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HIV/AIDS has emerged as a significant health threat for African American women with well-documented disparities. The purpose of this study was to assess the association between social network characteristics and high-risk sexual behaviors among a sample of urban African American women at risk of heterosexually acquired HIV/STIs. We performed a cross-sectional study of baseline data collected from the CHAT study, a randomized HIV-prevention trial targeting urban HIV-at-risk women in Baltimore, MD. Our primary outcomes were risky sexual behaviors defined as either (a) two or more sexual partners or (b) having a risky sex partner within the past 90 days. Bivariable and multivariable logistic regression examining the associations between individual and social network factors and our two outcomes of interest were conducted. The study population included 513 sexually active African American women with a mean age of 41.1 years. High levels of unemployment (89.5%), depressive symptoms (60.0%), and drug use (68.8%) were present among this high-risk urban cohort. Controlling for individual factors including participant drug use, age, and depression, having two or more sex partners within the past 90 days was associated with having a larger personal network (OR=1.11; 95% CI, 1.06 and 1.17); more network members who pitched in to help (OR=1.22; 95% CI, 1.04 and 1.44), provided financial support (OR=1.33; 95% CI, 1.11 and 1.60), or used heroin or cocaine (OR=1.26; 95% CI, 1.14 and 1.40). Having a risky sexual partner within the past 90 days was associated with having a larger social network (OR=1.06; 95% CI, 1.00 and 1.12) and having more social networks who used heroin or cocaine (OR=1.30; 95% CI, 1.14 and 1.49).In summary, social network characteristics are associated with HIV sexual risk behaviors among African American urban women. Social-network-based interventions that promote norms pertaining to HIV risk reduction and provide social support are needed for African American women at risk of heterosexually acquired HIV/STIs.
African Americans disproportionately bear the burden of sexually transmitted infections (STIs) in the USA.1 STIs take an especially heavy toll on black women and can threaten fertility, increase risk of HIV transmission, and ____ other health risks.2 Racial disparities in incidence of new HIV/AIDS diagnosis are greatest among African American women and exceed those of every other racial/ethnic group of women and men.3 The annual rate of HIV/AIDS diagnosis among non-Hispanic black females is 20 times higher than rates among non-Hispanic white females.4 Most HIV/AIDS infections in African American females (80.3%) are acquired heterosexually (HET).4 Women have an increased risk of HET HIV transmission when compared with men; African American women account for almost twice as many of these cases as African American men.5,6
Though the etiology of these disparities remain elusive, research on HIV among African American women has demonstrated several behaviors that increase the risk of HIV transmission, including unprotected intercourse, early age of sexual debut, history of STIs, and multiple sexual partners.7,8 However, individual-level factors alone do not account for these disparities. Several studies of HET HIV transmission among African American women have examined the roles of social contextual factors and sexual network patterns. Social determinants of health, including poverty and access to health care, play an important role in HIV/STI transmission and acquisition.9,10 The social and economic environment in which many African Americans live shapes sexual network patterns.11 Sexual network patterns, such as concurrent sexual partnerships (relationships that overlap in time), have been associated with HIV infection acquired through heterosexual activity and may help to explain the disproportionately high prevalence of HIV among African Americans.3,11 Few studies, however, have examined the association between social network patterns and HIV/STI risk behaviors among African American women.
Social networks are a powerful source of influence on a number of HIV/STI risk behaviors including drug use and sexual partnerships.12 Social network members may include sex or drug partners, friends or family, neighbors, or coworkers.12 Social networks are believed to mediate the behavior of network members through social influence, social engagement, and social support.13 Social norms, a function of social networks, have a strong influence on numerous health behaviors.14 There is a long-standing recognition of the role that social networks have in transmission of HIV and other infectious diseases.14 For example, social network characteristics have been found to be associated with HIV-related high-risk sexual behaviors among intravenous drug users (IDUs).15–17 Latkin et al. explored the association between index participants’ sexual behaviors and the drug use of members within their personal networks. They found that higher levels of alcohol and crack use among drug network members were associated with reports of multiple sex partners among the index participant, demonstrating that the behaviors of network members help to explain the behaviors of the index participant.15 Research conducted among non-intravenous drug users and their network members found that having multiple sexual partners was associated with social network factors including: having a large personal network, receiving drug or housing support, and having a large number of network members who use drugs.16 Finally, one study examining social network characteristics of men who have sex with men (MSM) found that social support and social conflict may be important factors associated with risk among MSM populations.12
While several studies have examined social network characteristics among populations at high risk of HIV infection including MSM and IDUs,12,13,18,19 little is known about the social networks of African American women at risk of heterosexually acquired HIV. The purpose of this study was to assess the association between individual level and social network characteristics and high-risk sexual behaviors among a sample of urban African American women at risk for heterosexually acquired HIV/STIs.
