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Sexual, social factors put women at greater HIV risk
Adaora Adimora, MD, MPH, professor of medicine in the Division of Infectious Disease at the University of North Carolina School of Medicine in Chapel Hill, recently discussed her research on the nuances of HIV risk behavior among women with AHC Media, publisher of Contraceptive Technology Update. Our first question was: Would you please explain your findings that there is an association between women having concurrent relationships and having non-monogamous partners?
Adimora: We found that women who have multiple partnerships often have relationships with men who also have multiple partners at the same time. This finding in and of itself is not especially surprising. If you know your partner is not exclusively committed to you, you'll probably have less motivation to be exclusively committed to him. The finding is important from an epidemiologic standpoint, though, because it suggests that the sexual networks are densely connected, affording more opportunities for HIV spread.
AHC Media: How important a factor is this when compared with other HIV risk factors, including substance use?
Adimora: From a network perspective, concurrency and sexual mixing between different risk subpopulations are important. These are links between substance users and non-substance users that can bridge spreading of infection from drug using networks to the general population of people who don't use drugs. What's notable from an epidemiological standpoint is the presence of sexual mixing between different subpopulations and concurrency. For an infection to spread within a population, you need both links to other people and a source of infection. This mixing between drug users and the general population and concurrency can be especially powerful in spreading infection.
AHC Media: Your research underscores the importance of reducing the economic and contextual barriers to long-term stable monogamy. Would you please explain some more about these barriers, particularly within the African American community?
Adimora: Probably the biggest barriers for African Americans are poverty, discrimination, and the low sex ratio the ratio of men to women. Here are some examples: the shortage of black men (low sex ratio) places women at a disadvantage in negotiating and maintaining mutually monogamous relationships. Poverty stresses relationships. It decreases the likelihood that people will marry and increases their risk of divorce. Incarceration is destructive to long-term relationships and is associated with concurrency, and it also increases risk of poverty and the number of available men.
I also refer you to a piece in The New York Times [May 30, 2010 "Blacks in Memphis Lose Decades of Economic Gains"] that graphically describes the marked differences in wealth between U.S. whites and blacks and Hispanics and the disproportionately devastating effects the recent recession has had on blacks in the U.S. These differences in wealth result in marked differences not only in life opportunities but also in risk environments for African Americans.
AHC Media: What is your 'take-home' message with regard to public HIV prevention strategies and also with how clinicians should address HIV prevention with patients who are newly infected?
Adimora: We need to gain more understanding of what personal and contextual factors influence concurrency, increase public awareness of the HIV transmission risk it poses, and develop effective, culturally appropriate interventions to reduce concurrency or increase condom use in such situations. To successfully control the HIV epidemic, we'll need to address the economic forces, social influences, and other contextual factors that [undermine] stable monogamy, thereby increasing concurrency in the overall population and in different population subgroups.