HIV Prevention Strategy for Survivors of Domestic Violence

Sexual Safety Planning as an HIV Prevention
Strategy for Survivors of Domestic Violence
Jill Foster, MD,1 Ana Nu´ n˜ ez, MD,2 Susan Spencer, LCSW,3
Judith Wolf, MD,2 and Candace Robertson-James, DrPH2
Victims of domestic violence (DV) are not only subject to physical and emotional abuse but may also be at
increased risk for less recognized dangers from infection with human immunodeficiency virus (HIV) and other
sexually transmitted pathogens. Because of the close link between DV and sexual risk, women need to be
educated about the consequences of acquiring a life-threatening sexually transmitted infection, risk reduction
measures, and how to access appropriate HIV services for diagnosis and treatment. It is therefore critical for DV
workers to receive sufficient training about the link between DV and HIV risk so that sexual safety planning can
be incorporated into activities with their clients in the same way as physical safety plans. In this article, we
discuss how the Many Hands Working Together project provides interactive training for workers in DV and
DV-affiliated agencies to increase their knowledge about HIV and teach sexual safety planning skills to achieve
HIV risk reduction.
Domestic violence (DV) is a serious threat to women’s
health. Each year, an estimated 4.8 million intimate
partner physical and sexual assaults occur against women,
and one in four women will experience DV in her lifetime.1
Safety planning, within the context of DV, is a crisis-oriented
process to focus attention on immediate safety needs for the
ultimate long-term survival of the woman.2 While safety
planning is a hallmark function of DV agencies, the safety
plan rarely includes strategies for identification and risk reduction of sexually transmitted infections (STIs), including
human immunodeficiency virus (HIV). The Institute of
Medicine and US Preventive Services Task Force recommend screening and counseling for DV, and the Affordable
Care Act requires it as part of its free preventive services.3
Yet, missing from all of these is integration of screening for
sexual coercion/abuse and attendant risks of STIs. Compared
to physical abuse, which is more clinically obvious and poses
a more immediate threat to women’s physical health, HIV is
initially more clinically occult—a silent killer of women.
Interventions for improving women’s ability to identify and
reduce HIV risk are needed. Integration of sexual safety into
the broader safety planning process already being performed
by DV workers is a critical next step.
The Many Hands Working Together (MHWT) project
provides training to DV agencies to achieve these objectives.
The training intervention is based in theory on the AIDS Risk
Reduction Model (ARRM) and employs interactive sessions to
train workers in DV and DV-affiliated agencies. Since most
clients seen in DV agencies are heterosexual women, our intervention focused on this group. However, similar kinds of
abusive power dynamics occur in same-sex relationships.
The purpose of this article is to outline in more depth the
theory behind the trainings, provide a brief curricular outline,
and share initial lessons learned in the project.
Models of DV: Situational Violence Versus
Intimate Terrorism
Developing a sexual safety plan requires acknowledging
risk and planning ahead to mitigate sexual risk. Despite how
much is known about DV, the widely held lay view is of a
sudden, unpredictable violent outburst resulting from some
type of victim-initiated trigger.4 Within this model, safety
planning is difficult because the episodes are unexpected,
explosive, and uncontrolled.
Even among professionals who study it, there is a debate
about the models used to describe DV. In one model, DV is
situational, that is, resulting from a more gender neutral
Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania.
Office of Urban Health Equity, Education and Research, Drexel University College of Medicine, Philadelphia, Pennsylvania.
Susan B. Spencer, Inc., Philadelphia, Pennsylvania.
Volume 25, Number 6, 2016
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2015.5252
dynamic that exists within the context of a relationship in
which both partners use violence symmetrically. This dynamic is theoretically remediable by counseling of the couple; however, situational violence is considered to be
relatively rare.5,6 In an alternative model termed intimate
terrorism first described by Johnson in 1995,7 the perpetrator
(usually a man) exerts physical force (including physical and
sexual violence) and emotional abuse as a means of control
and subordination of a partner (usually a woman)—a situation unlikely to be alleviated through discussion. Physical
injury is almost always associated with a pattern of escalating
controlling behaviors, including limiting access to friends
and family, insisting on knowing the woman’s whereabouts,
jealousy, and limiting information about family finances even
when asked. A study by Lichtenstein8 using focus groups and
in-depth questionnaires with HIV-positive women in the
southeastern United States elucidated the close link between
sexual risk and DV. In this study, the women consistently
described a pattern of highly sexualized abuse from disempowered men asserting power and control and projecting a
sense of enforced ownership over women. A corroborating
study from Finland by Flinck and Paavilainen9 interviewed
male perpetrators of DV who described it as their quest to find
personal dignity, respect, and control by directly inviting
communication through confrontation. Because the dynamic
in intimate terrorism is rooted in a need to control and subdue,
this places the health of the subdued partner at significant risk
emotionally, sexually, and physically.
