HIV Screening and Testing for Survivors of Domestic Violence Jenny Namur Karp, MPH Social Solutions International, Inc. jnkarp@socialsolutions.biz www.socialsolutions.biz

Overview This presentation will provide an overview of: -Importance of screening and testing -Common barriers to and proposed solutions for HIV screening and testing -Practical information on how to screen Counselors and advocates have frequent contact with survivors. As a result they have a unique opportunity to provide HIV prevention interventions. This module will provide an overview of the need for and importance of HIV screening and testing, common barriers to HIV intervention, well as practical information on how to screen. *It is important to note that implementation of screening and testing interventions in a DV setting does not require that you and your staff become HIV experts or HIV counselors and testers. In fact, provision of screening and testing services can be accomplished with minimal funds, staff time, or paperwork and has enormous benefits for the women you serve.

Why Screen? At-risk women seek care. At-risk women speak with their providers. Brief interventions work. So Why Screen? As previously discussed, women survivors of violence are at high risk for HIV. Regular or irregular use of services provided by the domestic violence community – shelters, hotlines, counseling, support groups, etc. provide an opportunity and venue for HIV screening and intervention. At-risk women seek care. Research suggests that women at risk for HIV, such as survivors of violence, seek medical care an average of up to four occasions per year. As a result, primary care providers have particularly good opportunities to conduct HIV screenings and HIV risk reduction interventions for women. In addition, once women access survivor services, they have repeated exposure to counselors and advocates with whom they develop relationships. These individuals – you - have a unique opportunity to conduct HIV screening with your clients. At-risk women speak with their providers. Research also indicates that survivors, as well as other high-risk individuals, are willing to speak with their counselors and providers about HIV, their risk behaviors, and strategies for reducing their risk for HIV/AIDS.

HIV Screening &Testing Benefits Prevents HIV transmission. Treatment works. Few recognize risk. Many women are asymptomatic. Delay in treatment seeking. Screening works. The benefits of HIV screening and behavior change interventions are numerous. However, few women perceive themselves as being at risk, and women with STDs, including HIV, are often asymptomatic. These factors may cause a delay in testing and treatment. Prevents HIV transmission. The most compelling argument for early detection is the potential to prevent transmission of HIV, which may occur over many years before infected persons develop further symptoms of HIV infection. Even small changes in transmission rates have important public health benefits. Treatment works. HIV testing, coupled with treatment, significantly reduces vertical transmission. Few recognize risk. Among those women at highest risk for STDs, including HIV—that is, younger women and those with multiple partners—fewer than 25 percent believe that they are at risk. Many women are asymptomatic. Women with HIV are often asymptomatic. These infections are detected primarily through HIV/STD screening programs. Delay in treatment seeking. Women with HIV who are asymptomatic or who have vague symptoms may not seek medical care. This delay may prompt an increase in morbidity and mortality among infected women and infection to others. Screening works. Early detection of asymptomatic HIV infection permits early treatment to slow disease progression, interventions to reduce perinatal transmission, and counseling to prevent transmission of the virus to uninfected sex partners or persons sharing injection needles.

HIV Screening and Testing: Challenges & Solutions Challenge: Time Constraints Time as provider barrier Time as client barrier Time Constraints: Solutions Provide Brief HIV Screenings Stress Importance of Health-related Issues Partner with an HIV service provider So we know there are enormous benefits to screening and testing, but we also know there are some challenges. Because of limited time today, I’m going to touch on the four most common challenges DV providers have shared with us over the years. Time constraints is always the 1st item on the list and the challenge most frequently cited. Time as provider barrier. Providers feel significant pressure to evaluate many clients each day. Many report that they have insufficient time to conduct sexual histories. They may also be reluctant to take time away from treatment issues to focus on HIV prevention. Time as client barrier. At the same time, clients may perceive that the provider is busy and may not want to "bother" their provider with additional issues. Solutions Provide Brief HIV Screenings. To counter time constraints, use brief screening tools and techniques. Use waiting room checklists, or ask one or two sensitive questions as part of the client exam. Once screening has been performed, use communication techniques discussed in previous modules of this course to help you provide an effective and efficient HIV risk reduction intervention. Stress Importance of Health-related Issues. Invite your clients to discuss health-related issues in general. By introducing the topic of women’s health and rather than HIV or sexual health as topic, women may be more open to sharing. When sexual health topics come up directly or indirectly, stress that sexual and other behaviors are important components of their overall health. Partner with HIV service provider. As previously mentioned you do not need to become an HIV expert – unless you have the resources and interest to do so, instead we encourage your to develop a strong and lasting relationship with a partner HIV service provider. Your partnership should be with an organization you know to be gender and culturally sensitive and a place where you can provide personalized referrals. I fyou have a strong relationship with the partner organization, your trust in them will show and your clients will be more likely to pursue and receive testing and/or other services from them

