There are many popular, yet erroneous, beliefs about HIV/AIDS held
by some women from the Black community. Such attitudes only
complicate their confusion surrounding the origin and fatality of
the disease.
The disproportionate number of Blacks who test positive for the
Human Immunodeficiency Virus (HIV) give reason to devote attention
to this segment of society. Blacks are 12 percent of the national
population (Selik, Castro, & Pappaioanou, 1988) and yet in September
of 1990 an estimated 28 percent of the reported Acquired Immune
Deficiency Syndrome (AIDS) cases in the United States affected Black
people (Center for Disease Control [CDC], 1990). In October,
1992, the HIV/AIDS Surveillance Report from the Center for Disease
Control reported 71,984 cases of AIDS among the Black population.
This number represented 30% of the AIDS cases in the United States.
The report further showed that Black adolescent/adult males
are 26 percent (56,081) of males with AIDS, and that females formed
53% of the adolescent/adult female population with AIDS. HIV/AIDS
is rapidly growing and affecting many Blacks. More recently in 1996
Blacks represented 41% of the adolescent/adult population who reported
having AIDS. This was the first time in the history of the AIDS
epidemic that this group exceeded Anglos (CDC, 1996).
According to the Center for Disease Control (1986), AIDS may be
defined as a set of symptoms occurring at the cumulative stages
of a human immunodeficiency virus infection. Moreover, it is characterized
by a loss of immunity against an otherwise nonthreatening disease.
The virus infects certain cells of the immune system and can also
affect the brain. Infected people remain in relatively good health
for several months to years before the illness develops. Infected
people who are in good health are classified as HIV positive, but
without the illness.
Once the symptoms develop, the severity of illness varies from
mild infections to life threatening infections called Acquired Immune
Deficiency Syndrome. Most infected people eventuality deteorate
from a state of good health to severe disease.
HIV is spread by sexual contact, needle sharing, blood, blood products,
or organ donation. The virus can also be transmitted from an infected
mother to an infant during pregnancy, at birth, or shortly after
birth (possibly through breast milk). There have also been a few
reported cases of transmission by an infected (HIV positive) health
care professional to the patient. While the research toward the
biomedical effects of this disease is vital, it is equally important
to address the psychosocial related behaviors that perpetuate the
transmission of HIV/AIDS throughout this population. According to
the National Institutes of Health (1997), the pharmacologic treatment
of HIV positive individuals may increase the longevity, but is unknown
how successfully treated individuals will alter their recreational
drug use or sexual behavior.
The Prevalence of HIV/AIDS Among Black Women
More women are testing positive for HIV. According to Mays and
Cochran (1988) the incidence of HIV infection among women is growing
at a proportionately faster rate than any other specific minority
group. AIDS is now the eighth leading cause of death among women
15 to 44 years of age (Jenkins, Lamar, & Thompson-Crumble, 1993).
Even women who are incarcerated have most reported HIV/AIDS cases.
AIDS has become a leading cause of death among female inmates (Brewer
& Derrickson, 1992).
The U.S. Department of Health and Human Services (1992) reported
that the rate of HIV infection among women in ten selected U.S.
jails, federal and state prisons increased from 3.2% to 14.7% in
1991. They compared these numbers with male cohorts that reported
an increase from 2.3% to 7.8% at the same locations during the same
year.
As the number of AIDS cases among women continues to rise, the
disease bares no preference. It cuts across all ethnic, cultural,
and socioeconomic groups. One group that draws much concern is adolescent
and adult Black females. More specifically, the groups that may
be greatly affected are the lower income Black and Latino women
who are exposed to HIV through sexual contact and drug use (Pettit,
1997). However, the number of AIDS cases continues to grow
most rapidly among Black women. Black women diagnosed with
HIV/AIDS are disproportionately over represented among females with
AIDS cases ( Wingood, Hunter-Gambles, & Di Clemente, 1993).
Deaths resulting from AIDS among Black women in 1987 totaled 739
and had increased to 995 in 1988 (Jenkins, Lamar, & Thompson-Crumble,
1993). During 1994 there were a reported 4,166 deaths caused by
AIDS, the following year the number had increased to 4,313 deaths
among adult Black females. Bakeman (1987) suggested that cumulative
incidence of AIDS among Black women is 12 times higher than that
of White women.
