Prenatal and Mental Health Care Among Trauma-Exposed, HIV-Infected, Pregnant Women in the United States Olga M. Villar-Loubet, PsyD Lourdes Illa, MD Marisa Echenique, PsyD Ryan Cook, BA Barbara Messick, MPH

Lunthita M. Duthely, MS Shirley Gazabon, PhD Myriam Glemaud, MSW, PsyD Victoria Bustamante-Avellaneda, PsyD JoNell Potter, PhD anxiety and PTSD-HIV. The majority of infants received zidovudine at birth and continued the recommended regimen. All but one infant were determined to be noninfected. Women improved their CD41 T cell counts and HIV RNA viral loads while in prenatal care. Results support the need for targeted prenatal programs to address depression, anxiety, substance use, and trauma in HIV-infected women.

Comprehensive prenatal care for HIV-infected women in the United States involves addressing mental health needs. Retrospective quantitative data are presented from HIV-infected pregnant women (n 5 45) who reported childhood sexual or physical abuse (66%), abuse in adulthood by a sexual partner (25%), and abuse during pregnancy (10%). Depression and anxiety were the most commonly reported psychological symptoms; more than half of the sample reported symptoms of posttraumatic stress disorder (PTSD), including HIV-related PTSD (PTSD-HIV). There was a strong association between depression and PTSD as well as between

(Journal of the Association of Nurses in AIDS Care, 25, S50-S61) Copyright Ó 2014 Association of Nurses in AIDS Care

Olga M. Villar-Loubet, PsyD, is a Research Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA. Lourdes Illa, MD, is Associate Professor, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA. Marisa Echenique, PsyD, is an Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA. Ryan Cook, BA, is a Research Associate, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA. Barbara Messick, MPH, is a Project Director, Ryan White Part D, Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, Miami, Florida, USA. Lunthita M. Duthely, MS, is

the Data Manager, Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, Miami, Florida, USA. Shirley Gazabon, PhD, is an Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA. Myriam Glemaud, MSW, PsyD, is a Research Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA. Victoria Bustamante-Avellaneda, PsyD, is Voluntary Faculty, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA. JoNell Potter, PhD, is an Associate Professor, Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, Miami, Florida, USA.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 25, No. 1S, January/February 2014, S50-S61 http://dx.doi.org/10.1016/j.jana.2013.06.006 Copyright Ó 2014 Association of Nurses in AIDS Care

Villar-Loubet et al. / Mental Health in Trauma-Exposed, HIV-Infected, Pregnant Women S51

Key words: HIV, mental health, prenatal, trauma

O

ften described as a special time in a woman’s life, pregnancy is a uniquely individual experience. For women living with HIV infection, pregnancy is complicated by challenges, such as treatment changes and the emotional stress of preventing mother-to-child transmission of HIV. According to the Centers for Disease Control and Prevention (CDC, 2009), an estimated 75% of the women living with HIV in the United States are of childbearing age. Since the advent of maternal therapeutic interventions, the live birth rate for HIV-infected women is now estimated to be 150% higher than in the pre–antiretroviral therapy (ART) era (Sharma et al., 2007). Increased birth rates in HIV-infected women represent significant challenges for health care providers serving this population at a national level. Comprehensive prenatal care for HIV-infected women in the United States involves effectively addressing mental health needs, including depression and substance use (Leserman et al., 2007; Rosen, Seng, Tolman, & Mallinger, 2007; Sharps, Campbell, Baty, Walker, & BairMerritt, 2008). Pregnant women, regardless of HIV serostatus, are particularly vulnerable to interpersonal violence (IPV) and psychological distress (Rosen et al., 2007). Research has consistently demonstrated that women living with HIV experience alarming rates of exposure to trauma (physical and sexual abuse) throughout their lives, placing them at serious risk for psychological distress (Simoni & Ng, 2000). HIV-infected women also are more likely to experience a traumatic event than are women in the general population. Kalichman, Sikkema, DiFonzo, Luke, and Austin (2002) reported a high rate of lifetime sexual assault (68%) in 110 HIV-infected women recruited from a variety of clinical settings. Similarly, Simoni and Ng (2000) interviewed 230 HIV-infected women living in New York City, who were primarily African American or Hispanic, and found that 43% had a history of childhood physical abuse, and 38% had a history of childhood sexual abuse (CSA). Many women living with HIV who encountered abuse during childhood are likely to relive a pattern of repeated traumatization as adults. For example, in

