The first day of the Summit concluded with a town hall-style meeting with twelve members of the Presidential Advisory Council on HIV/AIDS (PACHA). PACHA has advised the White House in preparation and implementation of the National HIV/AIDS Strategy, and used this opportunity to consult with Summit attendees about the social drivers of HIV.
While panel members responded to some audience questions, their focus was on gathering as much feedback as possible in the time allowed, which often meant listening. Questions and comments from the audience touched on:
concerns over HIV stigma in housing (including landlord refusal based on funding source) and housing affordability
the importance and necessity of Housing First programs
missed opportunities to collect data on food and nutrition programs through HRSA and other means
the possibility of passing the Employment Non-Discrimination Act (which would prevent employment discrimination based on sexual orientation and gender identity)
the needs of trans communities and concerns that these communities may not benefit from or be visible in the updated Strategy
immigration reform, particularly as it concerns undocumented populations and their access to health care
the need for empowerment and decreased stigma among people living with HIV.
Wayne Duffus, of the Centers for Disease Control and Prevention office of Health Equity, emphasized the need to provide training programs to new employees who are replacing the retiring workforce during his presentation on CDC initiatives.
Duffus highlighted workshops, training programs and working groups the CDC has developed around the social drivers of health and health equity.
Ron Valdiserri, of the US Department of Health and Human Services, described initiatives underway to address the social determinants of health for people living with HIV. Valdiserri explained that many successful initiatives up to this point were funded through either the Secretary’s Minority AIDS Initiative Fund (SMAIF) or HRSA’s Special Projects of National Significance (SPNS), both of which were at risk at the time of the Summit.
Turning his focus to social drivers, Valdiserri praised the Ryan White HIV/AIDS Program as being the only federally-funded program to embrace the importance of nutrition and food services as integral to primary care. He highlighted Ryan White’s collaboration with HOPWA to create an integrated database to better understand client needs.
“At a policy level,” Valdiserri said, “we tend to forget that employment is a fundamental way to support health.” That’s why his office is funding a new demonstration project to develop comprehensive models of HIV prevention and care for gay and bisexual men, which include counselling, access to housing and employment services. The office is also funding development of clinical guidelines and training opportunities related to intimate partner violence, and has launched an online self-study course for family planning providers. Valdiserri noted that the Substance Abuse and Mental Health Services Administration (SAMHSA) has also released a Treatment Improvement Protocol on trauma-informed care, and that stigma training activities for community health centre staff were underway.
Valdiserri emphasized that, until we address the social drivers of HIV, we will not be successful in meeting the goals of the national strategy.
Ann Oliva, of the US Department of Housing and Urban Development, shared some of the key initiatives HUD is involved in to address the link between housing and health care.
Oliva explained that her office is proposing formula reforms to HOPWA funding and working to elevate housing within the national HIV strategy through contributions to the Federal Action Plan – which was forthcoming at the time of the Summit.
Oliva’s office is also in the process of investigating the link between intimate partner violence and HIV, which includes working with the Department of Justice to determine holistic approaches that will work at the community level. They’ve also developed a partnership with the Department of Labor, to focus on employment as an essential response to HIV, and have launched online training on employment issues for HOPWA grantees.
In terms of alignment between HUD priorities and the national Opening Doors strategy, Oliva named intimate partner violence, coordinated data entry and data collection as key areas of focus.
Janet Hope, Assistant Deputy Minister of Municipal Affairs and Housing in Ontario presented on the province’s Affordable Housing Strategy. Hope explained that, in Ontario, most of the population is along the southern border, but that there are many variations in demographics, geography and economy throughout the province, as well as several First Nations communities. Responsibility for housing is at the municipal level.
Poverty reduction is a major focus of the current Ontario government, and its second strategy includes a long-term goal to end homelessness in the province, as well as a client-centered approach. “As systems evolve over time,” Hope said, “they often become very program and legislation-focused, and you lose sight of why you’re doing what you’re doing.” Moving to a client-centered, outcome-oriented approach is an attempt to counteract that. The province is also focused on developing a framework that allows for local flexibility.
