Beyond the Male Condom: The Evolution of Gender-Specific HIV Interventions for Women
Exner, Theresa M
As the number of HIV infections in women has increased, there has been a concomitant recognition that prevention efforts to reduce sexual transmission must address the gendered context in which risk behavior occurs. This paper provides a longitudinal perspective on the emergence of the HIV epidemic in U.S. women and the parallel development of interventions to reduce risk. In the first portion of this paper, we briefly discuss the growth of the epidemic among women and how public health responses reflected the early discourse about infected women. We also address methods of protection available to women, and the emerging recognition of the importance of gender relations. In the second half of this paper, we show how gender-specificity in prevention efforts has evolved, using a framework developed by Geeta Gupta (2001) and relying on published reviews of the intervention literature in the past 10 years. Finally, we discuss in detail several recent examples. We conclude with a discussion of future directions.
Key Words: gender specific HIV interventions, gender theory, women and HIV
Since the onset of AIDS in the late 1980s, the global pandemic has claimed 25 million lives (UNAIDS, 2000, 2002a, 2002b). Worldwide, 42 million people are currently living with HIV/AIDS (UNAIDS, 2002b). In 2002, UNAIDS reported for the first time that 50% of all adults living with HIV/AIDS were women. In the United States in 2001, women accounted for 26% of all newly diagnosed adult AIDS cases and 32% of newly identified adult HIV infections (Centers for Disease Control [CDC], 2002a), a percentage that has been increasing steadily. As recognition of the impact of HIV on women has emerged over the past 10 years, there also has been a growing understanding that efforts to slow the spread of the virus need to account for the ways that gender structures women’s lives and sexual interactions, creating both constraints and possibilities. In this paper we trace historically the evolving epidemic among U.S. women and the parallel evolution of interventions directed to their sexual risk behavior. We do not aim to present a comprehensive review of interventions for women, as several overviews have been completed in recent years (Choi & Coates, 1994; Exner, Seal, & Ehrhardt, 1997; Fisher & Fisher, 1992; Ickovics & Yoshikawa, 1996, 1998; Kelly & Kalichman, 2002; Logan, Cole, & Leukefeld, 2002; Mize, Robinson, Bockting, & Scheltema, 2002; Oakley, Fullerton, & Holland, 1995; Wingood & DiClemente, 1996). Rather, by broadly reviewing developments over time and presenting a more detailed discussion of recent gender-specific interventions, we hope to highlight trends, identify unanswered questions, and lay the ground for future interventions.
The Evolution of the HIV Epidemic Among U.S. Women
HIV disease in the Western world first appeared among men who have sex with men and intravenous drug users (IDUs). Although women who used intravenous drugs were among those early affected, attribution of infection in women to heterosexual transmission was slow to emerge (Holmes, Karon, & Kreiss, 1990). This was true even though heterosexual transmission was the dominant mode in sub-Saharan Africa and the Caribbean (UNAIDS, 2002b). To this day, guidelines set by the CDC are hierarchical, whereby a case can only be attributed to heterosexual transmission among women if there is no evidence of intravenous drug use. By the end of 1992, over 18,500 U.S. women had officially died of AIDS (CDC, 2002b). However, the CDC AIDS case definition at that time did not include some common disease manifestations unique to women (e.g., recurrent vaginal yeast infections and invasive cervical cancer [Hankins & Handley, 1992; Wright, Ellerbrock, Chiasson, Van Devanter, & Sun, 1994]). Following pressure from women’s advocates, in 1993 the AIDS case definition was expanded (CDC, 1992)-a year that saw an explosion of women officially recognized as having AIDS. This delay in recognizing HIV disease presentations in women compounded difficulties many faced in accessing treatment and procuring ancillary social services, as government aid was contingent on an AIDS diagnosis (Corea, 1992). Women were also often excluded from early drug trials and from natural history studies of disease progression (Fox-Tierney, Ickovics, Cerrata, & Ethier, 1999; Strebel, 1995), leading to inadequate diagnosis, poor understanding of disease manifestation, and delayed treatment (Cohan & Atwood, 1994).
Although slow to be recognized, the HIV epidemic among women was growing rapidly. Between 1984 and 1995 the proportion of AIDS cases among women tripled, from 6% to 19% (CDC, 1995; CDC, 1996a). Concurrent with this growth was the increasing proportion of cases attributable to heterosexual transmission. In 1994, heterosexual contact surpassed intravenous drug use as the predominant route of transmission to U.S. women with a diagnosis of AIDS (CDC, 1995), and HIV infection became the third leading cause of death for women aged 25 to 44, following cancer and unintentional injuries (CDC, 1996b). By the mid 1990s, there was no longer any doubt that HIV had become a major health problem for women.
