In the first comprehensive study of its kind, we tested a model through which the health-related outcomes of IPV were mediated by mental health problems in a sample of HIV-positive sexual minority men. This is the first report of which we are aware to examine the relations among latent factors representing different types of abuse that include multiple measures of violent physical, sexual, and psychological acts, and their associations with mental health and health-related outcomes. This is also one of the few reports to focus on HIV-positive sexual minority men or even same-sex IPV in general. Although IPV is primarily studied among women, men (especially sexual minority men) are also frequently victims of abuse, and sexual minority men with HIV may be particularly vulnerable to abuse and susceptible to adverse health outcomes if abused (Greenwood et al., 2002
; Relf, 2001
Through our model testing efforts, we found our hypothesis to be largely supported. In the final trimmed model, greater frequency of adult and partner abuse experiences was associated with more frequent or severe mental health problems. Having more mental health problems was, in turn, related to self-reported HRQOL, self-reported adherence, and chart-extracted viral load. One unexpected direct link emerged during the model testing—that of adult abuse to ER visits, unmediated by mental health problems.
As hypothesized, both adult and partner abuse were independently related to mental health problems while controlling for each other. This finding in itself has important clinical implications in terms of the need to assess for all forms of IPV as vulnerability factors for mental disorders, poorer HIV health, and overuse of health care resources. Frequently, the HIV literature focuses on child abuse leading to HIV risk behaviors (e.g., Arriola, Louden, Doldren, & Fortenberry, 2005
), which highlights an important but incomplete picture of IPV-health relations. Mental health problems resulting from abuse experiences may be exacerbated by homophobia or anti-HIV attitudes of the perpetrator (Meyer, 2003
). Unfortunately, data indicate that screening for abuse experiences frequently does not occur in health care settings (e.g., Rodriguez, Bauer, McLoughlin, & Grumbach, 1999
), despite victim support for screening efforts (Zink, Elder, Jacobson, & Klostermann, 2004
). It is possible that provider-focused interventions aimed at increasing both screening efforts and sensitivity to posttrauma sequelae would identify IPV victims and more successfully triage them into mental health care (Whetten et al., 2008
As expected, participants who endorsed greater frequency and severity of mental health problems were those whose health-related outcomes were poorer. It appears clear that violence victimization and mental health problems influence individuals’ perceptions of their physical health and their ability to function independently to meet the demands of multiple roles. The self-report HRQOL measure was highly correlated with virtually all of the predictors and mediators at the bivariate level. The final model was able to explain 41% of the variance in HRQOL, providing a clear message about the potential benefits of treating mental health problems to improve perceptions of physical health as well as functional capabilities. Interventions that focus on increasing social support and self-care behaviors may be able to improve HRQOL (Gielen, McDonnell, Wu, O’Campo, & Faden, 2001
In addition, the model explained a small but significant amount (7%) of the variance in medication adherence, our health behavior measure. This finding is consistent with other published reports in the adherence literature. Symptoms of both PTSD and depression (Boarts, Sledjeski, Bogart, & Delahanty, 2006
) have been associated with poorer adherence, and a study by Mugavero et al. (2006)
showed a linear relationship between the number of categories of abuse experienced and the proportion of the sample reporting < 100% adherence. Few published HIV-related interventions address abuse exposure (not just stress), and fewer still report adherence as an outcome. There are some promising findings from a group psychoeducational intervention for female HIV-positive childhood sexual abuse survivors; postintervention improvements were seen in adherence but only for women who attended eight or more sessions (Wyatt et al., 2004
). Dose may be crucial in impacting adherence behavior, which has been found to be especially difficult to improve through behavioral interventions, according to recent meta-analyses (e.g., Simoni, Pearson, Pantalone, Crepaz, & Marks, 2006
). Research focused on teaching adherence skills in the context of treatment for mental disorders, such as depression, appears promising (Safren et al., 2009
). Additional research is needed that integrates mental health and health behavior interventions for PTSD.
Given the innumerable biological and psychological factors that could impact biomarkers of HIV infection, it is notable that our model explains a significant amount of the variance in viral load (13%), especially with controls for time since diagnosis, CD4 count, and adherence. Because viral load is much less stable over time than our other outcome measures, its direct relations with predictor and mediator variables are likely to be based on events that occur relatively close in time to the interview. The accumulation of experiences that chronically up-regulate the sympathetic nervous system may increase cellular vulnerability to infection and diminish immune responses (e.g., Cole, 2008
). Although the discrete experiences of abuse exposure provide a less ambiguous link in a potential causal chain than depression, for example (Leserman et al., 2005
), future longitudinal studies with frequent assessments are needed to address questions of sequencing and causality of symptom exacerbations and consequent changes in health behaviors and biomarkers.
Nine percent of the variance in past year ER visits was accounted for by the model, predicted directly from adult abuse. Those who reported for emergency care were also those who reported experiencing more frequent IPV by nonpartners. This was the only direct effect that emerged, and it is consistent with the results of several large-scale studies of HIV-positive outpatients (Eisenman et al., 2003
; Leserman et al., 2005
). Our sample was actively engaged with medical care; the modal participant attended at least one outpatient visit per quarter, the recommendation for HIV-infected patients. We would expect acute care to be more related to physical or sexual (i.e., contact) IPV or to more recent or severe abuse than the indirect effects of mental health. This finding is surprising, though, because the partner abuse measure captures more recent (past year) experiences than the adult abuse measure (since age 18), although it may be that participants experiencing partner abuse were less likely to visit an ER out of fear that providers would discover the abuse. In any event, ER staff should routinely screen for IPV in all HIV patients, irrespective of the presenting problem. No data were collected on the presenting problem of ER visits; however, there were chart-extracted data (not shown) on past year physical injuries, and there were no associations between physical injuries noted by providers and any of the violence measures.
