Psychosomatics 2015:56:107–118

& 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Review Articles The Syndemic Illness of HIV and Trauma: Implications for a Trauma-Informed Model of Care Christina Brezing, M.D., Maria Ferrara, M.D., Oliver Freudenreich, M.D., F.A.P.M.

Background: People living with HIV infection are disproportionately burdened by trauma and the resultant negative health consequences, making the combination of HIV infection and trauma a syndemic illness. Despite the high co-occurrence and negative influence on health, trauma and posttraumatic sequelae in people living with HIV infection often go unrecognized and untreated because of the current gaps in medical training and lack of practice guidelines. Objective: We set out to review the current literature on HIV infection and trauma and propose a trauma-informed model of care to target this syndemic illness. Methods: We searched PubMed, PsycINFO, and Cochrane review databases for articles that contained the following search terms: HIV AND either trauma (specifically violent trauma), PTSD, intimate partner violence (IPV), abuse, or trauma-informed care. Articles were limited to primary clinical research or metanalyses published in English.

Articles were excluded if they referred to HIVassociated posttraumatic stress disorder or HIVassociated posttraumatic growth. Results: We confirm high, but variable, rates of trauma in people living with HIV infection demonstrated in multiple studies, ranging from 10%–90%. Trauma is associated with (1) increased HIV-risk behavior, contributing to transmission and acquisition of the virus; (2) negative internal and external mediators also associated with poor health and high-risk HIV behavior; (3) poor adherence to treatment; (4) poor HIV-related and other health outcomes; and (5) particularly vulnerable special populations. Conclusions: Clinicians should consider using a model of trauma-informed care in the treatment of people living with HIV infection. Its adoption in different settings needs to be matched to available resources. (Psychosomatics 2015; 56:107–118)

BACKGROUND

ethnic and sexual minorities, women, and injection drug users, are disproportionately affected and carry

Over the past 3.5 decades in the United States, with the investment in research and development of effective and tolerable antiretroviral treatments and their increasingly widespread availability, infection with HIV has evolved from a quickly fatal diagnosis with all but assured death from AIDS into a chronic disease that can be managed.1 Today in the United States, more than 1.1 million people are living with HIV2 thanks to prolonged life expectancy from effective combination antiretroviral therapy (cART).3 However, despite these significant advances, vulnerable nondominant groups in the United States, specifically Psychosomatics 56:2, March/April 2015

Received September 5, 2014; revised October 6, 2014; accepted October 6, 2014. From Division of Substance Abuse, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY (CB); Department of Mental Health and Substance Abuse, AUSL Modena, Modena, Italy (MF); Division of Medicine and Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA (OF). Send correspondence and reprint requests to Christina Brezing, M.D., Division of Substance Abuse, Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 66, Rm 3736, New York, NY 10032; e-mail: [email protected] & 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

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The Syndemic Illness of HIV and Trauma the greatest burden of new infections2 and resultant medical and psychiatric comorbidities, which is thought to be due to these affected populations' substantial social obstacles.4 Primary care providers and infectious disease physicians are often the sole providers of care to people living with HIV (PLH).5 Although the training programs for these specialties in the United States focus on caring for patients with multiple medical problems and treatment of HIV infection, generally, they do not adequately cover education and training in psychiatric disorders that, left untreated, are important risk factors in poor adherence to cART6 and transmission of HIV,7 while contributing to higher health care costs8 and use of services, such as emergency department visits for primary care.9 Moreover, few practice guidelines have been developed to address the treatment of HIV infection and co-occurring psychiatric disorders, leaving providers caring for these patients with little direction on best care practices.10 Psychiatric disorders and complicated social factors in the lives of HIVpositive individuals are common and substantially higher than in the general population, making it imperative that physicians caring for individuals with HIV infection have the knowledge to identify and the support to manage commonly occurring psychiatric comorbidity and complicating social factors.11 Of particular importance when working with patients with HIV infection is the acknowledgment that they are disproportionately affected by trauma, in many instances leading to posttraumatic stress disorder (PTSD) and dissociative symptoms.12 A history of trauma not only plays a role in acquiring and transmitting the HIV, but also is associated with the progression of the disease and poor quality of life,12 making the combination of these 2 conditions (i.e., HIV infection and trauma) a syndemic illness,13 defined by the Centers for Disease Control and Prevention as 2 or more epidemics interacting synergistically and contributing as a result of their interaction to excess burden of disease in a population.13 Left unaddressed, trauma in HIV-positive individuals has the potential to cause detrimental and concerning individual and population health consequences. This review covers the epidemiology of HIV infection and trauma in the United States, the nature of the syndemic of HIV infection and trauma, particularly regarding mediators of this relationship, including psychiatric sequelae and cooccurring disorders, and identifies particularly at-risk 108

