Sex scripts and power: a framework to explain urban women's HIV sexual risk with male partners

Attitudes Toward the Uptake of Combination HIV Prevention Methods Among Young Black and Latino Heterosexual Couples Living in New York City: A Qualitative Study

ABSTRACT

Couple-based HIV interventions that increase uptake of two or more effective biomedical HIV prevention methods may be a promising HIV prevention strategy for young Black and Latino heterosexual couples. We conducted in-depth, semi-structured individual interviews with 23 Black and Latino adolescent and young adult heterosexual couples that explored their attitudes toward using combination HIV prevention methods (CHPMs). A qualitative hybrid thematic analysis approach was used to identify key themes. Themes included: (a) attitudes that encouraged uptake-CHPMs increased assurance of safety against HIV/sexually transmitted infections and (b) attitudes that impeded uptake-CHPMs are too much to do and are not appropriate for serious relationships. Although Black and Latino adolescents and young adults may recognize the combined protective benefits of using multiple HIV prevention methods, personal and relational considerations play an instrumental role in uptake of CHPMs.

Feminine gender norms and syndemic harmful drinking, sexual violence, and sexually transmitted infections among Black women at risk for HIV

BACKGROUND

This study examined the associations between feminine gender ideologies (i.e., socially constructed attitudes and beliefs of women's appropriate behavior and roles) and the syndemic comorbidities of harmful alcohol use, sexual violence, and sexually transmitted infections (STI), which disproportionately affect Black women.

METHODS

Black women, aged 18-44 (n = 305) were recruited from STI clinics in Baltimore, MD into a retrospective cohort study. A survey assessed feminine gender ideologies using a measure of hyperfemininity and sexual hyperfemininity (subscale of sexual domains), harmful drinking (AUDIT), lifetime STI (Y/N and count), and syndemic burden (no burden [0-1 morbidity] and syndemic burden [2-3 comorbidities]). Multivariable regression models identified correlates of harmful drinking, STI, and syndemic burden. The analytic sample included (n = 231) women with complete data.

RESULTS

Nearly half of our sample reported high hyperfemininity and high sexual hyperfemininity, 23% reported harmful drinking, 39% experienced sexual violence as an adult, and 74% reported a lifetime STI. High sexual hyperfemininity (Adjusted Odds Ratio [AOR] = 1.94, 95% Confidence Interval [CI]: 1.00-3.76) and sexual violence (AOR = 2.82, 95%CI: 1.43-5.58) were associated with greater odds of harmful drinking. Experiencing sexual violence in adulthood was associated with an increased count of lifetime STIs (Adjusted Incidence Rate Ratio [AIRR] = 1.33, 95%CI: 1.06-1.68). Syndemic burden affected 41% of our sample. High sexual hyperfemininity was associated with experiencing syndemic burden in unadjusted models (OR = 1.98, 95%CI: 1.16-3.37), but was not significant after controlling for confounders.

CONCLUSIONS

Interventions to reduce harmful drinking and STIs among Black women in the U.S. should address sexual gender ideologies and sexual violence.

Acceptability of the "Love, Sex, & Choices" HIV Prevention Intervention by Hispanic Female College Students

INTRODUCTION

Hispanic women are affected by HIV. "Love, Sex & Choices" (LSC) is an innovative 12-episode urban soap opera video series targeting young adult Black women streamed to smartphones. This study purpose was to determine whether LSC is an acceptable HIV prevention intervention for female Hispanic college students in South Florida.

METHOD

After institutional review board approval, female Hispanic college students were recruited from two campuses to watch the LSC video series and complete an online evaluation survey.

RESULTS

Study participants (n =101) evaluated LSC as definitely/probably important for women (97.0%), helpful for making relationship decisions (86.2%), changing attitudes about having sex (79.2%), asking partners to use a condom (80.2%), leaving partners who won't use condoms (74.2%), handling oneself in tough situations in a relationship (79.2%), and getting an HIV test (83.2%). Participants liked/related to LSC and thought their friends would also like the series.

CONCLUSIONS

Results indicated that young Hispanic women related to the video series, were likely to get HIV tested after watching the video series, found the story lines realistic, and thought their friends would like the series. The next step is to test the effectiveness of LSC to change behaviors of young Hispanic women at risk of HIV.