Methods of HIV/AIDS Exposure
Among women heterosexual contact and injecting drug use account
for 40 % and 34% of cases reported in 1996 (CDC, 1996). However,
most of the Black women who are exposed to an HIV infection contract
it via unprotected heterosexual activity, illegal drug use behavior,
or a combination of both. The exposure categories for AIDS may vary
by gender for Blacks. Nevertheless researchers who study Black adult
females showed that the virus is primarily contracted through needle
sharing for drugs and heterosexual contact (Belgrave & Randolph,
1993). Higher rates of infection among Black women are the result
of higher rates of intravenous drug abuse and higher rates of infection
among their drug using sexual partners (Jenkins, Lamar, & Thompson-Crumble,
1993).
The relative risk of intravenous drug abuse related AIDS has been
consistently higher among Black women than with White women since
1982 (Selik, Castro, & Pappaionmoare, 1988). Therefore, researchers
hypothesize that the greater proportion of Black women who abuse
intravenous drugs in the Black community accounts for many differences
in the distribution of AIDS cases by ethnicity.
Despite HIV/AIDS messages directed toward injectable drug users
(IDUs), needle sharing continues to occur. Poor IDUs who are
unable to obtain needles and syringes may use ìshooting galleriesî
where needle sharing is common (Jue & Kain, 1989). Shooting
galleries are usually abandoned and condemned buildings or
houses where people can hide and inject drugs into their veins.
According to Friedman (1990) and Inciardi (1992) a shooting gallery
may be the most significant factor in the drug related transmission
of HIV, because an HIV infected person may pass the infection onto
other patrons of the shooting gallery.
Some women engage in unprotected heterosexual behavior in exchange
for illegal drugs. Others participate in unlawful sexual activity
to get money to purchase illegal drugs, and there are women who
believe that ìgetting highî before having sex make
the activity a more pleasurable experience. These actions
contribute to greater exposure to HIV/AIDS among Black women. It
is estimated that Black women represent about one third of female
AIDS cases in the United States whose primary HIV risk was sex with
a bisexual male (CDC, 1993).
Moreover the research shows that higher HIV infection rates among
female inmates may be attributed to the prevalence of substance
abuse, exchanging sex for money or drugs, and the greater
efficiency of male to female HIV transmission (CDC1989; Graham &
Wish, 1994; Van Hoeven, Stoneburner, & Rooney, 1991; Weisfuse,
Greenburg, Back, Makki, Thomos, Rooney, & Rautenberg, 1991).
Socio-Cultural Dimensions and Self Efficacy
The cultural norms within many Black communities hold significance
for addressing HIV/AIDS among Black women. Important social and
biological contexts and co-factors can increase or decrease the
likelihood of risk behaviors. Moreover many behavioral risk factors
are quite well known but the contextual risk factors are only beginning
to be understood (National Institutes of Health [NIH], 1997).
AIDS education and prevention efforts have previously lagged in
the development and implementation of gender and cultural specific
programs that can help Black women in incorporating general AIDS
knowledge into safer sex behaviors (Dalton, 1989; Mays & Cochran,
1988; Peterson & Marin, 1988). An understanding of the African
American culture is important for educating Black women who exhibit
risky behaviors.
A major concern for many Black women is how to deal with role strain
produced by ìcultural conflict.î Cultural conflict
occurs when some peeople stick to the status of their own culture
and fail to assimilate to the norms of the dominate culture. For
Black women this may mean they are often expected to adhere to certain
behaviors that have been put into place in Anglo-male western civilization.
Cultural conflict causes a great deal of stress for these women
(Aponte, Rivers, & Whohl 1995). Cultural conflict may lead to
sex role conflict such as identity crisis, feelings of isolation,
alienation, or depression.