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and affected populations to which practitioners should pay special attention. Additionally, we review a model of trauma-informed care and propose adaptation of this model to different treatment settings based on the needs of the patients and resources in the community. METHODS PubMed, PsycINFO, and Cochrane review databases were searched for articles that contained the following search terms: HIV AND either trauma, PTSD, intimate partner violence (IPV), abuse, or trauma-informed care. Trauma and abuse were defined for this article as violent trauma and included either acute trauma, such as a physical or sexual assault, or trauma that is chronic and repetitive in nature, such as childhood physical and sexual abuse and physical and sexual intimate partner violence. Articles were limited to primary clinical research or metanalyses of clinical studies published in English. Articles were excluded if they referred to HIVassociated PTSD, where the identified trauma is the diagnosis of HIV infection and not violent trauma, or HIV-associated posttraumatic growth, where the diagnosis is also the defined trauma and leads to subjective personal, emotional, or psychologic improvements. RESULTS Epidemiology of HIV Infection and Trauma It has been observed for a long time that individuals with HIV infection are disproportionately affected by trauma. Notably, violent traumas are more common than nonviolent traumas in HIV-infected individuals. Reported rates of trauma have ranged from 10%– 90%.14–18 Such wide ranges of rates are likely due to differences in the clinical samples involved in the studies and lack of uniform definitions of trauma. However, in most studies that examined the issue of trauma, estimates are quite high, typically multiples greater than rates in the general population. For example, approximately half of individuals who are HIV-positive in 2 separate large studies reported a history of childhood physical or sexual abuse, which is 1.5–2 times greater than the general population,16,19 and up to 90% of HIV-positive individuals in another large study reported at least one severe traumatic event in their lifetime.15 Although rates of trauma are high in both men and women living with HIV, women with HIV infection are particularly affected by Psychosomatics 56:2, March/April 2015

Brezing et al. trauma and there are noted gender differences in the manifestation of PTSD symptoms in people with HIV infection.20 A recent meta-analysis estimated rates of psychologic trauma and PTSD in HIV-positive women in the United States.21 It found that 55.3% of HIVpositive women experience intimate partner violence, and 30% of HIV-positive women have recent PTSD.21 Those rates are 5 times and 2 times the national rates, correspondingly. Other studies have demonstrated rates of acute stress disorder in HIV-positive women at 55% as compared with 38% of HIV-positive men.22 Overall, 68% of HIV-infected women reported a history of sexual assault compared with 35% of HIV-infected men.23 In another recent retrospective study of HIVpositive women, 66% reported a history of childhood physical or sexual abuse, 25% reported a history of abuse by a partner in adulthood, and 10% reported abuse while pregnant.24 Although rates of trauma are lower in HIV-positive men as compared with HIV-positive women, they are higher than rates of trauma in HIV-negative men. An important subgroup of HIV-positive men who are disproportionately affected by trauma is HIV-positive men who have sex with men (MSM). Many studies have looked at the role of trauma in engagement in HIV-risk behaviors in the MSM population as this risk group is currently most affected by HIV in the United States, carrying the burden of 63% of all new HIV infections.2 MSM have higher rates of trauma and are more likely to experience worse psychologic outcomes as a result, compared with HIVpositive men who do not have sex with men. A study where many of the subjects were MSM found that more than 35% of these HIV-positive men had a history of childhood sexual abuse, which was associated with higher rates of experiencing dissociative symptoms, and greater than 55% of those men met the criteria for PTSD.25 Another study demonstrated equal rates of experiencing trauma in both MSM and men who have sex with women population; however, MSM were more likely to have posttraumatic symptoms, such as dissociation.26 The Syndemic of HIV Infection and Trauma: Trauma and the Association With Acquisition, Transmission, and Poor Health Outcomes in HIV Infection Acquisition and Transmission Trauma, particularly sexual trauma, plays both indirect and direct roles in its relationship with HIV Psychosomatics 56:2, March/April 2015

