In doing HIV/AIDS work, it is critical to operate with the awareness that a large proportion of adolescents and adults were sexually abused as children and that abuse has had a profound and devastating effect on their consequent psychosocial development. Childhood sexual abuse has been strongly associated with numerous disturbing behavioral and psychological outcomes in adolescent and adult women. Among them are further domestic violence, adolescent pregnancy, child abuse, drug and alcohol abuse, bulimia, sexually transmitted infections, depression, prostitution, self-mutilation, running away from home and dropping out of school (Rosenfeld, 1993; Boyer, 1992). The emotional trauma of childhood sexual abuse is compounded by the fact that the perpetrator of the violence is usually a close, male family member. In most cases, sexual abuse occurs in a family atmosphere of silence, secrecy, protection of the perpetrator and disbelief or blaming of the child victim.

The link between child sexual abuse and risk for HIV infection has been proposed by several authors (Caseese, 1993; Paone, 1993; Rosenfeld, 1993; Zierler, 1991), and recent research strongly confirms that association. Large, prospective, multisite studies of cohorts of women with and at high behavioral risk for HIV have uncovered striking data by conducting structured interviews with participants. Of 771 women enrolled in HIV Epidemiology Research Study (HERS) sites in Baltimore, Detroit, and the Bronx, 43% had been sexually abused as children and 45% had been sexually abused as adults (Vlahov, 1996). In this cohort, 28.3% of the women reported having witnessed a murder.

In the Women's Interagency HIV Study (WIHS), data from 1560 women enrolled in New York City, Chicago, Washington, DC, and Los Angeles revealed that 40% reported a history of childhood sexual abuse (Cook, 1997) For these women, a history of sexual abuse, physical abuse or domestic abuse was highly correlated with engaging in risk behavior for HIV. In particular, childhood sexual abuse was significantly associated with: use of IV drugs; exchange of sex for drugs, money or shelter; higher number of sexual partners; and having had a sexual relationship with a person at high risk for HIV. Additionally, childhood sexual abuse was significantly related to adult domestic violence as well as adult sexual abuse.

HIV and Increased Domestic Violence

A review of the first 138 deaths at Chicago's Cook County Hospital program for HIV-positive women and children provided further evidence of the extent to which HIV and violence are interrelated. The review discovered that only 80% of the deaths were due to AIDS. Substance abuse, cardiac disease and other chronic illnesses accounted for most of the remaining 20%. Significantly, 3% of the deaths in this group were due to domestic homicide (Cohen, 1996). Childhood sexual abuse may be emerging as a primary risk factor for HIV infection, but violence is a major risk factor for mortality in HIV-positive women.

For HIV-positive women, there is increased risk of domestic violence related to HIV status. The decision to test for HIV, disclosure of HIV status to family and partner, partner notification and mandatory newborn HIV screening (as in New York State) are all situations that may increase the risk for violence. There is evidence that women have been beaten, abandoned, shot, and even murdered by domestic partners after revealing their HIV-positive status (North, 1993; Lester, 1995). It has been shown that when physical abuse has occurred in the past, it is even more likely to occur during a pregnancy (Amaro, 1990). Thus, HIV testing during pregnancy, and newborn screening for HIV may set women up for further violence.

Abuse Survivors and Their Care Providers

Childhood sexual abuse may also set the stage for unsatisfactory relationships with health care providers. In general, clinicians fail to screen for a history of childhood sexual abuse or current risk for domestic abuse. Symptoms of domestic abuse may be easily misread. Often an abused woman will miss appointments and be considered noncompliant. Or she may report injuries, falls, forgetfulness and clumsiness. Women who have histories of childhood sexual abuse often have numerous physical complaints, including: digestive upsets, headaches, joint and muscle pains and chest pains (AMA, 1992). When clinicians are unable to find underlying medical causes for these symptoms, they become frustrated and often label the patient a "malingerer."

Sexual trauma can also result in post-traumatic stress syndrome with symptoms such as anxiety, phobias, hypervigilence and isolation. Common coping behaviors in sexual abuse survivors are denial, dissociation and repetition compulsion (Caseese, 1993). Denial and repetition compulsion (repeating behaviors that lead to trauma) are major mechanisms operating when engaging in risk behaviors, or staying in an abusive situation. Dissociation (pushing painful experiences and emotions out of conscious recognition) often occurs when survivors are asked about the trauma. They may respond blankly or without any emotional affect. Care providers often interpret dissociative reactions as the patient being "not too bright," "spaced out" or "on drugs."

The available data on the incidence of sexual trauma and domestic abuse in the U.S. is staggering. It is estimated that more than 30% of all females and nearly 15% of all males in the U.S. have been victims of childhood sexual abuse. Seventy-five percent of sex workers (female and male) have experienced sexual abuse. One in four women have been raped, and one in five women have experienced domestic abuse. During pregnancy, it is estimated that one in six women is sexually or physically assaulted by her partner.

Investigation and data regarding the prevalence, consequences and relationship to risk for HIV of the sexual abuse of boys are nearly absent in the literature. There are currently no clinical recommendations regarding incorporating what is known about childhood sexual trauma into HIV prevention efforts or into principles for forming therapeutic alliances with HIV-positive clients who are trauma survivors.

