Addressing the Intersection of HIV/AIDS, Violence against Women and Girls, & Gender Related Health Disparities

Transcription

1 Addressing the Intersectin f HIV/AIDS, Vilence against Wmen and Girls, & Gender Related Health Disparities Interagency Federal Wrking Grup Reprt September 2013

2 Backgrund In March 2012, President Obama issued a Presidential Memrandum creating an interagency Federal Wrking Grup (Wrking Grup) t explre the intersectin f HIV/AIDS, vilence against wmen and girls, and gender-related health disparities. The President underscred tw verlapping challenges t the health and well-being f cmmunities acrss the United States: the effects f HIV/AIDS, and the alarming number f wmen and girls wh experience vilence. The Memrandum highlighted the need t determine and address the barriers t care and preventin fr bth HIV and vilence t imprve the lives f wmen and girls. C-chaired by the White Huse Advisr n Vilence against Wmen and the Directr f the Office f Natinal AIDS Plicy, the Wrking Grup was tasked with explring ways t develp and implement evidence-based and culturally relevant actin steps fr Federal agencies. The Wrking Grup priritized addressing intimate partner vilence (IPV) because f its high verall prevalence amng wmen and girls, especially amng wmen living with HIV. Because the scpe f ur wrk was limited t dmestic effrts, ur fcus was n dmestic data and prgrams, althugh relevant lessns learned frm abrad were included in discussins. Als, because f the cnsiderable crss-agency wrk already underway t address the issue f human trafficking, the Wrking Grup did nt address this issue in its scpe f wrk. T infrm ur actin steps, the Wrking Grup cnducted an inventry f agency prgrams that address the intersectin f HIV/AIDS, vilence against wmen and girls, and gender-related health disparities; reviewed published studies that examined these intersecting issues within the United States; cnsulted researchers and representatives frm the Presidential Advisry Cuncil n HIV/AIDS (PACHA); and hsted pen webinars t slicit stakehlder input. This dcument charts a path frward t imprve cllabratin amng agencies by leveraging existing federal resurces in supprt f the health and wellbeing f wmen and girls, particularly thse living with r at high-risk fr HIV/AIDS and affected by r at high-risk fr vilence. While a majr fcus f the Wrking Grup s effrt is t encurage the scaling-up f interventins t link wmen affected by vilence and HIV t apprpriate services and care, it als recgnizes the need fr brader preventin effrts and research. This reprt utlines five cre bjectives fr actin: I. Imprve health and wellness fr wmen by screening fr IPV and HIV; II. Imprve utcmes fr wmen in HIV care by addressing vilence and trauma; III. Address certain cntributing factrs that increase the risk f vilence fr wmen and girls living with HIV; IV. Expand public utreach, educatin, and preventin effrts regarding HIV and vilence against wmen and girls; and V. Supprt research t understand the scpe f the intersectin f HIV/AIDS and vilence against wmen and girls, and develp effective interventins. Each bjective utlines cncrete recmmended actins fr federal agencies. These are nt a set f exhaustive actin steps, but a strng fundatin fr bth near-term actin and lng-term cmmitments. 2

3 Intrductin Addressing the dmestic HIV/AIDS epidemic and vilence against wmen and girls are Administratin pririties. Onging implementatin f the Natinal HIV/AIDS Strategy, cmbined with multiple effrts thrughut the Administratin t imprve the lives f wmen and girls, prvide many pprtunities fr meaningful actin. President Obama created the White Huse Cuncil n Wmen and Girls t ensure that federal agencies cnsider the needs f wmen and girls in plicies and prgramming, including vilence against wmen. As the riginal authr f the Vilence Against Wmen Act, Vice President Biden has fcused attentin n crdinating federal effrts t reduce dmestic vilence and sexual assault. Ntably, the 2013 reauthrizatin f the Vilence Against Wmen Act (VAWA) includes a new purpse area t prvide HIV testing, cunseling, and pst-expsure prphylaxis (PEP) fr survivrs f sexual assault. Hwever, the data belw reinfrce the need fr a sustained cmmitment thrughut the federal gvernment t address nt nly vilence against wmen and girls and HIV/AIDS, but als the intersectin f these tw issues. IPV is prevalent amng wmen and girls: ver ne-third (36%) f wmen in the United States have experienced rape, physical vilence, r stalking by an intimate partner in their lifetime; f these wmen, 69% reprted experiencing IPV 1 at age 25 r yunger, and 22% experienced IPV fr the first time between the ages f 11 and 17 years. 2 There is an nging need t address HIV/AIDS amng wmen and girls in the United States: apprximately 280,000 wmen in the United States were living with HIV in An estimated 15% f wmen living with HIV are undiagnsed, and nly 26% have the virus suppressed. 3,4 Of the estimated 47,500 new HIV infectins in the United States in 2010, 9,500 were amng wmen, with black and Latina wmen accunting fr ver three-quarters f cases amng wmen. 5 Greater than half f new infectins amng wmen during 2010 were amng thse aged 25 t 44 years. 6 Data supprt the need t address nt nly HIV/AIDS and IPV, but als their intersectin: Fr wmen living with HIV/AIDS, vilence is especially prevalent: in a metaanalysis, ver half f wmen living with HIV had experienced IPV, cnsiderably higher than the natinal prevalence amng wmen verall (55% vs. 36%). 7,8 1. The term "intimate partner vilence" describes physical, sexual, r psychlgical harm by a current r frmer partner r spuse. This type f vilence can ccur amng hetersexual r same-sex cuples and des nt require sexual intimacy. CDC. Intimate Partner Vilence: Definitins, Available at 2. Black, M.C., et al. The Natinal Intimate Partner and Sexual Vilence Survey (NISVS): 2010 Summary Reprt. Atlanta, GA: Natinal Center fr Injury Preventin and Cntrl, Centers fr Disease Cntrl and Preventin CDC. HIV Surveillance Supplemental Reprt. 2012; 18(2). Available at 4. Hall H.I., et al. Differences in human immundeficiency virus care and treatment amng subppulatins in the United States. JAMA Internal Medicine. 2013; 173(14): CDC. HIV Surveillance Supplemental Reprt. 2012; 17(4). Available at 6. Ibid. 7. Machtinger, E.L., et al. Psychlgical trauma and PTSD in HIV-psitive wmen: a meta-analysis. AIDS Behavir. 2012; 16(8): Black, M.C., et al. The Natinal Intimate Partner and Sexual Vilence Survey (NISVS): 2010 Summary Reprt. Atlanta, GA: Natinal Center fr Injury Preventin and Cntrl, Centers fr Disease Cntrl and Preventin

