Addressing the Unique Needs of African American Women in HIV Prevention

Abstract

African American women continue to be disproportionately affected by the HIV/AIDS epidemic, yet there are few effective HIV prevention interventions that are exclusively tailored to their lives and that address their risk factors.

Using an ecological framework, we offer a comprehensive overview of the risk factors that are driving the HIV/AIDS epidemic among African American women and explicate the consequences of ignoring these factors in HIV prevention strategies.

We also recommend ways to improve HIV prevention programs by taking into consideration the unique life experiences of adult African American women.

Despite more than 25 years of accumulative research demonstrating that behavioral interventions can curb HIV risks among adult women,^1–7 few US-based studies have focused exclusively on African American women and only a limited number of studies tailored for this population have been identified as Centers for Disease Control and Prevention–sanctioned evidence-based HIV prevention.⁸

Recent US incidence data show that the rate of HIV infection is 7 times higher among African Americans than it is among Whites.⁹ In the United States in 2006, African American women had an HIV incidence rate that was 15 times higher than that of White women and nearly 4 times higher than that of Hispanic women.¹⁰ This alarming discrepancy raises several important questions: What is driving the HIV/AIDS epidemic among adult African American women? What unique prevention challenges do these women face? How well do available prevention strategies consider the everyday realities of the lives of African American women?

Using Bronfenbrenner's ecological perspective,¹¹ we present factors related to the HIV/AIDS epidemic among African American women that can be used to effectively target prevention interventions. We also describe how the various factors in each system interact and their additive impact on African American women's risky behaviors. An understanding of these factors will inform the development of appropriate HIV prevention strategies.

The ecological perspective consists of 4 levels of risk factors: (1) the ontogenetic system, which refers to personal factors such as childhood sexual abuse, posttraumatic stress disorder (PTSD), and substance abuse; (2) the microsystem, which refers to interactional and relationship contexts, such as relationship dynamics and experience and fear of intimate partner violence (IPV); (3) the exosystem, which refers to external stressors that impinge upon the immediate setting and increase the likelihood of engaging in risky behavior, such as poverty and lack of access to HIV prevention services; and (4) the macrosystem, which includes the broad cultural values and belief systems (e.g., gender roles, gender inequalities, social norms, attitudes toward sexual activity and safe sexual practices) that interact with all the other system levels. We discuss how lack of attention to these factors in existing prevention strategies poses major challenges that constitute barriers and prevent African American women from participating in HIV prevention programs. We also identify the types of strategies that are needed to reduce their risks of HIV transmission.

ONTOGENETIC SYSTEM

African American women, especially those who are economically disadvantaged, are highly likely to have suffered childhood sexual abuse.¹² The rates of childhood sexual abuse among African American women range from 14% to 44%.^13–15

Childhood Sexual Abuse, PTSD, and Substance Abuse

Over the past decade, research has consistently linked childhood sexual abuse to PTSD, depression, and substance abuse.^16–18 Women with a history of childhood sexual abuse often turn to alcohol and drugs to self-medicate their symptoms of PTSD.^19,20 Substance abuse impairs their ability to function effectively in all areas of their lives, including engaging in risky sexual behaviors that may expose them to HIV/AIDS.^21,22

Women with histories of childhood sexual abuse who develop PTSD may also exhibit interpersonal skill deficits related to the symptoms.²³ These interpersonal skill deficits may impair a woman's ability to assess risk, to utilize effective problem-solving, and to communicate successfully when negotiating condom use.