risk. A history of trauma and the associated development of psychiatric sequelae, such as dissociative symptoms and PTSD, are known determinants of engagement in high-risk HIV behaviors, leading to HIV acquisition and transmission. A history of childhood sexual abuse is highly associated with greater engagement in high-risk HIV behaviors, leading to higher rates of HIV transmission and acquisition in addition to other sexually transmitted infections in both heterosexuals and sexual minorities, but a greater proportion of gay and bisexual men demonstrated this finding.27 Another study examining the high-risk HIV behavior of unprotected anal intercourse with casual partners in a group of HIV-positive MSM demonstrated that a history of sexual abuse was positively associated with participation in this behavior.28 MSM who had a history of childhood sexual abuse and were seronegative for HIV were more likely to engage in high-risk HIV behavior and to have subsequent HIV infection.29 O'Cleirigh et al.30 similarly found that HIVpositive gay and bisexual men with PTSD were more likely to engage in high-risk HIV transmission behaviors as compared with a similar cohort without PTSD.30 A subtype of trauma related to discrimination due to race, sexual orientation, or HIV status was associated with increased engagement in unprotected anal sex in a group of HIV-positive African American men, a group very susceptible to high levels of discrimination-related trauma.31 A study of HIV-positive African American men who have sex with both men and women demonstrated increased sexual risk behaviors that directly correlated with the extent of PTSD symptoms experienced by the men.32 In this same study, 117 participants experienced at least one traumatic event before the age of 4 years and three-fourths of them had moderate to pervasive trauma exposure.32 Similar to sexual minorities and nondominant ethnic groups of men, African American and Latina women carry a substantial burden of the new cases of HIV infection and have significant exposure to trauma.2 In a population of low-income, urban African American girls, whose HIV status was unknown, a history of more extensive exposure to violence, defined as physical abuse and victimization, neighborhood violence, and intimate partner violence, was associated with engagement in high-risk HIV behaviors including unsafe sexual practices, increased number of sexual partners, and inconsistent use of condoms.33 HIVpositive biologic and transgender women with a history www.psychosomaticsjournal.org

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The Syndemic Illness of HIV and Trauma of recent trauma and resultant PTSD had significantly higher rates of engaging in HIV transmission risk behaviors compared with HIV-positive women without exposure to trauma.34 However, not all women with a history of childhood abuse have increased HIV-risk behaviors. In a study of Asian American women, multiple experiences with childhood maltreatment were not associated with increased HIV risk behaviors.35 It was, however, associated with worse mental health outcomes, including increased rates of depression, suicide, and suicidal ideation.35 This suggests that cultural and sexual preference differences may exist in the relationship of trauma to HIV risk behavior and health care interventions should specifically target at-risk populations, such as women sexual minorities, black, and Latina women who are more likely to engage in high-risk HIV behavior. A history of childhood sexual abuse may also play an important role in the acquisition and transmission of HIV in nonminority groups, including men who do not have sex with men. In the Coping with HIV/AIDS in the Southeast study, HIV-positive men who do not have sex with men with a history of childhood sexual abuse predicted a higher number of sexual partners, problems with substance use, PTSD, depression, and less trust in health care providers.36 Sexual assault and violence are also directly associated with HIV risk.37 Rates of HIV acquisition in women are higher through coercive sex as compared with consensual sex.38 Generally, the lower female reproductive tract's multilayer stratified epithelium garners some protection against the transmission of HIV.39 However, inflammation, abrasions, and injury to this epithelium degrade its protective properties and allow the virus to gain access to the subepithelial cells, that owing to cell membrane receptor differences, the virus binds and infects. These insults to the protective barrier are often the result of traumatic sex and are more likely in instances of sexual assault as compared with consensual sex. The single layer epithelium in the lower gastrointestinal tract is much more susceptible to injury through anal sexual contact, even when consensual, as compared with the lower female reproductive tract, making sexual assaults and coercive anal sex an even greater risk of transmission of HIV.39 Mediators Trauma's influence on HIV-risk behaviors and HIV health outcomes, particularly adherence, is thought to 110

