Difficult-to-Treat Youth With HIV Typically Traumatized

Heather Boerner

November 13, 2018

DENVER — Homelessness and substance abuse in young people living with HIV could be an indication of post-traumatic stress disorder (PTSD), and the treatment of PTSD could help those in this hard-to-treat population engage in HIV care, data from a small pilot study show.

True trauma-informed care isn't simply a referral to a mental health professional, said Brian Dentoni-Lasofsky, MSN, MSW, from Benioff Children's Hospital at the University of California, San Francisco (UCSF).

It requires the complete reorganization of an institution to remove top-down leadership and to train everyone — from the chief executive officer to members of the housekeeping staff — to understand, identify, and help patients exhibiting signs of trauma, he told a standing-room only crowd here at the Association of Nurses in AIDS Care 2018.

There also needs to be a structure for providers to address vicarious trauma and prevent burnout, he added. But you don't have to start with wholesale restructuring to meet patients where they're at and provide a space for them to begin to heal that trauma, he said. Starting with psychiatry nurse practitioner students could be a way in.

The Adverse Childhood Experiences (ACE) study showed that people who experience more adverse events in childhood — including physical, emotional, and sexual abuse; emotional and physical neglect; watching their mother be abused in the home; having a family member incarcerated; and dealing with mental illness in the home — are more likely to experience a broad range of poor health outcomes as an adult (Am J Prev Med. 1998;14:245-258).

Such experiences can make it more likely that a person will acquire HIV and, once acquired, could speed disease progression and lead to poorer outcomes (Curr HIV/AIDS Rep. 2012;9:344-450).

Of the estimated 78,949 adolescents and young adults living with HIV in the United States in 2014, only 7% were virally suppressed, Dentoni-Lasofsky reported.

A growing body of research suggests that the identification and treatment of trauma could help address these gaps in care, as previously reported by Medscape Medical News.

Dentoni-Lasofsky and his colleagues identified 16 young people with HIV who were homeless, engaged in substance abuse, and receiving treatment at a San Francisco clinic.

At baseline, the participants, whose mean age was 23.1 years, had scores that indicated generalized anxiety and depression. And the mean score on the PTSD-5 checklist that assesses trauma was 64.

PTSD Score Off the Charts

The threshold score for PTSD, according to the checklist, is "33 or higher," Dentoni-Lasofsky told a shocked audience.

The median number of adverse childhood experiences in the study cohort was 6.13; in the original ACE study, only 12.5% of participants had four or more adverse experiences.

But if healthcare providers "are going to assess for and diagnose trauma, they need to have a plan for where this client is going to go," he told Medscape Medical News.

The good news is that there are programs to address trauma that can be implemented relatively quickly and with the help of students, he pointed out.

UCSF "isn't a trauma-informed organization," Dentoni-Lasofsky explained. So he and his colleagues started with Seeking Safety, a modular, weekly program that helps patients understand what trauma is, how it can impact their lives, and how to seek safety. Providers can offer 25 teaching modules to patients, depending on the kinds of triggers they have and the kinds of coping mechanisms they use.

Evidence-based Trauma Care

Seeking Safety has been shown to provide the moderate relief of PTSD symptoms, depression, anxiety, and substance use commensurate with relapse-prevention programs (Curr Psychiatry Rep. 2012;14:469-477). And a 2016 review of Seeking Safety studies showed a medium effect in all these areas (J Counselings Dev. 2016;94:51-61).

Seeking Safety "kind of mashes motivational interviewing and cognitive behavioral therapy," Dentoni-Lasofsky said. What it does not do is delve into the types of trauma that participants have experienced.

"When you go through a trauma narrative with a client, it can often be retraumatizing," he pointed out.

Seeking Safety is focused on giving participants ways to cope when their nervous systems sound the alarm, other than engaging in risky behavior, like substance use.

The researchers put together three 8-week support groups at housing locations run by Larkin Street, a nonprofit organization. Each of the three groups was staffed by two psychiatric nurse practitioner students from UCSF and was supervised by Dentoni-Lasofsky.

Using students for the program proved critical, he said. "It's hard to implement a trauma-informed care program across the board. By starting with students, we are integrating it within and then spreading it out" as the students move into their own clinical practices.

And although the quantitative data have not yet been analyzed and there is no control group, qualitative interviews indicate that the program was embraced by participants, he said.

One participant "truly enjoyed the class topic of seeking healthy and unhealthy relationships. Felt safe and inspired," Dentoni-Lasofsky reported.

Joachim Voss, PhD, RN, from Case Western Reserve University in Cleveland, said he is excited to bring this model — particularly the student training portion — back to his colleagues.

Bringing the Practice Home

"If you have a large-enough psych NP cohort, you could actually do this," Voss told Medscape Medical News. "The challenge is that not everyone wants to work with adolescents." But, he added, you could use this model with different age groups.

For Kisten Nolan, RN, a nurse consultant who worked for years in an adolescent program at Johns Hopkins in Baltimore, the presentation put to words something she experienced for years with her patients.

She rattled off just a few examples.

A young man mentioned during a visit with her one day that he was never in relationships as an adult because he'd been sexually abused as a child. He was tough. He wasn't interested in therapy.

A young woman revealed, after about a year of treatment, that she spent most days in her apartment, not getting dressed or brushing her teeth. "This was also during a time that she was not taking her ART," Nolan reported. The young woman was in a financially and emotionally coercive relationship with her younger brother, and came to Nolan not to talk about her 18 different medications, but to discuss how to have a healthy relationship with her new girlfriend.

And a 29-year-old man told her during one visit that someone had shot at him and his friend as they were hanging out on a stoop. "He was not thinking about the pills that were in front of him, the 15 unique medications that were being sorted into a three-times-a-day pill box," she said. He has since died of pancreatitis and sepsis related to alcoholism.

"I've been such a mental health advocate that it's kind of embarrassing that I haven't named it and called it out before," she said of trauma. Although the clinic tries to meet patients where they are, they don't routinely screen patients for trauma. Now, she said, she thinks they could.

She has recently moved to Chicago, but will share the findings with the Baltimore clinic, which is already looking for ways to fund trauma-informed care. She especially liked that Seeking Safety could start small.

"We don't want to let our morals get in the way of doing what's right," Nolan said. "We have a much smaller cohort, but I wouldn't let the small numbers get in the way."

T he Seeking Safety program for young people with HIV and substance use in San Francisco was funded by a grant from the Substance Abuse and Mental Health Services Administration. Dentoni-Lasofsky, Voss, and Nolan have disclosed no relevant financial relationships.

Association of Nurses in AIDS Care (ANAC) 2018. Presented November 8, 2018.

Follow Medscape Nurses on Twitter @MedscapeNurses and Heather Boerner @HeatherBoerner

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