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The Public Health Implications of Violence Exposures: Violence and Immunological Factors Among Perinatally HIV-Infected Youth
Journal of Adolescent Health 59 (2016) 3e4
www.jahonline.org Editorial
The Public Health Implications of Violence Exposures: Violence and Immunological Factors Among Perinatally HIV-Infected Youth In the United States, children and adolescents in many urban cities are exposed to high rates of community trauma. Among these exposures are loud traumas such as homicides with the United States having the highest such rates when compared to other highly resourced nations [1]. However, what often gets overlooked are the more pervasive everyday silent traumas such as being a victim of or witnessing robberies, gang violence, police aggression, and brutality and sexual assault. National estimates conclude that these silent traumas are 120 times higher than deadly homicides [2]. Several studies have long documented that youth who are exposed to these silent traumas are at high risk for experiencing a number of negative sequelae such as mental health problems (e.g., depression, anxiety, aggression, and posttraumatic stress symptoms and disorders), low school success (e.g., poor grades and studenteteacher relationships), and becoming involved with negative peer networks such as gangs [3]. More recently, a growing number of studies have provided evidence that community traumas are associated with greater sexually transmitted infection (STI) risk behaviors (e.g., having sex without condoms, reporting a higher number of casuals sexual partners, and using drugs while having sex) and higher STI incidence [3]. These recent findings emphasize that community trauma is a significant public health concern that must be addressed when attempting to curtail the high rates of adolescence STIs. However, the austere reality is that youth who reside in ecological niches where loud and silent community traumas are prevalent have caregivers who themselves have also been exposed to various forms of violence. In many instances, caregivers in these communities are also combating violence outside the home and within their intimate relationships especially when the family is impacted by human immunodeficiency virus (HIV) [4]. Without question, caregiver exposure to community trauma and intimate partner violence can negatively impact the developmental trajectories of youth by disrupting important parenting practices and youth monitoring functions. Unfortunately, our understanding of how these multiple forms of youth and caregivers’ violence exposures might be related to youth STI/ HIV health-related outcomes are often limited by parsimonious research designs that only measure adolescent or parent trauma but seldom both.
To date, we know that exposure to community traumas are correlated with STI risk behaviors and infections [3]. We also know that intimate partner violence is related to nonadherence to antiretroviral therapy (ART) [4]. However, the extant literature has not examined whether a relationship exists between exposures to recent community trauma and virologic and immuniologic functioning among HIV positive youth while accounting for exposures to physical and sexual violence among their caregivers. Kacanek et al. [5] in this issue of the Journal of Adolescent Health address this cavernous gap in the current literature thereby situating the violence literature squarely within the public health domain of HIV disease progression among youth with perinatal HIV infection (PHIV). Worldwide during the past decade, the number of persons living with HIV has remained virtually unchanged and the rates of new infections and Acquired Immune Deficiency Syndrome (AIDS)-related deaths have significantly decreased [6]. The Joint United Nations Programme on HIV/AIDS has established the goal of ending the spread of HIV by 2020 and eliminating the disease altogether by 2030 [6]. To achieve this ideal, an important component is to have at least 90 percent of those HIV infected attain an undetectable level of virus in their bodies (essentially a functional cure). Existing rates range from 40 to 80 percent in various countries [6]. Globally, approximately 3.3 million youth are living with HIV [6]. Among this group are perinatally HIVinfected infants who are now reaching preadolescence and adolescence. Ensuring that these youth maintain an undetectable HIV viral load is critical to supporting overall quality of life and eliminating new infections especially as youth transition into sexual relationships and childbearing. This article brings needed attention to this often under researched population of youth with PHIV. Between 2007 and 2015, Kacanek et al. conducted a prospective study of a matched sample of 286 8e15 year youth who were PHIV and their caregivers from 15 clinics in the United States including Puerto Rico. Follow-up data were collected at multiple time points and included clinical examinations, medical record abstraction, and interviews. An important methodological contribution of this study was the collection of violence data from both youth and their caregivers across a broad spectrum of exposures which included past 12 months direct and indicated exposures and caregivers’ recent adult violence exposures by a
See Related Article p. 30 1054-139X/Ó 2016 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2016.04.017
4
Editorial / Journal of Adolescent Health 59 (2016) 3e4
