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Adverse Childhood Event Scores Associated With Likelihood of Missing Appointments and Unsuppressed HIV in a Southeastern U.S. Urban Clinic Sample

Campbell, Kari PhD, MPH; Raffanti, Stephen P. MD, MPH; Nash, Robertson PhD, ACNP, BC*

Journal of the Association of Nurses in AIDS Care: November-December 2019 - Volume 30 - Issue 6 - p 605–606
doi: 10.1097/JNC.0000000000000117

Kari Campbell, PhD, MPH, is a Health Policy Services Analyst III, Southeast AIDS Education and Training Center, Vanderbilt Comprehensive Care Clinic, Nashville, Tennessee, USA. Stephen P. Raffanti, MD, MPH, is a Professor of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, and Medical Director of the Vanderbilt Comprehensive Care Clinic, Nashville, Tennessee, USA. Robertson Nash, PhD, ACNP, BC, is an Assistant in Medicine, Vanderbilt University School of Medicine and Director of the PATHways Program, Vanderbilt Comprehensive Care Clinic, Nashville, Tennessee, USA.

Corresponding author: Robertson Nash, e-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Our team has produced evidence suggesting the Adverse Childhood Events (ACE) instrument might be used in HIV care to deepen understanding of the psychosocial roots of missed clinical care appointments and unsuppressed HIV, two related and clinically challenging problems. These findings highlight the adverse impact of childhood trauma and chaos on adult HIV management, especially in the U.S. Southeast (LeGrand et al., 2015). Furthermore, these findings offer the possibility of multiple clinically relevant uses from a single 10-item screening tool.

The fact that trauma is a common facet of the lives of many southeasterner people living with HIV (PLWH) is well documented (LeGrand et al., 2015), and trauma has been associated with poor HIV outcomes in this population (Mugavero et al., 2009). ACE scores equal to or greater than 4 have been associated with increased risks for a variety of health concerns associated with poorer HIV suppression, including substance abuse, depression, and risky sexual behaviors (Felitti et al., 1998). These associations have been replicated over time in the relatively few studies investigating ACE scores in samples of PLWH or individuals at elevated risk of HIV infection (Campbell, Walker, & Egede, 2016). Despite such findings, our team is unaware that PLWH are widely screened for childhood trauma as part of routine HIV clinical care. Our preliminary data suggest that using the ACE as a screening tool in HIV care may have several clinically relevant applications.

Our sample (N = 155) was studied at a large urban HIV clinic in the Southeastern United States, where we reviewed associations between a variety of psychosocial measures, including the ACE and HIV suppression, from November 2017 through September 2018. Compared with those in the Goal group (two or fewer ACE events), those in the Baseline group (three ACE events) were three times more likely to no-show for care, whereas those in the Risk group (four or more ACE events) were eight times more likely to no-show for clinical care (odds ratio, 2.9 vs. 7.9; p < .001). Participants with an ACE score of 4 or greater were twice as likely to have an HIV viral load greater than 200 copies/mL than those in the Goal group (odds ratio, 2.1 vs. 1.2; p = .01).

These data were collected as part of a nurse-led, interprofessional, intensive, and individualized program targeting PLWH whose cumulative life experiences have left them bereft of the self-efficacy required to successfully negotiate the intersectional challenges of minority race, minority sexual orientation, minority socioeconomic status, childhood trauma, and untreated mental illness. We have had excellent rates of HIV suppression in our program, and we attribute this in part to our use of ACE and other psychosocial screening tools to help patients and providers uncover, explore, and, hopefully, heal old wounds that interfere with successful HIV management in adulthood.

We hope our preliminary findings encourage additional research into associations between ACEs and management of HIV in adulthood. If we are ever to end the epidemic of HIV, we must engage our most challenging patients in a manner that acknowledges the complexities of their lived experiences.

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

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Grant support for this work was provided by UL1 TR000445 from NCATS/NIH (PI: Gordon R. Bernard, MD). We gratefully acknowledge the contributions of Asghar Kheshti, MS, MT (ASCP) during the study design and analysis phases of this work.

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Campbell J. A., Walker R. J., Egede L. E. (2016). Associations between adverse childhood experiences, high-risk behaviors, and morbidity in adulthood. American Journal of Preventive Medicine, 50, 344–352. doi:10.1016/jamepre.2015.07.022
Felitti V. J., Anda R. F., Nordenberg D., Williamson D. F., Spitz A. M., Edwards V., Marks J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258. doi:10.1016/SO749-3797(98)00017-8
LeGrand S., Reif S., Sullivan K., Murray K., Barlow M. L., Whetten K. (2015). A review of recent literature on trauma among individuals living with HIV. Current HIV/AIDS Reports, 12, 397–405. doi:10.1007/s11904-015-0288-2
Mugavero M. J., Raper J. L., Reif S., Whetten K., Leserman J., Thielman N. M., Pence B. W. (2009). Overload: Impact of incident stressful events on antiretroviral medication adherence and virologic failure in a longitudinal, multisite human immunodeficiency virus cohort study. Psychosomatic Medicine, 71, 920–926. doi:10.1097/PSY0b013e3181bfe8d2

adverse childhood events; missed appointments; Southeastern United States

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