a racially and ethnically diverse sample of 490 women, Wyatt et al. (2002) found that HIV infection was associated with a ‘‘severe trauma history’’ involving exposure to multiple events (e.g., CSA, adult sexual assault, and/or physical violence or conflict). Furthermore, Kalichman et al. (2002) reported that HIV-infected women with a sexual assault history had a lifetime average of 7.5 sexual assault experiences, and many were likely to have experienced non–sexual relationship violence as well. Such evidence indicates that women living with HIV are likely to encounter not only a history of repeated traumatization but also exposure to more than one type of traumatic event. Further, Simoni and Ng (2000) found a significant correlation between childhood abuse and assault for adult HIVinfected women, suggesting that many HIV-infected women live in a context of IPV throughout their lives. Traumatic experiences can often have serious and long-lasting consequences. Research has demonstrated that consequences of trauma, such as childhood physical and sexual abuse, include increased vulnerability to low self-esteem, anxiety, depression, suicide, sexual difficulties, and interpersonal problems (Johnsen & Harlow, 1996). Zlotnick, Warsaw, Shea, and Keller (1997) found that abused women reported more frequent and longer episodes of depression and anxiety compared to women without a history of trauma. Other evidence has suggested that low-income women may be particularly vulnerable to IPV as well as to depression, PTSD, and substance use as a result of the abuse (Martin, Mackie, Kupper, Buescher, & Moracco, 2001; Rosen et al., 2007; Tolman & Rosen, 2001). These consequences are especially serious in persons living with HIV, given that existing evidence suggests that psychiatric disorders may significantly worsen adherence to ART (Horberg et al., 2008; Mellins, Kang, Leu, Havens, & Chesney, 2003). Moreover, depressive symptoms were noted as an independent predictor of mortality in a survey of mortality trends for women with HIV infection from 1995 to 2004 (French et al., 2009). IPV during pregnancy is particularly dangerous because of the potential risk to both the mother and fetus. Studies have estimated that 3% to 19% of

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women report experiencing some form of abuse in the year before, during, or after a pregnancy (Bacchus, Mezey, & Bewley, 2004; Campbell, Garcia-Moreno, & Sharps, 2004; Koenig et al., 2006; Sharps et al., 2008). Studies have also shown that women who experienced IPV were more likely to become pregnant and to describe their pregnancies as unwanted or unplanned (Bacchus et al., 2004; Lang, Salazar, Wingood, DiClemente, & Mikhail, 2007). Despite varying prevalence rates, violence during pregnancy occurs more frequently than do some obstetric complications, such as pre-eclampsia and gestational diabetes (Bacchus et al., 2004), which indicates the significance of violence as an important clinical and public health concern. Violence has been demonstrated to have deleterious medical and psychological consequences on both the mother and unborn child. Poor maternal outcomes include traumatic injuries that may cause premature termination of the pregnancy, inadequate weight gain, and late entry into prenatal care (Sharps et al., 2008). In addition, pregnant women who have experienced abuse are more likely to report depression, PTSD, and substance abuse (Bullock, Mears, Woodcock, & Record, 2001; Sharps et al., 2008). Substance abuse, in particular, is of concern due to underreporting, which has been documented in general population studies and studies of pregnant women (Fendrich, Johnson, Wislar, Hubbell, & Spiehler, 2004; Lester et al., 2001). IPV has been associated with poor fetal and neonatal outcomes through direct injury, which may cause placental damage, preterm delivery, or fetal demise (Koenig et al., 2006), or through indirect mechanisms, such as depression, stress, or substance abuse. IPV also has been associated with low birth weight (Boy & Salihu, 2004), particularly among women who experience depression and/or PTSD as well as IPV (Rosen et al., 2007). In its extreme form, IPV can lead to intimate partner homicide of a woman, fetus, or neonate, both during and after the pregnancy (McFarlane, Campbell, Sharps, & Watson, 2002; Sharps et al., 2008). Disclosure of an HIV-infected woman’s serostatus to a partner also increases the risk of violence (Kiarie et al., 2006).

