Diverse Strategies to Address the
Intersection of Women, Violence,
and HIV in the U.S.
Vignetta Charles, PhD
Chief Science Officer, ETR
Johns Hopkins Bloomberg School of Public Health Amazing Alumni Series
March 9, 2016
What we’ll do today
•
A little bit about me and my academic/professional path
•
A little bit about changing landscape of the HIV/AIDS epidemic
domestically
•
A lot about how violence/trauma intersect with HIV, specifically
focused on women
•
Q&A
2
Academics
PhD, Population, Family, and Reproductive Health
B.A. American Studies, Minors in
African-American Studies & Integrative Biology
ScM Health and Social Behavior,
Harvard School of Public Health
3
Professional life
DIRECT SERVICE
•
Teen Pregnancy- and HIVPrevention programs for youth
•
San Francisco and Oakland
GOVERNMENT
•
Ministry of Health,
Commonwealth of Dominica
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Boston Public Health
Commission
PHILANTHROPY
• William and Flora Hewlett
Foundation
• National AIDS Fund/AIDS United
APPLIED RESEARCH
• JHSPH Center for Adolescent
Health
• ETR
4
Volunteering!
•
Early ’90s
HIV STIGMA
5
HIV & AIDS Over Time: Our Legacy
HAART Introduced
6
Estimated New HIV Infections
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Stages of Care—The U.S. Treatment Cascade
100%
1,178,350
80%
941,950
61%
725,302
41%
480,395
36%
426,590
28%
328,475
HIV-Infected
Diagnosed
Linked to HIV
Care
Retained in
HIV Care
On ART
Suppressed
viral load
Centers for Disease Control and Prevention—United States, MMWR 2011;60(47)1621
8
=
Lifetime Treatment
Cost $379,668
50,000 New Infections
Treatment Costs of HIV
=
Lifetime Treatment
Cost $18.9 Billion
= $94.9 Billion
Insurance Coverage of
Nonelderly Adults with HIV
2009 Pre-ACA
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Affordable Care Act
•
No rescissions, no ability to exclude based on pre-existing conditions;
•
Establishing a base of essential health benefits;
•
Optional expansion of Medicaid;
•
Expansion of preventative health services, including testing; and
•
Redefining the Health Care system in the United States.
10
HPTN 052: HIV-1 Transmission
Total HIV-1 Transmission Events: 39
Linked
Transmission: 28
Immediate
Arm: 1
Delayed
Arm: 27
Unlinked or TBD
Transmission: 11
•
1,763 Sero-discordant couples (97% heterosexual)
•
Delayed = start at CD4 <250
•
Single transmission in patient in immediate ART
therapy arm believed to have occurred close to
time therapy began and prior to suppression of
genital tract HIV
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HPTN 052 – Treatment as Prevention
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Pre-Exposure Prophylaxsis
PrEP IS A NEW HIV PREVENTION METHOD IN
WHICH PEOPLE WHO DO NOT HAVE HIV
INFECTION TAKE A PILL DAILY TO REDUCE THEIR
RISK OF BECOMING INFECTED
PrEP CAN ONLY BE PRESCRIBED BY A HEALTH
CARE PROVIDER AND MUST BE TAKEN AS
DIRECTED TO WORK
Up to 90% Efficacy with Detectable Levels of Medication Present;
Average Efficacy for MSM: 44%
13
Rodger A et al. HIV transmission risk through condomless sex if HIV+ partner on suppressive ART. PARTNER Study. 21st Conference on
Retroviruses and Opportunistic infections, Boston, abstract 153LB, 2014. | Graphic developed by THESTIGMAPROJECT
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Defining Intimate Partner Violence
Violence perpetrated by a current or former boyfriend, cohabiting
partner, husband, or date
•
Physical violence
•
Sexual violence
•
Stalking
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Control of reproductive or sexual health
•
Aggressive/coercive tactics
•
Emotional abuse
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U.S. Prevalence Data
1.3 million women raped in 2009
•
1 in 5 women raped in their lifetime (1 in 71 men)
•
1 in 4 HIV-infected women raped in their lifetime *
•
1 in 6 women stalked (1 in 19 men)
•
1 in 4 women experience severe physical violence by intimate
partner (1 in 7 men)1
1. National Intimate Partner and Sexual Violence Survey, CDC, 2010, * 2008
2. A Phillips, Deborah Y. et al. The Intersection of Intimate Partner Violence and HIV in U.S. Women: JANAC, Volume 25, Issue 1, S36 – S49.
