HIV and Intimate HIV and Intimate Partner ViolencePartner Violence

Skills You Will Need When HIV Affects Women Exposed to Violence

August 22, 2009

Presented by:

Neena Smith-Bankhead, MSDirector, Department of Education and Volunteer Services

AID Atlanta, Inc.

"I have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas."

Neena-Smith-Bankhead, MS August 22, 2009

DisclaimerDisclaimer

Session OverviewSession Overview

At the end of this session, participants will be able to:

Discuss the relationship between intimate partner violence and HIV among women

Discuss HIV risk and prevention with women presenting to Community Service Agencies

Review how HIV prevention counseling is conducted, and provide other HIV-related services for women

Provide appropriate HIV care and prevention referrals for women exposed to violence

Women and HIV/AIDSWomen and HIV/AIDS

Women and HIV/AIDS Women and HIV/AIDS

Women and HIV Overview Women and HIV Overview

Women and HIV OverviewWomen and HIV Overview

Women and HIVWomen and HIV

Leading cause of Death for black women ages 25-34

Women are more than ¼ of all new HIV/AIDS Diagnoses

CDC, 2009

BODY FLUID + CUT = HIV BODY FLUID + CUT = HIV

Blood Semen

Vaginal FluidsBreast Milk

PiercingsCuts, Tears, or

Rips in SkinMucous

Membranes

More About Needle Sharing:

Steroid use

Tatooing

Drug Use

HIV HIV TransmissionTransmission

Unprotected sex (anal, vaginal, or oral) with infected partner

Sharing needles with someone with HIV

During pregnancy, birth, or breast-feeding from an infected mother

Getting a blood transfusion from a person with HIV

HIV Risk Factors for WomenHIV Risk Factors for WomenRISE Coalition Training Manual, 2009RISE Coalition Training Manual, 2009

PhysiologyLack of Control in Relationships

◦Communication with partner◦Lacking negotiation skills◦Infidelity in relationships

Socioeconomic IssuesRole as CaregiversSubstance Use and AbuseRecognition of risk in partnersPsychological Issues

Why Women Are At Additional Why Women Are At Additional RiskRisk

Sex with older, riskier men (younger women) who are less likely to use condoms

Trading sex for drugs or money – can make more when condoms are NOT used

Women, IPV and HIV Women, IPV and HIV

HIV Positive Women at increased risk of abuse◦Disclosing to partner may enhance or initiate

violence ◦Partner notification can put women at additional

riskWomen who are abused are at higher risk

of contracting HIV◦Substance use to cope◦Relationships with substance users◦Fear of requesting safer sex or saying ‘no’◦Rape or sexual assault

““Violet’s Violet’s Story” Story” told by told by an HIV an HIV Case Case ManagerManager

Challenges Addressing HIV in Challenges Addressing HIV in Hard-to-Reach CommunitiesHard-to-Reach Communities

Stigma◦Gay disease◦Substance users◦“BAD” people

Fear of Getting tested/HIV Test ResultsLack of Knowledge and Information about

HIV/AIDS and how it’s transmittedLack of Knowledge and Information about

HIV Care and Treatment Services

Considerations for Considerations for ProvidersProviders

Conducting Screening, Providing Prevention Counseling, and Making Referrals

When to Talk about HIV Risk?When to Talk about HIV Risk?

Agency/Service Intake◦Screen for risk behaviors◦Screening for abuse could indicate HIV Risk

activity as wellCase Management/Mental Health ServicesMedical Services

◦Examinations◦Sexual History◦Risk Assessment

Screening and AssessmentScreening and Assessment

Qualities of a Good Motivational Interviewer

Accurate Empathy

Respect

Warmth

Genuineness

Immediacy

Concreteness

Conclusive

Motivational Interviewing

HIV Prevention CounselingHIV Prevention Counseling

An intervention designed to help individuals make behavior changes that will reduce their risk of acquiring or transmitting HIV

CDC, 2008

HIV Prevention CounselingHIV Prevention Counseling

… communication, both verbal and nonverbal, made in response to and in the presence of feelings.

