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. Author manuscript; available in PMC: 2013 Feb 2.
Published in final edited form as: AIDS Educ Prev. 2012 Oct;24(5):422–430. doi: 10.1521/aeap.2012.24.5.422

SOURCES OF PERSONAL INCOME AND HIV RISK AMONG SEXUALLY ACTIVE WOMEN

Melissa A Davey –Rothwell 1,✉, Beth S Linas 2, Carl A Latkin 3
PMCID: PMC3562362  NIHMSID: NIHMS435772  PMID: 23016503

Abstract

We examined the relationship between sources of income and sex behaviors among a sample of low-income, sexually active women in Baltimore, MD (n=517). Data were collected through interviews administered by a trained interviewer and Audio Computer Assisted Self-Interviewing (ACASI). The study assessed 4 categories of income including government payments, money from other people, selling items and irregular jobs (i.e. odds jobs). Having multiple sex partners was associated with receiving income from other people [AOR: 2.60, 95% CI: 1.66–4.09], selling items [AOR: 2.67, 95% CI: 1.64–4.36], and irregular jobs [AOR: 1.57, 95% CI: 1.08, 2.29]. Women who exchanged sex were more likely to acquire income through these sources but less likely to receive government assistance [AOR: 0.62, 95% CI: 0.39–0.97]. Sexual behaviors are associated with multiple sources of personal income. HIV prevention interventions should address the role that economic factors play in risk behaviors.

Keywords: HIV, women, income, poverty, sexual behaviors, sex exchange

Introduction

It has been well documented that poverty, measured such as annual income, food insufficiency, and community-level measures like per capita income and social capital is associated with HIV risk behaviors and acquisition as well as poorer outcomes among HIV positive persons (Krueger, Wood, Diehr, & Maxwell, 1990; Holtgrave & Crosby, 2003; Arnold, Raymond, & McFarland, 2011; Vogenthaler et al., 2010a; Vogenthaler et al., 2010b; Reilly & Woo, 2001; Cunningham et al., 2005; Riley, Gandhi, Hare, Cohen, & Hwang, 2007).

As many HIV prevention interventions are being developed and implemented with low income women, there is a growing body of literature on the link between individual economic circumstances and HIV risk behaviors (Mize, Robinson, Bockting, & Scheltema, 2002; Carey et al., 2000; Sikkema et al., 2000; Peragallo et al., 2005). In the U.S., research has shown that women with low income may engage in risky sex practices such as having a partner who is HIV positive or injects drugs (Ickovics et al., 2002). International studies suggest that women may engage in risky sexual relationships as a means to provide food and other necessities for themselves and their children (Bene & Merten, 2008; Jarama, Belgrave, Bradford, Young, & Honnold, 2007).

Researchers have demonstrated a link between main source of income and HIV risk behaviors (Schonnesson et al., 2008). In a study of primary sources of income and HIV risk behavior, Essien and colleagues (2004) found that individuals whose primary source of income came from illegal sources such as drug dealing or theft, had higher numbers of sex partners. One limitation of this study is that it only focused on primary sources of income. Since many people living in urban, impoverished communities, especially women, have limited skills and opportunities, they often garner income through numerous legal and illegal sources, such as involvement in the drug economy, which may increase their risk for HIV (DeBeck et al., 2007; Miller & Neaigus, 2002). Also, sources of income may vary on a regular basis among disadvantaged groups. Thus, it is important to examine all sources of income. In addition, this study did not adjust for covariates that may be associated with risky sex behaviors such as housing situation and drug use.

The purpose of the current study is to examine the relationship between personal sources of income and sexual risk behaviors (i.e. exchanging sex for money or drugs and having multiple sex partners) among a sample of low-income sexually active women in an U.S.-based urban setting. In addition to employment status, we focused on 4 categories of income: government assistance, money from others, selling items, and irregular jobs. Specifically, we were interested in whether having a steady source of income was associated with less risk behavior.

Methods

Participants and procedures

This study was conducted in Baltimore, MD, USA. The data were collected through a baseline assessment of individuals enrolled in an HIV prevention program for at high risk heterosexual women and their social network members. Women (i.e. index participants) were recruited through street outreach and posted advertisements. Study eligibility criteria for women were 1) 18–55 years; 2) did not inject drugs in the past 6 months, 3) self-reported sex with at least 1 male partner in the past 6 months, and 3) sexual risk behavior in the past 6 months which included any of the following: a) more than 2 sex partners; b) recent Sexually Transmitted Infection (STI) diagnosis, and c) having a high risk sex partner (i.e., injected heroin or cocaine, smoked crack, HIV seropositive, or man who has sex with men). Index participants referred social network members into the study. Social network members were eligible if they were an injector of heroin or cocaine, sex partner of the index participant, or a person the index participants felt comfortable talking to about HIV or STIs.

