Abstract
HIV and intimate partner violence (IPV) epidemics propagate and interact in a syndemic fashion contributing to excess burden of disease and poorer health outcomes. In order to understand the impact of IPV on HIV disease management, a universal screening program was implemented in the Southern Alberta Clinic in May 2009. We evaluated our IPV screening protocol and made recommendations for its usage in HIV care. IPV data obtained from patients were evaluated, supplemented with responses from a subset of in-depth interviews. 35% of 1721 patients reported experiencing IPV. Prevalence was higher among females (46%), Aboriginal Canadians (67%), bisexual male/females (48%), and gay males (35%). Of 158 patients interviewed, only 22% had previously been asked about IPV in any health care setting. Patients were responsive to routine IPV screening emphasizing that referral services need to be easily accessible. 23% of patients disclosing IPV subsequently connected to additional IPV resources after screening. We recommend that universal IPV screening be incorporated within regular HIV clinic care. The IPV survey should be given after trust has been established with regular follow-up every 6–12 months. A referral process to local agencies dealing with IPV must be in place for patients disclosing abuses.
Introduction
I
The negative health effects of IPV are varied with mental, 9,10 reproductive, 11,12 and physical 13 –15 health implications. Individuals experiencing IPV have an increased rate of depression and a higher risk of suicide. 16,17 IPV induces the physiological stress response leading to interconnected neural, neuroendocrine, and immune responses, which may exacerbate other conditions such as control of cancer and viral infections such as HIV/AIDS. 18 –22
IPV and HIV infection are syndemic. 23 –27 Not only are victims of IPV more vulnerable to acquiring HIV infection, but also the presence of IPV negatively impacts their HIV care by delaying access to diagnosis and subsequent engagement in care, missed clinical appointments, non-adherence to antiretroviral therapy, increased all cause hospitalizations, and progression to AIDS. 28 –31 The presence of HIV infection may increase the risk of subsequent IPV within a relationship. 32,33 Identifying HIV patients, who have suffered or are suffering from the effects of IPV, offers the potential for mitigating its negative effects on both their general as well as HIV health.
Past research on IPV and HIV infection has primarily focused on understanding the synergistic interactions between violence and HIV, 34 determining the prevalence of IPV within different populations, 28,29,35 –39 expanding HIV prevention services to address IPV education, 40 and expanding IPV prevention services to address STI/HIV education. 41 –44 However, the best practices for implementing a continuous universal IPV screening protocol within a HIV clinical care setting has not yet been fully developed.
Routine screening for IPV has been introduced in family medicine, 45,46 emergency department, 47,48 prenatal care environments, 49 –51 and HIV care centers 26,52 with mixed results. Reported barriers to disclosure of IPV voiced by patients have included the fear of increasing violence from partners and a lack of sensitivity of the health care workers to deal adequately with IPV issues in a clinical setting when IPV issues are presented. 53,54 Health care workers themselves have noted a lack of their own knowledge and education surrounding IPV, and how to best manage IPV within a clinical setting with respect to the resources available after IPV is identified (e.g., community or in house resources). 55 In New York, while the majority of counselors and physicians agreed that adverse health outcomes could be prevented if IPV screening became routine, physicians were much more likely to feel uncomfortable with IPV screening than counselors. 52 In San Francisco, one study reports while IPV screening in HIV was felt to be important, no consistent protocols were in place for such screening. 26
In 2009, the Southern Alberta HIV Clinic (SAC) implemented a standardized IPV screening protocol within its regular practice that provides screening for childhood, past, and/or current IPV. In this study, a sample of previously identified IPV-affected and non-affected patients gave in-depth interviews to determine from their perspective, the best practices for screening IPV in an HIV care center. Using our program's 5 years of experience, and the patients' responses on the screening program, we have developed a set of recommendations for the introduction of routine IPV screening into regular HIV care. Identifying and understanding IPV among HIV infected patients, and then providing both empathy and access to appropriated resources is important if the negative syndemic of HIV infection and IPV is to be addressed and lead to improved well being and health.
