Reed AC Siemieniuk, BSc,1,2 Patricia Miller, MSW,1,3 Kate Woodman, PhD,4 Karen Ko, MA,1 Hartmut B Krentz, PhD,1,3 M John Gill, MB, ChB1,3

1. Southern Alberta HIV Clinic, Calgary, AB2. Mount Royal University, Calgary, AB3. University of Calgary, Calgary, AB4. EndAbuse Canada, Edmonton, AB

DisclosureThere are no conflicts of interest.

BackgroundIntimate partner violence (IPV):

any behaviour in an intimate relationship causing physical, psychological, or sexual harm.1

Not often studied among gay and bisexual men( which might mean that we are more socially tolerant or socially ignorant)

Our research looks to reconstruct the social health discourse, specific to IPV/HIV/Gay/Bisexual Men’s health.1. World Health Organization. Intimate partner violence

[Fact sheet]. Available at: http://www.who.int/violence_injury_prevention/violence/world_report/factsheets/en/index.html

BackgroundIPV:

A risk factor for HIV-acquisition among women2 and increasingly recognized among gay and bisexual men3

Associated with behaviours conferring poor HIV-related outcomes

Also, IPV’s impact is starting to be acknowledged as impacting a HIV- pos. person’s quality of life.

2. Jewkes RK, et al. Lancet. 2010;376:41-8.3. Parsons JT, et al. Am J Public Health. 2012;102:156-62.

Goals of studyDescribe:Prevalence and subtypes of IPVClinical associationsOutcomes

Health-related quality of life (HRQoL)PsychiatricContinuity of careClinical outcomes (AIDS, hospitalizations)Information to develop preventative/intervention

health care strategies.

MethodsRoutine screening implemented in Southern

Alberta for all HIV patients May 2009.Screening tool modified from local Emergency

Department’sPreliminary findings and protocol previously

described4

Study inclusive to December 2011.

4. Siemieniuk RA, et al. AIDS Patient Care and STDs. 2010;24:763-70.

MethodsInclusion criteria:

Self-reported sex is male and self-reported sexual orientation is gay or bisexual

Figure 1: Screening Interview Algorithm

1. Screening Question

“Domestic violence and the threat of violence in the home is a problem for many people at SAC and in the community; this can directly affect health. Abuse can be a problem in relationships from all cultures and sexual orientations, and can take many forms: physical, sexual, emotional, isolation, neglect, intimidation or financial.We routinely ask all patients about domestic abuse in their lives. This often brings up many strong emotions, including different types of fear and uncertainty, but rest assured that this is a safe place to discuss this issue. Have you or your child(ren) ever experienced domestic abuse in any way?”

2. If yes, continue semi-structured conversation:

• Identify when abuse occurred:

a) As an adult with current intimate partner

b) As an adult with a previous intimate partner

c) As a child (<16 years of age)

• Identify type(s) of abuse experienced:

a) Physical abuse

b) Sexual abuse

c) Emotional abuse

d) Isolation

e) Neglect

f) Intimidation

g) Financial abuse

2. If no, continue with regular HIV care.

3. Identify perceived safety:

“Do you feel safe in your current

relationship?”

4. Offer professional consultation

Methods

MethodsClinical and demographic data is recorded

continually on all patientsMultivariable analysis conducted with

Poisson regression, adjusted a priori forAgeMonths living with HIVLog of CD4 at initial presentation to careLocation of HIV diagnosis (local vs non-local)

Results687 of 739 (93.0%) gay or bisexual males

engaged in care were screened for IPV154 of 687 (22.4%) reported IPV

Current relationship: 23 (14.9%)Previous relationship: 140 (90.9%)

Results154 of 687 (22.4%) reported IPV

Current relationship: 23 (14.9%)Previous relationship: 140 (90.9%)Persons disclosing IPV were more likely Aboriginal,

younger, victims of childhood abuse, had depression prior to diagnosis, use ongoing psychiatric resources, to recently have participated in unprotected sex, have poor to fair versus good to excellent quality of life.

Also, higher rates of clinically relevant interruptions in care, more HIV-related hospitalizations.