After providing written informed consent, participants took part in an interview that was administered face-to-face by a trainer interviewer and Audio-Computer Assisted Self Interviewing (ACASI). Details on study procedures have been reported previously (Davey-Rothwell et al, 2011). The present study used baseline data collected September 2005 through July 2007. All protocols were approved by the Johns Hopkins Bloomberg School of Public Health.

Measures

Sources of income

In addition to employment status, participants were asked about their other sources of income in the past 30 days. Numerous sources were reported and these sources were categorized into four categories:

  1. Government sources included social security, unemployment, food stamps, and checks from welfare.

  2. Selling items included pawning items and selling food stamps

  3. Money from others included child support and money from family, friends, or partners.

  4. Irregular jobs included hacking (i.e. providing transportation by car to others) and doing odd jobs such as cutting hair, childcare, temporary office work, etc.

Sexual risk behaviors

Data on sexual behaviors was collected through ACASI. The present analyses focused on having multiple sex partners and exchanging sex. Multiple partners was defined as having oral, vaginal, or anal sex with two or more sex partners in the past 90 days. Exchanging sex was defined as having a partner with whom the participant exchanged sex for food, money, shelter, or drugs in the past 90 days.

Other covariates

We also examined several sociodemographic variables that may influence the relationship between sources of income and risk behavior. Participants were asked about their current employment status which was coded as employed (full or part-time) and not employed. Since the majority of participants were African American, race was coded as African American vs. other. Age was dichotomized based on the median. Homelessness was measured as a self-report of being homeless in the past 6 months. Drug use was measured as self-reported use of heroin or cocaine (any route of administration) in the past 6 months. Total personal income was defined as total amount of income, regardless of source and including wages, in the past 30 days. This variable was dichotomized as less than $500 versus $500 or more. Having a main sex partner was assessed by the question “Do you currently have a main sex partner?” Finally, self-reported HIV serostatus was assessed.

Data analysis

This study focused on sexually active women. Seven hundred and forty six participants completed the baseline visit. Of these participants, 567 (76%) were women. Among women, 47 (8.3%) were excluded because they were not sexually active in the past 90 days. In addition, three cases were removed due to missing data on number of sex partners and exchange sex. The final sample size for the study was 517 women who reported being sexually active in the past 90 days. Due to missing data, 4 cases were excluded from the exchange sex analyses (n=513).

Chi-square and t-tests were conducted to examine unadjusted relationships between sources of income, sociodemographics, and both of the sex behavior outcomes. Eight logistic regression multivariate models were computed. Each model included one of the income categories (out of 4) and one of the 2 sexual risk outcomes- multiple partners or sex exchange. Each source of income was modeled independently to determine their independent association with each sex behavior. Multivariate models controlled for covariates that were significant (p<0.05) in the bivariate analyses or have been shown to be associated with HIV risk behavior in previous studies. All analyses were conducted using SAS 9.2 (SAS Institute, Cary, North Carolina USA).

Results

Multiple sex partners

Of the 517 women included in the analyses, 254 (49.1%) reported having 2 or more sex partners in the past 90 days. The average number of sex partners among women who reported multiple partners was 5.41 (sd=10.9). Approximately 78% reported having unprotected vaginal or anal sex in the past 90 days. Thirty-one percent of women who had multiple sex partners reported that they had not exchanged sex in the past 90 days. As shown in Table 1, women who had multiple sex partners were more likely to obtain income through selling items (29% vs. 11%, p<0.001), getting money from other people (83% vs. 68%, p<0,001) and irregular jobs (43% vs. 33%, p<0.05). These participants were also younger [41 (8.3) years vs. 42 (7.7), p<0.01] and reported being homeless (0<0.001) and less likely to have a main partner (p<0.01).

Table 1.

Comparison of women who had multiple sex partners and those who reported only 1 sex partner in the past 90 days, chat study, Baltimore, MD

Number of Sexual Partners
1
N=263		 2+
N=254
Characteristic N Col % N Col % P-value
Median Age (SD) 42 (7.7) 41 (8.3) 0.002
African American 250 95 248 98 0.119
Homeless in the past 6 months 56 21 99 39 <0.001
Used heroin or cocaine in the past 6 months 176 67 176 69 0.563
Currently has a main sexual partner 219 83 182 72 0.002
HIV positive (self-report) 29 11 27 11 0.885
Total personal income in past 30 days (Less than $500) 128 49 133 52 0.401
Employed full-time or part-time 41 16 37 15 0.745
Income sources in past 30 days
      Government sources 203 77 183 72 0.179
      Selling items 30 11 73 29 <0.001 
      Money from others 179 68 211 83 <0.001
      Irregular jobs 88 33 109 43 0.027
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After adjusting for covariates, selling items [AOR: 2.67, 95% CI: 1.64–4.36], getting money from others [AOR: 2.60, 95% CI: 1.66–4.09], and irregular jobs [AOR: 1.57, 95% CI: 1.08–2.29] were associated with higher odds of having multiple sex partners (table 2). There was not a significant association between obtaining money from government sources and having more than one sex partner.

