Trauma Drives HIV Epidemic in Women
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"Effectively addressing trauma and PTSD may be an opportunity to make a transformational impact on the HIV epidemic. Given the high rates and known consequences of trauma and PTSD in HIV-positive women, screening and referrals for recent and past trauma and PTSD should be considered a core component of HIV treatment in this population, along with medication adherence, CD4 counts, and viral loads. Additional studies of trauma-prevention and trauma-recovery interventions in HIV-positive and at-risk women are greatly needed."
Newswise - Physical violence, sexual abuse and other forms of childhood and adult trauma are major factors fueling the epidemic of HIV/AIDS among American women. Scientists have known for years that traumatized women are at greater risk of becoming infected.
Now, two new studies from the University of California, San Francisco (UCSF) and Harvard Medical School demonstrate that a high rate of trauma among women already infected with HIV also plays a role in the epidemic.
Described in back-to-back papers in the journal AIDS and Behavior, the new work demonstrates that women with HIV are exposed to trauma and suffer from posttraumatic stress disorder (PTSD) at rates far higher than those occurring in women in general.
The work may help to reframe many types of discussions about HIV/AIDS so that more clinicians take trauma into account when working with their patients.
Traumatized women fare worse in treatment for HIV/AIDS than women who have not suffered traumatic stress. Trauma also puts women in situations where they are more likely to spread the virus.
"For a long time we have been looking for clues as to why so many women are becoming infected with HIV and why so many are doing poorly despite the availability of effective treatment," said Edward Machtinger, MD, who directs the Women's HIV Program at UCSF and who was the co-principal investigator on both studies. "This work clearly shows that trauma is a major factor in the HIV epidemic among women."
American women with HIV are more than five times more likely to have PTSD and twice as likely to have been the victim of intimate partner violence compared to national samples of American women. The work also demonstrates the personal and public health consequences of trauma in HIV-positive women: women with HIV who report recent trauma are over four times more likely to fail their HIV treatment and almost four times more likely to engage in risky sexual behavior.
How Trauma Contributes to HIV/AIDS in Women
The proportion of U.S. women diagnosed with HIV/AIDS has grown steadily for the last 30 years. In 1985, only 8 percent of new U.S. cases occurred in women. By 1992, that number had risen to 14 percent of new cases. Today, women account for at least 27 percent of new U.S. cases.
The new work helps understand some of the problems helping to drive the epidemic among American women, an epidemic that particularly impacts women of color.
Previous studies have shown that trauma contributes to the HIV/AIDS epidemic among American women because it is associated with variety of risky situations and behaviors among at-risk HIV-negative women and girls. But until now, no definitive estimates existed of the rates of trauma and PTSD among women and girls already infected with HIV.
Machtinger and his colleagues used the statistical technique of meta-analysis to combine data from 29 prior studies that included 5,930 HIV-positive women to estimate the rates of trauma and PTSD in American woman with HIV. They found highly disproportionate rates of trauma exposure and PTSD-mostly between two and six times higher rates of various types of child and adult sexual and physical abuse and PTSD in HIV-positive women. This is particularly striking because rates of trauma in the general population of women are already high. As an example, the estimated rate of recent PTSD among HIV-positive women is 30 percent while that of the general population is 5.2 percent.
In a companion paper, the scientists sought to determine why so many women with HIV fare so poorly when taking HIV/AIDS drugs and also why many end up in situations where they could transmit the virus to others. To do so, the scientists analyzed detailed clinical and behavioral data collected from 113 women and female-identified transgender women in San Francisco who have HIV/AIDS.
The analysis revealed that ongoing trauma was strongly associated with both treatment failure and with risky situations and behaviors. Specifically, the study demonstrated that HIV-positive women who report recent trauma had more than four times the odds of experiencing virologic failure, a situation where the HIV virus becomes detectable in the blood despite being on antiretroviral mediations. This situation can lead to HIV-related illnesses and to the virus developing resistance to the antiretroviral medications. The work also revealed that women who had suffered recent trauma were more almost four times more likely to have had sex with someone without the virus or whose HIV status was unknown to them, and to not always use condoms with these partners.
This has important public health consequences, said Machtinger. People failing their medications are particularly infectious because their virus is not suppressed. If they have unprotected sex with someone who does not already have HIV, there is a higher risk of further infection.
