HIV Risks, Substance Abuse, and Intimate Partner Violence Among Hispanic Women and Their Intimate Partners

HIV Risks, Substance Abuse, and Intimate Partner Violence Among Hispanic Women and Their Intimate Partners Rosa M. Gonz alez-Guarda, PhD, MPH, RN Nilda Peragallo, DrPH, RN, FAAN Maria T. Urrutia, MS, BSN, RN Elias P. Vasquez, PhD, NP, FAAN, FAANP Victoria B. Mitrani, PhD Hispanic women in the United States are disproportionately affected by HIV infection. Substance abuse and intimate partner violence (IPV) are conditions that have been associated with risk for HIV in the general population. However, few studies have explored the intersection of these three conditions within one integrated framework. The purpose of this exploratory study was to describe the relationships between HIV risks, substance abuse, and IPV among Hispanic community-dwelling women. A total of 82 structured interviews were conducted with Hispanic women between the ages of 18 and 60. Data regarding the participant’s and her partner’s histories of sexually transmitted infections, substance abuse, risky sexual behaviors, and IPV were collected. Relationships between the participant’s history of sexually transmitted infections, her partner’s substance abuse, risky sexual behaviors, and IPV were explored. Results from this study support the importance of targeting HIV, substance abuse, and IPV prevention among Hispanics within one integrated framework. Key words: Hispanic women, HIV, intimate partner violence, risky sexual behaviors, substance abuse A mong the greatest health disparities that affect the Hispanic population in the United States today is HIV infection and associated conditions such as substance abuse and intimate partner violence (IPV). In 2005, the HIV/AIDS incidence rate for Hispanics (24.0 per 100,000) was more than three times the rate for non-Hispanic Whites (6.9 per 100,000) (Centers for Disease Control and Prevention [CDC], 2007b). Although rates of HIV are much higher among Hispanic men than women, when stratified based on gender and compared with non-Hispanic Whites, Hispanic women are reported to experience a greater disparity than their male counterparts. Although the rate of new HIV/AIDS cases among Hispanic men (36.0 per 100,000) was three times that of non-Hispanic White men (12.1 per 100,000), the rate among Hispanic women (11.3 per 100,000) was more than five times higher than that of non-Hispanic White women (2.0 per 100,000) (CDC, 2007b). Heterosexual contact is the most frequent (69%) mode of transmission for HIV among Hispanic Rosa M. Gonz alez-Guarda, PhD, MPH, RN, is assistant professor; Nilda Peragallo, DrPH, RN, FAAN, is dean and professor; Maria T. Urrutia, MS, BSN, RN, is a PhD student; Elias P. Vasquez, PhD, NP, FAAN, FAANP, is associate dean of community affairs and associate professor; and Victoria B. Mitrani, PhD, is professor; all at the University of Miami School of Nursing and Health Studies, Coral Gables, Florida. JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 19, No. 4, July/August 2008, 252-266 doi:10.1016/j.jana.2008.04.001 Copyright Ó 2008 Association of Nurses in AIDS Care Gonzalez-Guarda et al. / HIV Risks, Substance Abuse, and Violence women (CDC, 2007b). Consequently, when targeting HIV prevention among Hispanic women, it is important to address the various factors associated with high-risk sexual behaviors within their intimate relationships. Substance abuse and IPV are important factors that may be inherently linked to HIV risks in this population. Project DYVA (Drogas y Violencia en las Americas, Drugs and Violence in the Americas) was a pilot research study that aimed to explore HIV risks, substance abuse, and violence among a community sample of Hispanic women in South Florida through the use of both qualitative (Phase I) and quantitative (Phase II) research methods. In this article, the results from the quantitative phase of the study are reported. Background Substance Abuse and HIV Among Hispanics Substance abuse is related to HIV in that it not only increases an individual’s risk of being exposed to the virus through direct contact with a contaminated needle when intravenous drug use (IDU) is involved but it also increases an individual’s likelihood of engaging in high-risk sexual behaviors such as unprotected sex (Edlin et al., 1994; Leigh & Stall, 1993; Santibanez et al., 2006). Substance abuse seems to disproportionately affect Hispanics in the United States. In fact, in the 2004 National Survey on Drug Use and Health, it was noted that drug abuse and dependence among Hispanics (9.8%) were higher than among Whites (8.3%) (Substance Abuse and Mental Health Service Administration [SAMHSA], 2005). Similarly, reported alcohol abuse among Hispanics (40.2%) was higher than reported in other ethnic minority groups including Asians (37.4%), Blacks (37.1%), and American Indians/Alaskan Natives (36.2%) (SAMHSA, 2005). Although there are higher rates of substance abuse among Hispanic men when compared with their female counterparts, Hispanic women are indirectly affected by their partners’ substance abuse because of close association with the perpetration of IPV and risk for HIV (Caetano, McGrath, Ramisetty-Mikler, & Field, 2005; ElBassel et al., 2007; Fonk, Els, Kidula, Ndinya- 253 Achola, & Temmerman, 2005; Lindenberg et al., 2002). Intimate Partner Violence and HIV Among Hispanics In a recent study reporting on the 5-year course of IPV among a nationally representative sample of married and cohabitating couples in the United States, Hispanics were reported to experience more than twice the incidence of IPV (14%) when compared with Whites (6%), even when socioeconomic variables were controlled (Caetano, Field, Ramisetty-Mikler, & McGrath, 2005). IPV includes physical, sexual, and/or psychological abuse or harm committed by a current or former intimate partner (i.e., current or former spouse or boyfriend/girlfriend) (CDC, 2007c). Recent studies that have examined the relationship between IPV and HIV have noted that male-to-female IPV is associated with numerous risk factors for HIV (Geilen, Burke, Mahoney, McDonnell, & O’Campo, 2007). In fact, women who reported victimization by an intimate partner were more likely to report a sexually transmitted infection (STI) (Bauer et al., 2002), inconsistent condom use, and forced sex without a condom (ElBassel et al., 2007; Raj et al., 2006). They were also more likely to report engaging in sex with an HIV-infected partner or an IDU, having multiple