Connection between social determinants and HIV prevention
Abstract Format : Structural factors such as housing and economic instability play a large role in Black women’s health and increase HIV risk. Precarious housing includes paying more than one-third of one’s income on rent, frequent evictions, overcrowding, and homelessness. Causes of precarious housing include shortages of affordable rentals, unemployment, and low minimum wage. Poverty increases HIV risk as Black women are more likely to start a romantic relationship due to economic hardships, are more likely to have sex for money, have less access to HIV prevention services, and have less access to quality housing. Housing instability is also associated with risky sexual behaviors increasing Black women’s risk for HIV. This study sought to determine how living and economic situations changed over 6 months and how these structural factors were related to HIV risk.
Methods : This qualitative, longitudinal study included 30 Black women (Mage = 31.97) interviewed 4 times over 6 months. Eligibility criteria included being at least 18 years old, self-identifying as a Black cis-gendered woman, self-identifying as HIV-negative, recently engaging in unprotected sex with a cis-gendered man, and having one of the following criteria: recently experienced intimate partner violence, recently engaged in problematic substance use, or recently engaged in transactional sex. Recruitment took place via community events and participant referral. The majority of semi-structured interviews took place in participants’ residences. Participants were asked questions and discussed topics such as current/past living situation (e.g., moves, evictions, unaffordable rent), plans for future living situation, current/past income and employment situation (e.g., job loss, underemployment, instrumental support), plans for future income and employment, romantic relationships (e.g., concurrent/multiple sex partners, incarcerated partner, intimate partner violence), and substance use. Thematic content analysis was used to explore how changes in housing and economic situations affected HIV risk.
Results : Almost all participants were mothers. Most women (n = 24) lived in precarious housing throughout the entire study. Participants lived in apartments or rental houses that were in poor physical condition, moved frequently into other poor living conditions, “doubled up” with friends or family, or were literally homeless. Poor living conditions included large holes in walls and floors, leaking or backed up plumbing, non-working appliances, leaking roofs, and mold or mildew. Of participants who were in decent housing throughout the study, 2 had well-paying full-time jobs and the remaining had considerable financial support from parents or significant others. Participants who experienced more precarious housing experienced much more economic instability. Most participants received food stamps and instrumental support from a significant other and family, many received disability, and most had difficulty with underemployment or finding employment. Many participants used alcohol or marijuana to cope with economic and housing difficulties or past traumas, leading to HIV-risk behaviors such as risky sexual behaviors. Participants who experienced precarious housing also reported and experienced more community violence. In addition, they engaged in more HIV-risk behaviors such as having multiple sex partners, inconsistent condom use, and sex exchange (i.e., survival sex). Thus, housing instability both directly and indirectly affected HIV risk.
Conclusions : Participants reported increased substance use due to stress regarding housing and economic instability, and survival sex due to poverty. There was a clear need among participants for housing programs, particularly supportive housing programs for families as most participants were mothers. There is a shortage of housing programs, especially for families. Increasing the number of family-based supportive housing programs can decrease the economic burden on families, decrease the stress directly related to housing and economic instability, and decrease HIV risk that is both directly and indirectly affected by housing instability. Structural interventions such as these are essential to decrease HIV rates among Black women.