From the outset, it also was evident that the epidemic was striking the poorest and most marginalized women, predominantly women of color living in the inner cities of the northeastern seaboard (Kamb & Wortley, 2000). This pattern has continued to the present day, with 47.8 new infections per 100,000 among Black women, 12.9 among Hispanic women, and 2.4 among White women (CDC, 2002b). Among women infected heterosexually, a large proportion were and are the partners of current or former IDUs. Additionally, beginning in the early 1990s, crack cocaine use came to be recognized as another risk factor for heterosexually acquired HIV, especially among women (Chiasson et al., 1991; Edlin, Irwin, Faruque, McCoy, & Word, 1994).
What accounts for these sharp racial and social class disparities in the way HIV emerged among women? It has been hypothesized that the growing “feminization of poverty” in the 1980s played a pivotal role in the early, rapid spread of HIV among women (Zierler & Krieger, 1997). Beginning in the mid 1970s there was a drastic restructuring of wealth in the United States, brought about by rapid deindustrialization of U.S. cities and the dismantling of the welfare state. The resulting cuts in social services, increasing instability of low-end jobs, and lack of access to health care disproportionately affected African-American and Hispanic women (Sidel, 1996; Wilson, 1996; Zierler & Krieger, 1997). Between 1980 and 1988 these forces combined to push more than 1.1 million women with children below the poverty line (Plotnick, 1993). Severe disruptions in the occupational structure increased reliance on the informal economy, fostering the exchange of sex for economic survival and participation in the illicit drug economy (Wilson, 1996; Zierler & Krieger, 1997), circumstances that markedly increased women’s exposure to infected partners. Continuing into the present, policies that restrict welfare support and those that produce low-end jobs without health care benefits or financial relief for child care deplete women’s financial resources and autonomy, and, therefore, may increase their dependence on male partners who may be at high risk (Gollub, 1999).
The HIV/AIDS Epidemic Among Women at the Beginning of the Second Millennium
Although the number of HIV/AIDS-related deaths among women has declined since 1995, largely as a result of success of antiretroviral therapy, HIV/AIDS remained the fifth leading cause of death for U.S. women aged 25-44 in 2000 (CDC, 2002a). Among African American women in this same age group, HIV/AIDS is the third leading cause of death.
Although a few anecdotal reports provide evidence for woman-to– woman transmission, suggesting a small but unquantified risk (Morrow & Allsworth, 2000), heterosexual transmission has continued to increase as a proportion of all AIDS cases among women. In 2001, it was estimated that 66% of all new AIDS cases among adult and adolescent women were a consequence of heterosexual transmission and 32% a result of injection drug use (CDC, 2002b). Although it appears that HIV incidence is declining in both men and women infected through injection drug use (Des Jarlais et al., 2002; Wortley & Fleming, 1997), probably as a consequence of concerted grass-roots and communitybased efforts among IDUs, including the formation of needle exchange programs (e.g., Booth & Watters, 1994), this has not been true for heterosexually transmitted infections (Davis et al., 1998; Wortley & Fleming, 1997). This fact strongly suggests that prevention efforts in relation to heterosexual behaviors have been less successful than those directed to drug-using behaviors. It underscores the need to develop new interdisciplinary efforts seeking to understand and to confront the contexts shaping heterosexual women’s HIV risk.
Early Intervention Efforts With Women
In this section we will describe some of the early intervention approaches among women. Gupta (2001) presented a useful framework for conceptualizing the extent to which interventions address critical gender-related issues and classified efforts as gender insensitive, gender neutral, gender sensitive, transformative, and empowering. We will use this framework to trace the development of interventions for women since early in the epidemic.
According to Gupta (2001), gender insensitive interventions are defined as efforts fostering “predatory, violent, irresponsible images of male sexuality and portray women as powerless victims or as repositories of infection” (p. 9). Gender neutral interventions are approaches that, while doing no harm, fail to distinguish between the needs and unique circumstances of women and men. Gender sensitive interventions recognize women’s and men’s differing needs and constraints. Transformative approaches seek to transfigure gender roles and create more gender-equitable relationships. Approaches that empower seek “to empower women or free women and men from the impact of destructive gender and sexual norms” (Gupta, 2001, p. 10). Empowerment is accomplished through collective action to change the conditions that limit women’s rights and choices.
Despite increasing numbers of women with AIDS in the 1980s, women and women’s perspectives were largely absent from research during the early epidemic (Amaro, 1995; Amaro, Raj, & Reed, 2001; Ehrhardt, 1992; Ehrhardt & Exner, 1991). The earliest prevention efforts with women largely centered on them as vectors of disease (Amaro, 1995; Cohan & Atwood, 1994; Corea, 1992; Sacks, 1996; Strebel, 1995). Two groups of women were particularly singled out: sex workers and mothers. Sex workers were viewed as sources of infection who would form the nexus for the spread of HIV into the general population via their male clients to the other female partners of these clients (Amaro et al., 2001; Berer, 1993). However, as Vanwesenbeeck (2001) comprehensively documented in her review, since 1990, research on the occupational hazards of sex workers has been dominated by HIV risk, despite empirical evidence dating from the early 1990s that sex workers in North America and Europe did not have higher incidence of HIV than other women.
