The history of women with HIV/AIDS in the United States is really a story of racial and ethnic health disparities.
Overall, the rate of American women contracting the disease relative to men has climbed from 8 percent in the 1980s to 25 percent today. But most of this burden is in underserved communities: one in 32 African-American women will be diagnosed with HIV in their lifetime, as will one in 106 Latina women. Meanwhile, one in 526 Caucasian and Asian women will contract the virus. Death rates are also higher for African-American and Latina women, making it one of the leading causes of death for those groups.
Researchers at Yale's Center for Interdisciplinary Research on AIDS (CIRA) are examining the many and complex reasons for these disparities with a variety of studies that consider how behavioral and cultural factors may be putting minority women at disproportionate risk.
"The spread of HIV, in theory, could be prevented," says Sarah K. Calabrese, Ph.D., a postdoctoral fellow at CIRA, who is studying how social, psychological and behavioral factors affect HIV acquisition.
Driven to understand barriers to condom use, Calabrese's research focuses on African-American women and how social and cultural norms influence a woman's sexual self-concept and confidence in asserting herself in sexual situations, such as discussing condom use with a partner.
Calabrese has found that a woman's acceptance of the idea that sex should be used as a commodity, for example, is associated with a negative sexual self-concept and indirectly associated with confidence in sexual situations, the latter of which has been consistently linked to sexual risk-taking among African-American women.
"The findings speak to the need to make changes in the culture," says Calabrese. Sexual stereotypes can be addressed on the individual level, but continued efforts are needed at the societal level. This means reducing negative portrayals of African-Americans in the media and promoting strong, successful role models. Replacing oversexualized, stereotypical portrayals of African-Americans with more positive images and messages about their sexuality could have implications for African-Americans' sexual experience.
Some sexual stereotypes of African-American women are rooted in slavery, says Calabrese, such as the "hypersexual" woman or the woman who is perpetually available sexually, an image that was constructed by slave owners to justify rape.
"I'm interested in how these and other racialized sexual stereotypes that persist in today's society are associated with African-American women's sexual health and well-being," she says.
Promoting condom use also is critical for African-American women who are living in communities with a high HIV prevalence. However, Calabrese says, this effort can be complicated by factors such as the scarcity of partners due to high rates of incarceration and premature deaths among African-American males in the United States, both of which can contribute to a woman's willingness to forgo condom use in order to maintain a sexual partnership.
Bundling HIV prevention
Other researchers are seeking to reduce women's HIV risk, as well as other sexually transmitted infections (STIs), while also improving pregnancy outcomes, for women in underserved groups ranging in age from 14 to 21.
Using a group care model known as Centering Pregnancy Plus, Jeannette R. Ickovics, Ph.D., professor and founding director of the Social and Behavioral Sciences Division and the principal investigator of a National Institute of Mental Health Interdisciplinary HIV Prevention Training Program at CIRA since 1999, and her colleagues are evaluating an intervention now being used in 14 hospitals and community health centers in New York City where STI rates are above the national average. Sexually risky behaviors and contracting an STI are known risk factors for HIV infection.
A pilot study in similar clinics in Atlanta and New Haven, where 80 percent of the participants were African-American, showed that young women who participated in the group intervention were less likely to become pregnant again within six months, increased their condom use when having sex and reduced the incidence of STIs at the end of their pregnancies.
Using data gathered from the project, Lisa Rosenthal, Ph.D., a CIRA postdoctoral fellow, has also established a link between experiences of discrimination and ensuing risky sexual behaviors and contracting an STI during pregnancy.
"This finding adds to an ever-growing body of literature demonstrating the far-reaching, deleterious effects of discrimination," Rosenthal says. "It suggests that we must find ways to reduce discrimination to reduce disparities and improve health, including the reduction of a woman's risk of contracting HIV and other STIs."
IPV and HIV
Another contributor to the high rates of HIV among some groups of women is intimate partner violence (IPV). One recent estimate found that more than one in three women have experienced rape, stalking and/or physical violence in their lifetime.
Not only is IPV a distinct risk factor for HIV: it also affects non-Caucasian women at higher rates than it affects Caucasians, although this difference started to decrease in the 1990s.
"The two epidemics, HIV and IPV, are linked," says Nicole Overstreet, Ph.D., a postdoctoral fellow at CIRA. Women who experience IPV may be at higher risk due to several factors, including substance use, post-traumatic stress and depression. Moreover, experiences of IPV have been connected to other HIV transmission risks, such as coerced sex, higher rates of STIs and sex with partners who engage in risky behavior, such as injection drug users.
For both of these epidemics, the contributing social factors need to be addressed. For instance, Overstreet found that experiencing stigma with regard to IPV, such as being told, "you deserved it" or "you provoked it," is linked to greater HIV risk behavior. More research is needed to find out whether addressing such stigma could reduce HIV risk, as well as mental health issues that have been linked to HIV risk.
Meanwhile, a newer approach to HIV prevention was approved last July by the FDA, known as pre-exposure prophylaxis, or PrEP, provides antiretroviral drugs to HIV-negative women who are at high risk for HIV. The goal is to reduce their susceptibility to infection. While the strategy is intended to complement condom use, the CIRA researchers believe it also has the potential to benefit women who are at risk because of difficulty negotiating condom use.
Looking toward the future of HIV prevention, Overstreet says that it is important to remember that experiences of IPV can interfere with access to medical care and stable housing—factors that affect adherence to antiretroviral therapy among people living with HIV/AIDS and could similarly be challenging for PrEP access and adherence for HIV-negative women experiencing IPV.
"The social and structural challenges of HIV prevention and interventions are multifaceted, and sometimes the pieces are difficult to put together," Overstreet says. "Many of these difficulties require addressing social and structural barriers, such as poverty and violence, that escalate the HIV epidemic."