Trauma-Informed Care and HIV

1. Trauma-Informed Care and HIV

2. What is trauma? • Trauma refers to negative events, circumstances, or experiences that are a threat to one’s physical and emotional well-being and elicit intense feelings of helplessness, terror, and lack of control • Traumatic experiences have lasting adverse effects on a person’s mental, physical, social, and emotional well-being

3. How common is trauma? • Trauma is very common • In the United States, 51% of women and 61% of men experience at least 1 traumatic event at some point in their lives • Trauma, including histories of childhood sexual and physical abuse, is even more common among people living with HIV than in the general population

4. How common is trauma? • Trauma is very common • In the United States, 51% of women and 61% of men experience at least 1 traumatic event at some point in their lives • Trauma, including histories of childhood sexual and physical abuse, is even more common among people living with HIV than in the general population

5. How trauma can affect health and well-being throughout life Death Birth

6. Trauma in childhood • Childhood trauma can include the following adverse childhood experiences (ACEs): • Physical, verbal, and/or sexual abuse • Physical and emotional neglect or abandonment, including food insufficiency, lack of money to meet basic needs, and homelessness • Loss of a parent • Family life that includes drug addiction, alcoholism, parental incarceration, or domestic violence • A family member struggling with mental illness

7. Trauma in adulthood • Traumatic experiences occurring in adulthood can also impact people living with HIV and can include: • Physical, emotional, and/or sexual abuse • Violence • Rape • The higher levels of trauma experienced by adults living with HIV are linked, in part, to racism, homophobia, transphobia, and other factors

8. Women and trauma • Women living with HIV experience much higher rates of trauma and violence than the general female population • A recent study of women living with HIV found that childhood and adult trauma are key drivers of HIV infection and poor health outcomes

9. MSM and trauma • HIV-positive men who have sex with men (MSM) have also been found to have a strong history of ACEs • According to one study:

10. Why understanding trauma is important • People who have experienced trauma may be very sensitive to situations that remind them of the traumatic event • These reminders may trigger internal discomfort or distress and may retraumatize people by causing them to relive their trauma • If retraumatizing triggers occur in healthcare settings, clients may come to view healthcare itself as a source of distress rather than of healing • Triggers can include removal of clothing, physical touch, personal questions, white lab coats, medical equipment, or antiseptic odors, among other things

11. Trauma’s negative impact on HIV care • Traumatic experiences adversely affect people living with HIV at every stage of the HIV continuum of care, resulting in: • Poor linkage to HIV care • Poor retention in HIV care • Poor adherence to HIV treatment • HIV treatment failure and disease progression

12. More about trauma’s negative impact • People with HIV and a history of trauma are also more likely to: • Experience disrupted or negative interactions with medical personnel • Engage in increased risk-taking behaviors, such as using substances and having sex without condoms • Transmit HIV to others because of their increased risk-taking behaviors • Have a poor quality of life

13. What is trauma-informed care? • Trauma-informed care emphasizes the physical, psychological, and emotional safety of trauma survivors and creates opportunities for them to rebuild a sense of control and empowerment • Trauma-informed care seeks to do no further harm to people with histories of trauma and to avoid retraumatizing them

14. What are the benefits of trauma-informed care? • By understanding the vulnerabilities and triggers of trauma survivors, trauma-informed care providers can better meet the needs and be more supportive of clients who have experienced trauma • Trauma-informed care can help improve client engagement in care and health outcomes

15. The 4 R’s of trauma-informed care • Trauma-informed healthcare: • Realizes the prevalence of trauma and understands potential paths for recovery • Recognizes the signs and symptoms of trauma in clients and their families • Responds appropriately by incorporating knowledge about trauma in medical procedures and practices • Resists retraumatization by working to minimize its potential

16. Steps for providing trauma-informed care • Train staff about trauma, trauma-informed care, and sharing critical information • Screen and assess clients for trauma • Communicate sensitivity to trauma issues • Create a safe and secure environment • Provide services in a trauma-informed manner

17. Step 1: Training staff • Increase awareness among staff members of the importance of trauma as a factor in health outcomes • Communicate with other staff members about: • The effect of trauma on physical and mental well-being • The variable comfort levels of clients with medical services and procedures

