african american females - NCBI

HUMAN IMMUNODEFICIENCY VIRUSRELATED RISK BEHAVIOR AMONG AFRICAN AMERICAN FEMALES Llewellyn J. Cornelius, PhD, Joshua Nosa Okundaye, PhD, and Maxwell C. Manning, PhD Baltimore, Maryland, and Washington, DC This study draws attention to the demographic shift in the population of HIV-infected African Americans from young, low-income, unmarried homosexual, and injecting drug users to female, heterosexual, higher income, and older persons. We used data from the 1995 Survey of Family Growth, sponsored by the National Center for Health Statistics, to examine the patterns of HIV-related risk behavior (consistent condom use, number of sexual partners, sex education in birth control methods) among African-American females. We found that only 33.3% of the African-American females had indicated that their partners always used condoms; 23.8% had seven or more lifetime sexual partners; and nearly 30% did not have any sex education in birth control methods, sexually transmitted diseases, or abstinence. In addition, African-American females who had partners who had not used condoms in the last 1 2 months were less likely than those who reported occasional condom use to perceive that they were infected with HIV (21. 1 % vs. 33. 1%). These risk factors were prevalent among low-income African-American females with low socioeconomic status (SES) as well as black women with higher SES who lived in smaller cities and suburbs. These results highlight the need for HIV prevention strategies that cut across socioeconomic class, gender, sexual orientation, and place of residence. U Natl Med Assoc. 2000;92: 183-195.)

Key words: HIV * AIDS * risk factors In the summer of 1998, the Congressional Black Caucus declared that AIDS had created a state of emergency in the African-American community." 2 They also indicated that they did not understand why others did not share their alarm. Their reason © 2000. From the School of Social Work, University of Maryland, Baltimore, Maryland and School of Social Work, Howard University, Washington, DC. The information reported in this article reflects the views of the authors, and no official endorsement by the Howard University, School of Social Work, or the University of Maryland, School of Social Work is intended or should be inferred. Requests for reprints should be addressed to Dr Llewellyn J. Cornelius, University of Maryland, School of Social Work, 525 W. Redwood St., Baltimore, MD 21201. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

for sounding this alarm was the spiraling growth of HIV infection and AIDS among people of color, despite the national decline in rates.3 By 1992, heterosexual intercourse accounted for over 80% of infections worldwide, with a 5:1 heterosexual-to-homosexual ratio.4 Wong and colleagues5 report that the case mix at the Richmond Virginia Medical College of Virginia Hospitals increased from 831 (20% AIDS) in 1991 to 1194 in 1997 (54.4% AIDS). Wong and colleagues also report that women now make up one-third of HIV patients. A greater proportion of persons over 40 years old are being diagnosed with HIV. The percentage of HIV patients who were African American has increased from 67% to 76%. The percentage of HIV patients who are heterosexual has increased from 20% to 42%. Between 1993 and 1998, there was a 75% decline 183

HIV-RELATED RISK BEHAVIOR AMONG AFRICAN-AMERICAN FEMALES

in the nutmber of deaths from AIDS. However, AIDS still disproportionately affects people of color. Latinos and African-American women accotunted for 77% of the HIV infections reported to the Centers for Disease Coontrol and Prevention between Jtuly 1998 and June 1999. About half (49%) of all adolescent and adtult females becamne infected throuLgh heterosexual contact. Another 46% were infected through injecting drtug use, whereas the remaining 5% were infected through some other means." Why is HIV/AIDS continuing to grow among the community of color? First, a greater portion of Af: rican Americans are represented among persons at risk for HIV infection. In a review of the relative rates of AIDS by race and ethnicity, Haverkos and colleagues'! indicated that "socioeconomic statuLs, access and receptivity to HIV prevention and treatment efforts, sexual behaviors, stubstance abuse and untreated sexually transmitted diseases" were correlated with the higher AIDS rates. Hetherington and colleagues7 reported that African-Americani women in an inner-city methadone maintenance program were less likely to engage in safe sex practices becauise of perceived powerlessness to negotiate condom use and negative attitudes about the use of condoms. Second, some may not be aware abotit how HIV/AIDS is transmitted. Hardy and Biddlecome8 reported that up to one-third of the adult respondents in the 1990 National Center for Health Statistics AIDS Attitude Survey still believed that AIDS can be spread via casual contact. Third, some are less likely to advocate for HIV prevention and treatinent because they perceive AIDS as an illness restricted to gays who are being ptunished for being gay."' What are some of the risk factors for HIV infection? Do some social, economic, or ethnic groups face a greater risk of HIV infection than others? What are the trends in the global reality of the HIV/AIDS pandemic? Having unprotected sex with multiple sex partners, inconsisteint condom use, and sharing needles for injecting drugs are some of the risky behaviors correlated with both sexually transmitted disease (STD) infection, including HIV and AIDS.'I-'8 In addition, poverty and drug use behavior is correlated with HIV infection. Wohl and colleagues9 reported that a large portion of AfricanAmerican women with AIDS in Los Angeles County were unemployed, single mothers, living on public assistance, poor, or had a history of crack use. Robert Fullilove notes that "inner-city poor neighbor184