The focus on perinatal transmission emphasized women as vectors for infecting their children, and, undergirded by punitive and conservative family values, offered little attention to the needs of the mothers, who were typically multiply stigmatized: disproportionately low income, minority, and often IDUs or partners of IDUs. Many of these women were vulnerable to forced or coercive testing or treatment, often advised to seek sterilization or abortion, and eschewed as unfit to mother a child or make informed decisions about their situation (Amaro, 1990; Amaro et al., 2001; Cohan & Atwood, 1994; Corea, 1992; Solinger, 1992).
Once women’s needs for protection in their heterosexual relationships began to be identified, there was a shift in focus to encourage women to “use” male condoms. Similar to the way in which early research on the epidemic left out the gender-specificity of AIDS manifestations, early intervention models either were atheoretical or were guided by models with assumptions of individual-level, gender-neutral behavioral change, such as the Health Belief Model (Becker, 1974), the Theory of Reasoned Action (Ajzen & Fishbein, 1980), the AIDS Risk Reduction Model (Catania, Kegeles, & Coates, 1990), Social Learning Theory (Bandura, 1986, 1992), and the transtheoretical model of behavior change (Prochaska & DiClemente, 1992). These models assume that individuals are free to act on their choices and that agentic behaviors are easily and consistently drawn upon after building knowledge, consciousness, or skills. In their review of the utility of these theories, Fisher and Fisher (2000) concluded that empirical support for the majority of models is limited. They noted that these approaches are based on rational models of decision-making, which ignore the dyadic nature of sexual behavior. Further, these models do not consider important contextual factors that influence women’s sexual behavior (Amaro, 1995; Amaro & Raj, 2000; Ehrhardt & Exner, 1991).
Many early prevention efforts were gender neutral, providing the same intervention to men and women in mixed gender groups (i.e., males and females together received the same intervention at the same time). These interventions were not effective for women. In methodologically rigorous reviews of the prevention literature, no mixed-gender, group-delivered interventions resulted in sexual behavior change for adult heterosexual women, except among college students (Exner et al., 1997; Kalichman, Carey, & Johnson, 1996; Logan et al., 2002; Wingood & DiClemente, 1996). Most interventions with gender-mixed groups of adults involved interventions for IDUs, and their effectiveness in changing sexual risk behavior was far less than their impact on high risk drug behaviors– often for men as well as women (Choi & Coates, 1994; Exner, Gardos, Seal, & Ehrhardt, 1999; Fisher & Fisher, 1992). Also notable is the fact that many evaluations of interventions that were offered to both men and women even failed to actually examine intervention effects by gender (Exner et al., 1997; Exner et al., 1999), underscoring the pervasiveness of a zeitgeist that, at best, minimized women’s needs and perspectives.
Gender Emerges as an Overarching Issue
In the early 1990s, as it was becoming increasingly clear that heterosexually active women were at risk for HIV, concern grew over the failure of researchers to demonstrate an understanding of the context and nature of sexual interactions and relationships. Behavior change models that focused on individual-level variables began to be widely challenged for negating the complexity of agency and constraint that operate within gendered, racialized, classed, and sexualized contexts (Amaro et al., 2001; Logan et al., 2002; Zierler & Krieger, 1997).
The developments in HIV prevention for women paralleled the growing global women’s rights movement, with its emphasis on the link between women’s rights to self-determination in reproductive choices and gender equity in access to schooling and economic resources. The 1994 International Conference on Population and Development (ICPD) in Cairo and the 1995 Fourth World Conference on Women in Beijing set the stage for a broader mandate for reproductive health and generated momentum around women and AIDS.