Intimate Terrorism and Risk for HIV
According to the CDC,10 women in relationships with
violence have four times the risk for contracting STIs, including HIV, compared with women in nonviolent relationships. Victims of intimate partner violence (IPV) more
frequently report behaviors associated with an increased risk
for HIV, including injection drug use, treatment for an STI,
multiple sex partners, and intercourse without a condom.11 A
study of women in low-income urban settings found an inverse association between higher rates of IPV and condom
use.12 Low self-esteem, depression, and fear of abuse contribute to poor safer sex negotiation practices. Furthermore,
coercive sex by a promiscuous partner who refuses condom
use, uses injectable drugs, and limits access to early diagnosis
and treatment places these women at high risk for HIV.11,13
Authors of reviews of cross-sectional studies have noted an
association between DV and HIV.14,15 In fact, some have
proposed that the inter-relationships between DV, substance
abuse, and HIV risk constitute a syndemic.15 However, few
have documented DV as a specific risk factor for HIV in
women, and the actual risk of acquiring HIV within the
context of DV is unknown. Dunkle et al.16 found a significant
association between DV and increased risk of HIV infection
(odds ratio 1.48, 95% confidence interval 1.15–1.89) in South
African women after adjustment for women’s own risk behavior. Lichtenstein’s work describes the power dynamic
whereby men actively subjugate women such that their vulnerability to an HIV-positive partner is increased. El-Bassel
et al.17 describe the progressive effect of DV on a woman’s
psyche resulting in her inability to resist unsafe sex. In addition, women with a history of childhood sexual abuse or
abuse before their current situation have been conditioned to
yield to power and control and will be unlikely to develop a
sexual safety plan on their own.13
Part of the subjugation of women is economic, and financial control is a key component of intimate terrorism. In
resource-poor countries, it is universally acknowledged that
violence against women and HIV acquisitions go hand in
hand. A novel intervention in South Africa using microfinance reduced IPV by 55%18; with longer term follow-up, it
may show a reduction in HIV as well. In the United States,
many women are no less bound to their partners economically—they are often dependent on their partners for housing,
food, and health insurance.
Knowing about HIV risk and risk reduction is not sufficient
for women to be able to practice risk reduction.19 Consistent
condom use is the most effective way of preventing HIV in
sexually active adults, but is not a viable solution for the
majority of women DV survivors. In general, negative attitudes by both men and women are a barrier to their use. Men
employing intimate terrorism will likely feel less control and
be more likely to inflict physical injury if asked to use a
condom. For women, the potential safety gain in STI risk
reduction with condom use is offset by the potential safety
loss in the violence in the relationship. Therefore, condom
use, the principal pillar of most HIV prevention programs, is
not available for most women in a violent relationship.
The ARRM (described in detail below) was designed to
change high-risk sexual behaviors associated with HIV transmission by examining contributing social and psychological
factors (e.g., perception of risk and self-efficacy beliefs) and
implementing solutions directed at reducing high-risk activities
(e.g., communication skills, help seeking behavior).20 Based on
this model, we developed an intervention (the MHWT project)
incorporating HIV education and sexual safety planning for
agencies that work with victims of IPV.
The Need for Sexual Safety Assessment and Planning
In the safety assessment phase, a woman must make behavioral changes based on her assessment of risk and lethality. Cognitive behavioral change models, the theoretical
models that underpin much of HIV prevention, assume that
participants have free agency to make change once knowledge is gained. Within DV, women have options, but may
become paralyzed by how limited the options are—harm
reduction rather than harm elimination. Planning around
physical safety is a hallmark of practice by DV agencies
and acknowledges harm reduction as the initial step in the
It is incumbent upon staff in agencies serving survivors of
DV to implement concrete sexual safety plans in the same
way that they develop safety plans around physical safety.
