1. Intimate Partner Violence and HIV risk: the role of cover-up, shame and fear Alejandra Mijares 1, Laura F. Salazar 2, Nicole Pitts 3, & Rachael Wendlandt 1 1 Abt Associates Inc. 2 Georgia State University, SPH 3 Dynamics Research Corporation

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Alejandra Mijares No relationships to disclose

3. Disparities in HIV Infection New HIV infections among African American women: –87% attributed to heterosexual contact. – 64% women African Americans in Georgia: –31% of Georgia’s population in 2010, –77% of the new HIV infections New HIV infections in Atlanta: –Occur within a group of inner city census tracts located inside the Atlanta metropolitan statistical area

4. Intimate Partner Violence 35.6% of women in the United States have experienced IPV in their lifetime 43.7% African American women Black, M. C., et al (2011)

5. Intersection of IPV and HIV Rate of IPV among HIV-positive women (55%) was double the national rate. Women who experience IPV have over 3 times the risk to be diagnosed with HIV Women who experience IPV are more likely to report HIV-related risk behaviors such as having multiple partners and lack of condom use CDC, 2008; Lang et al., 2011; Sareen, H., Pagura, J., & Grant, B., 2009 Seth, Raiford, Robinson, Wingood, &DiClimente, 2010; Stockman, Campbell, &Celentano, 2010;

6. Mechanisms of Risk Forced sex with infected partner Negative coping strategies in response to IPV Constrained negotiation of condom use or safer sex

7. Relational Factors Economic dependence Communication styles Fear of condom negotiation Low relationship power Lack of social and family support

8. Personal factors Low-self esteem Depression Age Belief in traditional gender roles Substance use Shame Fear

9. Stigma vs. Shame Stigma is socially constructed Shame is internally constructed

10. Purpose The purpose of the study was to identify individual and relational factors that may increase risk for HIV in women who experience IPV

11. Methods Participant eligibility –18 years or older –Black/African American –Female –IPV experience in previous 12 months –Vaginal sex in previous 12 months –Residing in a high Risk Area in Atlanta, GA Recruitment venues: –1 community-based organization –2 libraries located in High Risk Areas

12. Data Collection –ACASI survey Psychological factors (e.g. Depression 20-item scale) Relational factors (e.g. sexual relationship power scale) Risk behaviors (e.g. condom use) –Qualitative interviews –Testing for three non-viral STIs: Chlamydia, Gonorrhea, Trichomoniasis

13. Analysis Qualitative Analysis ­ Codebook development ­ Transcripts coded by 3 analysts Quantitative Analysis ­ Descriptive statistics ­ Laboratory data

14. Preliminary Results: Demographics Sample: 48 African American women Mean age =31.3, STD=11.4 47.9% did not complete high school 52.1% single, 27.1% Married/Living Together, 8.4% Separated/Divorced Income source: 43.8% job, 18.8% husband/boyfriend, 18.8% family support, 18.8% government assistance

17. Shame “I mean… why would you be with somebody who does those types of things to you?” – Karen

18. Fear “I felt like if I did tell somebody that he would really really hurt me or kill me!” - Yvette

19. Fear “We didn't use a condom all this time, so why start now? He'd probably get mad, probably say, 'Oh you must be cheating on me' or something.“ - Julia

21. Cover-up 62.5% covered-up the abuse –30% (n=9) feared condom negotiation –63.3% (n=19)perceived low relationship power

22. Cover-up “I felt embarrassed! God, that was the most embarrassing! I always had a lie before I even got to work. I already knew what lie I wanted to tell everybody. Whether it was ‘I was in a car accident’, or ‘I fell down the stairs or something’. I always had a story to tell.” – Dana

23. Cover-up “It was embarrassing! If people asked me what happened, I was just like ‘Oh it’s nothing’ because I didn’t really want to tell any of my friends anything.” –Crystal

25. Isolation “They say I’ve distanced myself from them since I’ve been involved with him… it’s just easier to stay away.” – Aisha

27. HIV Risk 79.2 % reported unprotected vaginal sex 22.9% reported anal sex in previous 6 months –63.6% did not use a condom

28. HIV Risk 62.5% (N=30)covered-up the abuse –30% (n=9) feared condom negotiation –73.3% (n=22) reported unprotected vaginal sex –30% (n=9) used illicit drugs in the previous 30 days

29. HIV Risk 31% (N=15) tested positive for a non-viral STI –73% (n=11) covered-up abuse

30. Conclusions Shame and fear are associated with experiencing IPV –Cover-up of IPV places women at an increased risk for HIV. Cover-up may increase isolation and affect help-seeking behaviors making intervention efforts less likely. Cover-up and isolation may contribute to an increase in negative coping strategies

31. Conclusions Interventions aimed at reducing HIV infection among women should address IPV: –Address shame and fear –Reduce victim blaming, allow women to feel comfortable –Stigma surrounding IPV needs to be reduced

33. Break the silence, stop the violence

34. Limitations Cross-sectional data Small sample size Descriptive analysis Self-report data (ACASI and interviews))

35. Thank you ! Questions? Contact: Alex_Mijares@abtassoc.com