Integrating HIV and IPV Interventions: Strategies for Effective Care Among Black Sexual Minority Women

Abstract

The intersection of human immunodeficiency virus (HIV) and intimate partner violence (IPV) presents a significant public health challenge, particularly among marginalized populations who face compounded risks and barriers to accessing care.¹ Biological, psychological, and behavioral conditions place women at a great disadvantage, increasing their risk for both IPV and HIV.² Women who experience IPV are at higher risk of contracting HIV, and conversely, HIV-positive women are at increased risk for IPV experiences.² More specifically, Black women, who face systemic inequities and social determinants of health limiting their access to care and resources, are disproportionately affected by these epidemics.³ Moreover, Black sexual minority women report higher rates of HIV and IPV than their White peers.^4–6 The stigmatization and discrimination associated with both conditions further compound these individuals’ vulnerability.^4,6–9 Cultural, socioeconomic, and healthcare barriers often prevent Black women from seeking or receiving adequate support, making targeted interventions and community-based support systems crucial.^4,10–12 This research article explores strategies for effectively integrating HIV and IPV interventions to enhance care for individuals experiencing these co-occurring conditions. Based on a comprehensive review of existing literature and analysis of intervention programs, this article identifies best practices and innovative approaches for tailored care for those experiencing and/or at risk for HIV and IPV.

Introduction

The syndemic of human immunodeficiency virus (HIV) and intimate partner violence (IPV) is often overlooked in research. More than one in four women experience IPV, while four in ten people are living with HIV (LWH) globally.¹³ Both these conditions independently present significant challenges; however, their co-occurrence can exacerbate vulnerabilities, particularly among Lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) individuals, those with low socioeconomic status, and marginalized populations, such as racial, sexual, and ethnic minorities.^14,15 Black women are disproportionately affected by HIV, in comparison to women from all other racial groups.4 In 2022, Black women were nearly eight times more impacted by HIV (15.1) than their White counterparts (1.9) and more than three times as impacted than Hispanic/Latino women.¹⁶ Moreover, Black sexual minority women (BSMW; women who identify as lesbian, bisexual, queer, ­pansexual, etc.) are at increased risk for HIV and other sexually transmitted infections (STIs).^4,5 These women encounter socio-structural factors that place them at higher risk for HIV, including discrimination, homelessness, stigma toward sexual minority people, access to care, poverty, knowledge about HIV prevention tools such as pre-exposure prophylaxis (PrEP), substance use, and violence.^4,12

More than 40% of Black women experience some form of IPV in their lifetime.^15,17 In comparison to other racial groups, Black women experience IPV at a rate 21% higher than their White counterparts.15,17 In fact, one in two Black women report lifetime IPV in comparison to the lifetime IPV reported by one in three White women.¹³ Additionally, those who identify as sexual minority women (SMW), including LGBTQ+ individuals, experience unique challenges that heighten their risk for both HIV and IPV.^14,15 Among SMW, those who experience IPV are more likely to engage in high-risk behaviors, increasing their vulnerability to HIV infection.^14,15 SMW are also more prone to gender-based violence, further contributing to and increasing their risk for HIV/STIs and impeding HIV testing.⁵ Among Black women LWH, higher rates of severe IPV and greater IPV frequency have been reported.¹³ Among both groups of women (SMW and those LWH), the compounded effects of discrimination, economic instability, and limited access to healthcare services further exacerbate risks for HIV and IPV.^4,12 Cultural barriers associated with limited access to health care, coupled with mistrust in the healthcare system, may deter many from seeking necessary care.⁸

Moreover, societal stigmas enacted upon these women contribute to higher rates of violence and reduced access to health care, thus making them more likely to encounter barriers when accessing HIV and IPV care and support services.^4,14 These factors create an environment where SMW may be less likely to seek help or disclose their identity to formal supports (i.e., law enforcement, clergy, crisis lines, shelters), further entrenching the cycle of violence and health disparities^.18 Additionally, racial bias in the healthcare system, and other historical injustices that have precluded them, may prevent Black women from fully participating in their healthcare.¹⁹ Evidence suggests that the quality of care among Black women is often poorer, resulting from stigma and the lack of healthcare providers’ awareness of, and insensitivity to, the healthcare needs of these patients.⁷ As BSMW experience inequities in health care (discrimination and sexual orientation stigma), their comfort in seeking healthcare services may contribute to delays in care.^4,12,19,20 Consequently, these delays and negative experiences often result in poorer mental and physical health ­outcomes.^19,20 These individuals are more prone to mental health issues such as substance use, bullying, isolation, rejection, anxiety, depression, and suicide compared to their heterosexual counterparts.^19,21 In relation to physical health, sexual minority populations have higher risks for cardiovascular diseases, obesity, and STIs than their heterosexual peers.^19,22