partners, and injecting drugs (El-Bassel et al., 2007). Research that has aimed to understand the mechanism through which IPV increases a woman’s risk for HIV have documented that abused women fear insisting that their partners use condoms (Suarez-AlAdam, Raffaelli & O’Leary, 2000) and report sexual control by their male partner (Raj, Silverman, & Amaro, 2004). High rates of HIV among Hispanic women may be driven in part by the fact that they are more likely to be exposed to IPV (Caetano, Field, et al., 2005). Socioeconomic stressors that disproportionately affect the Hispanic population in the United States (U.S. Census Bureau, 2008) may partly explain why the rates for IPV among Hispanics are higher than for other racial/ethnic groups (Kantor, Jasinski, & Aldarondo, 1994; Tjaden & Thoennes, 2000). Additionally, cultural values that sanction wife abuse that have been documented among certain Hispanic subgroups (e.g., Puerto Ricans) may provide 254 JANAC Vol. 19, No. 4, July/August 2008 additional explanations for higher rates of IPV among this population (Kantor et al., 1994; Torres, 1998). Substance Abuse and Intimate Partner Violence Among Hispanics Substance abuse practices within relationships and their association with IPV victimization and perpetration have been extensively studied among Hispanics (Caetano, Schafer, Clark, Cunradi, & Raspberry, 2000; Field & Caetano, 2003; Lipsky, Caetano, Field, & Bazargain, 2005; Perilla, Bakeman, & Norris, 1994). Results from these studies indicate that substance abuse may not play the same role among Hispanics as it does among other groups. For example, in a study that compared drinking patterns among victims of IPV across different racial/ethnic groups, the rates of drinking in Black (23.6%) and White (11.4%) victims were significantly higher than in Hispanic victims (5.4%) (Lipsky et al., 2005). In another study that examined ethnic and racial differences in a probability household sample of White, Black, and Hispanic couples, it was reported that female alcohol abuse was a predictor of IPV victimization for White and Black women but not for Hispanic women. However, alcohol abuse by Hispanic male partners predicted the perpetration of IPV (Field & Caetano, 2003). Other studies have noted that, just as with other racial and ethnic groups, male alcohol and illicit drug use is associated with male-to-female IPV (Caetano, Cunradi, Clark, & Schafer, 2000; Perilla et al., 1994). Whereas drinking during violent episodes has been reported to be as common among Hispanic men as among non-Hispanic White and Black men (Caetano, Cunradi, et al., 2000), the approval of marital aggression resulting from alcohol abuse has been shown to be higher among Hispanics than either Blacks or Whites (Field, Caetano, & Nelson, 2004). In Hispanics, it seems that IPV is more closely associated with the male partner’s substance abuse practices and beliefs than substance abuse in the female partner. Gaps in the Literature Despite the growing body of literature that has aimed to quantify the intersection between substance abuse, IPV, and HIV (Newcomb, Locke, & Goodyear, 2003; Suarez-Al-Adam et al., 2000), few studies have explored the relationships between these three conditions among Hispanics. Those that have (Moreno, 2007; Raj et al., 2006, Raj et al., 2004) have focused on Hispanics in the northeastern United States. Results from these studies may not be generalizable to Hispanic women in South Florida who may differ in regard to their country of origin, socioeconomic situation, acculturation level, cultural practices and beliefs, and other environmental conditions that shape their experiences as Hispanics living in the United States. Furthermore, in a recent review of studies that described the intersections between HIV and IPV, the importance of including substance abuse as a third interwoven health issue was stressed (Geilen et al., 2007). Despite this recommendation, only a few studies have explored the relationships between HIV risks, substance abuse, and IPV within one integrated framework and in a culturally diverse Hispanic population. Conceptual Framework The conceptual framework used for this study was adapted from a framework developed by the institution that funded this study, the Inter-American Drug Abuse Control Commission, Organization of American States. The original framework, which conceptualized the intersection of violence and substance abuse among Hispanic women in the Americas (Wright, 2006), was adapted to also include HIV risk as a major interwoven issue and to identify the specific variables that would be used to define HIV risks, substance abuse, and IPV in this study. HIV risks were conceptualized as consisting of both the participant’s risks (i.e., consistent condom use and history of STIs) and her partner’s risks (i.e., IDU or sex with other men, commercial sex worker [CSW], or IDU). Substance abuse was also conceptualized as the participant’s and partner’s alcohol and drug use in relation to sexual intercourse. Finally, IPV was conceptualized as the woman reporting a history of physical and/or sexual abuse during her current or most recent intimate relationship. The following research questions guided the examined relationships between HIV risks, substance abuse, and IPV: Gonzalez-Guarda et al. / HIV Risks, Substance Abuse, and Violence 1. What is the relationship between being under the influence of alcohol or drugs during sexual intercourse and HIV risks? 2. What is the relationship between IPV and HIV risk? 3. What is the relationship between being under the influence of alcohol or drugs during sexual intercourse and IPV? Methodology Design Project DYVA was a pilot study that explored HIV risks, substance abuse, and IPV among Hispanic women in South Florida through both qualitative (Phase I) and quantitative (Phase II) research methods. This article reports on the quantitative phase of the project, in which questionnaires were administered to 82 participants in a structured face-to-face interview format and in the participant’s preferred language of either English or Spanish. The instruments were translated into Spanish using translation and back translation and reviewed for accuracy by a certified translator. All data were collected between June and October 2006. Sample and Setting To be eligible for the study, candidates had to selfidentify as Hispanic or Latina, female, and between 18 and 60 years of age. Participants were recruited into the study by flyers posted at a community based organization (CBO) that provided a wide range of services to Hispanics and other immigrants (e.g., English classes, career counseling, parenting courses), by members of this CBO promoting the study and through a local newspaper article about the project. Candidates were informed that Project DYVA was a study to explore the experiences of Hispanic women in the community with sexual behaviors, substance abuse, and violence. Snowball sampling methods, in which individuals who were interested in participating in the study were encouraged to inform other Hispanic women in the community about the study, were also used (Miles & Huberman, 1994). 