Cultural attitudes influence the Black communityís experiences
with AIDS and seeking health care for HIV/AIDS (Broman, 1987). Many
Black people within lower socioeconomic strata are confronted with
high unemployment, poverty, and disproportionately high incidences
of morbidity and mortality. There are other Blacks who view AIDS
as relatively unimportant when compared to other more immediate
problems such as paying rent and feeding their families (Icard,
Schilling, El Bassel, & Young, 1992) According to research,
Black women may have to confront pressing social problems such as
poverty, racism, unemployment, inadequate education and crime that
make AIDS are far less urgent (Freudenberg, Lee, & Germain,
1994).
There are many popular yet erroneous beliefs about HIV/AIDS held
by some women from the Black community. Such attitudes only complicate
their confusion surrounding the origin and fatality of the disease.
For example there is a myth that HIV/AIDS is the disease of White
middle class homosexual males. This notion may stem from reports
presented by the Center for Disease Control (1996) which reported
that in 1981 five-healthy White males with a history of having sex
with men were diagnosed with pneumocystis pneumonia. Their condition
was later called Acquired Immune Deficiency Syndrome (AIDS), and
also became associated with being White, middle to upper middle
class, homosexual, and male.
There are also certain traditional beliefs perpetuated within much
of the Black community. However, these beliefs are sometimes
misunderstood by members of the community. That is, they may engage
in risky behaviors based upon mores. For example, one
traditional philosophical concept emphasizes an extended
kinship among people of similar culture and ethnicity. This concept
may involve certain communal group practices. Given the notion
that as a group they are all ìsisters and brothersî
(extended kinship), then sharing needle within the ìfamilyî
is probably safe.
Moreover, Mays and Cochran (1988) noted that sharing ìworksî
sometimes denotes bonding among ìbuddiesî who use drugs.
Those IDUs who are most in need of social validation may be more
likely to engage in this form of behavior. The practice of
needle and syringe sharing should never occur.
Black women IDUs may face stressors stemming from racial discrimination,
poverty, and deprivation. Ascribing to a ìsubcultureî
status, many Black women IDUs may perceive that there is limited
access to the same resources made available to White women. They
may experience feelings of alienation and reach out for any opportunity
to use an available needle and syringe. Research has suggested that
Black and Hispanic IDUs are more likely to share syringes than White
IDUs (Des Jareais, Friedman, & Hopkins, 1985)
Many Black women maintain a poor self concept and often perceive
themselves in a less than favorable manner. They may develop a sense
of helplessness and inclinations toward victimization from a system
that fosters dependence. As such, these women exhibit greater risk
behaviors that would expose them to people who are HIV positive.
They may subconsciously place small value on the integrity of life
by putting themselves in hazardous situations. The women often feel
trapped by an environment that only offers to them oppression. This
experience usually results in manifestations of internal emotional
dissatisfaction.
Black women often lack an internal locus of control. They believe
that they are unable to take the responsibility for the direction
of their lives. According to Sue and Sue (1990) an internal locus
of control refers to a personís belief that lifeís
affirming reinforcements are contingent upon their own actions,
and that a person can shape her own fate. Many Black women from
this group may not possess self confidence in their own ability
to decide. They often become the victims of circumstance and fail
at any attempt at controlling their own destiny. In essence, these
women do not feel good about whom they are, their means of maintaining
survival, and the environment in which they exist.
Intervention, Prevention, and Educational Programs
There is a consensus in much of the literature that many Black
women who test positive for HIV contracted the virus through unprotected
heterosexual contact and illegal drug use behavior. Local and community
outreach programs have been established throughout the country to
address the treatment and prevention of HIV/AIDS. According to the
National Institutes of Health (1997), community workers have developed
many innovative and promising programs. There is a great need for
the programs to work with researchers to further HIV/AIDS risk behavior
intervention through scientific analysis.
Researchers suggest that many programs that are currently in existence
fail to meet the needs of Black women. This is primarily among those
women who are educationally disenfranchised from the lower socioeconomic
strata. The weaknesses in the programs may be attributed to format
and design. Quimby (1993) suggested that appropriateness of content,
methods, and personnel have been questioned. He noted that the major
funded efforts are generally top down actions organized by professional
elites and aimed at their constituencies rather than neighborhoods.
These programs are useful for some, but they are inappropriate and
lack authenticity for certain ethnic and gender groups.
