RISK FACTORS AND BARRIERS TO PREVENTION
For women of all races and ethnicities, the largest number of HIV/AIDS diagnoses during recent years was for women aged 15–39. From 2001 through 2004, the number of HIV/AIDS diagnoses for women aged 15–39 decreased for white, black, and Hispanic women. There was an increase in the number of HIV/AIDS diagnoses during this period for Asian and Pacific Islander women and for American Indian and Alaska Native women aged 15–39.
Diagnosis of HIV/AIDS in females aged 15-39 years 2001 - 2004:
No. (%)* No. (%)* White 1,218 (63) 996 (56) Black 5,229 (62) 4,091 (58) Hispanic 1,192 (60) 819 (57) Asian/Pac.Isl. 31 (55) 62 (66) American Indian/ 23 (52) 39 (68) Alaska Native
* Percent (%) of women age 15-39 in corresponding sub-group.
Lack of Recognition of Partner’s Risk Factors
Some women may be unaware of their male partner’s risk factors for HIV infection (such as unprotected sex with multiple partners, sex with men, or injection drug use). Men who engage in sex both with men and women can acquire HIV from a male partner and then transmit the virus to female partners. In a 2003 report of a study of HIV-infected people (5,156 men and 3,139 women), 34% of black men who have sex with men (MSM), 26% of Hispanic MSM, and 13% of white MSM reported having had sex with women. However, their female partners may not have known of their male partner’s bisexual activity: only 14% of white women, 6% of black women, and 6% of Hispanic women in this study acknowledged having a bisexual partner. In another CDC survey, 65% of the young men who had ever had sex with men also reported sex with women. Women who have sex only with women and who have no other risk factors, such as injection drug use, are at very low risk for HIV infection (CDC, unpublished data, 2006).
High-Risk Heterosexual Risk Factors
Most women are infected with HIV through high-risk heterosexual contact. Black and Hispanic women account for 81% of the women living with HIV/AIDS in 2005 who acquired HIV through high-risk heterosexual contact. Lack of HIV knowledge, lower perception of risk, drug or alcohol use, and different interpretations of safer sex may contribute to this disproportion. Relationship dynamics also play a role. For example, some women may not insist on condom use because they fear that their partner will physically abuse them or leave them. Such sexual inequality is a major issue in relationships between young women and older men. In a CDC study of urban high schools, more than one third of black and Hispanic women had their first sexual encounter with a male who was older (3 or more years). These young women, compared with peers whose partners had been approximately their own age, had been younger at first sexual intercourse, less likely to have used a condom during first and most recently reported intercourse, or less likely to have used condoms consistently.
Biologic Vulnerability and Sexually Transmitted Diseases
A woman is significantly more likely than a man to contract HIV infection during vaginal intercourse. Additionally, the presence of some sexually transmitted diseases greatly increases the likelihood of acquiring or transmitting HIV infection. The rates of gonorrhea and syphilis are higher among women of color than among white women. These higher rates are especially marked at younger ages (15–24 years).
An estimated 1 in 5 new HIV diagnoses for women are related to injection drug use. Sharing injection equipment contaminated with HIV is not the only risk associated with substance use. Women who use crack cocaine or other noninjection drugs may also be at high risk for the sexual transmission of HIV if they sell or trade sex for drugs. Also, both casual and chronic substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol.
Nearly 1 in 4 blacks and 1 in 5 Hispanics live in poverty. Socioeconomic problems associated with poverty, including limited access to high-quality health care; the exchange of sex for drugs, money, or to meet other needs; and higher levels of substance use can directly or indirectly increase HIV risk factors. A study of HIV transmission among black women in North Carolina found that women with a diagnosis of HIV infection were significantly more likely than women who were not infected to be unemployed; to have had more sex partners; to use crack/cocaine; to exchange sex for money, shelter, or drugs; or to receive public assistance.
The rates of HIV diagnosis and the risk factors for HIV infection differ for women of various races or ethnicities—a situation that must be considered when creating prevention programs. For example, even though the annual estimated rate of HIV diagnosis for black women decreased significantly—from 82.7 per 100,000 population in 2001 to 60.2 per 100,000 population in 2005—it remained 20 times the rate for white women. Overall, the rates of HIV diagnosis are much higher for black and Hispanic women than for white, Asian and Pacific Islander, or American Indian and Alaska Native women. The rates for black women are higher than the rates for all men except for black men.
Multiple Risk Factors
Some women infected with HIV report more than 1 risk factor, highlighting the overlap in risk factors such as inequality in relationships, socioeconomic stresses, substance abuse, and psychological issues. For example, in the North Carolina study of HIV infection in black women, the participants most commonly reported that that their reasons for risky behavior were financial dependence on male partners, feeling invincible, low self-esteem coupled with the need to feel loved by a male figure, and alcohol and drug use.