# Presentation: 374742

## Drug-Involved Women and HIV: Co-Occurring Risk Factors 

- Columbia University School of Social WorkSocial Intervention Group

## Outline of Presentation

- Disparities in HIV/AIDS among women in the U.S.
- Co-occurring risk factors for HIV among African American and Hispanic drug-involved women
- Implications for HIV prevention, intervention and services for drug-involved women

## Slide 3

**Notes:**
The blue bars show the number of new AIDS cases in women each year.  The yellow line shows the percentage of new AIDS cases that are women.  The percent of new AIDS cases that are women steadily increases from 1985 until 2002.  This slide is from CDC.

## Slide 4

## Prevalence of HIV/AIDS among Women in the U.S.

- In 2002, 86,778 women were living with HIV/AIDS in the US (CDC, 2002)
- Of women living with HIV/AIDS, 19% were White, 58% were African-American, and 18% were Hispanic (CDC, 2002)

## Slide 6

## Slide 7

**Notes:**
16% of new AIDS cases are from sex with men who inject drugs and an additional 50% of new cases are from sex with men with other risks 

## AIDS and Poverty among Women

- HIV/AIDS is related to economic deprivation and population density (Zierler, 2000)
- HIV/AIDS found to be related to discrimination and poverty (Karpati, 2004; NYC DOHMH)

**Notes:**
Adam Karpati, MD, MPH is the Assistant Commissioner of the Brooklyn District Public Health Office in the Division of Health Promotion and Disease Prevention, NYC Department of Health and Mental Hygiene.  He gave testimony on Health Care Disparities between Minorities and Non-Minorities before the NY State Assembly Committee on Health and the Black, Puerto Rican and Hispanic Legislative Caucus on April 22, 2004.  Health disparities exist for almost every condition including access to care, HIV and AIDS, obesity, diabetes and cancer.  These disparities are due to differences in the way people live including social, economic and physical conditions.  Poor health shares common root causes: poverty, discrimination, poor housing and other social inequalities.

## People Living with HIV/AIDS in NYC

**People Living with HIV/AIDS in NYC**

**Notes:**
This slide shows the percent of the population living with HIV/AIDS by neighborhood in New York City.  The neighborhoods with the highest rate of AIDS cases are Harlem and the South Bronx, which are low-income Hispanic and African-American neighborhoods.  A smaller area with a high rate of AIDS cases is the West Village and Chelsea, which is a neighborhood with a large number of gay men.  This map was included in the NYC Department of Health’s HIV Epidemiology Program Quarterly Report in January 2004.

## Poverty and HIV/AIDS in NYC

- The areas with the highest percentage of women living with HIV/AIDS are in Harlem and the South Bronx, which are primarily low-income African-American and Hispanic communities (NYC DOHMH, 2004)
- AIDS death rates in NYC’s poorest neighborhoods are more than 6 times higher than rates in the wealthiest neighborhoods (NYC DOHMH, 2004)

## Risk Factors for HIV among African American and Hispanic Drug-Involved Women

## Risk Factors for HIV among Women

- Ontogenetic factors: CSA, PTSD, drug use
- Interpersonal factors including IPV
- Structural factors such as lack of access and availability to women-specific treatment and services
- Macro factors including economic power imbalances, attitudes toward drug-involved women and sexual gender roles

## Women’s Health Project (WHP)

- Funded by NIDA
-  (Grant #R01DA11027)

## WHP Overview

- Qualitative phase (*N* = 68)
- Understand the contexts that link the intersecting epidemics of drug abuse, IPV and HIV
- Quantitative phase (*N* = 416)
- Describe the prevalence of IPV
- Examine risk factors associated with HIV

## WHP Overview

- Recruited a random sample of 416 female patients from 11 methadone clinics located in NYC
- In order to be eligible, a woman had to:
- be between the ages of 18 and 55
- have had a regular partner in the past 12 months
- have been on methadone for 3 or more months

## Demographics(N = 416)

| Age (yrs.) | 	Mean = 39.8    (SD = 6.7) |
| --- | --- |
| Ethnicity (%)	African American	Hispanic	White	Others | 	30.8	47.5	16.8	4.5 |
| Marital Status (%)	Single, never married	Divorced/Separated	Widowed	Married | 	46.5	22.4	11.3	19.7 |

