Before we begin, a little about our format… Presentation by seminar speakers (approx. 40 min.) Followed by question and answer session (approx. 20 min.) **************************************************** Please press *6 on your telephone keypad to mute your line (to un-mute your line, press *6 again) If you are experiencing difficulty with your phone connection, dial *0 for the conferencing service operator Questions submitted prior to the web seminar will be addressed first during the Q&A For questions that arise during the presentation, click on the “hand” button and type your question or wait to be called on to ask your question over the phone Welcome to the Acci ó n Mutua web-seminar

Acción Mutua is a capacity building assistance (CBA) program of AIDS Project Los Angeles in collaboration with the César E. Chávez Institute of San Francisco State University Funded by the Centers for Disease Control and Prevention

Women, Violence and HIV Strategic Directions for HIV Prevention ManChui Leung HIV Program Director Asian & Pacific Islander American Health Forum APLA Web Seminar March 13, 2008

Overview 1.Key questions 2.Definitions/ Prevalence 3.How violence intersects with HIV 4.What can we do now? 5.Opportunities for impact

Key Questions How can we better reach women and girls in communities of color? How can sharpening our focus on violence improve our HIV prevention strategies? What kind of impact will this make?

HIV/AIDS – gender & racial/ethnic distribution

HIV/AIDS – transmission categories

Violence – definitions Physical, sexual and emotional abuse Living in a climate of fear, misery, mistrust, humiliation, despair, shame and devaluation Dependency, isolation Intimate partner (current/former), family/group Occurs throughout a woman’s lifespan (infant  elder) Impact across multiple populations – women, young people, gay & bisexual men/MSM – abuses are experienced in the contexts of race, ethnicity, age, sexual orientation, gender identity, education level, class, disability, or immigration/refugee status

How prevalent is violence? Intimate partner violence results in nearly 2 million injuries and 1,300 deaths nationwide every year ( CDC 2003). A national study found that 29% of women and 23% of men had experienced intimate partner violence during their lifetime (Coker et al., 2002). A review of representative samples found that between 8-27% of women have experienced child sexual abuse (Koenig, 2004) Prevalence of violence among women with HIV or at risk for HIV may be as high as 67% ( Cohen et al., 2000 ). Prevalence of child sexual abuse among HIV+ women ranges from 31%-53% ( Koenig & Clark, 2004) Source: CDC NCIPC/DVP fact sheet

Patricia’s story  Child sexual abuse  Denial  Homelessness / Runway  Drug use  STDs  Attempts to improve health and reduce risks  Older man  Economic dependence  Limited mobility  Accusations of infidelity  Forced Sex / Rape  Multiple partners and no condoms  Fear/ Lack of self esteem

Intersection VIOLENCE AS A BARRIER TO ENGAGE IN HIV RISK REDUCTION BEHAVIORS Violence limits a woman’s ability to access and engage in HIV preventative behaviors (e.g. condom-use, risk reduction strategies)

What does the research say? Women in abusive relationships: Are more likely to never use a condom (Hamburger et al., 2004; Koenig & Moore, 2000; Maman et al., 2000) Report escalation of abuse when asking their partner to use a condom (Wingood & DiClemente, 1997, 2002; Kalichman et al., 1998) Find it difficult to carry out long range planning or to make decisions on their own (Bard & Sangrey, 1986) Experience depression, anxiety, substance use, suicide ideation (Tjaden & Thoennes, 2000)

Intersection PARTNERING WITH HIGH RISK MEN Women who experience violence are more likely to be in partnerships with men who are at high risk for HIV (substance use, multiple partners).

What does the research say? This can be examined in 3 ways: 1.As a consequence of a history of abuse Women with a history of abuse are 4 times more likely to engage in sex with a high risk partner (Beadnell et al., 2000 ). 2.A history of abuse is linked with a lesser ability to assess individual risk and safety Women, even in high risk and violent relationships, are often unable to label sexual abuse as rape (El-Bassel, 2000). 3.Interpersonal dynamics with partners (cultural/economic) Interaction of gender and culture is significant. Values of love, trust and intimacy and being part of the group may override personal safety (Chin, 2004).

