A history of abuse has a lasting impact on HIV care engagement and health outcomes

A Canadian study that followed people living with HIV for nine years found strong relationships between a history of abuse and long-term HIV care engagement and health outcomes. Participants with a history of violence or abuse, in particular childhood abuse, were more likely to discontinue care, have a detectable viral load, and be diagnosed with AIDS.

Interpersonal violence can occur between intimate partners, family members, friends, and acquaintances. Previous studies have shown that experiencing abuse or violence can greatly impact physical and mental health. People reporting abuse are more vulnerable to acquiring HIV, more likely to engage in unprotected sex, and more likely to have delays in HIV testing. Those who have experienced childhood abuse are more likely to experience drug and/or alcohol abuse, suicidal thoughts or attempts, and socioeconomic disadvantages as adults.

The majority of prior research focusing on interpersonal violence and HIV utilised a cross-sectional approach and didn’t follow participants over time. One study with two years of follow up found that intimate partner violence had detrimental effects on CD4/CD8 ratios in 103 women with HIV.

Because HIV requires life-long treatment, this longitudinal study was important to understand how past experiences influence present health outcomes and care engagement. The results of this study provide stronger support for causality between abuse and these poor outcomes.

Led by Alexandra Budd of the University of Alberta, researchers conducted the study among people living with HIV who received care at the Southern Alberta HIV Clinic in Canada. A total of 1064 clinic patients that received an interpersonal violence screening between 2009 and 2010 were included in the study and followed for nine years.

The screening, delivered during assessments of new patients, was introduced as a standard of care in 2009. First, a researcher or registered nurse defined interpersonal violence (abuse) as including physical, sexual, emotional or financial abuse, as well as isolation, neglect or intimidation. Then they asked if the patient had experienced any abuse either currently or in the past.

Those indicating they had experienced or witnessed abuse during childhood were categorised as reporting childhood abuse, although some may have also experienced abuse during adulthood. Those classified as experiencing adulthood-only abuse answered ‘no’ to questions about experiencing or witnessing any forms of abuse during childhood.

Over one-third of patients reported abuse, with 21%  of participants experiencing childhood abuse, and 15% reporting abuse as adults. Just over three-quarters of participants were male. Females were more likely to report any history of abuse compared to males (46% vs 33%, respectively), and especially in adulthood compared to males (25% vs 15%, respectively).

Ethnicities of participants were Aboriginal/Indigenous (n = 78); African, Caribbean, and Black (214); White (691); and other (83). Indigenous participants were most likely to report abuse, with 49% reporting childhood abuse and 22% abuse as an adult. White people were less likely to report abuse (24% childhood, 14% adulthood). African, Caribbean, and Black participants had the lowest rates of interpersonal violence, with 3%  reporting childhood abuse and 17% adulthood only.

Educational attainment was a significant factor associated with reporting a history of interpersonal violence. Fifty-eight per cent of participants with less than 12 years of education reported a history of abuse, compared to 28% of those with more than 12 years of education.

Physical co-morbidities, including diabetes, cardiovascular conditions, gastrointestinal conditions, and cancers, didn’t differ between those with history of abuse and those without. However, hepatitis C virus co-infection, suicide risk, and psychiatric co-morbidities were elevated in those reporting any abuse.

The rates of substance abuse were 47% for those reporting childhood abuse, 29% for abuse as an adult, and 19% for those with no history of violence. Those reporting childhood abuse were more likely to have a history of intravenous drug use.

Overall, these challenges with substance use and mental health meant that participants reporting childhood abuse had a higher burden of co-morbidities, compared to the other groups (p < 0.001).

"This longitudinal study was important to understand how past experiences influence present health outcomes and care engagement."

At baseline, the proportion of people receiving antiretroviral therapy, previous or current AIDS diagnosis, nadir and current CD4 counts were similar across groups. Viral loads greater than or equal to 500 copies were more common in people reporting childhood abuse compared to those with no history of abuse (28% vs 18%, respectively).

During the nine years of follow-up, people reporting childhood abuse were more likely to discontinue care (40%) than those reporting adulthood-only abuse (26%) or no abuse (27%). They also had higher mortality (16%) compared to those reporting adulthood-only or no abuse (around 8%). These differences were highly significant (p < 0.001). Deaths were more often from overdose, violence, and suicide or HIV-related causes in the childhood-abuse group.

Yearly rates of missed appointments were higher for those with any history of abuse compared to those without such history (childhood 17%, adulthood 14%, no abuse 12%, p < 0.001).

After adjusting for other factors, people reporting any history of abuse were more likely to discontinue HIV care (34% increased risk), experience a detectable viral load (57% increased risk), and experience a CD4 count below 200 (42% increased risk).

These poor outcomes were seen even though anyone reporting a history of abuse was offered in-clinic social services and referrals to external resources. The authors call for better and standardised screening for a history of interpersonal violence or abuse. Results of such screenings could inform the development of an affordable, trauma-informed intervention that focuses on mental health, self-efficacy, and prevention of future violence.