The rate of
in the United States from 1999 to 2003 for African American women was approximately 25 times the rate for white women and four times the rate for Hispanic women.1–3
Most cases were attributed to heterosexual transmission (80%) or to injecting drug use (19%).2
Recent, direct estimates of HIV infections through extended back-calculation indicate that the frequency of annual HIV infection among women continues to rise despite stable rates among men.1
There remains a critical need to identify and diffuse effective prevention interventions for women. Woman-focused interventions to reduce HIV/sexually transmitted infection (HIV/STI) risk behavior have demonstrated effectiveness for women where drug use was not a criterion for study entry, including adolescent women from ethnic minority communities and women living in low-income housing developments.4–9
These interventions integrate the concept of personal empowerment for women as a key ingredient in behavior change.
Of particular interest to the study described in this article is an ongoing empowerment program targeting inner-city women based on collective empowerment principles and prioritizing women's learning and making healthy choices about the body.10
This program aims to increase the level of resources for women as well as build on their current resource strengths, “particularly their shared strengths as members of dyads, families and social groups.”10(p168)
although not numerous, woman-focused HIV/STI prevention interventions have increasingly demonstrated their relevance for drug users. Wechsberg et al.11
conducted a randomized trial comparing a woman-focused, mixed individual and group intervention with the National Institute on Drug Abuse (NIDA) standard intervention, which is a Centers for Disease Control and Prevention (CDC)-developed approach comprising standard HIV counseling and testing (HIV-CT), including a woman-focused supplementary discussion for drug users and their sex partners.11
The authors reported a statistically significant difference in the frequency of unprotected sex at 6 months (p
0.03), favoring the woman-focused intervention. The woman-focused intervention was grounded in empowerment theory and African American feminism and contained psychoeducational information and skills training. A short feasibility study of the culturally adapted woman-focused intervention in South Africa among 93 recent substance users demonstrated changes toward reduced risk over the monthlong follow-up for both standard and woman-focused arms, with a tendency to favor the woman-focused arm for sexual risk reduction outcomes (including any use of male or female condom).12
Other studies targeting drug-involved women were either not able to demonstrate statistically significant differences between the woman-focused interventions tested (e.g., as against a standard intervention) or were compromised by high losses in retention.13–16
To the extent that standard or control arms in these trials are enriched in gender-specific content (e.g., female condom), the underlying value of either assigned intervention arm will be difficult to demonstrate using conventional analytical methods.
The Women Fighting Infection Together (Women FIT) study was motivated by the need for novel intervention strategies for female out-of-treatment drug users that nonetheless built on successful themes used in prior interventions among at-risk women. The body empowerment intervention approach tested in this pilot study represents a distinct and complementary approach to empowerment for women. In addition to a framework that examined gender-based power imbalances in heterosexual relationships, a key focus in our study was increasing knowledge about, confidence in, and a sense of ownership of the body, especially the reproductive organs. These desired effects were thought to be mediated through promotion of woman-controlled barrier methods, such as the female condom (in addition to the male condom), and the use of peer counseling and participatory sessions to augment the empowerment process. Group sessions led by near-peers aimed to encourage participation and exchange among the women and to build solidarity among women as a means to confront the collective experience of economic stress and poor health emanating from their low status in a patriarchal society, effects greatly exaggerated in the drug-using culture. Finally, a philosophical framework of risk reduction rather than risk elimination in STI/HIV prevention was considered to be most appropriate for this woman-focused approach, underscoring successes (e.g., achieving greater levels of protection against disease as shown by increasing proportions of protected sex acts and improving negotiation powers) rather than failures (e.g., inability to achieve 100% protected acts).
The body empowerment approach draws heavily from feminist health principles espoused widely in the 1970s in such works as Our Bodies, Ourselves.17
The approach we tested here has evolved through a series of trials on high-risk women in Harlem, NY,18
among STI clinic attendees in Philadelphia,9
and among community-based organization members, including African immigrant women in southern France, which proved to be successful and popular.19
The feminist health model as applied to HIV underscores the need for holistic education about reproductive organs and genitals rather than a narrow focus on HIV. By demystifying the body, women collectively achieve a stronger sense of physical self and experience awe and pride in the functions of the normal female body. The feminist health approach has not, to our knowledge, been tested for efficacy at increasing knowledge or changing behavior, and the population we intervened with could be expected to have little a priori
exposure to this approach to education and empowerment of women.
The body empowerment approach also draws from Freirian principles for effective community education, underscoring the need for critical consciousness as a precondition for positive behavior change by marginalized social groups (drug-involved women here representing the marginalized).20
We incorporated numerous elements of Community Empowerment Theory, a model positing that lack of control over destiny reinforced by objective structural constraints promotes susceptibility to ill health for people living in chronically marginalized situations.21–23
To reverse this cycle, the model thus demands positive inputs, especially skills building. In body empowerment theory, this input is increased access to information, techniques, and technologies to increase a sense of control over the body and keeping it healthy. This, in turn, should increase psychological empowerment.23
The body empowerment model posits that body information specifically (along with increased sense of ease, ownership, and sense of responsibility to protect the body/self
) contributes to a sense of collective identity for women and is moderated by the process of solidarity found in a woman-only group setting. These dynamic effects are theorized to provide an independent pathway to self-esteem, which in turn raises a woman's intention to protect herself from HIV and to self-protective behavior.
This pilot study was undertaken to assess acceptability and feasibility of this multisession, woman-focused intervention model among women at high HIV risk with a recent drug use history. Our intervention made considerable demands on attention spans for this population (sessions of 2.5 hours with one break), and its success was theorized to operate partly through group cohesion. Some of our key questions were: Will women be enthusiastic about participating in the study? Will they find the intervention material relevant to their lives? Will women attend group sessions and actively participate? Will women be able to move beyond the drug culture's deeply negative images of women—breeding mistrust and intense interfemale competition for male partnership and resources—to be able to connect with other women in a relatively short time frame in order to provide mutual support for prevention behaviors?