The sample for the analysis presented here were 26 adolescent and young adult women with HIV. All study participants contracted HIV through heterosexual transmission. describes the participant demographics, time since diagnosis, and highly active anti-retroviral therapy (HAART) for participants. The mean age of participants was 21 years old (range 16 to 24 years). The mean age at time of diagnosis was 18 years old (range 15–23). Two thirds (65%) of the sample were African-American, 23% were Latina and 12% were of other race or ethnicity. About one-third of the young women were enrolled in school at the time of the study (31%). Many of the participants (39%) had not graduated from high school or acquired a GED. Only 19% were currently employed and a little more half of those had a full time job (12%). About 62% of participants reported currently being on highly active anti-retroviral treatment.
Demographic and Treatment Characteristics of Adolescent and Young Adult Women with HIV.
Sexual behavior from the quantitative survey is presented in . About 15% of females reported having their first sexual intercourse before the age of 11 and 65% reported 6 or more life time sexual partners. Over three quarters (77%) reported two or more sexual partners during the last three months; 81% reported using a condom for vaginal or anal sex the last time they had sexual intercourse and about 8% reported use of alcohol of drugs the last time they had sex. Most (81%) self-identified as heterosexual and 19% as bisexual.
Sexual Behavior of Adolescent and Young Adult Women with HIV.
Qualitative data provided more nuanced information on sexual behavior among participants (). When asked about sexual behavior with their current sexual partner about 8% (N=2) reported they were not sexually active (no risk), 42% (N=11) reported condom use every time for vaginal or anal sex and having fewer than three sexual partners (low risk), 27% (N=7) reported using condoms most but not all of the time for vaginal and anal sex and having three or more sexual partners (moderate risk), and 23% (N=6) reported multiple episodes of unprotected vaginal or anal sex in the last three months (high risk).
Self Reported Sexual Behavior in Women since HIV Diagnosis - Qualitative Interview Results.
illustrates partner relational characteristics of high risk participants as reported in the qualitative interviews. The primary reason reported for unprotected sex was partner refusal to use a condom (5/6). Among this group half (3/6) of their male partners were more than 10 years older (12 to 15 years) older. In two cases, male partners were positive for HIV infection which also affected condom use; both young women with HIV positive partners reported negative attitudes toward condoms. Female participants having unprotected sex also described their own and/or their partners’ inaccurate beliefs about HIV transmission as reasons for unprotected sex. In addition, a few women expressed, fears of rejection by a new partner upon disclosure of HIV thus, they remained with their current partner who refused to wear condoms.
Partner Relational Characteristics among HIV Positive Adolescent and Young Adult Women with Continued High Risk Sexual Behavior (N=6).
In five out of six cases, women had disclosed their HIV infection to their male partners. One participant, who had not disclosed to any sexual partners, did not report any of the above reasons for continued high risk behavior. She indicated that she used condoms with some partners but not with others. However, she did not describe any discernable patterns or partner characteristics that appeared to affect her condom use.
The cases presented below are illustrations of partner relationship dynamics and attitudes toward condoms among adolescent and young women with continued high risk sexual behavior.
Male partner refused to wear condom
A 22 year old African-American female, who tested positive for HIV at age 17, described her unsuccessful attempts to get her HIV negative boyfriend (age 25) of two years, who knows about her infection, to use condoms for sex. She said she was afraid that she would infect him and was trying to have less sex to reduce that chance. When asked why her boyfriend did not want to use condoms she explained:
“He was just like I love you, I don’t care… I was like - you know, I don’t want to give it - he’s like I don’t care. That day it took like an hour and a half trying to convince him to put that condom on. He was like no, I don’t want to, I don’t want to and that’s how it’s been.… I want him to use them all the time but if he don’t, what can I do but just keep suggesting it?” (R1)
She said she feels “a little guilty” sometimes. In response to his refusal she expressed a passive acceptance of the situation; “if he’s not really caring I’m not really gonna let it stress me out. That’s how it is.”