partner or nonpartner. Important data because these overlapping forms of violence exposures better approximate the unfortunate realties of low-income youth and their families who are living with HIV. Major findings indicated that youth reporting violence exposures were more likely to be older, living with less educated caregivers, and residing with a caregiver who was not partnered. These findings corroborated ones which showed that low-economic and household capital are risk factors for violence exposures [7,8]. Novel study findings documented that youth with any violence exposures in the previous year had elevated odds of unsuppressed viral loads. Indirect community violence exposures were associated with unsuppressed viral loads and CD4 <.24%. In addition, nonadherence to ARTs was related to unsuppressed vial loads and poorer CD4 scores. In general, few gender differences were observed with regard to the above associations. Interestingly, youth and caregivers’ direct violence exposures were not associated with HIV-related health outcomes while indirect exposures were. The authors quickly concluded that nonsignificant findings for direct violence and HIV-related health outcomes may be partly due to the fact that indirect exposures were more pervasive than recent direct victimization. A plausible explanation but what if the authors had also suspended their concerns about recall bias and assessed youth and caregivers’ lifetime exposures to violence would a different pattern emerge? Clinically, we know that the effects of long-term trauma rarely subside unless treated and that loud traumas are rarely forgotten by individuals. Too few studies account for the syndemic effects of recent and lifetime exposures to community trauma and violence on health, especially as they may relate to HIV-related concerns. Consequently, this gap remains another dimension of the violence and HIV public health domains that await exploration. So what are some of the lessons to be learned from this
present study and the trauma literature to which it expands? There are many that can be summed into onedexposures to violence is a major public health concern and reducing new STI infections and promoting ART adherence, and HIV suppression requires the assessment for and treatment of violence especially among populations who are at elevated risks for such exposures. Dexter R. Voisin, Ph.D. School of Social Service Administration University of Chicago Chicago, Illinois
References [1] United Nations Office on Crime and Drugs. UNODC Homicide Statistics 2013. Homicide counts and rates, time series 2000-2012. [2] CDC. Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control, Office of Statistics and Programming; 2010. [3] Voisin D, Jenkins E, Takahashi L. Toward a conceptual model linking community violence exposure to HIV-related risk behaviors among adolescents: Directions for research. J Adolesc Health 2011;49:230e6. [4] Sullivan KA, Messer LC, Quinlivan EB. Substance abuse, violence and HIV/ AIDS (SAVA) Syndemic effects on viral suppression among HIV positive women of color. AIDS Patient Care STDs 2015;29:S42e8. [5] Kacanek D, Malee K, Mellins C, et al. Exposure to violence and virologic and immunological outcomes among youth with perinatal HIV in the pediatric HIV/AIDS cohort study. J Adolesc Health 2016;59:30e7. [6] Global report: UNAIDS global AIDS response progress reporting 2015. Geneva, Switzerland: UNAIDS; 2015. [7] Harrell E, Langton L, Berzofsky M, Couzens L, Smiley-McDonald H. Household poverty and nonfatal violent victimization, 2008e2012. Bureau of Justice Statistics, November. Available at: http://www.bjs.gov/content/pub/ pdf/hpnvv0812.pdf. Accessed April 15, 2016. [8] Gorman-Smith D, Henry DB, Tolan PH. Exposure to community violence and violence perpetration: The protective effects of family functioning. J Clin Child Adolesc Psycho 2004;33:439e49.
www.jahonline.org Editorial
The Public Health Implications of Violence Exposures: Violence and Immunological Factors Among Perinatally HIV-Infected Youth In the United States, children and adolescents in many urban cities are exposed to high rates of community trauma. Among these exposures are loud traumas such as homicides with the United States having the highest such rates when compared to other highly resourced nations [1]. However, what often gets overlooked are the more pervasive everyday silent traumas such as being a victim of or witnessing robberies, gang violence, police aggression, and brutality and sexual assault. National estimates conclude that these silent traumas are 120 times higher than deadly homicides [2]. Several studies have long documented that youth who are exposed to these silent traumas are at high risk for experiencing a number of negative sequelae such as mental health problems (e.g., depression, anxiety, aggression, and posttraumatic stress symptoms and disorders), low school success (e.g., poor grades and studenteteacher relationships), and becoming involved with negative peer networks such as gangs [3]. More recently, a growing number of studies have provided evidence that community traumas are associated with greater sexually transmitted infection (STI) risk behaviors (e.g., having sex without condoms, reporting a higher number of casuals sexual partners, and using drugs while having sex) and higher STI incidence [3]. These recent findings emphasize that community trauma is a significant public health concern that must be addressed when attempting to curtail the high rates of adolescence STIs. However, the austere reality is that youth who reside in ecological niches where loud and silent community traumas are prevalent have caregivers who themselves have also been exposed to various forms of violence. In many instances, caregivers in these communities are also combating violence outside the home and within their intimate relationships especially when the family is impacted by human immunodeficiency virus (HIV) [4]. Without question, caregiver exposure to community trauma and intimate partner violence can negatively impact the developmental trajectories of youth by disrupting important parenting practices and youth monitoring functions. Unfortunately, our understanding of how these multiple forms of youth and caregivers’ violence exposures might be related to youth STI/ HIV health-related outcomes are often limited by parsimonious research designs that only measure adolescent or parent trauma but seldom both.