Despite high rates of IPV in HIV-infected women and the known harmful effects of trauma on maternal and infant health, relatively few studies have focused on pregnant women living with HIV. The Perinatal Guidelines Evaluation Project HIV and Pregnancy Study, which interviewed HIV-infected and -noninfected women in late pregnancy to 6 months postpartum between 1996 and 1998, found high rates of depression, stress, and recent negative life events in their sample, regardless of HIV status (Ethier et al., 2002). Women diagnosed with HIV during pregnancy were less likely than were seronegative women, however, to report having experienced violence. The authors speculated that this could have been because newly diagnosed women may have received greater support services and may have been more likely to make changes in their lives that decreased the risk for violence (Koenig et al., 2006). Given the scarcity of literature on the impact of trauma among HIV-infected pregnant women, our study aimed to gather retrospective quantitative data on a cohort of HIV-infected pregnant women who had reported a history of trauma and abuse (IPV, childhood abuse). We also examined maternal mental health (e.g., symptoms of depression, anxiety, and substance abuse), as well as maternal and neonatal outcomes (e.g., viral load, delivery, and neonatal outcomes). The purpose of the study was to provide a greater and nuanced understanding of prenatal and mental health care for trauma-exposed HIV-infected pregnant women, which may inform ways to improve treatment during the antepartum period. Because many women view pregnancy as a time to embrace healthier lifestyles, such openness and willingness to change may offer a crucial window of opportunity for providers to identify and treat HIV-infected women who have experienced trauma and abuse (Potter et al., 2009; Villar-Loubet et al., 2012).

Methods Our study reviewed the records of pregnant women living with HIV who received care at the University of Miami/Jackson Memorial Medical Center’s Prenatal Immunology (PRIM) Clinic. The

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PRIM Clinic is one of the largest perinatal HIV programs in the United States, having served more than 2,900 HIV-infected pregnant women (125– 150 annually) over 22 years. The clinic is located in a large metropolitan city (Miami, FL, USA) and provides comprehensive medical, psychological, social, and case-management services to HIVinfected pregnant women who are primarily of low income and of racial/ethnic minority (African American, Haitian, Hispanic). UM Miller School of Medicine institutional review board approval was obtained prior to the extraction and review of retrospective data from the HIV perinatal database. Data were collected from a sample of 45 HIVinfected pregnant women at the PRIM Clinic who delivered over a 2-year period (January 1, 2010, through December 31, 2011) and who had reported a history of and/or current abuse. Women who denied a history of or current abuse were excluded from the study. PRIM Clinic The PRIM Clinic is an outpatient clinic dedicated to the care of pregnant women living with HIV and has been in operation at UM/JMMC since 1988. The clinic is held 1 day a week and is staffed by UM providers, working in conjunction with the UM Departments of Obstetrics and Gynecology, Psychiatry and Behavioral Sciences, and Medicine (special immunology). A multidisciplinary team, including a perinatologist, three advanced registered nurse–practitioners, a nurse–case manager, a psychologist, a peer educator, and researchers, staffs the PRIM Clinic to provide comprehensive, on-site medical, mental health, and psychosocial services. Providers adhere to the Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States (U.S. Department of Health and Human Services, 2012). Patients generally are seen for prenatal care every 4 weeks for the first 28 weeks of gestation, every 2 weeks until 36 weeks, and then weekly until delivery. Because these patients are considered high risk, they are often seen more frequently than are pregnant women in general perinatal clinics. Appointment