4 Vilence and HIV are particularly prevalent amng transgender wmen. A systematic review fund a mean f 58% f transgender wmen reprted vilence at hme, with a mean HIV prevalence f 28%. 9 Cmpared t wmen wh have nt experienced vilence, wmen with a histry f IPV are mre likely t reprt HIV risk factrs, including unprtected sex, injectin drug use and alchl abuse. 10,11 Wmen wh experience IPV are less likely than ther wmen t display high levels f self-efficacy fr HIV preventin, 12 and mre likely t miss health care appintments. 13 Amng wmen living with HIV/AIDS, trauma, abuse and vilence are assciated with less use f antiretrviral medicatin, decreased medicatin adherence, and 14, 15, 16 increased risk f death. HIV infectin may trigger r augment physical vilence, particularly against wmen; ne large study reprted that ver ne in five wmen living with HIV reprted physical harm since HIV diagnsis, with half f these events attributed 17, 18 t being HIV-psitive. The relatinship between tissue damage and HIV susceptibility emphasizes the imprtance f understanding hw genital tract injury assciated with sexual vilence can increase the risk fr HIV infectin. 19 Research suggests a synergistic relatinship between vilence and HIV that results in health utcmes wrse than either cnditin alne, referred t as a 20, 21, 22 syndemic relatinship. 9. Herbst, J.H., et al. Estimating HIV prevalence and risk behavirs f transgender persns in the United States: a systematic review. AIDS and Behavir. 2008; 12(1): CDC. Adverse Health Cnditins and Health Risk Behavirs Assciated with Intimate Partner Vilence --- United States, MMWR. 2008; 57(5): Available at Lang, D.L., et al. Rape victimizatin and high risk sexual behavirs: lngitudinal study f African-American adlescent females. Western Jurnal f Emergency Medicine. 2011; 12(3). 12. Villegas, N., et al. Predictrs f self-efficacy fr HIV preventin amng Hispanic wmen in suth Flrida. Jurnal f the Assciatin f Nurses in AIDS Care. 2013; 24(1). 13. Illangasekare, S., et al. Clinical and mental health crrelates and risk factrs fr intimate partner vilence amng HIV-psitive wmen in an inner-city HIV clinic. Wmen s Health Issues. 2012; 22(6). 14. Lpez, E.J., et al. Vilence, cping, and cnsistent medicatin adherence in HIV-psitive cuples. AIDS Educatin & Preventin. 2010; 22(1): Chen, M.H., et al. Medically eligible wmen wh d nt use HAART: the imprtance f abuse, drug use, and race. American Jurnal f Public Health. 2004; 94(7): Weber, K., et al. The effect f gender based vilence (GBV) n mrtality: a lngitudinal study f US wmen with and at risk fr HIV. Internatinal AIDS Cnference Gielen, A.C., et al. Wmen's lives after an HIV-psitive diagnsis: disclsure and vilence. Maternal and Child Health Jurnal. 2000; 4(2): Zierler, S. et al. Vilence victimizatin after HIV infectin in a US prbability sample f adult patients in primary care. American Jurnal f Public Health. 2000; 90(2): Klt J.F., et al. Greentree white paper: sexual vilence, genitanal injury, and HIV: pririties fr research, plicy, and practice. AIDS Research and Human Retrviruses. 2012; 28(11): Meyer, J.P., et al. Substance abuse, vilence, and HIV in wmen: a literature review f the syndemic. Jurnal f Wmen s Health. 2011; 20(7): Brennan, J., et al. Syndemic thery and HIV-related risk amng yung transgender wmen: the rle f multiple, c-ccurring health prblems and scial marginalizatin. American Jurnal f Public Health. 2012; 102(9): Schafer, K.R., et al. Intimate partner vilence: a predictr f wrse HIV utcmes and engagement in care. AIDS Patient Care and STDs. 2012; 26(6):

