Cumulative trauma among women who use drugs: measurement development and implications for HIV prevention

Kathleen Mary Ward

doi:10.17918/00011081

Women who use illicit drugs (WWUD) experience high rates of co-occurring post-traumatic stress disorder (PTSD) and substance use disorder (SUD) driven by cumulative exposure to trauma and resulting in high HIV risk. This HIV risk environment has been explored among women using the Substance Abuse, Violence, and HIV/AIDS (SAVA) Syndemic Framework. SAVA-focused research describes how women with co-occurring experiences of trauma and illicit drug use report high rates of HIV risk behaviors such as injection drug use, sharing injection equipment, and unprotected sex, which may contribute to the high rates of HIV infections among WWUD. However, the far-reaching effects of cumulative trauma are poorly characterized in WWUD. Current traumatic event indices typically focus on one period of life (i.e., childhood) or assess a single type of trauma (i.e., sexual violence; combat). These tools fail to capture cumulative trauma, which is important in highly traumatized groups such as WWUD who experience high rates of revictimization following traumatic events, resulting in increased severity of PTSD, SUD, and HIV risk exposure. Valid and reliable measurement is needed to generate an accurate assessment of trauma exposure prevalence in this group. Using a concurrent mixed-methods design, this dissertation assessed the validity and reliability of the TLEQ-WWUD, a traumatic events index designed to capture the wide-ranging and unique traumatic experiences of vulnerable cisgender women who use drugs. The index was based on a commonly used and validated trauma index (TLEQ) that was adapted in collaboration with women who have a history of substance use, and experts in trauma treatment and psychology (Chapter 2). Aims 1 and 2 tested the validity of the index using data from a randomized controlled trial designed to reduce HIV acquisition risk among women who injected drugs in the past 6 months (NCT05192434; N=162). Aim 1 assessed the correlation between traumatic experiences (TLEQ-WWUD summary scores) and (1) PTSD (PCL-5 symptom screener), (2) depression, and (3) anxiety symptom scales (predictive validity) (Chapter 3). Aim 2 used logistic regression to assess the association between traumatic experiences (TLEQ-WWUD summary scores) and drug- and sex-related HIV-risk behaviors (predictive validity) (Chapter 4). In Aim 3, the TLEQ-WWUD was administered to a cohort of women who have used illicit substances within 12 months (N=32) (Chapter 5). Participants completed the electronic, self-administered, TLEQ-WWUD on two different occasions, approximately 7 days apart. Test-retest temporal stability was evaluated using intraclass correlation for TLEQ-WWUD summary scores and Gwet's AC1 for each individual event type. At the second assessment, participants completed a semi-structured interview to reflect on their experience completing the TLEQ-WWUD and discuss potential improvements. Across both samples, cumulative trauma and prevalence of each event captured on the TLEQ-WWUD were exceptionally high. In Aims 1 and 2, out of the 21 events on the TLEQ-WWUD, the median number of traumatic events was 14 (IQR: 11,16). Further, women were suffering from mental health concerns such as PTSD (74%; median score: 46 [IQR:32,61]), moderate/severe depression (71%), and anxiety (77%). Results from Aims 1 and 2 provide evidence that the TLEQ-WWUD is a valid tool for measuring cumulative trauma among WWUD. There was a moderate-weak, positive correlation between the TLEQ-WWUD summary score and PTSD ([rho]=0.39 (p<0.01)). Further, women with PTSD reported significantly more traumatic events on average compared to women without PTSD (15 events [IQR:12,17] v. 12 events [IQR:8,14], respectively) (p<0.01). In addition, there was a statistically significant difference in median TLEQ-WWUD scores across anxiety (p<0.01) and depression score groups (p<0.01). In another test of the TLEQ-WWUD's predictive validity, after controlling for age, race/ethnicity, and housing status, cumulative trauma exposure was significantly associated with increased odds of daily injection drug use (OR=1.14, CI:1.04-1.24, p<0.01) and sharing drug use paraphernalia (OR=1.12, 95% CI: 1.02-1.22, p=0.01). Results from Aim 3 provide preliminary evidence of weak-moderate test-retest reliability (ICC=0.38). Agreement coefficients varied across individual traumatic events, with AC1 values ranging from 0.14 (slight agreement) to 0.86 (excellent agreement). Fifteen out of 22 events had moderate to excellent agreement (AC1≥.41), 5 had fair agreement (0.21-0.40) and 2 events had only slight agreement (0.00-0.20). In qualitative interviews, women discussed their experience completing the TLEQ-WWUD and identified key features of the index that supported their mental health safety during the administration process: (1) Women's past experiences managing distress in their daily lives helped them mitigate the emotional impact of the TLEQ-WWUD. (2) Women saw value in the TLEQ-WWUD's potential to build community and raise awareness among healthcare providers. (3) Features of the TLEQ-WWUD administration process, such as self-administration in a private, low-pressure environment supported the acceptability and mental health safety of the index. Findings from each of these aims were compared using triangulation to provide a comprehensive understanding of the psychometric properties of the TLEQ-WWUD as well as key areas for future research and index implementation (Chapters 6-7). Overall, the TIARAS study was the first administration of the TLEQ-WWUD, a traumatic life events questionnaire designed specifically for women who use drugs. Results from Aims 1 and 2 provide evidence that the TLEQ-WWUD is a valid tool for measuring cumulative trauma among WWUD. Our findings are consistent with the SAVA framework, in which syndemic factors such as exposure to trauma (i.e., violence) and drug use dependence have a significant impact on mental health and HIV risk behaviors. Quantitative and qualitative results from Aim 3 also provide important findings about the reliability, acceptability, and mental health safety of the TLEQ-WWUD. TLEQ-WWUD summary score test-retest reliability was lower than hypothesized which could indicate that multiple administrations of the TLEQ-WWUD may be warranted to increase comfort with disclosure. This is consistent with the wider literature describing trauma disclosure as a complex process dependent on the nature of the event and the individual's comfort level. Validating and testing the reliability of the TLEQ-WWUD is the first step towards the goal of identifying and describing traumatic experiences common among women who use drugs, an understudied group with high rates of HIV and mental health illness. The TLEQ-WWUD is one tool that can help us understand the magnitude of events WWUD have experienced, and identification could have secondary HIV prevention benefits.

Cumulative trauma among women who use drugs: measurement development and implications for HIV prevention

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Cumulative trauma among women who use drugs: measurement development and implications for HIV prevention

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