255 Procedures Approval from the university’s internal review board was obtained before any recruitment or data collection activities were conducted. Signed informed consent was obtained from each study candidate before her participation in the study. The consent process and the administration of the questionnaire took approximately 1.5 hours to complete and were conducted by one of the coinvestigators of the project or a trained graduate assistant. All staff who administered questionnaires were female, bilingual, and bicultural. Participants were paid $50 in cash upon completion of the interview to compensate for time, travel, and child care arrangements. Measures The measures used for analyses presented in this report were selected from the larger battery of measures that were administered in Project DYVA. The selection of these measures was based on the work of Peragallo et al. (2005), who originally developed the interview to evaluate the efficacy of an HIV risk reduction intervention that also addressed IPV among Hispanic women. The original set of questionnaires was adapted to better meet the needs of Project DYVA by eliminating some of the questions that related to HIV and adding more questions that addressed violence and substance abuse (Peragallo, Gonzalez, & Vasquez, 2007). Because the measures used in this study have not been described in detail elsewhere, they are described broadly and the variables within the measures that were used to measure HIV risks, substance abuse, and IPV are specified. Demographic section. The demographic component of the questionnaire was administered at the beginning of the interview. Each participant was asked to report her age, how many years she had lived in the United States, her country of origin, and her civil status. She was also asked to report whether or not she was currently living with a partner, the number of children that she had, and the number of children that lived with her. Finally, she was asked about her religion and religiosity, education, employment, individual and household income, and health insurance status. 256 JANAC Vol. 19, No. 4, July/August 2008 The Bidimensional Acculturation Scale. The Bidimensional Acculturation Scale (BAS) (Marin & Gamba, 1996) was used to assess acculturation. This tool consists of 24 questions regarding the participant’s English and Spanish language behaviors and customs in three domains: general language use, language proficiency, and language use in media. These domains are assessed within two subscales (i.e., the Hispanic and non-Hispanic subscales), with each subscale containing 12 questions. Responses for each of the questions ranged from 1 (almost never) to 4 (almost always). A higher score on the Hispanic and non-Hispanic subscales is indicative of a greater level of cultural activities for that particular domain. A mean score of $ 2.5 for both the Hispanic and the non-Hispanic subscales is indicative of biculturalism. High internal consistency has been reported for the BAS (Marin & Gamba, 1996; Peragallo et. al, 2005). In this study, the BAS as a whole showed favorable reliability (Cronbach’s a 5 .80). However, the non-Hispanic subscale performed much better (Cronbach’s a 5 .90) than the Hispanic subscale (Cronbach’s a 5 .68). Sexual History Questionnaire. The Sexual History questionnaire (Peragallo et al., 2007) included five major questions regarding the participant’s contraceptive use during the last 3 months, reasons for not using contraception (i.e., if the participant reported no use), history of HIV testing, and history of STIs. Information regarding the participant’s history of STIs was collected in a table that included rows with the names of different STIs (e.g., syphilis, HIV, chlamydia, herpes) and columns specifying the time of diagnosis (i.e., within the last 3 months, within the last year, and ever) and the number of times she had been diagnosed with the identified STI. Because the Sexual History questionnaire included general screening questions that were not scaled, no psychometric properties can be reported. The Partner Table. The Partner Table (Peragallo et al., 2007) was developed to collect detailed information regarding HIV risks, substance abuse, and IPV that occurred within the participant’s past five sexual relationships. First, participants were asked to report the number of sexual partners they had in their lifetime, specifying the number of male and female partners. They were also asked to report the number of sexual partners they had in the past 3 months and the number of sexual partners that had forced them to have sex. The participants were then asked to recall their last five sexual partners, starting with their current or most recent partner (i.e., if they were not currently in a sexually active relationship) and working backward. If the participant had only one partner, information was collected for that one partner only. However, if the participant had more than five partners, information was collected for the participant’s past five partners only. Each column of the table represented a partner. For example, the first column represented the participant’s current or most recent partner, and the second column represented the previous one. The rows consisted of 34 questions regarding the relationship with the partner specified in the column. These questions asked participants to report each partner’s gender, age when the relationship began, duration of the relationship, partner’s ethnic background, sexual practices that occurred throughout the relationship (i.e., vaginal, oral, and anal sex and respective condom use), substance abuse practices surrounding sexual intercourse (i.e., participant and/or partner having sex while under the influence of alcohol and drugs), partner’s alcohol and illicit drug use during the relationship, partner’s screening behaviors