The Role of Relationship Type, Risk Perception, and Condom Use in Middle Socioeconomic Status Black Women’s HIV-prevention Strategies

Abstract

This research analyzes qualitative focus group and interview data from the Sister Circle Study— a pilot study that explored HIV risk among middle SES Black women ages 25– 45 in North Carolina. Findings reveal that gendered relationship dynamics, perceptions of a sex ratio imbalance, and levels of trust in relationships may reduce some women’s ability to negotiate monogamy and condom use with their male partners. The research suggests that higher socioeconomic status does not fully buffer some middle SES Black women from HIV risk and highlights the role interpersonal and structural factors play in shaping HIV risk for this group.

Black women account for the majority of HIV/AIDS cases among U.S. women (Center for Disease Control [CDC], 2015b). While Black women made up 12% of the female population in 2010, 64% of HIV cases occurred in Black women while 18% were among White women and 15% were among Latinas (CDC, 2015b). Until now, most HIV research on Black women has focused on young, low SES Black women. This has been due to the high incidence and prevalence of HIV infection in low socioeconomic status (SES) Black communities in various areas of the U.S. (Adimora & Shoenbach, 2005; CDC, 2015a; Kyomugisha, 2006; Sionean et al., 2014). While the focus on young, low SES Black women has yielded important insights into how structural factors such as poverty shape low SES Black women’s vulnerability to HIV infection, research on this specific population has tended to overlook SES differences within the Black community. As a result, little is known about some middle SES Black women’s perceived or actual risk for HIV infection or their condom use behavior (Heath, 2014). In addition to the relative lack of HIV research focusing on middle SES Black women, this group has also been invisible in most data on HIV/AIDS rates. This is largely due to HIV/AIDS surveillance data disseminated by government agencies such as the CDC includes race but does not include SES as a variable (CDC, 2014). The lack of data on SES prevents some researchers from understanding whether and how some middle SES Black women’s access to education, income, and additional resources might act as protective factors against HIV infection.

To address these empirical gaps, we qualitatively examine a sample of middle SES Black women between the ages of 25 and 45 years old in the context of dating and sexual relationships to better understand some of the factors that influence their perception of risk for acquiring HIV and condom use behaviors. This pilot study highlights the experiences of an understudied group that may be at risk for acquiring HIV, given the prevalence of the disease among some Black women. Although some researchers may assume that people coming from the same racial and gender group have similar experiences with HIV prevention, we pull insights from previous sociological research that demonstrates qualitative differences between low and middle class Black people’s lived experiences (Lacy, 2007). We argue that middle class status may create unique challenges for some Black women that should be assessed. For example, some middle SES Black women may be able to limit their risk for acquiring HIV through their access to financial, educational and social resources not available to some low SES Black women. However, due to small and overlapping sexual networks within Black communities (Adimora & Shoenbach, 2005; Rosenfeld, 2008), as well as a possible perception that monogamy buffers one from risk for acquiring HIV and other sexually transmitted diseases (STDs) (Corbett, Dickson-Gomez, Hilario, & Weeks, 2009), some middle SES Black women may continue to be at risk. As a result, SES may not completely buffer some middle-class Black women from the risk of acquiring HIV in ways that some researchers and health professionals might expect.

In this study, middle SES is primarily defined by income, educational level, employment status, and occupation. For inclusion in the study, research participants were required to have incomes above the median for women in the state of North Carolina, which was $26,000 according to census data available at the time of study recruitment (U.S. Census Bureau, 2009). In addition, study participants were required to not be a student and to have completed study beyond the high school level, either in college or a professional training program. While government agencies such as the U.S. Census Bureau (2010) and the Department Of Commerce Economics and Statistics Administration (2010) have not historically provided a precise definition of the middle class, we use Black women’s median personal incomes that fall above the poverty line as a measure for determining middle class status.

It is important to understand what implications middle SES has on various aspects of some middle SES Black women’s lives, and particularly unmarried, middle SES, Black women’s health behaviors and health outcomes. Middle SES Black women comprise a growing segment of the middle class Black community (Marsh, Darity, Cohen, Casper, & Salters, 2007). Researchers have found that some Black women who are living alone and have never married have greater odds of achieving middle SES status than their Black male counterparts (Marsh, Darity, Cohen, Casper, & Salters, 2007). In recent years, social science researchers have identified a sub-population of middle SES Black men and women known as the “Love Jones Cohort” (Dickson & Marsh, 2008; Marsh, Darity, Cohen, Casper, & Salters, 2007). This term refers to the 1997 movie Love Jones, which focuses on middle class Black men and women’s dating experiences. The “Love Jones” cohort includes 25 to 44 year-old Blacks who live alone, are single (never married), hold high-wage occupations, have advanced degrees, maintain household incomes above average and are homeowners (Marsh, Darity, Cohen, Casper, & Salters, 2007). Between 1980 and 2000, the Love Jones Cohort made up the second largest segment of the Black middle class and were the fastest growing Black middle class household type in the 25 through 44-year-old age range (Dickson & Marsh, 2008; Marsh, Darity, Cohen, Casper, & Salters, 2007). However, some Black women’s middle SES and access to resources and education have not sufficiently protected them from a host of adverse health outcomes such as high infant mortality, low infant birth weight, and high levels of stress (MacDorman, 2011). Given some middle SES Black women’s vulnerability to adverse health outcomes, scholars should aim to better understand the different factors that may place them at risk for acquiring HIV.

Condom use has been a major focus of HIV prevention research, particularly given the fact that heterosexual sexual contact is the primary mode of HIV transmission for some Black women (Bird & Harvey, 2000;Branch-Vital, Hale, & Mazon, 2009; Chatterjee, Hosain, & Williams, 2006; Crosby et al., 2013; Perkins, Stennis, Spriggs, Kwegyir-Afful, & Prather, 2014; Perrino, Fernandez, Bowen, & Arheart, 2006; Wingood & DiClem-ente 1997,1998; Zukoski, Harvey, Branch, & Branch, 2009). According to data from the CDC, in 2010 some new HIV infections among Black women (87%) were attributed to heterosexual contact (CDC, 2015a). In addition, Black women who were infected through heterosexual contact comprised the fourth largest number of all HIV infections in the U.S. in 2010 (CDC, 2015b). However, given the lack of HIV/AIDS surveillance data by SES, little is known about rates of new HIV infection or modes of transmission among middle SES Black women. Moreover, their condom use practices have received negligible attention from researchers.

Middle SES Black women’s experiences with dating and relationships may influence their willingness and ability to negotiate condom use. For example, the sex ratio imbalance that works in men’s favor may constrain middle SES Black women’s ability to negotiate monogamy and condom use in relationships with their male partners (Kyomugisha, 2006). Researchers have found that higher incarceration rates and lower educational attainment of Black men, as compared to Black women, create a sex ratio imbalance in many Black communities which makes it hard for Black women to find Black male partners of equal socioeconomic status (Adimora & Shoenbach, 2005; Toldston & Marks, 2011). Additionally, there are some overlapping sexual networks in Black communities due to discrimination against Black women in interracial dating (Herman & Campbell, 2012; Mendelsohn, Shaw Taylor, Fiore, & Cheshire, 2014) and a higher likelihood that Black men and women will date each other due to residential segregation (Adimora & Shoenbach, 2005). These multiple factors have been found to exacerbate Black women’s ability to negotiate monogamy and condom use (Adimora & Shoenbach, 2005) and place them at higher risk due to higher HIV prevalence rates in Black communities (Paranjape et al., 2006; Smith & Larson, 2014). In some cases, researchers have noted that some Black middle class women may stay in relationships with non-monogamous men (Bontempi et al., 2008; Ferguson et al., 2006) and increase their risky sexual behaviors (el-Bassel et al., 2009) because they feared losing their partner due to the sex ratio imbalance. Our analysis seeks to understand how a sex ratio imbalance between middle SES Black women and their male partners may shape women’s perceptions of HIV risk and condom use behavior.

Much of the previous research on condom use has not focused on potential similarities or differences by SES among Black women, often focusing on some women from low SES backgrounds. More often than not, researchers have focused on younger Black women with limited financial and social support resources to negotiate condom use (Bauman & Berman, 2005; Bird & Harvey 2000; Crosby et al., 2013). Several studies have highlighted how economic insecurity may increase some Black women’s vulnerability to acquiring HIV and inability to negotiate condom use (Chatterjee, Hosain, & Williams, 2006; Kyomugisha, 2006). Common barriers to condom use for some Black women include gendered power imbalances between men and women (Amaro, 1995; Bowleg, Belgrave, & Reisen, 2000; Hall & Pichon 2014; Long, 2009; Pulerwitz, Amaro, deJong, Gort-maker, & Rudd, 2002, Wingood & DiClemente, 1998), threats of violence from intimate partners (Wingood & DiClemente, 1997, 1998), lack of self-efficacy to negotiate condom use (Crosby et al., 2013), and lowered perception of risk for acquiring HIV when in committed relationships (Perrino et al., 2006; Sheeran et al., 1999). In particular, some Black women in physically abusive relationships may be unable to negotiate condom use with their primary partner because of the threat of physical violence if they ask their partners to use condoms; they may also feel isolated from other sources of social and financial support, such as family and friends (Wingood & DiClemente, 1997, 1998; Epperson et al., 2009).

Some Black women also have been found to be less likely to use condoms in monogamous, committed relationships than in casual and multiple partner relationships (Chatterjee, Hosain, & Williams, 2006; Duncan, 2011). Research suggests that emotional connections, particularly those in monogamous, committed relationships, may decrease some Black women’s perceptions of risk and willingness to use condoms (Epperson et al., 2009; Kyomugisha, 2006). Lastly, scholars have found that older Black women may be at risk for HIV, particularly when married or in committed relationships in which they do not use condoms because pregnancy prevention and sexual concurrency, or having overlapping sexual partnerships, are not major concerns for them (Frye et al., 2013; Smith & Larson, 2015).

Despite the challenges that may arise due to a sex ratio imbalance, some Black women’s difficulties negotiating condom use may ease as they age, gain more access to resources and attain higher educational levels (Paranjape et al., 2006; Smith & Larson, 2015). In contrast, some low SES Black women who were found to have difficulty communicating with their partners about condom use (Perrino et al., 2006), middle SES Black women may have more opportunities to buffer themselves from abusive relationships because they may be able to maintain financial independence from their male partner (Dickson & Marsh, 2008) and develop communication skills to negotiate condom use. However, more research is needed to understand the impact of higher SES on some Black women’s experiences in these areas. In non-abusive relationships, some Black women have been found to express feelings of empowerment to communicate with their partners in verbal and non-verbal ways about condom use (Bird & Harvey, 2000; Bowleg, Belgrave, & Reisen, 2000; Zukoski, Harvey, Branch, & Branch, 2009). However, these studies do not report the educational or income status of their participants, so it is unclear whether some women who are able to express feelings of empowerment and communicate with their partners were lower or middle SES. Nonetheless, it is possible that a Black woman’s access to higher income and education may provide them with the opportunity to develop communication skills that make it easier to negotiate condom use with their partners.

Given the paucity of research that disaggregates the Black female population by SES, this article seeks to contribute to our understanding of the experiences and perspectives of some middle SES Black women as they relate to perceptions of HIV risk and condom use as an HIV prevention method. We analyze qualitative data collected as part of the Sister Circle Study. The Sister Circle Study addressed the following research questions: 1) How are sex ratios, sexual networks, and overlapping sexual partnerships in Black communities associated with middle SES Black women’s HIV risk?; 2) How do middle SES Black women’s perceptions of HIV risk influence their sexual behavior, use of HIV prevention methods, and frequency of HIV testing?; and 3) Where do middle SES Black women get messages about HIV prevention and testing. This article analyzes focus group and interview data that relates to the first two research questions, including the factors that shape a small sample of middle SES Black women’s HIV risk perception, protective behaviors, and views of the impact of HIV on other middle SES Black women. Our analysis assesses factors that may put middle SES Black women at risk rather than compare middle SES Black women’s experiences to that of low SES Black women. This is an important means of developing a broader and more nuanced understanding of the impact of the HIV/AIDS epidemic on the Black female population across socioeconomic categories.

Method

Participants

The Sister Circle Study examined perceived HIV risk and condom use behaviors among a sample of middle SES Black women in North Carolina. Focus groups and interviews were conducted between October 2010 and March 2011. Participants in the Sister Circle study were unmarried middle SES Black women who lived or worked in three counties in North Carolina. The definition of “Black women” used in the study included women born in the U.S. and those of Caribbean, Latin American and African descent born in the U.S. or in other countries. Criteria for study participation included: (1) self-identification as a Black woman, (2) unmarried, (3) between 25 and 45 years of age, (4) sexually active with a Black male in the past year, (5) not a full-time student, and (6) a college degree recipient or graduate of a professional training program. We focus on Black women’s sexual relationships with Black men because Black women are more likely to date and/or marry Black men than men from any other racial group (Rosenfeld, 2008). It is possible that some Black women’s sexual relationships and perceptions of risk with non-Black men may be qualitatively different from their relationships with Black men; however, interracial relationships were not a focus for this study. Research participants were also required to have a minimum personal income of $26,000, which was the median annual income for women in the state of North Carolina at the time the study was conducted. (U.S. Census Bureau, 2009).

The mean age of the focus group participants was 34 years old (range 25– 45). Nearly half of the focus group participants had earned a master’s degree (n=10). The remaining participants had some college or professional training (n=4), were college graduates (n=7), or completed some graduate work (n=2). The median personal income for focus group participants ranged from $40,000 to $59,999 annually. Their occupations ranged broadly and included law enforcement officers, educators, counselors, graduate students, and human resources managers. These data indicate that many focus group participants were highly educated and had incomes well above the median for women in NC. However, it is important to note that three women lived with their main partners who provided additional household income. Eight women had one child and five had two children, which made them financially responsible for themselves and their dependents. The remaining women did not have any children.

Recruitment

Study recruitment was concentrated in three target counties, all of which were in close proximity to each other and had high HIV prevalence rates in the state of North Carolina. Recruitment was done at a health fair, through the use of flyers that were posted at community organizations and at a local university, and handbills that were made available at regional organizations and businesses. In addition, the study was advertised on email listservs for a nearby university, Black professional associations, and community organizations, as well as advertised in a community online magazine targeting people within Black neighborhoods. Recruitment materials described the study as “Sister Circle: Black Women Talking about Health, Sexual, and Relationship Experiences.” The study’s focus on HIV/AIDS was not explicitly used in recruitment materials to avoid possible stigma and encourage participation from a broad range of middle SES Black women. We screened each woman for eligibility to participate in the study. A total of 114 women were eligible to participate in the focus group discussions and interviews; however, non-response during follow-up calls for scheduling resulted in 45 women agreeing to participate. Due to failures to attend, the study resulted in a final total of 23 women who fully participated in the focus group discussions. Participants were given an opportunity to indicate whether they preferred to participate in focus groups, individual interviews, or both during the screening and consenting processes.

Data Collection

Two research assistants, who were Black women in the same age range as the study participants, collected the study data. The research assistants conducted four focus groups with two age cohorts: 25 to 34 year olds and 35 to 45 year olds. There were between five to six women in each focus group. The majority (n=13) of women participated in both focus groups and interviews, eight women participated in focus groups only, and two women participated in interviews only. Focus group participants also completed a demographic questionnaire. Two focus groups were conducted with each age group, with one focus group for each age cohort taking place in two of the three target counties for the study. Due to a low response rate, focus groups were not conducted in the third target county. The age cohorts were developed to examine the experiences of women at different stages of their lives; women who were similar in age were grouped in the same cohort. The lower age limit of 25 years was set to avoid inclusion of undergraduate students in the study. This was an important exclusion criterion given the large number of universities in the area where the study was conducted.

After completion of the focus groups, the research assistants conducted fifteen semi-structured individual interviews with women between 25 and 45 years of age who lived or worked in one of the three target counties. The interviews and focus groups took place at local community organizations and public libraries. Research participants provided written informed consent and received a $50 cash incentive for their participation. The Social and Behavioral Institutional Review Board at a local university approved this study.

Measures

Both the focus group and interview guides were exploratory in nature and were developed based on themes identified in the literature related to Black women’s middle class status (Dickson & Marsh, 2008; Lacy, 2007; Marsh, Darity, Cohen, Casper, & Salters, 2007), as well as Black women’s dating experiences (Herman & Campbell, 2012; Paranjape et al., 2006), their perceptions of a sex-ratio imbalance (Adimora & Shoenbach, 2005; Amaro, 1995; Bontempi et al., 2008), their condom use behaviors (Branch-Vital et al., 2009; Chatterjee et al., 2006; Perrino et al., 2006; Reece et al., 2010; Sheeran et al., 1999), and their understandings of HIV risk (Heath, 2014; Perkins et al., 2014). While most of the literature in these areas focused on the experiences of low-income Black women, it was helpful in identifying possible themes that could be explored with middle SES Black women. We also adapted some of the focus group questions from a previous qualitative research study the authors were part of called LinCS 2 Durham, which assessed sexual risk behaviors among Black young adults in Durham, NC (MacQueen et al., 2015). The questions were adapted to apply to a women-only focus group setting instead of assessing relationship dynamics and sexual health behaviors among both men and women participants.

The focus groups examined sexual behavior, use of HIV prevention methods, and perceptions of HIV risk among some middle SES Black women based on the research participants’ observations of norms and practices among their peers and within their social networks. Sample focus group questions included: “What are the different types of sexual relationships Black women typically have with Black men?” and “What is your sense of Black women’s perceptions of their HIV risk when they have these types of sexual relationships?” The individual interviews examined similar issues however they explored the experiences and perspectives of individual research participants. The individual interviews allowed for more in-depth discussion of research participants’ perspectives on sexual behavior, sexual relationships, and HIV prevention. Sample interview questions included: “What are some reasons why you and your partner(s) decided to use condoms?” and “Are there certain types of male partners that you are more likely to use condoms with?”

Data Analysis

The focus groups and individual interviews were digitally recorded, transcribed by a professional transcriptionist, and coded by two research assistants using NVivo 9.0 software. A codebook was jointly developed by the research assistants and principal investigator based on the research questions and key themes that emerged during the focus group and interview discussions. Codes included deductive codes based on the research questions, study aims, and focus group and interview questions, including condom use practices and attitudes, relationship status, and facilitators and deterrents to using condoms. We used grounded theory to identify inductive themes that emerged from participants’ responses to focus group and interview topics, such as negotiating emotional connection with a sexual partner and calculating risk of exposure to HIV, STDs, and pregnancy when engaging in sexual relationships (Strauss & Corbin, 1990). We then used axial coding to examine relationships between the deductive codes and inductive themes to determine possible links (Strauss & Corbin, 1990). We also compared responses across age cohorts and analyzed similarities and differences in the responses provided by focus group and interview participants.

Results

Finding a Partner

Participants from the 35 to 45 year old focus groups noted that there were not many Black men who matched their education, economic, or employment status, especially with respect to dating prospects. For example, in response to a question about how similar or different Black men and women were in terms of the types of jobs they have, three participants explained

R2: I do believe my job, in my building, there’s at least seventy people. There’s only three Black men and one’s gay, one’s married, and one’s in a long term relationship.

R1: I agree. Not that many.

R3: There’s not that many, yeah.

Later in the same focus group discussion, participants criticized some Black men of similar age for not dressing professionally:

R5: [I know] an older man that’s my age and he has like cornrows [and] the little black thing tied around his head. That is so unattractive. Why are you forty five [years old] with that on? I don’t understand.

R4: I agree again.

R2: We were talking about the doo rag¹ and the cornrows. Why are you forty-five and you have pants hanging below your behind? When women have more education, more work experience, just more of whatever, my friends and I have found that men try to be more controlling … and I’ve lived in other places [where older] men use recreational drugs.

The criticisms participants from the 35 to 45 year old focus group made of older Black men about their clothing and recreational drug use convey a sense of class based antagonism that seemed to make dating difficult. Age and gender power imbalances also played a role in these women’s ability to find a Black male partner to date because of their perception that some Black men attempted to control women because of their educational and professional status. Focus group participants who were in the 35 to 45 year age range also discussed the difficulties of finding middle SES Black men who were not married and/or engaging in concurrent or overlapping sexual partnerships with younger women.

R6: The granddaddies are the ones slinging their dongs [penises] everywhere with the young folk.

In another focus group with 35 to 45 year old participants, respondents echoed similar concerns:

R6: Maybe they [older men] have a wider range and therefore more options than women between thirty-five and forty-five … A lot of them are already married and may think that because you’re over thirty-five that you’ll be more willing to be a mistress … And that goes for Black men as well as other races.

There was a perception by some of the women from the 35 to 45 year old cohort that older men were more willing to engage in casual sexual relationships with younger women and cheat on their wives. Importantly, this focus group participant also had a perception that there was less of an expectation of monogamy for women over 35 years old, perhaps because their dating options were also limited by a lack of single middle SES Black men of similar age. The quotes above suggest that some 35 to 45 year old focus group participants perceived a gendered imbalance in power that was impacted by their age and the limited availability of single middle SES Black men to date. These dynamics were identified by the 35 to 45 year old focus group participants based on observations of women in their peer group. They point to potential challenges that might compromise some 35 to 45 year old middle SES Black women’s ability to negotiate monogamy.

Condom Use by Type of Sexual Relationship

Focus group discussions and interviews reveal some of the factors that may facilitate or prohibit participants’ use of condoms in casual versus main sexual relationships that are perceived to be monogamous. For example, in response to the moderator’s question about Black women’s condom use with particular types of people, a participant in a 25 to 34 year old focus group pointed out that condom use often varied by woman and relationship type:

I think it depends on the female. Some people just get in the heat of the moment and they really don’t even think about it. I know a female who is very sexually active with different men, this one, that one, and I’ve never heard of her using a condom. I don’t even believe she uses them. And then again, you could have another female who uses it every time and then you could have a female who is in a monogamous relationship and just uses condoms in the beginning of the relationship and then falls off and stops using them because they are in a monogamous committed relationship. Even in marriage, some people probably don’t even use them in their marriage because you’re married. You’re one with this person.

As discussed in the quote above, some women had multiple partners and may or may not have used condoms; however, the focus group participant portrayed this as an independent decision. As indicated by the discussion from this focus group participant, the emotional connection and expectations of monogamy within a marriage may limit some women’s motivation to use condoms. Other focus group participants also noted that in monogamous, committed relationships, a woman might choose to not use condoms because of the status of the relationship and emotional connection to her partner.

Data from the demographic questionnaire administered during the focus groups revealed that the majority of focus group participants (n=16) had a main partner. While three focus group participants lived with their main partner, most did not (n=13). With respect to number of sexual partners, seven focus group participants indicated they had one sexual partner in the past year, fourteen indicated they had between two and five sexual partners in the past year, and two indicated they had between six and nine partners in the past year. The data also indicate that focus group participants with no main partner (n=7) had several sexual partners within the past year and were likely to use condoms with their casual sexual partners.

Findings from interviews with middle SES Black women in this study reveal a similar pattern to focus group responses regarding their motivation and ability to use condoms with a main partner. Interview excerpts below highlight two women’s perspectives on the relationship between trust and condom use. Below is an exchange from an interview with a 31-year-old participant:

I: What are some factors that influence your decision to use condoms in your relationship?

R: I guess trust. There has to be trust. The last time I didn’t use a condom with a partner it was a trust in them because we were together all of the time … So there would have to be that trust there that would influence me not to use a condom.

Another 31-year-old interview participant responded to an interview question about how concerned she was about acquiring HIV:

I won’t say so much concerned [about acquiring HIV], but because I feel like once I’ve done the pre-work, if people are telling you the truth, then … but, I still always get checked. So, I will say there is a level of concern if I’ve ever had unprotected sex with a boyfriend, ‘cause you don’t know if they’ve been truthful to you or not.

For both interviewees, trust was built through time spent with their partners and having honest communication. Trust was a theme that emerged as a major factor in both focus group participants’ and interviewees’ discussion of their decisions to use condoms. Often, the emotional connection women felt toward their partners influenced their decision to use condoms. Interviewees explained that women typically experienced increased trust and comfort to forgo condom use if they were in relationships with a main partner (n=6), communicated with their partner about STI or HIV testing (n=2), or communicated about monogamy and/or other sexual partnerships (n=3). Several interviewees also explained that they were more likely to use condoms if they knew their partner was cheating (n=4). Others indicated that they consistently used condoms with most partners because they did not trust anyone with unprotected sex (n=3) and “never knew” if someone was cheating (n=1). Similarly, three focus group participants discussed the patterns among Black women like them who stopped using condoms in their main relationships, while one focus group participant mentioned that some women use condoms because of the uncertainty associated with a partner who might be infected or non-exclusive. Infidelity was a recurring them for several focus group participants, which highlighted how women’s concerns in this area might influence their condom use.

Several interviewees also mentioned how awareness of their partner’s infidelity influenced their decision to use condoms. For example, the following quotes highlight how a 33-year-old participant assessed who she was less likely to use condoms with:

My current boyfriend, one of the reasons why I was … [willing to not use condoms with him was] obviously he got tested, but he had been … he was married and he had only been … he’s had way less partners than I have. So if I hear someone who has had less partners [than me], then I am a little bit more prone … [to not use condoms]. He did have a [previous] partner that I felt a little questionable about, but then he went and got tested…. We are in a monogamous relationship, we live together and I trust this man more than I’ve trusted any man in my life. So that is another factor, being really able to trust the person.

This interviewee’s comments highlight several criteria that seemed to shape her perception of HIV risk in her relationship: a sense of monogamy in the relationship, the results of her partner’s HIV test, his previous sexual history, and the amount of trust she had in her partner. Her comments suggest that the level of trust in her relationship was tied to her partner meeting the first three criteria; this also appeared to give her a sense that she had low HIV risk in the relationship.

Trust and Condom Use

As discussed above, several interviewees highlighted the role of trust in their partners as a factor shaping their condom use decisions. The potential to be lied to by one’s partner and unknowingly be in a non-monogamous relationship was a concern identified by several focus group participants. In response to a question focused on Black women’s concerns about acquiring HIV, one participant in a 35 to 45 year old focus group elaborated on the factors that might come into play when women decide whether or not to use condoms:

I think they’re [my friends] still concerned because although they may believe their relationship is monogamous, they really don’t know. I think there is still a large amount of concern about protection and feeling guilty when they don’t use protection because they know it’s still a possibility. There are no ‘Get out of Jail Free’ cards where this is concerned.

As seen in the quote above, doubt in the fidelity of monogamous relationships might influence some women’s decisions to use condoms. By mentioning “guilt,” this focus group participant suggests that women’s knowledge of HIV risk could shape their responses to having unprotected sex and lead to negative feelings later. Another participant in this focus group provided a different perspective on why women might not use condoms:

If the guy says, ‘I want to do this without the condom,’ I think there are women who would go ahead and do it because they don’t want to lose him with the shortage of single, available Black men. They’re like, ‘Oh, what’s one time,’ or something stupid like that. In my opinion, it is stupid because you’re putting yourself at risk. You’re trying to be happy but you could eventually get pregnant or die so you really got to take that seriously and a lot of women will put the option of having a relationship or a committed relationship above their own safety as far as sex is concerned.

This focus group participant appeared to weigh self-protection above risking pregnancy and STI or HIV infection in exchange for relationship maintenance and she criticized other Black women who may have unprotected sex as a way to maintain a relationship because of their perception that there is a lack of available Black men to date.

Women from the 25 to 34 year old focus groups had conflicting attitudes about the role that a perceived sex ratio imbalance between eligible Black men and women played in their peers’ dating and sexual behaviors. One participant from a 25 to 34 year old focus group explained that the small network of educated Black men and women in the area where she lived influenced people’s experiences with dating and sexual behaviors:

R5: I have a bunch of different types of friends and it is such a range like the age range, the education level, military, people who are just really active in the community versus people who don’t want to hear anything about the community at all and yet they try to date each other and in nine times out of ten turns into one big mess because they’re not on the same level. Once they have sex, ‘cause that’s usually a physical attraction, and then they get past the physical and realize, ‘Oh, there’s nothing here. Let’s move on to the next bad decision.’

As this focus group participant’s comments suggest, there was a perception among some women from a 25 to 34 year old focus group that men with less education, and especially those without jobs, “were not on the same level” as middle SES Black women, but might be suitable for casual sexual encounters. According to this participant, the mismatch in status and social interests did not prohibit middle class women from engaging in sexual relationships with men who were not middle class. Indeed, another participant from the same focus group agreed with this observation, saying that women her age did not have problems being approached by men or finding someone to date casually, but described the difficulty her friends experience in finding male partners who were interested in marriage and also had a similar socioeconomic status. She stated:

R4: So it’s really been difficult for my group of people to find anyone. I mean, we do get approached, you’re absolutely right, but [it’s hard] to find someone that is up to where you are … We come from big cities where we’ve done the going out, the whole young thing. We’re done, we’re on our next stage and it’s hard to find that so that’s where we are at.

The study findings suggest that fear of losing their partner and the view that there were not a lot of available Black men to date may contribute to young middle SES Black women’s condom use decisions. The perception of the lack of availability of Black men to date may be tied to the increasing number of single Black women with middle SES status as compared to middle SES Black men (Dickson & Marsh, 2008).

Risk Perception and Condom Use

Some focus group participants discussed risk perception as an influential factor in Black women’s condom use decisions. One participant from a 35 to 45 year old focus group explained that many Black women, especially those in casual relationships, had heightened perceptions of HIV risk and were more likely to use condoms:

R: I think they’re very cognizant of the [HIV] risk from conversations that you hear, from conversations with your friends. If there are multiple partners, everybody is wearing a condom and it’s not an option. Even if there’s just one partner, even if it’s Friends with Benefits or the Maintenance Man² that you see every six weeks, he’s wearing a condom too. So I think they’re very cognizant of their HIV risk and protecting themselves.

Several focus group participants (n=5) mentioned that perceptions of HIV risk became more pronounced when middle SES Black women knew someone directly impacted by the disease. One participant from a 35 to 45 year old focus group described how HIV became more salient when a friend became infected:

It hit home. I have a friend. She knows exactly where she got it from. She knows exactly and she confronted him on it and he’s in denial …. he wanted to have unprotected sex with her. So we were like ok, ‘That’s a flag. That’s a flag up. Now do you understand? He gave it to you and he doesn’t … I mean he knows that he gave it to you ‘cause he’s having unprotected sex with you. You just told him what your status was,’ and it goes back to the emotional and physical abuse because he treats her terribly. He’s still out here with other women.

This participant’s awareness of her friend’s experiences with an unfaithful partner raised her own awareness of how infidelity and physically abusive relationships may increase women’s risk of HIV infection.

Some interviewees expressed a heightened perception of HIV risk, particularly those who did not experience trust in their relationships. For some, the decision to use condoms was influenced by concerns about STI/ HIV risk due to an unfaithful partner. One 36-year-old interviewee explained how her partner’s infidelity changed her perception of trust and safety in their relationship, and also led her to use condoms as a form of protection from STIs. During her interview she stated, “I used them. [I have had sex] and didn’t use condoms. I mean I was like, “Ooh, I had to go” [to the doctor] and I needed to know.” In this case, the woman’s partner cheated on her, which resulted in him contracting an STI and also fathering a set of twins. The pain that this participant experienced as a result of her partner’s infidelity was clearly expressed during her interview. Discovery of her partner’s infidelity raised concerns about her exposure to STIs and also caused her to seek medical services to confirm her own health status. She described her feelings about having sex with her partner after learning of his infidelity:

After I found out, it was like I didn’t want to [have sex] … But when we did, it was like, ‘I don’t know if I want to do this. I don’t even know if I want to.’ I guess with any female you’re thinking about that other female. So for a while it wasn’t like I felt like I had any power. He had power. I felt powerless.

This excerpt highlights the conflicting feelings her partner’s infidelity raised for this interviewee. She experienced a heightened awareness of her STI risk, as well as a sense of insecurity about her health. She also seemed to feel powerless because she was emotionally invested in her relationship. Despite feelings of powerlessness and having an emotional connection with a partner, some middle SES Black women, like the 36-year-old woman described above, recognized the importance of being tested for HIV and using condoms to prevent further vulnerabilities to STIs. The interview participant quoted above noted that, after discovering her partner’s infidelity, a change took place within her that caused her to prioritize her own well-being and begin to focus on self-protection.

In contrast, some interviewees explained that they may be less inclined to perceive HIV risk in sexual interactions with their main partner. For example, when a 29-year-old interview participant was asked whether there were certain types of partners she was less likely to use condoms with, she explained:

Only someone that I … like I said, previously, if I’m in a relationship … committed relationship with them, at one point, I felt that, you know, well, maybe we can use them in the beginning, and then, when that trust is built to stop using them.

This quote illustrates the importance that trust played in this interview participant’s perception of risk and subsequent decision not to use condoms. The actions some women took to build trust in relationships, including discussing past sexual partners, getting tested for HIV and STIs, and spending time together might also reduce their perception of HIV risk. In contrast, a 26-year-old interview participant emphasized her heightened awareness of HIV risk from any partner, regardless of relationship status:

I: How important of an issue do you think HIV is for Black women, who are similar to you?

R: I think it’s important to everyone. Some people will have a serious boyfriend and not use condoms …. but like I said you never know. Even when you’re married, you just never know what people are doing. So I just think it empowers you and helps you to have control over yourself to ask people. I think it’s really important, especially if you’re really successful and you have all these plans for your life. You have to be worried about being embarrassed, ‘cause now you have HIV and everything you worked for is done.

This interviewee’s comments about her heightened perception of HIV risk suggest that, for her, condom use as a form of HIV prevention was tied to a larger life project, including her hopes, dreams, and future plans. This long-term perspective motivated her to make sexual and reproductive decisions that were in keeping with her goals. This future goal orientation may be an indication of how some middle SES Black women might use goal attainment and aversion to social embarrassment as motivations to minimize HIV risk. This interviewee provides an alternative perspective to having complete trust in one’s partner by saying, “you never know.”

Barriers to Condom Use

Some focus group members and interviewees described factors that made it more difficult for women to negotiate condom use with their partners. They noted that women’s ability to negotiate condom use with their partners could be diminished due to a combination of factors, including sexual attraction, alcohol use, and gendered power imbalances. Below a 38-year-old interviewee describes challenges she experienced in negotiating condom use with one partner:

I have had the experience before where the guy was just like ‘We don’t need to use a condom. I’m good. I ain’t got nothin’ goin’ on. There is nothin’ wrong with me.’ In those cases it is kind of, actually it has happened more than once. So it is kind of like you are feelin’ the person, so it is like, ‘Dang, I don’t really want to,’ but then again that comes into how much have you had to drink, you know, what exactly is goin’ on. There have been those cases.

This participant’s experience highlights how the combination of power that some men may yield in relationships as well as sexual attraction and alcohol use may reduce a woman’s willingness or ability to use condoms.

Discussion

Our research findings highlight how some middle SES Black women’s experiences negotiating sexual partnerships with Black men, both monogamous and non-monogamous, influence their perceptions of HIV risk and condom use behaviors. Similar to previous studies conducted with other groups, we found that relationship type and levels of trust in sexual partnerships are important factors shaping some middle SES Black women’s decisions to use condoms for HIV prevention (Chatterjee, Hosain, & Williams, 2006; Duncan, 2011; Epperson et al., 2009; Kyomugisha, 2006). Interviewees’ concerns about self-protection and condom use seemed to be influenced by multiple factors, including their personal and relationship goals, levels of trust and intimacy in relationships, and a perceived lack of eligible Black male partners. Our research findings suggest that gendered power dynamics in their sexual partnerships can reduce some middle SES Black women’s likelihood to prioritize HIV risk prevention. As a result, a higher socioeconomic status may not fully buffer middle SES Black women from HIV risk. In particular, data from our focus groups and interviews highlight the role that both interpersonal and structural factors, including relationship dynamics and an imbalanced sex ratio, play in shaping middle SES Black women’s HIV risk and decision-making related to prevention.

Our findings indicate that study participants often observed or experienced gendered power imbalances that impacted their or their peers’ ability to negotiate monogamy and condom use in their sexual partnerships with Black men. Some participants described feeling powerless and dis-advantaged in their dating experiences because of the difficulties they experienced finding middle SES Black men who wanted to be in monogamous relationships. Clarke’s (2011) research provides important insights into middle SES Black women’s dating and romantic relationships that are relevant to our findings. Clarke (2011) highlights how the “inequalities of love,” including high rates of unemployment and incarceration and low educational attainment of Black men constrain the dating and marriage options of many college-educated, heterosexual Black women. Other scholars also highlight how middle SES Black women’s desire to maintain relationships with men, despite their constrained options for romantic relationships, tends to shape their sexual behavior and may limit their ability to enter into mutually monogamous relationships and negotiate condom use (Adimora & Schoenbach 2005; Kyomugisha, 2006). These findings highlight how some middle SES Black women’s limited dating options may exacerbate power differentials with male partners related to monogamy and condom use, thus placing some women at risk for acquiring HIV.

Relationship type was also a major factor that shaped the current study participants’ ability and willingness to use condoms. Specifically, the participants were less likely to use condoms in main, committed relationships than in casual sexual relationships. This finding is not surprising and is consistent with literature examining condom use behaviors of people from low SES backgrounds (Duncan, 2011), as well as across racial (Sheeran, 1999) and sexual orientation categories (Starks, Payton, Golub, Weinberger, & Parsons, 2014). There are several possible explanations for middle SES Black women’s greater likelihood to use condoms in casual relationships than in committed, apparently monogamous relationships. When middle SES Black women have expectations for a long-term commitment in a relationship, they may experience increased feelings of trust and stability, thus reducing perceptions of risk for contracting HIV/AIDS (Epperson et al., 2009; Kyomugisha, 2006; Sionean et al., 2014). In committed relationships, condom use may be viewed as interfering with physical and emotional intimacy, as well as indicating a lack of trust in one’s partner (Corbett, Dickson-Gomez, Hilario, & Weeks, 2009; Kyomugisha, 2006). Moreover, previous research has also shown that some Black women’s condom use with casual partners may be inconsistent, with scholars citing availability of condoms, location of the sex act, and perceptions of risk as factors that may lower the consistency of condom use (Chatterjee, Hosain, & Williams, 2006). Our research findings suggest that some women tend to trust their main partners and may be concerned about losing the benefits of relationships they worked to build or hoped to build with them. Participants’ feelings of trust and concern seemed to reduce their power and willingness to negotiate condom use in their main relationships. This is particularly important given some participants’ perception of a shortage of potential eligible Black male partners and difficulties that were expressed about finding monogamous Black male partners who wanted to be in long term relationships and/or get married. In such cases, the fear of losing a partner could result in either inconsistent or no condom use.

Our findings are similar to those of Pulerwitz et al. (2002), who examine the role relationship power plays in helping Latina women to make safer sex decisions and reduce their HIV/STI risk. Pulerwitz et al. (2002) argue that researchers and program designers who promote condom use should consider gendered power issues within heterosexual relationships, particularly those that disadvantage women (Pulerwitz, Amaro, deJong, Gortmaker, & Rudd, 2002). This analysis is relevant to our participants’ descriptions of the ways that partner infidelity may place some middle SES Black women in situations of HIV risk. It seems important to interrogate further how empowerment plays out for women of middle SES since most analyses and frameworks for gender power are typically based on the assumption that disempowered women have lower income levels, and are affected by factors such as addiction and past sexual abuse (Amaro, 1995). Since some middle SES Black women may not meet many of the criteria commonly associated with a disempowered gender status, researchers and health professionals may overlook questions of gender power in their sexual partnerships due to other factors, such as partner availability and trust.

Even though several of our research participants acknowledged the importance of condom use as a method of HIV prevention, they also noted that they and their peers did not always use condoms consistently. We believe a multi-faceted approach to understanding how middle SES Black women negotiate condom use is needed. Rather than isolating condom use from other aspects of women’s lives, it is important to consider how multiple factors, including gendered power imbalances, relationship type, and desire to maintain a relationship, may influence the context in which women make decisions related to condom use. Scholars and HIV prevention practitioners should design prevention strategies that are responsive to middle SES Black women’s lives, including their cultural and social context, limited ability to negotiate condom use in communities that experience sex ratio imbalances, and motivation to attain higher education and income attainment. Our perspective is supported by research that has found that interventions aimed at increasing knowledge of HIV/AIDS risk and condom use have not had a significant impact on condom use behaviors based on relationship type (Branch-Vital, Hale, & Mason, 2009).

Our research findings also highlight how beliefs in a male partner’s trustworthiness may lead some middle SES Black women to forgo condom use, particularly in primary or monogamous sexual relationships. Researchers have noted that prevailing gender norms often play a key role in shaping how the dynamics of love and trust affect condom use in heterosexual relationships (Amaro, 1995; Hall & Pichon, 2014; Wingood & DiClemente, 1998). Wingood and DiClemente’s (1998) conceptualization of the Structure of Cathexis in Black heterosexual relationships is useful in understanding how gender ideologies can influence social norms for women’s appropriate sexual behavior as well as negative perceptions about condom use in primary sexual relationships. Hall and Pichon (2014) found that gender roles affected middle class Black women’s willingness to engage in casual sexual relationships. For example, some Black women who endorsed masculine gender traits were more willing to engage in casual sexual relationships than women who endorsed feminine gender traits. Moreover, some Black women who endorsed masculine gender traits tended to be highly educated and employed in high status positions.

Our interview and focus group data suggest that some women’s preventive behaviors were often contingent upon their ability to find partners of equal socioeconomic status and to negotiate monogamy and commitment with their male partners. Thus, scholars should examine how heterosexual men’s sexual behavior and privilege play a role in making women vulnerable to HIV transmission, regardless of women’s SES (Dworkin, 2005). The insights gained from our study reinforce previous scholars’ suggestions to incorporate an analysis of men’s role in women’s HIV preventive behaviors (Higgins, Hoffman, & Dworkin, 2010). Our research participants repeatedly discussed condom negotiations and relationship status in relation to their and their peers’ ability to find monogamous, heterosexual Black male partners. Additionally, our findings challenge the idea that HIV sexual risk should be solely defined by demographic characteristics, such as low-income and poverty. Instead, we argue that scholars should focus more on the interpersonal and structural factors that shape power differentials in heterosexual Black men and women’s sexual behaviors and affect Black women’s ability and willingness to engage in HIV preventive behaviors.

While some research participants highlighted women’s reluctance to use condoms in their main relationships, others noted that condom use was important regardless of the relationship type. The latter perspective is important for both researchers and practitioners to incorporate in their HIV prevention work with middle SES Black women, as well as other groups of women. Encouraging women to use condoms regardless of relationship type can be used to decrease their HIV risk exposure and encourage self-protection. However, it is also important to encourage women and their sexual partners to discuss how beliefs about trust and mutual monogamy influence condom use and, ideally, to do so in ways that encourage critical examination of gendered power dynamics.

While most research on condom use among Black women has focused on women of low SES, some studies have shown that Black women with higher education levels use condoms at higher rates (Reece et al., 2010; Upchurch, Kusunoki, Simon, & Doty, 2003). Previous research findings suggest that class status may play a role in Black women’s ability and motivation to use condoms. As noted by one of our research participants, a desire to pursue a career and other life goals may influence middle SES Black women’s decisions to use condoms to prevent pregnancy and reduce their HIV risk. Several focus group and interview participants also discussed the tendency for their peers and themselves to use condoms as a form of contraception, rather than as a form of STI or HIV prevention. This finding suggests that, although women may have knowledge of HIV risk, some women’s primary concern may be pregnancy prevention. Additional consideration should be given to the disconnect that may exist between middle SES Black women’s knowledge of HIV risk and their engagement in protective behaviors (Perkins, Stennis, Spriggs, Kwegyir-Afful, & Prather, 2014).

STRENGTHS

This study contributes to researchers’ and public health professionals’ understanding of how factors such as availability of desirable male partners, perceptions of a sex ratio imbalance, and relationship dynamics influence middle SES Black women’s views of HIV risk and condom use. Examining the experiences of women from two age cohorts (25– 34 and 35– 45) was a useful means of analyzing potential similarities and differences in the experiences of middle SES Black women at different stages of their lives. Women in both age groups identified a shortage of desirable male partners as a factor that shaped their dating and sexual relationships, as well as one constrained that their options for finding monogamous male partners. Moreover, some women in the 35 to 45 year age group perceived their age to be a factor that negatively influenced their dating experiences.

Older focus group participants explained how Black male partners who matched their SES were often married and were not interested in monogamous, committed relationships. The low number of men who matched their desired criteria made it difficult for older middle SES Black women in the study to be in mutually monogamous relationships. Examining the experiences of middle SES Black women of different ages underscores how stage of life might shape a woman’s expectations for a relationship and potential preference for a more serious and committed relationship, as opposed to a casual relationship, and vice versa. Understanding the ways in which women’s relationship expectations and preferences align, or fail to align, with their actual relationships can offer important insights into how they negotiate protective behaviors, such as condom use.

LIMITATIONS

There are some limitations to this study. Our study examines data from a small sample, which limits the generalizability of our findings. The Sister Circle Study was a pilot study that aimed to understand factors that influenced middle SES Black women’s HIV risk perception and condom use. Given the small sample size, it is important that the findings not be generalized or viewed as representing the experiences of all middle SES Black women.

While the demographic questionnaire given to focus group participants asked about the number of children women had, this study did not explore how the number of children, a woman’s partnership status (i.e. living with main partner), or debt to income ratio might influence a woman’s financial status or level of financial security. Examination of these factors might be useful in understanding how factors such as having a dual income household, levels of indebtedness, and costs associated with raising children might influence the economic standing and financial security of middle SES Black women.

The sensitive nature of some of the interview questions and social desirability bias might have influenced how interview and focus group participants responded to the questions on sexual behavior and condom use. This might have caused interview and focus group participants to overestimate their condom use or to avoid discussing sexual experiences when condoms were not used. Other limitations of this study are related to the difficulties associated with defining middle-class status in the United States. While this study used a combination of factors (i.e. income and educational level) to determine middle SES, defining middle-class status continues to be a challenge for many researchers. This is particularly true when defining middle SES for minority groups, since their income levels may fall below those of their white counterparts, often despite the fact that they have professional jobs and advanced degrees. In addition, gendered income gaps between men and women may also play a role in middle-class women’s earnings being lower than those of males in similar occupations. Finally, since racial and gender dynamics shape Black women’s income and earnings, both should ideally be taken into account when determining which Black women fall within the middle SES category.

While further research is needed on the HIV prevention practices of middle SES Black women, this study highlights the importance of examining HIV risk perceptions and protective behaviors among Black women of age and different class backgrounds in order to reach a population that is disproportionately affected by the HIV epidemic. By exploring the nuances of age and socioeconomic status among Black women, we believe HIV researchers will be better equipped to understand and address HIV risk in a broader cross section of the Black female population.

Biographies

Dr. Kia Caldwell is an Associate Professor in the Department of African, African American, and Diaspora Studies at UNC Chapel Hill. Her research interests include health policy, HIV/AIDS, gender and race in the United States and Brazil.

Dr. Allison Mathews is a postdoctoral fellow at the Institute for Global Health and Infectious Disease at UNC Chapel Hill. Her research interests include the sociology of race and ethnicity, gender and sexuality, religion, HIV/AIDS, and social psychology.