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be mediated by a number of factors that are both internal, or specific to the individual, and external, or related to the person's environment. Together, these internal and external factors mutually affect the other and overall contribute to vicious cycles negatively influencing one's health. Two theoretical models have attempted to describe this relationship between internally-mediated factors and externally-mediated factors that contribute to high-risk behaviors and negative health outcomes seen in the context of traumatic events: (1) The Schnur and Green model40 and (2) McEwan's model of allostatic load.41 The Schnur and Green model suggests that trauma that results in PTSD has negative psychologic (e.g., depression, anxiety, and dissociation), biologic (e.g. hypothalamic-pituitaryadrenal axis dysregulation), attentional (altered symptom perception and mislabeling), and behavioral (substance abuse and unprotected sex) changes within an individual that negatively mediate health outcomes.40,42 McEwan's model of allostatic load suggests that psychosocial stress and traumatic events lead to maladaptive health behaviors and changes in the immune system and brain that results in poor mental and physical health.41 Both models note the importance of the bidirectional interaction between the environment (particularly a traumatic environment) and the individual, and there is a growing body of clinical research that supports these theories. A study with HIV-positive men demonstrated that individuals with worse posttraumatic stress symptoms had worse HIV-related medical symptoms.42 People with HIV infection diagnosed with PTSD who are symptomatic have associated greater pain,43 functional impairment, poorer health-related quality of life, and higher health care utilization.44,45 Internally-Driven Mediators of Negative Health Outcomes Factors specific to the individual, or thought to be internally related as opposed to factors in the environment, that mediate trauma's negative effect on HIV transmission, acquisition, and negative health outcomes include the following: poor (i.e., less active and emotion-focused/emotionally reactive) coping styles, avoidant attachment styles, a poor sense of selfefficacy, mistrust in the medical system and medical providers, a greater burden of mental health disorders and psychiatric symptoms (specifically posttraumatic Psychosomatics 56:2, March/April 2015

Brezing et al. stress, depressive, and cognitive symptoms), alcohol and drug use, hostility, sexual identity confusion, difficulty with risk appraisal, and sexual impulsivity.45–48 Coping Styles and Attachment As compared with individuals with passive coping styles, the use of active coping styles in HIV-positive individuals with a history of trauma has been associated with decreased engagement in high-risk sexual behaviors.28 Use of avoidance and denial to cope with stress as a result of trauma has been associated with diminution of the immune system and accelerated HIV disease progression.49,50 Additionally, HIV-positive individuals with avoidant attachment styles and emotion-focused or emotionally-reactive coping have greater PTSD symptomatology.48,51 Mental Health: Psychiatric Symptom Burden The burden of psychiatric symptoms, both sequelae of trauma and co-occurring symptoms of other disorders such as major depressive disorder (MDD), affects HIV behaviors and outcomes. Dissociative symptoms during sexual encounters in individuals with a history of childhood sexual abuse are thought to increase the risk of sexual revictimization and highrisk sexual behavior.52 In a study of HIV-positive adults with a history of childhood sexual abuse, current PTSD, dissociative disorders, rape by an intimate partner, duration of the childhood abuse, and number of perpetrators who abused the individual were associated with increased dissociative experiences during sex as an adult, implicating a greater likelihood of high-risk sexual behavior and future revictimization.52 Although a synergistic effect on neurocognition between trauma and HIV has thus far not been demonstrated, trauma alone could induce memory disturbances in women53; this could represent a further risk for HIV-infected women exposed to trauma,53 as HIV infection itself is responsible for neurocognitive dysfunction (HIV-associated neurocognitive disorder).54,55 Women with more significant burden of PTSD symptoms are less able to negotiate safer sexual practices and are more likely, as a result, to be unable to refuse sex without a condom, abstain from drinking before sex, and refuse sex before both partners receive HIV testing, putting them at a higher Psychosomatics 56:2, March/April 2015

