioritize safety!

18. IPV and Fear of Partner STI Notification RRadj 1.46 (1.20, 1.77) Decker et al., 2011

19. IPV and Partner Response to STI Notification Among those with STI history & who notified partners: Decker et al., 2011

20. Violence and sex trade • IPV and other forms of violence are common among women involved in sex trade, including sexual exploitation, and economically motivated sex • Abusive partners can pressure women into sex trade as a means of control or obtaining scarce resources • Sex trade as a means of escaping abusive relationships • Pimp relationships can begin as, and be presented as, romantic relationships

21. A brief history:Women in Sex Workoften known as Female Sex Workers (FSWs) • Consistently demonstrate high rates of HIV and other STDs • ~11 times that of women of reproductive age (Baral et al., 2012) • Historically regarded as a vector for disease transmission • Recent recognition of gender-based vulnerabilities within this context • Trafficking • Violence victimization • Coercion and limitations on power to negotiate sex and condom use

22. What’s in a name?transactional sex SEX TRADE commercial sex work prostitutioncommercial sexual exploitation survival sexSEX WORK SEXTRAFFICKING • Common: exchange of sex for drugs, money or other resources • Distinct: [assumed] degrees of agency, exploitation, control • Realities: • assumptions have not been well tested • many that trade sex do not identify as sex workers • little is known about agency e.g., conditions of entry, ability to exit

23. What does this mean for advocates? • Sex trade a context for intense HIV risk • Be sensitive and aware of the possibility that IPV can co-occur with sex trade or sexual exploitation for your clients • Establish relationships with programs in your area that work with women in sex work and/or sexual exploitation • Anticipate unique dimensions of shame and trauma for women involved in sex trade

24. IPV & HIV:Implications for Violence Providers • Raise awareness about links between IPV and STI/HIV • Remind your clients that abusers engage in greater risk behavior • Ask them if they have been tested and support them in doing so • Leverage these data to generate discussion about sexual negotiation, condom negotiation, anal sex • Frame within safety, health

25. Raise the issue of sexual violence and coercion • Give clients an opportunity to raise these issues • Affirm that their experiences are • Normalizing probes • Sexual decision-making • How much do you feel you can refuse sex? • Condom coercion • What does condom negotiation look like? How much do you feel that you have a say in protection? • Anal intercourse • We are hearing so much about violence and unwanted anal sex we are starting to ask about it.

26. What can I do to support STI/HIV testing? • Assure access to STI/HIV testing for clients! • Make connections with your local STI/HIV providers • Find out how sensitive your local STD/HIV testing clinics are to issues of violence • Make sure you feel confident referring patients, or provide in-person advocacy • Need an STI/HIV testing site in your area? • http://hivtest.cdc.gov

27. Supporting safety in testing • The best defense is preparation • Safety planning with women for potential STI/HIV diagnosis • Become familiar with the STI/HIV partner notification protocols in your area • Anonymous notification, or clinic-facilitated notification, can enhance safety • Enable safety through • Anonymous disclosure • www.sotheycanknow.org • Clinician or advocate supported referral • Safety planning specific to disclosure

28. Postexposure Prophylaxis (PEP) • PEP is an antiretroviral therapy regimen that can reduce risk for HIV after potential exposure • Should be used within 72 hours of exposure • Should not be used by people with frequently recurring exposure • Part of standard options for sexual assault survivors; less applicable for women experiencing chronic abuse • Can be covered by insurance or accessed through the Office for Victims of Crime

29. SupportingHIV+ Women • Help to prevent violence and abuse • Provide a safe and supportive environment for disclosure • Consider issues with medication adherence and access to medical services • Use universal precautions to reduce stigma • Be aware of other associated issues • Create a service support network

30. Violence and HIV status disclosure • Violence can result from disclosure of HIV status • Abusers can use women’s HIV status as a tactic of abuse and coercion • Threaten to reveal HIV status to family, friends, employer • Threaten to use HIV status to influence parental custody decisions • Humiliate or degrade her for being HIV positive • Using her HIV status as an excuse for violence or abuse

31. Providing a safe and supportive environment for HIV+ women • Assure confidentiality • Use non-stigmatizing and non-judgmental language and actions • YOU are an important part of changing the culture that stigmatizes HIV+ women! • Talk about HIV just the way you would anything else • Remind your staff and other clients that HIV is not transmitted through skin-to-skin contact • Demonstrate that you are not afraid of becoming infected!