Methods
Study population and setting
The Southern Alberta HIV Clinic (SAC) is the exclusive provider of outpatient multidisciplinary care to all HIV positive adults living in southern Alberta, Canada. Extensive sociodemographic and clinical data are collected on an ongoing basis including gender, sexual orientation (homosexual, heterosexual, bisexual), ethnicity (Caucasian, Aboriginal Canadian, black, other), age at HIV diagnosis, and HIV risk factor (MSM, men having sex with men; MSW, men having sex with women; WSM, women having sex with men; IDU, intravenous drug use; and other). In May of 2009, a protocol 29 was initiated by the consensus of the health care workers to screen all adult HIV-infected patients attending a routine clinic visit for their IPV experience either during childhood or as an adult. All patients were eligible to be screened except when a significant language barrier, superseding medical issue, or failure to isolate a patient from a partner precluded screening on that occasion.
Following a preamble defining IPV, a registered nurse or a social worker asked the patient about any history of abuse. A standardized form was used to help guide the conversation and for documentation. Patients disclosing IPV were advised of the resources immediately available within the clinic (including an in-house social worker) and/or within the community (e.g., safe housing). Patients were only screened once if they reported no IPV. Patients disclosing IPV were subsequently asked about their IPV status as deemed clinically appropriate on a case-by case basis at their routine visits.
Evaluating the IPV screening protocol
To assess and strengthen the IPV screening protocol, we then conducted a qualitative follow-up study using a sample of 158 patients previously screened for IPV and who attended a regular clinic visit (i.e., ‘study participants’) between June 1 and July 31, 2014. After informed consent was given, patients were initially asked a series of nine questions by a researcher (SER) to gain their insight into optimizing the IPV screening program in our HIV clinic. Two additional questions were introduced following participant feedback after about one-third of the surveys were completed (Table 1). Participation was voluntary.
Questions were asked to previously screened patients at the Southern Alberta Clinic (SAC) in order to evaluate the IPV screening protocol
The participants' responses were data entered, coded, and analyzed using their sociodemographic and clinical characteristics derived from the SAC database. The survey and use of non-nominal demographic and clinical data has been approved for research purposes by the University of Calgary Ethics Committee. All data were analyzed using a chi-squared test using p<0.05 as the level of significance.
Results
SAC patient population and IPV
Between May 2009 and August 2014, 1769 of 2153 (81%) patients who attended at least one regular clinic visit were screened for IPV; of these 48 patients started but did not complete the IPV screen. The prevalence of IPV and the demographic characteristics of the remaining 1721 screened patients are listed in Table 2. Overall, 605 (35%) reported experiencing IPV either currently, or in past relationship, or as a child, or a combination of these. The prevalence of IPV was higher in females than for males (46% vs. 32% respectively; p<0.0001). Patients diagnosed with HIV at a younger age (i.e., ≤30 years of age) reported IPV more frequently than individuals who were diagnosed between 30 and 45, or >45 years of age (41% vs. 32% vs. 30%, respectively; p<0.0001). Females had a higher prevalence of IPV experiences in all three age categories. Two-thirds (67%) of Aboriginal Canadians reported experiencing IPV; the prevalence among Aboriginal females was 81%. Patients self-reporting as ‘black’ (95% were born in sub-Saharan Africa) reported the lowest incidence of IPV at 20% overall compared to 38% of Caucasians. Patients with IDU were more likely than patients with MSM or MSW/WSM as their HIV risk factor to report IPV (54% vs. 35% vs. 31% respectively; p<0.001). Bisexual male and females had the highest prevalence of IPV (48%); 17 of 17 (100%) females who self-reported as bisexual stated they had experienced IPV. Homosexual males had higher rates of IPV than heterosexual males (35% vs. 25%; p<0.01). Forty-four percent (44%) of heterosexual females screened positive for IPV.
Screening at Southern Alberta Clinic (SAC) between June 30, 2009 to July 31, 2014. Approximately 81% of all patients (n=2153) who attended at least 1 routine clinic visit at SAC during this time period completed the IPV screen.
IPV+ indicates that patients stated they had experienced IVP either in their current or past relationship or as a child. c95% of black patients were born in sub-Saharan Africa; 3% were born Caribbean countries; 2% were born in Canada or the United States. dIncludes 18 patients from East Asia; 76 from Indo-Asia, 42 from Central/South America, and 19 from other countries. eIDU, intravenous drug use; IPV, Intimate Partner Violence; MSM, men having sex with men; MSW (men having sex with women)/WSM (women having sex with men), heterosexual sex; SAC, Southern Alberta Clinic.