Risk behaviors for HIV infection. A review of emerging trends

HIV infection, acquired with the conscious participation of the recipient, is a complex problem of international concern, especially among men who have sex with men. Behaviors emerge such as bareback (intentionally unprotected anal sex between men) and bugchasing (bareback sex when one participant is HIV+ and the other is not). A group of emerging risk behaviors for HIV infection was characterized. A review of the literature in the MEDLINE, Web of Science and regional SciELO databases was performed. HIV-related search terms such as unprotected sex, barebacking/bareback and bug chasing, were used. Bareback and bug chaser behaviors occur, among other factors, through social homonegativity, ART positive coverage, insufficient prevention campaigns, search for new sensations and attempts to strengthen the relationship with the HIV+ member. Unprotected sex is primarily associated with having HIV/AIDS diagnoses, physical violence due to sexual orientation, viewing homosexual sex sites, and having bought or sold sex. It is necessary to work with individual behaviors that draw individuals close to infection.

Reduction in a high-risk sex script among young urban women in the Love, Sex, & Choices web video HIV prevention intervention study

For women, the high-risk sex script of condomless sex to maintain relationships with men is concerning, particularly in regard to heterosexual HIV acquisition. This secondary analysis of data from a clinical trial evaluated the effect of a 12-episode, web-based video series intervention, entitled Love, Sex, and Choices, versus a text message control on lowering the high-risk sex script. The sample comprised 238 predominately urban Black women, ages 18-29, having HIV sex risk behavior. Data were collected at baseline and 6 months post-intervention. The Sex Script Video Response score was used to measure a high-risk sex script. HIV sex risk behavior was measured by Vaginal Equivalent Episodes with high-risk partners. At baseline, lower education, younger age at first sexual intercourse, and alcohol/non-injection drug use before sex were positively associated with a high-risk sex script. At baseline, as the high-risk sex script increased by one log unit, sex risk behavior increased by 0.47 log units (p < 0.001), equivalent to a 60% increase in the geometric mean of sex risk behavior. ANCOVA analysis indicated that from baseline to 6-months post intervention, lowering the high-risk sex script by one unit was associated with an additional reduction of 0.26 units in sex risk behavior. Compared to the text messages, the LSC video series was associated with a 27% greater reduction in the geometric mean of the sex script (p = 0.03). Further investigation into the effect of lowering sex scripts to reduce sex risk behavior is recommended.

Black Women's Approaches to Encourage a Male Partner to Test for HIV: Preliminary Adaptation and a Factor Analysis Study of the HIV Testing Approach Scale

BACKGROUND AND PURPOSE

Black women are disproportionately affected by HIV. Increasing status awareness through partner testing can improve status awareness and reduce transmission. Varying approaches to encourage HIV testing are described but a measurement instrument is lacking. The AIDS Discussion Strategy Scale (ADSS) was adapted into the HIV Testing Approach Scale (HTAS) to measure Black women's approaches to encourage partners to test for HIV.

METHODS

Preliminary adaptation included five steps to ensure validity. Participants comprised 158 sexually active 18-29-year-old Black women. The HTAS was analyzed with principal components analysis (PCA).

RESULTS

PCA indicated a four-factor model explaining 67% of variance. Four distinct approaches were Active Persuasion, Decisive Collaboration, Ultimatum, and Sweet Talking. The HTAS approaches demonstrated adequate reliability.

CONCLUSION

The HTAS may serve as a valid and reliable instrument for research. HIV prevention should encourage testing discussion to increase status awareness.

Gender and race as correlates of high risk sex behaviors among injection drug users at risk for HIV enrolled in the HPTN 037 study

BACKGROUND

Sexual contact has been shown to be a major mode of HIV transmission among people who inject drugs (PWID). This study examined gender and racial differences among PWID' sexual risk behaviors from the perspective of sexual scripts.

METHODS

696 PWID enrolled from Philadelphia on HPTN 037 were classified as engaging in high-risk sex behaviors if they reported having sex in the past 30 days and condomless sex with a non-primary partner, giving/receiving sex for money, or multiple partners. A multivariable logistic regression model was used to assess associations between demographic factors and high risk sex.

RESULTS

Findings of the multivariable regression analysis demonstrated that being White (OR = 0.52, p < 0.001) and male (OR = 0.59, p = 0.002) were protective of high risk sex, while homelessness (OR = 1.7, p = 0.005), and being single (OR = 1.83, p = 0.006) were positively associated with high risk sex. African American (AA) women were 1.7 times more likely to report high-risk sex than AA men (p = 0.002), 3.28 times more likely than White men (p < 0.001), and 1.93 times more likely than White women (p < 0.001).

CONCLUSIONS

Since AA women report high-risk sex behaviors more than other demographic groups, behavioral interventions for HIV risk reduction among PWID may benefit from focusing on sex-risk reduction among AA women.

