A history of childhood sexual abuse overshadows all other factors that place a woman at risk for contracting HIV infection, suggests a new UCLA and Charles R. Drew University study. The American Journal of Health reports the findings in its April issue.
"Our findings disprove the notion that HIV-positive women are promiscuous or drug addicts," said Dr. Gail Wyatt, principal investigator and associate director of behavioral sciences for the UCLA AIDS Institute. "HIV caregivers need to look more carefully at HIV-infected women's sexual histories and offer appropriate resources for dealing with past trauma."
The UCLA/Drew Women & Family Project followed 490 women in Los Angeles. Half of the group was HIV-negative and half was HIV-positive. Each HIV-positive woman was matched with an HIV-negative partner of similar ethnicity, age, and marital and socioeconomic status. Over two years, the researchers interviewed each woman in person every six months about her sexual behavior and disease management and tested her for new sexually transmitted diseases.
Of the total women surveyed, UCLA researchers found that 49 percent were sexually abused as children, 43 percent suffered sexual abuse as adults, and 41 percent were or had been in physically violent relationships.
"Sexual abuse before age 18 increased a woman's risk for becoming HIV-positive more than any other factor," said Wyatt, a professor of psychiatry and biobehavioral sciences at the UCLA Neuropsychiatric Institute. "This finding crossed all racial and ethnic groups."
In addition to sexual abuse, HIV-positive women were more likely to possess fewer years of formal education and to live in poverty than their HIV-negative counterparts.
"Sexual abuse has its own unique effect on women's decision-making," Wyatt said. "But abused women who live in poverty have greater difficulty moving on with their lives. Their lack of economic resources severely restricts their choices. This makes them dependent on men who continue to abuse them and put them at risk for HIV."
Women who reported chronic childhood sexual abuse were seven times more likely to engage in high-risk unprotected sexual behavior as adults. Most dramatically, the number of HIV-positive women who had suffered rape doubled that of HIV-negative women in all ethnic categories.
"We found that the same factors that increase a woman's risk for contracting HIV might also contribute to her risk for rape and domestic abuse," Wyatt said. "Relationships with coercive and abusive partners severely diminish a woman's ability to negotiate safer sex."
According to Wyatt, few HIV-prevention programs address the effects of childhood abuse on sexual risk-taking.
"You can't tell abused women to use condoms and 'just say no to drugs,'" Wyatt stressed. "HIV service providers need to ask more questions about their patients' sexual history. It may not be the number of partners that matters — but the type of predatory person they gravitate toward.
"Those who use alcohol or drugs may be self-medicating to dull the pain of their pasts," she said. "Physicians need to ask these women why they're doing what they're doing."
The UCLA/Drew study also challenges caregivers' assumptions about HIV-infected women's sexual behavior — and medical providers' stereotypes about who gets infected.
"Because public health clinics treat more women of color with HIV, these clinicians perceive the women as uncooperative if they don't change their risk-taking behavior," Wyatt said. "But they're missing the full picture. White women with HIV don't go to public clinics as frequently because they can afford private care."
Finally, Wyatt said, the health-care system needs to consider offering psychotherapy to everyone who needs it — not just those with the ability to pay. As the UCLA/Drew study demonstrates, the inability to resolve childhood sexual abuse measurably influences risky adult behavior — which shapes AIDS epidemics.
"Sexual abuse will alter the course of anyone's life," Wyatt said. "The aftereffects don't go away by themselves. Most of these women didn't get help after they were abused."