To date, we know that exposure to community traumas are correlated with STI risk behaviors and infections [3]. We also know that intimate partner violence is related to nonadherence to antiretroviral therapy (ART) [4]. However, the extant literature has not examined whether a relationship exists between exposures to recent community trauma and virologic and immuniologic functioning among HIV positive youth while accounting for exposures to physical and sexual violence among their caregivers. Kacanek et al. [5] in this issue of the Journal of Adolescent Health address this cavernous gap in the current literature thereby situating the violence literature squarely within the public health domain of HIV disease progression among youth with perinatal HIV infection (PHIV). Worldwide during the past decade, the number of persons living with HIV has remained virtually unchanged and the rates of new infections and Acquired Immune Deficiency Syndrome (AIDS)-related deaths have significantly decreased [6]. The Joint United Nations Programme on HIV/AIDS has established the goal of ending the spread of HIV by 2020 and eliminating the disease altogether by 2030 [6]. To achieve this ideal, an important component is to have at least 90 percent of those HIV infected attain an undetectable level of virus in their bodies (essentially a functional cure). Existing rates range from 40 to 80 percent in various countries [6]. Globally, approximately 3.3 million youth are living with HIV [6]. Among this group are perinatally HIVinfected infants who are now reaching preadolescence and adolescence. Ensuring that these youth maintain an undetectable HIV viral load is critical to supporting overall quality of life and eliminating new infections especially as youth transition into sexual relationships and childbearing. This article brings needed attention to this often under researched population of youth with PHIV. Between 2007 and 2015, Kacanek et al. conducted a prospective study of a matched sample of 286 8e15 year youth who were PHIV and their caregivers from 15 clinics in the United States including Puerto Rico. Follow-up data were collected at multiple time points and included clinical examinations, medical record abstraction, and interviews. An important methodological contribution of this study was the collection of violence data from both youth and their caregivers across a broad spectrum of exposures which included past 12 months direct and indicated exposures and caregivers’ recent adult violence exposures by a
See Related Article p. 30 1054-139X/Ó 2016 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2016.04.017
4
Editorial / Journal of Adolescent Health 59 (2016) 3e4
partner or nonpartner. Important data because these overlapping forms of violence exposures better approximate the unfortunate realties of low-income youth and their families who are living with HIV. Major findings indicated that youth reporting violence exposures were more likely to be older, living with less educated caregivers, and residing with a caregiver who was not partnered. These findings corroborated ones which showed that low-economic and household capital are risk factors for violence exposures [7,8]. Novel study findings documented that youth with any violence exposures in the previous year had elevated odds of unsuppressed viral loads. Indirect community violence exposures were associated with unsuppressed viral loads and CD4 <.24%. In addition, nonadherence to ARTs was related to unsuppressed vial loads and poorer CD4 scores. In general, few gender differences were observed with regard to the above associations. Interestingly, youth and caregivers’ direct violence exposures were not associated with HIV-related health outcomes while indirect exposures were. The authors quickly concluded that nonsignificant findings for direct violence and HIV-related health outcomes may be partly due to the fact that indirect exposures were more pervasive than recent direct victimization. A plausible explanation but what if the authors had also suspended their concerns about recall bias and assessed youth and caregivers’ lifetime exposures to violence would a different pattern emerge? Clinically, we know that the effects of long-term trauma rarely subside unless treated and that loud traumas are rarely forgotten by individuals. Too few studies account for the syndemic effects of recent and lifetime exposures to community trauma and violence on health, especially as they may relate to HIV-related concerns. Consequently, this gap remains another dimension of the violence and HIV public health domains that await exploration. So what are some of the lessons to be learned from this
present study and the trauma literature to which it expands? There are many that can be summed into onedexposures to violence is a major public health concern and reducing new STI infections and promoting ART adherence, and HIV suppression requires the assessment for and treatment of violence especially among populations who are at elevated risks for such exposures. Dexter R. Voisin, Ph.D. School of Social Service Administration University of Chicago Chicago, Illinois
References [1] United Nations Office on Crime and Drugs. UNODC Homicide Statistics 2013. Homicide counts and rates, time series 2000-2012. [2] CDC. Web-based Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control, Office of Statistics and Programming; 2010. [3] Voisin D, Jenkins E, Takahashi L. Toward a conceptual model linking community violence exposure to HIV-related risk behaviors among adolescents: Directions for research. J Adolesc Health 2011;49:230e6. [4] Sullivan KA, Messer LC, Quinlivan EB. Substance abuse, violence and HIV/ AIDS (SAVA) Syndemic effects on viral suppression among HIV positive women of color. AIDS Patient Care STDs 2015;29:S42e8. [5] Kacanek D, Malee K, Mellins C, et al. Exposure to violence and virologic and immunological outcomes among youth with perinatal HIV in the pediatric HIV/AIDS cohort study. J Adolesc Health 2016;59:30e7. [6] Global report: UNAIDS global AIDS response progress reporting 2015. Geneva, Switzerland: UNAIDS; 2015. [7] Harrell E, Langton L, Berzofsky M, Couzens L, Smiley-McDonald H. Household poverty and nonfatal violent victimization, 2008e2012. Bureau of Justice Statistics, November. Available at: http://www.bjs.gov/content/pub/ pdf/hpnvv0812.pdf. Accessed April 15, 2016. [8] Gorman-Smith D, Henry DB, Tolan PH. Exposure to community violence and violence perpetration: The protective effects of family functioning. J Clin Child Adolesc Psycho 2004;33:439e49.