5 Furthermre, as described in the Natinal HIV/AIDS Strategy, Since mst infectins amng wmen ccur thrugh hetersexual sex, their risk is predicated n the risk behavirs f their male partners. This raises cmplex plicy and research questins, as negtiating safer sexual practices can be especially challenging fr wmen wh may be vulnerable t physical vilence, and emtinally r ecnmically dependent n men. 23 In respnse t these cmplex dynamics, in March 2012, President Barack Obama issued a Presidential Memrandum n the Intersectin f HIV/AIDS, Vilence Against Wmen and Girls, and Gender-related Health Disparities, and established an interagency Federal Wrking Grup devted t this issue. The Memrandum directed the Wrking Grup, cnsisting f members frm a diversity f Federal agencies, t imprve data cllectin, research, interventin strategies, and trainings, as well as t imprve cperatin between agencies and with external partners. Assessment The Wrking Grup fcused n interagency crdinatin and the develpment f evidence-based and culturally relevant actin steps. The Wrking Grup cnducted an inventry f agency prgrams that address the intersectin f HIV/AIDS, vilence against wmen and girls, and gender-related health disparities. A review f published peer-reviewed studies that examined vilence against wmen and girls in relatin t the dmestic HIV epidemic was als cnducted. T help infrm its wrk, the Wrking Grup hsted tw webinars that were pen t the public and where key stakehlders, cmmunity members, and ther individuals prvided input. Additinal public cmment was invited thrugh an nline submissin prcess. Tw research review cnsultatins were als held with academics and public health experts. Thrughut this prcess, the fllwing key questins guided discussin: What d we knw abut the relatinship between hw wmen and girls experience vilence and their risk fr HIV infectin? T what extent des vilence cntribute t pr health utcmes amng wmen and girls wh are living with HIV/AIDS? What are the majr barriers t identifying and reaching wmen and girls affected by HIV/AIDS and vilence? What are mdel prgrams and prmising practices t address the intersectin f HIV/AIDS and vilence against wmen and girls? What are the mst effective ways t prevent bth vilence and HIV infectin amng wmen and girls? What additinal research is needed t learn hw, where, and why vilence and HIV intersect and hw t best intervene? 23. White Huse Office f Natinal AIDS Plicy. Natinal HIV/AIDS Strategy fr the United States. July

6 Hw d we best respnd t gender-related health disparities with regard t HIV and vilence against wmen and girls? These disparities include: The higher rate f IPV amng wmen cmpared with men; 24 The higher rate f wmen, cmpared t men, f reprting subsequent impacts f vilence n their lives, including psttraumatic stress disrder (PTSD) symptms, injury, need fr healthcare, and need fr husing services; 25 Amng persns recently infected with HIV, the greater HIV-related mrbidity amng wmen cmpared t men; 26 The scial, ecnmic, and cultural cnditins that cause wmen and girls t be vulnerable t vilence, which cmpunds their risk fr HIV infectin; 27 The higher prevalence f vilence against wmen living with HIV, cmpared with men living with HIV, which may instigated by r wrsened 28, 29, 30 because f HIV-related stigma r fear. In cnsidering these key questins, the Wrking Grup identified bjectives and actin steps fr federal agencies t take t imprve the effectiveness f respnses t the cmplex intersectin f HIV/AIDS, vilence against wmen and girls, and gender-related health disparities. These actin steps will help meet the gals f the Natinal HIV/AIDS Strategy and are synergistic with the Administratin s additinal effrts t address vilence against wmen and girls. Objective 1: Imprve health and wellness fr wmen by screening fr IPV and HIV. Research indicates that IPV screening rates have been lw in health care settings, and mre than half f wmen aged 18 t 64 have never been tested fr HIV; mrever, HIV 31, 32, 33 testing rates amng wmen wh have experienced IPV als remain lw. 24. Black, M.C., et al. The Natinal Intimate Partner and Sexual Vilence Survey (NISVS): 2010 Summary Reprt. Atlanta, GA: Natinal Center fr Injury Preventin and Cntrl, Centers fr Disease Cntrl and Preventin Ibid. 26. Meditz, A.L., et al. Sex, race, and gegraphic regin influence clinical utcmes fllwing primary HIV-1 infectin. Jurnal f Infectius Diseases. 2011; 203(4), Garcia-Mren, C., et al. Glbal and reginal estimates f vilence against wmen: Prevalence and health effects f intimate partner vilence and nn-partner sexual vilence. WHO Press, Wrld Health Organizatin: Geneva, Switzerland Gielen, A.C., et al. Wmen's lives after an HIV-psitive diagnsis: disclsure and vilence. Maternal and Child Health Jurnal. 2000; 4(2): Zierler, S. et al. Vilence victimizatin after HIV infectin in a US prbability sample f adult patients in primary care. American Jurnal f Public Health. 2000; 90(2): Rthenberg, K.H., Paskey, S.J. The risk f dmestic vilence and wmen with HIV infectin: implicatins fr partner ntificatin, public plicy, and the law. American Jurnal f Public Health. 1995; 85(11): Waalen, J., et al. Screening fr intimate partner vilence by health care prviders. American Jurnal f Preventive Medicine. 2000; 19(4): CDC. Early Release f Selected Estimates Based n Data frm the 2012 Natinal Health Interview Survey, June Available at Nasrullah, M., et al. HIV testing and intimate partner vilence amng nn-pregnant wmen in 15 US states/territries: findings frm behaviral risk factr surveillance system survey data. AIDS Behavir. 2013; 17:

7 Implementatin f the Affrdable Care Act expands pprtunities t imprve these rates. New health plans were required t prvide cverage with n cst sharing fr screening all wmen fr IPV, and HIV testing and cunseling, fr sexually active wmen in plans beginning n r after August 1, Cverage als includes brief cunseling frm the health prvider shuld the patient screen psitive fr IPV. 34 Reinfrcing evidence-based supprt fr IPV screening was the United States Preventive Services Task Frce (USPSTF) January 2013 recmmendatin t screen all wmen f childbearing age fr IPV. 35 Additinally, in April 2013, the USPSTF revised HIV testing recmmendatins t include recmmending testing fr all adlescents and adults aged 15 t 65, 36 meaning that new health plans will als be required t prvide cverage with n cst sharing fr HIV screening fr all persns in this age range in plan years beginning April In additin t increasing screening in health care settings, prmting HIV/AIDS awareness and HIV testing is an imprtant part f cmprehensive care fr wmen wh have experienced vilence. 37 This can be dne, in part, thrugh leveraging the natinal netwrk f shelters and rape crisis centers. The netwrk f mre than 1,600 lcal dmestic vilence shelters and resurce centers fr survivrs f IPV funded by the Family Vilence Preventin and Services Prgram (FVPSP) serves nearly ne millin wmen each year. 38 This large ppulatin already expsed t vilence may represent a key demgraphic at increased risk fr HIV infectin. 39 Rape crisis centers als serve wmen wh may be at higher risk fr acquiring HIV infectin as a result f either recent sexual assault, r lng-term histries f sexual abuse and trauma-related risk factrs. Recmmended Actin 1.1: Increase IPV screening and HIV testing fr girls and wmen and encurage cncurrent screening. Actin steps: The Health Resurces and Services Administratin (HRSA) will prmte screening recmmendatins fr HIV and IPV in reprductive health, prenatal, and primary care settings and in prvider trainings with Federally Qualified Health Centers (FQHCs). The Substance Abuse and Mental Health Services Administratin (SAMHSA) will prvide Minrity AIDS Initiative Center fr Substance Abuse Treatment grant prgrams infrmatin n the imprtance f IPV screening, especially fr wmen and girls at risk fr r living with HIV, fr use in their HIV testing, screening, and referral activities. HHS Office f Ppulatin Affairs (OPA) will train staff f Title X-funded family planning clinics t explain the intersectin f HIV/AIDS, IPV, and family planning, 34. HRSA. Affrdable Care Act expands preventin cverage fr wmen s health well-being. Wmen s Preventive Services Guidelines, Available at USPSTF. Screening fr intimate partner vilence and abuse f elderly and vulnerable adults: U.S. Preventive Services Task Frce recmmendatin statement, 2013 Available at USPSTF. Screening fr HIV: U.S. Preventive Services Task Frce recmmendatin statement, Available at CDC. Fact Sheet: HIV Amng Wmen, March Available at Cmmunicatin with Family Vilence Preventin and Services Prgram, June Sareen J., et al. Is intimate partner vilence assciated with HIV infectin amng wmen in the United States?. General Hspital Psychiatry. 2009; 31(3):

8 and the imprtance f screening fr bth HIV and IPV, in rder t increase the numbers f wmen wh receive bth HIV and IPV screening, cunseling, and linkages t apprpriate fllw-up care in Title X family planning clinics. OPA will prmte USPSTF recmmendatins fr screening fr HIV and IPV in reprductive health clinics. The Veterans Health Administratin (VHA) will develp prtcls fr cscreening fr HIV, IPV, and military sexual abuse in an effrt t integrate individual screening recmmendatins. The Administratin fr Children and Families (ACF) Runaway and Hmeless Yuth prgram will prvide technical assistance t grantees n the need t prmte HIV testing fr yuth, with an emphasis n transgender wmen and girls and wmen and girls f clr, because research indicates these ppulatins are at high risk f hmelessness, vilence, and HIV. 40 ACF s Health Resurce Center n Dmestic Vilence will prvide resurces t infrm physicians, nurse practitiners, and cmmunity health care prviders abut screening recmmendatins fr HIV and IPV. HRSA will cllabrate with ACF t disseminate HIV and IPV screening and cunseling tls t Ryan White prgrams, FQHCs, rural health, maternal and child health prgrams, and Natinal Health Service Crps prviders. Recmmended Actin 1.2: Prmte HIV testing and linkages t medical care fr wmen and girls thrugh existing netwrks f dmestic vilence and rape crisis centers and advcacy rganizatins. Actin steps: The Centers fr Disease Cntrl and Preventin (CDC) will cnsult with FVPSP and the DOJ Office n Vilence Against Wmen (OVW) t develp culturally relevant campaigns t prmte HIV testing amng wmen and girls, with a particular fcus n serving black and Latina wmen and girls because f their increased risk fr HIV. OVW and CDC Divisin f Vilence Preventin will make this infrmatin available t the public and dmestic vilence shelters and rape crisis centers thrugh highlights n the website, VetVilence.cdc.gv, and scial media. The HHS Office n Wmen s Health (OWH) is cmpleting and will release Addressing The Link Between Vilence Against Wmen and Increased Risk f HIV: A Skills Enhancement Guide, which fcuses n educating and training vilence preventin casewrkers and prviders n the link between vilence and HIV/AIDS. It will be used t train dmestic vilence cunselrs t prmte HIV testing and HIV risk-reductin in their service delivery. The guide will als be 40. Herbst, J.H., et al. Estimating HIV prevalence and risk behavirs f transgender persns in the United States: a systematic review. AIDS and Behavir. 2008; 12(1):