Patient feedback on the IPV screening process
Between June and August 2014, 179 patients previously screened for IPV were approached to provide their insights and perspectives into the IPV screening protocol. Thirteen patients declined to complete the survey, and 8 declined due to language issues. One hundred and fifty eight (n=158) were interviewed; 103 had experienced IPV.
Despite belonging to demographic groups well known to be at increased risk for IPV and where IPV screening is recommended, only 22% of interviewees recalled ever being asked about IPV by any healthcare provider prior to the screening in the HIV program (Table 3, Question #11). Patients who had been abused reported a slightly higher rate (26% vs. 15%) of being asked than patients never abused.
IPV, Intimate Partner Violence; SAC, Southern Alberta Clinic; Responses made via face to face interviews between June 1 and July 31, 2014.
IPV+, patients had previously stated they had experienced IPV. cIPV−, patients had previously stated they had not experienced IPV. dParticipants were able to provide more than one answer. eOnly 120 of 158 participants were asked this question. fOnly 96 of 158 participants were asked this question.
Nearly three-quarters of interviewed patients (73%) indicated that IPV should be discussed routinely as an integral part of HIV care (Question #1). Over half of respondents (53%) recommended delaying routine initial screening for IPV until >2 clinic visits after initiating HIV care in order to establish trust (Question #2). The establishment of a “trust relationship” was cited as being a critical factor for successful questioning. No clear preference for the specialty of the health care worker (i.e., clinician, nurse, or social worker) inquiring about IPV exposure was expressed (Question #3). The gender of the health care worker screening for IPV was not seen as being important, but for patients expressing a preference, most preferred females to ask the questions (Question #4). One half of respondents recommended that a clear and precise definition of IPV must be included in any questioning about partner violence rather than using terminology such as ‘relationship stress’ (Question #5). Regular follow-up of patients reporting current IPV was recommended by 97% of patients (Question #6). Participants felt that questioning for IPV exposure should be asked routinely either at every visit (41%) or every 6 months (31%) (Question #7).
Of the 103 patients interviewed who had previously self-reported IPV on the initial survey, 25 patients (24%) reported that they had agreed to see the in-house social worker at SAC, and 24 of the 25 had attended the appointment (Question #8). Five of these patients reported that they had subsequently been referred on by the in-house social worker to specialized IPV resources within the community for additional support (Question #9) and 4 of 5 followed up on the referral (Question #10).
Discussion
The updated data on the 1721 patients screened at SAC since May 2009 for IPV confirms our earlier findings that intimate personal violence is common, ongoing, and a pervasive issue across all of our different communities living with HIV in southern Alberta. 2,28,29,56 In this study we also gained our patient's perspective on the most sensitive and appropriate approaches to screen and provide follow-up for IPV in an HIV population.
We found that 78% of study participants stated that our HIV clinic was the first center to inquire about IPV among all of their healthcare contacts. Although being introduced in some settings, 45,47,50 screening for IPV within health care settings including HIV care centers remains underutilized despite a high prevalence of IPV and its recognition by agencies such as WHO as an important social determinant of health. One of our study participants noted that “abuse thrives in secrecy and only if a professional initiates a conversation about abuse will a victim disclose.” From a patient's perspective, inquiring about abuse often raised new awareness about the connection between abuse and their physical health, and the importance of addressing IPV.
Our findings suggest that screening and providing proper follow-up and referral for IPV can and should be incorporated effectively in the HIV clinic setting. We found that 23% of the patients interviewed who had been identified by the screening program as having experienced or experiencing IPV had subsequently accessed the resources offered to them (i.e., in-house social worker). This suggests a significant unmet need that was only identified through our programmatic IPV screening. Based on experiences gleaned from 5 years of general screening and from patient interviews, we present seven recommendations on incorporating screening for IPV in an HIV clinical setting (Table 4).
