IAS-presentation_Abuse-and-Mortality-in-WIHS-July - PWN-USA

The Effect of Gender Based Violence (GBV) on Mortality: a longitudinal study of US women with & at risk for HIV

K. Weber, SR Cole & K. Anastos, J. Burke-Miller, D. Agniel, R. Schwartz, T. Wilson, M. Young, E. Golub and M. Cohen

Background GBV is a significant public health issue with a high prevalence (24-78%) among women with and at risk for HIV.  Studies have shown that abuse is associated with reduced medication adherence and poor treatment outcomes among people with HIV 

Study Objective 

To determine the prevalence of recent sexual, physical & emotional abuse & its effect on mortality in women in the Women’s Interagency HIV Study (WIHS), largest on-going study of a representative cohort of women with and at risk for HIV in the U.S.

Methods 

Included 2,222 (1642 HIV+/580 HIV-) women enrolled during 1994 and 2001 at Chicago, DC, Bronx and Brooklyn sites who had study visits every 6 months for up to 12 years



Marginal structural modeling was used to determine mortality risk & survival time associated with recent abuse controlling for sociodemographic, behavioral, & clinical factors

Study Measures 

Recent Abuse: self report in past year of forced

sexual contact, physical abuse/assault, and/or emotional abuse including intimate partner violence (IPV). IPV: threat to hurt/kill, prevent from leaving/entering home, making phone calls, meeting w/ friends, attending work/school, or getting needed medical care 

Outcome: All cause mortality & time to death confirmed by National Death Index registry matches

Baseline characteristics by survival status Characteristic

Survivors

Deaths

(N= 1785)

(N = 437)

69% 34 (29, 39) 71%

94% 39 (34, 43) 77%

22%

30%

29% 67% 14% 65%

15% 72% 13% 76%

Education < HS

35%

43%

Depressive symptoms

47%

64%

HIV+ Serostatus Age, Median (IQR) History of Pre-WIHS Abuse Childhood Sexual Abuse (CSA) Race White African American Other Income < 18,000

Characteristic

Survivors

Deaths

Current Crack, cocaine, heroin CCH) CCH Ever

21%

35 %

53%

77 %

IDU Ever

22%

51%

Current Smoking

55%

70%

Smoking Ever

68%

83%

Transactional Sex

24%

40%

Hazardous Drinking

15%

21%

Partnered

38%

34%

Unstable Housing

19%

17%

CD4 Count, Median

426

209

Abuse exposure by study year, HIV status, and prior abuse

-History of episodes Abuse -72%; new -6%; cumulative abuse -78% 2,450 abuse reported by abuse 794 (36%) women -2450 abuse events were reported by 794 (36%) of women during the study period

Survival Curves by Current Abuse 1.0 Abuse in Past Year

1.0

Abuse inNo Past Year No Yes

0.9

Yes

0.9

0.8

Crude Survival

Crude Survival

0.8

0.7

0.7

0.60.6

0.50.5

0.4

0.4

0

0

2

4

2

4 Years of Follow-up 6

6

8

Years of Follow-up

10

8

12

10

12

Association of recent abuse with mortality Current Abuse Unadjusted

Deaths

Personyears

HRa

95% CIa

No

392

16495

1

NA

Yes

45

1682

Baseline-Adjusted b

1.16 1.17

0.84, 1.60 0.84, 1.64

Fully-Adjusted c Weighted c Weighted, trimmed d

1.13 2.07 1.54

0.79, 1.60 1.66, 2.57 1.18, 2.02

a

HR, hazard ratio; CI, confidence interval b Adjusted for baseline variables: Study Site, HIV Serostatus, Age, Race, Income, Education, History of Pre-WIHS Abuse, Childhood Sexual Abuse, Health Care Utilization, CES-D Score, Cognitive Function, Drug Use, Smoking Status, Having a Partner, Unstable Housing, Transactional Sex, Hazardous Drinking, Viral Load, CD4 Count, Nadir CD4 Count, HAART Use, Non-adherence c Adjusted (or weighted) for baseline and time varying variables: Study Site, HIV Serostatus, Age, Race, Income, Education, History of Pre-WIHS Abuse, Childhood Sexual Abuse, Health Care Utilization, CES-D Score, Cognitive Function, Drug Use, Smoking Status, Having a Partner, Unstable Housing, Transactional Sex, Hazardous Drinking, Viral Load, CD4 Count, Nadir CD4 Count, HAART Use, Non-adherence d Weighted trimmed at the 0.1 and 10

Conclusions In this longitudinal study, marginal structural modeling allowed us to estimate the causal effect of recent abuse on mortality  Lifetime prevalence of abuse in women in this study is 78%; one third of women in WIHS reporting recent abuse during our study observation  Women who experienced recent abuse were nearly twice as likely to die than those who did not experience abuse 

Implications 

Since recent abuse reduces survival in women with HIV, identification of current abusive episodes and provision of interventions are needed to reduce mortality.



Provide resources to design, test and utilize innovative interventions to prevent GBV and treat those affected by GBV



Future research into identifying the causal pathway linking abuse to mortality is needed

What is needed Research into how intimate partner abuse and childhood sexual abuse affect the immune system may help explain why trauma seems to be associated with increased morbidity and mortality in HIV and other diseases.  Health care systems need to integrate and improve violence screening and referrals to keep women safe and alive. 

Addressing family and community level violence including a no tolerance approach can change the culture of violence.  Gender equity, reducing poverty, increasing education opportunities and women’s empowerment are needed to challenge current structural violence  A national sustainable plan is needed to ensure that women with and at risk for HIV are safe and continue to benefit from treatment advances. 