Gender came to be understood as one of the most important variables framing the context of dyadic heterosexual interactions (Amaro, 1995; Ehrhardt, 1992; Ehrhardt & Exner, 1991), in as much as predominant cultural notions of women’s sexuality are embedded in a male perspective and male understandings of motivation and desire (Amaro et al., 2001; Schneider & Gould, 1987). Relational norms and broader cultural definitions of gender scripts can guide understanding of women’s and men’s sexual motivations, desires, and actions (Amaro et al., 2001; Connell, 1995, 2002; Schneider & Gould, 1987). Despite some suggestion that gender scripts may be changing for both women and men, traditional norms remain common within many heterosexual relationships (Dunn, 1997; Ortiz-Torres, Williams, & Ehrhardt, 2003; Segal, 1994). These view men as sexual initiators and orchestrators of sexual activity, with women ascribed the role of responsiveness in meeting their partners’ sexual and emotional needs (Byers, 1996; Byers & Wilson, 1985; O’Sullivan & Byers, 1992). Women are frequently socialized to be more sexually passive and ignorant about sex than men, acting as sexual gatekeepers while remaining highly relationally defined (Chodorow, 2001). This is a role that can be in tension with the expectation that men will actively pursue sexual opportunities with women and control their partners’ sexual decisions. The existence of a nearly universal sexual double standard gives men greater sexual freedom and rights of sexual determination than women (Blanc, 2001; Seal & Ehrhardt, 2003) and views male desire as naturally uncontrollable and women as responsible for satiating male arousal (Gilder, 1992). The higher status that men derive from sexual conquests, coupled with assumptions that men have unrestricted access to women’s bodies, can help facilitate a view of women as sexual objects or that regular sexual intercourse forms an implicit contract, particularly in established relationships (Dworkin & Wachs, 1998; MacPhail & Campbell, 2001).
Lastly, many individual and institutional norms tolerate men’s use of a wide range of coercive strategies, from the subtle to the extreme, to overcome their partners’ resistance when withholding sexual “access” (Kaufman, 1997; Messner, 1997; Sanday, 1997). The prioritization of male needs, the expectation of female sexual ignorance, and socialization that can prohibit women from owning their own sexuality and asserting their needs or desires (Segal, 1994) present barriers to active participation in condom decisions for women (Amaro, 1995; Fullilove, Fullilove, Haynes, & Gross, 1990; Logan et al., 2002; Miller, 1986; Wingood & DiClemente, 1992).
In contrast to standard and ubiquitous messages to use condoms for all sex occasions, a gender perspective argues that attempts to promote condom use need to consider the social and cultural realities in which sexual interactions are embedded, including structural and institutional inequality, power differentials within relationships, meanings of condom use, and pregnancy intentions (Amaro, 1995; Cochran & Mays, 1993; Currie, 1988; Ehrhardt & Exner, 1991; Ehrhardt, Yingling, Zawadzki, & Martinez-Ramirez, 1992). Regardless of their desire to enhance their protection, many women report considerable difficulty negotiating condom use, especially when they are economically and socially dependent on male partners. Raising the issue of condom use can entail risk to the relationship in the form of relational conflict or dissolution, loss of economic or emotional security, or abuse (Logan et al., 2002), a particularly problematic situation for women who are isolated emotionally or who are financially dependent (Campbell, 1995; Gupta & Weiss, 1993; Logan & Leukefeld, 2000; Sobo, 1993, 1995). A history of abuse and violence is an even greater deterrent for women to insist on condom use with an unwilling partner. Researchers have found that women who have experienced abuse, who fear a negative partner reaction to safer sex, or who perceive negative consequences to the relationship are significantly less likely to request condom use or to report condom protected intercourse (Amaro & Raj, 2000; Cabral, Pulley, Artz, Brill, & Macaluso, 1998; Ehrhardt et al., 2002b; Gomez & Van Oss Marin, 1996; O’Leary, 2000; Wingood & DiClemente, 1997).
Within committed relationships, where desires for closeness and pleasure and traditional patterns of gendered behaviors become entrenched, initiating condoms can be seen as interfering with trust, intimacy, and pleasure (Amaro, 1995; Ehrhardt et al., 1992; Fullilove et al., 1990). A substantial body of literature indicates that male condoms are less likely to be used in committed relationships with main partners than with casual partners (Bowleg, Belgrave, & Reisen, 2000; Dolcini et al., 1993; Hobfoll, Jackson, Lavin, Britton, & Shepherd, 1993; Lansky, Thomas, & Earp, 1998; Misovich, Fisher, & Fisher, 1997; Richter, Sy, Mukhtar, Addy, & Macera, 1992). Once sex without condoms has occurred, women find it difficult to introduce (or reintroduce) condoms into a relationship (Deren, Shedlin, & Beardsley, 1996).
Condoms interrupt sex and can interfere with arousal and feelings of closeness, and women and men who find intercourse less pleasurable with male condoms than without are less likely to report use (Ehrhardt et al., 2002b). Although the mass availability of oral contraception in the late 1960s contributed to increasing women’s reproductive decision-making autonomy, it had the side-effect of marginalizing the male condom as a method for disease prophylaxis. Despite its high efficacy for preventing unwanted pregnancy, the male condom has become synonymous with disease, infidelity, and casual sex. Raising the issue of condoms means potentially acknowledging the sexual double standard between women and men, while also raising the contentious domains of trust and fidelity. Even considering that one’s steady partner might be unfaithful or disease-infected is counter to the ideal of a committed, trusting relationship. Sexual safety often becomes a secondary concern in relation to the desire for emotional and sexual intimacy (Logan et al., 2002; Sobo, 1993).