Hope explained that, under the previous funding system, providers were incentivized to keep people in emergency shelters rather than moving them into stable housing, because they received funding based on how many people used the shelter each day. The new strategy marks a shift in which organizations can use their allocated funding in whatever way they deem appropriate, as long as they’re meeting the objectives to assist people who are homeless to become stably housed and prevent at-risk populations from becoming homeless.
One challenge in measuring success is that the total number of homeless people in Ontario is unknown – the only data we have, Hope explained, is on the number of people who stay in shelters. This doesn’t reflect the diversity of people experiencing housing challenges, and we need to track housing stability better in order to set a baseline. Through developing its Affordable Housing Strategy, the government has also learned more about the heterogeneity of Ontario populations, and how the legacy of the residential school system has affected the experience of homelessness.
Hope noted that there is still work to be done in managing transitions for individuals who age out of the child welfare system, as well as for those leaving correctional institutions or hospitals. She explained that the province’s Mental Health and Addictions Strategy, updated during the past year, also identifies housing and employment as key supports. In both strategies, there is an increasing awareness that we must work collaboratively across sectors and levels of government, which requires time and investment.
Tim Foran, of Employment and Social Development Canada, gave an overview of research and policy decisions leading to the 2013 Homelessness Partnering Strategy, focused on Housing First.
Foran explained that Canada has a population of approximately 35 million people, 150,000 of whom use the emergency shelter system on an annual basis. Research has demonstrated that the homeless population experiences higher rates of mental and physical illness, as well as mortality.
In the late 1990s, the federal government became involved in homelessness programming, focusing on the emergency shelter system but, by the late 2000s, the focus changed to longer-term solutions, involving an investigation into the links between mental health and homelessness.
Foran explained that Housing First is an approach to mental health and addictions treatment that emphasizes moving clients quickly into stable, permanent housing, offering them as much choice as possible as to where they live, and separating the provision of housing from treatment – meaning that housing is not contingent on treatment. Based on the evidence behind Housing First strategies, the Mental Health Commission of Canada launched At Home/Chez Soi, a five-year study using a Housing First model, which demonstrated that Housing First could rapidly end homelessness among populations experiencing mental illness, across many different contexts and communities.
Implementing a Housing First model has involved a transition in how cities spend the money they allocate to housing as well as challenges related to partnerships, but the process has so far been successful. Foran reported that communities have embraced the evidence and need for change, and the project is well-positioned to meet its targets.
The strategy is not ours, it’s yours – it’s not the CDC’s, it’s not ours, it’s not California or Alabama’s or Washington DC’s, it’s all of ours. And it’s our responsibility to make sure the nation knows about it.
The Summit was pleased to welcome Douglas Brooks, Director of the Office of National AIDS Strategy, to deliver a special presentation on the updated National HIV/AIDS strategy, released in July 2015.
Brooks began by acknowledging the recent anniversary of the Ryan White Comprehensive AIDS Resource Emergency Act, passed in 1990. The Act allowed for the creation of the Ryan White HIV/AIDS Program, which provides HIV care to people who are uninsured.
Changing focus to the Strategy, Brooks explained that the overall vision articulated in the strategy to 2010 remains the same – the United States will become a place where new infections are rare and, when they do occur, every person will have unfettered access to high-quality, life-extending care, free from stigma and discrimination. Among other things, the updated strategy attempts to harness the benefits of the Affordable Care Act, incorporate new scientific knowledge and build on lessons learned from the 2010 strategy.
Throughout his presentation, Brooks highlighted the need to focus on the right people, places and practices in the updated strategy. He identified the disproportionate burden on men who have sex with men, black and Latino men and black and Latina women, including trans women, as well as the burden felt in major metropolitan areas and in the southern United States, where half of all new HIV diagnoses are found. Brooks also identified the need for widespread testing and linkage to care, early access to treatment, and access to PrEP.
