Posttraumatic Stress Disorder and HIV Risk Among Poor, Inner-City Women Receiving Care in an Emergency Department

摘要

Objectives. We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department. Methods. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence. Results. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months. Conclusions. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women. The relationship between posttraumatic stress disorder (PTSD) and HIV risk behaviors remains relatively underresearched. However, several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status. 1 – 3 Emergency departments have been identified as the first and primary source of medical treatment of many women infected with or at high risk for HIV 4 – 6 and for those with high rates of interpersonal violence and trauma, including those suffering from PSTD. 7 – 11 Hutton et al. found that, after adjustment for potentially confounding factors, a PTSD diagnosis was associated with engaging in anal intercourse and exchanging sex for money or drugs in a sample of 177 female inmates. 12 High rates of PTSD have also been found among HIV-positive women, 3 , 13 , 14 many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (IPV). 3 , 13 , 14 In a study of HIV-positive women, 35% of those with a trauma history met the criteria for PTSD, 15 a rate far exceeding both the lifetime PTSD rate (10.4%) among women in the general population 16 and the PTSD rate (4.6%) in a nationally representative sample of female crime victims. 17 The relationship between PTSD and HIV risk behaviors has been found to vary according to the presence of different PTSD symptoms (avoidance, hyperarousal, and reexperiencing trauma). In their study of 64 HIV-positive women and men, Gore-Felton and Koopman found that moderate to severe reexperiencing symptoms were associated with multiple sexual partners and unprotected sex during the preceding 3 months. 18 Individuals with avoidant symptoms were less likely to have engaged in unprotected sex, possibly as a result of deficits in establishing and maintaining intimate partnerships. 18 The presence of hyperarousal symptoms may trigger individuals to seek sexual stimulation and engage in riskier sex, and they may experience difficulty in problem solving and negotiating safe sex. 19 The research just described highlights mechanisms of how different PTSD symptom clusters may increase the likelihood of engaging in HIV risks. However, it should also be acknowledged that the relationship may be bidirectional: a traumatic experience (e.g., forced unprotected sex) associated with a risk of HIV may lead to PTSD. Furthermore, research suggests that the relationship between PTSD and HIV risk may be mediated by several factors, including childhood sexual abuse, IPV, and substance abuse. Those who have experienced childhood sexual abuse are at increased risk of developing PTSD, 20 – 22 engaging in subsequent sexual HIV risk behaviors, and HIV transmission. 3 , 23 Similarly, IPV has been found to increase the risk of both developing PTSD and engaging in a range of HIV risk behaviors, including unprotected sex, 24 – 38 sexual practices leading to a high risk of sexually transmitted infections, 6 , 32 , 39 – 42 sex with multiple partners, 31 , 32 , 43 trading of sex for money or drugs, 40 , 44 sex with risky partners, 38 , 45 and sex with HIV-positive partners. 38 Finally, substantial research indicates that drug and alcohol dependencies are associated with both PTSD 46 , 47 and engaging in a range of HIV risk behaviors. 48 – 51 We examined the relationship between PTSD (and the symptom clusters of avoidance, reexperiencing trauma, and hyperarousal) and sexu