schedules are also influenced by medication adherence rates, timing of initiation of an HIV medication regimen, and pregnancy-related complications, such as hypertension or diabetes. All patients are encouraged to attend a free, sixsession, curriculum-based childbirth education class that is held on-site each week during clinic. Classes are open to all PRIM Clinic patients, including postpartum women, and provide psychoeducational information on prenatal care, medication adherence, labor and delivery, caring for a newborn, and postpartum care. The implementation of these program components ensures that all patients are managed in a comprehensive manner, a factor we believe to be important when interpreting pregnancy outcomes in a large cohort of women. Mental Health Protocol All women in the clinic received mental health services as standard of care. A psychiatrist and psychologist attended the PRIM Clinic to conduct on-site mental health assessments and follow-up psychiatric evaluation as needed, as well as to intervene in crisis situations. Mental health services are initiated with the administration of a brief mental health screen by a psychologist, who can identify potential mental health issues of concern (e.g., depression, anxiety, PTSD) and provide appropriate treatment and follow-up. The screen is based on the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ; Spitzer, Kroenke, & Williams, 1999). Patients are reassessed during subsequent visits for monitoring of progress on care and treatment plans or for addressing new issues that may arise. Women who need more intensive treatment are referred to the on-site team psychiatrist for further evaluation. To help overcome barriers to mental health services, the mental health team has implemented an integrative preventive behavioral health program in which all patients participate over the course of prenatal care. Regardless of mental health status, all women are offered three cognitive–behavioral therapy sessions, which focus on stress management, HIV disclosure, and medication adherence. Patients who require additional mental health services are

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referred to The Healing Place, a specialty mental health clinic in the Department of Psychiatry and Behavioral Sciences that is dedicated to psychological treatment of patients living with HIV. The psychologist also serves as a liaison with the inpatient psychology team in preparation for delivery and assesses clients for postpartum depression at the 6-week postpartum examination or at the infant’s 2-week screening appointment. The mental health team also coordinates care with other mental health programs, including UM/JMMC’s Health and Recovery Program, which offers substance abuse treatment and detoxification services, and the Psychiatric Partial Hospitalization Program, which provides intensive treatment for patients who do not require psychiatric hospitalization but who could benefit from a higher level of care than that provided by outpatient services. Measures Brief mental health screen. The brief mental health screening instrument was adapted from the PRIME-MD PHQ (Spitzer et al., 1999) and contained subscales for depression, anxiety, panic, abuse, PTSD, PTSD-HIV, substance abuse, and psychosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals for the diagnosis of any one or more PHQ disorders (k 5 0.65, overall accuracy 5 85%, sensitivity 5 75%, specificity 5 90%), similar to the original PRIME-MD. Patients who screened positive on a symptom subscale were referred for a more comprehensive assessment with the clinic psychology staff. The data reported on symptoms were based on a single mental health screen at the initial patient–provider contact and were not repeated during the pregnancy. Depression subscale (9 items). The depression subscale used a 3-point Likert scale, with the following response items: 0 5 not at all, 1 5 several days, and 2 5 more than half the days. A patient screened positive if she received a score of 1 or 2 to the first two statements: Over the last 2 weeks, how often have you been bothered by any of the following problems: Little interest or pleasure in doing things?; and/or Feeling down, depressed, or hopeless?

Anxiety subscale (4 items). The anxiety subscale used a 3-point Likert scale, with the following response items: 0 5 not at all, 1 5 several days, and 2 5 more than half the days. A patient screened positive if she received a score of 1 on the first question, which read: Over the last 4 weeks, how often have you been bothered by any of the following problems: Feeling nervous, anxious, on edge, or worrying a lot about different things? Panic subscale (15 items). The panic subscale items required a yes or no response. A patient screened positive if she responded yes to the following two questions: In the last 4 weeks have you had an anxiety attack, suddenly feeling fear or panic?; and Has this ever happened before? Abuse subscale (7 items). The abuse subscale items required a yes or no response. A patient screened positive if she responded yes to the following two questions: In your lifetime, have you ever been physically or sexually abused (hurt) by your partner, a family member, or anyone else?; and Is this situation still affecting your life? PTSD subscale (4 items). The PTSD subscale items required a yes or no response. A patient screened positive if she responded yes to any of four questions. A sample item was: In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you had nightmares about it or thought about it when you did not want to? PTSD-HIV subscale (4 items). PTSD-HIV subscale items required a yes or no response. A patient screened positive if she responded yes to any of four questions. A sample item was: In your life, have you ever had any experience(s) related to HIV that was so frightening, horrible, or upsetting that, in the past month, you had nightmares about it or thought about it when you did not want to? Substance abuse subscale (4 items). The substance abuse subscale items required a yes or no response. A patient screened positive if she responded yes to any of four items. Sample items were: You drank alcohol or used drugs even though

