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1. http://www.samhsa.gov/traumajustice/traumadefinition/definition.aspx

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2. Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implications for healthcare. In: Lanius RA, Vermetten E, Pain C, eds. The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Cambridge: Cambridge University Press; 2010:77-87. 3. Breiding, M. J., Black, M. C., & Ryan, G. W. (2008). Chronic disease and health risk behaviors associated with intimate partner violence—18 US states/territories, 2005. Annals of epidemiology, 18(7), 538-544. 4. Centers for Disease Control and Prevention. HIV Among Women March 2013. http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/index.htm. Accessed July 18, 2013.

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5. Maman, S. et al. 2000. The intersections of HIV and violence: Directions for future research and interventions. Social Science and Medicine 50 (4):459-478 6.  Zierler, S. et al. (2000). Violence victimization after HIV infections in a U.S.

probability sample of adult patients in primary care. American Journal of Public Health 90 (2):208-215.

7. Machtinger, E. L., Haberer, J. E., Wilson, T. C., & Weiss, D. S. (2012). Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders. AIDS and Behavior, 16(8), 2160-2170. 8. Machtinger, E. L., Wilson, T. C., Haberer, J. E., & Weiss, D. S. (2012). Psychological trauma and PTSD in HIV-positive women: a meta-analysis. AIDS and Behavior, 16(8), 2091-2100.

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9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association; 2013.

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10. Institute of Medicine Committee on Preventive Services for Women. Clinical Preventive Services for Women: Closing the Gaps Institute of Medicine; 2011. 11.National HIV/AIDS Strategy. In: Office of National AIDS Policy (ONAP), ed. Washington, DC: U.S. Government Printing Office; 2010.

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12. Curry MA, Durham L, Bullock L, Bloom T, Davis J. Nurse case management for pregnant women experiencing or at risk for abuse. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2006;35(2):181-192. 13. Kiely M, El-Mohandes AA, El-Khorazaty MN, Gantz MG. An integrated intervention to reduce intimate partner violence in pregnancy: A randomized trial. Obstetrics and Gynecology. 2010;115(2 Pt 1):273. PMC2917915. 14. El-Mohandes AA, Kiely M, Joseph JG, et al. An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstetrics and Gynecology. 2008;112(3):611-620. PMC2935657. 15.El-Mohandes AA, Kiely M, Gantz MG, El-Khorazaty MN. Very preterm birth is reduced in women receiving an integrated behavioral intervention: a randomized controlled trial. Maternal and Child Health Journal. Jan 2011;15(1):19-28. PMC2988881. 18. Ford-Gilboe M, Merritt-Gray M, Varcoe C, Wuest J. A theory-based primary health care intervention for women who have left abusive partners. Advances in Nursing Science. 2011;34(3):198-214. 19. McFarlane JM, Groff JY, O'Brien JA, Watson K. Secondary prevention of intimate

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22. Substance Abuse and Mental Health Services Administration (SAMHSA). Trauma Definition Part One: Defining Trauma. 2012. http://www.samhsa.gov/traumajustice/traumadefinition/definition.aspx. Accessed 3/24/14.

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22. Substance Abuse and Mental Health Services Administration. SAMHSA's Concept of Trauma and Guidance for a Trauma-informed Approach. Rockville, MD: SAMHSA;2014. 23. Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: A systematic review to update the U.S. Preventive Services Task Force recommendation. Annals of Internal Medicine. 2012;156(11):796-808, W-279, W-280, W-281, W-282. 24. Cloitre M, Courtois CA, Charuvastra A, Carapezza R, Stolbach BC, Green BL. Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress. 2011;24(6):615-627. 25. Community Connections. Creating Cultures of Trauma-informed Care. Washington, DC: Community Connections; 2009. 26. Substance Abuse and Mental Health Services Administration. National Registry of Evidence-based Programs and Practices. www.nrepp.samhsa.gov. Accessed 3/24/14. 27. Cloitre M, Courtois CA, Ford JD, et al. The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. 2012. http:www.istss.org. Accessed 3/24/14. 28. Cloitre M, Koenen KC, Cohen LR, Han H. Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology. 2002;70(5):1067.

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This result has been a conceptual model of trauma-informed primary care, consisting of 3 core components: The first is a trauma-informed environment that is calm, safe, and empowering for both patients and staff. In such an environment, - Providers, and staff from every discipline are educated about the impact of trauma on health - The clinical flow is configured to reduce triggers and promote trust, collaboration and healing. ______________________________________________________________________ The second core component is screening. In a trauma-informed clinic, providers routinely inquire about both current trauma and lifelong abuse, as well as the consequences of lifelong abuse including complex PTSD, depression, and substance abuse. -Although screening is routine and universal, disclosure is ultimately led by the patients guided by respect for patients’ choices. _______________________________________________________________________ Finally, screening is directly linked to on-site and community based interventions that address current and lifelong abuse. - For recent trauma, immediate safety and autonomy are prioritized, and interventions might include an algorithm for safety plans, lethality assessments, and referrals to community-based domestic violence organizations. -  For the consequences of lifelong abuse, interventions are longer-term and ideally would include evidence based group interventions for complex PTSD. At least, existing services such as social work, therapy, substance abuse counseling, and medication adherence become trauma-informed and recognize the link between lifelong abuse and physical and behavioral health and integrate this understanding into their care. ________________________________________________________________________ These three components are dependent upon a strong foundation that includes: -  A core set of trauma-informed values -  robust partnerships with community-based organizations -  clinic champions from each discipline - continuous monitoring, evaluation, and feedback to providers; and, importantly -  A ongoing response to vicarious trauma among providers

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In the near future, we plan to refine and publish this model, and then perform a formal implementation and evaluation study of it. The model’s novelty and power relate mostly to its recognition that screening and interventions for lifelong abuse and its consequences need to exist alongside our more familiar focus on IPV. The ultimate goal is to disseminate and scale the model so other clinic's can more effectively address the impact of trauma on the lives of women living with HIV, as well as with other populations of men and women who experience high rates and negative health outcomes from recent and lifelong abuse. Thank you very much. I welcome your comments and input.

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