risk for HIV infection.56 MDD, which frequently cooccurs with PTSD after a traumatic exposure, may also mediate the syndemic of HIV infection and trauma. MDD could have a synergic effect when comorbid with PTSD, as demonstrated by a study performed on US soldiers, whose HIV status was unknown: it has been demonstrated that those with symptoms of PTSD and MDD were more likely to engage in HIV-risk behaviors than those with MDD or PTSD alone.57 Moreover people with HIV infection having MDD also have increased HIV-risk behaviors, poor antiretroviral medication adherence,58 and a worse HIV clinical progression.59,60 Mental Health: Substance Use Substance abuse appears to be particularly important in mediating trauma's effect on HIV-risk behavior and adherence to treatment.19,47 There appears to be an important relationship between burden of posttraumatic symptoms and substance abuse particularly in women. It is suspected that the use of substances by women with HIV infection, as compared with men, serves as a maladaptive coping strategy for the consequences of trauma. High levels of distress following trauma may precipitate a relapse to substances leading to disinhibited behavior, dissociation,61 and poor decision-making that increases HIV risk.62 Frequently, excessive drinking worsens PTSD symptoms and creates a vicious cycle of use and increased HIV risk.63 Externally-Driven Mediators of Negative Health Outcomes External factors that appear to mediate trauma's relationship with HIV infection include poor social supports, recent stressful life events, poverty, high-risk occupations including sex work, infrequent condom use, and homelessness.42,46 Homelessness in particular brings profound life challenges that predispose an individual to increased traumatic experiences and poor health outcomes. Oftentimes, in addition to loss of shelter, homelessness is accompanied by unemployment, economic insecurity, poor physical and mental health, threatened personal security, and inadequate fulfillment of basic subsistence needs, such as access to a toilet, a place to wash, clothing, food, or a safe place to sleep. A study looking at HIV-positive women who were homeless www.psychosomaticsjournal.org

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The Syndemic Illness of HIV and Trauma demonstrated that those with unmet subsistence needs had greater exposure to traumatic events, worse medical and psychiatric symptom burden, and poor health outcomes.64 Considerations of ways to intervene and improve these external factors through access to social services and case management will likely mitigate the synergistic and negative consequences of HIV infection and trauma. Health Outcomes—As Related to Adherence Adherence to antiretrovirals is critical in reducing rates of new infection and preventing disease progression in PLH and poor adherence results in increased viral load, decreased CD4 T cell count, and consequential negative health outcomes.65 Poor adherence to cART has been associated with increased number of childhood traumas, a history of sexual abuse before puberty, PTSD, and depression.66,67 HIV-positive women are more likely than their male counterparts to poorly adhere to cART.19,47 This may in part be explained by their higher rates of trauma and associated poor adherence to medication. Recent trauma is associated with 4 times the odds of antiretroviral failure in HIV-positive women.34 In addition to medication nonadherence, histories of traumatic experiences also predict mortality in PLH/ people living with AIDS.46 One-third of a group of MSM newly diagnosed with HIV infection had a history of physical or sexual abuse, which contributed to their views on HIV stigma and concerns about adherence to cART, leading to increased medical morbidity and poor health outcomes.68 A history of sexual trauma is also associated with higher rates of HIV treatment failure in the presence of good adherence, leading to great morbidity and mortality.69 This is owing to 2 factors. First, stress, particularly traumatic stress, has a negative effect on the immune system and overall physical and mental well-being as a result of excessive allostatic load.41 Second, sexual trauma can result in psychologic sequelae including PTSD and dissociative symptoms. Both greater burden of PTSD symptoms and dissociative symptoms lead to poor adherence to antiretrovirals.70 As mentioned earlier, PTSD and trauma have direct biologic effects leading to poor health outcomes in HIV. It has been demonstrated that stress71 and PTSD negatively affect the immune system.72 A study looking at African American men with HIV 112

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demonstrated that a history of PTSD positively correlated with elevated biomarkers of stress, such as neurohormonal mediators of stress, such as cortisol and catecholamines.32 Special Populations Certain populations, which include sex workers and individuals with serious mental illness, are even more vulnerable to the risks and effects of co-occurring HIV infection and trauma. The lifetime prevalence of abuse in a group of Miami-based female sex workers was 88%, with half of the group reporting childhood abuse (occurring before the age of 18), and 34% endorsing a violent encounter in the last 90 days (often related to their experience with clients).73 Overall, 74% of women in this group endorsed severe symptoms of depression, anxiety, and posttraumatic stress, which were associated with increased engagement in unprotected sexual contact.73 A study investigating high-risk HIV transmission behaviors in a group of Puerto Rican women with serious mental illness found that violence was associated with higher rates of injection drug use and unprotected sexual encounters, putting them at increased risk of acquiring HIV.74 Serious mental illness independently is also associated with poor cART adherence, greater medical and psychiatric symptom burden, poor HIV outcomes, and poor quality of life.75–77 The combination of serious mental illness and trauma puts these individuals at a substantially greater risk of acquisition and transmission of the virus, in addition to poor health outcomes once it is acquired. DISCUSSION Trauma-Informed Care and Treatment Implications The negative effect of trauma on physical and mental well-being has long been identified.78–81 However, the implementation of treatment strategies to address the adverse effects of trauma on health has lagged behind, particularly in nonmental health services,82 and only recently has become a pressing issue on the national agenda with increasing concerns about posttraumatic stress sequelae in veterans.83 Mental health organizations have paved the way for creating a focus around understanding the effects of trauma and treatment practices to best manage it, and there are Psychosomatics 56:2, March/April 2015

