In the shadow of the ever-growing worldwide HIV/AIDS epidemic, intimate partner violence (IPV) has been closely linked with HIV risk and HIV infection for women and men, both as victims and perpetrators of violence. Research over the past decade has highlighted the complexity of this intersection in domestic and international arenas. In addition to studies that demonstrate an overlap of prevalence between HIV and IPV population-based and community-based studies have determined that violence and fear of violence can impede an abused partner's ability to negotiate safe sex behaviors such as negotiating condom use or refusing sex. IPV can be also a precursor to engaging in sexually risky behaviors which in turn increases the risk of HIV infection for men and women. It can also be a barrier to participation in HIV voluntary counseling and testing (VCT). Although heterosexual women have been the focus in the majority of research on the intersection between HIV and IPV, it is important to recognize that this overlap exists for heterosexual men and sexual minorities as well.

In light of this growing body of evidence, the importance of addressing the overlap between HIV and IPV has been emphasized in global efforts to stem the epidemics by groups such as the World Health Organization, the United Nations General Assembly Special Section on HIV/AIDS, and the Joint UN Programme on HIV/AIDS. Yet, there remains a dearth of evidence supporting best practice interventions that address both simultaneously, particularly in the United States.

The purpose of this article is twofold: 1) to provide an overview of the current recommendations for both HIV testing and counseling and IPV screening, and 2) to discuss considerations and concerns germane to providing services for persons at risk that address the overlapping epidemics. The article concludes with implications for practice and policy as well as suggestions for moving forward.

Existing Recommendations for Screening and Counseling

The clinical value of screening for IPV has been widely accepted, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires policies and procedures for identifying, treating, and referring IPV victims in emergency departments and ambulatory settings. Professional organizations for healthcare providers, such as the American Medical Association (AMA), the American College of Obstetricians and Gynecologists (ACOG), and the American Association of Colleges of Nursing (AACN) have published guidelines that encourage screening as a way to identify IPV and abuse early and to positively impact health outcomes for their clients. In 2004, the United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend universal screening for IPV primarily due to a lack of direct evidence that screening impacts the negative health outcomes related to abuse and that screening did not harm the individuals. However, evidence has shown that both abused and non-abused clients support universal screening for IPV in health care settings. Chamberlain provides an in-depth discussion of the disconnection in the government's recommendations.

In 2006, the Centers for Disease Control and Prevention (CDC) revised their recommendations for HIV testing and counseling from a risk-based model to a routine-testing model to take a more proactive approach to early identification and treatment. In the past, a vast majority (94%) of practitioners recommended testing for their high-risk patients, only 54% recommended their pregnant patients to be tested, and only 37% recommended testing for their sexually active adult patients between 18 and 50 years of age. Under the new guidelines, the CDC recommends testing for all sexually active patients between 13-64 years of age in all health care settings with only general medical care consent necessary. These revisions addressed three problematic aspects of risk-based testing: 1) the reliance on a patient's and provider's accurate perception of risk, 2) the subjectivity and stigmatizing of testing only those at risk, and 3) the time-consuming and inefficient protocols for specific consent and testing associated with HIV risk-based testing. It is not yet known how extensively these guidelines have been adopted by health care facilities and departments of health across the United States since it is a lengthy process that often must pass through state legislatures. The USPSTF recommends testing among high-risk individuals and pregnant women, but it makes no recommendation either for or against the testing of those individuals who are not at an increased risk. All states participate in mandatory reporting of positive HIV tests for the purposes of surveillance.

To date, few recommendations in the U.S. address the overlap of IPV and HIV. If a person declines an HIV test, the CDC recommends that the clinician discuss and address reasons for the hesitation as these may include IPV concerns. The CDC suggests collaborations between VCT sites and state/local violence prevention organizations to assist in developing safe disclosure plans for clients who fear abuse upon disclosure.

Of the state laws regarding HIV screening, only seven states made allowances regarding the intersection between IPV and HIV (see Table 1). South Dakota, Mississippi, Illinois, and West Virginia focus only on the risks associated with sexual assault by mandating HIV testing for those accused and convicted of such crimes. However, very little is mentioned regarding the victims of sexual crimes. Connecticut law dictates that the Department of Public Health work with sexual assault crisis services to develop materials explaining how HIV/AIDS relates to sexual assault. These materials, intended for victims of sexual assault, focus primarily on the HIV risks associated with sexual assault. The law stipulates that the materials should be distributed through hospitals, clinics, HIV testing centers, and criminal justice venues.

