1. THIS WEBINAR WILL BEGIN AT 4:00PM-5:30PM EST, 3:00PM-4:30PM CT, 2:00PM-3:30PM MT, 1:00PM-2:30PM PDT LISTEN THROUGH YOUR COMPUTER SPEAKERS OR CALL IN: 1-719-234-7800, PASS CODE: 755365

2. Gender-Based Violence, Health, and HIV Intersections and Implications for HIV Clinicians

3. Poll: Who is on the call today? 1.Local or State DV/SA Program 2.Health care provider (Primary, Women’s Health, etc.) 3.HIV Testing, Treatment and Care Provider 4.Other

4. Making the Connection: Gender-Based Violence and HIV 4

5. As a result of this activity, learners will be better able to: 1.Describe the intersection between gender-based violence and STIs/HIV. 2.Describe how gender-based violence can affect health and treatment outcomes for people living with STIs/HIV. 3.Identify strategies to assess for gender-based violence and respond appropriately to disclosures 4.List harm reduction strategies for partner HIV notification 5.Identify options for HIV prevention and risk reduction in the context of GBV Learning Objectives

6. Research shows us that violence is both a significant cause and a significant consequence of HIV infection among women. Judy Auerbach American Foundation for AIDS Research (AmfAR ) Research shows us that violence is both a significant cause and a significant consequence of HIV infection among women. Judy Auerbach American Foundation for AIDS Research (AmfAR ) “ 6 “

7. Understanding the Problem Gender-based violence increases the chance of becoming infected with HIV. Women are 2-5 times more likely than men to contract HIV from during heterosexual sexual intercourse. Can anyone tell me why? 7

8. (Decker et al, 2009; Gielen et al, 2007; Decker et al, 2005; Wingood et al, 2000; Campbell &Soeken, 1999) Victims of GBV are More Likely to be Infected Women and girls who are victims of GBV are 4 times more likely to become infected with STIs including HIV. Women who were beaten or dominated by their partners were 48% more likely to become infected with HIV than women in non-violent relationships. 8

9. Women disclosing physical abuse were 3 TIMES more likely to experience an STI. Women disclosing psychological abuse were 2 TIMES more likely to experience an STI. (Coker et al, 2000)

10. Men and Health Impact of IPV Men who have sex with men (MSM) are at higher risk for experiencing both HIV and intimate partner violence. Among men who had experienced intimate partner violence, there were higher rates of depression. 10 http://www.ncbi.nlm.nih.gov/pubmed/26222752 http://www.ajpmonline.org/article/S0749- 3797(08)00224-9/abstract

11. GBV and HIV Status Disclosure 24% of female patients experienced physical abuse after disclosing their HIV status and 45% feared such a reaction. 11 (Rothenberg K.H. et al, 1995)

12. Over half of women living with HIV have experienced GBV, considerably higher than the national prevalence among women overall (55% vs. 36%). (Machtinger, 2012; Black, 2011)

13. HIV AND GBV Among women who are experiencing GBV, women who are HIV-positive experience more severe violence and more frequent abuse compared to HIV- negative women. Review study by Gielen et al, 2007 13

14. Among a small sample of HIV-positive men: 39% reported physical intimate partner violence by a primary sexual partner 17% reported physical intimate partner violence by a casual sexual partner Shelton et al, 2005 14

15. HIV is a social disease with clinical implications The infection moves primarily through social and sexual networks Communities that are most marginalized by stigma and discrimination are also most vulnerable to HIV Clinical outcomes also reflect the prevailing inequities and health disparities It’s not just viral load! Why do we talk about co- occurrence of HIV and GBV? 15

16. Violence is a driver of the HIV epidemic 16 Violence and the threat of violence: interfere with women’s negotiating power introduces elevated risk, through coerced sex May increase risk taking behaviors, like transactional sex may be a more immediate threat than HIV May prevent access to treatment and care Increased vulnerability to HIV/STI infection, poor treatment outcomes

17. RISK REDUCING RISK REQUIRES AN INDIVIDUAL BEHAVIORAL SOLUTION VS. VULNERABILITY REDUCING VULNERABILITY REQUIRES STRUCTURAL SOCIAL CHANGE 17

18. GBV increases the risk for HIV infection through: 18 Sexual coercion/forced sex with an infected partner Limited or compromised negotiation of safer sex practices Increased sexual risk-taking behaviors, including survival and transactional sex Increased risk of mother-to-child HIV transmission among abused pregnant women Increased risk of unsafe injecting practices and coerced drug use Maman, S. et al. 2000. The intersections of HIV and violence: Directions for future research and interventions. Social Science & Medicine 50(4):459-478.

