HIV and Intimate Partner Violence

1. HIV and Intimate Partner Violence Skills You Will Need When HIV Affects Women Exposed to Violence August 22, 2009 Presented by: Neena Smith-Bankhead, MS Director, Department of Education and Volunteer ServicesAID Atlanta, Inc.

2. "I have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas." Neena-Smith-Bankhead, MS August 22, 2009 Disclaimer

3. At the end of this session, participants will be able to: • Discuss the relationship between intimate partner violence and HIV among women • Discuss HIV risk and prevention with women presenting to Community Service Agencies • Review how HIV prevention counseling is conducted, and provide other HIV-related services for women • Provide appropriate HIV care and prevention referrals for women exposed to violence Session Overview

4. Women and HIV/AIDS

5. Women and HIV/AIDS

6. Women and HIV Overview

7. Women and HIV Overview

8. Leading cause of Death for black women ages 25-34 • Women are more than ¼ of all new HIV/AIDS Diagnoses Women and HIV CDC, 2009

9. Blood Semen Vaginal Fluids Breast Milk Piercings Cuts, Tears, or Rips in Skin Mucous Membranes BODY FLUID + CUT = HIV

10. HIV Transmission • Unprotected sex (anal, vaginal, or oral) with infected partner • Sharing needles with someone with HIV • During pregnancy, birth, or breast-feeding from an infected mother • Getting a blood transfusion from a person with HIV More About Needle Sharing: Steroid use Tatooing Drug Use

11. Physiology • Lack of Control in Relationships • Communication with partner • Lacking negotiation skills • Infidelity in relationships • Socioeconomic Issues • Role as Caregivers • Substance Use and Abuse • Recognition of risk in partners • Psychological Issues HIV Risk Factors for WomenRISE Coalition Training Manual, 2009

12. Sex with older, riskier men (younger women) who are less likely to use condoms • Trading sex for drugs or money – can make more when condoms are NOT used Why Women Are At Additional Risk

13. HIV Positive Women at increased risk of abuse • Disclosing to partner may enhance or initiate violence • Partner notification can put women at additional risk • Women who are abused are at higher risk of contracting HIV • Substance use to cope • Relationships with substance users • Fear of requesting safer sex or saying ‘no’ • Rape or sexual assault Women, IPV and HIV

14. “Violet’s Story” told by an HIV Case Manager

15. Stigma • Gay disease • Substance users • “BAD” people • Fear of Getting tested/HIV Test Results • Lack of Knowledge and Information about HIV/AIDS and how it’s transmitted • Lack of Knowledge and Information about HIV Care and Treatment Services Challenges Addressing HIV in Hard-to-Reach Communities

16. Considerations for Providers Conducting Screening, Providing Prevention Counseling, and Making Referrals

17. Agency/Service Intake • Screen for risk behaviors • Screening for abuse could indicate HIV Risk activity as well • Case Management/Mental Health Services • Medical Services • Examinations • Sexual History • Risk Assessment When to Talk about HIV Risk?

18. Screening and Assessment Motivational Interviewing Qualities of a Good Motivational Interviewer Accurate Empathy Respect Warmth Genuineness Immediacy Concreteness Conclusive

19. An intervention designed to help individuals make behavior changes that will reduce their risk of acquiring or transmitting HIV HIV Prevention Counseling CDC, 2008

20. … communication, both verbal and nonverbal, made in response to and in the presence of feelings. … “client-centered” — that is, it is tailored to the behaviors, circumstances, and special needs of the person being served … not solving the client’s problem for her/him or giving advice; the counselor brings a set of skills to the interaction that can enable the client to reach a better understanding of the problem, deal with her/his related feelings and concerns, and assume responsibility for evaluating alternatives and making choices HIV Prevention Counseling CDC, 2008

21. HIV Prevention Counseling Steps • Introduce and orient client to session • Identify client risk behaviors and circumstances • Identify safer goal behaviors • Develop action plan • Make referrals and provide support • Summarize and close the session Prevention Counseling Steps CDC, 2008

22. Introduce self • Explain what will happen in this session • Assess comfort and readiness to discuss risk behaviors and activities • Consent forms Step #1: Introduce and Orient Client to Session CDC, 2008

23. What risk activities is client engaging in and when are these activities likely to occur • Address triggers or vulnerabilities that lead to the client engaging in these activities (Circumstances) Step #2: Identify client risk behaviors and circumstances CDC, 2008

24. Discuss specific behaviors that directly prevent or greatly reduce HIV transmission; harm reduction • Discuss with client goals that they want to accomplish • With which partners • In what settings • Under what circumstance • During what time periods; how often • Address behaviors that client is likely to accomplish Step #3: Identify safer goal behaviors CDC, 2008

25. Develop a realistic, specific action plan to help the client adopt the safer goal behavior • Support the changes that have already taken place or have been attempted • Discuss contributing factors that support or hinder ability to implement an action • Discuss benefits and barriers to implementing new behaviors Step #4: Develop Action Plan CDC, 2008

26. Refer to known and trusted resources • Ensure that the client can access the referral and help to eliminate any barriers Step #5: Make Referrals CDC, 2008