“The nation needs to know that PrEP works,” he said. “We need to not be ashamed of promoting it and not be shaming of people who are trying to access it and save their lives.”
Changes to the Strategy
Brooks explained that the executive summary to the updated Strategy mentions housing, specifically, as an important structural approach to health care and that linkage to supportive services such as housing and employment is essential. He highlighted the fact that access to housing is an important precursor to stable treatment regimens, and that it would be impossible to advocate for treatment without considering whether people living with HIV are stably housed.
The updated Strategy includes a series of 10 indicators, and Brooks noted that indicator seven has been modified. The previous indicator, “Increase the percentage of Ryan White HIV/AIDS Program clients with permanent housing from 82 percent to 86 percent” has been changed to “Reduce the percentage of persons in HIV medical care who are homeless to no more than 5 percent.” The government has also released supplementary documents detailing how the indicators are measured.
The Strategy includes three indicators under development – meaning that targets and quantitative measures for these indicators have yet to be identified, but that they will be tracked in the future. These three indicators concern PrEP uptake, stigma and HIV among trans people. Brooks noted that systems and structures that capture information related to trans people will need to be built before stakeholders can develop helpful ways to respond.
Brooks explained that, as a social worker, he’s pleased that the Strategy focusses on whole person health and the understanding that people interact with systems on a daily basis and have bio-psycho-social needs that must be addressed. He emphasized that implementation of the Strategy needs to be a national – rather than federal – project in which communities work with the next administration to advance their goals.
In an interview with OHTN staff, David Holtgrave, Vice-Chair of the Presidential Advisory Council on HIV/AIDS, sounded a similar note when he expressed confidence that efforts to address the HIV epidemic will survive the 2016 presidential election. “Just because there’s a change in political office, whether it’s a party or a person, we can’t let up on our efforts around HIV and AIDS, and so I think it’s been critical to be able to put [the Strategy] in place,” he said. “I think the best way to prepare for the next election is making sure that there’s a long-term strategy, and our foot is firmly on the throttle moving forward.”
Strengths and Weaknesses of the Updated Strategy
In a panel discussion following Brooks’ address, David Holtgrave shared highlights from the SWOT analysis that he and Robert Greenwald completed in response to the updated strategy. Among the Strategy’s strengths were:
It strikes a balance between addressing the needs of the general population and communities disproportionately affected by HIV.
It includes complimentary services to address the social determinants of health.
Potential weaknesses identified through the analysis include the fact that the Strategy is not (and is not intended to be) a budget document, which means that it is unclear how some of its recommendations will be funded.
For example, Holtgrave’s calculations revealed that the annual cost of providing PrEP to everyone eligible would be 6.7 times the entire CDC HIV prevention budget, and he emphasized that funding plans involving private sector partnerships would be important.
Changes to the indicators may also present reporting challenges. Incidence and transmission rates have been replaced by an indicator that tracks new diagnoses. Holtgrave pointed out that, in the short term, new diagnoses should actually rise in areas where people have had less access to testing.
Among the opportunities identified were:
the chance to reenergize as a nation and focus on addressing the HIV epidemic
the chance to link a national strategy with local planning efforts to end AIDS.
Potential threats included:
proposed decreases to HIV funding
the fact that 19 states had not yet expanded Medicaid
malaise about HIV.
Holtgrave argued that, at times, the response to HIV is too reactive, with organizations and policy makers responding after the fact rather than taking proactive steps.
Speaking as part of the same panel discussion, Russell Bennet, Executive Director of the National AIDS Housing Coalition, argued that, while the Strategy currently portrays housing as a structural intervention that mediates access to care, housing should also be considered HIV prevention. He added that there was a need for broader affordable housing policy in the United States, and that homelessness is not, by itself, a complete indication of the role that housing plays in health contexts.