Table 2.

Multivariate model of the associations between sources of Income and multiple sex partners (n=517)

Characteristic Adjusted
Odds ratio		 95%
Confidence
Interval		 P-value
Model A: Government sources 0.71 0.47, 1.08 0.111
Model B: Selling items 2.67 1.64, 4.36 <0.001
Model C: Money from others 2.60 1.66, 4.09 <0.001
Model D: Irregular Jobs 1.57 1.08, 2.29 0.017
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*

Multivariate model adjusted for age, homelessness, having a main sex partner, use of heroin or cocaine in the past 6 months, and total personal income.

Exchanging sex

Five hundred and thirteen women provided data on sex exchange. Among these participants, less than one third (n=143, 27.9%) reported exchanging sex in the past 90 days (Table 3). The average number of sex partners among women who exchanged sex was 7.11 (sd=18.1). As shown in Table 2, there were several differences between women who exchanged sex in the past 90 days and women who did not. Sources of income varied between the two groups. Women who exchanged sex were more likely to get income through selling items (40% vs. 12%, p<0.001), and money from other people (91% vs. 70%, p<0,001). Women who exchanged sex were less likely to acquire income from government source (69% vs. 77%, p<0.05).

Table 3.

Comparison of women who exchanged sex in the past 90 days those who did not, chat study, Baltimore, MD

Exchanged Sex
No
N=370		 Yes
N=143
Characteristic N Col % N Col % P-value
Median Age (SD) 42 (7.7) 41 (8.3) 0.002
African American 356 96 138 97 0.877
Homeless in the past 6 months 91 25 64 45 <0.001
Used heroin or cocaine in the past 6 months 236 64 112 78 0.002
Currently has a main sexual partner 297 80 101 71 0.019
HIV Positive Status (self-reported) 35 9 21 15 0.089
Total personal income in past 30 days (Less than $500) 176 48 83 58 0.033
Employed full-time or part-time 60 16 18 13 0.305
Income sources in the past 30 days
      Government sources 285 77 98 69 0.047
      Money from others 257 70 130 91 <0.001
      Selling items 46 12 57 40 <0.001
      Irregular jobs 125 34 71 50 0.010
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Women who exchanged sex were more likely to be younger [(41 (8.3) vs. 42 (7.7), p<0.01], received less than $500 in the past 30 days (p<0.05), reported being homeless (p<0.001) and using heroin or cocaine in the past 6 months (p<0.01). Approximately 16% of women who did not use drugs exchanged sex. Women who exchanged sex were less likely to report having a main sex partner (71% vs. 80%, p<0.05).

The multivariate models revealed that women who exchanged sex were less likely to get income through government sources [AOR: 0.62, 95% CI: 0.39–0.97] (table 4). Participants who sold items [AOR: 3.64, 95% CI: 2.26–5.86], got money from others [AOR: 4.38, 95% CI: 2.32–8.29], or had irregular jobs [AOR: 1.92, 95% CI: 1.27–2.80] had greater odds of exchanging sex.

Table 4.

Multivariate model of the associations between sources of income and exchange sex, (N=513)

Characteristic* Adjusted
Odds ratio		 95%
Confidence
Interval		 P-value
Model A: Government Sources 0.62 0.39, 0.97 0.036
Model B: Selling Items 3.64 2.26, 5.86 <0.001
Model C: Money from others 4.38 2.32, 8.29 <0.001
Model D: Irregular Jobs 1.92 1.27, 2.80 0.002
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*

Multivariate model adjusted for age, homelessness, having a main sex partner, use of heroin or cocaine in the past 6 months, and total personal income.

Discussion

This cross-sectional study of heterosexual women at risk for HIV revealed that sexual behaviors are associated with multiple sources of personal income. On average, women received income from 2 of the categories of income. We found that both having multiple sex partners and exchanging sex were associated with acquiring income through selling or pawning items and irregular jobs. These sources of income are unstable which may result in variable income over a monthly period. When money is low, women may seek out new partners for relationships or transactional sex, who can provide economic support or exchange sex for money.

Both multiple sex partners and exchanging sex were also associated with getting money from others. Reliance on others for money may place stress on a relationship; hence, women may seek out other sources of support. Unfortunately, we did not assess the relationship of this source of income. More research is needed to learn more about the extent and frequency of the economic exchanges between family and friends among impoverished inner-city communities and how these exchanges affect the relationships.