Cross culturally, women’s gender roles frequently regard motherhood as a valued feminine ideal (Gupta, 2001). Because the male condom functions as a contraceptive as well as a disease prophylactic, pregnancy intention can be a major barrier to consistent condom use (Ezeh, Seroussi, & Raggers, 1996; Hobfoll et al., 1994). Men’s intentions regarding pregnancy, with or without partner concurrence, are also likely to affect condom use. Both factors combine to pose a significant, complex dilemma for women in risky relationships (Gupta, 2001).
At the same time that there may be multiple barriers to negotiating safer sex, the terrain of gender relations is by no means static, but rather, it is dynamic, shifting, and at play (Connell, 1995, 2002). The pivotal role that domestic and global feminist movements have played in shifting conceptions of masculinity and femininity, and providing gains to women across economic, political, bodily, and sexual realms cannot be underestimated in this regard (Connell, 1987; Dunn, 1997; Lorber, 1994; Segal, 1994). Furthermore, rapid regional and global economic change have restructured both women’s and men’s social positions in postindustrial society, offering major fissures to past notions that men as a group own power, whereas women do not. Researchers must, therefore, continue to find multiple ways to intervene, drawing on nuanced and culturally specific understandings of constraints and agency for both women and men (Mane & Aggleton, 2000; Messner, 1997).
Protection Methods That Give Women Greater Control
Recognizing that women do not “use” male condoms, women’s health advocates also called for the development of female controlled barrier methods and microbicides (Elias & Heise, 1994; Stein, 1990, 1993). It still is unknown whether the diaphragm and cervical cap confer any HIV/STD protective efficacy, although the results from observational studies suggest these barriers may offer some protection against gonorrhea, chlamydia, and cervical cancer (Cates & Stone, 1992; Rosenberg & Gollub, 1992; Stone, Grimes, & Madger, 1986 ).
Following a vigorous campaign for the female condom, the U.S. Food and Drug Administration approved it as a contraceptive method in 1993. The female condom is a thin, soft, transparent polyurethane sheath, with an outer ring at one end that covers the labia on the outside of the vagina and a flexible inner ring at the opposite end of the sheath to help insert it and to keep it in place, in a manner similar to the ring in the diaphragm. Although approved for one-time use, Beksin– ska et al., (2002) recently demonstrated that it can safely be reused after being washed and disinfected with bleach. The female condom has been demonstrated efficacious in preventing pregnancy (Farr, Gabelnick, Sturgen, & Dorflinger, 1994; T!russell, 1998) and has a high likelihood of disease prevention efficacy (Drew, Blair, Miner, & Conant, 1990; Soper et al., 1993). The potential of the female condom to reduce the risk of HIV transmission has been estimated to be greater than 90% (Trussell, Sturgen, Strickler, & Dominik, 1994). Although evidence is not yet definitive, there also is a suggestion that offering the female condom as an additional option for couples may increase the total number of protected occasions (Artz et al., 2000) and that it may enhance women’s perception of empowerment within their relationships and their ability to raise issues of risk and protection with their male partners (Gollub, 2000).
Nevertheless, it is clear that the female condom does not eliminate the need for acceptance by the male partner. Most investigators confirm that partner cooperation in using the female condom is necessary even if the method is female-initiated. Male partners have been reported to be positive about the method, when assessed either by the woman’s report (World Health Organization [WHO], 1997) or directly from the male partners themselves (Bounds, Guillebaud, & Newman, 1992). However, in some reports (Ford & Mathie, 1993; Farr et al., 1994), women who discontinued female condom use cited partner dislike as a major reason.
In part because the female condom requires some degree of negotiation with a partner, advocacy continues for the development of a vaginal microbicide, which, theoretically, would offer women a covert method of protection (The Rockefeller Foundation, 2002). Research on a large number of candidate compounds continues after the report that nonoxynol-9 spermicide does not protect against infection with HIV or other sexually transmitted infections (STIs) (Van Damme et al., 2002). Nevertheless, the most optimistic estimates suggest that it will be close to 2010 before a first-generation microbicide is on the market (The Rockefeller Foundation, 2002). Thus, at present, microbicides remain but a hope, and although female condoms are now available, higher cost relative to male condoms, the need for partner negotiation, and lack of marketing in the West contribute to its limited usage (Gollub, 2000; Kaler, 2002; Mantell et al., 2002). Safer sex for the sexually active remains focused on male condoms.