Karen Pearl, President and CEO of God’s Love We Deliver, a New York program that delivers 5,500 meals a day to people living with severe illnesses, presented an overview of research and policy surrounding food, nutrition and HIV. Noting that 34-71% of people living with HIV are food-insecure, Pearl explained that research has shown that food and nutrition meet the goals of the prevention, engagement and care cascade as well as the IHI Triple Aim to improve patient experience, improve the health of populations and reduce the per capita cost of health care.
People living with HIV who are food-insecure have lower CD4 counts and are less likely to have undetectable viral levels. They also use emergency room services more frequently, are more likely to miss appointments with their primary care providers and score lower on measures of health functioning. On the flip side, medical nutrition therapy is associated with more energy, fewer symptoms, weight gain, higher CD4 counts and greater quality of life. Food security and better nutrition also help with comorbidities such as cardiovascular disease, diabetes and kidney disease.
In the United States, up to one third of hospitalized patients have malnutrition, which can lead to longer hospital stays and higher costs. Citing results from a study of the MANNA program in Philadelphia, Pearl explained that health costs for patients who received food fell by 80% over three months. In-patient stays for MANNA clients were 37% shorter and hospital costs were 30% less. Rates of hospitalization decreased by 50% overall and MANNA clients were 20% more likely to be released to homes than to another facility.
Pearl concluded by noting that nutrition is an inexpensive intervention, since it’s possible to feed someone for six months for the same price as one day of hospitalization.
Spaces of care, spaces of risk: Mapping food as harm reduction
Christiana Miewald, Department of Geography, Simon Fraser University
People who use substances and who are also low-income have profound concerns when it comes to accessing nutritionally adequate, safe, appropriate foods that they can consume in safe, nurturing spaces. Geographical research has highlighted the ways in which low-income people construct routes, pathways and schedules through cities to access food. At the same time, understanding the geographies of food access that are constructed and experienced by low-income people living with HIV who use substances can play an important role in their health and well-being. The project, Food as harm reduction: Documenting the health effects of food provision for people who use drugs, addresses the following questions: 1) in what ways do low-income people living with HIV who use substances experience food insecurity and greater risk of disease; 2) what is the distribution of knowledge and practice around food provision among harm reduction providers in Greater Vancouver; and 3) what are the geographies (routes, pathways, barriers and schedules) that low-income people living with HIV who use substances construct and experience as they access food each day? The geography of food access influences the daily lives and overall health of people living with HIV who use substances including encounters with spaces of care and risk.
Capacity building around food as harm reduction
Grace Dalgarno, Dr. Peter AIDS Foundation
Food as harm reduction is a collaborative, community based research project between Simon Fraser University Geography Department and the Dr. Peter AIDS Foundation, funded by the Vancouver Foundation. Using a community-based research framework, the Food as Harm Reduction project explores the ways in which food provision can mitigate the physical, social and psychological harms associated with substance use. The project consisted of three parts: surveying 60 people living with HIV who use substances, half of whom use the Dr. Peter Centre and half of whom do not; mapping daily routines to learn about daily routes used to access food; and conducting qualitative interviews with harm reduction service providers. Slides describe the project and also address community involvement, lessons learned and recommendations.
Food is medicine: The Ryan White Food and Nutrition Services Program as a model for comprehensive food and nutrition services in the United States
Alissa Wassung, Director of Policy and Planning, God’s Love We Deliver
In a chapter recently published in The Health of HIV Infected People: Food, Nutrition and Lifestyle with Antiretroviral Drugs, researchers reviewed significant research on food programs and health outcomes, demonstrating how access to adequate food and nutrition services helps accomplish the Triple Aim of national healthcare reform for people living with HIV: better health outcomes, lower cost of care and improved patient satisfaction. Researchers examined the structure, funding and delivery methods for the Ryan White Food and Nutrition Services (FNS) Program, arguably the most robust FNS program in the country for people living with chronic illness, through the lens of improving health outcomes and implementing cost effectiveness. Co-authored case studies from six FNS providers around the country showcase the RW benefit in practice over the 30-year history of the providers and demonstrated how each agency has leveraged their core capacity to integrate with state-based health care reform efforts to expand coverage for people living with HIV and other populations. Analysis of the Ryan White FNS Program, in policy and practice, is then used to model how FNS, a relatively inexpensive benefit, could be incorporated into our nationwide health care delivery system to capitalize on the results evident in the outcomes of Ryan White for all people living with HIV as well as for people living with other chronic and severe illnesses.
