Exploring HIV concern in a population of Dominican American women midlife and older

In the United States (US), Latino communities bear a disproportionate share of the HIV burden. Latinos comprise 17% of the US population, but account for 23% of the people living with HIV and AIDS (PLWH), with an estimated 21% of all new infections annually [1, 2]. If rates of infection persist, one in 50 Latinos will be diagnosed with HIV during their lifetime. Although men account for 87% of new HIV infections in US Latino communities, disturbing trends emerge among women [1, 2]. HIV rates among Latino women are four times that of White women, with heterosexual intercourse being the primary mode of transmission [1, 2]. Cultural values promoting inequitable gender norms, along with other risk reasons, create a unique configuration for HIV risk among Latino women [3, 4]. Furthermore, additional attention must be given to women midlife and older, where significant increases in the rates of HIV acquisition have been observed. Studies on HIV and women indicate that rates are declining for almost all women except those over 50 [5‐7]. For Latino women over 50 years if age, increased risk is associated with aspects of aging and culture [3]. Age presents additional population-specific risk reasons contributing to poor utilization of diagnostic, treatment and prevention services [8, 9]. With over half of the 1.1 million PLWH in the US age 50 years of age and over, and rates for older Latinos five times higher than their non-Hispanic White counterparts, sexual risk behaviors of older Latino women must be explored to inform targeted prevention efforts [3, 8].

The full determinants of HIV risk in US women are not completely clear, particularly in populations of women midlife and older [5]. Studies that attempt to use theoretical frameworks for behavioral predicators of HIV risk in women have focused on the younger women of adolescence and reproductive age [10, 11]. Yet, considerable measurement errors exists to capture demographic characteristics, beliefs and attitudes in studies of younger women, where a variety of other reasons contribute to risk behavior (e.g., pregnancy) [9, 11]. This results in the inability to quantify and relate observed effects to women midlife and older [5]. Intervention efforts and prevention programs have traditionally excluded older age groups as well. Many women midlife and older are sexually active [5]. In past populations of older adults, sexual activity was not discussed or deemed inappropriate [5]. However, the sexual revolution of the 60s and 70s, led to different beliefs regarding sexual expression among baby boomers [12]. These and other steadily changing reasons associated in the demographic profile of the AIDS epidemic, challenges HIV prevention strategies to remain relevant and up-to-date [13]. Moreover, the ethnic diversification of HIV in US women, have resulted in a call for the development and evaluation of gender- and culture-specific HIV prevention strategies [13, 14]. Research in populations of Latino women exclude an understanding of the psychosocial reasons related to older women and HIV [1, 2]. In fact, older Latino women are one of the least studied American demographic groups with regard to social, health or sexual behavior [1, 2, 15]. Knowledge gaps can leave health professionals ill-prepared to effectively discuss HIV/AIDS prevention [3, 4, 16].

We sought to identify perceptions of HIV risk in a US-based immigrant population of Dominican women age 50 and older living in the Northeast, where the HIV diagnostic rates in women remain high [1]. The vulnerability to HIV in older immigrant Dominican women remains under explored. Guided by the Theory of Gender and Power, our study sought to explore the perceptions of HIV risk, and to identify themes that describe the socio-cultural and contextual reasons that contribute to perceptions of risk. Theoretical construct analysis that leads to important mediators of behavior change can be viewed in the context of personal characteristics, such as age, and can assist in the intervention development and refinement processes. Our study is timely as the Centers for Disease Control and Prevention (CDC) recently called for an understanding of country-specific perceptions of HIV risk among Latinos, as such perceptions may lead to different risk profiles and preventive behaviors [1, 17].

The current study was a sub-study of the Washington Heights/Inwood Informatics Infrastructure for Community-Centered Comparative Effectiveness Research (WICER) [18, 19]. The WICER study included a longitudinal patient household health survey, administered to over 5000 Washington Heights/Inwood (WH/I) community residents of New York City [18, 19]. To encourage ongoing involvement, participants were asked to list their three top health concerns. Over 921 female participants listed HIV as a top health concern ranking it fourth overall behind diabetes, hypertension and heart disease. Survey demographics indicate these respondents were mainly female immigrants of Dominican descent ages 50 and over [18, 19]. To identify themes that describe the socio-cultural and contextual reasons that contribute to perceptions of risk, we recruited WICER women ages 50 and over to participate in focus group discussions.