Brief HIV Interventions: Challenges & Solutions Challenge: Provider Skills Inadequate counseling skills Provider Skills: Solution Obtain behavioral health intervention training Partner with an HIV service provider Develop a referral network Challenge: Provider Skills Few healthcare providers initiate conversations about HIV and STD-related issues with clients. For example, only 15 percent of women of reproductive age say that they have had a conversation with a health provider about STDs at their first gynecological or obstetrical visit. Inadequate counseling skills. Some providers have inadequate training in counseling clients in the areas of sexual health and drug use. Some do not realize that there are easy-to-learn techniques for discussing sexual health. Provider Skills: Solution Obtain Behavioral Health Intervention Training. Your staff may differ in their comfort level in addressing sexual health issues and familiarity with confidentiality issues. Some staff may be consciously or unconsciously judgmental about sexual behaviors. Identify local resources to provide trainings on such topics as understanding privacy, diversity, and being nonjudgmental, and to employ effective communication skills. When all staff members have the same training on these issues, their ability to work together as an effective team and to provide the same message is greatly enhanced. OR PARTNER

Brief HIV Interventions: Challenges & Solutions Challenge: Multiple Client Needs Biopsychosocial needs Survival needs Multiple Client Needs: Solutions Proactively Identify Biopsychosocial Needs Support Community Resource Trainings Prioritize Needs Challenge: Multiple Client Needs Clients may have multiple problems and needs which can become barriers to seeking and maintaining medical care, and can reduce follow-through on agreed-upon decisions and the effectiveness of HIV interventions. Compounded problems can make clinicians feel overwhelmed by their seeming inability to sufficiently address all of a their clients' issues. Biopsychosocial needs. Clients have a wide range of biopsychosocial needs. These extend to basic needs such as housing, nutrition, substance abuse, and mental health. Many clients will have serious legal, social, relationship, and child-related problems. Survival needs. Women often live in circumstances characterized by abuse and economic dependence. They may be fearful of the potential repercussions of testing. Women who test HIV-positive may experience negative consequences, such as having partners leave them, or even emotional or physical abuse. Multiple Client Needs: Solutions Proactively Identify Biopsychosocial Needs. Over the course of the clinical relationship with your clients, you can discuss the different biopsychosocial domains of their lives to determine unmet treatment needs, even if they extend beyond your medical expertise. Identify, retrieve, and utilize assessment tools designed to elicit information regarding biopsychosocial health. Respond to positive results by providing assisted referrals to community resources. Support Community Resource Trainings. Have representatives of local community resources provide in-service trainings to you and your staff about the services that they provide and how best to help your clients receive these services. Encourage staff to adopt the perspective that reducing barriers to healthy behaviors is everyone's responsibility. There are many external resources that can help staff obtain resources for clients. Prioritize Needs. Work with your clients to identify which problem(s) they feel is most critical and which they feel most prepared to change. Focus on these issues rather than trying to address all of them in one short visit. Follow-up visits can serve to discuss progress in priority areas, as well as identify new priorities for your clients. While HIV may not be item number one on the list, health and well-being is certainly likely to be a part of the list and that provides you with a window of opportunity to discussion concerns about HIV risk.

Brief HIV Interventions: Challenges & Solutions Challenge: Lack of HIV Policies Lack of policies. Competing policies. Lack of HIV Policies: Solutions Develop a screen-everyone policy. Challenge: Lack of HIV Policies Several factors impede healthcare professionals' provision of appropriate HIV testing and treatment. These include lack of policies and competing policies. Lack of policies. Medical practices that do not have written policies and protocols about HIV screening and testing have an increased likelihood of not providing appropriate sexual health and related clinical services. Medical practice staff members who are unaware of clinical HIV policies are less likely to follow them. Competing policies. In some situations, providers are subject to policies, guidelines, and protocols from multiple entities. They may have somewhat conflicting protocols from professional associations; Federal, State, or regional laws; and insurance guidelines. For example, managed care organizations may not support notifying and counseling sexual partners, although State policy may mandate partner notification. This can lead to confusion about how to handle sensitive and difficult issues and hinder the intervention process. Lack of HIV Policies: Solutions Develop a Screen-Everyone Policy. Establish the practice of encouraging all clients to participate in HIV screenings. Incorporate HIV into routine medical examinations. The AMA urges clinicians to assess risk factors for HIV infection in all clients by obtaining a careful sexual history and inquiring about drug use.

Practical Implementation of Screening and Testing Provide multiple screening options Provide privacy Inform staff Ensure confidentiality Identify point person When you choose to provide HIV screening and/or testing for clients, you should consider the following tips: Provide multiple screening options and opportunities. As previously mentioned screening can take the form of a checklist, intake form, paper-based screening, or it can be an interview, casual conversation, or organizational event. Providing multiple opportunities for women to disclose risky behaviors and/or HIV concerns increases likelihood of the conversation and opportunity for intervention. Provide privacy. Regardless of the screening format, provide women with a space where they can answer personal questions without worrying about whether other clients or staff can see or hear the questions or answers. Screenings take only minutes, so a multi-use room is appropriate. Inform staff. Ensure that staff understands the goals and objectives of HIV screening as well as the organizations screening policies and services. Ensure confidentiality. Ensure that staff understand State and regional laws regarding HIV confidentiality issues and HIV reporting laws, and that clients understand their confidentiality is protected at all times. Explain where forms and files are stored and locked and who has access to what. Identify point person. Identify a staff member to be HIV screening point person. This person should be well acquainted with the organizations HIV screening policies and services.

Questions and Thank you Jenny Namur Karp Social Solutions International, Inc. www.socialsolutions.biz jnkarp@socialsolutions.biz