California's Department of Health is responsible for developing a brochure that addresses both HIV transmission and domestic violence. It is to be made available to all who apply for marriage licenses. As such, this brochure will not be seen by many who are at risk for both HIV and IPV, nor will those who receive it necessarily make the connection between the two epidemics. The New York (NY) law is the most extensive concerning the overlap of IPV and HIV because it provides guidelines for practitioners (National HIV/AIDS Clinicians' Consultation Center, 2008d). Those persons who test positive for HIV are to be screened for IPV during their post-test counseling per the protocol developed by the NY Health Commissioner. For all health care practitioners and others who are required to report HIV test results, documentation of IPV screening must be included. The extent to which these laws are carried out is unknown at this time, and the level to which county and city health departments address the overlap in their literature and provider recommendations has not been studied.

Practical Considerations

Although much work remains regarding the development of best practices specifically for the intersection of HIV and IPV, there are several practical considerations for professionals working in the fields of violence prevention and HIV care.

1. Stigma: Although the CDC's recommendations are an attempt to "normalize" the process, HIV testing and diagnosis remain heavily stigmatized in many communities in the United States. The same is true for IPV. It is important to note that at-risk clients may also be battling internalized stigma surrounding either HIV or IPV or both, meaning that a person believes the negative stereotypes associated with HIV and IPV. This can have a substantial influence on whether a client is forthcoming about his/her own status, fears, or conditions. In addition, health care providers, counselors, and other professionals must be aware of their own beliefs regarding HIV and IPV. Their perceptions, beliefs, and discomfort can influence their behaviors which can convey a prejudice against a person in need of assistance. If this is the case, professionals may avoid asking the necessary questions to ascertain risk or they may ask the questions in a manner that inhibits the client from disclosing. Universal screening can address this stigma. For general health care providers, incorporating HIV testing and IPV screening into routine health visits for all patients may build trust and decrease the discomfort surrounding disclosure. Those providers working in reproductive health should routinely assess for IPV as well as HIV risk. In addition, those working in areas where HIV-related services are offered such as VCT, prenatal and postnatal care, and general HIV treatment, should incorporate violence screening and resource referrals into usual care for all.
2. Warning Signs of Overlap: Health care practitioners and other professionals must be aware of the signs of potential overlap between HIV and IPV. If a client is engaging in HIV risk behaviors, is reluctant to get tested for HIV, and/or resists disclosing a positive test result to a partner, the client may have an underlying fear of abuse from that partner. If an HIV positive individual is having difficulty adhering to an HIV medication regime, there may also be underlying abuse issues. Additionally, if a client screens positively for IPV, this may indicate that they are at a higher risk for HIV. Domestic violence advocates who are aware of the overlap between IPV and HIV should encourage their clients to get tested. Health care professionals should also consider these possibilities when working with their clients and offer strategies to promote safer sexual practices.
3. Disclosure plans: Special care must be taken when considering partner notification if abuse is present in the relationship. Not all victims are ready to leave the relationship and plans must be developed accordingly. Clients who experience abuse will need to develop safe disclosure plans if they are HIV positive. HIV counselors who incorporate IPV screening into their post-test counseling can help their clients develop safe disclosure plans with the understanding that the disclosure may result in an escalation of violence.
4. Trauma Histories: Because there is often a history of trauma among those individuals who are HIV positive, HIV support group facilitators should address trauma histories as part of the counseling process.
5. Couples testing and counseling: This relatively new approach to HIV testing and counseling has demonstrated promise in a few African countries, and was added to the VCT priorities of the President's Emergency Plan for AIDS Relief in 2006. However, a search of PubMed, Web of Science, and NLM Gateway databases was unsuccessful in locating any published studies or meeting abstracts describing its use in the United States.

There are three major considerations for this approach. First, this is not an appropriate option if there is evidence of violence in the relationship. Second, out of respect for their rights as individuals, both persons would have to feel ready and consent to this approach without coercion. Finally, mediated disclosure utilizing a trained counselor is a necessary component of this approach. This mediation can assist in providing accurate information about transmission and prevention, diffusing blame and tension, and creating a safe environment for disclosure of test results.

Concerns

When professionals consider the aforementioned considerations, certain concerns may come to mind. Two of the key issues are outlined and discussed below.