Recommendation #1: IPV screening can and should be universally incorporated into regular HIV care
Participants were very receptive to including IPV questions into routine HIV care. Despite concerns that asking about IPV might cause distressing situations to be revisited and retraumatize the patient, no negative consequences from the screening program were voiced by study participants, suggesting this may be an important but rare event. Our participants suggested that universal IPV screening provides the opportunity to “normalize” the questioning so that patients view screening as part of clinical care for a common event in our population and they do not feel “singled out.” Routine screening and referral can have therapeutic effects by reducing levels of abuse and stress. 8 Studies suggest that asking about abusive issues shows empathy and understanding from the health care team and allows the patient to discuss their situation in a safe and compassionate environment. 57
The optimal screening tool for IPV in any particular health care setting is still to be determined. 8,58 Our initial screening survey was adapted from protocols used within Alberta Health Services but others have been proposed. For example, Chuang and colleagues have examined methods for IPV screening within primary care settings and proposed the use of the written instrument HITS (Hurts, Insults, Threatens, and Screams). 45 Such screening protocols and surveys can be readily adapted to ensure that clinics do ask about IPV in some manner. Perhaps the best approach is to have a routine screening approach that is targeted to the population, defines the issue, normalizes disclosure, and is open-ended.
Recommendation #2. A “trust relationship with the patient” should be established prior to asking about IPV
Patients recently diagnosed with HIV/AIDS may need time to adapt to lifelong engagement with the health care system. Study participants indicated the need for a period of time allowing for patients to become more comfortable with their HIV diagnosis and to have established a trust relationship with a clinic to optimize the chances of patients disclosing IPV experiences. IPV is often associated with strong emotions such as shame, guilt, and fear 59 that need to be addressed before a dialogue can begin. The length and continuity of care through attending the same HIV care center over long periods of time may help a positive trusting relationship to develop, thereby facilitating disclosure. 60
Recommendation #3. Any healthcare provider with an established trust relationship can inquire about IPV
Henderson and colleague suggest that a healthcare worker of the same sex is preferable when asking about IPV, 61 while research on IPV screening protocols in reproductive health clinics found that a male inquiring about IPV and a health care provider other than an obstetrician/gynecologist were noted as barriers to disclosure. 62 Female health care workers in other settings were often preferred for IPV screeners as they were perceived to be more compassionate. 63,64
While we found that each individual's past experiences with nurses, social workers, and clinicians influenced their opinion for the optimal healthcare worker to inquire about IPV, the patient's comfort level with the healthcare worker in an HIV program was more important than the professional designation. In practice, building positive relationships with patients outweighs the need to implement a specific type or demographic of HCW to ask about abuse. Patients preferred health care workers who are empathetic, thereby empowering the patient.
Recommendation #4. A clear and understandable definition of ‘abuse’ must be included when asking about IPV
Participants preferred an explicit question defining abuse—“Are you currently experiencing any forms of abuse including physical, psychological, sexual, intimidation, neglect, isolation, and economic, within your relationships?” It was suggested that this helped raise awareness as to what abuse is and helps the healthcare professional specifically understand the type of abuse a patient might be experiencing. Patients themselves often have a narrower understanding of what abuse is, commonly first thinking of physical and sexual abuse. Cultural and ethnic differences also exist between definitions of abusive behaviors within relationships. 65
Recommendation #5. A protocol and referral process needs to be in place for those disclosing IPV
The importance of having a process in place in response to disclosure was raised by patients on several occasions. Patients are more likely to disclose knowing that there is help available. Patients did expect every health care professional inquiring about IPV to have a plan in place on how to act once a disclosure is made. Lack of education about abuse has been identified as one of the barriers for clinicians inquiring about abuse. 66 Discussion of a safety plan should be offered to every patient disclosing abuse. 67
Recommendation #6. Patients disclosing abuse in a current relationship must have close follow-up and be asked about abuse at subsequent routine appointments
Participants felt that routine follow-up with patients regarding IPV specific well-being on subsequent visits is important and that simply by asking about IPV, it helped build a stronger patient-healthcare provider relationship. This relationship is critical in HIV care as those experiencing IPV are more likely to disconnect from HIV care and have poor HIV specific outcomes. 2,68
Recommendation #7. All HIV patients should be asked about their IPV status at least annually regardless of previous IPV experiences
Participants stated that as abuse may be cyclical or may be experienced in one relationship but not another, repeated questioning was appropriate and necessary. Repeated questioning may also allow some to disclose as more trust is established with the healthcare system. Screening for abuse every 3–4 months coordinated with routine HIV care was supported by the majority of participants. This concurs with others findings of abused and non-abused women being receptive to repeated screening. 39,69 Of note, Bonds and colleagues have shown that previous screening for abuse is associated with a positive attitude toward a routine screening. 70 These data should help health care providers who are hesitant about IPV screening in fear of offending or exacerbating the situation for the patient.