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hoods often shelter a vigorous drug trade, numerous opporttun-ities for strangers to engage in drugmediated, unprotected sex, and numerous locations, where these and other risk behaviors go virtually un-

challenged."19 Althouigh these sttudies have highlighted the risk of infection among poor African Americans and African Americans who are drug users, most research has overlookedl the potential effect of the risk of HIV infection on middle and upper income African Americans. A recent study in Ghana examined the attittude and reaction of 15 professional male urban dwellers (aged 34 to 41 years) toward the HIV epidemic and sexual risk (unprotected sexual intercourse with multiple partners whose HIV status is not known). These men had, at minimum, a Bachelor's degree and were in private businesses, accounting, law, engineering, and in the civil service. From these unstruictured, one-on-one in-depth interviews, Sallar20 reports that participants believe their risk of contracting HIV remains low as long as they do not take new sextual partners and their cuirrent multiple partners remain faithful; or where there is a new sexual encounter they use condoms uintil they feel comfortable with the new partner. None of the study participants had physically seen somneone with a complete manifestation of AIDS except on television. These partners did not communicate an awareness of behaviors that would lead to a reduction in the risk of HIV infection. The goal of this article is to use national data to examine correlates of the rise of HIV infection. In particular, this article will explore: 1. How do African-American females fare on risky behavior correlated with HIV/AIDS (i.e., having mnultiple sex partners, a lack of awareness of sexual practices, or a lack of consistent condom use)? 2. Does the proportion of African-American females with these risk-related behaviors vary by sociodemographic characteristics? 3. How do African-American females fare on their perception of being HIV-infected? 4. Does the perception of HIV risk by AfricanAmerican females vary by sociodemographic characteristics?

METHODS We used data from cycle five of the 1995 National Survey of Family Growth (NFSG) sponsored by the VOL. 92, NO. 4, APRIL 2000


National Center for Health Statistics.2' A national probability sample of approximately 10,847 wonmen 15 to 44 years of age was selected for this survey. This study focused on a subpoptulation of AfricanAmerican females between the ages of 15 and 44 (unweighted numnber = 2446, weighted number = 8.2 million).The sample for the NFSG was selected from households that had participated in the 1993 National Health Interview Survey, another National Center for Health Statistics survey. Respondents in the NFSG were asked questions about their pregnancy history, past and current use of contraception, ability to bear children, prenatal care, and marriage and cohabitation history along with a variety of social, economic, and sociodemographic questions. The overall response rate for this survey was 79%. The findings reported by the sampled respondent were weighted to reflect their proportionate representation of the U.S. population as reflected in the Bureau of the Censtus March 1995 Current Population Survey. These weights account for the differences that occur in the probability of selecting an individual from the population.

Race and Ethnicity Classification by ethnic/racial background was based on information reported for each household member. Respondents were asked if their racial background was best described as African-American, black, Asian or Pacific Islander, Native American or Alaskan Native, white, or other race. All respondents were also asked whether their main national origin or ancestry was among the following Hispanic-American subpopuilations, regardless of racial background: Puerto Rican, Cuban, Mexican, Dominican, Costa Rican, Colombian, Ectuadorian, Honduran, El Salvadoran, or other Hispanic. The category "African American" was formed by including only respondents indicating their ethnicity as black and African American and not Hispanic (Latino).

