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 Services AID Atlanta, Inc.

"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

Session Overview 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

Women and HIV/AIDS

Women and HIV Overview

Women and HIV Leading cause of Death for black women ages Women are more than ¼ of all new HIV/AIDS Diagnoses CDC, 2009

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

More About Needle Sharing: Steroid use Tatooing Drug Use 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

HIV Risk Factors for Women RISE Coalition Training Manual, 2009 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

Why Women Are At Additional Risk 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

Women, IPV and HIV 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

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

Challenges Addressing HIV in Hard-to-Reach Communities 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

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

When to Talk about HIV Risk? 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

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

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

HIV Prevention Counseling … 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 CDC, 2008

Prevention Counseling Steps 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 CDC, 2008

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

Step #2: Identify client risk behaviors and circumstances 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) CDC, 2008

Step #3: Identify safer goal behaviors 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 CDC, 2008

Step #4: Develop Action Plan 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 CDC, 2008

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

Step #6: Summarize and Close the Session 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 CDC, 2008

Prevention Counseling 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

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

Basic Counseling Skills 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 CDC, 2008

HIV Counseling and Testing N. Smith-Bankhead, 2009

HIV Counseling and Testing 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 N. Smith-Bankhead, 2009

Assessing for Readiness for HIV Counseling and Testing 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? N. Smith-Bankhead, 2009

HIV Counseling and Testing Tips for Disclosing 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,

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

Making Referrals 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) CDC, 2008

Best Practices for Resource Development 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 N. Smith-Bankhead, 2009

Best Practices for Making a Referral 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).

Care Services for HIV+ Women 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 N. Smith-Bankhead, 2009

Case Management 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 N. Smith-Bankhead

Primary Medical Care 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 N. Smith-Bankhead

Prevention Services 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

For More Information SEATEC Key Contacts Booklet National AIDS Hotline CDC-INFO ( ) TTY: Hours: 24 hours a day, 7 days a week GA AIDS/STD Hotline National Association of People With AIDS Hotline Hours: Monday - Friday 9:00 am to 5:30 pm (Eastern Time)

Thank You! Neena Smith-Bankhead AID Atlanta, Inc