9 used by AIDS service prviders wh will be trained t screen and refer clients t IPV services. CDC will cllabrate with the Institute n Dmestic Vilence in the African American Cmmunity, Casa De Esperanza, and ther federally funded institutes t reach at-risk wmen and girls experiencing vilence with culturally relevant infrmatin abut HIV testing and treatment. OVW will include infrmatin in future grant slicitatins abut the new purpse area in the VAWA grants prgram allwing grantees t use funds fr HIV testing, cunseling, and PEP fr survivrs f sexual assault. OVW will prvide funds t expand a curriculum n the intersectin f HIV and IPV, which includes e-learning mdules and incrprates a train-the-trainer apprach that prmtes safe strategies fr survivrs t access HIV testing; OVW will incrprate the curriculum int trainings and webinars fr grantees. CDC and the DOJ Office fr Victims f Crime will cllabrate with LGBT service rganizatins t identify methds fr reaching and linking transgender wmen wh have experienced vilence t IPV and HIV-related supprt services, including HIV testing. The HHS Natinal Resurce Center n Dmestic Vilence (NRCDV) will develp a cmpendium n HIV and IPV t include infrmatin n cllabratins, partnerships, and relevant screening tls fr prviders. NRCDV will then disseminate this infrmatin t all FVPSP grantees and thers via webinar. VHA will wrk with dmestic vilence, rape crisis, r ther apprpriate cmmunity rganizatins t ensure that wmen with HIV and IPV are linked t care in a timely manner and receive the services they need. Objective 2: Imprve utcmes fr wmen in HIV care by addressing vilence and trauma. Because IPV is prevalent amng wmen living with HIV, increasing IPV screening rates in this ppulatin may be especially imprtant and require special fcus within HIVspecific prgrams. Prgrams that prvide trauma-infrmed care as part f HIV/AIDS care fr wmen shuld be pilted and evaluated. Given that rates f clinical depressin and PTSD are higher amng wmen with histries f abuse, 41, 42, 43 culturally relevant prgrams that prvide supprt, teach healthy cping strategies, and ffer plans fr safety in crdinatin with a prescribed treatment plan fr HIV/AIDS may be vital t the attainment f ptimal health and wellness. A limited but grwing bdy f evidence als 41. Herbst, J.H., et al. Estimating HIV prevalence and risk behavirs f transgender persns in the United States: a systematic review. AIDS and Behavir. 2008; 12(1): Duttn, M.A., et al. Intimate partner vilence, PTSD, and adverse health utcmes. Jurnal f Interpersnal Vilence. 2006; 21(7): Glding, J.M. Intimate partner vilence as a risk factr fr mental disrders: a meta analysis. Jurnal f Family Vilence. 1999; 14(2):

10 44, 45 suggests that recent trauma amng wmen is assciated with HIV treatment failure, suggesting that addressing trauma may imprve HIV-specific utcmes amng wmen. Recmmended Actin 2.1: Screen wmen living with HIV fr IPV and link them t apprpriate services. Actin steps: FVPSP, OWH, HRSA, and ther relevant agencies will cllabrate t identify evidence-based screening, referral and linkage tls fr IPV fr wmen living with HIV. These agencies will prmte thse tls t dmestic vilence prgrams, rape crisis centers, and ther relevant cmmunity-based services. The HRSA Natinal HIV/AIDS Resurce Center will wrk with the Netwrk f AIDS Educatin and Training Centers t prmte use f these tls by HIV service prviders. FVPSP and OWH will develp and hst a webinar series that prmtes partnerships between health prviders and dmestic vilence prgrams that will include infrmatin n the abve tls OPA will include training n the intersectin f HIV/AIDS and IPV, including the imprtance f cncurrent HIV and IPV screening, at the December 2013 rientatin cnference fr the new grant cycle fr Integrating Rutine HIV Testing and Linkage t HIV Care and Treatment in Family Planning Services Grants. These grantees are family planning prviders that receive funding frm the Secretary's Minrity AIDS Fund and Title X apprpriatins. SAMHSA will encurage HIV grant service prviders t partner with primary health care prviders t cnduct screening fr trauma amng wmen living with HIV and prvide interventins directly r thrugh apprpriate referral and linkage. VHA will screen wmen living with HIV and IPV and link them t apprpriate services either within VA r the cmmunity. Recmmended Actin 2.2: Develp, implement, and evaluate mdels that integrate trauma-infrmed care int services fr wmen living with HIV. Actin steps: CDC and OWH, in cllabratin with HRSA and SAMHSA, will identify mdels that integrate trauma-infrmed care and safety planning int HIV services. 44. Machtinger, E.L., et al. Recent trauma is assciated with antiretrviral failure and HIV transmissin risk behavir amng HIV-psitive wmen and female-identified transgenders. AIDS Behavir. 2012; 16(8): Kalkhe, A.S., et al. Intimate partner vilence amng HIV-infected crack ccaine users. AIDS Patient Care and STDs. 2012; 26(4):

11 HRSA in partnership with the HRSA-SAMHSA Center fr Integrated Health Slutins, will prmte and share lessns learned frm these prgrams that integrate a trauma-infrmed apprach fr engaging and retaining wmen living with HIV/AIDS in care. HRSA will review and update the Guide fr HIV/AIDS Clinical Care t include a sectin addressing the need t prvide trauma-infrmed care t wmen and girls with HIV/AIDS wh disclse histries f IPV r ther abuse. HRSA will encurage the recruitment f dmestic vilence and sexual vilence preventin advcates t serve n State and lcal Ryan White Planning Cuncils. In an effrt t develp targeted interventins, HRSA will cnduct a webinar with grantees and key stakehlder grups t learn mre abut the needs f wmen living with HIV/AIDS wh have als experienced vilence and trauma. SAMHSA s Natinal Center fr Trauma-Infrmed Care (NCTIC) will prvide training and technical assistance n implementatin f trauma-infrmed care t publicly-funded systems, agencies, and prgrams that serve wmen living with HIV. SAMHSA will release a paper utlining key principles f and guidance n implementatin f trauma-infrmed appraches, including fr SAMHSA prgrams addressing the needs f wmen living with HIV. The dcument will als prvide a framewrk fr crss-agency dialgue and cllabratin. Objective 3: Address certain cntributing factrs that increase the risk f vilence fr wmen and girls living with HIV. While multiple factrs cntribute t vilence and HIV risk amng wmen and girls, the Wrking Grup fcused n tw areas: certain laws that may cntribute t increased stigma surrunding HIV/AIDS, and lack f stable, affrdable husing. Sme state laws require peple diagnsed with HIV t disclse their status t sexual partners, irrespective f actual transmissin risks. 46 These laws cntribute t a climate f fear and stigma that may increase the vulnerability f wmen living with HIV; while these wmen may experience vilence frm their partner if they disclse their HIV status, they may face criminal prsecutin if they d nt. 47 Mrever, wmen living with HIV and experiencing vilence are ften dependent n an abusive partner fr resurces, including husing. These barriers ften prevent wmen frm attaining the ecnmic independence needed t escape their abusers. 48 Studies 46. Lazzarini, Z., et al. Criminalizatin f HIV transmissin and expsure: research and plicy agenda. American Jurnal f Public Health. 2013; 103(8) There are currently 32 states that have criminal laws that punish peple fr expsing anther persn t HIV, even in the absence f actual HIV transmissin r even a meaningful risk that transmissin culd ccur. The Center fr HIV Law & Plicy. Chart: State-by-State Criminal Laws Used t Prsecute Peple with HIV, June Available at Muradian, V.E. Abuse in intimate relatinships: defining the multiple dimensins and terms. Natinal Vilence Against Wmen Preventin Research Center, Available at 11

