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THE PARADOX BETWEEN CONDOM USE AND HIV RATES:

ADDRESSING ONE DISPARITY IN THE CONTEXT OF ANOTHER:

AN ANALYSIS OF WHY PUBLIC HEALTH


MUST DO MORE FOR MINORITY WOMEN

Vanessa Sochat
April 19, 2007
Public Health
Many times during health policy creation, the human element of adaptation is forgotten. Policies and

research with regards to condom use have largely targeted minority women due to lower socioeconomic status,

and a higher prevalence of HIV within the population. It is a rare case that a population logically facing more

barriers to a protective health behavior can work its way to equality with a less disadvantaged population. The

story of the disparity between minority women and white women with regards to condom use exemplifies this

idea. Social stereotypes might lead to the belief that the minority women would have lower condom use rates in

comparison to the white women, but this is not the case. In the presence of more challenging environmental,

social, and cultural barriers, minority women, particularly lower income African American and Hispanic women,

have higher rates of condom use than white women. Although health policy and social marketing play into this

story by influencing how these populations use and experience condoms, the success of both initiatives is

dependent on the ability of the target populations to adopt the learned skills and provided resources knowledge in

their lives (Artz 238). Measuring success based on condom use rates, minority women come out on top, but still

fall behind white women in regards to rates of sexually transmitted disease. The success in high rates of condom

use among minority women is a strong supporter of policy that encourages individuals to have a proactive role in

their sexual health. The disparity of higher rates of HIV amongst minority women is still posing a challenge. The

paradoxical nature of these two disparities makes it clear that correct usage still needs to be addressed.

The correct utilization of condoms is essential for decreasing the chance of transmitting HIV and other

STD’s, and preventing pregnancy. Correct condom usage is attributed to decreasing the chance of HIV transmittal

by ninety percent (St. Lawrence 8). Women are the fastest growing HIV infected group within the United States,

and half of these infections are due to heterosexual sex (Moore). Therefore, condoms are a logical approach to

attacking this prominent disparity that involves ethnicity and HIV rates. Latina women make up only 10% of

women in the United States but represent 20% of all women infected with AIDS (Moore). Additionally, AIDS is the

leading cause of death for African American women between 25 and 44 years of age, and this rate is ten times

larger than that of white women (St. Lawrence 7). The difference in AIDS cases among these three populations is

very significant. There are 73 AIDS cases out of every 100,000 African American women, 32 out of every 100,000

Hispanic women, and only 5 out of every 100,000 white women (St. Lawrence 7). This disparity might be
attributable to lower self efficacy in using condoms, and misconceptions about HIV transmission (Pulerwitz 789).

In the 1980’s, condom use amongst Latina and African American woman fell behind white women, but increased

to reach and surpass white women’s rates by 1995 (Soler 83). Use amongst African Americans increased by almost

sixteen percent in comparison to seven percent amongst whites. According to the National Survey of Family

Growth (NSFG), African American women in large metropolitan areas were the biggest customers for free

condoms (Catania 180). The outcome of this trend was a steady decline in HIV and syphilis (sexually transmitted

diseases) starting at the end of the 1980’s in minority heterosexuals. At the same time, whites experienced only

minor fluctuations (Catania 182). Currently, minority women faced with more challenging barriers to sexual health

resources are more consistent in their condom use, but are still suffering from higher rates of STD’s. This two

sided disparity can be attributed to environmental, cultural, and social factors, which public health officials might

need to address.

The environment plays a salient role in facilitating the spread of HIV and encouraging condom use.

Minority women infected with HIV tend to live in large metropolitan areas that expose them to higher drug use

and violence. In fact, 45% of minority women living in New York in a particular study had a history of drug use

(Moore). This environment is a double edged sword, because these women are more likely to be poor and lose

men to violence and incarceration. It is arguable that a short supply of males makes them in high demand, and

consequently leads to desperate women submitting to male dominance (St. Lawrence 22). It is clear in this context

that Latina and African American women might be at higher risk of HIV infection due to the behavior of their

partners, and not due to their own behavior. In a US study looking at the sexual practices of migrant workers, 44%

of Mexican migrant worker men reported having unprotected sex with a prostitute (Organista 246). In fact,

Hispanic men are more likely than white men, women, and Hispanic women to have had many sexual partners

over a year (Moore). In a time of war and urbanization in many areas, the breaking apart of family structures and

sexual relations might lead men to seek these prostitutes. On the other side of the equation, minority immigrant

women desperate for finances might seek economic stability through the same risky trade (Altman 258).