Understanding the Impact of Employment on Mental and Physical Health
Kenneth Hergenrather, a member of the National Working Positive Coalition and professor at George Washington University, delivered a presentation on employment as a social determinant of health. Hergenrather noted that the World Health Organization defines health as wellbeing, rather than the absence of disease or infirmity, and that the highest rates of HIV infection occur in areas where people live below the federal poverty level, have annual incomes of less than $36,000, have less than high school education or are unemployed.
Results of a meta-analysis on longitudinal research into the relationship between employment status and health reveal that mental and physical health both suffer in the face of unemployment. The analysis involved a scan of 4,500 papers, of which 48 articles on mental health and 22 articles on physical health met study criteria. Results revealed that:
22% of participants in these studies had clinical depression – twice as many as in the general population
25% had trauma or post-traumatic stress disorder (rates were higher among women)
Those who were unemployed had lower levels of social support, and showed symptoms of psychological distress and depression after three months to a year
Those who had been in non-permanent employment for two to twelve years displayed anger, nervous symptoms and psychological distress.
Hergenrather explained that depression correlates with worse immune functioning and a slower response to infection, as well as increased suicide risk. People living with HIV are up to seven times more likely to commit suicide compared to people who have not been diagnosed with HIV.
Overall, employment was associated with:
better mental health
less distress, anxiety and depression
better quality of life.
Job loss was associated with:
poorer mental health
more distress and depression
People who were re-employed after a period of unemployment scored higher on measures of mental health and lower on measures of distress, depression and anxiety.
In terms of physical health people who were employed:
experienced better physical health, as measured by pain, fatigue and difficulty completing the daily activities of living
had more physical activity
experienced fewer limitations.
People who were unemployed experienced more hospitalization, higher mortality rates and more general medical complaints. The results were similar for participants who had experienced recent job loss.
Hergenrather explained that, in the United States, people living with HIV are eligible for state rehabilitation services under the 1973 Rehabilitation Act and the Americans with Disabilities Act. Of those who received vocational services between 2002-2007, 45% of people living with HIV reported successful employment.
Employment and economic well-being of people living with HIV in the New York Eligible Metropolitan Area
Maiko Yomogida, Mailman School of Public Health, Columbia University
The success of antiretroviral therapies has shifted the focus of HIV care from mere survival to quality of life. Data are from the CHAIN study, an on-going prospective cohort study of people living with HIV in NYC and three northern counties (Tri-County; TC) were used to examine an important dimension of quality of life for people living with HIV: economic wellbeing and labor force participation. The CHAIN study sample was designed to be representative of people living with HIV receiving medical and/or social services in the NY Eligible Metropolitan Area. Trends in employment and economic well-being were analyzed by pooling all 5,911 interviews completed with 1,869 CHAIN cohort members between 2001 and 2013. The analyses of factors associated with employment were restricted to data obtained from the interviews, completed between 2008 and 2013. Results showed that despite the widespread use of antiretroviral therapy and reduced mortality rates, CHAIN participants’ labor force participation remained consistent over the 12-year period of this study and the reason most frequently noted for unemployment was poor health.