## Demographicscont.

| Homelessness (%)	Homelessness in lifetime	Homelessness in past 6 mos. | 	47.1	9.6 |
| --- | --- |
| Currently Employed | 	16.6 |
| Criminal Justice (%)	Arrested in lifetime	Arrested in past 6 mos.	Incarcerated in lifetime	Incarcerated in past 6 mos. | 	70.0	14.3	44.0	5.0  |

## Prevalence of HIV Risk Indicators 

**Notes:**
Let me now go over prevalence of different types of abuse.  Nearly three-quarters of the women in our sample reported severe life time physical or sexual abuse.  By severe abuse we mean such acts as using a gun or knife, choking, punching, kicking and physically forced to have sex not acts such as slapping, pushing or shoving.  Again what is more disturbing to me is the past year rate of severe abuse –one out of every four women in our sample reported experiencing severe physical or sexual intimate partner violence in the past year.   

## History of Childhood Sexual Abuse (CSA)

## Prevalence of CSA

**Notes:**
Let me now go over prevalence of different types of abuse.  Nearly three-quarters of the women in our sample reported severe life time physical or sexual abuse.  By severe abuse we mean such acts as using a gun or knife, choking, punching, kicking and physically forced to have sex not acts such as slapping, pushing or shoving.  Again what is more disturbing to me is the past year rate of severe abuse –one out of every four women in our sample reported experiencing severe physical or sexual intimate partner violence in the past year.   

## CSA and HIV Risk Indicators

## CSA: Partner HIV Risk Indicators

## Post-Traumatic Stress Disorder and HIV Risks

## PTSD and HIV Risk Indicators

## PTSD: Partner HIV Risk Indicators

**Notes:**
Let me now go over prevalence of different types of abuse.  Nearly three-quarters of the women in our sample reported severe life time physical or sexual abuse.  By severe abuse we mean such acts as using a gun or knife, choking, punching, kicking and physically forced to have sex not acts such as slapping, pushing or shoving.  Again what is more disturbing to me is the past year rate of severe abuse –one out of every four women in our sample reported experiencing severe physical or sexual intimate partner violence in the past year.   

## Intimate Partner Violence (IPV) Among African American and Latina Drug-Involved Women: Physical and Sexual Abuse

## Prevalence of Physical and Sexual IPV

**Notes:**
Let me now go over prevalence of different types of abuse.  Nearly three-quarters of the women in our sample reported severe life time physical or sexual abuse.  By severe abuse we mean such acts as using a gun or knife, choking, punching, kicking and physically forced to have sex not acts such as slapping, pushing or shoving.  Again what is more disturbing to me is the past year rate of severe abuse –one out of every four women in our sample reported experiencing severe physical or sexual intimate partner violence in the past year.   

## Physical IPV and HIV Risk Indicators

## Physical IPV: Partner HIV Risk Indicators

## Sexual IPV and HIV Risk Indicators

## Sexual IPV: Partner HIV Risk Indicators

## Drug Use Contexts and HIV Risks: Qualitative Findings

##  Linking HIV and Drug Use Context and Physical and Sexual IPV

**Drug context leads to HIV risk and triggers sexual IPV**
- Disputes over sharing/splitting drugs
- Forced unprotected sex while high
- Partners often take advantage of a woman’s withdrawal to coerce sex
- If a couple is high on different types of drugs, it creates conflicts that lead to physical and sexual violence.

## Drug Use Contexts Lead to HIV and Sexual IPV

**Heroin**
- Women in the early stages of heroin addiction reported that it helps them get into the mood to have sex
- Women who have used heroin for many years reported that it reduces their desire for sex
- Men on heroin can have sex for an extended period of time, which can make his partner physically uncomfortable.  If she wants him to stop or refuses sex, it often leads  to sexual violence.

