Hit, kicked, slapped, bit, raped : Trauma, Intimate Partner Violence, and HIV Risk Among Incarcerated African American Women in North Carolina

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1 Hit, kicked, slapped, bit, raped : Trauma, Intimate Partner Violence, and HIV Risk Among Incarcerated African American Women in North Carolina Claire Farel, MD, MPH UNC-Chapel Hill

2 Background HIV disproportionately affects African American women in the Southeastern U.S. 1-3 For reasons not completely understood, women who have been in prison carry a greater lifetime risk of HIV. 4 HIV is five times as prevalent among incarcerated African American (AA) women in North Carolina (NC) as among their unincarcerated AA counterparts. 5,6

3 Background Trauma, Women, and HIV Sexual and physical abuse are important contributors to sexual risk behavior and specifically HIV risk. 7-9 Childhood sexual abuse (CSA), intimate partner violence (IPV), and resulting psychological trauma play a central role in the lives of incarcerated HIV-positive and at-risk women

4 Methods Parent study designed to explore the differences in HIV risk factors between HIV-positive and HIVnegative women in prison in NC. Audiotaped qualitative interviews conducted with 29 AA women (15 HIV-positive, 14 HIV-negative) by two interviewers. Interviews explored potential pre-incarceration HIV risk factors on multiple levels. Participants were interviewed within three months after entry into the NC prison system.

5 Results Participant characteristics HIV-positive (n=15) HIV-negative (n=14) Total (n=29) Mean age in years (range) 37.8 (24-60) 29.9 (19-41) 34.0 (19-60) Participants born in NC 12 (80%) 13 (93%) 25 (86%) Mean number prior NC incarcerations (range) 3.8 (1-9) 1.9 (1-8) 2.9 (1-9) Mean years of school Completed 12 th grade or GED 8 (53%) 12 (86%) 20 (69%)

6 Results HIV-positive (n=15) HIV-negative (n=14) Total (n=29) Childhood sexual abuse 8 (53%) 9 (64%) 17 (59%) (CSA) 1 Intimate partner violence (IPV) 9 (60%) 9 (64%) 18 (62%) IPV with >1 partner 5 (33%) 4 (29%) 9 (31%) IPV and CSA 4 (27%) 6 (43%) 10 (34%) Other sexual violence 2 7 (47%) 3 (21%) 10 (34%) Other nonsexual violence 4 (27%) 6 (43%) 10 (34%) Transactional sex ever 10 (67%) 4 (29%) 14 (48%) Crack cocaine use ever 13 (87%) 5 (36%) 18 (62%) 1. Defined as unwanted sexual experiences under the age of Non-IPV, non-csa sexual violence

7 Lifelong violence: A 48-year-old HIV-positive woman Hit, kicked, slapped, bit, raped all of it. I think if you name it, I ve been it. I grew up being abused, so after a while, you get sort of kind of used to it. It s like a pattern. It seem like, in my life, that s all I attract, abusive men. I never had nobody nice to me growing up. I never had nobody did anything for me.

8 Lifelong violence: A 33-year-old HIV-positive woman Whenever I was at my mom s house whenever I did stay the night there [her boyfriend] would just it was always touching and I was very young at that time, and the last time he molested me, I was nine. Yeah, and I got raped one time in Myrtle Beach by three guys. I think I was about 13 then. And, again, when I was 13, I met this [33-yearold] man, and I lived with him for two years. And I didn t know that he was paying my mom in drugs at the time for her not to call the police. Childhood sexual abuse Betrayal and abuse at the hands of adults and caregivers Older partners

9 Lifelong violence: A 33-year-old HIV-positive woman Substance abuse Transactional sex Betrayal and abuse at the hands of adults and caregivers Older partners Intimate partner violence I ran away and went to this lady s house I just felt very alone, and I ended up gettin high. I had money, and she was an addict she started bringin guys to the house And she d always tell me, You don t have to do nothin, But one time, it didn t work, and I ended up gettin raped, and I never did that again. I was 17. He was 35, and drugs were involved crack cocaine and alcohol, and I don t even remember why we used to fight I looked like the elephant woman. as soon as my face healed, I left him.

10 Results: CSA CSA was reported by 59% of women in this cohort, with repeated episodes of unwanted sexual contact prior to age 18 reported by many. Consistent themes included substance use by parents or caretakers, much older partners, and unsuccessful attempts to report abuse or establish protection from attacker.