"Women who report experiencing trauma often do not have the power or self-confidence to protect themselves from acquiring HIV," Machtinger said. "Once infected, women who experience ongoing abuse are often not in positions of power to effectively care for themselves or to insist that their partners protect themselves. Effectively addressing trauma has the potential to both improve the health of HIV-positive women and that of the community."
The study was not large enough to determine exactly how recent trauma leads to treatment failure; one possibility is that suffering trauma interferes with a woman's ability to take her HIV medications as consistently as necessary. The authors also believe that, for some women, substance abuse and depression are closely related to trauma and that all may contribute to the poor outcomes seen in the study.
The work identified very simple screening questions for recent and lifetime trauma which could be readily used in clinical practice. According to Jessica Haberer, MD, MS of Harvard Medical School, "Our studies have the potential for immediate clinical impact in that we ascertained practical ways for clinicians to identify patients at risk."
For example, asking a simple question about recent trauma may help identify patients at higher risk for poor health outcomes and risk of further transmission. This may allow for a more effective allocation of scarce clinic and community resources, such as safety assessment, trauma-related therapy, medication-taking support and transmission-prevention counseling. The authors also believe that efforts to treat substance abuse and depression may be more effective if such counseling acknowledges that ongoing trauma may be contributing to both conditions.
"We have to learn to ask about trauma and to develop creative approaches to trauma-prevention and trauma-recovery," Machtinger said. "This is actually an amazing opportunity to have a significant impact on the HIV/AIDS epidemic, especially among minority women."
The article, "Psychological Trauma and PTSD in HIV- Positive Women: A Meta-Analysis" by E. L. Machtinger, T. C. Wilson, J. E. Haberer and D. S. Weiss was published online by the journal AIDS and Behavior on January 17, 2012. See: http://dx.doi.org/10.1007/s10461-011-0127-4
The article, "Recent Trauma is Associated with Antiretroviral Failure and HIV Transmission Risk Behavior among HIV-positive Women and Female-identified Transgenders" by E. L. Machtinger, J. E. Haberer, T. C. Wilson, and D. S. Weiss will be published online by the journal AIDS and Behavior this month. Once the article appears online, it will be accessible at:
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HIV/AIDS and American Women
50 percent of all people living with HIV/AIDS worldwide are women
27 percent of all U.S. HIV/AIDS diagnoses today are in women
77 percent of all U.S. women with HIV/AIDS are black or Latina
#3 cause of death for U.S. Black women, age 30-44 is HIV/AIDS
30 percent of American women with HIV/AIDS suffer PTSD (5 times national rate)
55.3 percent American women with HIV/AIDS suffer intimate partner violence (more than twice the national rate)
AIDS and Behavior Jan 2012
Psychological Trauma and PTSD in HIV-Positive Women: A Meta-Analysis
E. L. Machtinger1 , T. C. Wilson1, J. E. Haberer2 and D. S. Weiss3
The estimated rate of lifetime sexual abuse is 61.1% (95% CI 47.7-73.8%); this estimate is five times the national prevalence in women . The estimated rate of lifetime physical abuse is 72.1% (95% CI 60.1-82.1%). The estimated rate of lifetime abuse (unspecified type) is 71.6% (95% CI 61.0-81.1%), compared to 39% in a national sample
Effectively addressing trauma and PTSD may be an opportunity to make a transformational impact on the HIV epidemic. Given the high rates and known consequences of trauma and PTSD in HIV-positive women, screening and referrals for recent and past trauma and PTSD should be considered a core component of HIV treatment in this population, along with medication adherence, CD4 counts, and viral loads. Additional studies of trauma-prevention and trauma-recovery interventions in HIV-positive and at-risk women are greatly needed.
Women bear an increasing burden of the HIV epidemic and face high rates of morbidity and mortality. Trauma has been increasingly associated with the high prevalence and poor outcomes of HIV in this population. This meta-analysis estimates rates of psychological trauma and posttraumatic stress disorder (PTSD) in HIV-positive women from the United States. We reviewed 9,552 articles, of which 29 met our inclusion criteria, resulting in a sample of 5,930 individuals. The findings demonstrate highly disproportionate rates of trauma exposure and recent PTSD in HIV-positive women compared to the general population of women. For example, the estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8-42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women. The estimated rate of intimate partner violence is 55.3% (95% CI 36.1-73.8%), which is more than twice the national rate. Studies of trauma-prevention and trauma-recovery interventions in this population are greatly needed.