Brezing et al. currently a number of evidence-based treatments that target and improve posttraumatic symptoms in the context of mental health concerns. However, even within mental health, a generalized approach to working with patients with a history of trauma, outside manual-based, trauma-specific treatments for PTSD and dissociative symptoms, has been sparse and predominantly focused on avoiding restraint and seclusion on inpatient units and residential settings84 or in substance abuse treatment settings.85 What should health care providers, who generally have not been trained in trauma-specific treatments, do to most productively work with patients who have HIV infection and a high likelihood of trauma? We propose all providers to PLH adopt a traumainformed approach to care that meets the needs of individuals with a history of trauma. This traumainformed approach should incorporate the following: (1) a trauma-sensitive practice environment, (2) identification of trauma and its mediators, (3) education to patients about the relationship between trauma and its negative influence on behavior and health, and (4) provision of appropriate resources and referrals to more specialized treatment when needed (Table). What is Trauma-Informed Care? The Substance Abuse and Mental Health Services Administration has been invested in the idea of appropriately meeting the treatment needs of people with a history of trauma, given the high prevalence of trauma co-occurring with substance use disorders and psychiatric disorders. In 2005, the Substance Abuse and Mental Health Services Administration developed the National Center for Trauma Informed Care, which is dedicated to the promotion of awareness and implementation of trauma-informed care, in addition to providing resources for information and

TABLE.

referral about trauma-specific treatments.86 National Center for Trauma Informed Care defines traumainformed care as an organizational culture that has adopted principles centered on thinking about and responding to individuals who have experienced or may be at risk of experiencing trauma; rather than a specific set of procedures.86 National Center for Trauma Informed Care sees the implementation of this approach as broadly applicable and possible, providing consultation, technical assistance, education, outreach, and additional supports to help with this paradigm shift in care. National Center for Trauma Informed Care encourages applying these principles to the following systems: mental and substance abuse services, primary care, housing services, child welfare, criminal justice, and education/schools. Applying these principles in the care to patients with HIV infection is not only possible, but optimal (Table). A Trauma-Informed Care Practice Environment The primary goal of a trauma-informed treatment environment is the promotion of a sense of safety. Past traumatic experiences shape an individual's response to future interactions, particularly around receiving health care, and often can result in mistrust of people in general, including physicians, and risk of retraumatization. To engage people with a history of trauma in their care, physicians, clinical, and administrative staff should foster collaborative, transparent, trusting, and supportive interactions. This can be done by educating all members of a HIV practice setting on the “3 R's,” which include: (1) realizing the high rates of trauma, (2) recognizing the effect of trauma on patients and providers, and (3) responding appropriately to trauma.86 Physicians and other practitioners should show supportive curiosity about the patient's experience and circumstances around her/his trauma. In

Summary of Trauma-Informed Care Practice Recommendations86

Access SAMSHA's NCTIC for information regarding consultation, technical assistance, education, outreach, and supports. Create a practice environment that promotes a sense of safety in all patient interactions with staff members, including physicians, clinical, and administrative staff. Screen for and identify trauma, its mediators, posttraumatic sequelae, poor adherence to treatment, and high-risk HIV behaviors. Provide patient education about the relationship between trauma and HIV infection. Become acquainted with resources in the area and make referrals when available for specialized trauma and mediator-specific treatments. Involve patient's social supports in treatment plans whenever possible. NCTIC ¼ National Center for Trauma Informed Care; SAMSHA ¼ Substance Abuse and Mental Health Services Administration.