DemographicsIPV (% or SD) No IPV (% or SD) APR (95% CI) P

Age (SD) 43.8 (9.7) 46.1 (10.7) 0.97 (0.95-0.99) 0.01

Years in care (SD) 5.5 (4.4) 5.7 (4.5) 1.03 (0.98-1.08) 0.28

Diagnosed elsewhere 39 (25.3) 126 (23.6) 1.11 (0.72-1.70) 0.6

Ethnicity

Aboriginal 13 (8.4) 18 (3.4) 2.48 (1.18-5.2) 0.02

Black 2 (1.3) 9 (1.7) 0.81 (0.12-3.79) 0.8

Other 14 (9.1) 48 (9.0) 0.97 (0.51-1.86) 0.9

Caucasian 125 (81.2) 458 (85.9) Ref

Childhood abuse 64 (41.6) 80 (15.0) 4.27 (2.84-6.41) <0.001

Lives alone 39 (31.0) 156 (35.5) 0.91 (0.59-1.41) 0.7

DemographicsIPV (% or SD) No IPV (% or SD) APR (95% CI) P

Age (SD) 43.8 (9.7) 46.1 (10.7) 0.97 (0.95-0.99) 0.01

Years in care (SD) 5.5 (4.4) 5.7 (4.5) 1.03 (0.98-1.08) 0.28

Diagnosed elsewhere 39 (25.3) 126 (23.6) 1.11 (0.72-1.70) 0.6

Ethnicity

Aboriginal 13 (8.4) 18 (3.4) 2.48 (1.18-5.2) 0.02

Black 2 (1.3) 9 (1.7) 0.81 (0.12-3.79) 0.8

Other 14 (9.1) 48 (9.0) 0.97 (0.51-1.86) 0.9

Caucasian 125 (81.2) 458 (85.9) Ref

Childhood abuse 64 (41.6) 80 (15.0) 4.27 (2.84-6.41) <0.001

Lives alone 39 (31.0) 156 (35.5) 0.91 (0.59-1.41) 0.7

Mental HealthIPV (%) No IPV (%) APR (95% CI) P

Alcohol abuse 11 (8.8) 31 (7.1) 1.16 (0.56-2.42) 0.7

Illicit substance use 36 (33.0) 86 (21.7) 1.54 (0.95-2.50) 0.08

Smoking

Current 75 (59.5) 171 (37.3) 2.53 (1.59-4.00) <0.001

Former 16 (12.7) 83 (18.1) 1.23 (0.64-2.38) 0.5

Never 35 (27.8) 204 (44.5) Ref

Depression prior to HIV diagnosis*

35 (43.2) 77 (28.4) 1.87 (1.10-3.16) 0.02

Anxiety disorder prior to HIV diagnosis*

22 (29.3) 48 (18.0) 1.82 (0.98-3.40) 0.06

HIV psychiatry appointment in the past year

11 (7.1) 16 (3.0) 2.67 (1.20-5.95) 0.02

HIV psychiatry appointment ever*

35 (30.4) 51 (12.5) 3.53 (2.05-6.10) <0.001

*Local patients only

Sexual risk-takingIPV (%) No IPV (%) APR (95% CI) P

Sex since last visit 58 (50.9) 198 (47.5) 1.08 (0.70-1.64) 0.9

Unprotected sex since last visit

36 (33.0) 86 (21.7) 2.29 (1.10-4.77) 0.03

Health-related Quality of LifeIPV (%) No IPV (%) APR (95% CI) P

Poor 5 (4.1) 8 (1.8)2.91 (1.57-5.39) 0.001

Fair 18 (14.8) 32 (7.2)

Good 56 (45.9) 180 (40.4)1.60 (1.02-2.50) 0.04

Very Good 28 (23.0) 173 (38.8)

Excellent 15 (12.3) 53 (11.9) Ref

*Local patients only

Continuity of careIPV (%) No IPV (%) APR (95% CI) P

Longest interruption ≥365 days

50 (32.5) 133 (25.0) 1.50 (0.97-2.32) 0.07

Clinically significant interruption in care§ 41 (26.6) 87 (16.3) 1.95 (1.23-3.08) 0.004

§Lost to follow up ≥365 days and returned with VL ≥200/mm3

Clinical OutcomesIPV (%) No IPV (%) APR (95% CI) P

History of AIDS 41 (26.6) 126 (23.6) 1.40 (0.90-2.19) 0.14

History of AIDS, presenting CD4 ≥200

22 (19.1) 44 (11.5) 2.06 (1.15-3.69) 0.02

§Lost to follow up ≥365 days and returned with VL ≥200/mm3

Clinical outcomesIPV No IPV RR P

Persons hospitalized

Total hospitalizations

Rate (/1000 patient-years)

(95% CI)

Persons hospitalized

Total hospitalizations

Rate (/1000 patient-years)

(95% CI)

All hospitalizations

52 11990.6

(75.4-108.1)175 396

89.3(80.9-98.5)

1.01(0.83-1.23)

0.9

HIV-unrelated 42 8967.8

(54.8-83.0)143 330

74.4(66.7-82.8)

0.92(0.73-1.15)

0.45

HIV-related 21 3022.9

(15.7-32.2)55 66

14.9(11.6-18.8)

1.55(0.99-2.33)

0.05

HIV-related after initial HIV diagnosis

20 2821.3

(14.5-30.4)30 34

8.6(6.1-11.6)

2.46(1.51-3.99)

<0.001

Follow-up time (patient-years)

1313 4433

LimitationsSelf-reported outcomesGay and bisexual men were studied together

– may experience IPV differently

ConclusionsHigh prevalence of IPV (1/4.5)Associated with:

Aboriginal ethnicityChildhood abusePsychiatric diseaseRisky sexual behaviourPoor health-related quality of lifeInterruptions in careProgression to AIDS among those presenting

earlyHIV-related hospitalizations

ConclusionsIPV is an important (but underecognized) social

comorbidity among HIV-positive gay and bisexual men

Prospective studies will help further clarify its impact

Evidence-based interventions to identify victims and provide effective support may improve wellbeing for a substantial proportion of HIV-positive gay and bisexual men.

Knowledge transfer needed between helping professionals in order to reduce the impact of IPV.

AcknowledgementsAlberta Health Services and its Information

Technology Department for support of the clinical database that has allowed us to undertake this work.

The Southern Alberta HIV Clinic nurses and social workers

Types of IPVType of abuse

Emotional 125 (81.2)

Physical 113 (73.4)

Sexual 30 (19.5)

Intimidation 22 (14.3)

Financial 21 (13.6)

Isolation 12 (7.8)

Neglect 8 (5.2)

Number of types of abuseNumber of abuse types

One 55 (35.7)

Two 52 (33.7)

Three 31 (20.1)

Four 6 (3.9)

Five 6 (3.9)

Six 3 (1.9)

Seven 1 (0.6)