THE INTIMATE PARTNER Reed Siemieniuk, MD

Department of Clinical AND HIV & Biostatistics, McMaster SYNDEMIC University Department of , University of Toronto CONFLICTS OF INTEREST

 No conflicts to declare. OUTLINE

 Syndemic : two or more afflictions, interacting synergistically, and contributing to excess burden of in a population

 Links from IPV -> HIV back to IPV  Clinical and social implications of IPV among PLWH with outcome implications IN 2009 OPPORTUNITIES FOR IMPACTFUL HIV RESEARCH SEEMED LIMITED

 ART freely available.  Many simple, well tolerated, potent drugs .  Five classes of ART minimized drug interactions and toxicities  Over 83% of those in care on ART and almost all doing really well and are functionally “non‐infectious”.  Lowest number of profoundly immune compromised patients in 20 years!  Small number of AIDS deaths often from late presentation Changes in ARV of Active Patients 1800

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0 Mar‐ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 16 >4 0 0 0 0 0 0 0 0 0 0 0 2 4 8 21 20 27 32 30 25 24 28 23 13 7 6 5 4 7 4 5 4 0 0 0 0 0 0 0 0 0 4 4 10 40 48 61 74 92 95 91 97 105 109 103 91 71 85 74 68 59 49 42 3 0 0 0 0 0 0 0 1 1 18 91 277 292 331 327 316 303 345 372 451 538 639 754 854 973 1018 1154 1253 1360 1440 1457 2 0 0 0 0 0 0 14 11 20 95 160 101 64 28 17 11 11 13 9 8 8 8 4 11 14 16 26 31 44 58 62 1 2 6 22 75 122 195 223 169 141 94 30 5 7 2 4 0 1 0 0 1 0 0 1 0 2 2 0 1 1 1 3 Not On 1 0 2 10 28 39 57 131 110 96 66 61 86 110 114 141 159 138 134 140 139 108 105 103 106 116 95 106 84 73 66 Naïve 11 57 90 121 146 97 118 140 148 119 92 63 73 95 105 113 154 135 130 149 163 188 160 162 143 128 98 93 100 61 53 CD4 COUNTS OF ACTIVE PATIENTS 1800

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0 Mar‐ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 16 >500 0 21 47 89 131 85 90 107 95 89 106 140 186 211 263 266 270 270 268 306 343 389 431 486 516 537 656 815 879 945 920 201‐500 3 15 37 66 89 130 178 167 148 147 158 216 243 267 267 307 349 357 390 447 490 545 567 594 647 695 664 606 635 605 623 75‐200 1 3 10 21 33 58 65 78 64 75 85 108 90 93 75 73 76 101 84 85 100 106 118 120 111 105 103 95 100 100 115 <75 0 3 14 28 39 54 78 95 111 113 91 50 42 46 39 25 34 28 23 29 42 38 31 29 39 32 29 37 33 31 26 Annual Deaths by AIDS or NON‐AIDS Related(Updated from HIV Med 2006)

80

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40 Number of patients 30

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0 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Mar‐ 16 HIV‐ AIDS Related 3 8 19 24 25 42 46 50 72 66 50 21 12 10 20 12 8 11 6 6 6 10 14 13 11 6 7 3 11 4 1 Non‐HIV‐ AIDS Related 035263574446114166710161111171515914131218130 Not Specified 0220012323311321100433522202112 BUT THEN..

 One of the most liked patients was killed by her common law partner in extremely violent domestic violence attack  From every program metric she was very success with normal immunity on ART but was there a missed opportunity?  Moment of conscience for an infectious clinic: “Are we treating the virus and CD4 count or the whole patient?” NEXT STEPS

 The entire clinic staff held a team meeting.  Little in our medical records suggestive of this patient’s danger. Consensus as mark of respect we need to try to ensure this never happens again.  We decided we needed to find out urgently:  How common was IPV in our program?  How was it impacting our patients? WHAT IS DOMESTIC VIOLENCE?

1. Siemieniuk RA. Curr HIV/AIDS Rep. 2013;10:380-90. SCREENING PROGRAM

 Soon after the event in May 2009 routine IPV screening initiated.  As of June 30 2016 , 1,994 (87.3%) of 2,284 patients have been formally screened for past or present IPV1 . 33.9% disclosed domestic violence as an adult or child

 Our findings fit well with the 20‐50% lifetime among people living with HIV reported elsewhere 1‐4

1. Siemieniuk RA. AIDS Patient Care STDS. 2010;24:763–70. 2. Raissi SE. AIDS Patient Care STDS. 2015;29:133-41. 3. Dhairyawan R. HIV Med. 2013;14:303–10. 4. Kalokhe AS. AIDS Patient Care STDS. 2012;26:234–40. INDIGENOUS POPULATION PROVERBS

‐Knowledge that is not used is abused ‐With Knowledge comes great responsibility PREVALENCE

DV, including IPV as an adult childhood abuse All 35% 23% Women 46% 40% Indigenous 67% 46% Indigenous women 81% 65% Gay/bisexual men 35% 22% Injection drug users 54% 32% TYPES OF IPV EXPERIENCED

Among women:1 All patients:2

1. Siemieniuk RA. J Acquir Immune Defic Syndr. 2013;64:32-8.. 2. Siemieniuk RA. AIDS Patient Care STDS. 2010;24:763-70 WHY SO COMMON?

