Being Trauma-Informed in the Care of People Living with HIV

www.healthfederation.org
Being Trauma-Informed in the
Care of People Living With HIV
By Marcy Witherspoon, MSW, LSW
Senior Training Specialist
Health Federation of Philadelphia

Health policymakers and
practitioners across the country are
increasingly recognizing the effects
of trauma on the health status of
individuals … let’s examine why.

Session Objectives
• To relay the profound impact of childhood trauma on
brain development, temperament and adult-specific
behavior.
• To discuss the Adverse Childhood Experiences
(ACE) Study and its potential effects over the life
course.
• To provide trauma-informed principles to reduce the
negative sequelae associated with HIV diagnosis,
disclosure, and treatment

Childhood decides …
Jean Paul Sartre

Early experiences help to
determine brain structure,
thus shaping the way
people learn, think, and
behave for
the rest of their lives.

Trauma occurs when one’s
internal resources are not
adequate to deal with one’s
external threats … these
events are deeply
distressing and/or
threatening and can have
long-lasting negative
effects.

What are some examples of
childhood trauma?

Trauma is under-reported and under-diagnosed
(NTAC, 2004)
Exposure to Trauma
Trauma can be:
• A single event
• A connected series
of events
• Chronic lasting stress
Used with permission from Trauma Informed Florida Project
http://www.djj.state.fl.us/trauma-informed-care/index.html

•race
•gender
•ethnicity
•religion
•socio-economic group
•community
•workforce
•sexual orientation
•gender identity
Trauma can occur at any age.
Trauma can affect any:
Used with permission from Trauma
Informed Florida Project
http://www.djj.state.fl.us/trauma-

www.healthfederation.org 10 21
Lower part of brain over-wired
at expense of upper parts
Unremitting Stress
Childhood Trauma
Challenging behaviors associated with
lower brain functions
Excessive stress
hormones dumped
into brain
Ongoing social, emotional, cognitive difficulties
The Brain on Trauma
Adult trauma and related
problems

Body’s Automatic CNS Response

www.traumahealing.com

Toxic Stress & The Brain
• Causes disruption of brain architecture, brain
organization and brain chemistry
– Impairs cell growth
– Interferes with healthy neural circuits
– Changes chemical and hormonal responses in the brain

Toxic Stress & PTSD
• After trauma, some people develop stress-
related symptoms that don’t go away …
1) re-experiencing the trauma
2) avoiding reminders of trauma
3) hypervigilance
4) change in mood/thoughts

We need to know that …
• trauma is common, pervasive & universal
• trauma is about perception of the event
• trauma can change the brain & concomitant
behavior
• trauma can impact one’s health

Trauma’s Lasting Negative Effects
1) world view
2) feelings of safety
3) sense of future
4) relationships with others
5) health & well-being
6) emotional awareness & expression

The ACE Study -- the largest public
health study of its kind that
nobody has ever heard of …

Study method
17,421 members of the Kaiser Health Plan
in San Diego County from 1995-1997
Confidential survey asking questions
about childhood trauma and current
health status and behaviors combined
with physical examination
Demographics:
• primary care setting
• educated
• middle class
• predominantly white

Ten Original ACEs
• 1)physical abuse
• 2)emotional abuse
• 3)sexual abuse
• 4)physical neglect
• 5)emotional neglect
• 6)mother a victim of IPV
• 7) HH member incarcerated
• 8) HH member mental health
• 9) HH member substance use
• 10)one/both bio parents absent

aces 5-minute primer

Adverse
Childhood
Experiences
Heart
Disease
Chronic Lung
Disease
Liver Disease
Suicide
Substance
Abuse
HIV and STI’s
Adverse Childhood Experiences
Increase the Risks of:
Used with
permission from
Trauma Informed
Florida Project:
http://www.djj.state.fl.us/trauma-informed-care/index.html

Philadelphia Expanded ACE Study
www.instituteforsafefamilies.org/philadelphia-urban-ace-study
Experiencing Racism/Discrimination
Witnessing Community Violence
Living in an Unsafe Neighborhood
Living in Foster Care
Experiencing Bullying

Philadelphia
Urban ACE
Project , a
collaboration
of (PHMC,
CHOP, St.
Christopher’s,
ISF, Drexel
University