for STIs, and partner’s behaviors that created a risk for HIVand other STIs (i.e., sex with other men, with CSW, and with IDU). Questions regarding sexual abuse (‘‘Were you ever forced to have sex with this partner?’’), physical abuse (‘‘Did your partner hit or hurt you in any way?’’), and psychological abuse (‘‘Did your partner scream at you in a frightening way?’’) perpetrated by the partner and subsequent help-seeking behaviors were also included. Because the Partner Table used screening questions relating to multiple domains including HIV risks, substance abuse, and IPV, most of which included fewer than three questions, psychometric estimates could not be computed. Violence Assessment. The Violence Assessment questionnaire (Peragallo et al., 2007) included nine questions related to community violence and abuse during childhood and adulthood. The first three questions were related to community violence. Participants were first asked if they had lost family or friends Gonzalez-Guarda et al. / HIV Risks, Substance Abuse, and Violence because of a drug overdose, gang violence, homicide, HIV, or suicide. Information on the participants’ relationship to the deceased as well as the victim’s age, gender, and cause of death were recorded. Participants were also asked if they or anyone close to them was ever part of a gang. The next six questions related to child and adult abuse. In these questions, participants were asked if they were ever physically abused (‘‘Were you ever physically abused?’’), sexually abused (‘‘Were you raped or sexually abused?’’), and/or psychologically abused (‘‘Were you verbally or emotionally abused?’’) as a child or adult. These questions allowed participants to self-categorize as victims of sexual, physical, and/or psychological abuse and to describe the abuse in their own words. For any positive responses to these questions, detailed information about the participant’s and perpetrator’s age when the abuse started and ended, the perpetrator’s relationship to the participant (e.g., partner, uncle, coworker), the perpetrator’s gender and ethnicity, as well as a description of the abuse was collected. As with the Partner Table, no psychometric properties could be computed for this questionnaire. However, a high level of agreement between the participants’ responses to the two questions relating to sexual abuse (98.7%) and physical abuse (96.3%) by current or most recent partner was obtained from the Partner Table and the Violence Assessment questionnaire. Variables HIV risks. Both the participants’ and their partners’ HIV risks were assessed. The participant’s responses to the Sexual History (Peragallo et al., 2007) were used to determine if she had a history of STIs. Participants who responded positively to having at least one of the STIs included in the Sexual History at any point in their lifetimes were identified as having a positive history of STIs. The rest of the HIV risks were obtained from the first column of the Partner Table (Peragallo et al., 2007), in which information about the participant’s current or most recent relationship was obtained. Participants were asked to report how often a condom was used during vaginal sex with the current or most recent partner. Response categories were dichotomized as consistent (i.e., always used condoms) and inconsistent condom use (i.e., used condoms sometimes or never). 257 Information regarding the participant’s partner’s risk for HIV was also obtained from the first column of the Partner Table. Participants were asked if their current or most recent partner had a history of STIs. The responses to these questions included yes, no, or don’t know. Because many of the participants suspected that their partners may have had an STI but did not know for sure, responses were dichotomized into a positive or suspected category (i.e., yes or don’t know) and a negative category (i.e., no). This classification was deemed appropriate because lack of knowledge regarding a partner’s STI history and risk behaviors is an established risk factor for HIV among women (CDC, 2007a; Hader, Smith, Moore, & Holmberg, 2001). Similarly, participants were asked to report if the partner had ever injected drugs or had sex with other men, a CSW, or an IDU. Response options for these questions were yes, no, or don’t know. As with the question regarding their partners’ histories of STIs, participants regularly responded that they suspected these behaviors but were unsure. Consequently, the responses to these questions were dichotomized into a positive/suspected category (i.e., yes or don’t know) or a negative category (i.e., no). Substance abuse. The first column of the Partner Table (Peragallo et al., 2007) was also used to assess alcohol and drug use in relation to sexual intercourse. Specifically, participants were asked how often they had sex while under the influence of alcohol and/or drugs. They were also asked how often they had sex while their partner was under the influence of alcohol or drugs (i.e., never, almost never, occasionally, or almost always). Responses to the alcohol and drug use questions were combined into one substance abuse variable and dichotomized into frequent (i.e., almost always or occasionally) or infrequent (i.e., rarely or never) alcohol or drug use during sexual intercourse. Participants who reported frequent substance abuse during sexual intercourse (coded as 1) were compared with participants who reported infrequent substance abuse (coded as 0). Similarly, participants who reported having a partner who frequently abused substances during sex (coded as 1) were compared with participants who reported having a partner who did not use or did so infrequently (coded as 0). 