… “client-centered” — that is, it is tailored to the behaviors, circumstances, and special needs of the person being served

… not solving the client’s problem for her/him or giving advice; the counselor brings a set of skills to the interaction that can enable the client to reach a better understanding of the problem, deal with her/his related feelings and concerns, and assume responsibility for evaluating alternatives and making choices

CDC, 2008

Prevention Counseling StepsPrevention Counseling Steps

HIV Prevention Counseling Steps ◦Introduce and orient client to session◦Identify client risk behaviors and circumstances

◦Identify safer goal behaviors◦Develop action plan◦Make referrals and provide support◦Summarize and close the session

CDC, 2008

Step #1: Introduce and Orient Client to Session

Introduce selfExplain what will happen in this sessionAssess comfort and readiness to discuss

risk behaviors and activitiesConsent forms

CDC, 2008

Step #2: Identify client risk behaviors and circumstances

What risk activities is client engaging in and when are these activities likely to occur

Address triggers or vulnerabilities that lead to the client engaging in these activities (Circumstances)

CDC, 2008

Step #3: Identify safer goal behaviors

Discuss specific behaviors that directly prevent or greatly reduce HIV transmission; harm reduction

Discuss with client goals that they want to accomplish◦ With which partners◦ In what settings◦ Under what circumstance◦ During what time periods; how often

Address behaviors that client is likely to accomplish

CDC, 2008

Step #4: Develop Action Plan

Develop a realistic, specific action plan to help the client adopt the safer goal behavior◦Support the changes that have already taken

place or have been attempted◦Discuss contributing factors that support or

hinder ability to implement an action◦Discuss benefits and barriers to

implementing new behaviors

CDC, 2008

Step #5: Make Referrals

Refer to known and trusted resources

Ensure that the client can access the referral and help to eliminate any barriers

CDC, 2008

Step #6: Summarize and Close the Session

Briefly review highpoints of session, including action steps and referrals

Reminds the client of actions that they’ve decided on and agreed to try

List contracts or commitments for risk reduction, referrals, and next steps

CDC, 2008

Prevention Counseling Prevention Counseling

Assess practice and knowledge of current prevention strategies

Encourage methods of HIV prevention that can be used without partner’s participation

Communication strategies

Consider multiple prevention options, not only condom use (harm reduction)

Workshops/programs that address gender, power, and control in relationships

Counseling Concepts for Counseling Concepts for Prevention CounselingPrevention Counseling

Focus on FeelingsManage Your Own Discomfort

Set Boundaries

CDC, 2008

Basic Counseling SkillsBasic Counseling Skills

Open Ended Questions◦ Questions that require more than a ‘yes’ or ‘no’ response

Attending ◦ Attending means physically showing the client that you are

listening. This means using positive nonverbal communication. Offer Options, not Directives

◦ Often sets up a power struggle between counselor and client.◦ Can be avoided by giving the client firm control over change

decisions Give Information Simply

◦ use simple, non-technical words◦ be brief and to the point ◦ address client needs specific to their concerns◦ saying “I don’t know” is okay

CDC, 2008

HIV Counseling and TestingHIV Counseling and TestingN. Smith-Bankhead, 2009

HIV Counseling and TestingHIV Counseling and Testing

Rapid (15-20 minutes)Conventional Testing (1-2 Weeks)Free or DiscountedNon-Profit Agencies or Medical FacilitiesCommunity Settings for TestingBlood or Oral Solution

N. Smith-Bankhead, 2009

Assessing for Readiness for HIV Assessing for Readiness for HIV Counseling and TestingCounseling and Testing

What response would you anticipate from your partner if he or she were notified of possible exposure to HIV?

What would you do if you were diagnosed HIV positive/negative?

Who knows you are here? What Support systems do you have?