Foundations for living: An integrated HIV housing and employment intervention for people living with HIV
Liza Conyers, Penn State College of Education and National Working Positive Coalition
The Foundations for Living integrated HIV/AIDS housing and employment services program model provides housing assistance to people living with HIV who are interested in working or volunteering full or part-time or advancing their education. The FFL model was funded by a Special Project of National Significance grant through HOPWA to CARES, Inc. who coordinated services in two distinct regions of upstate New York: Rochester (relatively rural) and Albany (major city). Fundamental to the implementation of the FFL model is recognition of both individualized and systems level interventions. While participants in FFL worked with a service coordinator to develop individualized service plans, resource identification staff worked with key stakeholders in both Rochester and Albany to identify and reduce systemic barriers to integrated housing and employment services. Housing, health and HIV prevention outcomes were reported for a cohort of individuals who completed FFL in Albany and Monroe counties from January 2012 to December 2014.
Minimal to comprehensive: Strategies to increase employment opportunities and economic security of people living with or at greater risk for HIV
Mark Misrok, Board President, National Working Positive Coalition
The National Working Positive Coalition is connected to and has been involved with implementation of a range of employment service models implemented and evaluated by HIV care and prevention programs in North America. This presentation describes how HIV care and prevention, housing and other supportive services can link and coordinate with a range of federal, state and local education and employment programs and resources to increase effective participation by people living with or at risk for HIV. Organizations and communities need to first assess their readiness and capacity, then review, select and implement strategies to adapt or revise their service delivery to better meet employment information and service needs of people living with or at greater risk of HIV. Goals for ending the epidemic and a post-HIV landscape need to prioritize addressing the economic and vocational vulnerability of survivors and communities disproportionately affected. Efforts to maximize available resources to increase employment opportunities need to be implemented now for sustained positive health and prevention outcomes in the years ahead.
I’ve fallen and I can’t get back up
Vernita Perry, Community Health Worker, Positive Pathways with Sabrina Heard and Ronette Moton
The Community Health Worker (CHW) serves many roles including helping to bridge the gap between clients and doctors, and working with community members who are HIV-positive and using drugs. CHWs reach out to members and meet them “where they are at.” Some of our members have no support system and no one to help them. CHWs listen, offer support and show members that we care. By understanding the significance of the CHW role, people can learn from CHW experiences and gain new tools for working with HIV-positive populations.
From engagement to empowerment: Addressing the social drivers of HIV through peer employment in community-based research
James Watson, Coordinator, Community-Based Research and Peer Training, Ontario HIV Treatment Network and Lynne Cioppa, Bruce House, Ottawa, Ontario
The episodic nature of HIV has isolated many people with HIV/AIDS (PHAs) from regular workforce participation, often resulting in their underemployment or reliance on government assistance. Research employment as peer engagement is an empowerment strategy that can benefit the health, well‐being and quality of life of PHAs. Through its employment of PHAs as Peer Research Associates (PRAs), the Ontario HIV Treatment Network pioneered a community‐based research (CBR) model that put peer engagement into action. CBR is a field where lived experience and a desire to build capacity are highly regarded. As part of its research efforts, the OHTN successfully implemented a series of mixed‐method CBR studies that collected extensive data on the social determinants of health of PHAs. PRA experiences from three OHTN CBR studies (the Positive Space Healthy Places housing study, the Employment Change and Health Outcomes study, and the Impact of Food Security on Health Outcomes in People Living with HIV/AIDS Across Canada study) highlight the peer researcher role as an effective peer engagement empowerment intervention.
Common Threads: An integrated HIV prevention and vocational development intervention based upon the principles of trauma-informed care
Margot Kirkland-Isaac, CBA Program Manager, DC CARE Consortium
This presentation is designed to increase awareness and skills related to the need to implement trauma-informed vocational and HIV prevention interventions for African American women with HIV. The slides: (a) review the development of the Common Threads intervention, including a review of principles of trauma-informed care; (b) discuss the relationship between vocational development / employment and outcomes associated with the HIV Continuum of Care; (c) demonstrate the integration of a trauma-informed care activity as a key component of the Common Threads intervention; and (d) share initial research findings that demonstrate some of the outcomes of this approach in facilitating vocational development and improving health and prevention outcomes. Common Threads uses interactive activities, such as a personal timeline to explore the impact of life experience. These activities help participants develop strategies to infuse trauma-informed care into vocational and HIV prevention services to better engage African American women in HIV care and prevention.