Substance abuse has also been recognized as a major risk factor for heterosexual transmission of HIV and other sexually transmitted infections (STIs) among African American women.^24,25 Substance use impairs judgment and negotiation skills, resulting in an increased risk of having unwanted sexual intercourse; having intercourse with multiple, concurrent partners; and not using protection during sexual intercourse.^26,27 Furthermore, evidence suggests that drug dependency may further lead women to exchange sex for money or drugs in risky unprotected encounters.^27,28

Approaches to Solutions

African American women with substance abuse problems are more likely to have experienced co-occurring childhood sexual abuse, IPV, and PTSD than women with no history of substance abuse and may not benefit from HIV prevention strategies that do not consider these co-occurring problems and their relationship to risky behaviors.²⁹

To date, only 2 HIV prevention interventions have incorporated the links between childhood sexual abuse and HIV infection and addressed the sexual trauma of childhood sexual abuse among adult African American women. Wyatt et al.³⁰ found that an interpersonal communication skills–building intervention was efficacious in reducing self-reported HIV risk behaviors among African American and Latina women who were HIV-positive and had a history of childhood sexual abuse. Sikkema et al.³¹ found that a trauma-based intervention delivered in a group modality addressing childhood sexual abuse and its sequelae was efficacious in reducing trauma-related symptoms and HIV risk among both men and women who were HIV-positive and who had experienced childhood sexual abuse and adult sexual trauma. These studies represent important first steps in addressing histories of trauma in HIV prevention programs for women.

Research shows that to reduce HIV risk behaviors among African American women, it is critical to assess women for childhood sexual abuse, PTSD, and substance abuse and incorporate specific strategies designed to ameliorate the effects of these stressors. These may include (1) psychoeducation for African American women about the links among childhood sexual abuse, PTSD, and substance abuse and how these factors interact to increase HIV risk behaviors; (2) skills-building activities that help women cope with substance abuse and PTSD symptoms; and (3) skills-building activities to help women increase their ability to protect themselves from HIV infection.^29–31

MICROSYSTEM

African American women are more likely to become infected by a steady sexual partner and less likely to use condoms with this partner than when they are in casual relationships.^32–35 Most HIV prevention approaches place the burden on women to convince their steady partners to use condoms and reduce extradyadic sexual relationships, a charge that has been extremely challenging for many African American women. Traditional individual or group-based HIV prevention programs for women that do not include male partners attempt to empower women to negotiate safer sexual practices; however, these programs often fail to demonstrate increased condom use among women in long-term intimate relationships.^36,37

Engaging Couples in HIV Prevention

To deal with this challenge, African American women need HIV prevention strategies that engage both the woman and her steady sexual partner in educational sessions to learn how to mutually protect each other. This will reduce the burden placed on the woman to convince her partner to use condoms.^38,39 Over the past decade, several couple-based HIV prevention interventions have been designed and tested that included African American participants.^38–41 However, to our knowledge, only a single study, currently being conducted, exclusively focuses on African American couples.⁴²

There are many potential advantages to having couples jointly learn how to protect themselves from HIV infection and other STIs. Bringing the couple to sessions together may (1) increase trust, intimacy, and commitment in the relationship; (2) reduce gender power imbalances associated with sexual coercion and inability to negotiate condom use; (3) increase their communication and negotiation skills about sexual activity in general and HIV risk reduction in particular; (4) allow partners to express their need to take care of and protect each other by using condoms^43,44; and (5) provide a supportive environment that might enable intimate partners to more safely disclose extradyadic sexual encounters, STI histories, injection drug use, or past experiences in abusive relationships to their partners.⁴⁴ Such disclosures may enable couples to gain a more realistic appraisal of their HIV risks.

Addressing Intimate Partner Violence

Studies conducted predominantly among African American women have demonstrated that experiencing physical IPV increases the likelihood of experiencing sexual coercion and leads to exposure to HIV and other STIs.^33,45 If threatened with sexual coercion, women often forgo requesting condoms out of fear that such requests may further provoke their partners and jeopardize their own safety.⁴⁶ Physical IPV and sexual coercion create a context of fear, male dominance, and control that strips women of power or agency to negotiate risk reduction strategies, often forcing them to choose between protecting themselves from HIV and other STIs or IPV.²⁷