12 shw that wmen wh experienced IPV were fur times mre likely t reprt husing instability as cmpared t wmen withut histries f abuse by an intimate partner. 49 Lack f stable husing is assciated with increased risk fr vilence amng wmen living with and at risk fr HIV, 50,51 and increasing husing stability thrugh prgrams such as Husing Opprtunities fr Persns with HIV/AIDS (HOPWA) is crrelated with imprved HIV-related utcmes. 52,53 While VAWA prvided new husing prtectins acrss HUD prgrams, such as preventing individuals frm being evicted frm r denied access t husing because they have experienced dmestic r sexual vilence, the Wrking Grup identified several additinal areas fr actin. Recmmended Actin 3.1: Assist states in prtecting wmen with HIV/AIDS frm vilence and retaliatin assciated with HIV status. Actin steps: DOJ will prvide technical assistance t states that seek t ensure that their HIV criminal laws accunt fr circumstances where disclsure f HIV status may subject the disclsing party t vilence, including IPV. DOJ will prvide technical assistance t states that want t ensure that their state hate crimes statute prvides prtectin t thse living with HIV/AIDS. OWH and FVPSP will strategize with state partners and ther relevant stakehlders t scale up effective strategies that address safety arund issues f disclsure fr wmen and girls testing HIV-psitive and living with HIV/AIDS. Recmmended Actin 3.2: Enhance federal effrts t address HIV and IPV amng hmeless and marginally hused wmen and girls. Actin steps: OVW will prvide training t its transitinal husing grantees abut serving wmen living with HIV/AIDS wh have experienced IPV. OVW, in crdinatin with HUD, will prvide training fr HOPWA prviders n respnding apprpriately t vilence against wmen. OVW will als advise n HOPWA s plans t address new VAWA husing prtectins. OVW will prvide guidance n the new prvisins in VAWA prhibiting discriminatin based n sexual rientatin r gender identity, including against transgender wmen, t OVW-assisted husing and shelters. 49. Pava, J., et al. Intimate partner vilence and husing instability. American Jurnal f Preventive Medicine. 2007; 32(2): Henny, K. D., Kidder, D. P., Stall, R., & Wlitski, R. J. (2007). Physical and sexual abuse amng hmeless and unstably hused adults living with HIV: prevalence and assciated risks. AIDS and Behavir, 11(6), Weir, B.W., et al. Vilence against wmen with HIV risk and recent criminal justice system invlvement: prevalence, crrelates, and recmmendatins fr interventin. Vilence Against Wmen. 2008; 14(8): Wlitski, R.J., et al. Randmized trial f the effects f husing assistance n the health and risk behavirs f hmeless and unstably hused peple living with HIV. AIDS and Behavir. 2010; 14(3), Buchanan, D., et al. The health impact f supprtive husing fr HIV-psitive hmeless patients: a randmized cntrlled trial. American Jurnal f Public Health. 2009; 99(S3): S

13 HUD will prvide infrmatin and training materials t HOPWA technical assistance prviders t increase their knwledge f the Equal Access Rule, which prhibits discriminatin based n sexual rientatin, gender identity, r marital status in HUD-assisted husing, as well as legal prtectins related t husing discriminatin fr persns living with HIV/AIDS. Objective 4: Expand public utreach, educatin, and preventin effrts regarding HIV and vilence against wmen and girls. Empwering girls with infrmatin abut their physical health and scial and emtinal wellbeing must cntinue t be part f a cmprehensive apprach t preventing and respnding t HIV/AIDS and vilence. In particular, reaching black and Latina wmen and girls shuld be a pririty, given their high risk fr HIV infectin. Research has shwn that an empwerment-based apprach t HIV preventin amng yung black wmen wh have experienced IPV reduces HIV risk. 54 A cmprehensive apprach must als include males, wh are mre likely t perpetrate abuse than females. 55 Cmbining existing mdels that engage men and bys t prevent IPV with initiatives that teach healthy relatinship skills, including HIV/AIDS preventin strategies, are an imprtant cmpnent f public educatin and utreach. Such mdels may als address scial and gender-specific nrms that encurage vilence. Recmmended Actin 4.1: Enhance vilence preventin prgrams, including thse targeting yuth, t address the intersectin f vilence and HIV/AIDS. Actin steps: OVW will include infrmatin abut the intersectin f HIV and dating vilence in the technical assistance prvided under the VAWA cnslidated yuth prgram. FVPSP technical assistance prviders cnducting yuth educatin n teen dating vilence will develp resurces t supprt educatin n HIV risks, safety strategies, and testing lcatins. SAMHSA will develp an ad hc wrking grup frm the trauma and HIV prgrams in the Center fr Substance Abuse Preventin, Center fr Substance Abuse Treatment, and Center fr Mental Health Services t address the intersectin f HIV/AIDS and vilence amng black and Latina wmen and girls. The gal f the wrking grup will be t develp language fr future preventin and treatment requests fr applicatins (RFA), as apprpriate, that address IPV and trauma as a risk factr fr HIV infectin. CDC will prvide infrmatin and resurces n the verlap between HIV and vilence against wmen and girls t calitins and cmmunities participating in the Dmestic Vilence Preventin Enhancement and Leadership Thrugh Alliances, Fcusing n Outcmes fr Cmmunities United with States (DELTA 54. Wingd, G.M., et al. Efficacy f an HIV preventin prgram amng female adlescents experiencing genderbased vilence. American Jurnal f Public Health. 2006; 96(6): Black, M.C., et al. The Natinal Intimate Partner and Sexual Vilence Survey (NISVS): 2010 Summary Reprt. Atlanta, GA: Natinal Center fr Injury Preventin and Cntrl, Centers fr Disease Cntrl and Preventin