The Summit was pleased to host a special panel on intimate partner violence, sponsored by the Public Health Agency of Canada. Intimate partner violence is an emerging field of HIV research, with service providers increasingly aware of the role violence plays in HIV risk and health outcomes.
Experiences of Violence among Street-Involved Women in Canada
Kate Shannon, Director of the Gender and Sexual Health initiative at the BC Centre for Excellence in HIV/AIDS, presented the results of several studies related to female sex workers and other marginally-housed or street-involved women, explaining that these women experience an elevated risk for violence.
Shannon argued that the criminalization and policing of sex work can perpetuate violence against women by forcing marginalized populations into isolated places due to fear of police harassment. She emphasized that, in Canada, there is also serious concern over missing and murdered Indigenous women, who are overrepresented in street-involved populations.
Citing early results from the AESHA study, which was still in progress at the time of the Summit, Shannon reported that, of 800 Vancouver sex workers in the study sample, 25% or more reported sexual violence, 50% reported physical violence, and that the violence came from partners, clients, police and other authority figures. Violence had a negative impact on the women’s ability to negotiate condom use, and also shaped access to HIV care. Sex workers living with HIV also experienced treatment interruptions due to incarceration, which, together with violence, predicted poor treatment outcomes.
Shannon noted that a recent paper from Elena Argento et al. demonstrates a high prevalence of intimate partner violence among sex workers: 25% of sex workers in Argento’s study experienced moderate to severe physical and sexual violence, especially those who were dependant on partners for drug use or had a partner who was economically dependent on them.
Results from a 2011 paper, co-authored by Shannon, illustrate how male-dominated housing models, including single room occupancy (SRO) hotels, can be unsafe for street-involved women. In this qualitative study, women spoke about harassment and threats of violence, which led them to use strategies like couch surfing – which also put them at risk – to stay out of these environments.
Shannon concluded by noting that, in Vancouver, women-only supportive housing models have become a promising alternative. These environments have sign-in of visitors, condom distribution on site, supportive guest policies that allow women to bring partners and clients into their rooms, supportive managers who intervene in altercations and police who remove violent partners or clients from the building.
Violence and Stimulant Use among Homeless Women in the United States
Elise Riley, a researcher from the University of California, discussed the results of a study into homeless and unstably-housed women in San Francisco, emphasising that crack cocaine use is one of the strongest predictors of negative health outcomes among this population. Results from her study reveal that men and women have different experiences with crack and homelessness, and that violence against women mediates and influences their other health outcomes.
Riley and her colleagues used the SF36 measure to rank factors that influenced physical and mental health outcomes among 227 homeless and unstably-housed adults, and discovered that mental health outcomes for HIV-positive women were most influenced by:
unmet subsistence needs (food, clothing, housing)
high adherence to ARV
having a close friend
using crack cocaine
sleeping on the street
adverse alcohol use
and not having instrumental support (someone to borrow money from or provide a place to sleep).
The results for men were different, in that crack use, withdrawal and sleeping on the street were not among the strongest predictors for mental health outcomes, as they were for women.
Based on these findings, the research team began a qualitative study to understand this gender difference. Women who participated in the study were asked what they did when they didn’t have a place to sleep, and their answers revealed that negotiations for housing mirrored the drug-sex economy, in which housing was traded for sex and relationships were often violent.