The discrimination faced by BSMW and lack of culturally competent healthcare services often result in inadequate prevention and treatment efforts for these women.^23–25 Addressing these epidemics requires an integrated approach that not only addresses the medical attention and needs associated with HIV but also the social and psychological impacts of IPV. We aim to highlight the specific needs of BSMW who face compounded health risks associated with HIV and IPV, due to systemic inequities, stigma, and discrimination in healthcare settings. Through a thorough analysis, this review aims to contribute to the development of more effective, compassionate, and comprehensive care models by identifying gaps in current interventions. Addressing the healthcare disparities faced by BSMW requires targeted, culturally sensitive interventions that acknowledge and address the unique vulnerabilities of these individuals. Enhanced care models should not only improve health outcomes for BSMW but also serve as a framework for addressing these disparities in other marginalized populations. This research article explores strategies for effectively integrating HIV and IPV interventions to enhance care for BSMW experiencing these co-occurring conditions.

Significance

Integrating HIV and IPV interventions is crucial for several reasons. First, those who have an abusive partner with HIV may be at increased risk for contraction.²⁶ This many times results from forced unprotected sex, limited negotiation power for safe sex, and engagement in high-risk behaviors.²⁶ For instance, their abusive partner may force or coerce them into sexual activity (either protected or unprotected) or influence their engagement in high-risk behaviors (i.e., injection drug use).²⁷ Furthermore, women who depend on their partners to supply drugs, housing, and economic needs might be less likely to use condoms.¹ Specific to BSMW LWH and experiencing IPV, these individuals may be dependent on their partners for emotional and financial support.^8,18 This dependency exacerbates their risk for both IPV and HIV, as it can impede their access to necessary healthcare services and support systems.^8,18 As such, dependency on partners in this way has the potential to influence these individuals to remain in an abusive relationship, limiting their ability to seek help or adhere to HIV treatment.^8,18

This review article contributes to the ongoing dialog on enhancing culturally competent care and underscores the importance of tailored health interventions for marginalized populations, such as BSMW. More specifically, it highlights the unique challenges faced by BSMW, illuminating significant gaps in provider training and the need for comprehensive medical and nursing education that addresses these disparities. Focusing on practical strategies to improve healthcare outcomes for BSMW, this article provides actionable insights for healthcare practitioners and also advocates for systemic changes to better support these women. The findings from our review emphasize the compounded effects of drug use and dependency on partners for emotional and financial support among BSMW, which further entrap them in cycles of IPV and limit their ability to adhere to HIV treatment regimens. These additional layers of vulnerability necessitate integrated care approaches that address both the medical and socioeconomic aspects of their lives. Developing targeted interventions that account for these complexities is imperative, ensuring that healthcare services are accessible, non-discriminatory, and supportive of BSMW’s unique needs. These findings have the potential to guide the development of targeted interventions, ultimately improving health equity and access for BSMW and advancing the broader goals of public health.

Barriers to Integrated Care

The integration of HIV and IPV care is crucial for addressing the co-occurring vulnerabilities among marginalized populations, particularly BSMW. However, several significant barriers impede the effective integration of these services (see Table 1). Stigmatization related to both epidemics can prevent individuals from seeking help due to fear of judgment or ­discrimination.18 In conjunction with stigma, discrimination in healthcare settings may prevent BSMW from accessing the necessary care to address their health needs.²³ This may result from biases or a lack of cultural ­competency among healthcare providers.²⁸ Healthcare providers may hold biases or lack cultural competence, leading to discriminatory practices that further alienate BSMW from accessing necessary care.^8,28 Thus, cultural sensitivity may be lacking within healthcare settings and among providers. Training gaps exist that disable healthcare professionals from the ability to address the unique needs of populations experiencing this syndemic.1 This results in inadequate care that fails to consider the compounded effects of these ­conditions.^5,8

Table 1: Barriers to Integrated HIV and IPV Care.
Barrier to Care	Definition	Examples
Stigma	Negative attitudes and beliefs, in relation to individuals with HIV and/or IPV	Fear of discrimination, social isolation
Individualized Services	Separate treatment systems for HIV and IPV lead to gaps in care	Lack of coordination between providers
Missed Training Opportunities	Inadequate training for healthcare providers on addressing both HIV and IPV	Limited understanding of intersectional issues
Lack of Resources	Limited funding and other resources to implement integrated HIV and IPV programs	Underfunded clinics, lack of staff
Socioeconomic Barriers	Economic and social conditions and barriers affecting access to care	Low income/poverty, lack of transportation