19. Pressuring a partner to have sex when the partner does not want to Forced or coerced non-condom use or not allowing other prophylaxis use Intentionally exposing a partner to an STI or HIV Threatening to tell friends or loved ones about HIV diagnosis Threatening retaliation if notified of a positive HIV result A range of behaviors that a partner may use to pressure or coerce a person to have sex without using physical force. Sexual Coercion 19

20. Knowledge Isn’t Enough Women with high STI knowledge who were fearful of abuse were less likely to consistently use condoms than nonfearful women with low STI knowledge. (Raiford et al, 2009) 20

21. GBV and Increased Sexual Risk Behaviors Women who have experienced past or current GBV are more likely to engage in high risk sexual behavior: Have multiple sexual partners Have a past or current sexually transmitted infection Report inconsistent use or nonuse of condoms Have a partner with known HIV risk factors Wu et al, 2003 21

22. GBV and Increased Sexual Risk Behaviors HIV-positive men and women who experienced GBV were more likely to engage in Bogart et al, 2005 22

23. Compromised Negotiation of Safe Sex HIV-positive women who experienced recent GBV were more likely to report: Inconsistent condom use Unplanned pregnancy Abuse stemming from requests for condom use Lang et al, 2007 23

24. Anal Intercourse and HIV Data show that where GBV is present, there is a higher rate of unprotected anal sex. Anal sex can be a part of a healthy sexual relationship, but it can also be used to degrade an individual particularly if they are not consenting to sexual activity. 24

25. Anal Intercourse and HIV Transmission Unprotected anal intercourse is a highly efficient means of HIV transmission – 18x greater risk relative to vaginal intercourse – Increased abrasions and lacerations that accompany anal sex can facilitate transmission – For people who engaging in anal sex in order to prevent pregnancy or because they have concerns around virginity and vaginal sex, the risk for HIV infection may be higher. 25 Baggaley, RF (2010) Grulich AE, Zablostka I (2010) Laura Duberstein Lindberg, Rachel Jones, and John S. Santelli, (July 2008

26. Condom non-use, including coercive condom non-use Sexual infidelity/concurrent partnerships More likely to have multiple sexual partners Injection drug use Unprotected anal intercourse Abuse perpetrators are more likely to engage in greater HIV risk behaviors: Perpetrator HIV risk 26 (Decker et al., 2009, Silverman et al., 2007; Dunkle et al., 2006)

27. Vulnerable Population: Sex Workers Sex work, transactional sex or economically motivated sex is not inherently a form of GBV The power dynamic implicit in the exchange of sex for money, drugs or necessities creates disproportionate vulnerability to GBV GBV and violence from other perpetrators are common among women involved in the sex industry, including sexual exploitation and economically motivated sex 27

28. Women involved in the sex industry, including those trafficked for sexual exploitation, suffer a high burden of HIV. GBV and sex work, sexual exploitation, and economically motivated sex Abusive partners can pressure women into sex trade as a means of control or obtaining scarce resources Sex trade as a means of escaping abusive relationships Violence from clients, police, and pimps is common, and significantly associated with increased HIV risk behavior and infection Lack of control around clients and condom use increases risk of infection 28

29. Vulnerable Population: Intravenous Drug Users Studies have found that violence increases women’s risk for initiation into injecting drug use, and the odds of intimate partner aggression are 3X greater when drug use is implicated.1 ~16% of new HIV infections among women are attributed to injection drug use2 Substance use and violence are considered bidirectional3 Vertical transmission rates among HIV positive women who use drugs are significantly higher than among HIV positive women without a history of drug use4 29

30. Violence, Injecting Drug Use and Sex work Significant overlap between women who engage in injecting drug use and sex work behaviors, particularly street-level sex work 1 Many female IDU are engaged in sex work regularly or occasionally, which increases HIV transmission risk 2 Transactional sex: female IDU have reported providing sex in exchange for housing, food and protection 1 30