1. Time: The lack of time to sufficiently address the issues of IPV and HIV during provider interactions is a valid concern for many health care professionals but it should not hinder the implementation of screening and testing. While a positive screen for IPV or a positive result for HIV requires additional time with a client, having context-specific resources regarding follow-up options and other mechanisms readily available can help with this process. For instance, reference brochures and pamphlets containing information and local resources can be used during the provider-client interaction. In addition, many health care facilities have social workers or other professionals either on staff or accessible via referral for additional assistance for these clients.
2. Provider/Staff Training: In addition to time constraints, practitioners cite a lack of knowledge regarding available resources and the inability to "fix" the problem as two major barriers to implementing IPV screening in their workplaces. Lack of training lies at the root of this concern. Given the overlap of the two epidemics, cross-training on IPV and HIV assessment and resources for professionals is needed. This includes health care providers (HIV specific and general), HIV counselors, domestic violence advocates, social workers, reproductive health care workers, and others.

Approaches and Implications

Both HIV and IPV remain uncomfortable subjects for many in the general population. In order to decrease the stigma and to increase the awareness of the overlap between HIV and IPV, public awareness campaigns should be undertaken in the United States to educate the general public about both issues. Successful mass media campaigns that address the sensitive topics of partner violence and HIV risks have been launched in some developing countries. These include the TV-based serial dramas "Soul City" in South Africa which reached 16 million people across the country; and "Sexto Sentido" in Nicaragua which reached over half a million young adults. The United States has not had a similar campaign. If the overlap of HIV and IPV gains more public visibility, political support for initiatives and policy change can be mobilized. In conjunction with these efforts, further legislation on both the state and federal levels should establish more comprehensive guidelines for screening and follow-up on both HIV and IPV in public health departments and clinical settings similar to those of New York State as outlined above.

Political and financial support of intervention research is of critical importance. In the past decade, the growing body of research on the overlap of HIV and IPV has laid the foundation for further work to establish the causal relationships as well as effective interventions. There is an urgent need for interventions that address both HIV and IPV simultaneously, but there have been a few that have shown promise in both abused and non-abused populations. One successful model of an HIV intervention that has demonstrated positive effects on safe sex behaviors with African American girls who have experienced relational violence is the Sistering, Informing, Healing, Living, and Empowering (SIHLE) program. Through small group discussions, the girls learn about HIV risk reduction, ethnic and gender pride, and healthy relationships. They also participate in role plays of safe sex conversations and condom negotiation. Another example is a HIV risk reduction intervention for HIV-negative, drug using women that included elements of negotiation and conflict resolution. This intervention demonstrated a statistically significant decrease in new physical, sexual, and emotional victimization as well as an increase in safe sex practices. Such interventions need to be tested for broader application, and new interventions that target risk factors for the co-occurrence of HIV and IPV should be developed.

Policies on the city, county, state, and federal level must also be developed to address the overlap of HIV and IPV. This includes dedicating funds to effective programs targeting those groups at risk. For instance, nearly 50% of high-school aged students who participated in the CDC's 2005 National Youth Risk Behavior Surveillance System (NYRBSS) reported having had sexual intercourse and nearly 40% of those did not use a condom during their last act of intercourse. Meanwhile, the federal government has dedicated over $1.5 billion dollars to abstinence-only-until-marriage programs since 1996, which have been shown to be ineffective. Adolescents mirror adult statistics of physical and sexual violence, with 9.2% of respondents in the NYRBSS reporting that they have been intentionally slapped, hit, or physically hurt by their boyfriend or girlfriend and 10.8% of female respondents reporting they have been physically forced to have sex at some time. These adolescents are in the formative stages of developing relationship skills and sexual negotiation skills. Interventions that have a broader scope than those the government currently endorses could have a much larger impact.

Conclusion

More remains to be learned regarding the overlap of HIV and IPV, particularly the causal mechanisms and effective interventions targeting both epidemics. However, the evidence supporting the connection is irrefutable. Awareness of the overlap should be raised among health practitioners, domestic violence advocates, HIV counselors and others, and adjustments should be made to assess for both HIV risks as well as IPV experiences. If action is taken to acknowledge the overlap in practice and in policy, progress can be made to ensure those individuals at risk for both HIV and IPV are cared for effectively and the deleterious health effects are minimized.

*Details based on findings from the National HIV/AIDS Clinicians' Consultation Center (2008a)

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