A growing number of researchers have underscored the need for HIV prevention strategies to incorporate IPV prevention.^47–51 Findings from several recent randomized controlled trials testing culturally congruent HIV prevention strategies for African American women, based primarily on social cognitive principles and an empowerment approach, found these interventions to be efficacious in increasing condom use, reducing risk behaviors, and decreasing STIs.^30,52–55

These interventions have not specifically addressed the co-occurring risk factor of IPV. To remedy this, HIV prevention strategies for African American women who are at risk for or experience IPV must be designed to simultaneously address the need to increase relationship safety while increasing condom negotiation self-efficacy and skills for reducing risk of HIV and other STIs. The women need to understand ways to avoid involvement in relationships that place them at risk for IPV and HIV infection and to have improved access to female-initiated and female-controlled prevention methods such as the female condom and vaginal microbicides.

Couple-based HIV prevention interventions have been found to create a safe environment for women to talk about conflicts in the relationship, such as forced sexual intercourse and sexual coercion. It provides a venue where they can discuss with their partner why they need to refuse unprotected sexual activity, postpone pregnancy, disclose HIV risks to each other, and address power imbalances in sexual decisionmaking.^38,39 However, couple-based HIV prevention may not be appropriate for women who are currently experiencing severe or life-threatening IPV. Before participation in couple-based HIV prevention, it is essential to assess the woman's level of fear of potential IPV.

Although there are few empirically tested HIV prevention strategies specifically designed to address all the co-occurring problems we mention here, a small number of intervention trials that included some African American women have found promising effects of group-based and mixed modality (couple or group-based) prevention strategies that consider the realities of IPV when attempting to increase condom use and reduce risky sexual behaviors.^56,57 Such interventions could be adapted to address the unique constellation of factors that contribute to the co-occurring problems of IPV and HIV risks among African American women.

EXOSYSTEM

Compared with African American women of higher socioeconomic status, those of lower socioeconomic status are exposed to more frequent, more severe, and chronic stressors including unemployment, homelessness, victimization, and exposure to community violence.^58,59 They often live in neighborhoods with high levels of substance abuse and HIV and other STIs and have limited access to HIV prevention services. Moreover, many poor African American women have witnessed urban gentrification and neighborhood displacement, which have dismantled social networks and undercut the social capital and prosocial norms of many low-income African American communities.⁶⁰

These stressors often have negative physical and psychological consequences that may lead to the use of maladaptive coping strategies that place African American women at high risk for HIV/AIDS.⁵⁸ Hasnain et al.⁶¹ found that African American male and female drug users with low educational attainment were significantly more likely to test positive for HIV and were more likely to engage in HIV risk behaviors than their better-educated counterparts. Ickovics et al.⁶² conducted a study with an ethnically mixed sample of women and found that those with lower socioeconomic status were more likely to experience high levels of stress and also had riskier sexual partners.

Because of the need to cope with daily stressors related to basic survival, poor women may give the risk of HIV/AIDS less importance or relevance than more immediate concerns.^58,63 Poor African American women may use alcohol or illicit drugs as a coping mechanism to help reduce negative emotions, or engage in sex-trading or prostitution as a way to obtain food, shelter, or drugs.⁶⁴ Moreover, African American women who are economically dependent on their partners may not challenge risky sexual practices.^65,66

Access to Preventive Services

The health insurance coverage available to poor women does not always cover preventive services related to HIV and other STIs.⁶⁴ Moreover, a large number of African American women may not seek prevention services because of their mistrust of service providers.^63,67 Some members of the African American community hold conspiracy beliefs about HIV/AIDS and birth control. These beliefs are associated with increased HIV risk behaviors.⁶⁸ In addition, the stigma associated with HIV/AIDS may prevent some African American women from getting tested, disclosing their HIV status, or seeking treatment because of fear of negative reactions or discrimination from family, community members, and service providers.^69,70