258 JANAC Vol. 19, No. 4, July/August 2008 Intimate partner violence. IPV was measured through self-reported abuse perpetrated by the participant’s current or most recent intimate partner. Any positive responses to the IPV questions related to sexual and physical abuse in the Partner Table or in the Violence Assessment questionnaire, in which the participant’s current or most recent partner was identified as the perpetrator, were used to identify participants who had been victims of IPV. Participants who reported being a victim of psychological abuse but did not report physical or sexual abuse were not included because the question regarding psychological abuse in the Partner Table (‘‘Did your partner scream at you in a frightening way?) was less specific than the questions for the other types of abuse. Consequently, participants who reported sexual and/or physical abuse (coded as 1) were compared with participants who did not report sexual or physical abuse (coded as 0). Analysis Before exploring the relationships between HIV risks, substance abuse, and IPV, descriptive characteristics of the sample were generated and analyzed. Differences between various demographic variables (i.e., age, years in the United States, years of education, and individual monthly income) and acculturation between participants who reported high-risk behaviors for HIV, substance abuse, and IPV (i.e., inconsistent condom use, substance use during sexual intercourse, and a history of IPV) and lower risks (i.e., consistent condom use, infrequent substance use during sex, and no history of IPV) were examined using independent sample t-tests. Although examining group differences was not a primary aim of this study, the information was used to understand differences between high-risk and lower risk participants and hence to generate explanations for why the variables under study may be related. Pearson’s chi-square tests and Fisher exact tests (FETs), when more than 20% of the frequencies within cells were less than five (Altman, 1999), were conducted to test relationships between HIV risks, substance use during sexual intercourse, and IPV. Contingency tables and crude odds ratios (ORs) with their respective 95% confidence intervals (Cis) were also generated. All dichot- omized variables included in these analyses compared the high-risk group (i.e., participants with a history of STIs, participants who were frequently under the influence of alcohol or drugs during sex) with the lower risk group (i.e., participants with no history of STIs, participants with infrequent or no substance use related to sexual activity). These analyses were conducted using Statistical Package for the Social Sciences version 15.0 (SPSS, Inc., Chicago). Results Characteristics of the Sample Participants were diverse with respect to age and socioeconomic situations (see Table 1). The women represented 12 different countries, with the greatest proportion born in Colombia (47.6%), Venezuela (13.4%), and Ecuador (8.5%), and they had spent an average of 9.31 years in the United States (SD 5 8.26). Only two women (2.4%) in the study were born in the United States. Although all participants scored above the cutoff score on the Hispanic acculturation subscale of the BAS, only 35.4% scored above the cutoff on the non-Hispanic acculturation subscale. This result indicated that whereas all the participants remained highly acculturated to their culture of origin, only slightly more than one third were highly acculturated to United States culture and hence could be considered to be bicultural. Most participants were currently employed (59.8%) and had a low monthly and household income, placing 24% of the participants and their families below the poverty threshold for 2006 (U.S. Census Bureau, 2007). Despite low employment rates and income, the participants had relatively high levels of education; 87.8% reported that they had graduated from high school, and 42.7% reported that they had graduated from a university. Only 26.8% of the sample had access to private or public insurance. The remainder of the participants paid for their health care out of pocket. Some women (19.5%) reported never having accessed health care in the United States. The majority of the participants were married (54%) and/or currently living with a partner regardless of marital status (64.6%). They had an average of just over three lifetime sexual partners (M 5 3.21, SD 5 3.09) and Gonzalez-Guarda et al. / HIV Risks, Substance Abuse, and Violence Table 1. Characteristics of a Community Sample of Hispanic Women Participating in Project DYVA (N 5 82) Variable Mean (M) Range Table 2. SD Age 39.28 (19-60) 10.91 Years in the United States 9.31 (.25-44) 8.26 Number of children 1.68 (0-5) 1.23 Number of children living with participant 1.17 (0-3) 1.00 Participant monthly income (U.S. dollars) 493.05 ( 0-4,200) 791.90 Household monthly income (U.S. dollars) 2,766.35 (200-35,000) 3,943.07 Number of people living off of monthly income 3.49 (1-7) 1.19 Years of education 14.28 (0-25) 3.87 Non-Hispanic acculturation (BAS) 26.48 (15-46) 6.82 Hispanic acculturation (BAS) 42.88 (33-48) 3.57 NOTE: BAS 5 Bidimensional Acculturation Scale (Marin & Gamba, 1996), DYVA 5 Drogas y Violencia en las Americas (Drugs and Violence in the Americas). just under one partner in the last 3 months (M 5.74, SD 5 .44). A total of 2 participants (2.4%) reported that they had never had an intimate partner and were therefore not included in the analyses. A total of 15% of the participants reported having at least one STI during their lifetimes, and 42.7% reported either having a partner with a positive or suspected history of STIs. Slightly more than one fourth (26.3%) of participants reported that they were frequently under the influence of alcohol during sexual intercourse. Similarly, slightly more than one fourth (27.5%) reported having a current or recent partner who was frequently under the influence of alcohol during sex. The occurrence of being under the influence of drugs during sexual intercourse was much lower for participants than their partners (1.3% and 5.0%, respectively). Risky behaviors among the participants’ partners seemed to be high, with a large proportion of participants reporting a positive or suspected history of their partner having sex with CSWs (40.0%) and IDUs (18.8%). History of IPV by a current or recent partner was widespread among participants (see Table 2); more than half of the participants (51.3%) reported at least one form of abuse by their 259 Frequency of Reported HIV Risks, Substance Abuse During Sexual Intercourse, and Intimate Partner Violence Among a Sample of Hispanic Women and Their Current or Most Recent Partners (N 5 80)a Variable Participant HIV risks Inconsistent condom use History of STI Partner HIV risks (yes or suspected) History of STI IDU Sex with men Sex with CSW Sex with IDU Substance abuse during sex (frequent) Participant drunk during sex Participant high during sex Partner drunk during sex Partner high during sex IPV with current or most recent partner Physical and/or sexual Physical Sexual Psychological At least one form Two or more types of abuse n (%) 75 (93.8) 12 (15.0) 35 (42.7) 6 (7.5) 5 (6.3) 32 (40.0) 15 (18.8) 21 (26.3) 1 (1.3) 22 (27.5) 4 (5.0) 24 (30.0) 23 (28.8) 10 (12.5) 39 (48.8) 