18. Step 2: Screening and assessing clients for trauma • Have clients complete a questionnaire, in private, to assess for trauma • The questionnaire can include statements requiring yes/no responses. For example: • I have been physically and/or verbally abused as a child • I have been threatened and/or abused as an adult by a sexual partner • I have been sexually molested and/or raped • My partner has threatened and/or abused my children

19. Step 3: Communicating sensitivity to trauma issues • Be sensitive to the needs of clients who have experienced trauma by: • Providing trauma-related informational materials in the waiting area for clients to read • Displaying posters in exam rooms that encourage clients to talk about trauma with their healthcare providers • Talk with clients about trauma before and during an exam

20. Step 4: Providing a safe and secure environment • Implement measures that make clients feel welcome and comfortable in your facility • Provide trauma-sensitive care and prevent retraumatization by eliminating traumatizing triggers • Ask staff to suggest improvements to the care and physical environment provided by your facility • Survey clients to get their feedback about the care and physical environment provided by your facility

21. Step 5: Providing services in a trauma-informed manner • Demonstrate your awareness and knowledge about trauma to your clients • Share information about trauma-related resources and services with your clients • In all of your interactions, continue to: • Show respect for your clients • Establish good rapport with your clients • Take time with your clients • Respect your clients’ boundaries

22. Why do many healthcare providers not offer trauma-informed care? • One reason that many healthcare providers do not offer trauma-informed care is that they may overlook the link between trauma and adult health status, mistakenly thinking that too much time has elapsed since the trauma occurred • Another reason is that some healthcare providers may feel uncomfortable—and therefore avoid discussing—sexual violence and other sensitive issues with their clients, fearing that such subjects are too intimate and personal

23. More reasons that healthcare providers may not screen for trauma

24. What happens if trauma is not addressed? • If not taken into account by healthcare providers, trauma can have a detrimental impact on the health and health outcomes of people living with HIV and can be harmful to their overall well-being • That is why the official US strategy for combating HIV emphasizes the important role that trauma-informed care can play to help improve the lives and health outcomes of people living with HIV

25. Some practical tips for implementing trauma-informed care • Engage clients, develop rapport with them, and build trust over time • Talk about any worries or concerns your client may have (for example, disrobing) and how you can help • Give clients as much control and choice as possible • Validate clients’ concerns as understandable • Explain each procedure thoroughly and get client consent • Ask clients if they are ready to begin and tell them that they can pause or stop the procedure at any time • Talk with your clients during procedures to let them know what you are doing and why • Allow a support person to be present in the exam room • Provide a calm and soothing office environment • Give relaxed, unhurried attention • Be personable, respectful, kind, and honest with your clients • Encourage clients to do what feels most comfortable (for example, keeping their clothes on) • Place a high priority on showing awareness of and respect toward the culture of your clients, including their ethnicity, race, religion, sexual orientation, and any history of social trauma, such as homelessness and poverty

26. Some practical tips for implementing trauma-informed care • Engage clients, develop rapport with them, and build trust over time • Talk about any worries or concerns your client may have (for example, disrobing) and how you can help • Give clients as much control and choice as possible • Validate clients’ concerns as understandable • Explain each procedure thoroughly and get client consent • Ask clients if they are ready to begin and tell them that they can pause or stop the procedure at any time • Talk with your clients during procedures to let them know what you are doing and why • Allow a support person to be present in the exam room • Provide a calm and soothing office environment • Give relaxed, unhurried attention • Be personable, respectful, kind, and honest with your clients • Encourage clients to do what feels most comfortable (for example, keeping their clothes on) • Place a high priority on showing awareness of and respect toward the culture of your clients, including their ethnicity, race, religion, sexual orientation, and any history of social trauma, such as homelessness and poverty

27. A quick review • The adverse impact of trauma on people living with HIV can be devastating • It is important that healthcare providers recognize and address the negative effects of trauma by adopting trauma-informed care practices in their interactions with clients • Better understanding of the complex association between trauma and health can help enhance the ability of healthcare providers to provide effective, compassionate, and comprehensive care for people living with HIV

28. Case study: Tiffany • 27-year-old black woman • Was diagnosed with HIV 1 year ago • Repeatedly fails to show up for appointments with her HIV healthcare provider and does not take her HIV medicine as prescribed • Is severely depressed • Has a history of trauma (physical abuse and sexual molestation as a child and intimate partner violence as an adult), of which her healthcare provider is unaware