If your HIV clinic is anything like mine, not a small number of the patients have major health challenges. Depression, anxiety, substance abuse, pack-a-day smoking habits, obesity, risky sex, domestic violence -- these turn up on my patients' problem lists much more regularly than any opportunistic infection or AIDS-related complication.
Increasingly, I have become more aware of how my patients' poor health behaviors began early in life and how their childhood experiences have shaped how they take care of themselves. This was most obvious in my prison-based HIV clinic, where the scars of past trauma were evident not only on the bodies, but also in the psyches of the men I saw.
In an analysis of data from a large telephone-based survey conducted with over 48,000 adults in Minnesota, Montana, Vermont, Washington and Wisconsin, adverse childhood events (ACE) such as physical, sexual and verbal abuse were probed and then associated with a number of outcomes including risky behaviors and morbidity, for example binge and heavy drinking, current smoking, high-risk HIV behavior, obesity, diabetes, cardiovascular disease (CVD), depression and disabilities.
Overall, the results were highly depressing: Over half of respondents reported at least one ACE. Greater than one in 10 reported at least four ACEs and these individuals had higher odds of risky HIV behavior as well as most of the morbidities examined. Specific patterns of ACE were associated with specific outcomes. Sexual abuse and verbal abuse independently were linked to most of these outcomes including risky behaviors but also diabetes and obesity. In addition to sexual ACE, incarceration of someone from the household was associated with high HIV risk behaviors in later life.
These data are from just five states, and these are hardly representative of the U.S. A broader survey would likely find an even more dismal picture.
The Bottom Line
A bad childhood doesn't necessarily excuse sins or bad judgments, but this analysis makes clear that cards can be stacked -- for some more than others -- against doing well physically and emotionally.
We need to appreciate this as we tend to our patients and, yes, even judge them. Too often, what we see in our patients are their failures: failure to use condoms, to adhere, to abstain, to floss, to stay out of jail, to show up on time. Even our terminology reeks of disappointment, such as when we say patients "failed" their regimen or had "virologic failure." These data help me to understand where these sometimes epic fails come from -- and to see that their roots reach back to the little versions of the people sitting before me.
The report also should rouse in all of us a commitment to protect children vulnerable to such abuse. Like many families, my own plays the wishing game, in which you say what you would wish for if granted but a single wish. I have thought a lot about this, and while "an end to war," "good health for all," and "stopping global warming" all contend for selection, the one that I have chosen and think would do the world the most good is for every kid from now on to have a happy childhood. Grant that one wish, and I believe the rest will follow.
What are some other top clinical developments of 2015? Read more of Dr. Wohl's picks.
David Alain Wohl, M.D., is an associate professor of medicine in the Division of Infectious Diseases at the University of North Carolina and site leader of the University of North Carolina AIDS Clinical Trials Unit at Chapel Hill.