There are, however, those intervention and prevention programs
that show gender, cultural, and socioeconomic sensitivity that are
helping many women of color. Community-based organizations contribute
a great deal of effort to control the HIV/AIDS epidemic. There are
programs with components that provide an ongoing and intimate relationship
which constituents an understanding of relevant cultural values,
beliefs, familiarity with relevant channels of communication, and
commitment to safeguard the well being of their neighborhoods (Singer;
1991; Freudenberg & Trinidad, 1992)
Other projects that have met with a large degree of success are
those that include training on self management and interpersonal
management skills. Kelly and colleagues (1989) discovered that training
in self management skills that consist of personal awareness, problem
solving, and coping skills tended to enhance the perception
of risk and to increase motivation toward risk reduction behavior.
In addition, teaching individuals to identify high risk circumstances
and to recognize prospective situations that are likely to lead
to unsafe sex and illegal drug use is vital. Moreover, some programs
stress the significance of working through high-problem areas by
developing and maintaining alternative coping behaviors. Enhancing
interpersonal skills helps to reduce a partnerís opposing
reactions, and to maintain a mutual relationship that is supportive
of safe sex.
Research has demonstrated the importance of having social support
and social networks in community based and culturally-oriented
prevention programs. Belonging to and keeping social connections
may become an integral aspect of living with HIV. Many ethnic minority
groups extol the family as a primary social unit and a necessary
means for support (Aponte, River, & Wohl, 1995). However,
Rhoads (1983) suggested that those women who use drugs tend
to lack the support systems that have been traditionally made available
to men. Many women who are substance abusers lack social support
from family and friends who do not abuse drugs.
In recent years, the Association of Black Psychologists addressed
the issue of culturally appropriate education to help in preventing
the spread of HIV/AIDS within the Black community. The Association
of Black Psychologists, in consultation with Progressive Life Center,
designed and carried out an Afrocentric model to train psychologists
to deliver culturally competent AIDS education, prevention programs,
and psychological services in the Black communities nationwide.
The Center for Disease Control funded this project for six programs
years beginning in 1988 and ending in 1993 (Foster, Phillips,
Belgrave, Randolf, & Braithwaite,1993). According to the
organizations, their effort to reduce the spread of HIV among the
Black community has been successful.
Addressing High Risk Behaviors
The Public Health Department of Beaumont, Texas, reported in 1995
and 1996 an increase in the number of Black women who tested positive
for HIV. It was believed that the increase was attributed to high-risk
behaviors that contribute to the spread of HIV. Unprotected
heterosexual contact and illegal drug use behavior may be the salient
concern regarding this population. According to the city Public
Health Departmentís demographic data report, in 1995, 26
cases were reported as HIV positive; of the 26 cases, 27% were females
and 73% were males. Within ethnic parameters, 8% were Hispanic,
27% were Anglo, and 65% were Black (Beaumont Public Health Department
[BPHD], 1995).
The following year the Public Health Department reported 32 positive
cases of HIV. Among this group, 47% were males and 53% were females.
Nine percent of this group were Hispanics, 31% were Anglos, and
59% were Black (BPHD, 1996). The Public Health Department has identified
this epidemic as an extremely critical concern. The number of positive
HIV cases in Beaumont is increasing within the Black community
especially among its female population. Therefore, it becomes
imperative to address the concerns and implement prevention measures
for those Black women at risk.
Womenís Empowerment Program
The Beaumont Public Health Department has an extensive, innovative,
and culturally sensitive Womenís Empowerment Program for
the large population of HIV at-risk, ethnic minority women that
live within the metropolis. More specifically, the targeted
population is women who receive drugs or money for sex, is
the sex partner of men who are intravenous drug users, ones
that may be actively abusing drugs, and those that presented a history
of illegal drug use.
Blacks represent more than 80 % of the clients that regularly visit
the two clinics. The clinics serve a metropolitan area of
a twenty-five-mile radius. The at risk women are also identified
through other local, county and state-supported organizations with
which the public health department has collaborative agreements
for HIV prevention education programs.