There are also economic barriers that impact healthcare access and quality. Having economic stability and healthcare insurance can foster access to healthcare services for both HIV and IPV.⁵ The high costs associated with healthcare insurance and lack of affordable options present significant barriers.^29,30 Often, there is a scarcity in the availability of integrated care services, especially among marginalized populations and in underserved communities.⁸ Thus, individuals who need comprehensive care are often unable to access these services.⁸ The separation of HIV and IPV services into different sectors often leads to fragmented care.⁵ This lack of coordination can result in gaps in service provision and continuity of care.5 Inefficient referral systems between HIV and IPV service providers could delay care and reduce the effectiveness of ­interventions. Integrated referral systems are crucial for timely and appropriate care.^8,27 Existing policies may not support the integration of HIV and IPV services, leading to a lack of funding and resources for comprehensive care models.⁵ Legal and privacy concerns also have the potential to hinder information-sharing between providers, which is essential for integrated care.³¹ Patients may also fear legal repercussions or breaches of confidentiality when seeking care.⁸ BSMW may also have limited access to supportive formal and social networks that understand their unique challenges.4,18 This isolation can exacerbate the impact of both HIV and IPV on these women.^5,8 Thus, consideration of the specific sociocultural contexts existing within BSMW populations may help promote culturally sensitive, appropriate, and competent services and influence effective interventions.⁸ Table 1 provides a detailed overview of the barriers that hinder the effective implementation of integrated HIV and IPV care models, highlighting how stigma, fragmented services, inadequate training, resource constraints, and socioeconomic factors contribute to gaps in care.

Successful Models of Integrated HIV and IPV Care

Addressing these intertwined epidemics requires innovative and integrated care models that comprehensively address the medical, social, and psychological needs of those impacted. Several models have been successfully implemented in integrating these intertwined epidemics (see Table 2). Haberland et al.,³² suggested that HIV testing and treatment address structural barriers to treatment initiation and adherence.³² Most prominent to these barriers is IPV, resulting from its impact on other health development indicators.³² Researchers acknowledge that care should go beyond IPV screening and discuss violence and power among women receiving HIV testing services during prenatal care.³² Thus, a two-arm randomized controlled trial was implemented which included training and support for HIV counselors, a take-home card for clients, and an onsite IPV counselor.³² The findings from this intervention revealed that those who participated in the intervention sessions perceived that support from the HIV treatment sessions was meaningful, compared to those in the control group._³² As other studies have found, social support to women experiencing IPV could be linked to both improved physical and ­mental health outcomes and is an important (intermediate) outcome of the intervention.³² The results of this study suggest that IPV/power counseling (not just IPV screening) should be provided to all women, not only those who disclose violence experiences.³²

Table 2: Successful Models of Integrated HIV and IPV Care.
Model	Key Features	Outcomes
Comprehensive Care	Provides comprehensive healthcare services (medical, counseling) in one setting	Improved access to care, accessibility to services
Coordinated Care Networks	Collaboration between multiple service providers to provide comprehensive care	Enhanced continuity of care, better health outcomes
Trauma-Informed Care	Recognizes the impact of trauma and integration into care	Increased patient−provider trust, improved mental health outcomes
Community-Based Approaches	Engagement of local communities and members in designing and implementing interventions	Higher program acceptability, community empowerment
Mobile Health Units	Services being brought directly to marginalized populations and communities	Increased patient reach, reduced barriers to care access
Cross-Training	Provides training for healthcare providers on providing both HIV and IPV services	Enhanced provider competence and sensitivity, tailored care, improved patient health outcomes

This intervention can be modified to the context of HIV and IPV services being provided to BSMW by including cultural competency training for counselors. In addition, establishing peer support groups facilitated by other BSMW could prove to provide a safe space for sharing experiences and receiving support for this population. A systematic review conducted by Alexander et al.,¹³ provided a comprehensive review of recently ­published (January 9, 2017–January 9, 2023) integrated behavioral interventions designed to address IPV and HIV across the care continuum.¹³ The review found that eight interventions showcased significant positive effects on both the IPV and HIV outcomes being measured across the studies.^13,32–39 In addition, there were four interventions that showed significant declines in the use of some IPV behaviors as well as reports of IPV experiences.^13,37–40 One study found that the effects of IPV-related interventions were associated with IPV screening and knowledge, knowledge about women’s rights in relationships and perceived relationship power, and confidence about how women deserve to be treated.³² In addition, this intervention increased screening, disclosure, referrals, knowledge, and safety strategies related to IPV, along with increasing HIV medication adherence.³²