31. Violence, Injecting Drug Use and Sex work Female IDU sex workers are at heightened risk of sexually acquired HIV due to: exposure to multiple sexual partners limited condom use (or forced non condom use) with partners 1 Female IDU sex workers are faced with significant health risks, high threats of violence, and high social marginalization. 1 31

32. Vulnerable Population: Men who have sex with men Approximately 26% of gay men report lifetime GBV 1 Recent studies have suggested that men who have sex with men (MSM) who experience GBV are more likely to be HIV positive than those not experiencing violence, and are more likely to 2 : – engage in substance use – suffer from depressive symptoms – engage in unprotected anal sex An Alabama study found that MSM who experience GBV also report feeling unable to negotiate condom use 3 32

33. Vulnerable Population: Transgender Communities Findings from a meta-analysis showed that 27.7% of transgender women tested positive for HIV infection. Of transgender individuals, 34.6% reported lifetime physical abuse by a partner and 64% reported experiencing sexual assault. Structural Inequity/Oppression -> Health Disparities Among newly diagnosed with HIV, 51% of trans women had documentation in their medical records of some combination of substance use, commercial sex work, homelessness, incarceration, and/or sexual abuse as compared with 31% of cisgender people. 33 http://www.cdc.gov/hiv/group/gender/transgender/ The Taskforce, 2014

34. Practice implications for HIV testing and counseling services 34

35. Victims are often isolated and not exposed to HIV prevention information Abusers may prevent victims from receiving medical care, which could negatively impact their health, limit their opportunities to receive information about HIV, and increase their risk of contracting HIV Clients may not be able to negotiate safe sex or safer injection practices with an abusive/coercive partner, which impedes ability to manage their own risk IPV may be a more immediate threat to a client than a sexually transmitted infection or HIV status IPV limits adherence to medication that might decrease viral load, which might increase the chances of transmission to others. GBV affects HIV prevention and risk reduction: Implications for HIV Programs 35

36. decreased women’s risk Receiving medical care decreased women’s risk of further sexual assault by an intimate partner by 32% 32%. (McFarlane et al, 2005)

37. Your Role is Important - DOABLE Providers do not have to be DSV experts to recognize and help patients experiencing GBV Ability to partner with local DSV agencies to support your work HIV testing and counseling offers a confidential, private and unique opportunity for education, early identification, risk reduction and intervention 37

38. Redefining screening NOT just a checklist, something that gets filled out and goes in the chart IS a conversation IS how a clinic is set up IS how providers are trained Move away from screening questions to universal education, assessment and brief counseling. 38

39. Getting Started: DO NO HARM Assessing for GBV can put your client in danger—always assess patients alone and not within earshot of a partner or family member Always disclose the limits of confidentiality before beginning any assessment Never use a family member or friend as an interpreter—use medically trained interpreters only You violate HIPAA reporting laws if you report something not mandated by law 39

40. Universal Education provides an opportunity for clients to make the connection between violence, health problems, and risk behaviors Strategies for HIV Programs 40

41. Safety cards can be ordered for a nominal shipping fee at: www.futureswithoutviolence.org/health/hiv Simple intervention tool and conversation starter: The Safety Card 41

42. Help survivors of violence and sexual coercion learn about risk, safety planning, harm reduction strategies and support services. Plant seeds for those who are experiencing abuse but not yet ready to disclose. Provide primary prevention for patients who have not been in this kind of relationship—so they can identify signs of an unhealthy relationship and ideally avoid them or help a friend who is experiencing abuse. This safety card is an evidence- based simple intervention and can take seconds to share with a patient. 42

43. How to Introduce the Card: "We’ve started giving this card to all our patients so they know how to get help for themselves or so they can help others." (Unfold card and show it) "It's kind of like a magazine or online quiz. It talks about respect, sex and how those things are connected to STDs and HIV." 43

44. The safety card lists specific questions related to condom negotiation and sexual coercion to help you assess for GBV and risk of HIV—always ask your patients if they feel afraid asking her partner to use condoms. After introducing the safety card, you can go over it and ask questions to assess for GBV and sexual coercion 44

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51. 51 Review the Resources Panel “On the back of the card are some phone numbers and websites, in case you or a friend ever needs information or support”

