Collateral Damage: How Shutdown Politics Abandons Survivors at the Margins
October is Domestic Violence Awareness Month - but in 2025, awareness is no longer enough. Across the United States, people living with HIV (PLWH), hepatitis C (HCV), and substance-use disorders (SUD) are facing a convergence of crises where intimate partner violence (IPV) amplifies every barrier to care. At the same time, the U.S. Department of Justice’s grant programs - lifelines that help survivors achieve viral suppression, complete HCV treatment, and sustain recovery - are being systematically dismantled after three decades of bipartisan progress.
The numbers tell a story every HIV provider knows. One in four people living with HIV (26.3%) has experienced intimate partner violence. When abusive partners prevent medication adherence, sabotage appointments, or create chaos that interrupts treatment, survivors show 36 percent lower odds of achieving viral suppression than those without IPV histories. Women carry a disproportionate burden, but men with IPV history face nearly triple the HIV prevalence of men without, and transgender people report lifetime IPV rates between 31 and 50 percent while experiencing 66 times higher HIV prevalence than the general population.
For HCV, the overlap is even tighter. Sixty-eight percent of women who inject drugs have HCV, and 40 to 60 percent of domestic-violence cases involve substance use. These aren’t parallel epidemics - they’re feedback loops. Violence undermines treatment; HIV or HCV status becomes a weapon of control; trauma drives relapse. Each condition magnifies the others, and when federal support for survivor-centered programs collapses, the entire structure of prevention and recovery begins to unravel.
The Bidirectional Syndemic
The relationship between intimate partner violence and HIV is both brutally direct and insidiously complex. Women in abusive relationships face a 48% higher likelihood of HIV infection than those in non-abusive relationships. Abusive partners often sabotage safer-sex practices - research shows that condom negotiation attempts frequently trigger coercion or violence. Among people living with HIV, 24% of women experience abuse after disclosing their status, and those reporting recent gender-based violence are significantly less consistent in condom use. Gay men report 26% lifetime IPV prevalence, underscoring that control operates across gender and orientation.
The link to hepatitis C exposes another layer of risk. In relationships where both partners inject drugs, power imbalances determine who controls access, dosing, and the act of injection itself. Partners with more control may withhold drugs to induce withdrawal or insist on injecting the other, reinforcing dependence and exposure. Violence-related bleeding raises the odds of HCV infection 5.5-fold, what researchers call “a previously unrecognized mechanism for HCV transmission.” Among women who inject drugs, 60% report receptive syringe sharing, a behavior shaped by depression and low self-esteem resulting from abuse.
Trauma also drives substance use itself. Eighty percent of women in drug treatment report lifetime sexual or physical assault. Reductions in PTSD severity correspond to four-fold decreases in substance use, while the reverse is rarely true - reinforcing the self-medication model in which survivors use substances to cope with violence.
This syndemic runs both ways. HIV, HCV, and substance-use disorders not only result from domestic violence - they also increase vulnerability to it. Nearly one-third of people living with HIV experience violence following serodisclosure, including coercion, control, and financial or sexual exploitation. Nearly one-third of survivors report that partners deliberately withheld essential medication, from HIV antiretrovirals to HCV or opioid-use-disorder treatments, weaponizing care itself as a means of control.
When Laws Become Weapons
HIV criminalization laws in 32 states create a deadly double bind for domestic violence survivors. Enacted largely between 1986 and 2000 - before modern antiretroviral therapy and long before the U=U consensus - these statutes criminalize potential exposure regardless of actual transmission, condom use, or viral suppression.
Twenty-four states require disclosure of HIV status before any sexual activity. Penalties range from 3 to 10 years in prison, extending to 25 or more in some states. At least five mandate sex-offender registration for HIV-related convictions.
The control dynamic is devastatingly simple. Disclosure can trigger violence - studies show 18% to 80% of women living with HIV experience violence after disclosing their status - yet non-disclosure remains a felony. Abusers exploit this legal trap, threatening to report partners to police or weaponizing the risk of decades-long sentences and sex offender registration as blackmail.
Research from Canada illustrates the toll: one-fifth of women living with HIV said criminalization laws increased violence in their relationships. The perverse outcomes are clear. In one documented case, a woman reported her partner for abuse, only to be charged herself after he alleged non-disclosure during a single encounter, despite a four-year relationship in which she had disclosed her status.
The 2025 Federal Funding Crisis
Hours after the government shut down on October 1, 2025, the Trump Administration furloughed staff in the Department of Justice’s grant-making offices, halting support for organizations that serve victims of domestic violence and other violent crimes. Officials cited the shutdown as the cause, but former staffers told Politico it didn’t have to be this way - these programs had operated during past shutdowns with existing funds.