Another intervention reduced symptoms of sexual trauma, concurrently boosting motivations for long-term HIV care engagement.³⁴ This was accomplished through an understanding of individual barriers and facilitators to antiretroviral therapy adherence.³⁴ Increased PrEP adherence, HIV knowledge, condom self-efficacy, number of protected sexual encounters, and reduced adolescent initiation of sexual activity and fewer sexual partners were attributed to decreased reports of physical or sexual IPV within these studies. Adapting the findings from Alexander et al., strategies for effective for BSMW experiencing IPV and at potential risk for HIV, include addressing specific cultural, social, and structural ­barriers faced by this population (i.e., stigma and discrimination, economic dependency, and inadequate healthcare access).¹³ Addressing the structural barriers to HIV and IPV treatment initiation and adherence to preventive methods (i.e., PrEP) among BSMW first involves recognizing and mitigating the multiple layers of disadvantages and discrimination these individuals face in accessing care. Removal of these barriers should include training healthcare providers on the specific challenges faced by BSMW, such as historical mistrust of the medical system due to the discrimination and stigma enacted upon this group. Although building trust is essential for effective interventions, historical and ongoing mistreatment of marginalized communities in the healthcare system fosters mistrust, further deterring individuals from seeking care.⁸ Thus, providers should be trained on how to screen for both IPV and HIV simultaneously and refer patients to appropriate services, without the presence of stigma, to build rapport and foster patient−provider trust. In addition, training on trauma-informed care that addresses the psychological impact of IPV and HIV could help reduce symptoms of sexual trauma and improve mental health outcomes among BSMW.

Finally, the Creating Opportunities for Personal Empowerment (COPE) program is an evidence-based cognitive-behavioral skills-building intervention that could also be used to integrate these epidemics in care practices.⁴¹ This program encourages timely treatment, delivered by healthcare providers, as a preventive mental health intervention.⁴¹ Participants of this program are taught how to cognitively structure their negative thinking patterns, turning them into more positive interpretations.^41,42 This transformation of thoughts enables these individuals to feel better (emotionally) so that they may behave in more healthy ways.41,42 In addition, goal setting is promoted in the program to encourage engagement in healthy lifestyle behaviors and effective problem-solving.41,42 The comprehensive approach of this cognitive-behavioral therapy includes individual counseling, support groups, and empowerment workshops, leveraging community partnerships to enhance service delivery and ensure culturally competent care.⁴¹ The COPE program could be used to integrate HIV and IPV services by incorporating ­trauma-informed care, mental health services, and HIV prevention and treatment within its sessions with a goal to increase HIV care engagement, reduce experiences of IPV, and improve mental health outcomes. Building upon these successful models, healthcare providers could potentially develop more effective strategies for future research and intervention implementation to address the complex interplay of HIV and IPV, particularly among BSMW. Table 2 outlines components of several successful models that have been implemented to provide comprehensive care to individuals affected by both HIV and IPV.

Strategies for Effectively Integrating HIV and IPV Interventions for BSMW

Addressing the healthcare disparities faced by BSMW requires targeted, culturally sensitive, interventions that acknowledge and address the unique vulnerabilities (both individual and systemic) of these individuals. Enhanced care models should not only focus on improving health outcomes for BSMW but also serve as a framework for addressing these disparities in other marginalized populations. Key strategies for effectively integrating HIV and IPV interventions among BSMW include trauma-informed care, cross-training for healthcare providers, community-based support systems, and policy advocacy (see Table 3). To address the intersection of HIV and IPV among BSMW, a multifaceted approach is needed.

Table 3: Recommended Strategies for Integrating HIV and IPV Interventions.
Strategy	Description	Implementation Steps
Trauma-Informed Care	Integrating trauma-informed principles into all aspects of care	Provide training and redesign service delivery
Cross-Training for Healthcare Providers	Train healthcare providers on providing services related to both HIV and IPV	Develop training modules, conduct workshops/seminars
Community-Based Support Systems	Establish support systems within targeted communities	Engage the community and its leaders, create social support groups
Policy Advocacy	Advocate for policies that support integrated care	Lobby for funding, develop policy briefs

Providing culturally competent care that is sensitive to the cultural, social, and economic contexts of these populations should be at the forefront of this approach. Cross-training healthcare providers on the complexities of both HIV and IPV helps ensure that they are equipped to recognize and respond to the healthcare needs of individuals impacted by these syndemics, facilitating a more comprehensive and informed care environment.

