As the human immunodeficiency virus (HIV) epidemic in the United States continues into its fourth decade, women have become increasingly affected by the disease [1
] and unprotected heterosexual sex has long surpassed injection drug use as the leading route of transmission to women [2
]. Surveillance data for 2005 indicate that women now represent one quarter of all new cases of HIV [3
]; African American women are disproportionately affected, constituting 67% of reported cases [3
]. Due to the late development of HIV testing and identification and the lack of early and adequate interventions, acquired immunodeficiency syndrome (AIDS), the group of conditions caused by HIV as the immune system fails, is the leading cause of death among African American women aged 25–34 and the fifth leading cause of death among African American women aged 35–44 [1
]. The increased transmission of HIV to women through heterosexual contact raises questions about the male partners who are the source of their infection. Despite high levels of public understanding of the risk factors and behaviors related to the transmission of HIV, levels of condom use remain unaccountably low [4
], suggesting that there are gaps in our understanding of the relationship between individual knowledge and behavioral response.
Given these epidemiological data, it is likely that many women may be unaware of or wrong in their assessments about their partners’ risk factors [6
] and/or they may be engaging in unprotected sex despite knowledge of partner risk factors [9
]. Research indicates that women are more likely to contract HIV from main partners or partners considered to be “close” due to the greater likelihood of having unprotected sex with them compared with casual partners or sex trade partners [5
]. Women may perceive main or close partners as being “safe” (i.e., monogamous or HIV negative) [5
], albeit possibly incorrectly [7
], or they may perceive them as potentially risky but they have other, competing priorities such as perceived partner disapproval of condom use [14
], fear of violence [10
] and loss of financial support [15
] due to requesting that a partner use a condom, or placing love for their partner over concerns about their own health [9
]. Despite well-established evidence that the risk of HIV transmission to women is greatest with main or close partners and a few studies indicating risky sexual behaviors among HIV serodiscordant couples [16
], the relative role of perceptions of partner risk factors and behaviors, given contextual factors such as partner type and substance use, remains largely unexamined.
Men’s primary risk factors that contribute to HIV transmission to women include: positive HIV status—the high prevalence of HIV among African American men in particular [3
]—having concurrent (i.e. overlapping) partners [19
], behavioral bisexuality [20
], and injection drug use. While some literature suggests that women may be either unaware of or incorrectly perceive their partners’ specific risk factors for HIV infection [2
], little is known about the extent to which women are aware of their partners’ risk factors, the effect of women’s perceptions of partner risk factors on condom use, or the moderating effects of contextual factors on the relationship between perceptions of partner risk and condom use (or the reverse—the moderating effects of perceived partner risk on the relationship between contextual factors and condom use).
The influence of risk perceptions on condom use and other protective health prevention behaviors is well-documented through risk perception models such as the health belief model and the theory of reasoned action [22
], but such models often do not simultaneously include perceptions of partner
risks or important situational and contextual factors that may uniquely influence the protective behaviors of the economically disadvantaged women who are most at risk for HIV [24
]. Such analytic deficiencies may explain why models examining the role of perceived risk in HIV risk behaviors have had mixed results and may be limited in their applicability [24
]. Several scholars have noted that the application of a single theory of health behavior decision-making and behavior change cannot possibly address all of the factors influencing condom use, particularly among economically disadvantaged women [10
]. Some of the contextual factors that affect condom use are homelessness [25
], a woman’s knowledge of her own HIV status [31
], casual versus chronic substance use [33
], and sex with a main or close partner compared with another type of partner, such as an unknown partner or a partner with whom sex is exchanged for drugs or money [5
]. There is a need for theoretical models that “take more seriously the social contexts in which decisions about health behaviors are made and the constraints that individuals face in making their choices” [24
In addition to adding contextual factors to risk perception models, some suggest that data on sexual behaviors would be more precise if measured at the event or episode level, within the context of specific sexual episodes, to account for factors that may vary by episode [40
] and to assist with recall of such practices through appropriate interview methodologies [43
]. Risk behaviors are not likely perceived as the same for each person [24
] or for each sexual relationship. Using appropriate statistical methodologies to examine behaviors within the context of specific episodes that take partner type, among other factors, into account may be particularly important for women because they typically demonstrate riskier behaviors with main or close partners than with other kinds of partners [5
] and often tend to make critical decisions about their own well-being within the context of close relationships with others [45
This article examines the influence of women’s perceptions of four partner risk factors—HIV status, bisexual behavior, sexual partner concurrency (i.e., their having other partners that overlap in time), and injection drug use—on condom use at the event-level, taking into account type of partner, homelessness, the woman’s HIV status, and drug and alcohol use by the woman and by her partner. Exploring the relationship between a woman’s perceptions of partner behaviors and condom use within specific sexual episodes may help illuminate whether awareness of partner risk factors is protective against HIV through increased condom use and whether consideration of such contextual factors affects the relationship between risk perceptions and condom use. Such illumination would, in turn, assist in the design or adaptation of HIV prevention strategies to optimize their impact.
Based on the basic elements of the health belief model, which suggests that awareness of one’s own risk for and susceptibility to disease are associated with protective behaviors [46
], we hypothesized that women’s perceptions that a male partner was HIV positive, had concurrent partners, was also having sex with men, and had a history of injection drug use would be associated in univariate models (i.e., models with a single predictor variable) with increased odds of condom use, before contextual factors were taken into account. We also hypothesized that sex with a main partner, homelessness, and the woman’s and man’s drug and alcohol use would be associated with decreased odds
of condom use and that the woman’s positive HIV status would be associated with increased
odds of condom use, and that we would see interaction effects between partner risk perceptions and these contextual variables.
As noted, some studies have examined associations between perceived risk and protective behaviors, but few have examined associations between perceptions of risk of specific sexual partners during specific sexual episodes. Event-level, partner-specific data allow for the examination of these relationships.