Research has shown that Intimate Partner Violence (IPV) is associated with higher incidences of HIV acquisition through forced, often traumatic sex and reduced ability to negotiate condoms (Li, et al., 2014). A recent systematic review and meta analysis (Hatcher, et al., 2015) has shown that IPV in women living with HIV is associated with reduced use of anti-retroviral therapy and fewer instances of viral suppression.
With advances in anti-retroviral treatment, People Living with HIV (PLWHIV) can now live long, healthy, fulfilling lives when engaged in services and treatment. There are, however, many people who fail to engage in services and therefore remain off treatment, resulting in more rapid disease progression and increased risk of onward transmission (Curtis, et al., 2015). Globally, violence and fear of violence is a significant barrier to seeking services for HIV prevention and treatment (UNAIDS, 2014).
The diverse backgrounds of PLWHIV in the UK (Public Health England, 2017) bring a varied client group who have a multitude of complex social and cultural influences impacting on health beliefs and behaviours. Some may be from countries where they have faced extreme stigma and discrimination, in which negative attitudes of healthcare workers towards HIV, social norms, and police corruption may have prevented them from seeking help for IPV. PLWHIV who have suffered IPV may lack bargaining power and be economically dependent on their perpetrator. The fear of stigma and ostracism from their community may result in reduced ability to look after their sexual health and attend HIV services (UNAIDS, 2014).
IPV has been shown to influence behaviours such as hiding HIV status to avoid violent reaction and hiding medications. Depression and anxiety can cause intentional or non-intentional missing of medication or the stopping of treatment altogether. IPV also reduces access to friends, family and social support which can all promote good adherence (Hatcher, et al., 2016).
Facilitating safer disclosure of HIV status was highlighted in 2006 by the WHO (WHO, 2006) as leading to both individual and public health benefit – however, evidence of the success of disclosure programmes was evaluated by Kennedy, et al., (2015) and found inconclusive results. In addition to this, recent evidence from the PARTNER study (Rodger, 2016) shows that PLWHIV who have sustained undetectable levels of HIV virus in their blood cannot pass on HIV to sexual partners. It could therefore be argued that the focus should be on service engagement and adherence support rather than disclosure. The British HIV Association (BHIVA, 2017) highlight the need to maximise access to treatment and spread the "undetectable equals untransmittable" message in order to reduce stigma experienced by people whose sexual partners fear infection.
My experience as an HIV Nurse has seen many women and men who have disclosed previous or ongoing abusive intimate partner relationships. I have seen them struggle with attending appointments and adhering to anti-retroviral medication. It can be extremely difficult as a hospital-based Nurse to reach out and connect with these people. Phone calls often go unanswered, we may have been asked by the patient not to contact them by post, and sometimes they do not give permission for us to write to their GP.
The recent Kings Fund Report (Anderson, et al., 2017) into the Future of HIV Services in England highlights the importance of addressing social, psychological and emotional factors in HIV care and promotes the need to develop joined up integrated services, building closer partnerships with other health services, GPs and community organisations . They also note that many HIV testing services do not currently address social and cultural drivers of health behaviours. Peer support is also well recognised as contributing to personal wellbeing and improved clinical outcomes (BHIVA, 2013) and could be key in building a more accessible support network for victims of IPV living with HIV.
More research is needed to explore in depth the specific issues and barriers to accessing HIV services facing those men, women and transgender people living with HIV who have experienced IPV. With this evidence we will then be able to form recommendations to develop and implement individualised support processes and care pathways to allow victims of IPV living with HIV to access medical and support services, and adhere to treatment.
My name is Debbie Talbot and I work for Sheffield Teaching Hospitals NHS Trust as an HIV Nurse Practitioner across the departments of Infectious Diseases and Tropical Medicine and Sexual Health. The role has enabled me to gain experience and knowledge in the field of HIV and antiretroviral therapy, along with an in depth understanding of the complexities facing people living with the virus. Prior to this post, I worked as a Staff Nurse on the Infectious Diseases unit and for Sheffield Travel Health Clinic. I am also studying for the MSc in Advanced Nursing Studies at the University of Sheffield. I gained an interest in Intimate Partner Violence and the effect it has on people living with HIV through working with people who struggle to engage with the HIV service and adhere to Anti -retroviral Therapy. I am currently exploring how IPV affects engagement with HIV services and in the future hope to develop support processes to facilitate safer links to HIV clinics.
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