Neighborhood Factors, Sexual Risk Behaviors, Sex Partner Risk, and Sexually Transmitted Infections among HIV-Infected and High Risk HIV-Uninfected Women in the Southern United States Open Access

Haley, Danielle Frances (2016)

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Introduction. Neighborhood characteristics shape sexual risk and sexually transmitted infections (STIs) in HIV-uninfected adults in the United States (US). This dissertation utilizes multilevel analyses to test relationships between census tract characteristics and sexual risk behaviors, sex partner risk, and testing positive for an STI in a predominantly HIV-infected cohort of women living in the southern US. Methods. This cross-sectional multilevel study analyzed data from 737 HIV-infected and HIV-uninfected women enrolled at the Women’s Interagency HIV Study’s southern sites. Administrative data (e.g., US Census) captured characteristics of the census tracts where women lived; individual-level data were gathered via survey. We used principal components analysis to condense tract-level variables into two components: social disorder (e.g., violent crime rate) and social disadvantage (e.g., alcohol outlet density). We used hierarchical generalized linear models to test relationships between tract characteristics and (1) sexual risk behaviors (unprotected vaginal intercourse [UVI], anal intercourse [AI], unprotected anal intercourse [UAI]); (2) sex partner characteristics (risk-level [e.g., lifetime history of injection drug use], non-monogamy); and (3) testing positive for a current STI (Chlamydia, gonorrhea, trichomoniasis, syphilis) and to assess whether these relationships varied by HIV status. Results. Greater tract-level social disorder was associated with less AI (OR=0.65, 95% CI=0.43, 0.96) and UAI (OR=0.50, 95% CI=0.31, 0.82), regardless of HIV status; less partner non-monogamy (OR=0.72, 95% CI=0.54, 0.96) among HIV-uninfected women; and greater partner non-monogamy (OR=1.20, 95% CI=0.96, 1.50) and partner risk (OR=1.41, 95% CI= 1.16, 1.72) among HIV-infected women. Greater tract-level social disorder was associated with more STIs (OR=1.34, 95% CI=0.99, 1.87), regardless of HIV status. Greater social disadvantage was associated with less partner non-monogamy (OR=0.73 95% CI=0.60, 0.96) and lower partner risk (OR=0.84, 95% CI=0.72, 0.97), but more STIs (OR=1.34, 95% CI=0.96, 1.86), regardless of HIV status. Perceived neighborhood cohesion was associated with lower partner risk (OR=0.84, 95% CI=0.70, 1.02), regardless of HIV status. Conclusion. Findings suggest that neighborhood characteristics may be associated with sexual behaviors, partner characteristics, and STIs among HIV infected and HIV uninfected Southern women. Future research should establish the temporality of relationships and explore pathways through which neighborhoods create vulnerability to STIs.

Table of Contents

Table of Contents Chapter 1: Introductory Literature Review Introduction 1 Neighborhood-Level Determinants of Sexual Behavior and HIV/STIs 1 Potential Mechanisms through which Neighborhood-Level Determinants Influence Sexual Behavior and HIV/STIs 2 Limitations in our Understanding of Whether and How Neighborhood- Level Determinants Influence Sexual Behavior and STIs among HIV-Infected Women 3 Significance of the Research 5 Figure 8 References 9 Chapter 2: Associations between Neighborhood Characteristics and Perceived Sex Partner Risk among HIV-infected and HIV-uninfected Women in the Southern United States Abstract 17 Introduction 19 Methods 21 Results 28 Discussion 33 Tables 39 References 45 Chapter 3: Associations between Neighborhood Characteristics and Sexual Risk Behaviors among HIV-infected and HIV-uninfected Women in the Southern United States Abstract 54 Introduction 56 Methods 58 Results 64 Discussion 67 Tables 71 References 77 Chapter 4: Do Relationships between Neighborhood Characteristics and Current STI Status among Women Vary by HIV Status? Abstract 85 Introduction 87 Methods 88 Results 93 Discussion 96 Tables 100 References 107 Chapter 5: Summary and Conclusion Introduction 115 Summary of Key Findings 115 Strengths and Limitations 120 Directions for Future Research 122 Conclusion 126 Figure 128 References 129

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