HIV infection risk is recognized to be on the rise in midlife and older women [6]. Culturally-specific HIV prevention programs are needed to address the unique context in populations of older women, where determinants of HIV risk are not completely clear [5, 23, 24]. The current study sought to use the Theory of Gender and Power to identify themes that describe the socio-cultural and contextual reasons that contribute to perceptions of HV risk in a population of Dominican women 50 years of age and older [20, 21]. Our study revealed a number of important findings that support the TGP constructs and inform population-specific interventions.

Our findings indicate a perception of economic dependence and financial need regarding partner dependence in our population of Dominican women. Identified in our study and based on the Gender Specific Norms construct, the ability to be financially independent allows for greater control and better negotiation in intimate partnerships. According to the literature, compared to other ethnic groups, Latino women in the US are more likely to be unemployed [4]. When employed they earn less and have limited opportunities for educational attainment, making them vulnerable to poverty and associated implications [3, 4, 25]. Studies report that higher levels of education results in greater financial stability and has protective effects on HIV risk [3, 7]. Moreover, adults with higher levels of education report a greater sense of control over their lives and health [3, 16, 26]. It is also found that women of color from low socioeconomic communities are at greater risk for HIV, with limited educational attainment directly associated with elevated risk [3, 4]. Language barriers further contribute to limited educational attainment in Latino populations and segregated neighborhoods [3, 16]. In fact, consistent condom use has been shown to be directly associated with both employment and higher education [3, 16]. Higher levels of education also increases the understanding of health information, and supports effective problem solving and improves coping skills [3, 26]. For women in unequal gender-based power relationships with dominant partners and heightened pressures, [3, 4] as expressed by our study sample, recommendations that interventions focus on communication skill building and risk reduction negotiations may improve HIV-related outcomes. To improve the comprehension of actual HIV risk, interventions should also provide an in-depth understanding of gender roles, generational reasons, and societal influences that contribute to relationship-specific vulnerabilities [12].

For sexual division of power, our participants discussed high risk sexual behaviors of both women and men. Participants indicated that women are motivated by a variety of circumstances which may result in unsafe sexual practices with multiple partners. A study in a population of Black and Latino women, who reported having multiple sexual partners, the older women were less likely to use condoms with their primary partners [4, 27]. Similar to our findings of high risk behavioral practices of both men and women, this study also suggests that multiple partnerships in older women may be at increased risk given primary partners’ behaviors [4, 16, 27]. The literature suggests a consistent trend with partner risk being one of the most significant contributors to risk perceptions [4, 16, 27]. However, condom use is observed to be lower in these aging populations of women [3, 16]. This is critical for intervention development, as research indicates that minority women perceive their HIV risk to be lower than actual risk [28].

Consistent with other studies [3, 16, 25, 29], our findings showed that religion and spirituality were central to descriptions of Dominican cultural beliefs and practices. Some participants expressed believing their spouses to be faithful because monogamy is a part of their religious beliefs. Catholicism, specifically does not support condom use as sex is believed to be only for procreation, further contributing to high risk sexual practices and difficulties with condom negotiation [3].

Marianismo, encouraging sexual passivity in women and machismo encouraging relationship dominance, sexual risk taking behaviors and multiple sexual partnerships in men, are commonly known aspects of Latino culture and important themes that emerged [3, 16, 25]. Such standards, coupled with religious beliefs, further increases women’s vulnerability to HIV [3, 16]. Additionally, HIV-related stigma is also proven to interfere with prevention efforts and ultimately behavior change. HIV-related stigma prevents HIV testing and health information seeking behaviors in populations of women midlife and older, evidenced in the story told by a participant about a widow being insulted when asked to take an HIV test [5, 29]. The potential of women being stigmatized for initiating discussions about safe sex practices within their intimate partnerships, also perpetuates high risk behaviors, particularly in primary partnerships [12, 29]. Although studies have shown a decrease in perceptions of HIV risk for women who are married and in steady partnerships [29], most of our focus group participants did not. They identified the travel of their husbands and steady partners back and forth to the Dominican Republic as an ongoing concern about fidelity and HIV risk. Perceptions of health threats is determined by a sense of susceptibility, which results in behavioral responses influenced by preventive actions [27]. With an estimated 67,000 in the Dominican Republic living with HIV/AIDS and the second highest HIV incidence rates in the Caribbean, there is tremendous cause for concern amongst Dominican women midlife and older [https://​www.​aidshealth.​org/​global/​dominican-republic/​].