Facebook Advertising to Recruit Young, Urban Women into an HIV Prevention Clinical Trial

Advertising via Facebook to elicit involvement in clinical trials has demonstrated promise in expanding geographic reach while maintaining confidentiality. The purpose of this study is to evaluate Facebook advertising to reach at-risk, predominately African American or Black women in higher HIV prevalence communities for an HIV prevention clinical trial, and to compare baseline characteristics to those recruited on-the-ground. Maintaining confidentiality and the practical aspects of creating and posting ads on Facebook are described. The advertising strategy targeted multicultural affinities, gender, age, interest terms, and zip codes. We report on results during 205 days. A total of 516,498 Facebook users viewed the ads an average of four times, resulting in 37,133 clicks to the study website. Compared to 495 screened on-the-ground, 940 were screened via Facebook ads, of these, half (n = 477, 50.74%) were high risk, and of those at risk, 154 were randomized into the 6-month clinical trial. Black women comprised 71.60% (n = 673) of the total screened online. Roughly twice as many Black women screened via Facebook compared to on-the-ground, yet, the percentage at high risk was similar. Preliminary data suggest that the extent to which ad headlines and photos tap into authentic social experience, advertising on Facebook can extend geographic reach and provide a comparative sample to women recruited on-the-ground.

Educated and At-Risk: How the Shortage of Available Partners Influences HIV Risk for College-Educated African-American Women

BACKGROUND

African-Americans have the greatest gender-ratio imbalance compared to other racial groups in the United States. This has been associated with higher rates of concurrent sexual partnerships, increasing risk of HIV infection. College-educated African-American women are of particular interest as they are not often represented in studies on HIV prevention, while their dating and sexual negotiation patterns may differ from those of their lower-educated and lower-income counterparts more often the subject of study in HIV research among African-Americans.

METHOD

In this qualitative study, we investigate: a) how the gender-ratio imbalance is perceived by college-educated African-American women, b) how they feel limited partner availability impacts heterosexual relationships in the African-American community, and c) the influence this has on their sexual decision making and HIV protective behaviors.

RESULTS

Four major themes emerged- Limited pool of available male partners, Pressure to get married, Feelings of competition among women for male partners, and Men's negotiating power in relationships.

CONCLUSIONS

Using the PEN-3 Cultural Model, we discuss how this information may be used to develop interventions for this group of women designed to address their more specific barriers to HIV risk reduction.

Theoretical Implications of Gender, Power, and Sexual Scripts for HIV Prevention Programs Aimed at Young, Substance-Using African-American Women

HIV continues to be a major public health problem for African-American (AA) women, and the burden of new cases to our society is significant because each case is at risk of infecting others. Substance use worsens the risk of HIV transmission to AA women. We provide specific recommendations to move the concept of tailoring HIV prevention interventions for substance users forward by focusing on young, sexually active, substance-using AA women and applying a culturally relevant revision to existing theoretical frameworks to include the Sexual Script Theory and the Theory of Gender and Power. We encourage use of these theories to guide adaptation of interventions to demonstrate efficacy within this hard-to-reach population. Consistent use of theories designed to exploit powerlessness and sexual scripts as barriers to adoption of protective sexual behaviors has potential to permeate sexual and substance use networks among African-Americans. This recommendation is being made because this theoretical framework has not been used in HIV prevention interventions targeting young, sexually active, substance-using AA women.

Leveraging changing gender norms to address concurrency: focus group findings from South African university students

Background This study aims to complement recent research on sexual concurrency in South Africa by providing a deeper understanding of women's roles and motivations for engaging in and accepting their partners' concurrency. Our goal is to inform the implementation of more effective interventions that embrace the powerful role that women can play in healthy sexual decision-making in consensual relationships.

METHODS

We conducted 12 focus groups with male and female students at the University of KwaZulu-Natal. Drawing on a subset of those focus groups, we examined the gender norms underpinning the apparently widespread acceptance of concurrent sexual partnerships. Our analysis focusses on women's attitudes and behaviours towards concurrency - from both men's and women's perspectives - with a goal of identifying opportunities to engage women as agents of change in sexual partnership patterns in their communities.

RESULTS

Our findings indicate that: (1) concurrent sexual partnerships were the norm among male students and increasingly common among female students; (2) material gain and changes in women's perceptions of their roles and power in relationships were the primary female motives for concurrency; (3) peer pressure, a perceived innate need and a fear of being alone were the primary male motives for concurrency; (4) women often know that their partners are cheating and stay with them because they believe they are the most important partner, for financial reasons, or because they worry they will not find another partner.

CONCLUSIONS

HIV prevention interventions in populations where concurrency is common would benefit from emphasising women's role and power in taking greater control of their own sexual decision-making in consensual and nonviolent relationships.

