Black women featured prominently in discussions among researchers at the Centers for Disease Control and Prevention’s annual HIV prevention conference this week. As African Americans have accounted for increasingly lopsided shares of the epidemic among women—67 percent of new AIDS cases in 2003—they’re primary risk has also gradually shifted from injection drug use to heterosexual sex. “We actually don’t know a lot about the partners of these women,” CDC epidemiologist Lisa Fitzpatrick acknowledges. “One of our next steps has to be to find out who the partners are.”
University of North Carolina researcher Dr. Adaora Adimora, however, presented a study at the Atlanta meeting that suggests poverty and structural inequality may be HIV risk factors. Her team interviewed just over 200 North Carolinian African Americans who said they were neither men who have sex with men nor injection drug users. Seventy-eight percent were women. She discovered trends that suggest slowing HIV’s spread among Black women will require more than simply encouraging safer sex. Adimora explained her findings to BlackAIDS.org editor Kai Wright.
BlackAIDS.org: So we’ve got this data about heterosexual transmission among women, but we don’t really know about their partners. What can we say broadly about what’s driving that?
Adimora: It’s quite complex. It’s many things at the same time. But it’s relatively clear that a couple of major issues are among the things that are driving heterosexual transmission among African Americans in the United States—specifically, the high prevalence of STDs, because STDs facilitate HIV transmission, and also sexual network patterns. Sexual network patterns have been recognized as increasingly important in HIV and STD transmission in recent years.
And when you say “sexual network patterns,” tell us what you mean by that.
Who is having sex with whom, and the nature of the links that connect people sexually with each other.
What ways are those unique for heterosexual Black women?
Among the patterns that are of particular interest are the patterns of mixing, for instance, and the patterns of monogamy–long-term monogamy and sequential monogamy. So, for the patters of mixing, it’s whether people at low risk for HIV infection are mixing exclusively with other people who are at low risk for HIV infection, or whether low- and high-risk people are mixing, which can promote the spread of HIV and other STDs throughout a population. Also, whether or not people have partners that overlap in time, or what we call “concurrent partnerships.” They may have sex with one person, then move on to another person, and then return to the original person—this is an example of concurrent partnerships. All of these network patterns are important in the spread of HIV and STDs.
And in those concurrent partnerships, are African American women more likely to be involved in those?
Well, I don’t want to make specifically that statement. What I’ll say is at least in some studies there is evidence that there is a higher prevalence of that type of partnership among African Americans. And we looked at that, for example, among women in the United States in the 1995 cycle of the National Survey of Family Growth. And in fact that type of partnership was more prevalent among Black women. However, the major reason for its prevalence among Black women appeared to be related to lower marriage rates, because marriage rates are considerably lower among Blacks than they are among other ethnic groups. So in fact when you control for marital status and age at first sexual intercourse—that’s another risk marker for STDs and future sexual behavioral risk—as well as age-at-time-of-interview, the difference between Blacks and whites in the extent of concurrency markedly decreases. So much of the concurrent partnership that we saw among African Americans appeared to be related at least in part to low marriage rates.
And where does that come from? That may be beyond the research you’re doing, but if you can speculate…
Well, I’m certainly not a sociologist, but I’ve read some of the work of sociologists. And there are a number of explanations. But the major explanation for the lower marriage rates among Blacks in the U.S. have included economic factors—such as joblessness, poverty and the other obvious economic factors that make it less likely that people will marry and less likely that people will stay married once they do marry. … The other major one is the ratio of men to women, which is much lower among Blacks than it is among other ethnic groups. That’s because of the [early] death of Black men due to violence, due to disease, and it is further lowered by the disproportionate incarceration of Black men. And it’s felt that this low sex ratio, in concert with other factors, has a negative impact on marriage rates, which in turn clearly influences the prevalence of concurrent relationships.
So the bigger picture that you’ve talked about is these social and economic structures are contributing to why Black women are more likely to encounter HIV.
Yes, specifically some of these socio-economic factors—poverty, inequality, discrimination—appear to relate to sexual network patterns and certainly too sexual behaviors. I mean, they’re not the sole explanation, but they do clearly influence them. And they influence people’s risk for getting infection once they engage in the behaviors.
One of the things you mentioned this morning was crack use in the South and its concurrence with HIV infection. Can you tell us about that?
My impression is that there are varying levels of crack use in different regions in the United States. We examined risk factors for heterosexual transmission of HIV infection among African Americans in certain parts of North Carolina, and crack was among the factors that emerged as independent risk factors—and I will say that this data was collected between 1997 and 2000, so that was a few years ago, but from what we see in our clinic, crack use is actually still quite prevalent. To return to the study though, risk factors that emerged were smoking crack—that’s crack use on the part of the respondent or crack use on the part of the respondent’s partner—having less than a high school education and having a partner who was an injection drug user.
You’ve also talked about women in that study who have no identified risk.
Most people in our study reported some behavior that you would identify as reasonably high-risk behavior. None of them injected drugs, but they had other behaviors, typically, that were high risk. And actually, the other thing that was associated independently was increased numbers of partners; the more partners you have the more likely you are to be at risk for HIV infection. But more than a quarter of respondents did not have such high-risk behavior, and in that group among the risk factors that emerged were having a high school education and reporting what I would call food insecurity–that is having a concern about getting enough food for themselves or their family in the past 30 days. And also, having a partner who had other partners in the course of the relationship.
Why do those things then equate to risk?
Well, first, having a partner who had other partners is not a surprise. But having low socio-economic status is a marker for disease in general. Decreased social capital over time can place people in situations that increase their susceptibility for a variety of things. So poverty is a risk factor for disease. And when you get to the intersection of poverty and discrimination [the risk factors multiply.]
Kai Wright is editor of BlackAIDS.org.