The Family Planning Council in southeastern Pennsylvania
instituted an outreach and education program around DV and
HIV in 2003. Their needs assessment discovered that DV
workers were reluctant to bring up sexual health issues, had
poor baseline knowledge about HIV and HIV prevention, and
had no tools for developing a sexual safety plan. Their intervention involved working to overcome partner resistance
to condom use, but was unsuccessful in creating change.21
Although the New York State Department of Health provides
excellent resources that integrate screening for DV during
HIV testing as well as resources for general practice social
workers around HIV risk reduction, it does not specifically
link DV and HIV for training for DV workers.22
Women need to be made aware that their HIV risk is
increased, HIV is lethal, it is preventable, and given tools for
harm reduction. This is accomplished first at an agency level
by improving staff knowledge about HIV risk and risk reduction, teaching skills around the risk interview and risk
reduction counseling, and helping staff find opportunities
for incorporating sexual safety planning into daily activities
with clients.
Theoretical Models for the Intervention
The ARRM summarized in Figure 120 is a three-stage
process involving (1) Labeling—recognition of risk for HIV,
(2) Commitment—developing a conscious commitment to
change behavior, and (3) Enactment—acting on the commitment to change through adoption of risk reduction practices.
ARRM was tested with high-risk heterosexual couples23
and found to be efficacious in improving condom use and
sexual communication. It is most effective in areas where the
risk of HIV infection is perceived as greatest; simple
knowledge of the threat is not enough. In a meta-analysis of
factors important in condom use in a general population,24
viewed through an ARRM lens, behavior-specific cognitions,
social interaction, and preparatory behaviors were more important than increasing knowledge and beliefs about the
threat of infection, that is, development of a specific commitment and enactment plan was more important than the
labeling alone. In a study by Longshore et al.,
25 examining
gender differences with use of ARRM, women’s confidence
that they could practice risk reduction was more significant
than improved knowledge alone.
ARRM teaches techniques based on motivational interviewing, a patient-centered counseling style that uses a form
of collaborative conversation to strengthen an individual’s
own motivation and commitment to change by addressing
ambivalence about change and exploring the person’s own
reasons for change within an atmosphere of acceptance and
compassion26 to develop a sexual safety plan. The client and
counselor form a partnership, in which the client’s autonomy
and freedom of choice drive the interaction. The motivation
to change is elicited from the client by her desire for safety. It
is the client’s responsibility to work through the conflict
between continuing in the current abusive relationship and
making changes that would bring with it new challenges. The
DV counselor acts as a consultant to provide information on a
menu of safety options, but does not proscribe particular risk
reduction choices. Motivational interviewing is effective
because the client’s readiness for change may fluctuate based
on time, distance from the most recent threat, and by what the
specific threat is. The vague threat of HIV infection may
seem less real than the bruise around her eye. Motivational
interviewing addresses these issues.
The MHWT program
The MHWT project is an interactive training intervention
based in theory on the ARRM for workers in DV and affiliated agencies developed in response to a request for proposal
from the federal Office on Women’s Health, Department of
Health and Human Services. The core of the program was
developed over the course of a year based on information
gathered through focus groups with DV staff and women who
were either in an abusive relationship or who had left one.
This information helped to identify issues the curriculum
would need to address and confirmed the strong desire expressed by the women about receiving information about
HIV/other STI. The project was initiated in 2007 at two DV
agencies in the Philadelphia area. Feedback was obtained
after each training. Check-in sessions were also conducted
with the staff on a regular basis to discuss progress in implementation of HIV risk reduction with their clients.
The goal of the MHWT project is to train DV workers to
help clients take measures to reduce their HIV risk through
improving their awareness of their HIV risk, taking concrete
FIG. 1. AIDS Risk Reduction
Model. (Adapted from Catania J,
et al. Towards and understanding
of risk behavior. 1990.)
steps to reduce their HIV risk when possible, and seeking early
diagnosis and treatment when HIV prevention has failed. The
design of the training is to build on an intervention where DV
counselors already have proficiency—the safety plan—by
adding a sexual safety plan. They are educated about the link
between HIV and DV through relevant case studies, about HIV
prevention measures and the importance of early diagnosis and
treatment, and how to access HIV testing and care services.
Through interactive sessions, counselors role-play sexual
safety planning and are provided assistance in how to integrate
sexual safety planning into existing practice.
Overview. The MHWT curriculum consists of two interactive educational programs for DV workers to increase
their knowledge about HIV and to teach sexual safety planning skills. The curriculum is followed by monthly check-ins
with DV staff to reinforce the material presented in the
trainings, help troubleshoot the process of integration of
safety planning into daily practice, and to provide periodic
updates to address knowledge gaps and offer new information as needed. The program is provided by program staff to
staff at DV agencies and other sites such as homeless shelters
where there is a high concentration of women DV survivors.