"Is Your Man Stepping Out?" An Online Pilot Study to Evaluate Acceptability of a Guide-Enhanced HIV Prevention Soap Opera Video Series and Feasibility of Recruitment by Facebook Advertising

Love, Sex, and Choices (LSC) is a 12-episode soap opera video series developed to reduce HIV risk among at-risk Black urban women. We added a video guide commentator to offer insights at critical dramatic moments. An online pilot study evaluated acceptability of the Guide-Enhanced LSC (GELSC) and feasibility of Facebook advertising, streaming to smartphones, and retention. Facebook ads targeted high-HIV-prevalence areas. In 30 days, Facebook ads generated 230 screening interviews: 84 were high risk, 40 watched GELSC, and 39 followed up at 30 days. Recruitment of high-risk participants was 10 per week, compared to seven per week in previous field recruitment. Half the sample was Black; 12% were Latina. Findings suggest GELSC influenced sex scripts and behaviors. It was feasible to recruit young urban women from a large geographic area via Facebook and to retain the sample. We extended the reach to at-risk women by streaming to mobile devices.

A randomized controlled trial of soap opera videos streamed to smartphones to reduce risk of sexually transmitted human immunodeficiency virus (HIV) in young urban African American women

BACKGROUND

Love, Sex, and Choices (LSC) is a soap opera video series created to reduce HIV sex risk in women.

METHODS

LSC was compared to text messages in a randomized trial in 238 high-risk mostly Black young urban women. 117 received 12-weekly LSC videos, 121 received 12-weekly HIV prevention messages on smartphones. Changes in unprotected sex with high risk partners were compared by mixed models.

RESULTS

Unprotected sex with high risk men significantly declined over 6 months post-intervention for both arms, from 21-22 acts to 5-6 (p < 0.001). This reduction was 18 % greater in the video over the text arm, though this difference was not statistically significant. However, the LSC was highly popular and viewers wanted the series to continue.

CONCLUSION

This is the first study to report streaming soap opera video episodes to reduce HIV risk on smartphones. LSC holds promise as an Internet intervention that could be scaled-up and combined with HIV testing.

Gender ratio imbalance effects on HIV risk behaviors in African American women

Although literature suggests that African American women are no more likely to engage in risky sex than their White counterparts, they are more likely to have sex partners with higher HIV risk. Thus, it is not solely an individual's behavior that determines their risk, but also the behavior of their partner and their position within a sexual network. For this reason, it is important to consider the dynamics of heterosexual relationships in the African American community. An important area of concern regarding African American heterosexual relationships is that of partner availability. A shortage of available African American men for potential partnerships exists and is reportedly due to poorer health and higher mortality rates. Some have argued that gender-ratio imbalance may be responsible for increased HIV vulnerability for African American women. This article reviews the literature on gender ratio imbalance and HIV risk in the African American community, and presents implications and suggestions for future research and intervention.

Risky relationships: targeting HIV prevention for women offenders

HIV is a health issue for women offenders who are at particularly high risk. Women's prisons can be opportune settings for HIV prevention interventions. How women perceive partner relationships could be central to targeting HIV interventions. Consequently, this study examines changes in women offenders' risky relationships. Baseline and follow-up data are presented from 344 women offenders. Intent-to-treat analysis is used as well as analysis of covariance to control for baseline values. Findings indicate that women released to the community from prison who were randomized into the prevention intervention were significantly more likely to report changes in five of seven risky relationship thinking myths. Findings suggest that a relationship theory-based prevention intervention for reducing HIV risk could be promising for women offenders reentering the community after prison. Additional research is suggested.

Streaming weekly soap opera video episodes to smartphones in a randomized controlled trial to reduce HIV risk in young urban African American/black women

Love, Sex, and Choices is a 12-episode soap opera video series created as an intervention to reduce HIV sex risk. The effect on women's HIV risk behavior was evaluated in a randomized controlled trial in 238 high risk, predominately African American young adult women in the urban Northeast. To facilitate on-demand access and privacy, the episodes were streamed to study-provided smartphones. Here, we discuss the development of a mobile platform to deliver the 12-weekly video episodes or weekly HIV risk reduction written messages to smartphones, including; the technical requirements, development, and evaluation. Popularity of the smartphone and use of the Internet for multimedia offer a new channel to address health disparities in traditionally underserved populations. This is the first study to report on streaming a serialized video-based intervention to a smartphone. The approach described here may provide useful insights in assessing advantages and disadvantages of smartphones to implement a video-based intervention.