41 (51.3) 23 (27.5) NOTE: CSW 5 commercial sex worker, IDU 5 intravenous drug user, STI 5 sexually transmitted infection. a. Two participants reported never being in an intimate relationship and were excluded from the analysis. current or most recent partner, and almost one third (30.0%) reported physical and/or sexual abuse. Many participants (27.5%) experienced more than one type of abuse by an intimate partner. Differences Between High-Risk and Low-Risk Groups There were no differences in mean age, years living in the United States, years of education, individual income, or acculturation between participants who reported inconsistent condom use during vaginal sex compared with participants who reported consistent condom use. There were also no differences in demographic variables and acculturation between participants who reported IPV and participants who did not. However, participants who reported being frequently under the influence of alcohol or drugs 260 JANAC Vol. 19, No. 4, July/August 2008 Table 3. Differences in Demographic Variables and Acculturation Between High-Risk and Lower Risk DYVA Participants in Regard to Consistent Condom Use, Substance Abuse During Sexual Intercourse, and Intimate Partner Violence Age Years in the United States Education Income Hispanic BASa Non-Hispanic BASb Condom Use Yes (M) No (M) t-test Substance Abuse Yes (M) No (M) t-test Intimate Partner Violence Yes (M) No (M) t-test 31.00 2.47 14.20 504.00 43.20 24.60 39.09 7.64 15.91 714.55 41.45 29.95 38.92 6.80 14.29 811.25 42.79 27.54 39.83 7.73 14.24 480.13 42.84 26.52 21.84 21.38 2.02 .065 .215 2.601 39.34 7.31 13.60 393.28 43.40 25.05 .10 2.16 22.44c 21.32 2.20c 22.98c 39.43 7.66 14.21 340.36 42.89 25.91 .20 .42 2.08 22.53 .114 2.970 Note: BAS 5 Bidimensional Acculturation Scale (Marin & Gamba, 1996), DYVA 5 Drogas y Violencia en las Americas (Drugs and Violence in the Americas). a. Acculturation to the culture of origin. b. Acculturation to the United States culture. c. p , .05 during sexual intercourse had a higher mean number of years of education (M 5 15.91, SD 5 3.28) than participants who reported infrequent or no use (M 5 13.60, SD 5 3.94), t (78) 5 22.65, p 5 .011. Frequent alcohol or drug users also scored higher than nonusers on the non-Hispanic acculturation subscale of the BAS (M 5 29.95 vs. M 5 25.05), t (28) 5 22.98, p 5 031 and lower than infrequent users on the Hispanic acculturation subscale (M 5 41.45 vs. M 5 43.40), t (78) 5 2.00, p 5 .004 [see Table 3]). Substance Abuse and HIV Risks Substance abuse was significantly related to some participant and partner HIV risks. Although the participants’ frequency of being under the influence of alcohol or drugs during sexual intercourse was not related to their use of condoms during vaginal sex (FET, p 5 .315), there seemed to be a trend toward significance in the relationship between the participant’s substance abuse practices during sex and her history of STIs, c2 (1, N 5 80) 5 3.59, p 5 .058. There was also a significant relationship between the participant’s substance abuse and her partner’s history of having sex with IDUs, c2 (1, N 5 80) 5 6.18, p 5 .013. In fact, participants who reported frequently being under the influence of alcohol or drugs during sexual intercourse were more than four times as likely to have a partner who had a positive or suspected history of having sex with an IDU than participants who reported infrequent or no use, OR 5 4.16, 95% CI 5 1.29, 13.47. However, they were not more likely to report having a partner who had a positive or suspected history of STIs, IDU, having sex with other men, or having sex with CSWs (see Table 4). Participants who reported frequently being under the influence of alcohol or drugs during sex were more than eight times more likely to report having a partner who frequently abused alcohol or drugs during sex, (OR 5 8.40, 95% CI 5 2.79, 25.34), c2 (1, N 5 80) 5 16.35, p , .0001. Participants who reported having a partner who was frequently under the influence of alcohol or drugs during sexual intercourse were almost three times more likely to report a partner with a positive or suspected history of having sex with a CSW (OR 5 2.96, 95% CI 5 1.10, 7.93), c2 (1, N 5 80) 5 4.80, p 5 .028. The partner’s substance abuse was not related to any of the participant’s HIV risks (i.e., condom use, history of STI) or any other of the partner’s risks (i.e., history of STI, IDU, sex with men, or sex with CSW) (see Table 4). Intimate Partner Violence and HIV Risks Whereas consistent condom use was independent of IPV (FET, p 5 1.00), participants who reported being a victim of sexual and/or psychological abuse were more than six times more likely to report a history of STIs (OR 5 6.50, 95% CI 5 1.73, 24.44), FET, p 5 .005. IPV was also associated with the partner’s HIV sexual risk behaviors. Participants with a history of IPV were more likely to report having a partner with a positive or suspected history of having sex with men (20.8% among victims of IPV vs. .0% Gonzalez-Guarda et al. / HIV Risks, Substance Abuse, and Violence Table 4. 261 The Relationship Between HIV Risks, Substance Abuse During Sexual Intercourse, and Intimate Partner Violence Among a Sample of Hispanic Women and Their Intimate Partners (N 5 80) Participant Substance Abusea OR (95% CI) c2 Participant’s HIV riskb Inconsistent condom use History of STI Partner’s HIV riskc History of STI IDU Sex with men Sex with CSW Sex with IDU Participant substance abusea Partner substance abusea Partner Substance Abusea OR (95% CI) c2 Intimate Partner Violence OR (95% CI) c2 NAd 3.25 (.92, 11.49) FET 3.59 1.77 (.187, 16.71) 2.78 (.79, 9.73) FET 2.69 1.77 (.19, 16.71) 6.50 (1.73, 24.44) FET FETf 0.519 (.13, 2.05) 0.51 (.06, 4.58) 0.64 (.07, 6.10) 1.76 (.65, 4.75) 4.16 (1.29, 13.47) FET FET FET 1.26 6.18e .37 (.10, 1.43) 2.52 (.471, 13.52) 3.86 (.60, 24.75) 2.96 (1.10, 7.93) 2.47 (.778, 7.85) 8.40 (2.79, 25. 34) 2.18 FET FET 4.80e 2.44 16.35g 8.40 (2.79, 25. 