Sexual Education History Questions regarding the type of sex education history (birth control method, STDs, safe sex, or abstinence) experienced by the respondent were based on self-reports of each type of sex education. The variables "ever had sex education on STDs," "ever had sex edtucation on birth control methods," "ever had sex education on safe sex," and "ever had JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

sex education on abstinence" represented persons who reported having sex edtucation for birth control methods, STDs, or abstinence, respectively.

Risky Sexual Behavior Questions The variable "'number of lifetime male sexual partners" was based on reported number of partners for both married and unmarried women who reported having sextual intercourse. The variable "how often did yotu or your partner use condoins for disease protection in the last 12 months" represents self-reported data on the frequiency of condom use by the respondents' m-ale partner. These self:reported meastures of behaviors are not the same as observations of their actual behavior. The variable regarding condom use does not determine correct use of the device, or the quality of the brand of condom used.

Perceptions of the Risk of HIV Infection The NFSG respondents who requested testing for HIV were asked, "What wouild you say are the chances that you are cturrently infected with HIV, the virus that causes AIDS?" They were also asked, "What would you say are the chances that yotu have had sexual intercoturse with someone who wvas infected with HIV, the virus that causes AIDS?" The responses for both of these quiestions wvere "high," "medium," "low," or "none." Responses from these questions were used to form the variables "Perceived chances of African-American females (ages 15-44) being infected with HIV" and "Perceived chances of African-American females having sex with someone who is infected with HIV" for the persons who reported having sexual intercouirse. The categories "high," "medium," and "low" were collapsed into the category "some" in these variables. None of the survey respondents were tested for HIV to verify self-reported responses to these

quLestions.

Tests of Significance Statistical significance of the findings wer-e assessed using SUDAAN, a program designed to account for the multi-stage sampling strategies used by the National (Center for Health Statistics in their health surveys. Student's t-test was used to determine the statistical significance of two percentages or means being compared in the analysis and to test the significance of the coefficients reported in the regression analyses. Unless otherwise noted, only VOL. 92, NO. 4, APRIL 2000

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statistically significant differences (p < 0.05) are discussed.

RESULTS Our data show (1995) nearly two-thirds of African-American females between 14 and 44 years of age reported receiving sex education about birth control methods, STDs, and abstinence. The other third did not receive any formal sex education (Table 1). Age, educational status, marital status, patterns of condom use, and perceived health status were correlated with sex education. Over 86% of African-American females between 14 and 19 years of age had some sex education about birth control methods, STDs, or abstinence compared with 55% of African-American females age 35 and 44, and 66% of African-American women age 30 and 34 (1 = 6.8, t = 5.8, p < 0.001). African-American women who were never married were more likely than married African-American females or widowed/divorced or separated African-American females to have ever received sex education on birth control methods, STDs, or abstinence. African-American females who had sex education about sexual abstinence were more likely to have had sex with male partners who used condoms occasionally (t = 3.6, p < 0.001). Corresponding with the patterns on age, AfricanAmerican females who had completed fewer than 12 years of schooling were more likely to have received sex education about birth control (t = 2.3, p < 0.01), STDs (t = 4.3, p < 0.001) or abstinence (t = 5.5, p < 0.001) than those with 12 years or more of completed schooling. This finding may reflect more of the current provision of sex education in the school system to those in middle or high school grades. Income level or place of residence did not factor significantly on chance of receiving sex education (Table 1). Table 2 shows the rate of condom use between African-American females and their partners. Consistent condom use is correlated with prevention of HIV infection. However, only one-third of the respondents reported consistent condom use. Consistent condom use varied by age, marital status, region, place of residence, education, lifetime number of sexual partners, and perceptions of anxiety. There was almost a linear relationship between age and the percentage of African-American females who stated consistent condoms use. The 186