52. Using the Safety Card 1.Disclose limits to confidentiality! 2.Universal Education – Everyone gets this! Normalize activity: "I've started giving this card to all of my patients” 3.Open the Card - Do a quick review: "It talks about healthy sex and safe relationships" 4.Make the Connection - Create a sense of empowerment: “We give this to everyone so they know how to get help for themselves if they were to need it and so they can help a friend or family member.” 5.Hotline and/or Local Referral 52

53. Sample script to disclose the limits of confidentiality before asking about GBV: “Before I get started, I want you to know that everything here is confidential, meaning I won’t talk to anyone else about what is happening unless you tell me that you are being hurt physically or sexually by someone or planning to hurt yourself.” 53

54. Although most reported victims of GBV are female, clinicians should screen all clients regardless of gender, age or other demographic characteristics, the gender of their partner(s) or the relationship between the potential victim and abuser. GBV occurs in all communities and can be found in all types of relationships. Universal Education 54

55. Be sensitive to the fact that individuals who are GLBT who are requesting HIV testing may be in an abusive relationship Use gender neutral terminology when referring to partners Recognize that individuals who are GLBT may not identify or disclose as such Be aware of GLBT community resources Provider Tips Universal Education 55

56. Opportunities to introduce a discussion of GBV: At Intake/Pre-test Counseling During Risk Assessment During Sexual History Taking During Discussion of How Individual Might React to Testing HIV Positive Whenever Partners are Discussed During Safer Sex Discussions At Post-test Counseling 56

57. To begin asking about violence, normalize the conversation Discussion of violence concerns should be introduced in a general way, using simple statements such as: "There are some questions that I ask all my patients because some of them are in relationships where they are afraid their partners may hurt them, or they know someone who is in that kind of relationship.” This framing statement normalizes the conversation, a critical step to making clients feel more comfortable. 57

58. Recommended Practice: Integrating GBV assessment into HIV pre-test counseling Providers are encouraged to begin discussions of violence issues in pre-test counseling, as part of an overall discussion of support systems and what the client might anticipate if the test result is positive. 58

59. Post-test counseling: Another opportunity for assessment Post-test counseling provides an additional opportunity to talk about GBV issues, regardless of the test result. GBV screening can take place during post-test counseling, when you discuss partner notification—but should take place before partner names are elicited. "It is important to let your partners know they have been exposed to HIV so they can learn their own status and we hope you will help with this. First, however, I want to make sure that notifying your partners won't put you at risk. Nothing will happen to you if you decide it is not safe for us to notify this person.” “A next step would be to try to let your partner and other contacts know that they may have been exposed to HIV. Of course, it is very important to try to stop the spread of HIV and help people get health care as quickly as possible. When we make a notification, we do not tell them who may have exposed them or even anything about the type of exposure.” 59

60. Post-test counseling: Another opportunity for Assessment Assessment takes place on a partner-by-partner basis for any partners voluntarily identified and for any additional partners or spouses known to the provider: – "What response would you anticipate from this partner/ex-partner if he/she were notified of possible exposure to HIV?” Follow-up questions to explore a history GBV and anticipated consequences of HIV partner notification: – “Have you ever felt afraid of your partner or ex-partner?” – "Based on what you've just told me, do you think that the notification of this partner will have a severe negative effect on your physical health and safety, or that of your children or someone close to you?” – "Are you afraid of what might happen to you or someone close to you if this partner were notified?" 60

61. 61 REMEMBER: Disclosure is not the goal, and, Disclosures Happen!

62. Responding appropriately to disclosures of GBV and/or sexual coercion 62

63. Thank them for sharing this with you and convey empathy Validate that GBV and sexual coercion are health issues that you can help with Let them know you will support them unconditionally and without judgment When a patient discloses that they are experiencing GBV, sexual coercion, or is afraid to ask their partner to use condoms, first validate their experience. Listen and Validate 63

64. Validating Statements: I’m glad you told me about this. I’m so sorry this is happening. No one deserves this.” “You’re not alone.” “Help is available.” “I’m concerned for your safety.” Your recognition and validation of the situation are invaluable. 64

65. Supporting survivors: What NOT to say “you should call the police and make a report” “You are definitely in an abusive relationship” “That does not sound like rape to me…” “Your partner is crazy, you need to break up with them” “So what happened after that, and what happened after that?” 65