## Drug Use Contexts Lead to Sexual IPV

**Crack**
- Some women stated that crack makes them feel like they do not want to be touched
- Some women believe that men on crack ejaculate too soon, which upsets them and causes them to think that the man doesn’t love them.  This leads to accusations and physical and sexual violence
- When a woman on crack refuses her partner, she is often forced to have sex, especially if he is high on heroin

## Linking Drug Use & HIV

**Drug use**
- Impairs women’s judgment
- Affects women’s ability to protect themselves and negotiate condom use
- Leads to paranoia and mistrust, which in turn lead to relationship conflicts and sexual IPV

## Interpersonal Factors and HIV Risks

## Power Imbalances

**Economic power imbalances **
- Women who are financially dependent on their partners often lack power in negotiation of condom use
**Social power imbalance leads to inconsistent condom use **
- Social dependency (protection from street network)
- Lack of support from kin network

## Structural Factors and HIV Risks

## Structural Factors

**Structural Barriers increase risks of HIV****  **
**Women reported:**
- Drug treatment programs rarely address trauma and IPV issues
- Domestic violence services and shelters rarely accept them because of their drug abuse
- Domestic violence services and shelters rarely address issues of HIV or drug abuse
- Domestic violence and drug treatment programs do not “speak” to each other

## Macro Factors

## Macro Factors: Sexual Gender Roles

**Requesting a partner to use condoms **
- Sign of infidelity
- Breach of gender roles and expectations
- Insult to male masculinity

## Macro Factors: Attitudes Toward Drug-Involved Women

- Low social status
- Social rejection
- Stigma
- Low self-esteem

## What are the implications of the findings to HIV prevention and intervention for minority drug-involved women?

## HIV Prevention Intervention Implications

- Behavior prevention is currently the only way to prevent further spread of the sexual transmission of HIV
- Scientific advances have been made in behavioral HIV intervention and prevention research
- HIV intervention and prevention scientists should be proud of the accomplishments that have been made

## Implications for HIV Prevention Interventions for Drug-Involved Women

- Few empirically-tested HIV prevention interventions exist for minority drug-involved women who experienced CSA, PTSD and IPV
- There is a need to develop effective and sustained HIV prevention intervention models to address the co-occurring problems of CSA, PTSD and IPV

## Implications for HIV Prevention Interventions for Drug-Involved Women

- There is a need to better integrate prevention and treatment services for women, including prevention and treatment of STIs
- Without addressing personal, interpersonal factors (CSA, PTSD, IPV) as well as structural and macro factors in prevention and treatment, HIV will continue to escalate among minority drug-involved women
- Ignoring these co-occurring problems also increases the risk of relapse and premature attrition from treatment

## Implications for Services Research

- Determine best models of collaboration between drug abuse treatment, domestic violence and  HIV services
-  Identify structural and organizational barriers to collaboration and integration of services across systems and to study the mechanisms to overcome these barriers
- Design and test innovative women-specific and culturally congruent services and treatments for drug-involved women

## 

	You know, I do drugs and sell sex.  I don’t use condoms and I do bad things to forget what happened to me when I was a child.  My father abused me sexually for 7 years.  He forced me to sleep with him and I did, but he also took care of me.  The pain stayed with me, and still it’s hard for me to forget what happened.  I always felt scared, and didn’t know how to communicate my feelings of fear and anger.  I went to college, became a nurse and worked for two years in nursing, but I was still not able to forget what happened to me when I was a child.  I started taking drugs from my job and ended up with crack.  Crack did for me.  Crack was the best.  Crack helped me forget and not care for anything, but I ended up with abusive men, in jail, in crack houses, and then got HIV.  These things happened to me because of the abuse. 

- 	You know, I do drugs and sell sex.  I don’t use condoms and I do bad things to forget what happened to me when I was a child.  My father abused me sexually for 7 years.  He forced me to sleep with him and I did, but he also took care of me.  The pain stayed with me, and still it’s hard for me to forget what happened.  I always felt scared, and didn’t know how to communicate my feelings of fear and anger.  I went to college, became a nurse and worked for two years in nursing, but I was still not able to forget what happened to me when I was a child.  I started taking drugs from my job and ended up with crack.  Crack did for me.  Crack was the best.  Crack helped me forget and not care for anything, but I ended up with abusive men, in jail, in crack houses, and then got HIV.  These things happened to me because of the abuse.

**Quote **

## Authors

- Nabila El-Bassel
- Louisa Gilbert
- Elwin Wu
- Hyun Go
- Social Intervention Group                                    Columbia University School of Social Work