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

Ontogenetic/ Interpersonal. HIV Risk. Macro and Structural. Drug-Involved Women and HIV: Co-Occurring Risk Factors. Columbia University School of Social Work Social Intervention Group. Outline of Presentation. Disparities in HIV/AIDS among women in the U.S.

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

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  1. Ontogenetic/ Interpersonal HIV Risk Macro and Structural Drug-Involved Women and HIV: Co-Occurring Risk Factors Columbia University School of Social WorkSocial Intervention Group

  2. 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

  3. Estimated* AIDS Incidence in Women and Percentage of AIDS Cases 16,000 16,000 30 30 25 25 12,000 12,000 20 20 % of Cases % of Cases Number of Cases Number of Cases 8,000 8,000 15 15 10 10 4,000 4,000 5 5 0 0 0 0 1986 1986 1987 1987 1988 1988 1989 1989 1990 1990 1991 1991 1992 1992 1993 1993 1994 1994 1995 1995 1996 1996 1997 1997 1998 1998 1999 1999 2000 2000 2001 2001 Year of Diagnosis Year of Diagnosis *Adjusted for reporting delay (CDC, 2001)

  4. New AIDS Cases and Rates among Women by Race/Ethnicity Reported in 2002, U.S. Rate per Rate per 100,000 100,000 Race/Ethnicity Race/Ethnicity % Number Number 2.3 2. 1,930 18 18 White, not Hispanic White, not Hispanic 7,339 7, Black, not Hispanic Black, not Hispanic 67 6 50.0 Hispanic Hispanic 1, 1,561 14 1 11.8 68 1. 1.4 Asian/Pacific Islander Asian/Pacific Islander American Indian/ American Indian/ <1 <1 4.5 4. 42 Alaska Native Alaska Native 10, 10,940 100 100 Total

  5. 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)

  6. AIDS Incidence Among Women By Region and Race/Ethnicity, Reported in 2001, U.S. 4,500 4,500 White, not Hispanic White, not Hispanic 3,879 3,879 4,000 4,000 Black, not Hispanic Black, not Hispanic 3,500 3,500 Hispanic Hispanic 3,000 3,000 2,500 2,500 Number of Cases Number of Cases 2,300 2,300 2,000 2,000 1,500 1,500 Number of Cases Number of Cases 951 951 1,000 1,000 785 785 777 777 542 542 500 500 342 342 294 294 281 281 218 218 196 196 55 55 0 0 West West Northeast Northeast Midwest Midwest South South N=846 N=846 N=4,062 N=4,062 N=803 N=803 N=5,033 N=5,033 Region

  7. AIDS Incidence in Women by Exposure Category, Diagnosed in 2001, U.S. Sex with Sex with Heterosexual Heterosexual injection drug user injection drug user transmission transmission 16% 16% 66% 66% Sex with men of Sex with men of other or other or † † unspecified risk unspecified risk Injection drug use Injection drug use 50% 50% 32% 32% Other/not identified** Other/not identified** 3% 3% ** Includes patients whose medical record review is pending; pat ients who died, were lost to follow - - up, or declined interview; and patients with other or undetermined modes of exposure † † Includes sex with a bisexual male, a person with hemophilia, a transfusion recipient with HIV infection, or an HIV - - infected person with an unspecified risk

  8. 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)

  9. People Living with HIV/AIDS in NYC

  10. 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)

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

  12. 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

  13. Women’s Health Project (WHP) Funded by NIDA (Grant #R01DA11027)

  14. 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

  15. 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

  16. Demographics(N = 416)

  17. Demographicscont.

  18. Prevalence of HIV Risk Indicators

  19. History of Childhood Sexual Abuse (CSA)

  20. Prevalence of CSA

  21. CSA and HIV Risk Indicators

  22. CSA: Partner HIV Risk Indicators

  23. Post-Traumatic Stress Disorder and HIV Risks

  24. PTSD and HIV Risk Indicators

  25. PTSD: Partner HIV Risk Indicators

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

  27. Prevalence of Physical and Sexual IPV

  28. Physical IPV and HIV Risk Indicators

  29. Physical IPV: Partner HIV Risk Indicators

  30. Sexual IPV and HIV Risk Indicators

  31. Sexual IPV: Partner HIV Risk Indicators

  32. Drug Use Contexts and HIV Risks: Qualitative Findings

  33. 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.

  34. 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.

  35. 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

  36. 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

  37. Interpersonal Factors and HIV Risks

  38. 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

  39. Structural Factors and HIV Risks

  40. 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

  41. Macro Factors

  42. Macro Factors: Sexual Gender Roles Requesting a partner to use condoms • Sign of infidelity • Breach of gender roles and expectations • Insult to male masculinity

  43. Macro Factors: Attitudes Toward Drug-Involved Women • Low social status • Social rejection • Stigma • Low self-esteem

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

  45. 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

  46. 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

  47. 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

  48. 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

  49. Quote 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.

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

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