“Their own contingency plan says that they have funds. So it’s a choice to say, ‘We want this to hurt,’” said Marnie Shiels, who worked 24 years in the Office on Violence Against Women (OVW). “I can’t know for sure what they’re thinking, but I very much fear that it is about a political motivation of wanting to get rid of this issue, get rid of this office, get rid of the staff.”
The furloughs followed a year of escalating disruptions. In February, OVW abruptly removed all eight fiscal-year 2025 funding notices, including a $40 million transitional-housing program that had served hundreds of survivors for nearly two decades. In April, the Department of Justice terminated more than 360 grants, cutting roughly $500 million in remaining funds and affecting hundreds of sub-awards for violence prevention, victim services, mental-health treatment, and reentry programs.
When new opportunities appeared in May, they came with expanded “out-of-scope” rules that barred activities “framing domestic violence or sexual assault as systemic social-justice issues.” The language aligned with a January 2025 executive order, “Defending Women from Gender Ideology Extremism,” and a subsequent directive ordering agencies to remove “gender ideology” from contracts, websites, and correspondence. PEN America later documented more than 350 banned words, including gender, women, trans, LGBTQ+, diversity, and disability - effectively erasing the terminology needed to describe many of the populations these programs serve.
The effects reach beyond domestic-violence services. NIH canceled dozens of HIV-related research grants in March; five CDC HIV-prevention branches were dissolved; and hepatitis funding was cut by $77 million. Proposed reductions to the Ryan White HIV/AIDS Program total $239 million.
For organizations serving survivors living with HIV, hepatitis C, or substance-use disorders, these converging cuts are existential - removing both their funding streams and, in some cases, their ability to even describe who they serve. Shiels noted that leadership had “said that they want federal employees to feel ‘trauma,’” and recalled the president’s remark that “a little fight with the wife shouldn’t be a crime.” The contrast, she said, “shows they don’t understand or care about these issues.”
The Office on Violence Against Women - created in 1995 and made independent in 2004 - has awarded more than $4.7 billion in grants since its inception, including $684 million across 880 awards in FY 2024. That bipartisan infrastructure recognized what decades of data confirm: 55 percent of women living with HIV have experienced intimate-partner violence, a link directly associated with lower care engagement, higher viral loads, and worse health outcomes.
Now, the systems built to protect those lives hang by a thread.
What We Must Do Now
The convergence of domestic violence, HIV, hepatitis C, and substance use disorders is not theoretical - it’s the reality providers see every day. Survivors’ viral loads rebound when housing instability forces them back to abusive partners. Hepatitis C treatment stalls when the only culturally competent program loses its grant. Trauma-informed care disappears, and relapse follows. The nation’s Ending the HIV Epidemic and hepatitis C elimination goals cannot succeed while survivors are forced to choose between safety and survival.
Rebuilding that safety net demands more than temporary fixes. The Department of Justice must reopen its grant-making offices - shutdown or not - and restore continuity for organizations on the front lines. Congress must fully fund these programs and eliminate restrictions that prevent them from even naming the people they serve. States must modernize or repeal HIV criminalization laws that trap survivors in violent relationships under the guise of public health.
A syndemic is not fate; it is a policy choice repeated, ignored, and justified until it becomes another fading bruise on a battered cheek. The systems we built to keep people alive are being dismantled in plain sight - not through neglect, but intent. And when government decides that survival itself is partisan, silence becomes complicity.
Xylazine: Advocates, Service Providers on High Alert
As friends to organizations whose missions are primarily centered on harm reduction and as an organization that recognizes and often seeks to break down the silos associated with HIV, Hepatitis C, and Substance Use Disorder as distinctive but intersecting health states, Community Access National Network (CANN) is sometimes skeptical as to “alerts” the United States law enforcement community might offer through various news media. The “rainbow fentanyl” hype from the fall of 2022 speaks to why advocates may find themselves questioning the veracity of these kinds of warnings. However, the issue of xylazine is unfortunately based in very tangible realities for the United States, which have been documented as far back as the 2000’s in Puerto Rico. The prevalence of xylazine is increasing across the country’s street-based drug supply, often times in combination with fentanyl – most significantly complicating efforts to reverse overdoses and causing wounds which are atypical to more common fentanyl or heroin use.
Last week I spent time discussing a friend’s personal (and social) sexual health and as conversation developed they expressed concern over the development of xylazine, sometimes known as “tranq dope” or “down”, becoming more prevalent in the illicit drug trade of their community. Planning for events and even social outtings are requiring them to consider carrying more doses of Narcan on them and they’re noticing a higher demand for fentanyl testing strips. They conveyed a familiarity with the strips being used to ensure the illicit substances being used were indeed fentanyl and not the animal tranquilizer that seems to be driving up fatal overdoses in the surrounding community. Our conversation wrapped up with my friend sharing with me a sentiment another friend had shared, “Crack sucked, opioids suck…but they were a progression. People knew what they were doing. This is innocent. People aren’t making these choices.”