Pathways to embodiment of HIV risk: black men who have sex with transgender partners, Boston, Massachusetts

A dearth of research to date has explored HIV risk among Black men who report sex with transgender partners. In 2008, 197 Black men residing in Massachusetts were recruited via modified respondent-driven sampling and completed an interviewer-administered survey. Overall, 8% reported sex with a transgender partner in the past 12 months. Over half (56%) reported unprotected sex during their last encounter with transgender partners. Factors significantly associated with having a transgender sex partner: history of substance abuse, incarceration, PTSD symptoms, lower levels of perceived social support, not having been exposed to HIV prevention services in the past 12 months, and endorsement of mobile van services as a comfortable location to access health care. These formative data suggest that Black men who partner with transgender individuals may be at elevated risk for an array of poorer health-related outcomes, including HIV sexual risk, substance abuse, incarceration, psychosocial vulnerability, and lack of access to health care. Theory-driven interventions that consider the broader context affecting the embodiment of HIV risk are warranted for men who have sex with transgender partners.

An alternate HIV preventive strategy: sex scripts in media for women of color

New cases of HIV/AIDS among women of color in the United States highlight the continuing need for the public and private sectors to develop alternate preventive strategies. The author discusses the conceptual basis for using television sex scripts to incorporate women of color relational needs (trust, romance, sexual pressure) to promote HIV risk-reduction messages through a process of association with the television storyline. Sex scripts are a source of implicit knowledge about how to behave in situations that involve sexual intimacy. The article suggests that sexual scripts prevention messages build on the agency of women through the use of power theory-that is supporting woman's self-power by participating in sexual behavioral change. Implications for sexual equality in media programming are discussed.

Elucidating women's (hetero)sexual desire: definitional challenges and content expansion

The literature on women's sexual desire is reviewed with an emphasis on definitional challenges, an assessment of the empirical basis for the distinction between spontaneous and responsive desire, a reconsideration of the extent to which women's sexual desire is relational in nature, and an exploration of the incentive value of sex for women as a factor partially independent from the experience of sexual desire. Nine recommendations are made regarding research and diagnostic directions. The article concludes with an appeal for the inclusion of eroticism in research and clinical work on sexual desire.

Reliability and validity of the Sexual Pressure Scale for Women-Revised

Sexual pressure among young urban women represents adherence to gender stereotypical expectations to engage in sex. Revision of the original five-factor Sexual Pressure Scale was undertaken in two studies to improve reliabilities in two of the five factors. In Study 1 the reliability of the Sexual Pressure Scale for Women-Revised (SPSW-R) was tested, and principal components analysis was performed in a sample of 325 young, urban women. A parsimonious 18-item, four-factor model explained 61% of the variance. In Study 2 the theory underlying sexual pressure was supported by confirmatory factor analysis using structural equation modeling in a sample of 181 women. Reliabilities of the SPSW-R total and subscales were very satisfactory, suggesting it may be used in intervention research.

Soap opera video on handheld computers to reduce young urban women's HIV sex risk

The purpose of this study was to develop a soap opera video, A Story about Toni, Mike, and Valerie, designed to communicate HIV risk reduction themes. The study evaluated viewing the video and responding to audio computer assisted self-interview (ACASI) on a handheld computer. The sample was 76 predominately African American women, aged 18-29, in sexual relationships with men. Data were collected in urban neighborhoods in the northeastern United States. A pretest-posttest control group design with systematic assignment indicated statistically significant reduction in expectations to engage in unprotected sex in the experimental group. The handheld computer was found to be acceptable to view the near feature length video and complete ACASI. To date, no study has reported on use of video and ACASI on a handheld device to reduce HIV risk. The significance is the potential to stream health promotion videos to personal devices, such as cell phones.

Young urban women's patterns of unprotected sex with men engaging in HIV risk behaviors

This study explored reasons women engaged in unprotected sex with male partners they distrusted and perceived to engage in HIV risk behaviors. Seven focus groups were held in public housing and neighborhood centers in the urban Northeast with 43 African American and Latina women. Content analysis was conducted by open and axial coding. Barrett's theory of power as knowing participation in change and sex script theory guided interpretation. Results indicated that Patterns of Unprotected Sex is a usual practice to maintain hope, sensuality, intimacy, strategic gain, and stability with a male partner. In low power sex scripts the salient risks of HIV were buried under an awareness of oneself as having to satisfy a man and accept cheating. High power sex scripts involved women's awareness of themselves as worthy of self care with diverse choices. High power scripts can be integrated into normative sex scripts as exemplars of more powerful ways of being and acting to reduce HIV risk.