66. Offer support and harm reduction counseling that focuses on safety Give them a safety card to keep and review if it is safe for her to do so Ask patient if they has immediate safety concerns and discuss options Make a ‘warm referral’ to a local DSV advocate or community resource 66

67. “If you would like, I can put you on the phone right now with [name of local advocate], and we can come up with a plan for you to protect your safety.” When you can connect to a local program it makes all the difference. Providing a “Warm” Referral 67

68. Although there may not be previous incidents of severe violence, the notification of HIV exposure may spark an abusive reaction Notification may escalate serious verbal threats to physical violence or may increase the severity of preexisting abuse – Concern about escalation of violence as a result of partner notification might be a higher priority than their HIV status Other severe adverse outcomes may occur, such as loss of housing, withdrawal of financial support, custody retaliation or withholding access to health care or medications. – Know your state’s specific laws regarding partner notification – If the partner is in clinic with your patient today, assess for them for immediate safety and staff safety—determine if partner notification deferral is appropriate If patient has a positive test result, discuss strategies to promote safety around partner HIV notification Harm Reduction: Safer Partner Notification 68

69. If it is learned that a partner may be experiencing GBV, this information is crucial for protecting the partner from risk of violence related to HIV partner notification, and for deciding whether any public health follow-up in relation to that partner should proceed. Providers must be sensitive to a risk for violence against a partner when that partner is notified Harm Reduction: Screening of Partners/Contacts 69

70. Harm Reduction: Deferral of HIV Partner Notification Partner notification can be deferred if there is risk of behavior toward the HIV-infected individual which may affect their physical health and safety, his/her children, or someone who is close to them or to a partner/contact. 70

71. The information provided will be kept strictly confidential The confidentiality of HIV-related GBV information is protected by law and regulations That such protected information will be used only to help make decisions about whether partner notification should proceed and to offer referrals for domestic violence services In no cases are names of HIV-infected individuals provided to partners by public health staff HIV-infected individuals should always be assured that: Harm Reduction: Confidentiality 71

72. Prevention of HIV: Risk Reduction Moving down the risk ladder—providers are uniquely positioned to help patients evaluate risky behaviors and lower their risk of HIV by: – Educating patient on risky sexual behaviors and how they increase the likelihood of HIV infection – Educating patient on condom use and safe sex practices – Connecting patient to community resources When violence enters the picture, however, risk reduction becomes more complex. 72

73. Violence is a barrier to risk-reduction counseling, and providers must become more creative in how they help patients manage risk, safety, and treatment plans

74. Prioritize patient safety when assessing risky behaviors and creating a risk reduction plan, and always disclose limits of confidentiality Recognize that violence might be a more immediate threat than risk of HIV Educate patient on alternative contraceptive options other than the male condom Refer patient to local resources that will assist her in reducing risk behaviors and staying safe GBV and Risk Reduction 74

75. Risk Reduction and Safety Planning If a patient is experiencing GBV, making a warm, supported referral to a local DSV advocate provides the opportunity to integrate a risk reduction plan with safety planning – Improves their ability to avoid HIV exposure – Increases their physical safety when they use tactics to avoid risky sexual behaviors 75

76. Pre-Exposure Prophylaxis (PrEP) PrEP is an antiretroviral therapy regimen that can reduce the risk of HIV transmission before exposure – Meant for people who are at high risk of infection – Requires strict adherence – daily dosage Studies showed that the risk of contracting HIV was 92% lower for those who took the medicines consistently than for those who didn’t. Covered by most insurance programs 76

77. Post- Exposure Prophylaxis (PEP) PEP is an antiretroviral therapy regimen that can reduce risk for HIV after potential exposure – Should be used within 72 hours of exposure – Should not be used by people with frequently recurring exposure – Part of standard options for sexual assault survivors; less applicable for women experiencing chronic abuse Can be covered by insurance or accessed through the Office for Victims of Crime 77

78. Offer patients the use of your office phone to make the call Hotline Referral 78

79. Online Resource on Health and IPV www.healthcaresaboutipv.org Offers policy memos, patient and provider educational tools and resources. Contact Kate Vander Tuig: kvandertuig@futureswithoutviolence.org

80. Thank you!