We performed a cross-sectional study of baseline data collected from the CHAT study, a randomized HIV-prevention trial targeting urban HIV-at-risk women and members of their social network in Baltimore, Maryland. The aim of the trial was to train HIV-at-risk women to be peer educators. The CHAT project had two types of participants: index and network participants. Index participants were recruited through targeted street outreach, posted flyers, and referrals from local health clinics and community agencies, and were randomly assigned to the peer educator training or control condition. Social network members, who were referred to the study by the indexes, did not receive the intervention directly; however, intervention diffusions were assessed via the network members. Eligibility requirements for index participants were (1) 18 years or older, (2) no injection drug use in the past 6 months, (3) self-reported heterosexual sex in the past 6 months, and (3) at least one sexual risk which included: more than two sex partners, STD diagnosis in past 6 months, or having a high-risk sex partner (injected, smoked crack, had an STD, or was HIV seropositive). Index participants referred their social network members to the study. Eligibility requirements of social network members included: (1) 18 years or older; and (2) at least one of the following: (a) injected drugs in the past 6 months, (b) index participant had sex with network member in the past 90 days and sees at least once a week, or (c) index participant felt comfortable talking to network member about HIV and STDs and interacts with network member at least a few times a month
After providing written consent, participants completed a baseline interview that lasted about 2.5 hours and focused on several domains such as demographics, drug use and history, sexual behaviors, physical and mental health, and social network characteristics. Participants were paid $35 for completing the baseline visit. All protocols were approved by the Johns Hopkins Bloomberg School of Public Health.
For this study, we included both index and network participants who were female, ≥18 years of age, and sexually active. This analysis focused exclusively on sexually active African American women. Eight hundred and nineteen participants completed the baseline visit. Of these participants, 640 (78.1%) were women. Among women, 53 (8.3%) were excluded because they were not sexually active in the past 90 days. The cohort was predominately African American (96%) and the 25 women of other races (21=white; 1=Hispanic; 3=Others) were excluded from further analysis. HIV testing (OraQuick rapid testing) was offered to all participants. Out of the remaining 562 women, 502 had an HIV test performed, with 43 women testing HIV positive (8.6% of those tested). These women were excluded from further analysis. The final cohort consisted of 513 sexually active African American women at risk of heterosexually acquired HIV/STIs
Our primary outcomes were risky sexual behaviors. We defined these as either having (1) multiple sex partners in the past 90 days or (2) a high-risk partner. Multiple sex partners were defined as having two or more sex partners in the past 90 days. Having a risky partner was operationalized as having a sex partner in the past 90 days who injected drugs, was HIV positive, smoked crack, or had an STD. HIV drug and sex behaviors were collected through Audio Computer Assisted Software (ACASI).
Individual-level factors assessed in this study included age, employment, income, education, history of incarceration, homelessness, depressive symptoms, and drug and alcohol use. These factors were collected via a face-to face interview, except drug behaviors which were collected through ACASI. Age was recorded as a continuous variable. Employment was categorized as employed at least part-time or unemployed; income was assessed as less than $500/month or $500/month or more. Education was dichotomized as a high school diploma or lower. Participants reported if they had been homeless or incarcerated in the past 6 months. We also assessed drug and alcohol use frequency. An interviewer asked the question “How often do you drink alcohol?” and responses included Never, monthly or less, two to four times a month, two to three times a week, four or more times a week, Don’t Know, Refuse to Answer, or Not Applicable. Drug use was categorized into two groups: heroin or cocaine use within the past 6 months, or no heroin/cocaine use within the past 6 months. Finally, depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale.20 Participants who scored 16 or higher were coded as having depressive symptoms.
Social network data were collected using a network inventory. The social network data were collected from both index and social network member participants. The network inventory has been shown to have concurrent and predictive validity.19 Participants were asked for the names (first name and last initial) of people who provided a variety of roles in their life. For example, participants were asked, “Who are the people who you talked to about things that were personal or private in the past 6 months?” as well as “Who has lent you money in the past 6 months?” After the participants listed these network members, they were asked information about each person such as how well they got along, age, relationship type, drug use, HIV status, etc. For instance, “What is the gender of each person you have listed?”