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The Syndemic Illness of HIV and Trauma doing so, care providers can elucidate potential vulnerabilities and triggers for patients with a trauma history and develop a treatment environment and plan that avoids retraumatization. It empowers the individual patient by acknowledging the need for her/him to be respected, informed, connected, and hopeful regarding treatment of their HIV infection and posttraumatic sequelae. Screening and Identification of Trauma and its Mediators All patients with HIV infection should be screened for a history of trauma, with particular attention and sensitivity to subgroups with an even higher risk, being sure to inquire about intimate partner violence. Once trauma is identified, physicians should inquire about posttraumatic symptoms, such as hypervigilance, avoidance, emotional numbing, re-experiencing through flashbacks, nightmares, and dissociative symptoms, such as amnesia, derealization, and depersonalization. All patients should then be screened for internal and external mediators of high-risk HIV behavior, poor medication adherence, and poor health outcomes as a result of the co-occurrence of HIV infection and trauma. If mediators are identified, they should be added to the treatment plan and actively addressed. For patients with HIV infection who screen negatively for a history of trauma, primary prevention strategies including education about their possible increased risk for being traumatized should be provided if other mediators of high-risk behaviors and poor health outcomes are present. For primary care providers working with a general population who are HIV negative, if a history of trauma is identified, those patients should be provided with information regarding HIV prevention strategies in light of a possibly increased risk related to the trauma. Education The role of educating patients about the relationship between trauma and HIV infection, and how they and their mediators negatively affect patients' health and the risk of transmission is essential in working with this population. Patients might not have made the connection about how their past traumatic experiences shape their current adult behaviors, thus increasing the risk for HIV infection. A randomized clinical trial in 114

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women with a history of trauma and HIV infection demonstrated that providing psychoeducation about the connection among their traumatic experiences, level of distress, and high-risk transmission behaviors was not only novel, but empowering for the participants in the study.87 In practice settings where referral for more specialized treatment for trauma or other mediators (e.g., substance use and psychiatric symptoms) is not available, education can be a very effective intervention to improve patients' understanding and their ability to take actions to improve their health in addition to prevent spread of the virus.

Resources and Referrals for Additional Services If a practice is in an area with easy access to psychiatric, substance abuse, and social services, once posttraumatic symptoms or internal or external mediators are identified, referrals should be made for specialized trauma- and mediator-specific treatments. Appropriate interventions targeting psychiatric symptom mitigation or relief, particularly around trauma, and substance abuse relapse prevention are likely essential in decreasing high-risk HIV behaviors and improving adherence to cART. Evidence-based treatments exist for trauma recovery, co-occurring trauma and substance use, co-occurring trauma and nonsubstance-related psychiatric disorders, and trauma and learning to manage affect dysregulation and distress tolerance.86 The acquisition of healthy, adaptive cognitive and behavioral coping skills has led to high patient satisfaction, reduced traumatic stress, and reduced sexual risk behavior.49,87 Physicians should acquaint themselves with the different services in their regions, as even brief, tailored interventions can have a meaningful effect on symptom burden. A 4-session guided written emotional disclosure intervention for individuals who were HIV-positive showed significant decrease in symptoms of PTSD, depression, and physical symptoms.88 Identification, recruitment, and involvement of family and other social supports are critical when implementing a treatment plan for patients with HIV infection and trauma. In couples who are serodiscordant, individual treatment of trauma may not be enough, and greater success has been seen in treatment strategies that involve both the affected individual and their significant other.89 A patient's loved ones can be Psychosomatics 56:2, March/April 2015

Brezing et al. helpful in recognizing problems at home and advocating for the patient in the health care setting. If the practice setting is in a more rural area or has less access to treatment resources or both, the Substance Abuse and Mental Health Services Administration provides a list of hotlines, referrals, online treatment tools, and support services for practitioners, patients, and family members on trauma-informed care.86 CONCLUSIONS Given the high prevalence of trauma in HIV-infected patients, we propose “universal precautions” when working with PLH, where practitioners should take care in their interactions with these patients, behaving in a sensitive manner that assumes a personal experience with trauma before further elucidating the social history.90 Once a history of trauma is identified, we propose using a model of trauma-informed care in conjunction with best medical practices to optimally care for these patients in the hopes of preventing or

mitigating the negative health consequences of this syndemic illness. No studies to date have looked at the implementation of a trauma-informed model of care for patients with HIV infection in the primary care/ infectious disease setting. A study designed to look at the effect of a trauma-informed model of care in the primary care setting on HIV-risk behaviors, adherence to cART, HIV and other health outcomes, and quality of life is essential to guide best practices and further elucidate ways of integrating psychiatric and medical care for patients with complex health problems. Other integrated and collaborative models of care for physical and mental illness have already demonstrated improvements in medication adherence, health outcomes, and costs of care, and these models could provide a framework for the implementation of trauma-informed care in the HIV care setting.91 Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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