32. Violence and access to HIV care • IPV can be a barrier for HIV-positive women to access health care • Fear of IPV as a result of disclosure can prevent women from seeking care • Abusive partners can prevent women from accessing care through • Threats of violence • Isolation • Stalking

33. IPV and interference in medication adherence • HIV medication regimens can be complex and adherence is critical • Consistent medication adherence can be a challenge for women in violent relationships • Medication interference by partners • Difficulty with consistently taking medication given competing priorities • PTSD and depression is associated with low medication adherence

34. Bringing it all together: IPV & STI/HIV • Raise awareness of the links of IPV with STI/HIV • Initiate discussion with clients about the STI/HIV risks that can accompany IPV • Be prepared to discuss coercive aspects of sexual and condom negotiation • Assure access to STI/HIV testing for clients • Make connections with your local STI/HIV providers • Know where STI/HIV testing sites are in your area • Be aware of the safety issues surrounding disclosure

35. Further Reading/Resources Campbell, J. C., Baty, M. L., Ghandour, R. M., Stockman, J. K., Francisco, L., & Wagman, J. The intersection of intimate partner violence against women and HIV/AIDS: a review. International journal of injury control and safety promotion, 2008;15(4), 221-231 Decker MR, Seage GR, Hemenway D, Gupta J, Raj A, Silverman JG. Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men. Sexually transmitted infections. Dec 2009;85(7):555-560. Decker MR, Seage GR, 3rd, Hemenway D, et al. Intimate partner violence functions as both a risk marker and risk factor for women's HIV infection: findings from Indian husband-wife dyads. Journal of acquired immune deficiency syndromes. Aug 15 2009;51(5):593-600. Decker MR, Wirtz AL, Baral SD, et al. Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. Sexually transmitted infections. Jun 2012;88(4):278-283. Dunkle KL, Decker MR. Gender-Based Violence and HIV: Reviewing the Evidence for Links and Causal Pathways in the General Population and High-risk Groups. American journal of reproductive immunology. Feb 2013;69 Suppl 1:20-26. Dunkle KL, Jewkes RK, Nduna M, et al. Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. Aids. Oct 24 2006;20(16):2107-2114. Gielen, A. C., Ghandour, R. M., Burke, J. G., Mahoney, P., McDonnell, K. A., & O'Campo, P. HIV/AIDS and intimate partner violence: Intersecting women's health issues in the United States. Trauma, Violence, and Abuse, 2007; 8(2), 178-198. Hess KL, Javanbakht M, Brown JM, Weiss RE, Hsu P, Gorbach PM. Intimate partner violence and sexually transmitted infections among young adult women. Sexually transmitted diseases. May 2012;39(5):366-371.

36. Further Reading/Resources Illangasekare, S.L., Tello, M., Hutton, H., Moore, R., Anderson, J., Baron, J., Chander, G. Clinical and mental health correlates and risk factors for intimate partner violence among HIV-positive women in an inner city HIV clinic. Women’s Health Issues, 2012; 22(6), e563-e569. Jewkes R, Sikweyiya Y, Morrell R, Dunkle K. The relationship between intimate partner violence, rape and HIV amongst South African men: a cross-sectional study. PloS one. 2011;6(9):e24256. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. Jul 3 2010;376(9734):41-48. Maman S, Campbell J, Sweat MD, Gielen AC. The intersections of HIV and violence: directions for future research and interventions. Social science & medicine. Feb 2000;50(4):459-478. Raj A, Reed E, Miller E, Decker MR, Rothman EF, Silverman JG. Contexts of condom use and non-condom use among young adolescent male perpetrators of dating violence. AIDS care. Sep 2007;19(8):970-973. Sexual Violence and HIV special issue: http://onlinelibrary.wiley.com/doi/10.1111/aji.2013.69.issue-s1/issuetoc Silverman JG, Decker MR, Kapur NA, Gupta J, Raj A. Violence against wives, sexual risk and sexually transmitted infection among Bangladeshi men. Sexually transmitted infections. Jun 2007;83(3):211-215. Weiss HA, Patel V, West B, Peeling RW, Kirkwood BR, Mabey D. Spousal sexual violence and poverty are risk factors for sexually transmitted infections in women: a longitudinal study of women in Goa, India. Sexually transmitted infections. Apr 2008;84(2):133-139.