Special Coverage: 12th Conference on Retroviruses and Opportunistic Infections
Study examines impact of abuse on HIV patients
Emotional abuse is significant marker
New research about HIV patients finds emotional abuse as a child is one of the strongest predictors of poor adherence, alcoholism, and drug abuse.1
Clinicians working at HIV clinics in urban New Mexico were surprised to see a familiar pattern of a past history of physical, sexual, and/or emotional abuse among HIV patients.
Social workers who interviewed new patients saw anecdotal evidence that some type of abuse existed in many patients’ pasts, says Karla A. Thornton, MD, MPH, an HIV clinician and an assistant professor in the division of infectious diseases and department of internal medicine at the University of New Mexico Health Sciences Center in Albuquerque.
"They thought it had a strong impact on how the patients dealt with medicine and risky sex," she recalls. "Their conversations with patients were what started the conversation about abuse and HIV patients."
Thornton and other investigators decided to find out what kind of impact childhood abuse had on HIV patients’ behaviors by designing a cross-sectional study of a convenience sample of 506 HIV-infected patients, who were seen at two urban New Mexico HIV clinics between July 2003, and May 2004.1
"Two to three years ago, we felt like a lot of our clients had these strong histories of sexual abuse, and we thought that might have an effect on their adherence," Thornton says. "So we designed the study to look at the relationship between abuse and risky sexual behavior and adherence and sexual abuse."
Adverse childhood experiences were measured using the Childhood Trauma Questionnaire, which measures five types of abuse, including sexual, emotional, physical, emotional neglect, and physical neglect.1
Nearly 90% of the participants were male, and 88% were men who have sex with men (MSM).
Investigators found that abuse was quite common among the participants: 41% had experienced moderate to extreme sexual abuse; 38% had experienced moderate to extreme emotional abuse, and 30% had experienced moderate to extreme physical abuse. Moderate to severe physical neglect was experienced by 50%, and 27% had experienced moderate to extreme emotional neglect.1
Depression increases nonadherence
"What we found that was significant statistically was that emotional abuse as a child was one of the strongest predictors of poor adherence," Thornton says.
"Depression modified the relationship between emotional abuse and nonadherence," she notes. "Those with a history of emotional abuse and depression were three times more likely to be nonadherent."
In the sample studied, it had to be stratified by depression, and the findings were that if the person was both symptomatically depressed and had the history of emotional abuse, he or she was three times more likely to be nonadherent to the HIV medication regimen, Thornton says.
The study found a lot of risk behaviors among the patients, in addition to a lot of abuse, so it was difficult to tease out small differences, she says.
"The other statistically significant finding was we looked at different kinds of substance abuse and found that people who had a history of emotional abuse were twice as likely to use illicit drugs in the last four months," Thornton says.
Marijuana was not included in the list of illicit drugs because it was so commonly used, she notes.
"The other thing that was significant was the relationship between people who had a history of physical abuse and drinking," Thornton adds. "Those who had been physically abused were 2.7 times more likely to be actively using alcohol and actively drinking, and they answered Yes’ to the question of have you ever considered yourself an alcoholic."
To the researchers surprise, sexual abuse did not have a significantly different impact on any of the factors addressed in the study, she says.
"Almost 50% of our people had experienced some kind of abuse," Thornton says. "It’s way beyond the normal population or even other populations. It was a disturbing finding."
Investigators continue to believe that sexual abuse has more of an impact on HIV patients’ behavior than what they were able to find in this study, she says.
"We’re trying to detect a difference between two groups, and it’s difficult to tease out unless the difference is huge," Thornton says. "There’s probably a lot more there than what we could find."
However, the study found that risky sexual behavior was commonplace among patients: of the MSM who engaged in anal intercourse, 35% reported never, rarely, or only sometimes using condoms, and they also were unlikely to report their HIV status prior to having sex.1
Ideally, the next step would be to compare the HIV group with a group that doesn’t have HIV and study the impact of abuse on different behaviors, Thornton says.
"HIV is such an alarming risk factor in itself," she continues. "It’d be interesting to do a study looking at uninfected people and ask the same questions."
Also, researchers intend to use the Childhood Trauma Questionnaire and screen patients who have a strong history of abuse to provide some sort of intervention, Thornton says.
"We’re not sure what that intervention will be, other than an acknowledgement of that history and referring the person, if he or she is willing, to a psychologist or social worker," she says.
The clinics have a full-time social worker and part-time psychiatric help, and there is a psychologist, who works for an AIDS service organization in the same building, who is available for referrals, Thornton adds.
She acknowledges that this area of research creates more questions than answers for HIV clinicians.
"As a clinician, I know it’s really difficult because if you open up Pandora’s box, it’s hard to know where to send people for help, and most of us are not trained to deal with it," notes Thornton. "But acknowledgement is the first step; ask questions, and just begin to recognize whether this has an impact on behavior."
Reference
- Thornton K, Veikley W, Hollifield M, et al. Surviving childhood abuse: Health risk behaviors in an HIV-infected clinic population. Presented at the 12th Conference on Retroviruses and Opportunistic Infections, Boston; February 2005. Abstract 978.
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