In the current study, we focused on seven network variables: (1) Total network size is the total number of network members participant named; (2) emotional support indicates network members whom participants talked to about things that were personal/private or got advice; (3) network members who provided financial support lent money to the participant; (4) have conflict with refers to people named in the network that participant reported they do not get along with; (5) pitched in includes network members who “pitched in to help do things that you needed some help with such as running errands, watching children, giving you a ride, etc”; (6) socialized with refers to individuals who participant “got together with to socialize or have fun with, doing things such as shopping, going to movies or clubs, or just hanging out”; and (7) used heroin or cocaine indicates network members who used these drugs in the past 6 months. Since individuals may fulfill more than one role, these categories are not mutually exclusive.
Our primary outcomes were dichotomous: two or more sexual partners (yes/no) and having a risky sex partner (yes/no) within the past 90 days. We first performed bivariate and multivariate logistic regression examining the associations between individual-level factors and our two outcomes of interest. We then examined the association between each social network variable individually with our outcomes, constructing seven separate models. We adjusted each model for the individual-level factors significant in our multivariable analysis. The final model also included education (dichotomized as a high school diploma or lower), given the established association of HIV infection with indicators of low socioeconomic status, including lower educational attainment.5 Incarceration within the past 6 months was also included in the final model given its documented association with high-risk sexual behaviors.21,22
Since the sample included both primary and network participants, General Estimating Equation was used to account for clustering of network members.23
The study population included 513 sexually active African American women with a mean age of 41 years. High levels of unemployment (89.5%), depressive symptoms (60.0%), and drug use (68.8%) were present among this high-risk urban cohort (Table 1). Approximately half (49.9%) of the cohort report having two or more sexual partners in the past 90 days and 322 women (62.8%) report having at least one risky sexual partner within the past 90 days. Baseline social network characteristics demonstrate the mean total social network size is equal to 8.81 network members.
The results of bivariate and multivariate analyses are presented in Table 2. Although older age was associated with being less likely to have two or more sex partners within the past 90 days (OR=0.96; 95% confidence interval [CI], 0.93 and 0.98; p<0.001), it was significantly associated with having a risky sex partner (OR=1.04; 95% CI, 1.02 and 1.07; p<0.001). A woman who reported being homeless within the past 6 months was twice as likely to have two or more recent sexual partners (OR=2.28; 95% CI, 1.48 and 3.52) and 76% more likely to have a risky sex partner (OR=1.76; 95% CI, 1.10 and 2.82). Depressive symptoms were significantly associated with both primary outcomes. Women who reported heroin or cocaine use within the past 6 months were 78% more likely to have two or more sexual partners within the past 90 days (OR=1.78; 95% CI, 1.14 and 2.77) and almost three times as likely to have a risky sexual partner (OR=2.78; 95% CI, 1.79 and 4.32).
The results of multivariable analysis are presented in Table 3. Controlling for individual factors including participant drug use, age, and depression, having two or more sex partners within the past 90 days was associated with having a larger personal network (OR=1.11; 95% CI, 1.06 and 1.17); more network members who pitched in to help (OR=1.22; 95% CI, 1.04 and 1.44), provided financial support (OR=1.33; 95% CI, 1.11 and 1.60), socialized with (OR=1.20; 95% CI, 1.05 and 1.37), or used heroin or cocaine (OR=1.26; 95% CI, 1.14 and 1.40). Having a risky sexual partner within the past 90 days was associated with having a larger social network (OR=1.06; 95% CI, 1.00 and 1.12) and having more social network members who used heroin or cocaine (OR=1.30; 95% CI, 1.14 and 1.49).
Among this cohort of urban African American women at risk of heterosexually acquired HIV, several individual and social network characteristics were associated with high-risk sexual behaviors. At the individual level, our findings, that homelessness and depression were associated with having multiple sexual partners or a risky sexual partner, support well-established evidence found in the literature. Research shows that housing or lack of housing and HIV are powerfully linked.24 Among individuals who engage in HIV risk behaviors, high rates of depression have been found.25,26 We found that while older age was associated with having fewer sexual partners, it increased the odds of having a risky sexual partner. At the individual level, the most important risk factor for STIs is sex with an infected partner.27 African American women are vulnerable to HIV/STIs often as a consequence of sex with male partners who engage in multiple high-risk sexual and drug using behaviors.28 The fact that older women in this cohort have riskier sex partners is even more concerning given research has shown that older women have less favorable attitudes toward condom use and lower perceived susceptibility for contracting HIV, even when engaging in high-risk sexual practices.29–31 African American women over 50 years of age represent the fastest growing group with HIV infection,32 and our findings suggest that older age may be associated with different risky sexual behaviors than younger age. Additional research should include older women and age-specific interventions should be developed to address differential risk factors between older and younger African American women.