When African American women access and receive HIV treatment, it is likely to be of poorer quality than that received by their White counterparts.⁷¹ Studies reveal that, even after demographic variables are controlled, African Americans are less likely to receive certain diagnostic procedures or pharmaceutical treatments for HIV/AIDS, and this places them at elevated risk for morbidity and mortality.⁷¹

Approaches to Solutions

Very few preventive strategies fully address the social and economic situations that African American women live in, and this reduces their effectiveness in helping these women to successfully incorporate and utilize the strategies offered. One of the few woman-focused HIV intervention studies designed to socially empower African American women who have recently come out of drug treatment found that the intervention was efficacious in improving the women's employment status, housing status, and access to HIV services, which, in turn, reduced their engagement in unprotected sexual activity.⁷² The findings highlight the importance of addressing the social context of HIV risk behaviors.

HIV prevention efforts for African American women may incorporate the following core components: (1) increase access to adequate housing, childcare, and job training and mobilize community resources and social support, which may reduce the daily stressors that affect African American women; (2) utilize trusted community members to deliver HIV prevention messages; (3) train service providers to provide culturally competent care as well as increase their awareness of biases that influence their decision-making and services provision^73,74; (4) increase funding for HIV prevention programs in the African American community; and (5) establish policies to ensure the elimination of violence against women as well as to ensure access to health care, HIV prevention services, and female-initiated and female-controlled prevention methods.

MACROSYSTEM

An understanding of the status of African American women that is based on social constructions of race, gender, and class is central to understanding the contexts in which HIV transmission occurs in this population.^75,76 Gender as a social construct enforces fundamental power imbalances by assigning to women inferior status and roles, and this limits their control over their reproductive life.⁶⁴ African American women are often socialized to be sexually passive and taught to defer to men when it comes to decision-making regarding sexual activities including condom use.³⁵ Moreover, studies suggest that both men and women accept promiscuity among men in the African American community, which contributes to women's HIV risk.⁷⁷

Gender Roles and Sex Ratio Imbalances

Because of African American men's higher incarceration and mortality rates than those of African American women, there is a sex ratio imbalance in the African American community that exacerbates gender inequalities and power imbalances within intimate relationships, rendering African American women less powerful and less able to control the negotiations of a safer relationship.⁷⁸ When the number of “available” African American men is diminished, women may alter their self-protective behaviors in ways that are driven by fear of losing their partners and not being able to find another.⁷⁸

El-Bassel et al.²⁷ argued that when a woman believes that an alternative partner may not be available, the fear of disrupting a partnership plays an important role in determining her willingness to insist on condom use. In addition, the fear of losing a partner may not only inhibit African American women from requesting the use of condoms but may also prevent them from resisting IPV or refusing drug use within an intimate partnership,⁷⁸ which may further increase their risk for HIV infection.

Using a gender and power framework, Amaro and Raj⁷⁹ posited that there are 3 overlapping processes that may reduce women's self-protective behaviors against HIV risks: silencing women to behave in passive ways, instilling fear through intimidation and the threat of violence, and internalization of a sense of self that is weak, unworthy, and without rights. All may have an impact on a woman's ability to protect herself from HIV.

Approaches to Solutions

Although preventive strategies have addressed issues of power imbalances, there is a continued need for effective HIV prevention strategies for African American women that challenge the existing gender inequalities and teach women ways to combat these issues without increasing their risk of violence and HIV infection. Moreover, the sex ratio imbalance issues may specifically be incorporated into HIV prevention messages by working with women to (1) become aware of the link between sex ratio imbalances and their fears of losing their partners if they insist on using condoms, (2) increase their comfort level with talking about this often hidden and unspoken matter and its link to HIV risk behavior, and (3) weigh the pros and cons of staying in or terminating an unhealthy relationship as well as discussing ways of seeking a healthy relationship.

