Cover Story

HIV/AIDS is soaring among women and adolescent girls in the United States, according to the Centers for Disease Control and Prevention (CDC). The proportion of all AIDS cases reported among women and adolescent girls more than tripled from 7 percent in 1985 to 25 percent in 1999. Women of color have been hardest hit: African-American and Hispanic women, who constitute less than a quarter of all women in America, make up three-fourths of U.S.-reported AIDS cases among women. And the rate of infection among teenage girls is staggering--it rose by 117 percent between 1994 and 1998, according to CDC data.

These sobering statistics are what's driving some clinical psychologists, such as Gail Wyatt, PhD, to push harder for better HIV/AIDS prevention for women and girls. Wyatt views the rise of HIV infections in women partly as a failure of behavioral scientists to develop population-specific interventions.

In fact, the CDC suggests that psychologists and other health professionals develop HIV-prevention programs that:

  • Place more emphasis on prevention and treatment services for young women and women of color.

  • Develop and widely disseminate effective female-targeted prevention methods.

  • Do a better job of integrating prevention and treatment services for all women.

Among those addressing these research needs are Wyatt and her colleagues. They're exploring ways to empower women to make safer sexual choices.

"It is important for women to have HIV-prevention programs and interventions specifically for them," says Wyatt, a professor at the University of California, Los Angeles. Women have reproduction to consider when they have sex; they can become infected with HIV and not have many apparent symptoms; and HIV may affect their bodies differently than men's bodies, she adds.

Negotiating condom use

Another researcher focusing her efforts on women and HIV/AIDS is psychologist Ann O'Leary, PhD, a senior behavioral scientist at the CDC in Atlanta who uses social cognitive theory--created by psychologist Albert Bandura, PhD--as the template for her prevention research on condom negotiation. Such negotiations can be dicey for women who aren't in control of their sexuality--particularly for abused women. Condom-based prevention efforts are only effective if men cooperate, explains O'Leary, but women often can't influence their partners' actions. In fact, many researchers and practitioners warn that interventions intended to encourage women to negotiate for condom use may lead to violent reactions from male partners.

In an effort to seek solutions, O'Leary and psychologist Charles J. Neighbors, PhD, questioned 104 male inmates from a county jail in New Jersey anonymously about how they might respond to 10 hypothetical requests by their partners to use a condom. Men in jail often share risk factors--such as poverty, joblessness, substance abuse and a violent history--identified with domestic violence and contracting HIV.

Key findings of the study, published in Health Psychology (Vol. 18, No. 4) and AIDS Education and Prevention (Vol. 15, No. 1), included that:

  • Message framing affects how men respond to requests for condom use, and domestically violent men are more likely to refuse to use a condom and react violently to requests that they perceive as relationship threats.

  • Men were likely to refuse requests for condom use and possibly become violent when they perceived that a woman was unfaithful, selfish or argumentative.

  • Men were more likely to use a condom when requests had the following themes: avoidance of yeast infections, concern about pregnancy, worry about the future welfare of children, protection from HIV infection and sensitivity to acidic sperm.

O'Leary--who received the APA Committee on Psychology and AIDS's Distinguished Leader Award in 2002--has since incorporated these and other findings into prevention programs. In one, a group of Latina women used the study to develop scenarios for condom negotiation that might work with their husbands. One woman finally convinced her husband to wear a condom by using the yeast-infection scenario--instead of putting him on the defensive about his suspected infidelity. Such strategies are especially important for women stuck in abusive relationships, says O'Leary.

Like O'Leary, Wyatt, associate director of the AIDS Institute at UCLA and Drew Medical University, has also explored the connections between abuse and risky sexual behavior.

In 1999, for instance, she began one of the first, ongoing studies of HIV-positive women with histories of being sexually abused as children. She uses an 11-week intervention that allows women to discuss their histories of sexual abuse, connect these experiences to their current risk-taking practices and learn risk-reduction skills. Participants are encouraged to practice communication skills and learn ways to cope with their past fears and feelings of powerlessness. They also learn problem-solving skills that increase their ability to make healthy decisions about sex, Wyatt says.

"We can't expect people to change their [risky sexual] behavior, until they understand how the violence has affected them," explains Wyatt, the first African-American woman to become a licensed psychologist in California. "Then, they can begin to develop skills for risk reduction with their past histories in mind."

Women are responding "extremely well" to the intervention, she says. The model can be applied to all women with abuse histories, regardless of race, ethnicity or culture.

Window of opportunity

While Wyatt and O'Leary are focusing on women's HIV-prevention needs, health psychologist Jeannette Ickovics, PhD, is targeting an arguably more vulnerable group at risk for HIV infection--pregnant teenagers and young women. Ickovics, an associate professor of psychology and epidemiology and public health at Yale University, is principal investigator of a National Institute of Mental Health study aimed at reducing pregnant 14- to 25-year-olds' risk of contracting HIV and other sexually transmitted diseases (STDs).

The five-year study--which began in 2001--is among the first to focus on reducing risky sexual behavior during pregnancy. Recruitment is more than halfway complete for the randomized controlled trial of 1,120 participants in New Haven, Conn., and Atlanta, where teen pregnancy, HIV and STD rates are very high, according to Ickovics. The intervention uses the Centering Pregnancy Program, a structured approach to group prenatal care developed by certified nurse-midwife Sharon Schindler Rising. Ickovics and her colleagues are testing traditional individual prenatal care versus standard group care versus an "enhanced" group care that promotes good reproductive health--including practicing safer sex--during and after pregnancy.

"Including messages regarding safer sex during pregnancy--a time when the girls are highly motivated to adopt healthy behaviors--gives us a window of opportunity, to instill in them the importance of adopting life-long safe-sex practices," Ickovics says.

She hopes the study will have implications for future intervention research and clinical care that integrates adolescent pregnancy, HIV and other STDs. "We believe that the potential sustainability of this program is one of its greatest strengths, because the intervention is completely embedded in prenatal care and does not require additional group visits," Ickovics says. "The ultimate goal of prevention science is to improve prevention practice."

APA's Behavioral and Social Science Volunteer program is seeking psychologists interested in providing HIV/AIDS technical assistance to community-based agencies, health departments and local community groups. Contact John Anderson, PhD, director of the APA Office on AIDS at the APA address; (202) 336-6042.