Transactional sex and HIV risk
among
incarcerated African American
women in North Carolina
Claire Farel, MD, MPH
UNC-Chapel Hill
cfarel@med.unc.edu
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
Background
Transactional 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.
Background
The 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
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.
Social Ecological Model of Behavior
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
Interpersonal Factors
Social support, living situation, intimate
partnership quality, transactional sex
Community Factors
Resources for information and assistance,
availability of condoms, safer sex messages
BEHAVIORS
Methods
• Interviews explored potential preincarceration 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.
Results
Participant characteristics
HIV-positive
(n=15)
HIV-negative
(n=14)
Total
(n=29)
37.8 (24-60)
29.9 (19-41)
34.0 (19-60)
Participants born in NC
12 (80%)
13 (93%)
25 (86%)
Mean number prior NC
incarcerations (range)
3.8 (1-9)
1.9 (1-8)
2.9 (1-9)
Mean years of school
10.5
10.9
10.7
Completed 12th grade
or GED
8 (53%)
12 (86%)
20 (69%)
Mean age in years
(range)
Results
HIV-positive
(n=15)
HIV-negative
(n=14)
Total
(n=29)
Childhood sexual abuse
(CSA)1
8 (53%)
9 (64%)
17 (59%)
Intimate partner violence
(IPV)
9 (60%)
9 (64%)
18 (62%)
IPV with >1 partner
5 (33%)
4 (29%)
9 (31%)
IPV and CSA
4 (27%)
6 (43%)
10 (34%)
Other sexual violence2
7 (47%)
3 (21%)
10 (34%)
Other nonsexual violence
4 (27%)
6 (43%)
10 (34%)
Transactional sex ever
10 (67%)
4 (29%)
14 (48%)
Crack cocaine use ever
13 (87%)
5 (36%)
18 (62%)
1. Defined as unwanted sexual experiences under the age of 18
2. Non-IPV, non-CSA sexual violence
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.
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.
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. ”
Drug use as a gateway
to transactional sex
A 39-year-old
HIV-positive
woman
“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. ”
“I ain’t gonna 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’t got
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-yearold HIVpositive
woman
Transactional sex and HIV risk
A 48-yearold HIVpositive
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.”
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-yearold HIVpositive
woman
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.”
“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-yearold] 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.”
• Childhood
sexual abuse
• Betrayal and
abuse at the
hands of
adults and
caregivers
• Older partners
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.”
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.
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.
Conclusions
• The legacy of trauma was significant and pervasive in
this vulnerable population of HIV-positive and HIVnegative 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.
Acknowledgements
•
•
•
•
•
•
•
Sharon D. Parker
Kathryn Muessig
Catherine Grodensky
Chaunetta Jones
Carol Golin
Cathie Fogel
David A. Wohl
• The North Carolina
Department of Correction
• Wardens and staff of the
study facilities
• Study participants
• The University of North
Carolina CFAR
• The UNC CFAR Criminal
Justice Working Group
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).
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