Original Study vs. 11th Street Results
# of
ACEs
(ACE Score)
Women Men Total
11th
Street
Patients
Original
Study
11th
Street
Patients
Original
Study
11th
Street
Patients
Original
Study
0 6.8% 34.5% 3.9% 38.0% 6.3% 36.1%
1 12.5% 24.5% 9.9% 27.9% 12.0% 26.0%
2 18.5% 15.5% 14.5% 16.4% 17.8% 15.9%
3 14.6% 10.3% 16.4% 8.6% 14.9% 9.5%
4 or more 47.5% 15.2% 55.3% 9.2% 49.0% 12-16%
From
Dr. Patty
Gerrity
and Dr.
Roberta
Waite,
The
Healing
Project

People Living With HIV …
• More likely to have significant trauma histories
(childhood sexual & physical abuse)
• More likely to have co-morbid medical conditions
• 95% of people living with HIV report at least one
severe traumatic stressor
• 54% are reported to have PTSD
• Behavioral, neurobiological and psychological
changes often prevent effective coping strategies
and positive health behaviors.

HIV and Current Trauma
• Any childhood trauma is worsened by stigma,
discrimination, and bias – by others, often in health care
settings
• Some settings are re-traumatizing and trigger patients
• For some patients, learning of their status is traumatic.
• A woman living with HIV is 4x more likely to experience
treatment failure and not remain virally suppressed.
• Women who had experienced trauma are more likely to
have sex with partners whose HIV status is unknown to
them, have sex without condoms, and are more likely to
spread the infection with unprotected sex.
• 55% of women living with HIV experience IPV

Due to systemic issues related to
homophobia, transphobia,
patriarchy and other systemic
types of oppression, HIV treatment
is often not working for:
• Women living with HIV
• Transgender women
• Young black gay men

Many clinics work with patients
who get to undetectable viral
loads, but …
• about 50% are depressed
• almost 50% are using substances
• most are poor
• most aren’t fully “out” re: status
• many are living with abusive partners
• many are not working

What would help?
• This information is important to consider when
assessing impact on members of the HIV positive
community.
• Focus has been on biomedical model (adherence to
medication, getting to an undetectable viral load,
etc.) and ignored other pieces of personal health &
experiences.
• More helpful focus might be a medical home model
where primary care is integrated into HIV treatment
• Routine screening for ACEs would exist – behavioral
health consultation would be available on-site
• Health-providing sites would be “safe spaces.”
• Harm reduction models would be utilized
Please keep
in mind,
there are
protective
factors
available to
people to
lessen the
impact of
ACES on
future health
outcomes

Just because you have had trauma,
this does not mean your disease will
spiral out of control …
But you must be aware of how
unresolved trauma impacts health
choices, lifestyle decisions, and begin
to learn ways to ameliorate the effects
of stress …

These challenges impact adherence
to medication and engagement in
care … so, in spite of new
medications/treatment, HIV is the
leading cause of death among Black
women ages 25-34.

At one clinic, 16% of deaths were
HIV-related, while 84% were
related to murder, substance use,
suicide and hopelessness…

What happened to
you?
vs.
What’s wrong with
you?
Trauma-Informed Care

TIC moves from shame, blame and
punishment to …
Understanding (What happened to you
and how has it affected you?)
Nurturing (How can I help you?)
Healing (How can I help you to heal, and not create
more problems for you?)

• requires universal trauma precautions and screening
• practice changes with patients with known trauma
histories
• patient-centered communication and care
• safe clinical environments
• shared decision-making for patients
• provider collaboration across disciplines
• requires awareness of own trauma histories

Framework
• requires change to organizational policies, practices
and culture
• reflects an understanding of the impact of trauma
and paths for recovery
• actively seeks to prevent re-traumatization
• reviews how services can trigger patient
• understands strengths-based approaches that
promote resiliency

For People Living with HIV
• Know this is a real and
present phenomenon
• Have patience with yourself
• Re-evaluate your coping
strategies
• Seek out safe, stable and
nurturing supports
• Engage your allies (peer,
personal, and professional)
• Explore, identify and
manage your triggers (as
much as is possible)
• Multiply your connections
• Handle yourself gently
• Seek consistency
• Consider trauma specific
services

The goal of TIC …
The entire health care community integrates
trauma-informed practices into daily practice based on
awareness of how the brain works and the science of
ACEs so that individuals, no matter what their health
challenges, can maximize their health and have better
outcomes…

“If you think you’re too
small to make a
difference, try sleeping in
a room with a mosquito.”
African Proverb

The Health Federation of Philadelphia
is continually developing new programs in response
to both the needs of underserved communities and the
availability of data indicating improved approaches
to health care and behavioral support.
For more information about our initiatives, please visit:
HFP0617001

Being Trauma-Informed in the Care of People Living with HIV

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