What Works in HIV Prevention for Women of Color

Chapter 3: HIV Prevention Strategies and Their Implications for Women of Color

Current Theoretical Frameworks

Current HIV prevention efforts have relied heavily on psychological foundations to explain risk behavior and identify the best methods to bring about permanent change. Interventions designed to reflect these theoretical frameworks tend to emphasize the individual and the influence of immediate peer groups and social networks when seeking to identify and change social norms. Most HIV prevention programs incorporate elements of one or more of the following theories of behavior change.

Although these theories of behavior change have effectively been incorporated into HIV prevention programs, women of color have special needs and concerns regarding HIV and AIDS prevention and education. Programs that effectively address these missing pieces are more likely to reach a greater number of women.

Missing Pieces: Gender and HIV Prevention

HIV prevention theory serves as an important starting point, but too often fails to account for "extra-individual" circumstances (Amaro, 1995). Amaro highlights the unique relationship women have with risk behavior -- which is too often thought of as a corollary, rather than the central focus, of HIV prevention strategies -- and criticizes the concept that sexual encounters are always within an individual's control. None of the existing HIV prevention models explicitly acknowledge the potential for an imbalance of power in relationships, and too often the decision to wear a condom is considered a shared responsibility between men and women when the reality may be quite different.

Cash (1996) echoes the importance of considering gender in HIV prevention for women. She contends that current HIV prevention strategies have focused on increasing condom use and discouraging multiple partners without acknowledging the implicit issues associated with condom use for women. Negotiating condom use may seem to question fidelity, character, and the overall integrity of the relationship. Traditional HIV prevention models that ignore these dynamics assume that sexual risk behavior is motivated by the same factors, carried out in the same manner, and affected by the same strategies for both men and women.

Notably, Wingood and DiClemente have examined theories of gender and power as they relate to HIV exposure, risk factors, and effective interventions. Based on a theory of gender and power that identifies three major social structures that characterize gendered relationships between men and women -- the sexual division of labor, the sexual division of power, and emotional energy -- Wingood and DiClemente explored the relationship between power and gender among disadvantaged women. Examination of this relationship creates new data, poses new and larger questions with regards to women and HIV, and creates new opportunities for prevention (2000).

Concerning these power imbalances, Wingwood and DiClemente have also found that there is a correlation between rape among African-American women and the sexual, psychological, and social factors that may predispose survivors of rape to increased risk of HIV infection as well as other sexually transmitted diseases (STD) (1998). They also found similar results with victims of childhood sexual abuse. African-American women who experienced childhood sexual abuse were 1.5 times more likely to have had an abortion, 1.4 times more likely to have a STD, 2.4 times more likely to have more than one STD, 5.1 times as likely to have a partner who had been physically abusive in the past month, and 2.6 times as likely to have a partner who was physically abusive when asked to use condoms (Wingwood and DiClemente, 1997). These power imbalances among women with regards to gender can lead to a heightened risk for HIV infection and should be addressed in comprehensive HIV prevention programs.

In addition to these interpersonal influences on women's risk behavior, research has identified additional psychosocial challenges for women. The Human Immunodeficiency Virus Research Study (HERS) began in 1991, and the Women's Interagency HIV Study (WIHS) started three years later in 1994, to examine and inform HIV prevention efforts, treatment, and care for women. These studies suggest that, for women, HIV risk reduction is secondary to basic and often urgent survival priorities such as food, clothing, housing, childcare, and transportation. High-risk activities such as substance use and sex work often occur simultaneously with psychological distress, risk of violence, family problems, and minimal social supports. A history of violence as a child or as an adult was frequently reported among women living with HIV and AIDS in both the HERS and WIHS studies. Also, women often take on additional caregiver responsibilities: one third of HERS study participants had a family member suffering from HIV or AIDS.

HIV Prevention: Identifying Misconceptions About Women

In developing HIV prevention efforts targeted towards women of color it is important not to oversimplify social situations or foster complacency among various communities. Hogan (1998) cautions against the portrayal of women as caretakers or maternal surrogates, since being a mother or wife alone is not sufficient to protect against HIV infection. Ogur (1998) suggests that women are defined categorically, as either good or bad, signifying an innocent victim or a deserving vector of disease. Roberts (1999) calls for more ethnographic studies to deconstruct this restrictive definition of women at risk for HIV infection. She emphasizes the importance of analyses that "challenge prevailing images of [women of color] as developmentally or psychologically bent towards adolescent pregnancy, sexual promiscuity, educational failure, and welfare dependency."

Racial and ethnic issues must be included in HIV prevention programs as well as the unique challenges posed by gender. Highlighting the strengths and challenges that exist where gender and race intersect may prove useful in the design of HIV prevention efforts for women of color. A new model of HIV prevention that enables women of color to influence public health, science, and political debate could be a major factor in stemming the tide of HIV infections. While a feminist movement in the conventional sense may seem unrelated to HIV prevention, ignoring the political implications underscores the limited amount of thoughtful attention that has been given to the HIV prevention needs of women of color.

Missing Pieces: Race and Ethnicity in HIV Prevention

The shared experience of women in the AIDS epidemic does not obscure the diversity among women in terms of race, ethnicity, social class, and sexual orientation. HIV prevention strategies designed for women must continually evaluate the most appropriate point of reference for interventions for women of varying cultural backgrounds and socioeconomic status. Variations in race, ethnicity, and social status will determine whether one form of discrimination is felt more acutely than another, and thus will affect both risk behavior and successful prevention efforts. HIV prevention programs must be sensitive to all of these factors and the way they shape the experiences of communities of color.

For example, Marin and Gomez (1994) have found that acculturation influences sexual behavior, as does ethnicity. Their work on HIV prevention in Latino men and women indicates that Latino married men may behave differently than their white, non-Latino counterparts. There was also some degree of variation among groups of Latino men themselves. While this is only one example, other studies underscore the different values and behaviors found among diverse communities. These variations should be incorporated into HIV prevention efforts while ensuring that these concepts are not used to generalize or stereotype communities.

Examples of Successful HIV Prevention Interventions for Women of Color

There has been limited success in extending HIV prevention messages to women of color. In 1995, DiClemente and Wingood found that African-American women who participated in small group interventions to discuss consistent use of condoms were significantly more likely than women in a comparison group to report consistent condom use with their partners, better skills in negotiating condom use, and choosing not having sex when a condom was not available. Wingood and DiClemente also believe that using women living with HIV and training them as facilitators to deliver secondary HIV prevention messages to other women living with HIV increases the effectiveness of secondary prevention interventions. Women living with HIV, especially women of color, serve as powerful opinion leaders for other women who are living with HIV to enhance their coping skills and to reduce their STD-related sexual risks (1997b).

Moving Forward: Suggestions for HIV Prevention for Women of Color

Roberts (1999) suggests moving beyond risk taking to incorporate social factors. She contends that focusing on risk behavior and risk factors overemphasizes an individual's poor decision making and neglects other conditions that motivate behavior; specifically, society's attitudes towards gender and historical and current experiences of racism and discrimination. The physical, social, and economic conditions of the immediate neighborhood and limited access to community resources are relevant to the successful delivery and influence of HIV prevention programs. Efforts to improve self-esteem as a means of preventing HIV infection should be broadened to examine structural inequities within resource poor settings that contribute not only to a higher incidence of HIV infections, but also to other health disparities as well. Roberts also suggests that health promotion strategies that integrate social justice themes may improve overall outcomes. The former seeks to alter individual behavior; the latter encourages collective action to challenge the social causes of health inequities.

---

This article was provided by AIDS Action Council.