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Why use the reference “Intimate Partner” Violence?
•
Violence Against Women - 64% by intimate partner
•
Rape
• 51.1% by intimate
partner
• 40.8% by an acquaintance
• 91.9% by someone known to the victim
NIPVS, CDC 2010
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Trauma
SAMHSA:
“… an event, series of events, or set of circumstances [e.g., physical,
emotional and sexual abuse; neglect; loss; and community violence]
that is experienced by an individual as physically or emotionally
harmful or threatening and that has lasting adverse effects on the
individual's functioning and physical, social, emotional, or spiritual
well-being”.
http://www.samhsa.gov/traumajustice/traumadefinition/definition.aspx
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Trauma’s link with HIV
•
More common among women living with HIV
•
Increases risk of HIV acquisition
•
Linked to poor HIV-related outcomes
•
Linked to secondary transmission risk
19
Why can IPV exposure increase a woman’s risk for HIV?
•
Forced sex with an infected partner
•
Limited or compromised negotiation of safer sex practices
•
Increased sexual risk-taking behaviors
FAST FACT: Women in relationships with violence have four times the
risk for contracting STIs, including HIV, than women in relationships
without violence.
20
HIV Care Cascade for Women
HIV in the United States: The Stages of Care. CDC, July 2012.
21
HIV Care Cascade for Women
IPV
3x more likely to
wait >90 days
Siemieniuk RA, et al. AIDS Patient Care STDs. 2010
Siemieniuk,RA, et al. J Acquir Immune Defic Syndr. 2013
IPV
≈ 2x rate of
lost-to follow
≈ 2X missed
gyn appts
IPV
½ as likely to be on ART
Trauma history
½ as likely to be on ART
Stressful Events
2-3x non-adherence
Illangasekare, S., et al. Women’s Health Issues. 2012
Kalokhe, A.S., et al. AIDS Patient Care and STDs. 2012
Cohen, M.H., et al. American Journal of Public Health. 2004
IPV
>2x rate of
failure
Recent
trauma
>4x rate of
failure
Lesserman, J. et al. AIDS PATIENT CARE and STDs. 2008
Mugavero, MJ, et al. Psychsomatic Medicine. 2009.
Machtinger EL, et al. AIDS and Behavior. 2012
CDC, 2012. http://aids.gov/federal-resources/policies/care-continuum
22
Results from a national survey of WLHIV, 2013
N = 179
•
69% of respondents had been sexually assaulted
•
34% had been sexually assaulted for the first time
before the age of 13
•
72% identified as survivors of IPV/DV
Johnson, Khanna, Margolese, & Pena. PWN-USA Survey, 2013.
23
Meta-analysis of studies of WLHIV
Machtinger E, Wilson T, Haberer J, Weiss, D. Psychological trauma in HIV-positive women: a meta-analysis. Aids and Behavior. January 17, 2012.
24
PTSD in WLHIV is correlated with poorer health
outcomes…
Machtinger EL, et al. Recent trauma is associated with antiretroviral failure and transmission risk behavior AIDS and Behavior. AIDS Behav. 2012
Nov;16(8):2160-70.
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… and increased transmission risk behavior
Recent trauma is associated with ≈ 4x the rate of:
Having HIV-negative or
unknown serostatus
sexual partners
OR 3.9 (1.3-11.9; p=.02)
These partners not
always wearing
condoms
OR 4.5 (1.5-13.3; p=.007)
Machtinger EL, et al. Recent trauma is associated with antiretroviral failure and transmission risk behavior AIDS and Behavior. AIDS Behav. 2012
Nov;16(8):2160-70.
26
Violence disproportionately impacts transgender women
of color
•
Almost three-quarters of LGBTQ homicide victims in 2013 were
transgender women. 67% were transgender women of color
•
Transgender women were 6 times more likely to experience physical
violence when interacting with the police than other LGBTQ survivors
of violence
•
Transgender people of color were 1.8 times more likely to experience
violence in shelters than other LGBTQ survivors of violence
National Coalition of Anti-Violence Programs (NCAVP) Annual Report, 2014
www.pwn-usa.org
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Types of Violence
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“I dated a guy who knew my HIV status,
but when his family found out, he
acted like he didn’t know and pressed
charges [on] me. I almost lost
everything. It has taken me a long
time to disclose to anyone since.”