34) 16.35g .37 (.10, 1.43) 5.40 (.92, 31.81) NAd 2.96 (1.10, 7.93) 5.00 (1.53, 16.32) 1.99 (.71, 5.58) 3.67 (1.32, 10.21) 2.17 FET FETd 4.80e 7.912f 1.720 6.53e NOTE: CI 5 confidence interval, CSW 5 commercial sex worker, FET 5 Fisher exact test, IDU 5 intravenous drug user, NA 5 not applicable, OR 5 odds ratio, STI 5 sexually transmitted infection. a. Reported frequent use of alcohol or drugs during sex. b. Reported yes. c. Reported yes or don’t know. d. Odds ratio was unavailable because one of the cells was zero. Therefore, Fisher exact test was used when one of the cell counts , 5; respective p values represent results of the FET. Chi-square (c2) test was used unless otherwise indicated. e. p , .05 f. p , .01 g. p , .001 among nonvictims) (FET, p 5 .002). They were also almost three times more likely to report a partner with a positive/suspected history of having sex with CSWs (OR 5 2.96, 95% CI 5 1.10, 7.93), c2 (1, N 5 80) 5 4.80, p 5 .028 and five times more likely to report a partner with a positive/suspected history of having sex with an IDU (OR 5 5.00, 95% CI 5 1.53, 16.32), c2 (1, N 5 80) 5 7.91, p 5 .005. IPV was not associated with having a partner with a history of STIs or IDU (see Table 4). Substance Abuse and Intimate Partner Violence Although participants’ substance abuse during sexual intercourse was independent from their history of IPV (c2 [1, N 5 80] 5 1.72, p 5 .190), a significant relationship was reported between having a partner who was frequently under the influence of alcohol and/or drugs during sexual intercourse and being a victim of sexual and/or physical abuse, c2 (1, N 5 80) 5 6.53, p 5 .011. Participants who reported having a history of physical and/or sexual abuse were almost four times more likely to report a partner who was frequently high or drunk during sexual inter- course than participants who did not report a history of IPV (OR 5 3.67, 95% CI 5 1.31, 10.21). Discussion The results of this study suggest that HIV risks, substance abuse, and IPV may be closely related to one another in multiple ways. Whereas neither the participant’s nor her partner’s substance abuse during sexual intercourse was directly related to the participant’s condom use or history of STIs (although trends were noted), substance abuse may indirectly have an impact on the participant’s risk for HIV because of a close association with HIV-related risk behaviors. Participants who reported frequently being under the influence of alcohol or drugs during sexual intercourse were more likely to have a partner who also abused alcohol or drugs. Substance abuse, in turn, was related to the partner’s risky sexual habits such as having sex with CSWs or IDUs. Consequently, participants were placed at risk for HIV not only because of their own substance abuse practices, but also from associating with men with problematic 262 JANAC Vol. 19, No. 4, July/August 2008 behaviors. The participant’s substance abuse practices during sexual intercourse were not related to her history of IPV. However, her partner’s substance abuse behaviors were. Although IPV was not related to consistent condom use, it was associated with the participant’s risk for HIV (i.e., history of STI) and her partner’s sexual risk behaviors, such as the participant’s history of STIs and having a partner with a positive or suspected history of having sex with men, CSWs, or IDUs. Raj et al. (2004) also noted that although condom use was not related to abuse, various partner HIV-related risk behaviors such as infidelity were. Taken together, these results suggest that a participant’s risks related to the variables under study may be more influenced by her partner’s behaviors than her own. This hypothesis has been well supported by results from other studies reported in the literature (Hader et al., 2001; Raj et al., 2004). The results from the qualitative component (i.e., Phase I) of Project DYVA can help explain the underlying cultural factors that shape the relationship between HIV risks, substance abuse, and IPV in this population. One of the major issues that emerged from focus group data collected in Phase I of the study was the role that machismo and culturally rooted gender inequalities played in propagating risky behaviors such as substance abuse, infidelity, and aggression among men and the lack of control over sexual/reproductive decision making among women (GonzalezGuarda, Peragallo, Vasquez, Urrutia, & Villarruel, 2008). In fact, participants believed that these inequities were so intrinsic to their culture that women themselves propagated these gender norms by raising their male and female children with different privileges and responsibilities. Other qualitative studies that have explored HIV, substance abuse, and/or IPV in this population have also documented the role that culturally ascribed ideals for men and women play in increasing Hispanic women’s risks for HIV and IPV (Klevens et al., 2007; Moreno, 2007). These results are in line with the theory of gender and power (Connell, 1987; Wingwood & DiClemente, 2000) that postulated that society promotes gender-based inequities in intimate heterosexual relationships that place women at risk for IPV and reduce women’s control over sexual decision making. More research is needed to obtain a better understanding of cultural factors that influence these conditions. When interpreting the results of this study, it is also important to note that whereas there were no differences in the demographic characteristics and acculturation statuses of participants who reported inconsistent condom use and IPV, there were differences in women who reported frequent substance abuse during sexual intercourse. Women who reported being frequently under the influence of alcohol or drugs during sexual intercourse had a higher mean education level and were more acculturated to U.S. culture than women who reported infrequent or no use. Other researchers who have studied substance abuse among Hispanics have noted that although education is a strong protective factor for HIV and IPV in Hispanic women, it is a risk factor for substance abuse (Newcomb & Vargas Carmona, 2004). It has also been well documented that being more highly acculturated to U.S. culture is a major risk factor for substance abuse (Caetano, Ramisetty-Mikler, & McGrath, 2004; Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005). The relationships between acculturation and risk behaviors were also supported by the qualitative (i.e., Phase I) results of this study. In fact, one of the main themes that emerged from the focus groups (i.e., ‘‘uprooted in another world’’) described how the adoption of the more ‘‘liberal’’ values of U.S. culture and the impact this had on women’s families made their community more vulnerable to HIV, substance abuse, and IPV (Gonzalez-Guarda et al., 2008). It may be that as Hispanic women acculturate to the U.S. culture, they begin to practice more problematic behaviors without the skills that are necessary to reduce risks (e.g., abstaining from sex while under the