Addressing Gender as an Integral Part of HIV Interventions: Recent Developments
By the mid 1990s, gender sensitive programs for women were emerging. These were reflected in initiatives that extended women’s access to STI services within reproductive care settings through Title IX funding and by a substantial increase in the number of studies targeting women (Exner et al., 1997; Ickovics & Yoshikawa, 1998; Logan et al., 2002; Wingood & DiClemente, 1998). Although there have been no formal empirical evaluations of the efficacy of gender neutral versus gender sensitive interventions, reviewers of the literature have observed that interventions specifically directed toward women, tailored to the unique issues and circumstances of the target population, and focused on the relationship and negotiation skills necessary to enact condom use with a partner were generally the most efficacious (Exner et al., 1997; Ickovics & Yoshikawa, 1998; Logan et al., 2002; Wingood & DiClemente, 1998). The vast majority of these efforts have been directed toward the individual, delivered one-on-one or in small groups.
In one of the earliest examples of a gender sensitive intervention for women, Kelly and colleagues (Kelly et al., 1994) targeted “high-risk” women (defined as those with multiple partners, risky partners, or an STI history) attending a comprehensive community health clinic in Milwaukee. Women were randomly assigned to either a 5-session HIV prevention program or to a health education condition focusing on nutrition. The HIV intervention, grounded in cognitive behavior principles, emphasized cognitions, risk reduction skills, and social support over the course of four 90-minute workshops for groups of 8-10 women, plus a 1-month group follow-up, all conducted in the clinic.
Intervention activities included participant role-play of sexual negotiation scenarios, including how to initiate a discussion about HIV concerns with a partner and how to resist sexual pressure from a man. Another focus was helping women to identify, to understand, and to manage their personal “triggers” for unsafe sex, such as drinking or drugs, loneliness, or involvement in a coercive or power-imbalanced sexual relationship. Group problem-solving strategies were used to help women brainstorm how to handle their high-risk situations, with women taking on roles that actively supported each other’s concerns and efforts to change. For example, many women shared how they had dealt with sexual pressure and discussed benefits of change, such as protecting one’s children or feeling in control of sexual decision making. At 3-month follow-up, relative to control participants, intervention women were significantly more likely to report condom use, had a higher percent of condom-protected intercourse occasions, and had significantly fewer occasions of unprotected intercourse (Kelly et al., 1994). This study illustrates critical elements characteristic of gender-sensitive interventions. Women were directly targeted, the intervention addressed critical partner negotiation/refusal skills while acknowledging the potential for abuse, and the negotiation scenarios and strategies themselves were derived from pretrial focus groups, thus tailoring intervention content to circumstances pertinent to the women’s lives.
Transformative approaches, which seek to transfigure gender roles and to create more gender-equitable relationships, began to emerge in the mid-to-late 1990s. Three case examples, all published within the last 3 years, are used to illustrate the broad range of efforts to accomplish this.
In a randomized clinical trial conducted with family planning clients in New York City, Ehrhardt et al. (2002a) tested the efficacy of a comprehensive gender-specific intervention (Project FIO-“The Future Is Ours”), which was based on a theoretical model modified to address the realities of women’s lives and their relationships with men. Women were assigned to an eight-session, a four-session, or a control condition, and followed at 1, 6, and 12 months postintervention.
The team had conducted extensive qualitative and quantitative studies on women’s sexual risk for several years predating this clinical trial (Ehrhardt et al., 1992; Ehrhardt et al., 1995). These studies provided data on women’s particular concerns, their barriers to condom use, and power imbalances in their relationships with men, and they informed the theoretical frame guiding the study as well as intervention content.
The theory used to guide the intervention and assessment (AIDS Risk Reduction Model [ARRM; Catania et al., 1990]) was modified to reflect an increased focus on issues concerning women’s relationships with men, set in the context of the multiple demands in women’s lives and the motivators of change that are important for adult women. It stressed protective options beyond the male condom and provided women with alternative strategies to protect themselves, including skills to refuse or avoid unsafe sex, to practice nonpenetrative sex, and to seek mutual HIV testing with a partner. Qualitative work was used to identify themes that ran throughout the entire intervention. Thus, the content of the intervention was based on a rich foundation of the realities of women’s lives.
The sessions were cognitive-behavioral in nature, using skills acquisition, structured practice with feedback, the development of helpful beliefs and the reduction of hindering attitudes, the provision of incentives, and the encouragement of social support. The intervention is described in more detail elsewhere (see Miller, Exner, Williams, & Ehrhardt, 2000). The content specific to gender scripts included exercises eliciting and challenging dysfunctional gender stereotypes; introduction of a “sexual bill of rights,” which stressed women’s control over their bodies, their sexuality, and their entitlement to respectful noncoercive treatment from partners; direct techniques for negotiating and refusing unsafe sex as well as more indirect strategies of avoidance; and erotization of safer sex and exploration of alternatives to male condoms.
