For some women, intimate partner violence (IPV) and the risk for human immunodeficiency virus (HIV) infection are often in a deadly, cyclical intersection that makes it difficult to discern which came first. Women in violent relationships are four times more likely than women in non-violent relationships to contract sexually transmitted infections (STIs), including HIV. Similarly, the rate of IPV among women already living with HIV is more than double the national rate. The behavioral and biological reasons for this intersection vary. The new tools in the Affordable Care Act (ACA) that offer protections for individuals experiencing IPV may also help address the risk for HIV infection.
Under the ACA preventive services requirements, non-grandfathered private insurance plans and Medicaid expansion plans must cover all United States Preventive Service Task Force (USPSTF) A and B recommendations without cost-sharing. One such recommendation is IPV screenings. Further, for covering USPSTF recommendations, state Medicaid programs can receive a one percent increase in their federal match. This requirement explicitly applies to Medicaid expansion plans, and does not necessarily apply to traditional Medicaid plans.
IPV screenings involve the patient answering a series of questions, either self-administered or in response to provider prompts, to discern signs of abuse. The ACA provides for other protections for women who have experienced IPV, such as an exemption from the individual mandate and the ability to receive premium tax credits to pay for insurance, even if she did not file taxes with her spouse. IPV screenings may result in referring a woman to needed assistance and the other protections can assist efforts to leave an abusive mate.
Lifetime exposure to abuse has a lasting impact on women physically and psychologically. Women who were sexually or physically abused during childhood or adolescence are at an increased risk of IPV. Being abused as a child is associated with multiple and unfamiliar sex partners later in life, engaging in injection drug use, and giving or receiving money for sex.
Further, the psychological trauma from forced sex or violence may make a woman less likely to resist sex or insist that her partner put on a condom. Subsequently, women who have experienced IPV are more likely to have unprotected sex, including anal sex. This, of course, increases the chances of HIV transmission.
There are also biological factors associated with sexual violence that increase the likelihood of HIV transmission. Tears and lacerations resulting from forced sex can facilitate HIV-transmission.
Sadly, the cycle continues as the woman living with HIV is more likely to experience IPV. This abuse may begin when the woman reveals her HIV status to her partner. Or existing IPV may be exaggerated after she receives an HIV diagnosis. This might be accompanied by threats that “no one else will want her” because of her status, which may increase the chances of her staying in the abusive relationship.
Due to advancements in medicine — specifically, antiretroviral therapy — an HIV diagnosis no longer has to be the death sentence that it was once. However, prescriptions cannot solve many of the societal issues, such as IPV, associated with HIV. The ACA can play a role in addressing these societal woes.
This blog was prepared by Jamille Fields, J.D./M.P.H., Reproductive Justice Fellow at the National Health Law Program.
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