HIV-Risk Practices Among Homeless and Low-Income Housed Mothers

Our results do not suggest an independent relationship between homelessness and HIV high-risk practices. Although previous reports described high prevalence rates of HIV among homeless samples,^43,44 only one study documented an association between homelessness and high-risk practices.¹⁰ Most of the previous studies have focused on adult individuals and have not differentiated between the unique contribution of homelessness and factors that are highly associated with street life, such as mental illness or substance abuse.^{10-12,33-35,44}

Our sample of low-income women who participated in high-risk behaviors failed to perceive themselves as susceptible to HIV, a finding that has been reported elsewhere.^45-47 Denial may be an adaptive response to the complex conditions of poverty. It is likely that the unremitting stress experienced by extremely poor women may lessen their sense of urgency about the risk of HIV. Although some of our sample’s misconceptions about HIV risk related to casual contact and condom and spermicide use could lead to an underestimation of risk, it is not unusual for individuals engaged in life-threatening behavior to incorrectly perceive their risk.^45,46 Although insufficient by itself to influence protective behaviors, realistic assessment of risk is a necessary step toward behavioral change.^45,48

As in other studies,^{3,5,7,9,49-52} we found a strong independent relationship between experiences of child and adult victimization and HIV-risk behavior. Victimization profoundly compromises a woman’s physical and mental health and may lead to increased HIV-risk behaviors. Child abuse, particularly sexual assaults, often produces severe and long-lasting trauma responses, including psychological and medical symptoms, diminished trust, pervasive fear, and a difficulty in forming supportive relationships as adults^53,54 For some women, the feelings of powerlessness, hopelessness, and low self-esteem associated with childhood victimization make it difficult to be self-protective. In addition, childhood violence also predisposes women indirectly to high-risk practices through its association with substance abuse.^3,51

For women in abusive adult relationships, the decisions about sexual activity are generally controlled by their partners. When women fear loss of financial support or a violent response if demands for safe sex are made, they are understandably less able to protect themselves sexually.^3,49,50 It is more difficult to practice safe sex in the context of sexual coercion, which is common in the lives of many low-income women.⁵⁰ High rates of victimization may also explain our study’s finding that women with higher self-perceived HIV risk were more likely to engage in high-risk behaviors, a result that runs counter to models of increased protective behavior in the context of higher estimates of personal susceptability.⁴⁷

The prevention of HIV among low-income women presents family physicians with a difficult challenge. It is critical to routinely screen for histories of victimization and, if possible, address the link between these experiences and sexual decision making. Efforts to specifically address the needs of these women may range from encouraging condom use to referring them to local HIV prevention programs that offer sexual communication skills training, social support, and risk-related knowledge. However, HIV risk must be viewed as only one of many challenges low-income women face, and it must be addressed in the context of their broader need for empowerment and economic self-reliance. Referrals to address education and vocational needs are imperative.

Our findings confirm the disproportionate rate of HIV infection in African American women.¹ However, our results do not indicate an increase in risk behaviors among Hispanic women (most of whom who are Puerto Rican in our study). This result contradicts other studies that describe high HIV prevalence rates and risk behavior in this subgroup.^1,57

Unlike previous studies that identified an association between high levels of emotional distress, depression, poor self-esteem, and HIV-risk practices in homeless women and those in drug recovery,^11,13-15 mental health factors were not significantly associated with HIV-risk behavior in our multivariate analyses. Although these differences may be related to measurement issues or variations in sample characteristics, the predictive capacity of mental health characteristics in relation to risk practices appears diminished in the context of other more significant factors, such as violent victimization.

Our study addresses limitations in previous research through inclusion of a comparison group of low-income housed (never homeless) women, the identification of risk factors among a community rather than using a high-risk sample, and an in-depth assessment of HIV knowledge and risk behaviors.

Limitations

Several limitations must be considered in interpreting our study results. Our sample was drawn from only one city with a distinctive ethnic population and, therefore, can best be generalized to small and mid-sized cities with a similar population. The accuracy of self-reports could have been limited by a desire to deliver socially desirable information; however, previous studies suggest that data related to sexual behavior are dependable.⁶⁰ Additionally, retrospective recall of the number and nature of sexual activities may be less accurate after a long period and may result in underreporting. Finally, we cannot comment on self-efficacy and coping strategies, which have been identified by other studies^11,13-15 as important determinants of HIV-risk practices.