One interpretation of the findings is some women who have multiple partners seek resources from these partners. Dunkle and colleagues (2010) reported that African American women, compared to Caucasian women, often started and maintained relationships as a result of financial hardships. Obtaining money or material items from sex partners may indicate informal sex exchange. There is a stereotypical perception that sex exchange occurs when a desperate person in need of money or drugs has sex with a stranger. While these types of exchanges do occur, informal sex exchanges between people who know each other are also prevalent. Women may seek out new partners who can provide gifts or money for necessities like rent or food for their children. It may be normative to expect men to provide material resources to their partners. Research in both the US and international settings has shown that women partner with men, known as sugar daddies, as a means to obtain economic resources (Luke, 2005; Longfield, Glick, Waithaka, & Berman, 2004; Miller et al., 2002). These relationships often involve unprotected vaginal or anal sex. Poor economic situations among women have been linked to having unwanted sex due to fears of violence, losing one’s shelter or wanting to remain in a relationship (Whyte, 2006). In this sample, none of the sources of income were associated with unprotected vaginal or anal sex in the past 90 days, which 70% of the sample reported (data not shown).

Receiving money from governmental sources was not associated with having multiple sex partners. Interestingly, women who exchanged sex were less likely to obtain money from government sources. While previous research has shown a link between receiving public assistance with condom use and having multiple partners, this is the first study to our knowledge that has found an association with sex exchange (Schonnesson et al., 2008; Adimora et al., 2002). Money received from government sources represents stable income since a specific payment is paid at an expected time point; hence women may be less reliant on sexual exchange for resources. Individuals who go through the process of obtaining financial support from government programs, such as welfare or food stamps, may also obtain other material resources. These individuals may be better connected to other sources of social capital and not need to engage in sex exchange. Furthermore, women, who exchange sex, may have interpersonal or structural barriers to obtaining material resources from government agencies. Program eligibility and work requirements may be barriers to getting government assistance among women (Metsch & Pollack, 2005). Women who exchange sex may not seek government assistance because the amount of time and paperwork needed to apply may not be worth the outcome; exchanging sex may be perceived as leading to greater resources compared to government assistance. Also, government assistance is distributed only one time during the month while exchange sex may occur throughout the month.

It is important to note that having a main sex partner was protective against the two risk behaviors. Since main partners may contribute to household income, having a main partner may improve one’s economic situation and lead to a more stable lifestyle. Yet many women are at high risk for HIV from main partners (Jenness, Neaigus, Hagan, Murrill, & Wendel, 2010; Moreno, el Bassel, & Morrill, 2007; Sherman & Latkin, 2001).

The study has several limitations that should be noted. The study is cross-sectional, thus limiting the causal inferences that can be made between sources of income and risk behavior. The study population was self-selected, which limits generalizability. Finally, the category money from others included family, friends, and sex partners. When participants were asked about income from other people, “family, friends, and sex partners” were grouped together. We are unable to determine where the income came from. While sex partners include individuals such as spouses, it may also refer to individuals that participants exchanged sex with or had no significant relationship.

Nonetheless, this study helps to disentangle some of the link between personal income and HIV risk. Previous research has shown that women who have unmet needs, such as limited food or sufficient housing, are more likely to engage in risky sexual behaviors (Schwartz et al., 2010). Limited economic opportunities may lead women to prioritize immediate needs, such as money and shelter over HIV prevention (Newman, Williams, Massaquoi, Brown, & Logie, 2008). Self-sufficiency of women needs to increase so that they are less dependent on others, especially partners. Since women tend to be the caregivers of both young and older family members, employment and adult educational programs need to provide child and senior care services. In addition, greater outreach and reduction in barriers for obtaining government assistance programs are needed. Government economic support program could also be linked to other health and social service programs.

Acknowledgements

This work was funded by the National Institute on Mental Health (grant# R01 MH66810).

Contributor Information

Melissa A. Davey –Rothwell, Johns Hopkins University, Bloomberg School of Public Health, Department of Health, Behavior and Society, 2213 McElderry Street- 2nd Floor, Baltimore, MD 21205, Phone: (410) 502-5368, Fax: (410) 502-5385, mdavey@jhsph.edu.

Beth S. Linas, Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, 615 North Wolfe St., Baltimore, MD 21205, Phone: (410) 502-5368, Fax: (410) 502-5385, blinas@jhsph.edu.

Carl A. Latkin, Johns Hopkins University, Bloomberg School of Public Health, Department of Health Behavior and Society, 624 North Broadway, Baltimore, MD 21205, Phone: (410) 955-3972, Fax: (410) 502-5385, clatkin@jhsph.edu.

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