Victimization history was significantly related to being at high risk for HIV exposure. Specifically, women in the high-risk group were more likely to have been sexually or physically abused during childhood and to have experienced physical violence by a partner. Of women in the high-risk group, there was an approximate twofold greater risk of both childhood abuse and adult partner violence than with women in the low-risk group.
High-risk women reported their first sexual contact at an earlier age and reported significantly more lifetime partners than low-risk women. We categorized the woman’s knowledge of HIV modes of transmission as “good” in 81% of those in the high-risk group and 58% of those in the low-risk group. HIV testing was more common among women in the high-risk group.
Perception of HIV risk was related to risk group classification. Among high-risk mothers, approximately 75% perceived themselves as having low or no risk of contracting HIV, and 16% reported that they did not know their risk of HIV infection. Only 14% of high-risk women correctly perceived their own risk as being medium or high, indicating a discrepancy in perception of risk and actual risk in these women. In the low-risk group, most women correctly perceived their HIV risk. Women who perceived themselves as being at medium or high risk for HIV were nearly 5 times as likely to be in the high-risk group as those who perceived that they were not at risk. After adjusting for potential confounding factors, the univariate association of homelessness to high-risk practices was attenuated, though homeless mothers remained at increased risk for HIV.
The crude and multivariable adjusted odds of being at high risk for HIV infection are shown in Table 4. After controlling for previously described covariates, African American women were significantly more likely to be considered at high risk. Paradoxically, women with good HIV knowledge were more likely to belong to the high-risk group.
A history of childhood sexual victimization or adult partner violence placed women at significantly greater likelihood of being at high risk for HIV. Because we were interested in examining the association between sexual victimization during childhood and adult partner violence, we included an interaction term in our model to examine the joint effect of these variables on the likelihood of being at high risk for HIV. We found a strong independent relationship between experiences of child and adult victimization and HIV-risk behavior: Women who had experienced childhood abuse and violence as adults were significantly more likely to be in the high-risk group.
Discussion
This is the first study to investigate HIV knowledge, the nature of high-risk practices, and predictors of HIV-related risk behaviors among a community sample of homeless and low-income housed mothers. We found that both homeless and low-income housed mothers had adequate knowledge of HIV-related risk practices but underestimated their overall risk. Although homeless mothers participated in more high-risk behaviors, the relationship between homelessness and HIV risk was attenuated after controlling for other factors associated with risk for HIV infection. We observed a strong association between high-risk practices and child and adult victimization with high rates in both groups of women. These findings highlight areas for preventive services for homeless women, specifically, and extremely poor women, in general.
As described previously,18 when compared with their low-income housed counterparts, homeless women reported higher rates of HIV-risk practices. Although our findings describe higher rates of risk behavior among homeless women than those previously reported,10,12,15,16,33-35 the results are difficult to compare, since most research to date has focused on individual homeless adults,10,12,33 used mixed samples of men and women,16,33 lacked comparison groups,10,13-16,33-35 or sampled women who have already exhibited high-risk behaviors.12-15,34,35 Thus, previous studies may not be generalizable to homeless mothers who have young children and may face a different set of exigencies that contribute to HIV risk.
The number of lifetime sexual partners, a factor associated with higher risk for sexually transmitted diseases and cervical cancer,36,37 was 2 times higher among homeless mothers than in the low-income housed group. The rate of sexual intercourse at a young age was significantly higher in homeless than in housed mothers, and several times higher then that described in other studies.30 These findings may be partly explained by the high rates of family disruption, especially out-of-home placements, among the homeless sample. Early age of first intercourse has been consistently associated with more sexually transmitted diseases,30,38-40 cervical cancer,30,41,42 and greater numbers of sexual partners;30 it also may be a marker for other risky behaviors, such as no condom use and less discrimination in partner choice.30