A critical link between the HIV/AIDS epidemic and an epidemic of intimate partner violence (IPV) can be fatal to victims, yet is not fully understood by health and human service workers, concluded a symposium panel of doctors, nurses, lawyers, social workers, police, and shock trauma specialists at the University of Maryland (UM) in Baltimore.
The June 29 symposium, "Secret Killer in HIV: Gender Violence," helped the University launch an effort to build an interprofessional model to best manage and refer IPV cases, which involve families affected by HIV. Or, as visiting professor Jody Olsen, PhD, MSW, at the University's School of Social Work said, our services "will better put words into actions to reduce fears. This is about family and community and a whole set of fractured disciplines trying to make an action whole."
Special guest Kate Joyner, DPhil, MSocSci, (pictured) a mental health nurse from Stellenbosch University in South Africa, opened the symposium with a lecture on gender violence and its impact on HIV/AIDS in her nation. She presented an overview of a multidisciplinary intervention that she developed and which will soon be piloted in several HIV/AIDS clinics in South Africa.
Although the American and South African societies differ in many ways, said the UM's director of global health initiatives, Joseph O'Neill, MD, MS, MPH, the two nations' experiences with gender violence and HIV provide lessons for each to build on. "The University of Maryland possesses unique capabilities that can be brought to bear on this issue on a global scale," said O'Neill.
Joyner said the two nations share the same links between the two epidemics: violence limits women's ability to engage in HIV preventive habits, women abused at an early age are likely to engage in behaviors placing them at greater risk for HIV, violently abused women are more likely to be in partnerships with men at elevated risk for HIV, and the stigma of being HIV-positive affects self-esteem and the reluctance of abused women to seek proper help.
The significance of the UM initiative was illustrated with a case study of an HIV-positive Baltimore mother and wife that was read at the symposium from a transcript of the woman's own words. She had finally visited one of the University's HIV clinics after more than a decade of violent rapes and mental abuse by her husband.
The panel members--at times supportive and at other times critical of their own professions' handling of thw woman's case--reached across discipline silos to understand how to best prevent and mitigate the impact of gender violence and HIV/AIDS.
Emilie J.B. Calvello, MD, MPH, assistant professor, Department of Emergency Medicine, UM School of Medicine, said of the case, the woman's "multiple contacts [with the patient] all started in the conventional way for their job, but didn't pursue [the question of violence] beyond the ER. Still, it wouldn't be surprising for people to say 'What am I getting myself into?' We need to push ourselves."
Calvello's comments were in response to the woman's words: "I think that my doctors and nurses suspected that I had been abused." They did not detect it, according to the woman. When she was asked, she denied it. Her husband continued to rape and beat her, apologize, then take her to the hospital. "Controlling behavior is part of the abuse," added Joyner.
"We have found that partner violence is actually a chronic disease," said Joyner, "so is AIDS." In every case, she said, an IPV champion is needed (just as champions are available in best practices for persons with HIV) in several areas: psychosocial counsel, patient stress, family counseling, patient support, and legal.
Carnell Cooper, MD, FACS, associate professor of surgery at the School of Medicine and the R Adams Cowley Shock Trauma Center, said, "We have an obligation. The leading cause of maternal death is by violence. How can we build into practice what Dr. Joyner has described? We have an opportunity to identify problems and refer them to the proper provider."
Olsen called the woman's story "a frequent story; a global story." The case study woman was the daughter of alcoholics. As a teen, she already had low self-esteem. Her boyfriends refused to use protection during sex. She was pleased that her current boyfriend agreed to marry her when she became pregnant at age 19, although she didn't know which boyfriend was the father. Sometime later her Ob/Gyn physician called to tell her she was HIV-positive. She thought her husband was going to kill her, beginning many years of violent abuse. Yet, health care workers never asked if she was safe at home.
"The information was horrendous, but each member of the health care team tried to help [in their own way]. So everybody just scratched the surface, the OB, ER, HIV clinic, and others," said Stephanie Pons, LCSW-C, director of social work/case management for the University's Institute of Human Virology. Pons suggested, "We have a model of medication adherence but what are we missing here?" She challenged the University to develop a similar model to track IPV.
Deborah Weimer, JD, LLM, professor, UM School of Law, said, "One mistake was that the disclosure that she was HIV-positive was made over the phone. No date, time, record. Not good legal practice." She continued, "Doctors are required to counsel the patients. We might have counseled her to learn if she was safe, and then return her to the medical health care worker."
Joyner said that the basis for intervention is a subject's situation at home. "It is helpful to talk it out," she said. "When a woman leaves a violent man she is more at risk for a few years afterward. This is a tricky area to understand."
Pons said, "Work in HIV is the ultimate social work job. The stigma compounds the problems of gender violence, such as fear of losing [a] relationship." Indeed, the woman said her situation had curtailed her plans for college and her hopes for her baby's future.
"The hospital environment of in-and-out quickly is not helpful in this," said Cooper. "And also, we don't have the skill set to know how to bring in the social workers."
Joyner said she has seen "lots of resistance of health care workers related to this issue." She added that workers might believe that it is a social issue, not a health concern; or that "there is insufficient time to handle the problem; or, for social workers, there is often a 'separation assumption' that the woman should leave the man [and solve the problem]. But, it is not that simple," she said.
UM President Jay A. Perman, MD, said, "This is a critical, but not well-known subject." Most people have an understanding of HIV and most people have an understanding of gender violence, but do not fully understand the important link, said Perman. "Today's topic at this University and I dare say, at other universities has not been adequately addressed."
Click here for a video of the "Secret Killer" symposium.