11 A 19-year-old HIV-negative woman And my mama owed [him] some money, and [he] raped me. And when I told my mother she didn t believe me. And my daddy, he didn t believe me either; they said that I was lying. And I wasn t lying; he really did. Yeah my mama, she was on drugs and I felt like she had let people touch us for drugs You know she was just high to the point and she d leave us in the room. And men would come in there and stuff. A 33-year-old HIV-negative woman

12 Results: IPV Intimate partner violence (IPV) was common among both HIV-positive and HIV-negative women with 9 women enduring both CSA and IPV. Many suffered repeated violence and lifethreatening injuries from partners or caregivers. Many participants described few alternatives to these situations given limited economic means and social support.

13 Results: Lifelong Violence Most women described a lifetime marked by traumatic violence and abuse and expressed a desire to process these experiences. Illegal drug use starting at a young age contributed to women s experience of violence/abuse Drugs were used as a coping mechanism in surviving traumatic events. Crack cocaine use was especially pervasive among the HIVpositive group. Transactional sex (TS) work (sex for money, drugs, or survival) was closely linked to crack cocaine use, particularly among the HIV-positive women. Both crack use and TS presented opportunities for violence in the lives of these women.

14 Conclusions The legacy of trauma was significant and pervasive in this vulnerable population of HIV-positive and HIVnegative women. Prison represents an opportunity for specific trauma screening in a high-risk population to break this cycle. The intersection of lifetime trauma with substance abuse and lack of agency and economic power underscores the need for integrated interventions in this population to decrease HIV risk and improve community health.

15 Acknowledgements Sharon D. Parker Kathryn Muessig Catherine Grodensky Chaunetta Jones Carol Golin Cathie Fogel David A. Wohl The North Carolina Department of Correction Wardens and staff of the study facilities Study participants The University of North Carolina CFAR The UNC CFAR Criminal Justice Working Group This project was supported by the NIH (F32 DA ). Additional support was provided by the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410).

16 References 1. Prejean J, Song R, Hernandez A, Ziebell R, Green T, Walker F, et al. Estimated HIV incidence in the United States, PloS One. 2011;6(8):e Hodder S, Hughes JP, Wang J, Haley D, Adimora A, et al. The HPTN 064 (ISIS Study) HIV Incidence in Women at Risk for HIV: US. Poster presented at: The 19th CROI Greenfeld LA, & Snell, T. L.. Women offenders (Bureau of Justice Special Report NCJ ). Washington, DC: Department of Justice Staton-Tindall M, Leukefeld C, Palmer J, Oser C, Kaplan A, Krietemeyer J, et al. Relationships and HIV risk among incarcerated women. Prison J. 2007;87(1): N.C. Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) 6. DOC RESEARCH AND PLANNING Automated System Query (A. S. Q. DOC 3.0b ) Prison Population Campbell JC, Baty ML, Ghandour RM, Stockman JK, Francisco L, Wagman J. The intersection of intimate partner violence against women and HIV/AIDS: a review. International journal of injury control and safety promotion. 2008;15(4):

17 References 8. Pence BW, Mugavero MJ, Carter TJ, Leserman J, Thielman NM, Raper JL, et al. Childhood Trauma and Health Outcomes in HIV-Infected Patients: An Exploration of Causal Pathways. Journal of acquired immune deficiency syndromes (1999). 2012;59(4): Kimerling R, Calhoun KS, Forehand R, Armistead L, Morse E, Morse P, et al. Traumatic stress in HIV-infected women. Aids Educ Prev. 1999;11(4): Machtinger EL, Wilson TC, Haberer JE, Weiss DS. Psychological Trauma and PTSD in HIV-Positive Women: A Meta-Analysis. AIDS and behavior Whetten K, Leserman J, Lowe K, Stangl D, Thielman N, Swartz M, et al. Prevalence of childhood sexual abuse and physical trauma in an HIV-positive sample from the deep South. American journal of public health. 2006;96(6): Harlow CW. Prior Abuse Reported by Inmates and Probationers. Washington,DC: U.S. Department of Justice, Bureau of Justice Statistics Slide background: Marc Soller/Flickr

HIV and Incarceration: Dual Epidemics

HIV and Incarceration: Dual Epidemics David A. Wohl, MD Site Leader. UNC AIDS Clinical Trials Unit at Chapel Hill Co-Director of HIV Services for NC Department of Public Safety Take Homes Incarceration