Making partners use condoms: a struggle for HIV-positive women

A small, qualitative study of HIV-positive women in the United States has found that most were sexually abstinent or practiced safe sex exclusively, while nearly all of the women who regularly had unprotected sex did so within monogamous relationships in which the women’s ongoing struggles to use condoms were overridden by their male partners. As a consequence, the women lived with constant fear of infecting their partners, and guilt and distress at their inability to control the sexual choices. The study was published in the June edition of the American Journal of Public Health.

Recent studies have reported that between 17% and 35% of HIV-positive women have unprotected sex. This study qualitatively investigated the sexual behaviour of 55 HIV-positive women from urban and rural Wisconsin during ten interviews between 2000 and 2003, with the goal of “develop[ing] an in-depth understanding of women’s experiences living with HIV”, including risky sexual behaviour. The women were recruited through community-based purposive sampling and were diverse in terms of race, education, disease stage and risk group. The mean age was 41 and the mean household income was $14,000.

By self-report, 32 (58%) of the women were completely sexually abstinent, and 13 (24%) used condoms every time they had sex. Ten of the women (18%) had sex on a regular basis without using condoms; this unprotected sex occurred entirely within monogamous relationships. Nearly all of these relationships were serodiscordant; i.e., the primary male partners were HIV-negative. The published report focused on these ten women to explore their situations and reasons for ongoing unprotected sex.

The researchers found that these women had unprotected sex “reluctantly, always fearful of passing the virus to their male partners.” The women in this study were “deeply troubled by sexual risk” and “actively resist[ed] posing risk to anybody else.” The dynamics of their relationships caused them to “give in to more dominant male partners…. Unsuccessful in their efforts to reduce sexual risk in their relationships, they live with a sense of doom about their actions.”

Quotes from the women illustrate their situations:

“I’ve talked to him until I’m blue in the face… I get nowhere.”

“I know I have to take charge and use condoms. But it is a hard problem… He gets to hollering and screaming… What can I do?”

“We argue about condoms all the time. It is an issue almost weekly.”

“I showed him all my meds and I said, ‘Do you want to take all these?’… But you can’t make him do anything.”

Significantly, “[h]ealth care providers were almost absent from these narrations about sexual risk, except as occasional bit players called on to coerce condom use.”

Although this was a very small study, other US studies have found that a large number of heterosexual, HIV-serodiscordant couples regularly have unprotected intercourse. The authors of the current report note that, in their study, half of the women who were partnered to HIV-negative men either practiced safe sex exclusively or declined sexual activity altogether.

When unsafe sex occurred in serodiscordant relationships, the authors suggest that “experiences and needs might differ according to who … is HIV infected … gender power relations may differentiate these relationships”. The researchers concluded that, “[if] these data are any indication of the struggles at least some HIV-infected women may experience in serodiscordant relationships, then there are a great many unmet needs to which … health care providers … could respond.”