Our IPV screening protocol program is among the earliest established for HIV clinic populations and has been active for over 5 years. This study is novel in that both females and males, whether they have had experiences of abuse or not, were evaluated within the screening process. Our results provide the HIV patients' perspective on how a practical screening protocol for IPV can be safely implemented in a chronic care setting. Identification of IPV helps mitigate the negative consequences of IPV on both HIV and general health. 71 Women who are HIV+ and who exhibit resilience (i.e., functioning competently despite adversity) have been shown to show a significant increase in ART adherence and a decrease in detectable viral loads. 72 Screening for and providing support individuals experiencing IPV may increase levels of resilience and increase HIV health outcomes. Based upon our experiences and the study results, we feel our recommendations for a continuous universal IPV screening will be helpful to address IPV and HIV infection within a HIV care center.
Despite the proposed benefits from asking and acting upon IPV in the HIV population, the actual positive results may not be easily quantified. Research into IPV inherently possesses challenges preventing consistent research methods. 8 Providing women with a list of partner violence resources has shown to make no difference in improving quality of life, 73 although McFarlane and colleagues 74 found that disclosing abuse is associated with the same reduction in violence as referring a victim of IPV to community resources. It is uncertain whether screening for IPV increases referral to social service agencies or decreases ongoing IPV. 75 Many women indicated the lack of coordination between health care providers and community resources. 76 Participants in our study alluded to the importance of connecting victims of IPV to supportive social services and the need to follow-up with patients.
Some health care providers may be reluctant to include IPV screening as part of their practice. Personal barriers such as a discomfort in discussing IPV with patients, resource barriers such as time constraints, lack of knowledge, or the appropriate resources to offer patients with a history of IPV, and a fear of acknowledging IPV for fear of offending the patient have been reported as a barrier. 77 We found that within the context of ongoing HIV care if the merits of IPV screening protocols are discussed prior to its implementation and educational and referral resources are available screening protocol was easily and universally accepted.
Future studies are needed to measure the benefits of asking about IPV and subsequent IPV management protocols in the HIV population. Despite absence of controlled data documenting effective intervention, we strongly believe that only with the recognition of the prevalence and intensity of this problem will better measurements of its effects and novel interventions and treatments be developed.
Our study has limitations and its recommendations must be placed in context of the local HIV care. As we sampled patients between June and August 2014, the sample of patients interviewed does not necessarily possess similar sociodemographic characteristics to the entire population of SAC. Although SAC provides care to a heterogeneous population differing in self-reported ethnicities, sexual orientations, and exposure to HIV risk factors, it is a single region in a developed country and it may not reflect other communities elsewhere. All recommendations may need to be modified for local circumstances and resources such as the availability of support systems. A social desirability bias 78 may have caused our participants to answer questions in such a way that they thought the clinic would find favorable. Finally, we have no ability to confirm in most situations the reality of the described IPV (i.e., there is no gold standard). Patients however, derived no benefit from participating in the study and we note their opinions showed significant internal and external consistency.
Conclusion
IPV is a common and negative determinant of health in HIV populations. 1 HIV patients are receptive to being asked about their IPV experiences in the long-term trust relationship established in HIV care. Resources for addressing any critical IPV situations identified should be in place before screening is undertaken. Repeated routine questioning within the context of HIV care is both acceptable and advisable, particularly for those with a history of IPV.
Footnotes
Acknowledgments
We wish to thank all of the staff at Southern Alberta Clinic for ensuring the continuation of the intimate partner violence screening program and to all the patients at SAC who have been a great resource in helping to continue and strengthen the screening program.
Funding: Canadian Institutes of Health Research Center for REACH 2.0 for HIV/AIDS; University of Calgary Infectious Diseases Research Group Summer studentship (SER)
Author Disclosure Statement
None of the authors report any conflicts of interest.