And while some might moralize what making “those” choices might mean, ultimately the best approach to helping folks navigate substance use doesn’t come with judgment but an acceptance that we all cope with the world around us differently. History tells us readily that prohibition movements seldomly achieve their goals and, economically, criminalization is less beneficial than harm reduction measures in curbing illicit substance use. Harm reduction measures, when adequately situated and supported, link people who use drugs to care where wounds may be treated, safe supplies might be obtained, chains of transmission of infectious diseases are identified and interrupted, and, when someone is ready, linkage to substance use counseling is available. It is this intersection of interest where harm reduction and patient advocacy intersect.
Hard-won victories which have helped advocates create safer environments for people who use drugs may not be sufficient for handling this corruption of street supply, as the wounds being associated with xylazine are resulting in amputations, in part because of providers being less familiar with how these wounds are presenting, which may still be present even when someone is not injecting their substance of choice, but swallowing, smoking, or snorting it. Trust in hospital providers is slim because emergency rooms are received as hostile environments which do not typically offer substance use treatment referrals and where people who use drugs often experience provider biases, sometimes resulting in substandard care. Fear of withdrawal is also a compelling factor for avoiding necessary care, as community-based programs are trying to meet the needs of their clients, their communities, mostly on their own.
While Philadelphia’s struggle with xylazine infiltrating the street supply is well documented, other jurisdictions are seeing signs of the tranquilizer. Delaware firmly expects to see 2022’s fatal overdose tally surpass 2021’s, even as provisional data is still being cleaned. Similarly, Connecticut, New Hampshire, and Rhode Island among several other east coast states have identified xylazine in the local supply as well as fatal overdoses increasing.
In the face of these challenges, House Republicans have asked the Drug Enforcement Agency and (DEA) to “schedule” xylazine and if the agency doesn’t, they might seek legislation to schedule it anyways – a move advocates warn might only make the problem worse. “Scheduling” refers to introducing a specific substance to the “schedule” of illegal and illicit substances maintained under the Controlled Substances Act – thereby adding certain criminal enhancements to the possession, use, and distribution of the tranquilizer. The concern from advocates in such a move is it would encourage further addition of other synthetic adulterators into street supplies, just as we’re learning (and researching) how to handle xylazine. Dr. Ryan Marino, medical director of toxicology and addiction medicine at University Hospitals in Cleveland scolded, “This is more of the same short-sighted and reactionary political grandstanding that may help politicians but won’t help any American citizens and doesn’t solve any of our drug problems.”
The U.S. Food and Drug Administration (FDA) issued an alert to health care professionals in November 2022, and the Biden Administration’s other agencies are already beginning to tackle the subject. But, what will it amount to?
Federal and state funding is already largely prohibited from backing safe consumption sites and Canada’s advocate proposal of a “safe supply” would be an ever further stretch for politicians wishing to appear “tough on drugs” (but apparently lacking the empathy and expertise to be helpful to communities struggling with deaths). A congressional Research Service report, also shared in November 2022, offered some answers, ranging from treating safe consumption sites similarly to medical marijuana dispensaries, wherein the U.S. Department of Justice (DOJ) is prohibited from using resources to seek prosecution of those businesses so long as they comply with state law, lawmakers could opt to fund these sites, giving explicit endorsement of a well-proven intervention that has already saved hundreds of lives in New York, or Congressional leaders or the President might choose to actively pursue criminal litigation and legislation which explicitly outlaw safe consumption sites. The Biden Administration appears to be leaning toward non-enforcement, if the recent updates about the DOJ and Safehouse, an organization in Philadelphia, meeting an “amicable settlement” prove to be fruitful.
Because overdoses of the tranquilizer are also presenting atypically from more traditional fentanyl overdoses, community health workers are noticing Narcan is less effective in reversing these overdoses and even when they are effective, the person experiencing the overdose may not rouse as easily because of the contamination with xylazine. Some have reported oxygen supplements might help in stabilizing someone in need of emergency care in response to an overdose. This would prove an exceptional challenge for street-based workers but certainly something a safe consumption site would be able to have on hand. As states continue to develop their harm reduction policies and empower community-based organizations to respond to these crises, policymakers should evaluate things like ensuring adequate oxygen supplies for these entities and even their community partners (which might include businesses like bars) and increasing allowable and covered purchases of Narcan, as administering the overdose reversal medication is still highly recommended when encountering an overdose.
We urge our partners to keep a close eye on this issue at it continues to develop.