N. Smith-Bankhead, 2009

HIV Counseling and TestingHIV Counseling and TestingTips for Disclosing Tips for Disclosing

Disclosure and Partner Notification

Avoid exposing others to HIV without warning them ahead of time.

The risk of violence may be greater if a person feels you knowingly put them at risk or lied to them.

Disclose in a semi-public place like a public park with many people around. It's private enough to have a conversation, public enough to get help if you need it.

Consider disclosing with a third person present, like a friend or a health professional.

If you feel at all threatened by the reaction you get, keep meetings public for a few weeks.

The Well Project, Website, 2003-2006

Resources for HIV Resources for HIV Care/PreventionCare/PreventionTypes of Resources or Referrals Needed

Making ReferralsMaking Referrals

Effective Referrals

Help client define prioritiesDiscuss and offer options

Offer referralsRefer to known and trusted services

(MOU’s that outline duties)

Assess client response to referralFacilitate active referral Develop a follow-up plan(include referral sources in plan)

CDC, 2008

Best Practices for Resource Best Practices for Resource DevelopmentDevelopment

Connecting with National, Regional, and Local Coalitions and Collaboratives◦Helps to maximize access to resources available in your area◦Also provides hints and tips on how to place hard-to-place clients

Know the treatment and care philosophy of the agency being referred to

◦Ensure that the needs of your client can be met by that agency◦Very supportive vs. hard-line mentality

N. Smith-Bankhead, 2009

Best Practices for Making a Best Practices for Making a Referral Referral

Ensure that your client is ready to make change and accept your referral◦ You can’t force change if a person is not ready for it or willing to accept it◦ Transtheoretical Model (Stages of Change)

Precontemplation - lack of awareness that life can be improved by a change in behavior;

Contemplation - recognition of the problem, initial consideration of behavior change, and information gathering about possible solutions and actions;

Preparation - introspection about the decision, reaffirmation of the need and desire to change behavior, and completion of final pre-action steps;

Action - implementation of the practices needed for successful behavior change (e.g. exercise class attendance);

Maintenance - consolidation of the behaviors initiated during the action stage;

Termination - former problem behaviors are no longer perceived as desirable (e.g. skipping a run results in frustration rather than pleasure).

Care Services for HIV+ WomenCare Services for HIV+ Women

Case ManagementLegal AssistanceEducation/InformationMedical Care

◦ OB/GYN and STD CareHousing (especially if in DV situation)Mental Health Services

◦ Social/Emotional Support◦ PTSD/Trauma care

N. Smith-Bankhead, 2009

Case Management Case Management

Recognize risk activities and behaviors ◦Ask questions at intake and check in

throughout relationshipAssist client in coming up with a plan and

prioritizing needsConsider financial needs and resources -

financial empowerment of womenConsider childrenGet signed releases of information

N. Smith-Bankhead

Primary Medical CarePrimary Medical Care

During sexual history, ask questionsObserve for discomfort Get signed release of information for follow upDocument physical abuse or rape

◦Take pictures, write statements, police reports

N. Smith-Bankhead

Prevention ServicesPrevention Services

For HIV+ and HIV- Women◦ Workshops/Programs◦ One-on-One Prevention◦ Focus on behavior change; community

support; empowermentTesting

◦ For women and their partnersSTD Screening and Treatment for STDs

◦ For women and their partners

For More Information For More Information

SEATEC Key Contacts Booklethttp://www.seatec.emory.edu/keycontacts/

National AIDS Hotline 1-800-CDC-INFO (1-800-232-4636) TTY: 1-888-232-6348 Hours: 24 hours a day, 7 days a week E-mail: cdcinfo@cdc.gov

GA AIDS/STD Hotline1-800-551-2728

National Association of People With AIDS Hotline

1-240-247-0880Hours: Monday - Friday 9:00 am to 5:30 pm

(Eastern Time)

Thank You!Thank You!

Neena Smith-BankheadAID Atlanta, Inc.

Neena.smith@aidatlanta.org404-870-7747