HIV prevention research highlights gender inequality and the resulting power differential between men and women as a factor in heterosexual HIV transmission, the primary route of HIV infection for women. Given the established link between substance use and increased HIV risk, drug-involved women are particularly vulnerable. Little research has examined relationship power among drug-involved women. Moreover, research on the association between relationship power and sexual risk has been hampered by a lack of theoretical specification of conceptual domains of power and inconsistent measurement. The purpose of this study was to examine the association between relationship power and unprotected sex among women enrolled in community-based substance abuse treatment (N = 515). It was hypothesized that increased power would be associated with decreased unprotected sexual occasions with primary male partners.
Baseline data was drawn from a National Institute on Drug Abuse Clinical Trials Network multi-site HIV prevention intervention trial. Relationship power was measured using the Sexual Relationship Power Scale (Pulerwitz et al., 2000) comprised of relationship control (RC) and decision-making dominance (DM) subscales. Mixed effect modeling was used to test the association of RC and DM to counts of unprotected sex, controlling for relevant empirical and theoretical covariates. Site (N = 12) was included as a random effect.
An association was found in the hypothesized direction for DM (t = -2.23, p < .05). Interactions between the RC subscale and substance use and condom use intention were found to be significant predictors of unprotected sex. For women with Ąd13 days of substance use in the past 30, a one point increase in RC was associated with twice the increase of unprotected sex compared to women with no use (t = -2.44, p < .05). For women who intended to use condoms with their male partners, a one point increase in RC was associated with a 39% smaller decrease in unprotected sex compared to women with less condom use intention (t = -2.09, p < .05).
Conclusions & Implications
DM appears to be a more direct mechanism through which women can reduce risky sexual behavior with primary male partners. Data show that more severe substance use, which may impede ability to use condoms, and less intention to use condoms are risk factors even with higher levels of RC. This emphasizes the importance of the context in which women use alcohol and drugs and the potential intervention opportunities during the transitional period around treatment entry. Rational choice theories of health promotion presume that personal health is a top priority for women; this may be so among more privileged women who have fewer concerns about concrete needs (e.g., housing), but might not be shared within marginalized groups. Multi-level interventions targeting interpersonal dynamics and structural barriers are needed, in conjunction with individual-based HIV prevention, to address socially constructed inequality. Social workers, trained in multi-systemic theoretical perspectives and collaborative research and practice skills, are well situated to lead future HIV prevention intervention development to address the needs of drug-involved women.