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a doctor told you not to because of your health?; and You missed work or school or another activity because you were drunk or high or were hung over or coming down? Psychosis subscale (3 items). The psychosis subscale items required a yes or no response. A patient screened positive if she responded yes to any of three items. Sample items were: Have you ever seen things other people couldn’t see?; and Have you ever heard voices that other people couldn’t hear? Maternal HIV ribonucleic acid (RNA). For this study we used the viral loads measured at the first prenatal visit and in the last trimester. Viral load was categorized as a dichotomous variable, with a cutoff for successful viral load suppression of less than 200 copies/mL. This cutoff is consistent with the marker recommended by the previously mentioned U.S. Department of Health and Human Services guidelines on the prevention of perinatal HIV transmission (Department of Health and Human Services, 2012). Statistical Analysis Data were entered into the SPSS version 19.0 (IBM SPSS Statistics, IBM Corporation, Armonk, NY). Descriptive analyses were conducted using frequencies, means, and standard deviations (SD). The Fisher exact test was used to examine the association between pregnant, HIV-infected women reporting trauma and abuse (past and/or current, physical and/or sexual) and other mental health concerns (e.g., depression, anxiety, PTSD, PTSD-HIV). A repeated-measures t test and the McNemar test were used to measure differences in CD41 T cell counts and viral load over time.

Results Demographic Characteristics Women in this sample (n 5 45) were, on average, 26 years of age (range 5 15–36, SD 5 5.5). Nearly two thirds were Black (African American or Haitian),

Table 1.

Demographics (N 5 45) Characteristic

Ethnicity Black/African American, Haitian White Hispanic Yes No Marital status Single, never married Married Dating Living with partner Divorced Insurance Status Medicaid Private insurance Other public insurance No insurance HIV status HIV-infected CDC-defined AIDS Mode of HIV transmission Heterosexual sex Intravenous drug use Perinatal transmission Estimated gestational age at deliverya No. of childbirth education classes attended during pregnancya ART during pregnancy ART 1 PI ART 2 PI None

n (%) 32 (71) 13 (29) 10 (22) 35 (78) 17 (38) 7 (16) 12 (27) 4 (18) 1 (2) 34 (76) 3 (7) 2 (4) 6 (13) 28 (62) 17 (38) 39 (87) 2 (4) 4 (9) 36.1 (4.1) 3.2 (2.9)

35 (77.8) 9 (20.0) 1 (2.2)

Note: CDC 5 Centers for Disease Control and Prevention; ART 5 antiretroviral therapy; PI 5 protease inhibitor. a. Values are M (SD).

and about one fourth were self-identified as Hispanic. Most had incomes at or below the U.S. poverty level (87%, n 5 39), and the majority relied on Medicaid for insurance. Most of the women named heterosexual sex as their mode of HIV transmission, and a little more than one third entered prenatal care with an AIDS diagnosis. The women attended an average of slightly more than three childbirth education classes during pregnancy. The average gestational age at which the women entered prenatal care was 16 weeks, and the average gestational age at time of delivery was 36 weeks (range 5 21–40

S56 JANAC Vol. 25, No. 1S, January/February 2014 Table 2.

Trauma and Abuse (N 5 45)

Table 3.

Mental Health Screening (N 5 45)

Parameter

n (%)

Characteristic

n (%)

Current abuse (within 1 year) Abuse as a child Abuse as an adult Abuse by sexual partner Abuse during pregnancy Sexual abuse

16 (35.6) 30 (66.7) 19 (42.2) 10 (22.7) 4 (9.1) 20 (44.4)

Depression Lack of interest Feeling down Changes in sleep Changes in energy level Changes in appetite Changes in self-esteem Trouble concentrating Psychomotor agitation Thoughts of/attempted suicide Anxiety Nervousness Restlessness Tension Irritability PTSDa Intrusion Avoidance Arousal Detachment PTSD-HIVa Intrusion Avoidance Arousal Detachment Substance abuse Affecting health Affecting work quality Missed work

