Transactional sex and HIV risk among incarcerated African American women in North Carolina

1. Transactional sex and HIV risk among incarcerated African American women in North Carolina Claire Farel, MD, MPH UNC-Chapel Hill cfarel@med.unc.edu

2. Background • HIV disproportionately affects African American women in the Southeastern U.S. 1-3 • For reasons not completely understood, women who have been in prison carry a greater lifetime risk of HIV. 4 • HIV is five times as prevalent among incarcerated African American (AA) women in North Carolina (NC) as among their unincarcerated AA counterparts. 5,6

3. BackgroundTransactional sex, women, and HIV • History of incarceration has been associated with unstable partnerships, partner concurrency, and transactional sex practices among women.7 • Incarceration, substance abuse, and transactional sex (TS) are closely linked HIV risk factors in our study population.

4. BackgroundThe role of lifetime trauma • Sexual and physical abuse are important contributors to sexual risk behavior and specifically HIV risk.8-10 • Childhood sexual abuse (CSA), intimate partner violence (IPV), and resulting psychological trauma play a central role in the lives of incarcerated HIV-positive and at-risk women and are common components of the life history of women who engage in TS. 11-13

5. Methods • These data are part of a parent study designed to explore the differences in HIV risk factors between HIV-positive and HIV-negative women in prison in NC. • The Social Ecological Model was used as a conceptual framework to explore risk on multiple levels.14 • Audiotaped qualitative interviews were conducted with 29 AA women (15 HIV-positive, 14 HIV-negative) by two interviewers.

6. Institutional Factors Information resources, condom distribution policies, church position on HIV/AIDS Intrapersonal Factors Mental health, substance abuse, attitudes/knowledge about HIV/AIDS and safer sex BEHAVIORS Interpersonal Factors Social support, living situation, intimate partnership quality, transactional sex Community Factors Resources for information and assistance, availability of condoms, safer sex messages Social Ecological Model of Behavior

7. Methods • Interviews explored potential pre-incarceration HIV risk factors on multiple levels (e.g. community, interpersonal, intrapersonal). • Participants were interviewed within three months after entry into the NC prison system. • We defined transactional sex as report of ever having received money, goods, drugs, or services for sex.

8. ResultsParticipant characteristics

9. Results Defined as unwanted sexual experiences under the age of 18 Non-IPV, non-CSA sexual violence

10. Results: Transactional sex • A history of TS in this population was common, with 14 of 29 women reporting a history of sex for money, drugs, or goods. • A greater number of HIV-positive women reported TS (10 of 15 HIV-positive women as compared to four of 14 HIV-negative women). • Of the 10 HIV-positive women reporting TS, four had both male and female non-transactional sexual partners and one reported only female non-transactional partners.

11. Results: Transactional sex • Most of the HIV-negative women related a small number of incidents in which they accepted money or goods for a sexual act. • All HIV-positive and –negative women reporting TS also reported crack cocaine use. • HIV-positive women related periods of time in which TS was linked to prolonged substance use and was a regular occurrence. • Most of the women who related a history of TS linked their TS to drug use, trading sex for drugs or for money to buy drugs.

12. Transactional sex and drug use: A 28-year-old HIV-negative woman “So when I first started out sniffing cocaine … it's the same thing as prostitution, but you just look at it different because of the fact that you're not on the street corner prostituting your body, selling your body. You're selling your body at the club … Or at a bar, you meet somebody and it's kinda like a one-night's thing kind of a thing … For money, you know what I'm saying. They pay you. But it's not like you go there and it's like, ‘pay me for sex’. It's like you kinda like let them offer you; you know what I'm saying, versus somebody that works the street corners like, "I need my money." ... But all in all it's the same thing. There's really no difference. ”

13. Drug use as a gateway to transactional sex “With the drug use and me wanting to get high … I had to do it some kind of way, so I just be walking down the street. Somebody see me and it went from there. That's how I went. And I just be walking. ” A 39-year-old HIV-positive woman “I ain’tgonna say I had to. When I was on drugs, yeah, I prostituted … I’m able to do what I got to do, but you go ahead and get out of my face because I ain’tgot time. And I mean when I wasn’t on drugs, like I said, I didn’t have that part in my life, because I’m not a promiscuous person and I don’t like being with nobody unless [my] heart in it.” A 40-year-old HIV-positive woman

14. Transactional sex and HIV risk A 48-year-old HIV-positive woman “I moved to [another city] one time and I was on crack real bad. These drug dealers or so-called pimps or whatever, I wanted to get high. I ain’t care how I got high, so I tricked without condoms or I’ll have sex with a couple boyfriends without condoms. Who does that? You don’t know these people for real, now that I got [HIV]. You don’t know these people.”

15. Transactional sex and HIV risk “You know, I don’t understand these men. I tell them that I’m HIV positive, and they act like I just said I have a headache. And you still want to have unprotected sex. That scares me, too. But of course, there go that security again, that money, the car to drive, the place to stay, the alcohol, the drugs. Okay.” A 33-year-old HIV-positive woman

16. TS as a part of lifelong violence:A 33-year-old HIV-positive woman “Whenever I was at my mom’s house – whenever I did stay the night there …[her boyfriend] would just – it was always touching and … I was very young at that time, and the last time he molested me, I was nine.” • Childhood sexual abuse • Betrayal and abuse at the hands of adults and caregivers • Older partners “Yeah, and I got raped one time in [city] by three guys. I think I was about 13 then.” “And, again, when I was 13, I met this [33-year-old] man, and I lived with him for two years. And I didn’t know that he was paying my mom in drugs at the time for her not to call the police.”