influence of alcohol or drugs). More research is needed to explore what happens during the acculturation process that may place Hispanics at risk for substance abuse and related conditions and why the direction of the relationship between acculturation and risk may vary depending on the behavior under consideration. Despite the fact that this study did not aim to identify the prevalence of risk behaviors, one cannot overlook the alarmingly high rates of inconsistent condom use (93.8%) and physical and/or sexual abuse (30.0%). Although these figures are much higher than rates reported in population-based studies (Tjaden & Thoennes, 2000), they are comparable to what has been documented with other high-risk, community- Gonzalez-Guarda et al. / HIV Risks, Substance Abuse, and Violence based samples of Hispanics (Hazen & Soriano, 2007; Raj et al., 2006; Raj et al., 2004). One of the reasons that these rates were so high may have been because the research team advertised Project DYVA as a study that explored substance abuse, violence, and risky behaviors among Hispanic women. It is likely that women who had experiences with some of these issues were attracted to the study, especially given the lack of access to trusted health care and social services in the community. Additionally, participants were mostly recruited from a CBO that was well-trusted within the community, and the study used bilingual, bicultural, female interviewers who were trained in establishing rapport with participants. It is also possible that because of this trust, the high recorded incidence of risk was more accurate than lower incidence rates reported in other studies. In either case, these rates underscore the immense risk that Hispanic women have for STIs and IPV. Additional methodological limitations must be considered when interpreting the results of this study. The data collected in this study were entirely self-reported and therefore subject to a wide range of biases. It is likely that participants who experienced IPV were more likely to recall events and situations (e.g., partner’s substance abuse) surrounding abuse (i.e., recall bias). Conversely, because such sensitive topics were discussed, participants may not have felt comfortable accurately describing their experiences with their partners. However, because the DYVA research team included female bicultural and bilingual interviewers who conducted interviews in a respected community organization and were trained to help participants feel safe and comfortable, the investigators in this study feel confident that trust was established. Second, the study used a cross-sectional design in which information about history of HIV risk, substance abuse, and IPV were collected simultaneously. Consequently, the directions of the relationships could not be ascertained. For example, it could not be causally established that substance abuse or IPV were risk factors for HIVamong participants. Third, because positive and suspected responses to partner behaviors were combined into one category and compared with negative reports, it is unknown what was associated with risks for IPV, an actual behavior, suspecting a behavior, or both. Lastly, the reported results were obtained from a small pilot project that used a convenience sample of Hispanic women 263 from South Florida. Given that Hispanics comprise a heterogeneous group with varying countries of origin, socioeconomic backgrounds, and levels of acculturation, caution must be used when generalizing the results of this study to other groups of Hispanics and women. Implications for Research and Practice The results of this study have various implications for research and practice. The high rates of exposure to HIV-related risk factors, substance abuse, and IPV among participants underscore the importance of targeting these health conditions among Hispanics. Despite the fact that strong relationships were established between the three conditions in this study and in previous studies, there are currently no prevention programs reported in the literature that address HIV, substance abuse, and IPV within one framework (Geilen et al., 2007). When developing culturally specific interventions that aim to prevent these conditions among Hispanic women, it seems to be especially important to target their male partners. In fact, as suggested by results from this study, targeting the partner’s substance abuse and risky sexual behaviors through treatment and prevention may be more important in addressing HIVand IPVamong Hispanic women than specifically targeting their own behaviors (e.g., substance abuse and condom use). Given the lack of differences in demographic characteristics and acculturation levels of the women who reported HIV risks and IPV, interventions need to be developed to target Hispanics across different age groups, socioeconomic conditions, and levels of acculturation. Additionally, more ‘‘Americanized’’ strategies must be incorporated in these interventions to target the prevention and/or treatment of substance abuse among more highly acculturated subgroups within this population. More research needs to be conducted to identify risk and protective factors that cut across HIV risks, substance abuse, and IPV among Hispanics. This is a fundamental concept that must be acknowledged to increase the understanding of how these issues are related and to identify strategies that are needed to effectively target the conditions within one framework. One of the risk factors that seems to cut across these conditions among Hispanics are culturally 264 JANAC Vol. 19, No. 4, July/August 2008 References Clinical Considerations When addressing risk for HIV among Hispanic women, it is important that clinicians and program planners consider the following:  HIV, substance abuse, and IPV are interwoven issues that must be addressed simultaneously.  Screening for IPV may be an effective way of identifying women at risk for HIV.  When evaluating risk for HIVamong women, it is not enough to only assess for STIs and behaviors that may place them at risk. A woman’s partner’s risk behaviors must also be considered.  Promoting positive aspects of culturally ascribed ideals for men (machismo) and women (marianismo), such as the role that men have in protecting their loved ones and the power women have over reproduction, may help address gender inequities that propagate HIV, substance abuse, and IPV in this population. rooted gender inequities. 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