Women bear a steadily increasing burden of the HIV epidemic. In the United States (US), women account for at least 27% of all new HIV/AIDS diagnoses, up from 8% in 1985 and 14% in 1992 [1-3]. Women of color bear the lion's share of this burden; Black and Hispanic women now represent more than three-quarters (77%) of women recently diagnosed with HIV/AIDS .
Despite the availability of effective antiretroviral therapy (ART), women face surprisingly high rates of HIV-related morbidity and mortality [1, 4, 5]. HIV/AIDS is now the leading cause of death for US Black women aged 25-34 . Numerous calls have been made to identify and respond to factors associated with the high prevalence and poor outcomes of HIV in women [6-8].
Trauma is increasingly recognized as an important factor associated with the rising prevalence and poor outcomes of HIV in women [9-11]. HIV-positive women are affected by high rates of sexual and physical trauma in both childhood and adulthood, as well as by posttraumatic stress disorder (PTSD) [12-40]. Trauma and PTSD are well known to predispose women to becoming infected with HIV [11, 16, 17, 41-43]. Once infected, women exposed to trauma and those who go on to develop PTSD have poorer health outcomes [44-49] and higher transmission risk behaviors [12, 15, 16, 25, 27, 50, 51].
Although prior studies [12-40] have documented high rates of different types of psychologically traumatizing experiences and PTSD in HIV-positive women, the rates reported by individual studies often vary, even for a specific type of trauma. For example, the reported rates of intimate partner violence (IPV) among US HIV-positive women range from 10 to 100% [25, 26] and the reported rates of recent PTSD range from 15 to 53% [23, 37]. Many studies cannot be generalized to the larger HIV-positive female population in the US because of the use of convenience samples or site-specific recruitment methods (e.g., prisons, drug treatment programs).
The purpose of this study is to employ meta-analytic technique to clarify rates of trauma exposure and PTSD in HIV-positive women and, where possible, to compare these rates to those in the general population of US women. To the authors' knowledge, this is the first time that a meta-analysis has addressed this question.
The results of the meta-analysis are presented in Table 3. The estimated rate of recent PTSD in HIV-positive women is 30.0% (95% confidence interval [CI] 18.8-42.7%). This estimate is over five times the rate of recent PTSD reported in a national prevalence sample of women [56, 57]. The rate of lifetime PTSD in one study is reported to be 74%. While this rate is much higher than 9.7% reported in a national sample of women [57, 58], a single study is not amenable to meta-analytic technique. The estimated rate of IPV among HIV-positive women is 55.3% (95% CI 36.1-73.8%). This estimate is more than twice the national prevalence rate of IPV in women .
Estimated rates of adult sexual abuse and adult physical abuse are 35.2% (95% CI 20.1-51.4%) and 53.9% (95% CI 30.2-76.8%), respectively. The estimated rate of adult abuse (unspecified type) is 65.0% (95% CI 58.9-70.8%). National prevalence rates in the general population of women for these three types of abuse are not available for comparison.
The estimated prevalence of CSA and CPA are 39.3% (95% CI 33.9-44.8%) and 42.7% (95% CI 31.5-54.4%), respectively. Both of these estimates are approximately twice those documented in a national prevalence sample of women . The estimated rate of childhood abuse (unspecified type) among HIV-positive women is 58.2% (95% CI 36.0-78.8%), compared to 31.9% prevalence in a national sample .
The estimated rate of lifetime sexual abuse is 61.1% (95% CI 47.7-73.8%); this estimate is five times the national prevalence in women . The estimated rate of lifetime physical abuse is 72.1% (95% CI 60.1-82.1%). The estimated rate of lifetime abuse (unspecified type) is 71.6% (95% CI 61.0-81.1%), compared to 39% in a national sample .
No category of PTSD or trauma exposure yielded significance for publication bias using Begg and Mazumdar's test. Of note, two categories (unspecified adult abuse and unspecified childhood abuse) contained too few studies to conduct the Begg and Mazumdar's test for publication bias. Forest plots of estimated prevalence rates of trauma exposure and recent PTSD can be found in electronic supplemental material (Supplementary material 2).