African American women may fail to benefit from HIV prevention strategies if these strategies ignore or gloss over the sex ratio imbalance and women's fears about losing their partners.^27,33

Social Norms and Beliefs

Studies suggest that social norms (family, peer, community, society) can also have a significant impact on whether African American women implement HIV protective behaviors. For example, Dancy and Berbaum⁸⁰ conducted a longitudinal study with a sample of 279 low-income African American women and found that the women who were not constrained by social norms, such as “women are not to talk about condoms or about sex unless the man introduces the topic” were more likely to engage in HIV protective behaviors.

Conservative religious institutions and beliefs may also prohibit discussions related to sexuality and condom use, and this also contributes to the imbalance of power that African American women experience in their relationships. These beliefs and practices promote norms that place African American women at risk for HIV/AIDS and make it difficult for them to implement self-protective behaviors.⁶⁴ HIV prevention efforts that focus solely on individual factors may not achieve their optimal effectiveness if social norms regarding sexuality and sexual behaviors remain unchanged and do not support these women's efforts to protect themselves.⁸¹

Approaches to Solutions

To date, African American women have little access to evidence-based prevention strategies that address social norms and beliefs around sexuality and HIV infection. Continued efforts are needed to develop and enhance existing prevention interventions at the macrosystem level. For example, media campaigns designed to increase HIV-related knowledge, encourage routine HIV testing, and promote condom use have been found to be beneficial in reducing HIV risk behaviors and promoting healthy behaviors.^64,73 Moreover, community-based prevention interventions that involve social networks, local organizations, and outreach efforts have been found to be effective in changing social and community norms around safer sexual relations and reducing HIV risk behaviors for African American women.^54,81,82

DISCUSSION

We used an ecological framework to offer a comprehensive overview of the multisystem risk factors that contribute to the HIV/AIDS epidemic among African American women and have explicated the consequences of ignoring these factors in HIV prevention strategies. These challenges can be addressed by taking into consideration the unique life experiences of African American women.

Prevention science has not sufficiently addressed the ontogenetic problems of childhood sexual abuse, PTSD, and substance abuse among African American women. Specific prevention strategies should include psychoeducation and skills-building activities to allow these women to cope with the consequences of trauma and substance abuse.

Microsystem issues related to couple dynamics and IPV have also not been adequately considered in HIV prevention among African American women. Combining single-gender groups and couple sessions with both the woman and her partner may be an effective prevention strategy to increase sexual decision-making power and to enable African American women to negotiate sexual and drug risk reduction with their male partners. Such hybrid approaches may effectively target the full range of individual and interpersonal risk factors and reduce the gender role power imbalances associated with HIV risk reduction among African American women and their sexual partners.

Exosystem risk factors such as poverty, unemployment, lack of access to health care, stigma, and lack of culturally congruent prevention approaches in health care systems are all serious challenges to expanding access to effective HIV prevention among African American women. Continued efforts toward improving the socioeconomic status of African American women and increasing their access to culturally congruent prevention strategies are needed.

Finally, macrosystem factors such as cultural beliefs, social norms, gender roles, and power imbalances among African American women need to be addressed. HIV prevention strategies may include media campaigns and community-based programs that involve social networks and local organizations. Moreover, policy-based interventions geared toward increasing funding for HIV prevention programs in the African American community and protecting and improving African American women's rights in the United States are essential.

We endorse the notion that risk factors overlap and interact with each other and that one prevention strategy or type does not fit all African American women. Women need to have access to diverse HIV prevention strategies from which they can choose one or more that speak to their life experiences and cultural context. Multilevel HIV prevention strategies (individual, couples, community, and macrolevel) are needed for African American women to deal with co-occurring risk factors; social, economic, and gender inequalities; and social norms related to sexuality and HIV risks.

Finally, because there is currently no cure for HIV/AIDS, contextually tailored prevention must continue to be a high priority and more attention should be paid to the development of and access to women-controlled methods that women can use to protect themselves from HIV transmission.