14 FOCUS) prgram, fr their cnsideratin as they plan and implement their preventin strategies. Recmmended Actin 4.2: Engage men and bys in the preventin f HIV and vilence against wmen and girls. Actin steps: FVPSP-supprted resurce centers will crdinate with the HHS Office f Minrity Health t prvide fact sheets, tlkits, and training resurces t engage men and bys in preventing IPV. The centers will engage men in learning abut healthy relatinships thrugh the Linkage t Life prgram, which addresses health and scial barriers that cntribute t HIV/AIDS incidence amng high-risk racial and ethnic minrities. OVW will include infrmatin abut the intersectin f HIV/AIDS and dating vilence in the technical assistance prvided under the VAWA Engaging Men in Preventing Sexual Assault, Dmestic Vilence, Dating Vilence, and Stalking Prgram. Objective 5: Supprt research t better understand the scpe f the intersectin f HIV/AIDS and vilence against wmen and girls and develp effective interventins. While wmen living with HIV experience high rates f vilence, there is a need t better quantify the degree t which vilence is independently cntributing t new HIV infectins and pr HIV/AIDS care utcmes amng wmen and girls in the United States. Dmestic data are als lacking with regard t the efficacy and effectiveness f interventins that jintly address vilence and HIV utcmes amng wmen and girls. 56 This includes the rle f micrfinance interventins and ther ecnmic empwerment strategies. 57,58 Mre research is als needed regarding pssible syndemic relatinships f vilence, HIV/AIDS, and ther factrs that affect health and wellness. The rle f men and bys in preventing and addressing vilence als warrants further explratin. Recmmended Actin 5.1: Imprve ur understanding f hw t mst effectively address the intersectin f HIV and vilence against wmen and girls by analyzing data frm existing studies and prgrams. Actin steps: The Natinal Institutes f Health (NIH) will fund nging research n interventins fr IPV amng teens with a particular fcus n effective methds t decrease IPV and HIV risk behavirs amng males. 56. Wingd, G.M., et al. Imprving health utcmes fr IPV-expsed wmen living with HIV. Jurnal f Acquired Immune Deficiency Syndrmes. 2013; 64(1): Prnyk, P.M., et al. Effect f a structural interventin fr the preventin f intimate-partner vilence and HIV in rural Suth Africa: a cluster randmized trial. The Lancet. 2006; 368: Vyas, S., Watts, C. Hw des ecnmic empwerment affect wmen s risk f intimate partner vilence in lw and middle incme cuntries? A systematic review f published evidence. Jurnal f Internatinal Develpment. 2009; 21:

15 CDC will cnduct a systematic review t identify interventins that address the intersectin f HIV/AIDS and IPV amng wmen. This review will describe differences and similarities n demgraphic, behaviral, and interventin characteristics and utcmes between U.S. and internatinal samples f wmen. CDC will analyze and reprt data, including frm the Natinal HIV Behaviral Surveillance System and Medical Mnitring Prject, n the intersectin f IPV and HIV risk; and the prevalence f the use f, and unmet need fr, IPV services amng wmen living with HIV in care. NIH-spnsred HIV research chrts and clinical trials netwrks, including the Wmen s Interagency HIV Study, the HIV Preventin Trials Netwrk, the Micrbicides Trial Netwrk, and the Adlescent Trials Netwrk, are cllecting data n recent, past, and lifetime histry f vilence, including sexual vilence fr use in future analyses. HRSA s Office f Wmen s Health will analyze the data n vilence against wmen and girls and sexual vilence within the cntext f HIV risk, mrbidity, and mrtality, as well as natinal data surces n HIV/AIDS and vilence, and will reprt results in the annual Wmen s Health USA Databk. Recmmended Actin 5.2: Supprt and prmte research that will identify gaps and increase ur understanding f the relatinship between HIV and vilence against wmen and girls, and develp effective preventin and care interventins. Actin steps: The Fiscal Year (FY) 2014 Trans-NIH Plan fr HIV-Related Research includes the intersectin f vilence against wmen and HIV risk as a research pririty. The FY 2015 plan will als include sexual vilence and HIV risk as a research pririty. NIH supprts research prjects that study ecnmic strengthening appraches fr wmen living with HIV and vilence in sub-saharan Africa and ther regins. These mdels may be relevant fr wmen in the U.S. NIH will cntinue t supprt a number f studies t better understand the behaviral and bilgic relatinship between sexual vilence and HIV risk in wmen: As a result f recent discussins n IPV and HIV risk fr wmen, the Office fr AIDS Research funded three pilt prjects t demnstrate the bilgic link between sexual vilence and HIV risk. This pilt research will prvide the fundatin fr larger in-depth studies. The Natinal Institute f Allergy and Infectius Diseases (NIAID) Divisin f AIDS has issued a RFA entitled, Mucsal Envirnment and HIV Preventin, that will supprt studies t better understand the effect f the mucsal envirnment, including mucsal damage, n HIV acquisitin. This is critical t establishing the link between genital injury during sexual vilence and HIV risk. 15