41 (91.1) 19 (42.2) 23 (51.1) 27 (60.0) 28 (62.2) 22 (48.9) 11 (24.4) 13 (28.9) 7 (15.6) 3 (6.7) 32 (71.1) 27 (60.0) 14 (31.1) 13 (28.9) 27 (60.0) 25 (56.8) 11 (25.0) 21 (47.7) 13 (29.5) 10 (22.7) 22 (50.0) 2 (4.5) 20 (45.5) 14 (31.8) 9 (20.5) 9 (21) 8 (18) 5 (11) 5 (11)

weeks). Additional demographic data are presented in Table 1. Trauma and Abuse A total of 194 deliveries occurred during a 2-year period at the clinic; of these, 23% (n 5 45) reported trauma exposure. Although all of the women in our sample reported a history of or current abuse, only one third reported abuse within the previous year, and a small percentage of women reported abuse during pregnancy. Two thirds reported abuse as a child, and two fifths reported abuse as an adult. Nearly one fourth reported abuse by a current sexual partner, and almost half had a history of sexual abuse. Trauma and abuse data are presented in Table 2. Mental Health Screen The average gestational age at the time of the screen was 21 weeks (range 5 6–38 weeks). Almost the entire sample screened positive for depressive symptoms. Many of the women in the sample reported symptoms such as lack of interest, feeling down, changes in sleep, changes in energy level, changes in appetite, trouble concentrating, and changes in self-esteem. A smaller percentage of women experienced psychomotor agitation and thoughts of or attempts at suicide. Nearly three fourths screened positive for symptoms of anxiety, including nervousness and irritability. About one third reported symptoms of restlessness and tension. In addition, more than half of the women reported symptoms consistent with PTSD and half reported symptoms consistent with PTSD-HIV. Three women screened positive for psychosis. One fifth of our sample disclosed substance abuse; most of the

Note: PTSD 5 posttraumatic stress disorder. a. This parameter was assessed in 44 patients.

women said that substance use affected their health, and more than half said it affected their ability to work. There was an association between depression and PTSD (Fisher’s exact test, p 5 .03) and between anxiety and HIV-related PTSD (Fisher’s exact test, p 5 .02). Mental health screening data are presented in Table 3. Delivery and Neonatal Outcomes Ninety-six percent (n 5 43) of the women had a live birth and 4% (n 5 2) experienced fetal loss (i.e., spontaneous abortions). Almost three fourths delivered via cesarean section. Almost the entire sample was given ART medication during labor, while all of the infants received zidovudine at birth and continued to receive zidovudine for 4 to 6 weeks

Villar-Loubet et al. / Mental Health in Trauma-Exposed, HIV-Infected, Pregnant Women S57 Table 4.

Delivery and Birth Outcomes (N 5 45) Measure

Delivery outcome Live birth Spontaneous abortion Delivery type Vaginal Cesarean section Meds given in labor Yes No ZDV given at birth and 4–6 weeksa Yes No Baby HIV statusa Negative Lost to follow-up CD41 T cell count (cells/mm3)b First visit Delivery Viral load .200 copies/mL First visit Delivery

n (%) 43 (95.6) 2 (4.4)

outcomes reported included: obesity (n 5 6), multidrug resistance and poor ART adherence (n 5 6), anemia (n 5 6), and placenta previa and incompetent cervix (n 5 6).

12 (26.7) 33 (73.3)

Discussion

41 (91.1) 4 (8.9)