This study incorporates novel design elements that build on the existing model testing literature by addressing several limitations of previously published work. Participants were recruited from two clinic sites and were not selected for having experienced previous abuse, providing for the full range of frequency and severity of predictor variables and examination of the specific contributions of each type of abuse experience. Previously published studies limited their abuse variables to one type (e.g., partner abuse only) or neglected the role of psychological abuse, which exerts unique effects on mental health, especially PTSD (e.g., Mechanic, Weaver, & Resick, 2008
). We measured frequency as a proxy for severity of violence rather than just presence or absence, and we assessed all domains of abuse (physical, sexual, psychological) to capture all potential victimization experiences. To increase comparability and minimize socially desirable responding, we administered commonly used measures with established psychometric properties via CASI. Outcomes included objective data extracted from medical records on viral load, CD4 count, and ER visits to increase validity.
As with any individual study, there are limitations that restrict generalizability. Most significantly, the design is cross-sectional; thus, no causality can be inferred (despite the “causal models” terminology of SEM). The project has a relatively small sample size for SEM and may be underpowered, compromising reliability. Replication in another, larger sample would provide greater assurance of the stability of these relations. The sample consists of patients engaged with medical care; some research suggests that such patients are qualitatively and quantitatively different than those who are not in care, which further limits generalizability (Cunningham et al., 2006
). Critics find behaviorally based IPV measures undesirable because they neglect the context, function, and chronology of IPV experiences. Most measures were self-reported and thus are subject to participant misunderstanding or biased responding, although social desirability was retained in the model as a covariate on the abuse variables. Some important questions were not asked, including the length of time on antiretroviral therapy and the relationship of perpetrators to victims in the adult abuse questionnaire. The latter omission creates a potential confound between the adult and partner abuse factors, as the adult abuse questions were presented first. Future models with more statistical power should incorporate child abuse as a predictor, as well as additional mediators such as substance use, HIV stigma, and other HIV biomarkers. As it unfortunately falls outside the scope of this article, future investigators may wish to address the issue of whether PTSD alone or mental health problems more generally best account for IPV–health relations (e.g., Boarts et al., 2006
As discussed above, provider-based interventions to increase IPV detection and treatment are needed. However, interventions to increase provider skill at identifying and triaging patients to mental health services more generally are also likely to be helpful. Results from a large-scale study of HIV-positive clinic patients indicate that more than one third of individuals who required mental health intervention were not receiving it (Taylor, Burnam, Sherbourne, Andersen, & Cunningham, 2004
), and other work has shown that providing such services to HIV-positive individuals with mental disorders decreased healthcare costs and increased health-related outcomes (Whetten et al., 2006
). Changes are needed to more accurately portray to traditional medical providers the impact of psychosocial variables on disease processes (Gore-Felton & Koopman, 2008
). Increased training and education or implementation of policy or practice guidelines appear to be needed to reinforce necessary attention to behavioral factors.
In light of these data and our own findings, it seems warranted to focus on integrating psychosocial interventions for patients into primary HIV care settings, especially those that address lifetime abuse exposure, negative affect, and anxiety or PTSD. What kinds of interventions are needed? The literature encourages a focus on active coping training as well as efforts to increase self-efficacy, process traumatic experiences, find or maintain meaning in life, connect with spiritual beliefs, and remain generally engaged with life (e.g., Ironson & Hayward, 2008
). Few interventions for HIV-positive IPV victims exist except those focused on childhood sexual abuse (e.g., Wyatt et al., 2004
). In contrast, there have been many published interventions on stress management more generally, tested in a variety of populations with different formats. A recent integrative review (Carrico & Antoni, 2008
) and meta-analysis (Scott-Sheldon et al., 2008
) each found strong support for postintervention improvements in stress-related and psychosocial factors. However, there is disagreement about the extent to which the interventions were able to impact immunologic and hormonal markers. For the studies in which the interventions were unable to change the psychosocial factors, no changes in biomarkers occurred, highlighting the significance of mental health factors in the relation between stress and health. Clearly, this is an area ripe for future research building upon the weaknesses of the extent literature (e.g., small sample sizes, short follow-up).
In conclusion, the results of this study provide strong support for the contribution of violence exposure and mental health problems to poor health-related outcomes among HIV-positive sexual minority men. Clinical practice implications include provision of more intensive mental health services to patients in order to contain costs associated with physical health problems, which are potentially exacerbated by psychological distress and an IPV history. Also, provider interventions that increase identification of abuse and mental health problems may be needed. Given their social and financial problems, many HIV-positive individuals clearly need referral to social services. However, rather than providing supportive counseling or case management alone, HIV care settings may also wish to offer evidence-based mental health treatments that target specific disorders or symptom clusters. Investigators are encouraged to test and disseminate such interventions in HIV care settings, especially those that combine traditional evidence-based approaches to mental disorders with a specific focus on relevant health-promotion behaviors (Safren et al., 2009