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youngest females (ages 14 to 19) were most likely (48.1%) to state always using condoms, whereas the oldest age group (ages 35 to 44) was least likely (26.9%; t = 5.0, p < 0.001) to always use condoms. Martial status was also an indicator of condom use, with never married or divorced/'widowed/separated black women four times as likely as married women to always use condoms (38.8% and 39.3% vs. 9.9%, respectively; t = 6.4, p < 0.001). African-American females living in the largest cities were more likely than those living in smaller cities and in suburbs (38.6% vs. 25.4%; t = 3.6, p < 0.001) to always use condoms. African-American females who felt worried or anxious over the last 6 months were less likely than those who did not feel worried or anxious to always use condoms (28.1 vs. 35.5%; t = 2.0, p < 0.05). Finally, African-American females with one to three lifetime sexual partners were more likely than those with more than six lifetime sexual partners to always use condoms (43.0 vs. 28.0%; t = 3.4, p < 0.01) (Table 2). One of the barriers to HIV prevention among partners in exclusive relationships is the belief that condom use conveys a lack of trust.22 Wingood et al. reported that couples who did not use condoms were four times more likely to believe that asking the man to use a condom implied that he was unfaithful.23 St. Lawrence and colleagues (1998) reported that African-American women in exclusive relationships were more likely to be of higher education and income, less likely to use condoms, and more likely to engage in preventive behaviors.'3 Thus, the large variance in condom use reported in Table 2 according to SES, marital status and level of education is critical because it highlights a risk behavior among African-American women with higher SES: lack of condom use. Given these findings, further analyses were computed based on income and marital status. Married African-American women earning more than $50,000 were significantly more likely to not use condoms than married AfricanAmerican women earning less than $15,000 (87.0% vs. 58.5%; t = 2.0, p < 0.05; data not reported in the tables). In addition, African-American women age 25 and 29 and 30 and 34 with more than 12 years of completed schooling were more likely to not use condoms than African-American females of the same age group with less than 12 years of completed schooling (44.1% vs. 27.1% [t = 2.1, p < 0.05] and 55.2% vs. 37.0% [t = 2.0, p < 0.05], respectively) (not reported in the tables). VOL. 92, NO. 4, APRIL 2000


Table 1. Sex Education History of Survey Subjects

Birth control methods Yes No 69.4 30.6

Yes 70.6

No 29.2

Abstinence Yes No 66.0 34.0

1409 1303 1358 1460 2668

86.4 79.9 73.4 66.1 55.2

13.6 20.1 26.6 33.9 44.8

92.9 82.3 70.5 66.7 55.7

7.1 17.7 29.5 33.3 44.3

93.5 81.4 66.7 55.7 48.1

6.5 18.6 33.3 44.3 51.8

2069 1467 4673

65.1 56.6 75.3

34.9 43.4 24.7

66.2 57.3 76.9

33.8 42.7 23.1

58.7 52.1 73.5

41.3 47.9 26.5

1359 1712 4373 766

68.4 70.2 69.3 69.8

31.6 29.8 30.7 30.2

71.7 70.6 69.9 74.1

28.3 29.4 30.1 25.9

62.9 63.9 67.9 66.7

37.1 36.1 32.1 33.3

4531 2598 1080

70.3 68.5 67.5

29.7 31.5 32.5

71.4 70.4 69.4

28.6 29.9 30.6

65.8 63.6 72.2

34.2 36.4 27.8

1834 1451 1580 718

69.5 69.0 69.8 70.6

30.5 31.0 30.2 29.4

69.9 71.9 72.2 71.1

30.1 28.1 27.8 28.9

65.4 67.2 67.2 62.0

34.6 32.8 32.8 38.0

2494 2927 2688

74.4 68.1 66.8

25.6 31.9 33.2

78.0 67.0 69.0

22.0 33.0 31.0

77.1 62.4 59.8

22.9 37.6 40.2

Population

Characteristic

Total Age (years) 14-19 20-24 25-29 30-34 35-44 Marital status Married

Divorced/widowed/separated Never married Region Northeast Midwest South West Residence SMSA central city SMSA other Non-SMSA Income $50,000 Education level