Riley explained that many of the women she spoke to were trying to extricate themselves from the downtown Tenderloin neighbourhood, and deliberately tried to isolate themselves in the meantime by holding up in their rooms. Over 50% of women in the study reported some form of violence in the past six months from neighbours, strangers, ex-partners and family members. Violence was more common if the women used cocaine or if they reported adverse alcohol use, psychiatric diagnoses and unmet subsistence needs. Riley emphasized that these were bidirectional relationships, meaning that women who experience violence are at risk for cocaine use and women using cocaine are also at risk for violence. Among women who were not using stimulants at baseline, homelessness and sexual violence were both predictors of stimulant use within the next six months.
Screening for Intimate Partner Violence among Men Living with HIV
Intimate partner violence really knocks people off balance and interferes with their ability to keep themselves safe
Conall O’Cleirigh, of the Harvard University Centre for AIDS Research, described the experience of introducing an intimate partner violence screening questionnaire at Fenway Health. He explained that researchers have known for some time that people do less well managing HIV in the presence of depression, PTSD and active substance use, and that nearly 40% of gay and bisexual men have histories of childhood sexual abuse. Intimate partner violence has emerged as a related intersectional factor, especially given that people who experience trauma as children are more likely to experience trauma as adults.
O’Cleirigh explained that one challenge in implementing an intimate partner violence questionnaire is that violence is a structural, syndemic issue that psychologists cannot treat directly. He noted that it doesn’t always make sense for providers to spend time collecting information they aren’t able to act on, and that Fenway was able to develop a simple, four-question survey to meet this need:
In the last year, have you felt isolated, trapped or like you are walking on eggshells in an intimate relationship?
In the last year, has your partner controlled where you go, who you talk to, or how you spend money?
In the past year, has someone pressured or forced you to do something sexual that you didn’t want to do?
In the last year, has someone hit, kicked, punched, or otherwise hurt you?
Just under 10% of patients who’ve taken the screening survey answered yes to at least one of the questions, and O’Cleirigh noted that bisexual men and women were much more likely to answer yes than heterosexual or gay and lesbian patients. Based on preliminary data, it appeared that trans patients were also more likely to report intimate partner violence. Patients reporting intimate partner violence were less likely to adhere to their HIV medication and less likely to arrive for scheduled appointments.
In an interview with OHTN staff, O’Cleirigh was asked about differences in the way heterosexual women and gay or bisexual men experience intimate partner violence. “In heterosexual relationships the man is often the aggressor, if not almost always the aggressor,” he said. “Sometimes, in same-sex relationships that are characterized by violence, it’s not always possible or therapeutically important to identify an aggressor and victim. There’s generally maladaptive patterns that are present. That’s a complicating factor, and I don’t think we know enough about how that plays out.”
Introducing Routine Screening for Intimate Partner Violence in Clinics
John Gill, Medical Director of the Southern Alberta HIV Clinic, shared how the discovery that one of their patients had been murdered by her common-law partner led the clinic to adopt a new intimate partner violence screening protocol.
Gill explained that Alberta has the highest incidence of intimate partner violence in Canada, and that violence is prevalent not just among women living with HIV, but also among men living with HIV, particularly Indigenous men. He noted that research has demonstrated the negative impact violence can have on engagement with care, mental health and missed appointments.
After implementing the screening tool, which was developed by a sexual assault program, uptake expanded so that now 80% of the clinic’s 1600 patients are screened, and a protocol is in place to do an immediate safety assessment if intimate partner violence is reported.
Results from the screening tool have shown that 23% of the clinic’s patients report experiencing intimate partner violence as adults, and many were abused as children. Gill noted that this was an issue his team was still researching.
Gill explained that, at one point, concerns were raised about the danger of re-traumatizing patients during the interview, so the team asked patients for feedback on the questions – whether they should be asked at all and, if so, by whom and how often. Responses showed that patients were overwhelmingly in favour of including these questions once a trust relationship had been established. Patients emphasized that providers should continue to ask at every visit, as living situations can change.
Because the clinic also collects information on housing stability, Gill was able to demonstrate that unstable housing was twice as common among patients who reported intimate partner violence, and that housing instability itself was associated with lower CD4 counts, alcohol use, injection drug use and incarceration.