This intervention was effective in reducing women’s sexual risk behavior. At both 1- and 12-month follow-up, women who were assigned to the eight-session group had about twice the odds of reporting decreased or no unprotected vaginal and anal intercourse compared to controls (Ehrhardt et al., 2002a). Women assigned to the 8-session condition reported approximately 3 and 5 fewer unprotected sex occasions than control women at 1- and 12-month follow-up, respectively. Women in the 8-session group also had greater odds of using any of a range of alternative protective strategies (e.g., refusal, outercourse, mutual testing, additional barrier method) at 1-month follow-up.
In contrast to some other recent interventions, this trial was not restricted to women with a recent STD or with multiple partners, who may be particularly primed for behavior change. Results suggest that, even among this broader range of women, gender-specificity and expanding women’s behavioral options for self-protection may prove highly effective.
Although targeting women to enhance their capacity for making informed sexual decisions is essential, the relational context of gender roles and use of power underscores the need to study couples as well. Across previous reviews of the intervention literature, only three intervention studies directed toward heterosexual couples were identified (Padian, O’Brien, Chang, Glass, & Francis, 1993; Sikkema, Winett, & Lombard, 1995; Tanner & Pollack, 1988). A recent study by El-Bassel and colleagues (2003) might mean a reversal of this trend.
El-Bassel et al. (2003) conducted a relationship-based intervention with heterosexual couples recruited through the woman from hospital– based outpatient clinics in the Bronx. Following individual assessments with gender-matched interviewers at baseline, couples were randomized to one of three conditions: (a) the couple condition (C), comprised of 6 weekly relationship-based sessions attended by the couple; (b) a woman alone condition (WA), in which only the woman received the same intervention; or (c) the education control (EC), in which the woman alone took part in one HIV/STD information session.
The intervention (C, WA), developed in collaboration with community representatives, was theoretically and empirically based on the AIDS Risk Reduction Model (ARRM; Catania et al., 1990) and the ecological perspective (Bronfenbrenner, 1979), which provides a way to conceptualize a context and relationship-specific approach to HIV risk reduction. The first of the six 2-hour sessions normalized the need for relationshipbased prevention and clarified the rationale for its use, processed misperceptions, and enhanced motivation to attend. Gender-matched facilitators conducted this orientation session individually. The following sessions centered on exploring the relationship, the meaning of monogamy and trust, and how all of these act as barriers to safer sex. The intervention emphasized communication, negotiation, and problem– solving skills and explored how relationship dynamics may be affected by gender roles and expectations. It also covered the New York State Department of Health hierarchy of safer sex practices, a harm reduction approach that includes a consideration of alternatives to the male condom, including the female condom and joint HIV testing.
At 3-month follow-up, women assigned to both of the experimental conditions reported a significantly greater percentage of protected sexual acts than the controls (44%, 50%, and 33% for C, WA, and EC, respectively). Among those assigned to either active intervention, there were no significant differences between women who received the intervention together with their partner and women who received it alone. The authors speculated that the lack of difference between the two intervention groups may be attributable to several factors. All exercises and homework assignments were geared toward the male partner. Women were asked to practice the skills they had learned between sessions with that partner, which allowed women and their partners to explore together how to protect themselves from HIV/STDs. A self-selection bias may also be operative, as partners in both conditions had agreed to participate in the study.
Results from this study support the feasibility and desirability of delivering a relationship-based intervention in inner-city primary care settings and suggest that the barriers to safer sex negotiation and condom use that are intrinsic to relationships may be successfully confronted by involving the male partner, either directly or indirectly. The gender role norms that can undermine negotiation for safer sex are culturally embedded and sustained in part by the wider community. An alternate approach to challenging such norms could involve launching an initiative designed to reach a critical mass of individuals with information, motivation, tools for change (such as free condoms), and/or skills training in order to alter behavior by influencing social norms for HIV risk reduction throughout a given community.
An example of this approach is a community-based intervention conducted in 18 low-income, inner-city housing developments in five geographically diverse U.S. cities that sought to harness existing social networks to change prevailing social norms and promote individual behavior change (Sikkema et al., 2000). Housing developments were matched on the basis of the demographic characteristics of tenants, and one of each pair was randomly assigned to the intervention condition. In the intervention housing developments, cadres of women regarded as opinion leaders were invited to attend a four-session risk reduction workshop and a focus group to offer input on the planned intervention. They were encouraged to form “Women’s Health Councils,” to recruit other women to participate in a 2-month long workshop series, and to carry out community events that supported and strengthened behavior change intentions. The risk reduction workshops focused on basic knowledge concerning HIV/STD risk, women’s reproductive and sexuality issues, male and female condom use, sexual assertiveness and negotiation skills, and community organizing skills. Community events included a potluck dinner with HIV-positive women and a family carnival with contests based on the theme of safer sex.