Our study enhances the understanding of mental health issues affecting trauma-exposed, HIV-infected pregnant women. Consistent with previous literature, our results indicated high rates of previous childhood sexual or physical abuse in women reporting a history of trauma (Simoni & Ng, 2000), with two thirds reporting a history of child abuse. Many of the women also endured abuse as adults, with one fourth reporting abuse by a sexual partner. Even more alarming, nearly 10% reported abuse during the pregnancy. Consistent with the general literature on HIVinfected women with a trauma history (Martin et al., 2001; Rosen et al., 2007; Tolman & Rosen, 2001), we found depression and anxiety as two of the most commonly reported psychological symptoms in our cohort. Nearly all of the women in our sample reported depressive symptoms during the pregnancy. Overall, women reported sad mood and anhedonia, as well as somatic symptoms such as changes in appetite, sleep patterns, and energy levels. Additionally, one fourth experienced changes in self-esteem. Not surprisingly, more than two thirds of our sample reported symptoms of anxiety and more than half reported symptoms of PTSD, including PTSD related to HIV. We also found an association between depression and PTSD and between anxiety and HIV-related PTSD. Women who had symptoms of anxiety also reported symptoms of PTSD-HIV. Our findings were consistent with research indicating a correlation between trauma, depression, and anxiety (Martin et al., 2001; Rosen et al., 2007; Tolman & Rosen, 2001). Women reporting PTSD-HIV symptoms may have been exhibiting more active symptoms, such as anxiety and nervousness related to diagnosis, transmission of the virus, and disclosure. These findings

43 (100) 0 42 (97.7) 1 (2.3) 420.0 (271.8) 453.2 (248.7) 32 (71.1) 16 (35.6)

Note: ZDV 5 zidovudine. a. This parameter was assessed in 43 patients. b. Values are M (SD).

after birth. Of the 43 infants in the sample, 42 were discharged from the screening clinic with negative DNA PCRs and one was lost to follow-up. Most of the women were retained in follow-up medical care. Over the course of their engagement in prenatal care, the women raised their CD41 T cell counts (t[44] 5 22.3, p 5 .03) and significantly decreased their viral loads, with those who had a viral load of more than 200 copies/mL decreasing from 71% to 36% (McNemar’s test, p , .001). Delivery and neonatal outcomes data are presented in Table 4. Delivery Notes A medical chart review of delivery notes indicated urinary tract and sexually transmitted infections (i.e., gonorrhea, chlamydia, genital and oral herpes simplex virus, trichomonas, thrush, bacterial vaginosis; n 5 15) as well as substance use (i.e., marijuana, cocaine, crack; n 5 7) in our sample. Medical

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may indicate that women who have a history of trauma and abuse or are experiencing PTSD symptoms should also be screened for depression and anxiety. It is imperative to address these issues in pregnant women, as some of the depressive symptoms might be masked by pregnancy-related changes (e.g., hormonal fluctuations). Exploring a woman’s mental health may lead to more effective and comprehensive prenatal care. Another issue identified in our sample was substance abuse during pregnancy, which was reported by one fifth of the women. Considering the documented underreporting of substance use both in the general population and in pregnant women (Fendrich et al., 2004; Lester et al., 2001), we estimated the actual substance use in our study sample to be higher than reported. A qualitative review of medical chart delivery notes indicated that the majority of reported substance use during pregnancy involved marijuana and cocaine. Consistent with other findings, the pregnant women who experienced abuse were more likely to report depression, PTSD, and substance abuse (Bullock et al., 2001; Sharps et al., 2008); our findings support the need to address substance use in pregnant women living with HIV who have also had a history of trauma. One third of our women presented with CDC-defined AIDS during their pregnancies, which may reflect poor prior adherence to medication regimens and/or drug resistance, important factors to consider in prenatal and mental health care settings. However, despite the severity of illness, presence of trauma, and high prevalence of mental health symptomatology, maternal delivery and neonatal outcomes were successful. Most of the women delivered around the 36-week estimated gestational age and 96% (n 5 43) were live births. All of the infants received zidovudine at birth and all but one, who was lost to follow-up, were not infected with HIV at the 4-month screening follow-up. Encouragingly, the women improved their CD41 T cell counts and viral loads throughout the course of prenatal care. These results may, in part, be due to the concerted effort of the clinic staff to ensure the women received the most comprehensive care and attended their prenatal and mental health care appointments. The positive maternal outcomes may also reflect