In this study several social network characteristics were associated with high-risk sexual behaviors after controlling for demographic factors. Having more social network members to socialize with and a larger total network size increased odds of having ≥2 sexual partners within the past 90 days. We defined “socialized with” as having network members they “got together with to socialize or have fun with doing things such as shopping, going to movies or clubs, or just hanging out.” These activities, and having a larger total network, may provide more opportunity to meet new sexual partners and risky partners. Also, socializing may involve alcohol or drug use, both well-established risk factors for high-risk sexual practices, including multiple sexual partners.
We found that having a larger number of social network members who provided financial support or pitched in to help increased the odds of having ≥2 sexual partners within the past 90 days. Our cohort was impoverished, given over half have a monthly income of ≤$500 and 90% had been unemployed within the past 6 months. Social and economic dependence on a male partner has been suggested as a possible target for gender-specific HIV interventions.33 Exchange of sex is often part of a personal economic strategy for at-risk women,34 and our findings suggest that an informal exchange of sex for material support exists within the social networks of our cohort. In areas with high rates of poverty, women may seek out multiple partners to get financial support. The increased number of sexual partners may include “resource partners” or individuals who provide financial resources such as money for food and rent.
Having more social network members who used heroin or cocaine was associated both with a risky sexual partner and having ≥2 sexual partners within the past 90 days. This sample of African American women at high risk of HIV contained a high proportion of drug users; 68% with heroin or cocaine use within the past 6 months. However, even after controlling for individual drug use, having social network members who were active drug users increased the odds of HIV sexual risk behavior. The direct effects of crack cocaine on sexual networks have been well documented. Crack cocaine use increases the risk of exchange sex and number of sexual partners, and bridges a high-risk population to each other and the general population.5,10,35,36 Our results among African American women at risk of heterosexual transmission of HIV are consistent with research conducted among IDUs and non-IDUs. Pilowsky and colleagues found that having a large number of network members who use, provide, or receive drugs was associated with high-risk sexual behaviors among non-intravenous drug users.16 Latkin et al. found that crack use by social network members was associated with high-risk sexual behaviors such as exchange sex among current and former drug users.37 The interplay of drug use and high-risk sexual behavior among African American women remains a target for further investigation and intervention.
There are a number of limitations to this study that should be acknowledged. First, our sample only included sexually active African American women at high risk of HIV/STIs. Our urban sample had high rates of poverty, depression, and drug use. Accordingly, generalizations to other African American women, including rural or less impoverished populations, cannot be made. Second, data for this study was collected in face-to-face interviews or ACASI and based on self-report. This may introduce recall and social desirability bias. Third, index participants were recruited through targeted street outreach, flyers, and referrals. This may introduce selection bias. Lastly, our study was cross-sectional. Accordingly we can only state that the characteristics were associated with HIV risk behaviors and not predicative.
Despite these limitations, this study has important strengths. Our findings that social network characteristics are associated with HIV sexual risk behaviors among African American urban women are an important contribution to the literature and have several public health implications. First, our findings suggest that an informal exchange of sex for material support exists within the social networks of African American women. Although poverty is an important component of the “nexus of risk” that facilitates HIV-risk behaviors, it is typically not addressed in public health interventions.38 Microenterprise encompasses a broad range of activities, including providing financial literacy, basic life-skills training, and development of commercially viable products and services.34 Sherman et al. reported findings from a pilot economic enhancement HIV-prevention study among women drug users involved in the sex trade in Baltimore.39 This high-risk cohort was taught how to make and sell beaded jewelry. Findings demonstrated that money earned through jewelry sales was associated with significantly fewer sex-trade partners at follow-up. Microenterprise interventions may be an essential strategy for effective HIV prevention among impoverished women at risk. Further research is needed to understand how microenterprise may be successfully incorporated into HIV intervention approaches.
The results of this study suggest that social networks may be an important target for intervention. Learning more about social network characteristics and their association with risky sexual practices can assist in the development of HIV-prevention programs that target both the individual and their network members.40,41 Although important, individual-level interventions often cannot address the broader social and structural factors related to HIV risk. Social networks can spread social norms, social support, and influence through a community.42,43 Social network-level approaches have been successfully used with injection drug users at risk of HIV.44,45 Cultural and gender-specific interventions have showed great success in reducing sexual HIV risk behaviors.46 Social network-based interventions that promote norms pertaining to HIV risk reduction and provide social support are needed for African American women at risk of heterosexually acquired HIV/STIs.
Funding Our work was supported by the National Institute of Mental Health (Grant: R01 MH 066810) who had no role in the collection, analysis, or interpretation of the data or in the decision to submit the paper for publication. Dr. Neblett received support from a T32 grant provided by HRSA, Bureau of Health Professions.
Competing interests There are no competing interests to report.