At 1-year follow-up, the proportion of women who had any unprotected intercourse in the past 2 months declined from 50% to 37.6% in intervention communities compared to a decline of 49.5% to 46.2% in comparison housing projects. The percentage of women’s acts of intercourse protected by condoms increased from 30.2% to 47.2% in intervention communities compared with a shift from 33.9% to 36.3% in comparison sites. There was also a significant shift in the proportion of women who carried a condom or had a condom at home and who talked to their partners about condoms. This study demonstrates that mobilizing women as agents of change in their communities can have a broad-based impact on sexual risk behavior, above and beyond any positive impact on the individual women involved directly in the project.
Approaches that empower involve collective action that typically takes the form of structural or environmental interventions that seek to affect policies and circumstances having an impact on HIV prevention. A common thread in most of the reviews of the HIV prevention literature previously cited is a call for more prevention initiatives that attempt to tackle the larger systemic barriers perpetuating and reinforcing norms and conditions that undermine attempts to decrease sexual risk behavior. This is echoed in the Platform for Action document, an outgrowth of the Fourth World Conference on Women in Beijing (1995). In this document, broad initiatives were called for to address and to challenge sociocultural practices that may contribute to risky sexual behavior. Also, identification of and building upon women’s available power sources, from economic ventures enhancing women’s bargaining power in relationships to the introduction of female-initiated methods of HIV and STD prevention, were advocated. Evaluations of such initiatives are largely absent from the U.S. literature. Internationally, one of the best examples of the efficacy of programmatic efforts to institute aggregate level changes in behavior can be seen in Thailand’s 100% Condom Program (Celentano et al., 1998; Hannenberg, Rojanapithayakorn, Kunasol, & Sokal, 1994). Initiated by the government in 1990 and implemented in partnership among brothel owners, police, and public health clinics, the policy of mandatory condom use in brothels resulted in a 90% increase in effective condom use and a 75% decrease in STD rates among sex workers. Concomitantly, the prevalence of HIV among military recruits, who frequent brothels, declined from about 11% prior to the policy to 6.7% afterward. This intervention, which directly empowered women to insist on condom use with their commercial partners, clearly had a major public health impact.
There is a clear need for prevention researchers to work simultaneously on targeting multiple levels of analysis, including individual, couple, community, and structural levels (Auerbach & Coates, 2000; Coates, Ehrhardt, & Celentano, 2001). There also is a need to develop interdisciplinary efforts that seek to understand and to confront the nuanced contexts that produce vulnerability to HIV and to understand the multiple processes that uniquely link gender, sexuality, and sexual behavior.
Greater attention to the environmental conditions impeding women’s ability to protect themselves successfully against HIV infection is also warranted. AIDS is not an isolated health problem. We have made the argument that AIDS is inseparably linked to other serious social problems affecting today’s society. Widespread individual change will not occur in an environment that does not support such change. Many women remain in unsafe sexual relations for economic, emotional, and/or physical security. Corollary intervention programs aimed at increasing women’s economic independence, decreasing physical violence, and changing traditional constraining gender norms, for men as well as women, can be important tools for creating a social and economic environment whereby women can successfully negotiate and enact safer sex without fear of physical or economic reprisal. On a more general level, open and frank public discussion of both the positive and negative aspects of sexuality would enhance a climate that could enable women to be more comfortable talking about and enacting their own sexual needs, including safer sex behavior. This public discussion would extend to early sex education for those who are not yet sexually active.
The shift in perspective from the individual to an increasing consideration of the larger social structure is reflected in the trajectory from gender-neutral to gender-sensitive interventions. These approaches call for researchers to attend to the complexities associated with exacerbated urban crises and to continue tailoring creative new intervention developments that take the intersection of gender, race, and class into account.
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Theresa M. Exner
Shari L. Dworkin
Anke A. Ehrhardt
HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University
Theresa Exner, Susie Hoffman, and Anke Ehrhardt are also affiliated with the Department of Psychiatry, Columbia University, New York, NY. Susie Hoffman is also affiliated with the Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY. This research was supported by center grant P50-MH43520 from NIMH to the HIV Center for Clinical and Behavioral Studies, Anke A. Ehrhardt, PhD, Principal Investigator, and by NRSA training grant T32-MH19139 to Behavioral Sciences Research Training in HIV Infection, Robert Kertzner, MD, Program Director.
Correspondence concerning this article should be addressed to Theresa Exner, HIV Center for Clinical and Behavioral Studies, 1051 Riverside Drive, Unit 15, New York State Psychiatric Institute, New York, NY 10032. (firstname.lastname@example.org)
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