27. Briefly review highpoints of session, including action steps and referrals • Reminds the client of actions that they’ve decided on and agreed to try • List contracts or commitments for risk reduction, referrals, and next steps Step #6: Summarize and Close the Session CDC, 2008

28. Assess practice and knowledge of current prevention strategies • Encourage methods of HIV prevention that can be used without partner’s participation • Communication strategies • Consider multiple prevention options, not only condom use (harm reduction) • Workshops/ programs that address gender, power, and control in relationships Prevention Counseling

29. Focus on Feelings Manage Your Own Discomfort Set Boundaries Counseling Concepts for Prevention Counseling CDC, 2008

30. Open Ended Questions • Questions that require more than a ‘yes’ or ‘no’ response • Attending • Attending means physically showing the client that you are listening. This means using positive nonverbal communication. • Offer Options, not Directives • Often sets up a power struggle between counselor and client. • Can be avoided by giving the client firm control over change decisions • Give Information Simply • use simple, non-technical words • be brief and to the point • address client needs specific to their concerns • saying “I don’t know” is okay Basic Counseling Skills CDC, 2008

31. HIV Counseling and Testing N. Smith-Bankhead, 2009

32. Rapid (15-20 minutes) • Conventional Testing (1-2 Weeks) • Free or Discounted • Non-Profit Agencies or Medical Facilities • Community Settings for Testing • Blood or Oral Solution HIV Counseling and Testing N. Smith-Bankhead, 2009

33. What response would you anticipate from your partner if he or she were notified of possible exposure to HIV? • What would you do if you were diagnosed HIV positive/negative? • Who knows you are here? What Support systems do you have? Assessing for Readiness for HIV Counseling and Testing N. Smith-Bankhead, 2009

34. Disclosure and Partner Notification • Avoid exposing others to HIV without warning them ahead of time. • The risk of violence may be greater if a person feels you knowingly put them at risk or lied to them. • Disclose in a semi-public place like a public park with many people around. It's private enough to have a conversation, public enough to get help if you need it. • Consider disclosing with a third person present, like a friend or a health professional. • If you feel at all threatened by the reaction you get, keep meetings public for a few weeks. The Well Project, Website, 2003-2006 HIV Counseling and TestingTips for Disclosing

35. Resources for HIV Care/Prevention Types of Resources or Referrals Needed

36. Effective Referrals Help client define priorities Discuss and offer options Offer referrals Refer to known and trusted services (MOU’s that outline duties) Assess client response to referral Facilitate active referral  Develop a follow-up plan (include referral sources in plan) Making Referrals CDC, 2008

37. Connecting with National, Regional, and Local Coalitions and Collaboratives • Helps to maximize access to resources available in your area • Also provides hints and tips on how to place hard-to-place clients Know the treatment and care philosophy of the agency being referred to • Ensure that the needs of your client can be met by that agency • Very supportive vs. hard-line mentality Best Practices for Resource Development N. Smith-Bankhead, 2009

38. Ensure that your client is ready to make change and accept your referral • You can’t force change if a person is not ready for it or willing to accept it • Transtheoretical Model (Stages of Change) • Precontemplation - lack of awareness that life can be improved by a change in behavior; • Contemplation - recognition of the problem, initial consideration of behavior change, and information gathering about possible solutions and actions; • Preparation - introspection about the decision, reaffirmation of the need and desire to change behavior, and completion of final pre-action steps; • Action - implementation of the practices needed for successful behavior change (e.g. exercise class attendance); • Maintenance - consolidation of the behaviors initiated during the action stage; • Termination - former problem behaviors are no longer perceived as desirable (e.g. skipping a run results in frustration rather than pleasure). Best Practices for Making a Referral

39. Case Management • Legal Assistance • Education/Information • Medical Care • OB/GYN and STD Care • Housing (especially if in DV situation) • Mental Health Services • Social/Emotional Support • PTSD/Trauma care Care Services for HIV+ Women N. Smith-Bankhead, 2009

40. Recognize risk activities and behaviors • Ask questions at intake and check in throughout relationship • Assist client in coming up with a plan and prioritizing needs • Consider financial needs and resources - financial empowerment of women • Consider children • Get signed releases of information Case Management N. Smith-Bankhead

41. During sexual history, ask questions • Observe for discomfort • Get signed release of information for follow up • Document physical abuse or rape • Take pictures, write statements, police reports Primary Medical Care N. Smith-Bankhead

42. For HIV+ and HIV- Women • Workshops/Programs • One-on-One Prevention • Focus on behavior change; community support; empowerment • Testing • For women and their partners • STD Screening and Treatment for STDs • For women and their partners Prevention Services

43. SEATEC Key Contacts Booklet http://www.seatec.emory.edu/keycontacts/ National AIDS Hotline 1-800-CDC-INFO (1-800-232-4636) TTY: 1-888-232-6348 Hours: 24 hours a day, 7 days a week E-mail: cdcinfo@cdc.gov GA AIDS/STD Hotline 1-800-551-2728 National Association of People With AIDS Hotline 1-240-247-0880 Hours: Monday - Friday 9:00 am to 5:30 pm (Eastern Time) For More Information

44. Thank You! Neena Smith-Bankhead AID Atlanta, Inc. Neena.smith@aidatlanta.org 404-870-7747