EFFECTS OF INTIMATE PARTNER VIOLENCE AND MENTAL HEALTH ON HIV DISEASE PROGRESSION IN WOMEN
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Background: Intimate partner violence (IPV) has the ability to negatively impact the lives of women living with HIV through decreased adherence, increased mental health symptoms and substance use and through physiologic responses to chronic stress. Objectives: This study addressed three specific aims: 1) To determine the prevalence of IPV in a sample of women attending an urban HIV clinic; 2) To examine the association between IPV and HIV treatment and adherence markers, including potential mediating effects of mental health symptoms; and 3) To explore participants’ perceptions of the impact of IPV on their HIV care. Design and Methods: This explanatory sequential mixed-methods study had two phases. Phase 1 included collecting survey data and medical records data from women receiving care at an urban HIV-specialty clinic. Phase 2 consisted of semi-structured in-depth interviews with a sub-set of women who reported IPV on survey measures. Sample: In total, 239 women completed IPV measures and had available medical records data. Nine of these women also participated in Phase 2 interviews. Results: Past year IPV was highly prevalent in the sample (51%; 95% CI: 45–58). In bivariate analysis IPV was independently associated having a CD4 count <200 (OR: 3.284; 95% CI: 1.251-8.619; p=0.016) and a detectable viral load (OR: 1.842; 95% CI: 1.006-3.371; p=0.048), but not with missing >25% of past year scheduled clinic visits. The association between CD4 count and IPV maintained its significance when controlling for demographic variables, substance abuse and symptoms of PTSD and depression (OR: 3.536; 95% CI: 1.114-11.224; p=0.032). Qualitatively, women’s focus in managing their HIV care included two main themes: (Re)establishing identity and managing labels and “I know what I’m suppose to do.” Being a mother or caregiver was seen as an important role that women took on, and as such it often impacted their health care decisions. Participants readily identified with this label and placed in as central to their identities and adherence. They were however resistant to accept the label of “victim/survivor” of IPV. They largely minimized the quantity and severity of violence when compared to what was reported on survey measures, and did not identify IPV as a primary barrier to HIV care. Conclusion: Our findings highlight two primary areas for future research. First, the association between IPV and a low CD4 count when controlling for demographic, behavioral and viral load measures indicates the potential for a physiologic pathway between trauma, including IPV and poorer immune functioning. Further research to identify the specific mechanisms of this pathway is needed in order to establish appropriate biobehavioral interventions. Secondly, the discordance between reported IPV on survey measures and during qualitative interviews indicates that while the relationship between IPV and poorer HIV outcomes may exist quantitatively, women are not identifying IPV as a primary driver of their adherence or health care. Future research including should include qualitative components to understand women’s perceptions of IPV, how these perceptions change over time and how best to design interventions tailored to addressing the complex needs of this patient population. In clinical practice, trauma-informed care models that focus on promoting safety and providing resources for all patients regardless of specific disclosures may begin to address the impact of IPV on HIV treatment outcomes.