Psychosocial factors and risky sexual behaviors among men and women having heterosexual sex in low income neighborhoods in Baltimore, MD

Background. Heterosexual contact is the second most common route of HIV transmission in the United States (U.S.), after male-to-male sexual contact. Areas with concentrated economic disadvantage in the U.S. have been found to have elevated HIV/STI rates. Understanding the relationship between psychosocial factors and sexual risk behaviors might help to explain the higher HIV/STI rates observed in heterosexual populations in high poverty areas. The current study describes the development of two scales: (1) Powerlessness and (2) Validation Through Sex and Sexual Relationships (VTSSR). The study population was recruited from high poverty and high HIV prevalence areas in the inner-city of Baltimore, Maryland and was 95% African American.;Methods. Data were collected from the heterosexual wave at the Baltimore site of the National HIV Behavioral Surveillance System, a cross-sectional, venue-based sample survey targeting high-risk heterosexuals. Recruitment areas were ten census tracts within the Baltimore City categorized as being in the top 20% of tracts most affected by poverty and AIDS in the Baltimore-Towson metropolitan statistical area. Multivariate log-binomial regression was used to identify non-psychosocial risk factors associated with unprotected sex with casual or exchange partners during the past 12 months. Confirmatory factor analyses were used to identify well-fitting measurement models for the Powerlessness and VTSSR scales. These measurement models were then used in structural equation models (SEMs) to examine the relationships among powerlessness, VTSSR and two sexual risk outcomes, unprotected sex with casual or exchange partners or exchange sex reported during the part 12 months.;Results. HIV prevalence was 3% overall. Factors independently associated with reporting sex with a casual or exchange partner in the past 12 months were: homelessness, age, four or more sex partners during the past 12 months, concurrent sex partners in the past 12 months, binge drinking during the past 30 days, and history of STD diagnoses. For the Powerlessness scale, factorial invariance was identified between men's and women's responses. For the VTSSR scale, measurement invariance was identified between men and women's responses. The SEM results for men indicated that powerlessness was significantly associated with an increase in VTSSR and VTSSR was significantly associated with increased odds of reporting both unprotected intercourse and exchange sex. For women, powerlessness was significantly associated with an increase in VTSSR and VTSSR was significantly associated with increased odds of reporting unprotected intercourse only.;Conclusion. HIV testing results suggest that a generalized epidemic is occurring among the population having heterosexual sex in these areas. Furthermore, sexual risk behaviors were widespread in this population, suggesting that HIV prevention efforts in these geographic areas are needed. Evidence front this study suggests that VTSSR is a potentially important mediator between the psychosocial effects of living in highly disadvantaged areas and risky sexual behaviors among inner-city men and women. Understanding the social norms of individuals living in high poverty areas can help to inform development of effective HIV/STI interventions. Neighborhood-level interventions should also be considered for the purpose of changing social norms.