• IPV leads to HIV infection • Prospective studies from Sub-Saharan Africa:

Study Country Population Increased Attributable adjusted HIV risk risk from IPV Jewkes1 South 1,100 women 51% 12% Africa Kouyoumdjian2 Uganda 10,000 women 55% 22%

Were3 Sub- 3,400 62% Saharan serodiscordant Africa couples

• Cross-sectional studies in Western countries show similar increased risk.

1. Jewkes RK. Lancet. 2010;376:41-8. 2. Kouyoumdjian FG. AIDS 2013;27:1331-8. 3. Were E. AIDS. 2011;25:2009-18. PATHWAYS FROM IPV TO HIV

Perpetrator’s partners fear HIV disclosure

Higher HIV Perpetrator Illicit substance use factors prevalence

Risky sexual practices

HIV IPV Illicit substance use Infection

Psychological Risky sexual distress practices Sexually transmitted

Sexual assault

1. Siemieniuk RA. Curr HIV/AIDS Rep. 2013;10:380-90. KEY CONNECTIONS WITH IPV AMONG PLWH

• Social factors – Homelessness/insecure housing – Illicit drug use – Smoking – Incarceration • Mental – Depressive disorders – Anxiety disorders – Suicide attempts/ideation • HIV outcomes – Health-related quality of life – Interruptions in care – HIV-related hospitalizations – AIDS in patients diagnosed early SOCIAL FACTORS

Table: Social/lifestyle associations with IPV in SAC Women1 Gay/bisexual men2 Insecure housing 4.5 (1.1-17.7) 2.6 (0.9-7.1) Incarceration 4.8 (1.9-12.7) 1.6 (0.6-4.0) Illicit drug use 7.6 (2.5-23.3) 1.5 (1.0-2.5) Smoking 5.1 (2.7-9.4) 2.5 (1.6-4.0) All reported as adjusted odds ratios (95% confidence interval)

1. Siemieniuk RA, et al. J Acquir Immune Defic Syndr. 2013;64:32-8.. 2. Siemieniuk, et al. HIV Med. 2013;14:293-302.

Table: Mental health associations with IPV in SAC Women1 Gay/bisexual men2 Depressive disorder 2.5 (1.2-5.5) 1.9 (1.1-3.2) Anxiety disorder (incl. 5.8 (2.1-15.6) 1.8 (1.0-3.4) PTSD) Suicide attempt 53.8 (5.2-556.5) 1.5 (0.5-4.2)

All reported as adjusted odds ratios (95% confidence interval)

1. Siemieniuk RA. J Acquir Immune Defic Syndr. 2013;64:32-8.. 2. Siemieniuk. HIV Med. 2013;14:293-302. CLINICAL IMPACT

Table: Clinical associations with IPV in SAC Women1 Gay/bisexual men2 Poor/fair vs. 2.9 (1.6-5.4) 2.9 (1.4-6.2) Good/excellent HRQoL

Interruption in care >1 1.9 (1.1-3.4) 1.5 (1.0-2.3) year Detectable VL at screen 2.1 (1.2-3.6) 1.5 (0.9-2.3)

All reported as adjusted odds ratios (95% confidence interval) HRQoL, health-related quality of life; VL, viral load

1. Siemieniuk RA. J Acquir Immune Defic Syndr. 2013;64:32-8.. 2. Siemieniuk RA. HIV Med. 2013;14:293-302. CLINICAL IMPACT

Table: Hospitalizations associated with IPV Women1 Gay/bisexual men2 All hospitalizations 1.4 (1.2-1.7) 1.0 (0.8-1.2) HIV-related (RR) 2.2 (1.0-4.9) 2.5 (1.5-4.0)

AIDS, presented with 1.5 (0.6-4.0) 2.1 (1.2-3.7) CD4>200 (AOR)

RR, relative risk; AOR, adjusted odds ratio (95% confidence interval)

1. Siemieniuk RA. J Acquir Immune Defic Syndr. 2013;64:32-8.. 2. Siemieniuk. HIV Med. 2013;14:293-302. IPV AND PREP

 IPV associated with approximately 50% more non-adherence by pill count and by plasma TDF levels

Roberts ST et al. J Acquir Immune Defic Syndr. 2016 Nov 1;73(3):313-322. WHAT CAN WE OR SHOULD WE DO ?

 Options 1. Denial: Don’t ask and rely on self-disclosure. But need self justification strategy! Well used approaches are “might reinjure the patient” or “no skill in area” or no resources to deal with it anyway” 2. Pass off the responsibility. FP /Specialist vice versa “better equipped to deal with issue “ 3.Ask and then panic. Good intentions but may be suboptimal for everyone .

4. Ask. Recognize and respect the reality of our patients’ lives. Plan ahead. Build trusting relationship. Empathize. Follow-up if disclosure. RESOURCES

 Rainbow Health Ontario . www.rainbowhealthontario.ca/  Family Services Toronto . www.familyservicetoronto.org/  Ontario Sexual Assault Treatment Centres . www.satcontario.com/ . HIV Post-exposure prophylaxis  Another Closet: DV in Gay and Lesbian relationships (Australia) . http://ssdv.acon.org.au/ THANK YOU!

 Dr John Gill for the foresight and drive to lead the DV screening program  Dr. Hart Krentz,and Elma Raissi.  Clinic Social Workers and nurses who are so dedicated to ensuring successful screening program . Patricia Miller, Natalie Marshall, Kevin Dong, Sherry Hurtubise, Nel Burroughs, Janet Furseth,  The SAC patients TIPS FOR IMPLEMENTING IPV SCREENING

1. Raissi SE. AIDS Patient Care STDS. 2015;29:133-41.