Meyer, J.P., S.A. Springer, F.L. Altice. (2011). Substance abuse, violence, and HIV in women: A literature review of the syndemic. Journal of Women’s Health, 20(7):991-1006.

By Lori Whitten, Staff Writer, RTI International, Rockville, MD

Since the identification of HIV, illness and death associated with the infection have declined and the number of people receiving treatment has increased in the United States. However, the consistent number of new HIV cases annually and the infection’s disproportionate burden on vulnerable populations belie such advances.

The HIV/AIDS epidemic is burgeoning among women—particularly those who are poor, live in urban areas, and are members of ethnic minority groups. The highly prevalent and co-occurring problems of substance abuse, violence, and HIV/AIDS (SAVA) interact in a synergistic way and result in a profound negative impact on the health of poor urban women. This “SAVA syndemic,” a term coined by Merrill Singer, Ph.D., at the University of Connecticut, is highly relevant to individuals in the criminal justice system, who have a three- to four-fold higher prevalence of HIV than those in the community; they are also more likely to have experienced interpersonal violence and substance abuse.

A literature review of 45 articles by Jaimie P. Meyer, M.D., and colleagues of the AIDS Program at Yale University School of Medicine, confirm that violence and victimization is intertwined with poor decision making and increased risk taking—for example, in the forms of intravenous drug use, participation in commercial sex work, and trading sex for drugs—and subsequent negative health consequences. Substance abuse is a major driver of perpetuating cycles of intimate-partner violence and power imbalance within relationships. These in turn, increase HIV-associated sexual risk-taking behaviors (e.g., unprotected sex), and influence the poor healthcare decision making (e.g., poor adherence to HIV treatment) and barriers to appropriate health care (e.g., HIV testing and counseling) among women who experience such abuse.

For women in the criminal justice system, HIV risk is heightened in the context of concurrent violence. Substance abuse and the nature of the relationship to one’s sexual partner (e.g., the power dynamics) influence victimization and sexual risk taking. Meyer and colleagues note that improving the overall health and outcomes of this population requires comprehensive and culturally informed approaches. HIV care in a wide range of settings—including correctional facilities—should include screening for substance abuse, depression and post-traumatic stress disorder, and violence. The researchers also suggest targeted interventions to prevent or cope with violence and substance abuse treatment programs, including medications for addiction. The authors also suggested areas for future research, including the development and adaptation of evidence-based interventions for the prevention of violence and management of victimization. They note the need to standardize definitions for substance abuse, violence, mental illness, adherence, and healthcare utilization to enhance the interpretation of findings in this important area of research.

Substance Abuse, HIV, and Violence are overlapping epidemics that contribute to the health status and social burden of poor women living in urban communities.

For more information contact Dr. Jaimie Meyer at Yale University School of Medicine, AIDS Program, in New Haven, Connecticut jaimie.meyer@yale.edu.