HIV patients increasingly at risk for domestic violence

Study shows HIV patients can be victims

Clinicians seeing HIV patients need to be aware of yet another problem their patients might experience during the course of their chronic illness: domestic violence.

Asking patients whether they’ve experienced any abuse is not a routine part of HIV management, but perhaps it should be, says Sally Zierler, DrPh, professor of medical science in the Department of Community Health at the Brown University School of Medicine in Providence, RI.

Zierler was the lead author of a report about domestic violence among HIV patients. The report bases its information on results from the HIV Cost and Services Utilization Study. The report found that nearly 13% of HIV patients surveyed had experienced physical harm since their diagnosis of HIV infection, and their injury came from someone close to them. More than 20% of the women reported violence victimization, and gay men reported more harm than straight men, with 11.5% of homosexual and bisexual men reporting violence vs. 7.5% of heterosexual men.

The study collected data on the number of people who reported physical assaults since their HIV diagnosis and on those who reported some type of physical harm within a loving relationship or relationships that were important to them.

Clinicians working with HIV patients are in a position to identify victims and offer information and resources that could help patients who are experiencing domestic abuse, Zierler says.

"Patients are more satisfied with their care when a provider asks them about safety in their personal relationships," Zierler says. "It is a quick question, and patients for the most part really are grateful to be asked."

If an HIV patient is being abused by a loved one, there is a good possibility that the person will be less compliant with HIV medications and treatments, Zierler theorizes.

"We know from studies with women and health care utilization patterns that women are less likely to access certain services if they’re in abusive relationships," she explains. "They’re more likely to show up later for prenatal care and are less likely to stay on medications they need."

One aspect of domestic abuse is a control factor, in which the abusive partner may withhold medication or prevent the victim partner from leaving the house for medical treatment, she adds.

Zierler suggests clinicians approach patients on the issue of domestic violence by beginning casually, and saying, "Everybody fights in their home. When you and your partner fight, or when you are with someone you love and you fight, do you ever feel afraid that you are really going to be hurt? Have you ever been hurt? If so, here is a pile of numbers you can call."

However, Zierler acknowledges that if the patient is a man, there may be fewer community resources available to help. "Most of the services have been built around women’s needs," she says. "And one of the issues we want to be sure comes out in this paper is that gay and bisexual men really need attention in the area of domestic violence."

Still, some AIDS or gay organizations might be able to help. In Zierler’s state of Rhode Island, there is an AIDS volunteer agency that provides counseling for men who are victims of gay male battering, and these types of services probably are available in most larger metropolitan areas.

"Particularly, since we noted that there were high reports of violence among Hispanic gay and bisexual men, it speaks to a particular need for support to groups that are more susceptible to isolation," Zierler adds.

The study found that Hispanic gay men reported the highest prevalence of violence against them, with a rate of 13.6%. Also, the study showed that gay and bisexual men under the age of 40 are three times more likely to be a victim of violence.

While the study did not seek causes for domestic abuse, there was one question relating to this. Participants were asked if they thought their physical harm resulted from or was related to their HIV infection. Close to half of the respondents said "Yes."

Although it’s possible HIV infection is a trigger for domestic violence, this study doesn’t prove that hypothesis. "This doesn’t mean that HIV caused the harm, because we don’t know if they didn’t have HIV whether the same thing would have happened," Zierler says. "People who are at risk for HIV infection have a lot of violence in their lives, as well."

Zierler says the factors related to risk of partner/relationship violence were a history of drug dependence, homelessness, and unemployment. Racism, homophobia, sexism, and poverty also play a role in raising the risk of violence, she adds.

"The point is that the conditions that set people up for HIV are very similar to those that put them at risk for violence," Zierler says. "These are populations of people who are essentially living lives that have been dehumanized and are finding strategies of resistance to the social forces that are beating down on them day to day."

Clinicians also can look for certain risk factors among their patients. For instance, there is a greater risk of domestic abuse among women who live in the Midwest and among women who have symptoms of vaginal infection.