Women bear an increasing burden of the HIV epidemic and face high rates of morbidity and mortality. Trauma has been increasingly associated with the high prevalence and poor outcomes of HIV in this population. This meta-analysis estimates rates of psychological trauma and posttraumatic stress disorder (PTSD) in HIV-positive women from the United States. We reviewed 9,552 articles, of which 29 met our inclusion criteria, resulting in a sample of 5,930 individuals. The findings demonstrate highly disproportionate rates of trauma exposure and recent PTSD in HIV-positive women compared to the general population of women. For example, the estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8-42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women. The estimated rate of intimate partner violence is 55.3% (95% CI 36.1-73.8%), which is more than twice the national rate. Studies of trauma-prevention and trauma-recovery interventions in this population are greatly needed.

In August 2013, a national strategy group convened in Washington, DC to clarify a framework for trauma-informed primary care (TIPC) for women. The group was motivated by an increasing body of research and experience revealing that people from all races, ethnicities, and socioeconomic backgrounds come to primary care with common conditions (e.g., heart, lung, and liver diseases, obesity, diabetes, depression, substance use, and sexually transmitted infections) that can be traced to recent and past trauma. These conditions are often stubbornly refractory to treatment, in part because we are not addressing the trauma and posttraumatic stress disorder (PTSD) that underlie and perpetuate them. The purpose of the strategy group was to review the evidence linking trauma to health and provide practical guidance to clinicians, researchers, and policymakers about the core components of an effective response to recent and past trauma in the setting of primary care. We describe the results of this work and advocate for the adoption of TIPC as a practical and ethical imperative for women's health and well-being. An Unrecognized OpportunityJanice 1 is a 45-year-old woman with poorly controlled diabetes, obesity, and alcoholism. She feels ashamed about her alcohol use and about her body. She fears that her clinician will be angry with her for not checking her blood sugar, not losing weight, and for missing multiple gynecology appointments. Janice's clinician has worked with her for over a year and is frustrated by their inability to make progress together on her health issues. Janice has never revealed to any of her clinicians that she was sexually abused during childhood nor that she is currently experiencing severe emotional abuse by her husband.For many people like Janice and her provider, understanding the connection between traumatic experiences and health can be transformative and healing. When patients understand that childhood and adult trauma underlie many illnesses and unhealthy behaviors, they often stop blaming themselves, feel more self-acceptance, and make progress toward health and well-being. Providers who understand this connection are able to create clinical environments that are less triggering for both patients and staff, identify referrals to appropriate trauma-specific services, and develop more effective therapeutic alliances and treatment plans with their patients.Our strategy group worked to clarify a practical framework for TIPC, a patient-centered approach that acknowledges and addresses the broad impact of both recent and lifetime trauma on health behaviors and outcomes. The goal of TIPC is to improve the efficacy and experience of primary care for both patients and providers by integrating an evidence-based response to this key social determinant of health. The Link between Trauma and Poor HealthThe Substance Abuse and Mental Health Services Administration defines trauma as "an event, series of events, or set of circumstances [e.g., childhood and adult physical, sexual, and emotional abuse; neglect;...

BACKGROUND: Little is known about whether health literacy affects anticoagulation‐related outcomes. OBJECTIVE: To assess how health literacy is associated with warfarin knowledge, adherence, and warfarin control (measured by the international normalized ratio [INR]). DESIGN: Survey. PARTICIPANTS: Patients taking warfarin through an anticoagulation clinic. MEASUREMENTS: Health literacy was measured using the short‐form Test of Functional Health Literacy in Adults (s‐TOFHLA), dichotomized as “limited” (score 0 to 22) and “adequate” (score 23 to 36). We asked patients to answer questions relating to their warfarin therapy and used multivariable logistic regression to assess whether health literacy was associated with incorrect answers. We also assessed whether health literacy was associated with nonadherence to warfarin as well as time in therapeutic INR range. RESULTS: Bilingual research assistants administered the survey and s‐TOFHLA to 179 anticoagulated English‐ or Spanish‐speaking patients. Limited health literacy was associated with incorrect answers to questions on warfarin's mechanism (adjusted odds ratio [OR] 4.8 [1.3 to 17.6]), side‐effects (OR 6.4 [2.3 to 18.0]), medication interactions (OR 2.5 [1.1 to 5.5]), and frequency of monitoring (OR 2.7 [1.1 to 6.7]), after adjusting for age, sex, race/ethnicity, education, cognitive impairment, and years on warfarin. However, limited health literacy was not significantly associated with missing warfarin doses in 3 months (OR 0.9 [0.4 to 2.0]) nor with the proportion of person‐time in therapeutic INR range (OR 1.0 [0.7 to 1.4]). CONCLUSIONS: Limited health literacy is associated with deficits in warfarin‐related knowledge but not with self‐reported adherence to warfarin or INR control. Efforts should concentrate on investigating alternative means of educating patients on the management and potential risks of anticoagulation.

Trauma and posttraumatic stress disorder disproportionally affect HIV-positive women. Studies increasingly demonstrate that both conditions may predict poor HIV-related health outcomes and transmission-risk behaviors. This study analyzed data from a prevention-with-positives program to understand if socio-economic, behavioral, and health-related factors are associated with antiretroviral failure and HIV transmission-risk behaviors among 113 HIV-positive biological and transgender women. An affirmative answer to a simple screening question for recent trauma was significantly associated with both outcomes. Compared to participants without recent trauma, participants reporting recent trauma had over four-times the odds of antiretroviral failure (AOR 4.3; 95% CI 1.1-16.6; p = 0.04), and over three-times the odds of reporting sex with an HIV-negative or unknown serostatus partner (AOR 3.9; 95% CI 1.3-11.9; p = 0.02) and <100% condom use with these partners (AOR 4.5; 95% CI 1.5-13.3; p = 0.007). Screening for recent trauma in HIV-positive biological and transgender women identifies patients at high risk for poor health outcomes and HIV transmission-risk behavior.

Despite the importance of clinician-patient communication, little is known about rates and predictors of medication miscommunication. Measuring rates of miscommunication, as well as differences between verbal and visual modes of assessment, can inform efforts to more effectively communicate about medications. We studied 220 diverse patients in an anticoagulation clinic to assess concordance between patient and clinician reports of warfarin regimens. Bilingual research assistants asked patients to (1) verbalize their prescribed weekly warfarin regimen and (2) identify this regimen from a digitized color menu of warfarin pills. We obtained clinician reports of patient regimens from chart review. Patients were categorized as having regimen concordance if there were no patient-clinician discrepancies in total weekly dosage. We then examined whether verbal and visual concordance rates varied with patient's language and health literacy. Fifty percent of patients achieved verbal concordance and 66% achieved visual concordance with clinicians regarding the weekly warfarin regimen (P < .001). Being a Cantonese speaker and having inadequate health literacy were associated with a lower odds of verbal concordance compared with English speakers and subjects with adequate health literacy (AOR 0.44, 0.21-0.93, AOR 0.50, 0.26-0.99, respectively). Neither language nor health literacy was associated with visual discordance. Shifting from verbal to visual modes was associated with greater patient-provider concordance across all patient subgroups, but especially for those with communication barriers.Clinician-patient discordance regarding patients' warfarin regimen was common but occurred less frequently when patients used a visual aid. Visual aids may improve the accuracy of medication assessment, especially for patients with communication barriers.