17. Lifelong violence:A 33-year-old HIV-positive woman • Substance abuse • Transactional sex • Betrayal and abuse at the hands of adults and caregivers • Older partners • Intimate partner violence • Further TS, HIV infection, Incarceration “I ran away and went to this lady’s house … I just felt very alone, and I ended up gettin’ high … she started bringin’ guys to the house [to make money] … And she’d always tell me, “You don’t have to [have sex with them],” … But one time, it didn’t work, and I ended up gettin’ raped, and I never did that again.” “I was 17. He was 35, and drugs were involved … crack cocaine and alcohol, and I don’t even remember why we used to fight … I looked like the elephant woman…. as soon as my face healed, I left him.”

18. Results • TS work was closely linked to crack cocaine use, particularly among the HIV-positive women. • Both crack use and TS presented opportunities for violence in the lives of these women, many of whom described a lifetime marked by traumatic violence and abuse. • Illegal drug use starting at a young age contributed to women’s experience of violence/abuse • Drugs were used as a coping mechanism in surviving traumatic events, providing another pathway to TS.

19. Conclusions • Individual and community-level pressures led these women to engage in TS, exposing them to disease, physical/sexual violence, and continued drug use. • As none of the women in this sample were incarcerated on TS-related charges, identification of women at risk for TS on release may be difficult but warrants further exploration. • The social harms conveyed by TS, crack cocaine, and lack of economic power warrant development of interventions to decrease HIV risk and improve lifetime health for these women.

20. Conclusions • The legacy of trauma was significant and pervasive in this vulnerable population of HIV-positive and HIV-negative women. • Prison represents an opportunity for specific trauma screening in a high-risk population to break this cycle. • The intersection of lifetime trauma with substance abuse, lack of agency and economic power, and TS underscores the need for integrated interventions in this population to decrease HIV risk and improve community health.

21. Acknowledgements This project was supported by the NIH (F32 DA030268-01). Additional support was provided by the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410).

22. References • Prejean J, Song R, Hernandez A, Ziebell R, Green T, Walker F, et al. Estimated HIV incidence in the United States, 2006-2009. PloS One. 2011;6(8):e17502. • Hodder S, Hughes JP, Wang J, Haley D, Adimora A, et al. The HPTN 064 (ISIS Study)—HIV Incidence in Women at Risk for HIV: US. Poster presented at: The 19th CROI. http://www.retroconference.org/2012b/Abstracts/43702.htm. 2012. • Greenfeld LA, & Snell, T. L. . Women offenders (Bureau of Justice Special ReportNCJ 175688). Washington, DC: Department of Justice. 1999. • Staton-Tindall M, Leukefeld C, Palmer J, Oser C, Kaplan A, Krietemeyer J, et al. Relationships and HIV risk among incarcerated women. Prison J. 2007;87(1):143-65. • N.C. Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) http://epi.publichealth.nc.gov/cd/stds/figures/Epi_Profile_2011.pdf • DOC RESEARCH AND PLANNING Automated System Query (A. S. Q. DOC 3.0b ) Prison Population 3-31-2012 http://webapps6.doc.state.nc.us/apps/asqExt/ASQ. • Khan MR, Wohl DA, Weir SS, Adimora AA, Moseley C, Norcott K, et al. Incarceration and risky sexual partnerships in a southern US city. Journal of urban health : bulletin of the New York Academy of Medicine. 2008;85(1):100-13.

23. References 8. Campbell JC, Baty ML, Ghandour RM, Stockman JK, Francisco L, Wagman J. The intersection of intimate partner violence against women and HIV/AIDS: a review. International journal of injury control and safety promotion. 2008;15(4):221-31. 9.Pence BW, Mugavero MJ, Carter TJ, Leserman J, Thielman NM, Raper JL, et al. Childhood Trauma and Health Outcomes in HIV-Infected Patients: An Exploration of Causal Pathways. Journal of acquired immune deficiency syndromes (1999). 2012;59(4):409-16. 10. Kimerling R, Calhoun KS, Forehand R, Armistead L, Morse E, Morse P, et al. Traumatic stress in HIV-infected women. Aids Educ Prev. 1999;11(4):321-30. 11. Machtinger EL, Wilson TC, Haberer JE, Weiss DS. Psychological Trauma and PTSD in HIV-Positive Women: A Meta-Analysis. AIDS and behavior. 2012. 12. Whetten K, Leserman J, Lowe K, Stangl D, Thielman N, Swartz M, et al. Prevalence of childhood sexual abuse and physical trauma in an HIV-positive sample from the deep South. American journal of public health. 2006;96(6):1028-30. • Harlow CW. Prior Abuse Reported by Inmates and Probationers. Washington,DC: U.S. Department of Justice, Bureau of Justice Statistics. 1999. • McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health education quarterly. 1988;15(4):351-77.