Once the women have been identified for being at risk, they
are interviewed and recruited to the Beaumont Public Health Departmentís
Womenís Empowerment Program (WEP). The women participate
in and complete the HIV prevention education program as a
component of WEP. The program has joined HIV prevention with education
on building self esteem and developing responsible decision making
skills related to sexuality and drug abuse. The curriculum is presented
by a full-time WEP coordinator who trains WEP peer educators to
provide on-going information and support to other women (and men)
of color who are at-risk for contracting HIV. The peer educator
who is also part of the at risk group serves as an essential component
to assure cultural and lifestyle sensitivities.
The Public Health Department acknowledges that WEP peer educators
need support and encouragement for circulating information to friends
in their community and maintaining their own low risk behaviors.
Therefore, support groups are provided for WEP peer educators to
advocate maintenance of low risk behaviors for HIV transmission.
Method
Subjects
The subjects for this investigation consisted of 28 adult females
(peer educators). They were referred to the day long program by
the public health departmentís outpatientsí clinic
and from local organizations that have collaborative agreements
with the cityís public health department for HIV prevention
education.
The subjectsí ages ranged from 20 to 47 years of age. They
were 71% Black, 21% White, 4% Hispanic, and 4% Native Americans.
The sample consisted of 68% who earned less than $ 10,000 a year.
Fourteen percent of the subjects earned between $10,000 and $15,000
annually. Among the sample, 4% had yearly incomes ranging from $15,001
to $20,000, and another 4% earned between $20,001 and $25,000 dollars.
Seven percent of the sample group had an annual income of more than
$25,000 a year.
The marital status consisted of 50% single women and 14% divorced.
Fourteen percent of the subjects said they were married, and 18%
reported married but not living with their husbands. Four percent
of the sample indicated a mutual cohabitation arrangement.
Fifty-four percent of the sample were mothers of two or fewer children.
Within the same sample 25% had four or fewer children. Eleven percent
reported having six or fewer children, and 11% of the subjects had
no children.
Within the realm of education, 39% of the subjects said they had
completed high school. Thirty-two percent indicated a limited college
education. Fourteen percent of the sample had gone beyond the ninth
grade, and only 4% indicated having graduated from a four-year college.
Among the sample, 96% reported having never tested positive for
the HIV infection. Four percent indicated a positive HIV infection
test result.
Instrument
The HIV/AIDS Attitude and Awareness Inventory for Unprotected Sex
and Drug Use - Form F (Geyen, 1997) was used in this investigation.
The instrument is newly developed and continues to undergo field
testing and evaluation. Its objective is to assess the womenís
attitude toward and awareness of risky behaviors that may lead to
contracting the HIV infection. Furthermore, the instrument is designed
with three components: (a) question demographic data, (b) unprotected
heterosexual activity, and (c) illegal drug use behavior.
The instrument suggests that higher response scores represent a
greater awareness of risky behaviors leading to HIV/AIDS. Conversely,
lower response scores suggest a lesser awareness of risky behaviors
leading to HIV/AIDS. In the initial test analysis of internal
consistency on the twenty-eight subjects of this investigation,
the instrument yielded a reliability coefficient of .83.
The sections of the instrument that assessed unprotected heterosexual
activity and illegal drug use behavior were constructed to be gender
appropriate and culturally sensitive. The instrument is geared toward
the population from which the subjects originated. It should be
emphasized that the content of the instrument is not intended in
any way to pass judgment, categorize, or negatively stereotype and
depict the participants in this investigation.
Data Collection and Procedure
Twenty-eight women, majority Black, took part in the investigation.
Subjects were given a written informed consent form to read and
endorse before their actual participation in the study. The women
were then administered the HIV/AIDS Attitude and Awareness Inventory
for Unprotected Sex and Drug Use. This segment of the investigation
took place in the morning before the women took part in the program.
The program was divided into two sessions, the first focused on
education and prevention of HIV/AIDS, and the second session involved
developing self-efficacy.
Representatives from both the cityís Public Health Department and
the university facilitated the program sessions. The facilitators
were majority Black women. Although there was an array of
important information delivered by the facilitators, the format
of each session centered on the subjects. This style allowed
for a relaxed, comfortable, and homogeneous environment suitable
to address the participantís personal issues related to HIV.
The language, behavior, mode of dress, and context of information
presented and discussed was informal. This arrangement was perceived
as appropriate and productive for the subjects.