16 The Natinal Institute f Child Health and Human Develpment (NICHD), in cllabratin with NIAID, has released an RFA fr studies that will lead t a better understanding f the intersectin f reprductive bilgy and HIV risk. As a result f this RFA, research will be cnducted in FY 2014 n the impact f envirnmental and physilgical factrs n sexual assault and HIV. The Natinal Institute n Alchl Abuse and Alchlism (NIAAA) will cnvene a wrkshp devted t the develpment f alchl-related HIV/AIDS preventin and interventin that will include discussing the intersectin f alchl use, vilence, and HIV risk behavir. The Natinal Institute f Mental Health (NIMH) will cntinue t supprt meritrius research grant applicatins devted t new studies n the intersectin f IPV and HIV risk. The fcus is n thse at risk fr HIV and thse living with HIV, with an emphasis n the develpment f interventins t reduce risk. CDC will expand research evaluating the effectiveness f plicies and strategies t prevent sexual vilence and IPV t determine whether strategies that reduce risk fr sexual and intimate partner vilence are als effective at reducing risk fr HIV. Fr example, the evaluatin f Dating Matters, a cmprehensive teen dating vilence preventin initiative, will include utcmes related t risk fr HIV. VHA will examine and analyze the prevalence f HIV amng veteran wmen that experience vilence and develp best practice and interventins t meet their needs. 16

17 Cnclusin The Wrking Grup will cntinue t meet n a regular basis t review prgress made implementing recmmended actins; identify and reslve barriers and delays; share lessns learned; and address emerging issues r cncerns. In apprximately 12 mnths frm the release date f these recmmendatins, the Wrking Grup will release an update describing which actin steps agencies accmplished and the status f actins yet t be cmpleted. The Wrking grup will cntinue t crdinate effrts with the White Huse Cuncil n Wmen and Girls and ther Administratin initiatives t address vilence against wmen and girls. Acrss the bjectives, the Wrking Grup supprts cntinued mnitring and evaluatin t build a strnger evidence base t effectively address HIV/AIDS and vilence against wmen and girls. Particular examples f where nging evaluatin and assessment are imprtant include prmting ecnmic security fr survivrs f vilence living with HIV/AIDS, and engaging men and bys t prevent vilence and prmte healthy relatinships. Areas fr pssible further actin include fcusing n structural factrs that cntribute t vilence and HIV risk; addressing hw substance use and mental health issues may synergistically cntribute t HIV risk and vilence against wmen and girls; and determining resiliency-related factrs that cntribute t wmen and girls vercming HIV-related stigma and the cnsequences f vilence. In clsing, a crdinate federal respnse t this cmplex issue is necessary, but is nt sufficient t maximize impact. A primary gal f the Natinal HIV/AIDS Strategy is achieving a mre crdinated respnse t the epidemic. Maximizing ur effectiveness in addressing HIV/AIDS and vilence against wmen and girls will take a similarly crdinated effrt acrss all levels f sciety. While the charge t the Wrking Grup was t develp recmmendatins fr specific federal actin, Wrking Grup members and participating agencies are encuraged t wrk with State, territrial, lcal, and tribal gvernments, the private sectr, faith cmmunities, service prviders, educatinal institutins, peple living with HIV, survivrs f vilence, and ther key stakehlders. Taken tgether, these cllective effrts will help us reach the gals f the Natinal HIV/AIDS Strategy and reduce vilence against wmen and girls. 17

18 List f Acrnyms ACA Affrdable Care Act ACF Administratin fr Children and Families (HHS) CDC Centers fr Disease Cntrl and Preventin (HHS) DOJ U.S. Department f Justice FQHCs Federally Qualified Health Centers FVPSP Family Vilence and Preventin Services Prgram (ACF) HHS U.S. Department f Health and Human Services HOPWA Husing Opprtunities fr Persns with AIDS (HUD) HRSA Health Resurces and Services Administratin (HHS) HUD U.S. Department f Husing and Urban Develpment IPV Intimate partner vilence LGBT Lesbian, gay, bisexual, and transgender NCTIC Natinal Center fr Trauma-Infrmed Care (SAMHSA) NIAAA Natinal Institute n Alchl Abuse and Alchlism (NIH) NIAID Natinal Institute f Allergy and Infectius Diseases (NIH) NICHD Natinal Institute f Child Health and Human Develpment (NIH) NIDA Natinal Institute n Drug Abuse (NIH) NIH Natinal Institutes f Health (HHS) NIMH Natinal Institute f Mental Health (NIH) NISVS Natinal Intimate Partner and Sexual Vilence Survey NRCDV Natinal Resurce Center n Dmestic Vilence (ACF) OVW Office n Vilence Against Wmen (DOJ) OWH Office n Wmen s Health (HHS) PACHA Presidential Advisry Cuncil n HIV/AIDS PEP Pst-expsure prphylaxis PTSD Psttraumatic stress disrder RFA Request fr applicatins SAMHSA Substance Abuse and Mental Health Services Administratin (HHS) USPSTF United States Preventive Services Task Frce VA U.S. Department f Veterans Affairs VHA Veterans Health Administratin (VA) VAWA Vilence Against Wmen Act f