Intersection VIOLENCE AS A BARRIER TO ACCESSING TESTING AND SERVICES Fear of violence and other negative outcomes are controlling factors that serve as a barrier to a woman’s ability to access HIV testing and other health and human services.

What does the research say? This can be examined in 3 ways. Violence as a barrier to: 1.Accessing HIV testing services. Women in violent relationships often have limited decision making authority with regard to accessing healthcare for themselves and their children (Tjaden & Thoennes, 2000; Wingood & DiClemente, 1997). 2.Disclosing HIV test results. Most common barriers to disclosure are fear of abandonment, rejection, further violence from partner and family (Gielen, et al., 1997). 3.Treatment adherence, accessing care and support HIV+ women in violent relationships report a reluctance to keep appointments because of fear, depression, and feeling “worn down”. Abusive partners can also sabotage efforts to keep appointments or take medications (Lichtenstein, 2006)

Intersection EXPERIENCE OF EARLY SEXUAL ABUSE The experience of early sexual abuse as a child or adolescent correlates with high risk behaviors and a limited ability to engage in risk reduction strategies

What does the research say? Women with a history of sexual abuse and violence: Have a 7-fold increase of HIV risk behaviors and other markers of risk (Wyatt, 2000) Are 14 times more likely to report an STD (Wingood & DiClemente, 1997) Tend to have more partners (Cohen et al., 2000), and high risk partners (Beadnell et al., 2000) “Scripts” for intimacy and sex (Lynn et al., 2004). Cognitive & psychological mechanisms to cope with trauma and betrayal (Zurbriggen & Freyd, 2004) Substance use (Wilsnack, 2004) Victims of child sexual abuse are more likely to be re-victimized as adults (Doll, Koenig, et al. 2004; Wyatt, 2000) Men of color compared to White men, and gay/bisexual men compared to heterosexual men have a higher prevalence of child sexual abuse (Doll et al., 2004, Voisin, 2005; Heitz & Melendez, 2006 )

Patricia’s story Child sexual abuse Poor self esteem Early initiation into sex Early initiation into drugs Runaway / Homelessness Re-victimization Multiple partners No/ Limited condom use Rape Distal Proximal HIV RISK

Opportunity for impact RELEVANCE FOR MULTIPLE POPULATIONS: Women of color, young people, gay/bisexual men of color, substance users (Bogart, 2005; El-Bassel, 2003; Koenig & Moore, 2000; Wingood, 2004, 2006; Wyatt 2002) PRIORITIZING HEALTH DISPARITIES IN COMMUNITIES OF COLOR Current research has centered women of color Promotion of minority and women researchers ACKNOWLEDGING COMMON GROUND Expanding entry points, stretching resources, building partnerships RESPONDING TO NEED AND ENGAGING IN CURRENT DIALOGUE International, domestic and local Research and communities have started to respond

What can you do now? Community – continue advocacy; stories; community organizing Providers (recruitment, interventions) – incorporate assessments and additional sessions to address violence and trauma; program development; referrals and linkages Providers (clinical, testing) – implement domestic violence screening tools and safety planning; referrals and linkages Health Departments – implement CDC 1998 Partner Counseling and Referral Services (PCRS) Guidelines; Counseling Testing and Referral guidelines Researchers – develop research agenda; additional studies on women, violence and substance use; mentorship Funders – fund comprehensive strategy for services and community change Policy makers – prioritize women and minority health as public health priorities to improve community health

Thank you! AIDS Project Los Angeles Acción Mutua Linda Koenig, Ph.D. Ann O'Leary, Ph.D. Wendell Price CDC Foundation CDC

Contact information ManChui Leung HIV Program Director Asian and Pacific Islander American Health Forum 450 Sutter Street – Suite 600 San Francisco, CA Phone: Fax:

CA HIV/STD Prevention Training Center Domestic Violence: Assessment and Referral course Health Intimacy course. Family Violence Prevention Fun Other resources: