Abstract
HIV risk perception and discrimination are important determinants of HIV prevention among vulnerable populations. Using Detroit’s 2016 National HIV Behavioral Surveillance (NHBS) Survey, we evaluated demographic variables, risk behaviors, and perception of HIV stigma and discrimination stratified by perceived HIV risk (high, medium, low) in a sample of high-risk women. Significant variables were identified using Pearson Chi squared tests and one-way analysis of variance tests. Among 541 females surveyed, 93.0% were black and 87.7% lived in poverty. Women’s poverty (p=0.010), employment (p=0.012), insurance (p=0.024) and homelessness status (p<0.001) were all significantly associated with their level of HIV risk perception. Among women with low HIV risk perception (76.7%), the majority did not know their partner’s HIV status at last intercourse (68.7%, p=0.007), had unprotected anal/vaginal sex in the past year (86.7%, p=0.025), participated in sex exchange (63.4%, p<0.001), and did not use condoms with a partner with HIV-unknown status (87.2%, p<0.001). Half of women agreed or strongly agreed most people would not be friends with someone with HIV (50.4%), and 46.3% agreed or strongly agreed most people would support PLWH to live or work where they want. Compared to women with low HIV risk perception, women with high perceived HIV risk were more likely to agree or strongly agree most people would discriminate against someone with HIV (87.3% vs 76.8%) and that people who got HIV via sex exchange or drugs got what they deserve (46.6% vs. 25.8%). Women’s perceived HIV risk was not significantly associated with these discriminatory attitudes. Despite multiple risk behaviors significantly associated with level of perceived HIV risk in the sample, the NHBS survey demonstrates many women with high risk behaviors still perceive themselves to be at low risk. Our findings highlight a complex interaction of risk perception, risk behaviors and stigma surrounding HIV in high-risk women.
Keywords: High-risk women, risk behaviors, HIV, discrimination
Introduction
In 2016, heterosexual transmission accounted for 84% of new HIV infections among U.S. women (Centers for Disease Control and Prevention [CDC], 2016). Furthermore, 61% of all new infections were seen in black women, with an incidence rate 25 times higher among black than white women (CDC, 2017).
Women’s HIV risk hinges on an understanding of structural, social, attitudinal and behavioral risk factors. Perceived risk and vulnerability are necessary precursors to adopting health promotive and protective behaviors. (Rosenstock, 1974; Rogers, 1975) as individuals who feel personally threatened by a condition are motivated to take action to avoid illness. Low HIV risk perception serves as a barrier to motivating at-risk women to adopt risk-reducing behaviors (Ford, Daniel and Miller, 2006; Buzi, Weinman, and Smith, 2015).
HIV stigma and discrimination are established HIV risk factors. While existing literature has explored the role of HIV stigma on the health of people living with HIV (PLWH) and on perceived HIV risk among men-who-have-sex-with-men (Courtenay-Quirk, Wolitski and Parsons, 2006), less is known about HIV discrimination, its association with risk behaviors, and levels of perceived HIV risk among high-risk heterosexual U.S. women. Identifying factors associated with women’s HIV risk perception is key for behavior change and prevention (Catania, Kegeles and Coates, 1990).
Utilizing responses from the National HIV Behavioral Surveillance survey of heterosexuals (NHBS-HET) in Detroit, Michigan, this study examines associations between perceived HIV risk and risk behaviors in a sample of high-risk adult women. Consistent with current literature, we hypothesized there would be incongruence between HIV risk perception and HIV risk behaviors among high-risk women, and that stigmatizing attitudes towards PLWH would influence women’s perceived HIV risk.
Materials and methods
Data were collected from Detroit’s Round 4 survey of the NHBS-HET, sponsored by the CDC and conducted using respondent-driven sampling from January to December 2016. Participants were recruited from “high-risk areas” in which 20% or more of the residents live in poverty and have a high per-capita density of heterosexually acquired HIV transmission. Eligible participants were female, were ages 18–49 years, and reported at least one act of sex with a male partner in the last year.
The primary outcomes of interest were high-risk sexual behaviors according to perceived HIV risk, our independent variable. Perception of HIV stigma among women’s community networks according to HIV risk perception was a secondary outcome of interest. Descriptive statistics were determined for all dependent variables – demographics, risk behaviors, and discriminatory attitudes – stratified by perceived HIV risk (high, medium, or low). Differences in perceived HIV risk among each categorical variable of interest were compared via Pearson Chi squared, and one-way analysis of variance tests compared continuous variables by HIV risk perception. Data analysis was performed using SPSS version 23.0 (SPSS Inc., Chicago, IL). An alpha level of 0.05 determined significance for all analyses. Use of anonymous de-identified secondary data from NHBS did not require Institutional Review Board review.
Results
Among 541 female participants, 93.0% were black (n=479) and 8.3% were Caucasian (n=43). In our sample, 72.1% (=378) reported a high school education or less, and most participants lived in poverty (87.7%, n=455), were unemployed (74.6%, n=388), and had health insurance (89.6%, n=466). As demonstrated in Table 1, a greater proportion of women were homeless in the last year among women with self-perceived high vs. low HIV risk (68.1% vs 35.8%, p<0.001). In addition to homelessness, women’s poverty (p=0.010), employment (p=0.012) and insurance status (0.024) were significantly associated with their level of HIV risk perception.
Table 1.
Demographic Variables by Level of Perceived HIV Risk
| Level of Perceived HIV Risk | Age(years)(n=520) | Black/African-American Race(n, %)(n=515) | Level of Education(n, %)(n=520) | Number of dependents (median, SD)(n=520) | Homeless in last 12 months(n, %)(n=520) | Poverty Status(n, %)(n=519) | Employment Status(n, %)(n=520) | Currently Insured(n, %)(n=519) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| (n=520) | (n=515) | (n=520) | (n=520) | (n=520) | (n=519) | (n=520) | (n=519) | |||||||
| High | Mean | No | 7(15.2) | Grades 1–8 | 4 (8.5 | 2.5 (2.1) | No | 15 (31.9) | No | 7 (14.9) | Unemployed | 42 (89.4) | No | 9 (19.1) |
| (n=47) | 42.2 | Yes | 39 (84.8) | Graces 9–11 | 14 (29.8) | Yes | 32 (68.1) | Yes | 40 (85.1) | Employed | 5 (10.6) | Yes | 38 (80.9) | |
| Median | High school/GED | 18 (38.3) | ||||||||||||
| 46 | Some college | 11 (23.4) | ||||||||||||
| SD 10.6 | Bachelor’s degree | 0 (0.0) | ||||||||||||
| Any post-graduate | 0 (0.0) | |||||||||||||
| Medium | Mean | No | 6 (8.1) | Grades 1–8 | 6 (8.1) | 1 (1.5) | No | 34 (45.9) | No | 2 (2.7) | Unemployed | 60 (81.1) | No | 11 (14.9) |
| (n=74) | 39.5 | Yes | 68 (91.9 | Graces 9–11 | 26 (35.1 | Yes | 40 (54.1) | Yes | 71 (97.3) | Employed | 14 (18.9) | Yes | 63 (85.1) | |
| Median | High school/GED | 26 (35.1) | ||||||||||||
| 38.5 | Some college | 14 (18.9) | ||||||||||||
| SD 12.2 | Bachelor’s degree | 2 (2.7) | ||||||||||||
| Any post-graduate | 0 (0.0) | |||||||||||||
| Low | Mean | No | 23 (5.8) | Grades 1–8 | 9 (2.3) | 2.0 (1.4) | No | 256 (64.2) | No | 55 (13.8) | Unemployed | 286 (71.7) | No | 33 (8.3) |
| (n=399) | 41.1 | Yes | 372 (94.2) | Graces 9–11 | 108 (27.1) | Yes | 143 (35.8) | Yes | 344 (86.2) | Employed | 113 (28.3) | Yes | 365 (91.7) | |
| Median | High school/GED | 163 (40.9) | ||||||||||||
| 43 | Some college | 103 (25.8) | ||||||||||||
| SD 12.4 | Bachelor’s degree | 15 (3.8) | ||||||||||||
| Any post-graduate | 1 (0.3) | |||||||||||||
| p-value | 0.422 | 0.056 | 0.146 | 0.754 | <0.001 | 0.010 | 0.012 | 0.024 | ||||||
SD=standard deviation
Multiple risk behaviors were significantly associated with women’s HIV risk perception, highlighted in Table 2. Compared to women with low-risk perception, women with high-risk perception had unprotected intercourse with greater frequency (mean 20.4 vs. 3.9 times, p=0.030), a higher number of male sex partners in the last year (mean 171.8 vs. 11.9, p<0.001), and a greater number of casual male sex partners (mean 174 vs. 13.6, p<0.001). Fewer women knew their partner’s HIV status at last intercourse among women with high vs. low HIV risk perception (10.6 vs. 31.3%, p=0.007). Even among women with low HIV risk perception, the majority did not know their partner’s HIV status at last intercourse (68.7%, p=0.007), had unprotected anal or vaginal sex in the past year (86.7%, p=0.025), participated in sex exchange (63.4%, p<0.001), and did not use condoms with a partner with HIV-unknown status (87.2%, p<0.001).
Table 2.
Risk Behaviors by Level of Perceived HIV Risk
| Level of Perceived HIV Risk | Ever tested for HIV (n, %) | Tested for STIs in past 12 months(n, %) | Unprotected anal/vaginal sex in past 12 months(n, %) | Ever exchange sex for goods (n, %) | Main male partner gave money/drugs for sex in past 12 months (n, %) | Number of casual male partners gave money/drugs for sex in past 12 months | Ever injected drugs(n, %) | Non-injection drug use (n, %) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| (n=517) | (n=519) | (n=520) | (n=520) | (n=65) | (n=416) | (n=520) | (n=520) | ||||||||
| High (n=47) | No | 8 (17.8) | No | 26 (55.3) | No | 0 (0.0) | No | 3 (6.4) | No | 0 (0.0) | Mean 179.1 | No | 37 (78.7) | No | 7 (14.9) |
| Yes | 37 (82.2) | Yes | 21 (44.7) | Yes | 47 (100.0) | Yes | 44 (93.6) | Yes | 3 (100.0) | Median 15 | Yes | 10 (21.3) | Yes | 40 (85.1 | |
| SD 770.9 | |||||||||||||||
| Medium (n=74) | No | 14 (18.9)) | No | 32 (43.2) | No | 11 (14.9) | No | 10 (13.5) | No | 4 (57.1) | Mean 16.6 | No | 66 (89.2) | No | 20 (27.0) |
| Yes | 60 (81.1) | Yes | 42 (56.8) | Yes | 63 (85.1) | Yes | 64 (86.5) | Yes | 3 (42.9) | Median 5.0 | Yes | 8 (10.8) | Yes | 54 (73.0) | |
| SD 27.2 | |||||||||||||||
| Low (n=399) | No | 70 (17.6) | No | 255 (64.1) | No | 53 (13.3) | No | 146 (36.6) | No | 30 (54.5) | Mean 14.5 | No | 357 (89.5) | No | 156 (39.1) |
| Yes | 328 (82.4) | Yes | 143 (45.9) | Yes | 346 (86.7) | Yes | 253 (63.4) | Yes | 25 (45.5) | Median 3.0 | Yes | 42 (10.5) | Yes | 243 (60.9) | |
| SD 40.1 | |||||||||||||||
| p-value | 0.015 | 0.003 | 0.025 | <0.001 | 0.177 | 0.001 | 0.090 | 0.001 | |||||||
| Level of Perceived HIV Risk | Number of times unprotected intercourse w/ partner in last 12 months | Number of male sex partners in past 12 months | Number of main male sex partners in past 12 months | Number of casual male sex partners in past 12 months | Knew partner’s HIV status at last intercourse (n, %) | No condom use with HIV- partner(n, %) | No condom use with HIV+ partner(n, %) | No condom use with HIV-unknown partner(n, %) | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| (n=100) | (n=520) | (n=442) | (n=416) | (n=520) | (n=419) | (n=422) | (n=453) | |||||
| High (n=47) | Mean 20.4 | Mean 171.8 | Mean 5.4 | Mean 174.0 | No | 42 (89.4) | No | 19 (50.0) | No | 36 (97.3) | No | 6 (12.8) |
| Median 2.0 | Median 20.0 | Median 1.0 | Median 18.0 | Yes | 5 (10.6) | Yes | 19 (50.0) | Yes | 1 (2.7) | Yes | 41 (87.2) | |
| SD 52.4 | SD 737.5 | SD 29.4 | SD 753.7 | |||||||||
| Medium (n=74) | Mean 2.2 | Mean 16.2 | Mean 0.9 | Mean 16.2 | No | 57 (77.0) | No | 25 (45.5) | No | 52 (94.5) | No | 11 (17.5) |
| Median 2.0 | Median 6.0 | Median 1.0 | Median 6.0 | Yes | 17 (23.0) | Yes | 30 (54.5) | Yes | 3 (5.5) | Yes | 52 (82.5) | |
| SD 1.1 | SD 25.5 | SD 0.9 | SSD 0.9 | |||||||||
| Low (n=399) | Mean 3.9 | Mean 11.9 | Mean 1.8 | Mean 13.6 | No | 274 (68.7) | No | 153 (46.9) | No | 324 (98.2) | No | 143 (41.7) |
| Median 2.0 | Median 4.0 | Median 1.0 | Median 4.0 | Yes | 125 (31.3) | Yes | 173 (53.1) | Yes | 6 (1.8) | Yes | 200 (58.3) | |
| SD 10.6 | SD 33.0 | SD 5.6 | SD 37.1 | |||||||||
| p-value | 0.030 | <0.001 | 0.064 | <0.001 | 0.007 | 0.909 | 0.257 | <0.001 | ||||
SD=standard deviation
Table 3 highlights stigmatizing attitudes toward PLWH stratified by perceived HIV risk. Half of women agreed or strongly agreed most people would not be friends with someone with HIV (50.4%), and 46.3% agreed or strongly agreed most people would support PLWH to live or work where they want. Compared to women with low HIV risk perception, women with high perceived HIV risk were more likely to agree or strongly agree most people would discriminate against someone with HIV (87.3% vs 76.8%) and that people who got HIV via sex exchange or drugs got what they deserve (46.6% vs. 25.8%). Despite these differences, none of the discriminatory attitudes toward PLWH evaluated were significantly associated with women’s perceived HIV risk.
Table 3.
Discriminatory Attitudes toward HIV Status by Level of Perceived HIV Risk
| Level of Perceived HIV Risk | Most people would discriminate against someone with HIV. Do you…? | Most people would support the rights of a person with HIV to live/work where they wanted to. Do you…? | Most people would not be friends with someone with HIV. Do you…? | Most people think people who got HIV via sex/drugs got what they deserve. Do you…? | ||||
|---|---|---|---|---|---|---|---|---|
| (n, %) | (n, %) | (n, %) | (n, %) | |||||
| (n=517) | (n=518) | (n=516) | (n=516) | |||||
| High (n=47) | Strongly Agree | 24 (51.1) | Strongly Agree | 4 (8.5) | Strongly Agree | 14 (30.4) | Strongly Agree | 10 (22.2) |
| Agree | 17 (36.2) | Agree | 14 (29.8) | Agree | 10 (21.7) | Agree | 11 (24.4) | |
| Neither agree/disagree | 4 (8.5) | Neither agree/disagree | 4 (8.5) | Neither agree/disagree | 3 (6.5) | Neither agree/disagree | 4 (8.9) | |
| Disagree | 2 (4.3) | Disagree | 19 (40.4) | Disagree | 16 (34.8) | Disagree | 15 (33.3) | |
| Strongly disagree | 0 (0.0) | Strongly disagree | 6 (12.8) | Strongly disagree | 3 (6.5) | Strongly disagree | 5 (11.1) | |
| Medium (n=74) | Strongly Agree | 37 (50.0) | Strongly Agree | 8 (10.8) | Strongly Agree | 14 (18.9) | Strongly Agree | 6 (8.2) |
| Agree | 24 (32.4) | Agree | 22 (29.7) | Agree | 22 (29.7) | Agree | 16 (21.9) | |
| Neither agree/disagree | 4 (5.4) | Neither agree/disagree | 10 (13.5) | Neither agree/disagree | 10 (13.5) | Neither agree/disagree | 11 (15.1) | |
| Disagree | 7 (9.5) | Disagree | 31 (41.9) | Disagree | 21 (28.4) | Disagree | 25 (34.2) | |
| Strongly disagree | 2 (2.7) | Strongly disagree | 3 (4.1) | Strongly disagree | 7 (9.5) | Strongly disagree | 15 (20.5) | |
| Low (n=399) | Strongly Agree | 169 (42.7) | Strongly Agree | 40 (10.1) | Strongly Agree | 67 (16.9) | Strongly Agree | 36 (9.0) |
| Agree | 135 (34.1) | Agree | 153 (38.5) | Agree | 133 (33.6) | Agree | 67 (16.8) | |
| Neither agree/disagree | 31 (7.8) | Neither agree/disagree | 49 (12.3) | Neither agree/disagree | 40 (10.1) | Neither agree/disagree | 55 (13.8) | |
| Disagree | 45 (11.4) | Disagree | 123 (31.0) | Disagree | 134 (33.8) | Disagree | 181 (45.5) | |
| Strongly disagree | 16 (4.0) | Strongly disagree | 32 (8.1) | Strongly disagree | 22 (5.6) | Strongly disagree | 59 (14.8) | |
| p-value | 0.630 | 0.382 | 0.295 | 0.063 | ||||
Discussion
The 2016 NHBS-HET survey in Detroit identifies a high-risk sample of adult women exhibiting multiple high-risk sexual behaviors. Women with high-risk behaviors tended to be aware of their risk engagement and perceived themselves to be at high HIV risk. Comparatively, many women with low HIV risk perception still engaged in high-risk behaviors. Previous studies of heterosexual women have similarly found that women who engaged in high-risk behaviors were largely unaware of their risk and reported low perceived HIV risk (Buzi, Weinman and Smith, 2015; Pringle, Merchant and Clark, 2013). Moreover, although HIV stigma and discrimination were previously identified as a catalyst to HIV risk behaviors among vulnerable populations (Caldwell, Orubuloye and Caldwell, 1999), these factors did not significantly influence HIV risk perception among women in this sample.
The finding that women with high perceived HIV risk engaged in high-risk behaviors counters prior evidence that suggests that individuals who perceive themselves to be at increased risk of negative sexual health consequences are more likely to engage in risk reduction behaviors (Maharaj and Cleland, 2005; Meekers and Klein, 2002). Despite awareness of their high HIV risk, women reported continued engagement in risky behaviors, compared to those who perceived themselves to be at low risk. The extent to which HIV risk perception modifies engagement in HIV risk behaviors continues to be unclear and inconsistent (Prata, Morris, Mazive et al., 2006). HIV risk perception may not ultimately lead to reductions in high-risk behaviors, as socioeconomic, sociocultural and structural constraints represent an external locus of control that high-risk populations face, but cannot necessarily overcome (Pharr, Enejoh, Mavegam et al., 2015).
Although women perceived a high level of discrimination exists toward PLWH in general, stigma towards PLWH did not consistently influence women’s HIV risk perception. Our results suggest a complex, nuanced interaction between HIV risk perception, attitudes, and HIV risk behaviors in this population. A greater percentage of women with high HIV risk perception endorsed agreement with two important stigmatizing attitudes – that most people would discriminate against someone with HIV, and that people who acquired HIV through sex exchange or drugs got what they deserve – compared to women with low perceived HIV risk. Moreover, 87.2% of women with high HIV risk perception did not use condoms with an HIV-unknown partner, and yet roughly half of these women with high perceived HIV risk believed HIV acquisition was somehow deserved (46.6%). Our findings highlight an important intersection between two important factors, one behavioral and one attitudinal, that show a clear incongruence with risk perception and arguably interact with one another to place women at increased HIV risk in this population. As experienced stigma is more common among women with greater risk behaviors (Hargreaves, et al., 2018), a woman’s perception of negative experiences associated with HIV risk may influence her to disassociate herself from HIV risk and engage in high-risk behaviors. This incongruence in risk behavior, HIV risk perception, and discriminatory attitudes requires greater examination of risk pathways among heterosexual women.
These data are subject to several limitations. The cross-sectional design does not capture changes in risk behaviors and attitudes over time. The sample was recruited among urban, mostly black women in Detroit, limiting the generalizability to other populations. Furthermore, data collection methods utilized by NHBS may have inherent sampling bias and NHBS does not use standardized measures of perceived HIV risk. HIV risk perception may be an insensitive predictor of HIV risk behaviors. Despite these limitations, our findings have implications for theory-based HIV research and interventions for high-risk women.
Conclusion
There exists a need to further elucidate how the psychological construct of risk perception interacts with other known factors, including stigma, and predicts HIV risk behaviors among women. Despite theoretical rationale, heightening women’s awareness and perception of their HIV risk may not necessarily result in HIV risk-reduction behaviors among high-risk women. More complex models are necessary to highlight multifactorial societal and structural influences that may mediate risk perception, risk behaviors, and the role of discrimination towards PLWH among high-risk HIV-negative heterosexual women.
Acknowledgments
Funding: Whitney Sewell has funding support from the Chancellor’s Graduate Fellowship Program at the Washington University in St. Louis, the National Institute on Drug Abuse TranSTAR, and from the Jane B. Aaron National Association of Social Work. Stephanie Blankenship has no funding sources to disclose. The above funding sources had no role in the study design, collection/analysis/interpretation of data, or manuscript preparation.
Footnotes
Disclosures
Disclosure Statement: The authors have no financial interest or non-financial benefits to disclose that have arisen from the direct applications of this research.
Data Availability Statement: The data set associated with this paper are available from the CDC’s National HIV Behavior Surveillance Study 2014–2016 in Detroit, Michigan.
Research Involving Human Participants and/or Animals: For this type of study formal consent is not required. This article does not contain any studies with human participants or animals performed by any of the authors.
Informed Conset: In the original National HIV Behavior Surveillance Study, informed consent was obtained from all individual participants included in the secondary data analysis for the current study.
Compliance with Ethical Standards: Approval from the Institutional Review Board was not required given the use of de-identified secondary data from NHBS.
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