A train the trainer module has also been developed so that
HIV providers in areas beyond Philadelphia can be trained to
provide the MHWT curriculum locally (Fig. 2).
Session 1. This module is intended to prepare DV workers
to perform sexual safety planning by modeling discussion
of sexual health matters in a comfortable yet authoritative
way and providing workers with the baseline knowledge
needed to develop a sexual safety plan. The didactic session
assumes that baseline knowledge about HIV is poor and is
given by a medical provider to all agency staff. The goal is to
improve awareness for anyone who might interact with clients around HIV issues, to inform the learners about the links
between HIV and DV, and to debunk common myths around
HIV. The lecture is divided into sections on basic epidemiology and HIV transmission, DV/HIV links, principles of
HIV prevention for DV survivors, and what happens after a
positive HIV test.
Session 2. This workshop-type format is provided only
for direct line staff interacting with clients clinically (i.e.,
case managers, hotline workers, and court advocates) within
1 month of session 1. The intent is that workers will seek
opportunities within their individual roles to provide information on sexual safety planning. This may be a case manager working with a client to develop a comprehensive safety
plan around physical and sexual safety over multiple sessions and/or a hotline worker advising a caller at risk to get
an HIV test.
The session explains how to perform a risk interview that
both seeks information from a client about her specific risks
and provides brief, concrete harm reduction information. The
risk interview is client centered, but semidirective, focuses on
providing small bits of pertinent information, and is goal
oriented. Figure 3 is a sample encounter demonstrating a risk
Before a risk interview can be performed, the counselor
must be comfortable talking about sexual matters, have sufficient HIV prevention knowledge to be able to provide risk
reduction strategies, and be willing to partner with the client
to determine the best plan for her. In the first exercise, Talking
the Talk, workers take turns role-playing interviewing a client
about her sexual risk. The purpose of this is to enhance worker
comfort with sexual content and to provide feedback about
their use of language. Workers are encouraged to speak frankly
about sexual health. Facilitators guide them away from using
indirect terms and euphemisms for reproductive anatomy and
sexual matters. Vernacular and slang terms used by clients are
explored and situations discussed where it is appropriate to use
the client’s terms rather than the correct clinical terms.
The second exercise, Stump the Professor, asks, ‘‘What
questions might your clients ask that you might not know the
answer to?’’ (e.g., ‘‘How can a woman using a female condom still urinate?’’). Workers are given a prize if they can
come up with a question about sexual health, HIV, and STIs
that project staff are unable to answer. This further increases
their comfort level in discussing sexual health, gives them an
opportunity to ask questions left unanswered in session 1, and
explores areas of knowledge gaps.
The third exercise, Shades of Gray, provides opportunities
to strategize around best- and worst-case scenarios in safety
planning—and then all the options in between. For example,
Jane has an abusive partner who is newly diagnosed as HIV
positive. He continues to force her to have unprotected sexual
intercourse. The best case is that she is able to eliminate her
risk by leaving him. The worst case is that she continues to
have unprotected sex and does nothing else. Options in between include encouraging him to take medicine to lower his
risk of transmitting HIV to her, introducing condoms as sexual
FIG. 2. Many Hands
Working Together
play in their relationship, decreasing the frequency of intercourse by feigning a yeast infection, headache, etc., and getting
an HIV test regularly. Although there is a risk that behavior
change could lead to escalating abuse, the goal is to provide
more information for workers about choices and allow them to
see that there may be intermediate options that can potentially
provide some harm reduction, so they can partner with and
empower Jane to choose among a menu of potential solutions.
The final exercise is a demonstration by staff of how to
provide sexual safety planning through a risk interview (in a
longer form than what is presented above as a sample). In this
exercise, comfort with discussion of sexual health is modeled, partnering with a client is demonstrated, and more risk
reduction content is delivered. At the end, workers are asked
to imagine performing a risk interview and provide an assessment on their readiness to perform one. Workers are
asked to try to integrate risk interviewing into their practice
for the next month and a date for the first check-in is given.
Participants complete both a pre- and post-test for HIV
knowledge, as well as a session evaluation and questionnaire,
assessing perceptions of their knowledge and comfort with
discussions about HIV. At the first and subsequent monthly
check-ins, workers are asked to give examples of how they have
integrated sexual safety planning into their practice. Feedback
is given by project staff to enhance effectiveness, correct information, and provide mini-lectures on topics where there is
consistently a need for more knowledge and/or clarification.
