Effects of Trauma on Reproductive Decisions by People Living With HIV
While many in the field of infectious disease research and medicine have noted the decline in new investigators and practitioners entering the workforce, the HIV Medicine Association (HIVMA) and the Infectious Disease Society of America Foundation (IDSA) have teamed up to do something about it. Over the summer, they announced a program to fund 15 medical students in the U.S. for clinical learning and research projects, each to be paired with an experienced mentor to support the student's research area of interest. This is one of a series of interviews with a mentor/mentee pair.
We spoke with Katherine Schafer, M.D., assistant professor of Infectious Diseases with the Wake Forest University School of Medicine. Her primary area of research is improving patient care and outcomes for rural people living with HIV. Her mentee, Doris German, is a third-year medical student at Wake Forest, who is interested in working with underserved populations and has a particular interest in women's health.
Jeanine Barone: HIV infection and trauma, including childhood sexual abuse or violence in intimate relationships, are related, but what is the nature of this relationship?
Katherine Schafer: As with any observational research, we cannot say that one causes the other ("correlation does not imply causation"). What we can say is that there is an association between having HIV and experiencing abuse (in many forms): People living with HIV (PLWH) report high rates of having experienced abuse in their lifetimes. Additionally, intimate partner violence (IPV) exposure can increase someone's risk for HIV infection. Because of these associations, health care providers need to be aware of how to screen for and respond to histories of abuse both to prevent HIV and to manage existing infections more comprehensively.
JB: How does a history of trauma negatively impact the health of PLWH?
KS: Trauma, specifically IPV, is associated with worse health outcomes in human beings, regardless of HIV status. IPV itself is associated with depression and increased risky health behaviors (smoking, binge drinking, unprotected sexual practices). People who have been exposed to IPV are more likely to report asthma, headaches, chronic pain, difficulty sleeping, worse mental health, and other somatic complaints. Specifically for PLWH, experiencing IPV in one's adult lifetime is associated with worse engagement in care (measured by clinic attendance) and a higher likelihood of having a detectable viral load.
JB: How can we get more health care providers to discuss this?
KS: As a first step, we need to increase provider awareness and offer education about IPV and trauma as health issues. There are also system-based barriers in the outpatient setting, namely time, that often get in the way of adequately assessing all of the myriad factors that affect the health of PLWH (IPV and trauma being just one part of that complex picture). Any lasting solution will require a comprehensive approach that will include providers and the systems in which we work. We also need more research to explore other, more specific, impacts of IPV and trauma on health, such as lab markers of inflammation and aging that may be worse in PLWH who have had these experiences, compared to PLWH who have not.
JB: What are your recommendations for incorporating reproductive health into HIV care for PLWH?
KS: An oversimplified answer would be to co-locate and integrate reproductive health care with the primary HIV care provision. As with all of the other questions here, it really depends on the setting and cultural context, which must be considered to guide any patient-centered approach to care. The answer to this question may be very different here in Winston-Salem compared to Bangalore, India. A much more comprehensive answer is can be found here.
JB: How does one empower PLWH to discuss their beliefs on reproductive health with their health care providers?
KS: Just as providers need to be aware and educated, so do our patients. Having information is empowering. PLWH need to know that their reproductive health beliefs (and any histories of trauma that may affect them) are an important part of their general health and that providers want to partner with them to give care and counsel that is congruent with each individual's beliefs. So, it is partially a responsibility of the providers and the systems in which we practice to let PLWH know that it is important to communicate their reproductive and other health beliefs. At the same time, we want our patients to ask questions to become knowledgeable in their own right.
JB: [Doris German], what are some findings from your research that you can discuss?
Doris German: We have published a literature review on Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living With HIV, and we are currently working on a manuscript: Gathering Trauma Narratives: A Qualitative Study on the Impact of Self-Identified Traumas on People Living With HIV (PLWH). Our review showed that while there is a large body of literature on the quantitative aspects of reproduction in people living with HIV, there is little research on the qualitative aspects, particularly in the Southeast U.S., where our study took place. We have not yet published our findings on the trauma interviews; however, we have presented preliminary results at conferences. Trauma that our participants identified included their HIV diagnosis, loss of a loved one, and sexual and physical abuse. Social support systems played a large role in how patients reacted to traumatic experiences and what they learned from these experiences.
JB: As a third-year med student, did you find any of your findings to be surprising?
DG: I was surprised and impressed by the resilience and willingness to share from our participants. All had experienced significant trauma, and seven out of 15 expressed gratitude at the ability to share their stories and/or participate in research that could benefit others living with HIV.
JB: Has your experience in this project stimulated your interest in infectious diseases, HIV in particular, or working with underserved populations, including women living with HIV?
DG: My experience with this project and the support of the IDSA and HIVMA has increased my interest in internal medicine as a specialty and infectious disease as a fellowship. I am very interested in working with underserved populations, and the field of infectious diseases is unfortunately underserved.
This transcript has been lightly edited for clarity.
Jeanine Barone is a scientist and journalist with an eclectic background. She's a nutritionist and exercise physiologist who regularly writes about travel, health, fitness, and food for numerous top-tier publications. Jeanine enjoys active travel, especially long-distance cycling and cross-country skiing.