In most cases in which a history of trauma is uncovered, the individual should be referred to a competent therapist, with the message that recovery, healing and relief of symptoms is possible. A woman who is currently in an abusive situation needs a counselor who is trained in crisis intervention and domestic abuse. In addition, the following guidelines may be useful in approaching and working with individuals with a history of sexual or other trauma (adapted from Denenberg, 1993):

1. Provide assurance that any abuse that has occurred was not the survivor's fault.

2. Validate the experience of sexual abuse ("I believe you") and reassure the survivor that she is not alone ("This has happened to others").

3. Offer the survivor support and the ability to be in control of her body during any medical examinations, especially during genital exams, rectal exams and other invasive procedures.

4. Assess if the survivor is in a safe living situation at the present time.

5. Assess if there are any children living with the survivor who are currently at risk for sexual abuse.

6. Incorporate knowledge of the survivor's history into current and future interactions, including any teaching about risk reduction.

7. Make appropriate referrals for counseling, crisis intervention, safe housing and other services.

References

American Medical Association (1992), Diagnostic and Treatment Guidelines on Domestic Violence. Chicago, IL.

Amaro H et al. American Journal of Public Health. May 1990; 80(5):575-79.

Boyer D & Fine D. Family Planning Perspectives. January 1992; 24(1):4-11.

Caseese J. SIECUS Report. 1993; 22(4):1-7.

Cohen M et al. Women and HIV Infection Conference. February 22-24, 1995; abstract TC2-118.

Cook JA. National Conference on Women and HIV. May 1997; abstract 122.4.

Denenberg R. Gynecological Care Manual for HIV-Positive Women. EMIS 1993.

Lester P et al. Journal of AIDS and Human Retrovirology. November 1995; 10(3):341-9.

Morrill A. National Conference on Women and HIV. May 1997; abstract 122.2.

North RL & Rothenberg KH. The New England Journal of Medicine. October 1993; 329(16):1194-6.

Paone D & Chavkin W. SIECUS Report. 1991; 21.

Rosenfeld S & Lewis D. AIDS & Public Policy Journal. 1993; 8(4):108-13.

Vlahov D et al. XI International Conference on AIDS. 1996; abstract Tu.D.135.

Zierler S. American Journal of Public Health. May 1991; 81(5):572-5.

Commentary Postexposure Antiretroviral Treatment for Rape Survivors? by Risa Denenberg RN, FNP, MSN The probability of HIV infection from a single needlestick exposure is considered to be 0.32%. A single sexual exposure to HIV through a mucosal surface (vagina or rectum) may pose a similar probability for HIV infection. In The New England Journal of Medicine (April 10, 1997), a "Sounding Board" editorial examined the question of offering postexposure treatment to people exposed to HIV via sexual contact or injection drug use. A concomitant issue is the question of offering postexposure prophylaxis to victims of rape and sexual assault. Several probable cases of HIV transmission resulting from rape have been reported, and the NEJM editorial recommended prophylaxis for rape victims. The CDC currently recommends postexposure treatment of health care providers who are exposed to HIV infected blood or other fluids by needlestick injury, but recommendations regarding victims of sexual assault are under investigation. The New York State Department of Health is discussing recommending antiretroviral prophylaxis following sexual assault after a risk-benefit discussion between the rape crisis counselor or health care worker and the rape survivor. Important questions for clarification regarding such recommendations include: timing of initiation of treatment; which drugs to recommend for treatment; cost and drug reimbursement; criteria to define "significant risk" and recommendations for follow-up HIV testing and medical care. A recently published case-control study found that treatment with AZT for post-occupational exposure decreased the risk of acquiring HIV by 79%. Current standard of care treatment for occupational exposure is AZT (200 mg three times a day), 3TC (150 mg twice a day), and indinavir (800 mg three times a day) for four weeks. Interventions for survivors of sexual assault presently include some or all of the following: crisis intervention; referral for follow-up counseling; physical exam for evidence; testing and/or prophylaxis for syphilis, gonorrhea, chlamydia and hepatitis; pregnancy testing and emergency contraception; and treatment for any physical injuries. HIV testing as a part of these interventions is uncommon, yet rape survivors are increasingly concerned about the possibility of HIV transmission as a result of the assault, and some are requesting HIV prophylaxis. The rape survivor should be counseled regarding risk of HIV transmission via the assault. Pre-test counseling and HIV testing should take place within two weeks of the assault and again three months later. If prophylaxis is requested, it should begin as soon as possible, certainly within 24 hours of the attack. The standard three-drug postexposure prophylaxis regimen is onerous to follow. It involves 17 pills taken in the course of the day and has a long list of potential side effects. This regimen also costs about $900 to complete. Clearly there is a need for emergency departments to receive guidance and training in order to implement post-rape HIV counseling and prophylaxis. Further, issues related to access and payment mechanisms will need to be addressed in order that all women have the same ability to exercise the postexposure prophylaxis option after a rape, should they choose to do so.