29
“I was in an abusive relationship for 4
years. When I attempted to leave, he
threatened to come after me under
HIV criminalization laws because I
didn’t disclose to him when we first
got involved. He also threatened to
have my kids taken away.”
30
“My partner didn’t want anyone else to
know about my HIV status. He didn’t
even allow me to see my HIV doctor,
because he was afraid of people
finding out. So I basically had no
support and was not getting care.”
31
“I have felt ashamed of my body and
worthless. My ex would tell me that
nobody else would ever want me,
because of my HIV.”
32
Federal Interagency
Working Group
Presidential Memorandum,
March 2012
Created an interagency
Federal Working Group
(Working Group) to
explore the intersection
of HIV/AIDS, violence
against women and girls,
and gender-related
health disparities.
Presidential Memorandum, March 2012
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Departments represented in Working Group
•
Health and Human Services
•
Education
•
Veterans Affairs
•
Justice
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Housing and Urban Development
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Homeland Security
•
Interior
•
Office of Management and Budget
34
The Summit: A community-driven response
Summit participants developed action plans focused on three specific
recommendations provided by the President’s Interagency Working
Group report:
•
Increase IPV screening and HIV
testing for girls and women and
encourage concurrent
screening.
•
Screen women living with HIV
for IPV and link them to
appropriate services.
•
Develop, implement, and
evaluate models that integrate
trauma-informed care into
services for women living with
HIV.
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Congressional Briefing
Moderator:
Vignetta Charles, PhD
Panelists:
Gina Brown, MD, NIH Office of
AIDS Research
Lynn Rosenthal, White House
Advisor on Violence against
Women, Office of Vice President
Maggie Czarnogorski, MD, MPH
White House Office of National
AIDS Policy
Jacquelyn Campbell, PhD, RN,
FAAN JHSPH & SON
Eddy Macthinger, MD, UCSF
Naina Khanna, Positive Women’s
Network
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Empowered Campaign
•
Panel focusing on Women,
Violence, and HIV
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Kaiser Family Foundation
“Greater Than AIDS” campaign
http://www.greaterthan.org/campaigns/empowered/
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38
Continuing the work at ETR
Partnering with The Well Project
•
Advanced analysis on role of violence and trauma on treatment
adherence
•
Deconstructing the intersection of stigma and trauma
39
Not just women
•
1 of 2 gay black men will be
diagnosed with HIV
1 in 4 Hispanic gay men
1 in 2 African American MSM.
FIFTY Percent.
HALF.
1 in 11 White gay men
http://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html
http://www.usatoday.com/story/news/nation-now/2016/02/23/cdc-black-gay-men-hiv-diagnosis-lifetime-at-risk/80812496/
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Headlines
www.pwn-usa.org
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Facing the Truth
Real women.
Real lives.
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CICELY BOLDEN
Stabbed to death, mother of two, 28 years old
http://mylifeofcrime.files.wordpress.com/2012/09/cicely-bolden.jpg
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SERENA LYNNE WILLIAMS
Murdered, 35 years old
http://blogs.sacbee.com/crime/archives/2012/09/man-convicted-in-hiv-murder-killed-previously-in-1975.html
45
DOMINIQUE DUVAL
Shot to death, 23 years old
http://blogs.browardpalmbeach.com/pulp/2009/08/dominique_duval_murder_hollywood.php
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Elisha Henson
Strangled, 30 years old
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Acknowledgments
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Gina Brown, MD; NIH Office of AIDS Research
•
Jacquelyn Campbell, PhD, RN; Johns Hopkins University, School of
Nursing
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Michael Kaplan, President & CEO, AIDS United
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Naina Khanna; Executive Director, Positive Women’s Network-USA
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Eddy Machtinger, MD; University of California, San Francisco,
Women’s HIV Program
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Krista Martel, Executive Director, The Well Project
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Maura Riordan, VP of Access & Innovation, AIDS United
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Questions?
Contact info:
Vignetta Charles
Chief Science Officer
ETR
[email protected]
49