Upon completion of both sessions in the afternoon, the same subjects
were administered the HIV/ AIDS Attitude and Awareness Inventory
for Unprotected Sex and Drug Use. Data were collected and recorded
from both sittings.
Analysis and Results
The mean score for the first administration of the HIV/AIDS Attitude
and Awareness Inventory for Unprotected Sex and Drug Use was 128.0.
The mean score for the second was 135.3. The womenís scores
ranged from 95 to 154 on the HIV/AIDS instrument before the
workshop sessions. Following the workshop sessions, the subjectís
scores on the HIV/AIDS Attitude and Awareness Inventory for Unprotected
Sex and Drug Use ranged from 111 to 155.
The mean scores for both administrations of the HIV/AIDS Attitude
and Awareness Inventory for Unprotected Sex and Drug use was compared
using the two-tailed t-test for paired samples. There was no statistically
significant difference found in scores at the .05 probability level.
(t= 4.89, df 27, P>.05).
The statistics suggested no significant difference in the mean
scores. More specifically, a seven-point increase from the mean
score of the first sitting compared to the mean score of the second
sitting. This increment of change in scores may suggest that, on
the average, participants enhanced their awareness of HIV/AIDS;
therefore, the increment of change in scores is clinically significant.
Preventing the contact of HIV to even one person could extend or
even save a life.
Discussion and Observations
This was a pilot study to address HIV prevention among Black women.
Research investigations such as this one may take certain
ìscientific research liberties.î The nature of some variables
like the sample size, a newly developed instrument, and the subjectsí
understanding of research are similar to confounding variables that
are found in much of this type of research. Future research within
this area should attempt to constitute greater control. However
close and systematic observation of subjects during the session
showed they actively engaged in the sessionís activities.
Many subjects in this study voiced their enlightenment on information
regarding behaviors that spread HIV/AIDS. Subjects expressed interest
in future sessions. Several subjects indicated their wanting to
share the knowledge learned from the sessions with friends, relatives,
boyfriends, and husbands. Subjects acknowledged their own
counterproductive behaviors and vowed to change their life styles.
The applications of culturally appropriate strategies demand ethnographic
or naturalistic research to understand values, attitudes, behaviors,
and factors, such as socioeconomic status in different communities.
Cultural factors may affect the ability of individuals to change
behavior. Researchers from different ethnic or cultural backgrounds
may help to address this issue. Language and other cultural barriers
to the delivery of interventions must be addressed with special
consideration for individuals whose physical or other impairments
limit access to most prevention and intervention programs.
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Black Women: Implication for HIV Prevention. Journal of Black Psychology,
Vol 19, No. 2, 190-203
Dr. Dashiel J. Geyen, Ed., M.P.H., is a behavioral scientist and
clinical practitioner. He serves on the graduate counseling
faculty at Sam Houston State University. Dr. Geyen is also
an adjunct psychology professor at the University of Houston.
He has completed research fellowships at the National Institute
on Drug Abuse and the National Institutes of Health.
Dr. Geyen had researched, published and presented works on youth-at-risk,
chemical dependency, and mental health. E-Mail: edu_djg@shsu.edu.
Ingrid Fisk-Holmes, M.P.H., is the Public Health Director of the
Beaumont Public Health Department. She has held positions
of Director of Health Education, Executive Assistant to the City
Manager, and Public Health Administrator. Ms. Fisk-Holmes
is responsible for the initiation and development of the Peer Empowerment
Program designed to work with at-risk women to reduce the spread
of HIV.
H. Mark Guidry, M.D., M.P.H., is a Regional Health Director for
the State of Texas. He has served as Public Health Directory
and Health Authority for the City of Beaumont. His professional
career experience also includes Associate Medical Director and Family
Physician for a Beaumont area manage care practice. Dr. Guidry
has researched and published articles on HIV/AIDS and other communicable
diseases.
Janice M. Beal, Ed.D., is an assistant professor and coordinator
of the psychology program at Prairie View A & M University in
Prairie View, TX. She is also a clinician in private practice
specializing in mental health issues that impacts women and children.
Dr. Beal has published and presented research on drug addiction
and mental illness at a number of national and international meetings.
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