Using meta-analytic technique to estimate rates of exposure to traumatic events and recent PTSD in HIV-positive women, we observed very high rates of all categories of trauma exposure and PTSD. Where data exist that allow comparison to nationally representative samples of US women, the estimated rates of the various categories of trauma exposure and recent PTSD in HIV-positive women are mostly between two and five-fold higher.
The implications of these findings are highly significant. HIV/AIDS has increasingly become a health crisis for women, especially among women of color.
These results estimating disproportionally high rates of trauma and PTSD support and inform longtime calls for studies of trauma-prevention and trauma-recovery interventions to reduce the high incidence and poor outcomes of HIV among women [9, 10, 24, 35, 62, 63]. Relatively few such interventions have been reported in the literature among HIV-positive women , or women at high risk for HIV [65, 66] and more are urgently needed.
The study conclusions have a number of limitations primarily based on the nature of the literature we utilized. First, we found considerable variation in the methods used to measure trauma exposure and PTSD in the set of 29 studies.
Methods to assess trauma exposure ranged from asking study participants a single non-validated dichotomous question to employing validated inventories in the setting of diagnostic interviews conducted by trained and calibrated clinicians. The majority of included studies, however, utilized unpublished, non-validated, methods to measure trauma exposure. The methods for diagnosing PTSD in the included studies were similarly variable. One study used the gold standard in the field, the Clinician Administered Post-traumatic Stress Scale for DSM-IV (CAPS), which is a comprehensive structured interview conducted by experienced clinicians that assesses the frequency and intensity of core and associated symptoms of PTSD . Others used self-report instruments that all measure symptom level but vary with respect to their ability to map to the DSM diagnostic criteria. For example, the Impact of Event Scale Revised (IES-R) was designed not to be a proxy for a PTSD diagnosis, but instead to measure the amount of distress from PTSD symptoms over the previous week . The PTSD CheckList-Civilian Version (PCL-C) is a 17-item self-report of PTSD-related symptoms  that does map to the 17 DSM symptoms. The PCL-C was the most common method for indexing a diagnosis of PTSD in the included studies, but it too is not formally diagnostic. In the included studies that utilized this measure, a variety of cut-off scores were utilized because there is no single validated cut-off value. The use of symptom-based assessments in the included studies has the potential to overestimate rates of PTSD. The variability in measurement of both trauma exposure and PTSD is a limitation inherent in the current literature and is not limited to this set of studies.
Second, there is a degree of heterogeneity among the rates of trauma and PTSD found in the included studies that may be partially attributed to each study's unique characteristics. These characteristics included geographic location, race, substance abuse, sexual activity, homelessness, incarceration, motherhood, and participation in a study cohort. Because many of these characteristics may be correlated with trauma exposure and/or PTSD [70, 71], our analysis may overestimate rates of trauma exposure and PTSD among HIV-positive women.
However, the possibility or degree of this overestimation is limited because these same characteristics are well-known to be associated with HIV in women. While these characteristics were abstracted and noted in Table 1, we did not formally analyze them as moderating variables. Doing so calls for a different study in which the design acknowledges that many of these characteristics are correlated and whose purpose is to tease out the complex mechanisms by which trauma and PTSD are associated with HIV. Nonetheless, the lack of consistent inclusion criteria across the included studies, or inclusion criteria that ensure a representative sample of HIV-positive women, may affect the generalizability of our results to all sub-populations of HIV-positive women.
Third, there was heterogeneity in the definitions for specific categories of psychological trauma among the included studies. To accommodate these multiple definitions, we included 10 categories of trauma and only included data if it clearly fit into one of these categories. This heterogeneity is an acknowledged limitation of the comparisons made between rates found in this study to those documented in national samples of US women.
Fourth, the time frame for IPV varied among the included studies, ranging from "in the previous three-months" to "ever". However, the great majority of included participants in this category reported IPV "as an adult" or "ever". The data we cite for comparison rates of IPV in the general population of women used "ever" for the timeframe of IPV. As such, if bias exists due to the variability of time frames for IPV in the included studies, our estimate of the rate of IPV among HIV-positive women would likely be an under-estimation when compared to the rates among the general population of women.
Lastly, our data could be affected by publication bias. Specifically, concern exists for the "file drawer effect" in which studies that identify trauma rates in the range of, or lower than, the prevalence in the general population of women are not published. In our study, however, no category of PTSD or trauma exposure yielded significance for publication bias using the Begg and Mazumdar's test, implying that it is unlikely that such bias substantially affects our results.