a woman’s desire to prevent transmission to her unborn child. Limitations Although our findings offer valuable contributions to the existing literature, we recognize the limitations of our study. For one, our findings may have limited generalizability, as our sample may not be representative of the overall population in the United States. Our population comprised various racial and ethnic groups, including African American, Haitian, and Hispanic women, representative of the minority community in Miami-Dade County, Florida. Furthermore, the majority of our women were living below the federal poverty level. Another limitation was the relatively small sample size. Although our clinic database was large (i.e., 2,900 HIV-infected pregnant women over a span of 22 years), we were limited to analysis of 2 years of data because the full range of measures and subscales was not collectively administered prior to 2009. Additionally, our study was retrospective in nature, which may have limited the type of information available. The psychosocial factors experienced by these women, such as history of abuse, chronic illness, mental health issues, and financial hardship, may have contributed to the inability to access additional needed health services. In addition, these factors may have influenced a woman’s ability to leave an abusive relationship. Targeting women in pregnancy, at a time when they are generally open to making lifestyle changes for the health of their infants, provides a unique opportunity to identify at-risk women and to help them develop valuable strategies and skills they can use throughout their lives to manage the effects of depression, anxiety, and trauma. Implementing comprehensive care at this sensitive time can prevent or delay the development of mood disorders, as well as provide women with the coping skills necessary to improve their abilities to parent newborns. Programs specifically designed for HIV-infected women beyond pregnancy should include defining roles for women as mothers and caretakers and acknowledging their centrality in the management of their own and their children’s health. Psychosocial

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factors, such as stress, mental health, and substance abuse, as well as familial, social, and economic barriers, often prevent consistent use of health care services by women living with HIV. Clearly, there is a need to develop women-focused models of health care for HIV-infected women during pregnancy to address these concerns. Client services that have facilitated women’s engagement and retention in care include ancillary services (Conviser & Pounds, 2002; Cunningham, Sanchez, Li, Heller, & Sohler, 2008; Lo, MacGovern, & Bradford, 2002), such as cognitive–behavioral stress-management interventions (Jones et al., 2007) and mental health and substance abuse treatments (Brach & Fraser, 2000).

Conclusion From a medical perspective, it is well-known that early comprehensive prenatal care for women living with HIV can promote healthier pregnancies by providing advice on health behaviors as well as early detection and treatment of risk factors and symptoms (Hamilton, Martin, & Ventura, 2010). A pregnant woman’s mental health should not be overlooked. Results from our study highlight the need for prenatal interventions to target depression, anxiety, substance abuse, and trauma in HIV-infected women. Medical care should include risk assessment, intervention, and management of mental health concerns during pregnancy to prevent and reduce depression and anxiety. Future research with HIV-infected women should compare trauma-exposed women with women who did not report past or current abuse to ascertain whether trauma-exposed women are at higher risk for mental health concerns or if these symptoms are common among all pregnant women living with HIV. Also, future studies should examine the impact of trauma and abuse before and during pregnancy and its relationship to other mental health concerns, such as depression, anxiety, PTSD, and PTSD-HIV. The integration of medical and mental health care is an important prevention and intervention strategy, as maternal behaviors and lifestyle choices are also determinants of neonatal health.

Key Considerations  The effects of trauma can be long-term and may affect a woman’s engagement in prenatal care.  Exploring specific symptoms of depression and anxiety may lead to more effective and comprehensive prenatal care.  Women who have a history of trauma and abuse or who are experiencing PTSD symptoms should also be screened for depression and anxiety. It is imperative to address these issues in pregnant women, as some of the depressive symptoms might be masked by pregnancyrelated changes (e.g., hormonal fluctuations).  It is important to assess actual and estimated substance use among HIV-infected pregnant women.  Prenatal care should include risk assessment, intervention, and management of mental health concerns during pregnancy to prevent and reduce depression and anxiety.  The integration of medical and mental health care is an important strategy to prevent or delay the development of mood disorders, as maternal behaviors and lifestyle choices are also determinants of neonatal health.

Disclosures The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.

Acknowledgments The authors thank the Health Resources and Services Administration/HIV/AIDS Bureau (HRSA/ HAB) and the Ryan White Part D Program as well

S60 JANAC Vol. 25, No. 1S, January/February 2014

as the PRIM Clinic staff members, who lovingly care for patients. And above all, the authors thank their patients, who place themselves and their babies in their hands.

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Prenatal and mental health care among trauma-exposed, HIV-infected, pregnant women in the United States.

Comprehensive prenatal care for HIV-infected women in the United States involves addressing mental health needs. Retrospective quantitative data are p...
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