Additionally, implementation of trauma-informed care practices is crucial, as it recognizes the pervasive impact of trauma on BSMW and may ensure that ­services are provided in a safe and supportive manner. Moreover, combining medical treatment for both HIV and IPV with mental health services and social support in promoting integrated support services is essential. To further enhance support, community-based interventions should engage local organizations and community leaders to create supportive environments and tailored programming. These organizations and leaders must understand the cultural and social nuances impacting BSMW to most appropriately influence the relevance and effectiveness of the interventions. Finally, policy advocacy is crucial in promoting policies that address the root causes of health disparities, including advocating for increased funding for integrated care models, access to health care, anti-discrimination protections, and economic support to alleviate the financial burdens that often prevent BSMW from accessing care. These combined efforts could create a more effective, compassionate, and comprehensive care model that significantly improves health outcomes for BSMW. Table 3 outlines several recommended strategies for integrating HIV and IPV interventions, providing a detailed description of each strategy and the necessary implementation steps.

Recommendations for Future Research and Interventions

To achieve a more representative sample, focusing on key groups at disproportionate risk for both HIV and IPV (i.e., BSMW, transgender women, and female sex workers) through targeted recruitment is recommended for future research.^2,4–6,13 In consideration of the strong link between HIV and IPV among BSMW, it is suggested that future interventions should target these women.^4,6 A systematic review by Marshall et al.,² found that the most effective interventions utilized multiple strategies and layered approaches and are multipronged.² As such, these efficacious interventions included both individualized and group-oriented approaches to address these intertwined epidemics.² Interventions that are dually focused (addressing both HIV and IPV among women) may help reduce costs associated with care and services related to both.² In addition, microfinancing, or providing loans to low-income individuals, has been proven to assist in addressing economic barriers to care and if offered, could prove to increase care engagement for BSMW in need.² Adapting successful models of dual-focused interventions to the context of BSMW may significantly improve health outcomes for this marginalized population.

It is important to consider several critical factors for effective intervention implementation, scalability, sustainability, and community engagement. Investigating how successful integrated care models can be expanded and adapted to different groups, various communities, and healthcare settings will help achieve scalability. To achieve sustainability, securing funding (to include funding that can be used to provide microfinancing to individuals) is imperative. Securing funding to provide both HIV and IPV healthcare services can help ensure the longevity of integrated care programs, supporting and maintaining their operations over time. Active involvement of individuals affected by these syndemics throughout the design and implementation phases of interventions may play a critical role in enhancing the relevance and effectiveness of these programs. In addition, leveraging individual (participant)- and community-level strengths through community engagement efforts may facilitate behavioral change by using a combination of interpersonal and individual-level activities.^{33–40,43–47} Incorporating both individual and interpersonal-level approaches to interventions may increase HIV PrEP adherence and improve social support and/or mental health outcomes of IPV survivors, improving their access to resources and coping strategies.^13,36,39,48 Additionally, utilization of individuals who share similar backgrounds and experiences with the target population in the planning and implementation phases of intervention may help provide culturally relevant support and influence individuals to adopt and maintain healthy behaviors. In addition, the inclusion of group sessions in interventions could create a supportive environment that reinforces positive behavioral change.

Conclusion

The intersection of HIV and IPV among BSMW highlights the critical need for culturally sensitive integrated care models that comprehensively address the medical, social, and psychological needs of these women. The systemic inequities, discrimination, and social determinants of health that make BSMW particularly vulnerable to these co-occurring conditions should be considered when developing these care models. Implementing trauma-informed care may help mitigate the impact of past trauma on current health behaviors, while cross-training healthcare providers may help ensure that these individuals are equipped to comprehensively address the dual challenges of HIV and IPV prevention among BSMW. Future research should focus on innovative, multilayered strategies that address both HIV and IPV and make certain that interventions are scalable, sustainable, and deeply rooted in community engagement. This requires not only addressing immediate healthcare needs but also advocating for structural changes that reduce stigma and increase access to resources for this population. Future policies should be designed to dismantle existing barriers to care and create supportive environments where BSMW can seek help without fear of discrimination or retribution in healthcare settings. Moreover, community-based participatory research methods should be employed to ensure that the voices and experiences of BSMW are central to the development and implementation of interventions tailored for them.

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