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

2. 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. 3

4. 4 New AIDS Cases and Rates among Women by Race/Ethnicity Reported in 2002, U.S. Number % 7,339 67 1,93018 1,56114 42 68 10,940 <1 100 Race/Ethnicity Rate per 100,000 White, not Hispanic 50.0 Black, not Hispanic 2.3 Hispanic 11.8 American Indian/ Alaska Native Asian/Pacific Islander Total 4.5 1.4 Number 7, 6 18 1,1 10, <1 100 Race/Ethnicity Rate per 100,000 White, not Hispanic Black, not Hispanic 2. Hispanic American Indian/ Alaska Native Asian/Pacific Islander 4. 1.

5. 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. 6

7. 7

8. 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. 9 People Living with HIV/AIDS in NYC

10. 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. 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. 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. 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. 16 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

17. 17 Demographics cont. Homelessness (%) Homelessness in lifetime Homelessness in past 6 mos. 47.1 9.6 Currently Employed16.6 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

18. 18 Prevalence of HIV Risk Indicators

19. History of Childhood Sexual Abuse (CSA)

20. 20 Prevalence of CSA

21. 21 CSA and HIV Risk Indicators

22. 22 CSA: Partner HIV Risk Indicators

23. Post-Traumatic Stress Disorder and HIV Risks

24. 24 PTSD and HIV Risk Indicators

25. 25 PTSD: Partner HIV Risk Indicators

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

27. 27 Prevalence of Physical and Sexual IPV

28. 28 Physical IPV and HIV Risk Indicators

29. 29 Physical IPV: Partner HIV Risk Indicators

30. 30 Sexual IPV and HIV Risk Indicators

31. 31 Sexual IPV: Partner HIV Risk Indicators

32. Drug Use Contexts and HIV Risks: Qualitative Findings

33. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 49 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

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