Initial Lessons Learned
Implementation of the MHWT training program at two DV
agencies in the Philadelphia area resulted in greater awareness, knowledge, and understanding of HIV among the 31
counselor participants, as well as greater comfort and confidence in discussing HIV and HIV risk reduction with clients,
referring them for HIV testing, and helping them address HIV
risks. At the end of the first year of the program, approximately two-thirds of the DV providers developed sexual
safety plans as part of a physical safety plan, referred clients
for testing, and distributed materials on HIV.
As our experience illustrates, the use of the sexual safety
plan as an intervention for DV workers to help reduce risk
of HIV can be effectively implemented, although its ultimate effectiveness is unknown and warrants further research. Safety planning is familiar to DV workers, so
addition of sexual health content is a logical next step. That
being said, there are cultural, attitudinal, and logistical
barriers to instituting HIV prevention in DV agencies that
must be overcome.
To measure the effectiveness of the MHWT program in
terms of impact on clients and reduction in HIV transmission would require a larger number of participants (both
workers and clients) and study over a prolonged period of
time. Unfortunately, feasibility of doing this in DV agencies
is questionable. Most agencies are working with limited
resources (time and financial) and these are allocated to
providing quality services to a high-need population. Taking time and focus from their primary service mission to run
a study, even with additional funding, would create cultural
and practical issues for the staff and potential trust issues
with clients. A more detailed study design would also likely
involve a more intensive consent process with a vulnerable
population in a setting where confidentiality is of high
concern. Thus, one of the strengths of our study was that it
focused on working with staff rather than clients, therefore
ameliorating these concerns.
FIG. 3. Sample risk interview encounter.
The field of DV ties together a diverse group of agencies
with the primary aim of providing physical safety for women
resulting from violence where immediate impact can be seen.
While national medical expert panels write practice guidelines for HIV,27 it is more difficult for DV. Agencies tend to
be either a social service agency or an extension of a legal
services agency, so it is difficult to develop a unifying set of
principles that would guide all workers. Many agencies avoid
use of written notes lest they be subpoenaed, yet the lack of
documentation makes it difficult to evaluate the impact of an
intervention or secure research funding. Agencies are perpetually underfunded and understaffed and many rely heavily
on workers who are themselves survivors of DV so that the
addition of HIV prevention may not seem possible. Workers
are more likely to view the danger of a client being hit by an
abusing partner as more dangerous than a woman acquiring
HIV from her partner—yet also feel that while HIV can be
life-threatening, there is nothing a woman can do to avoid it.
All of these challenges lead to difficulty in developing and
implementing evidence-based measures that can be widely
Careful project planning is important in overcoming these
challenges. Each agency brings with it a specific culture,
practice model, and demographic that requires fine-tuning of
the curriculum. Meeting with program leadership first to
learn about their motivation to participate and how they see
this fitting in with what they already do is important. Agencies with a strong history of valuing training and innovation
will be the most successful. Agencies with a paid professional
staff that consistently provides service over time will benefit
the most from this training rather than agencies with staff that
consists primarily of volunteers who may be transient.
Whatever the perceived comfort level with HIV knowledge a
staff has, it is important that a solid foundation of HIV
knowledge is laid down; sexual safety planning without HIV
risk reduction content is inadequate. Beyond knowledge, skill
in discussing sexual health is essential. Although DV workers
are trained in social services, they may lack the knowledge
and skills to address other aspects of women’s lives, including sexual health. DV workers may perceive that since
they talk to women about their intimate relationships, those
skills translate to efficacy in sexual health. In our experience,
rarely have we found this to be the case.
Connecting DV agencies to an HIV infrastructure much
the same way they are already tied into the legal system is an
important component of the program. It would be unthinkable for a DV worker to not know how to help a client obtain
an order for protection, but we discovered that few workers at
baseline know how to obtain an HIV test. As workers gain
comfort in sexual safety planning, they will need to have
linkages with HIV testing agencies, providers, and other
services and resources for their clients. Finally, involvement
of HIV providers is crucial, not only during the train the
trainer component of the project but also in becoming proficient in appropriate DV screening referral. Development of
strong professional relationships that outlast the MHWT
project will help to ensure reinforcement of the curricular
content and sustainability of the project goals.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Ana Nu´n˜ez, MD
Office of Urban Health Equity, Education and Research
Drexel University College of Medicine
2900 W. Queen Lane
Philadelphia, PA 19129
E-mail: [email protected]
Copyright of Journal of Women’s Health (15409996) is the property of Mary Ann Liebert,
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