Another young woman described her HIV negative boyfriend’s resistance to using condoms. Her partner, who is 12 years older, has known about her HIV infection since the beginning of their relationship. She explained that she had made multiple attempts to get him to use condoms. She reported that they only used condoms about 50% of the time. When asked why they didn’t consistently use condoms she responded:
“I do not know why … I really can’t say. He’s negative, he know he’s negative, he’s been tested but he’s like …we’ve been down this road before. I’ve argued with him, I’ve cried - just to try to get him to wear it if - he would put it on and then he would take it off and then I would put it on and then he would pull it out of me - so I don’t know” (R5).
Partner HIV status influences sexual behavior
Two young women who reported partner resistance to using condoms had current partners who were also infected with HIV. Both of these young women reported their partner’s HIV positive status influenced their decision to have sex without a condom. One, a 23 year old HIV-infected female, described her perspective on the benefits and risks of unprotected sex with her HIV-infected male partner who refused to use a condom:
“I have like just one sex partner. He’s HIV-infected too. Which is even bad but it just feels better you know knowing he already have it, not telling him, you know - because he knew me for a long time so it’s like - it’s just better. Even though it’s dangerous, at the same time because I could get a new strain of HIV". (R3)
Another participant with an HIV infected partner who was 15 years older accepted his refusal to use condoms. She interprets his refusal as evidence that he cares about her: “It’s like a comfort like— okay he knows that he’s not using them so that means he must care about me….” (R2).
Both partners have negative attitudes toward condoms
Both young women with HIV infected partners described above also expressed negative attitudes toward condoms. One said that she, herself, did not like to use condoms because they irritated her and that she was somewhat relieved that her partner did not want to use them. The other young women with an HIV infected partner also expressed negative attitudes toward condoms but said they did not use them because they were too expensive. This couple had been in a relationship for more than 8 years.
Two sub-themes related to acceptance of partner refusal to use condoms were identified in women with HIV negative partners: Beliefs about HIV transmission risk and fear of disclosing HIV status to a new partner.
Inaccurate beliefs about HIV transmission risk influence sexual behavior
One young woman described her partner’s belief that he was protected from HIV by practicing penile withdrawal before ejaculation: “Well for him protection is not coming in me” (R5).
Another young woman who had unprotected sex with two partners described her beliefs about transmission of HIV to her unprotected partners: “neither one of them is positive. I thank God for that…so I pretty much see myself as a carrier and not really a giver. But you never know when that time’s gonna happen and somebody can get it” (R1).
A participant whose HIV negative partner refused to use condoms explained “they say it’s harder for a man to get it from a woman than for a woman to get it from a man. That’s what he said but still.” She said she will continue to urge him to use condoms but knows that he won’t and she will have sex with him anyway because he is her partner (R4).
Fear of disclosing HIV status to a new partner influences condom use
Among the young women who had continued unprotected sex, 83% (5/6) had disclosed their HIV status to their current partner. Two of these young women described their fears of disclosing to a new sex partner. One explained:
“If me and my boyfriend don’t stay together for some reason, it’s not gonna be easy just to have sex with somebody else, especially with my condition. And you know to get to that point with this guy to let him know first my status and then if he’s willing to take that step with me, you know maybe it’ll happen but other than that I don’t see it happening.”(R6)
The other young woman described her previous experience of rejection by a new partner:
“Yeah. I don’t want to start over. I don’t want to explain anything to anybody. That’s pretty much it. It’s a mistake to be with a negative person even if the person thinks they can deal with it at the beginning… With Joey (pseudonym), the person I was really, really, really trying to be with but towards the end he kind of lost it. He couldn’t deal with it for the duration of us being together.” (R2)
In contrast to the findings in women with high sexual risk behavior, the problem of partner resistance is reported by only one of the twenty young women in the moderate, low, and no risk group. In that case, the young woman refused to have sex with her HIV negative partner without a condom.