Other life experiences associated with the aging process also increases the vulnerability of older women to HIV [30]. Widowhood, loss of meaningful spousal roles, loss of friends, and diminished economic resources can contribute to a potential decline in self-esteem and interpersonal power [30, 31]. Moreover, vulnerable older women will find their pool of available partners diminished [31, 32]. These aging-related reasons can result in difficulties negotiating condom use and in implementing other safe sex practices [31, 32]. In younger women, socioeconomics alone was the greatest contributor to decreased self-efficacy for condom negotiation [33]. A study of older women, many ethnically diverse, 38% reported high risk sexual behavior for fear of loneliness [34]. Research also indicates that changes in physical health status with age are also associated with negative self-perceptions and feelings of powerlessness; mentioned often in our focus group discussions around partner fidelity [5, 34]. These aging-related reasons can result in feelings of social devaluation, making them open to non-monogamous intimate partnerships [5, 34].

Personal risk reasons (Cathexis) identified by our participants include knowledge gaps that may diminish perceptions of HIV risk, persistent in populations of older women. In a study of Black women, midlife and older, only 18% of participants knew condoms were effective in preventing the transmission of HIV [31]. Our focus group participants acknowledged generational differences in perception of HIV risk. While campaigns targeting older adults with knowledge about HIV transmission risk have emerged, risk reduction materials remain sparse [27]. Further increasing women’s vulnerability is the lack of discussion around sexual and drug use behaviors with primary care providers [8, 27]. Although not asked directly in focus group discussions, providers were never mentioned as a source of prevention information. These results potentially suggest, as has been shown by other studies, that there is a need for primary care providers to deliver culturally-specific HIV prevention information for their aging populations [27]. Providers are also recommended to address self-esteem issues in aging populations of women of color, including the societal and cultural reasons around aging that may increase their susceptibility to HIV [3]. Studies have also found provider endorsement of HIV testing amongst Latino women, to be significant [3]. This indicates the critical need for providers to have conversations around sexual health with patients, as the likelihood of testing decreases with increasing age [3, 7]. Yet, it remains uncomfortable for many providers to address sexual health during visits, with only 9 % of both men and women reporting such conversations during routine medical care [35]. Older adults have greater risk reasons for HIV transmission [35]. However, as a result of HIV risk prevention efforts being traditionally focused on youth, [16, 36] the ongoing beliefs that sexuality should not be a concern of the mature does not prepare patients nor their providers for the necessary and critical conversations [37]. Specific to women midlife and older, partner risk-related communication should support the recognition of multiple sexual partnerships with both men and women, and signs and symptoms of substance and drug abuse, for effective risk reduction [3, 16, 28]. In fact, preventive measures and testing was a major focus group theme, indicating the need for improved self-efficacy. Although not identified as a theme, drug abuse as it relates to HIV risk was discussed several times during the focus group discussions. Additional research on the sexuality of the mature, should focus on the reasons that both mediate and moderate patient and provider communication around sexual health [36, 37].

Our study explored the perceptions of HIV risk, and identified themes that describe the socio-cultural and contextual reasons that contribute to perceptions of risk.in a group of HIV concerned Dominican women 50 years of age and over that could have implications for HIV prevention interventions. Based on our finding, women 50 and over could benefit greatly from interpersonal skills training to support educational limitations, literacy barriers and the lack of occupational skills. Interpersonal skill building can improve self-efficacy for greater control over their livelihood and will be addressed in future research activities. Older women with inadequate literacy will need specialized interventions to ensure the understanding of health education messages, and the effective comprehension of sexual risk. Social capital, defined as descriptions of social structures that facilitate collective action, are proven to be a strong predictor of HIV infection rates. An understanding of such salient reasons that impact risk behaviors among older Latino women is essential for policy updates and development; evidenced in the recent CDC call for the identification of country-level differences in HIV risk reasons for Hispanic populations. As research shows the decrease likelihood of older adults to adopt prevention strategies, our study supports intervention research for targeted risk reduction in vulnerable aging populations.