At the same time, the concentration of public health resources within the environment of a city has made

these women aware of their situation, and given them incentive to take measures to protect themselves. Puerto
Rican women in the northeast have the highest rates of condom usage across the nation (Moore). The Health

Belief Model, which says that an individual will engage in preventative action when their perception of being at risk

is high and the benefits of prevention outweigh costs, fits well in this scenario. It might be the case that these

women are taking more initiative to protect themselves, even more so than lower risk white women, because of

increased awareness. This case shows the dual role of environment in regards to promoting health benefiting

behaviors. The environment is a positive and negative health determinant that has both created barriers and

solutions to good sexual health. In the comparison between white and minority women, it is interesting that a

suboptimal environment has led to improved behavior in sexual health for the more disadvantaged population, as

36% of AIDS cases among white women are attributed to sexual contact as opposed to 33% for African American

women (Moore). The size and makeup of the community might be an important factor, as a larger population

brings with it increased political and economic power, and a stronger peer support structure.

Relationship dynamics also play a prominent role in creating this paradoxical disparity. The level of

communication within a relationship with regards to HIV is important for implementing safe sexual practices. In a

study comparing communication between ethnically diverse populations, the majority (90-90%) of white and

African American women said they were somewhat to extremely comfortable talking about condoms, as opposed

to 76% of Hispanic women. Hispanic women might be more verbally submissive because of traditional gender

roles, leading to little discussion with their partners about HIV risky behaviors (Moore). However, as an adaptive

population, they have taken creative measures to protect themselves. Comparing Hispanic women to white

women, a city based study reported that 55% of Hispanic women use more than one contraceptive in comparison

to 31% of white women in the same area. Hispanic women were most confident in their ability to use condoms,

but unfortunately were more likely to use them incorrectly. This observation might suggest that although 17% of

minority women are consistent condom users as opposed to only 4% of white women, the minority women may

be using them incorrectly, leading to higher rates of HIV transmission (Soler 82). This incorrect usage might be

attributable to a lack of skill or communication between partners.

Additionally, financial power in a relationship is correlated with condom use and consequently HIV

infection rates. In a gender role study, women who shared financial decision making with their partners were 80%
less likely to use a condom than women who made financial decisions independently, and women who had no say

were 90% less likely to use a condom (Soler 87). Being financially dependent on one sexual partner places these

women in a submissive sexual role, and it is clear that men do not take initiative to use condoms. In contrast,

women with multiple partners rarely communicated about HIV and condom use, probably because they were

inclined to not talk about their risky behavior (Moore). These financially based power issues place women in a

submissive gender role, and the degree of this meekness varies by culture.

Varying partner sexual roles within the Hispanic population contribute to sexual practices and

consequently HIV infection rates. In a study conducted with sixty nine focus groups of Hispanic women across the

United States, the issue of power and gender roles emerged as a dominant variable to reducing HIV in 75% of the

groups (Pulerwitz 794). This study creatively came up with a scale called the Sexual Relationship Power Scale

(SRPS), which correlated lack of power in a relationship to low condom usage. Among these Hispanic women, only

8% said that they frequently used condoms, alluding to their submissive sexual role. It is arguable that bringing a

condom into the relationship brings up issues of trust, more so for minority women than for whites. Perhaps these

women fear a negative reaction from their sexual partner and stay quiet (Moore). As a result there is lower

condom use in long term relationships and more frequent condom use in casual relationships where trust isn’t an

issue (Pulerwitz 797). Perhaps addressing these power issues would further increase communication, leading to

more frequent and effective condom use, and subsequently contribute to lower HIV prevalence.

Although Hispanic women face this power barrier to good sexual health, they have learned to adapt. By

tweaking the dynamics of their relationship, these women are able to engage in healthier sexual practices without

breaking traditional, cultural roles. As was alluded to earlier, Hispanic women employ more indirect and secretive

methods of contraception. These women are using pregnancy prevention, an accepted practice in the Hispanic

culture, to promote condom use. This clever strategy protects these women from any potential infidelity by their

partner without having to bring up issues of trust. Women even reported the common practice of hiding other

contraceptive methods, such as birth control pills, to increase the likelihood of using a condom. African American

women also reported that the attitude of their partner towards condoms correlates with condom use, and that

most male partners associated condoms with infidelity, more casual relationships, and lack of commitment.
Unfortunately, these women have not widely adapted other methods of bypassing these power issues to protect

themselves (Soler 87).

These environmental, social, and cultural practices come together to form the disparity of high rates of

HIV amongst minority women in comparison to white women. The services made available by both the public

health system and social marketing groups tilt the disparity between ethnicity and condom use in the minority

women’s favor, but this clearly isn’t enough to sway HIV infection rates. Condom use does not guarantee

complete protection for STD’s, because they occasionally break and do so more often when not used correctly.

Clearly, there have been public health initiatives that have successfully made minority women aware of their risk

status, including clinic, school, and church based programs (Artz 237). The success of these programs in

distributing contraceptives is evident in the high usage rates. At the same time, however, the disproportionate

rates of HIV infection among these minority populations suggests that barriers still exist concerning the correct use

of condoms. While public health officials must be given credit for creating increased local awareness amongst

minority, high risk populations, analysis must be done to shed light onto the shortcomings of this policy.

More initiative must be taken to target young minority populations. Schools are an ideal environment to

reach out to and educate young minority populations that are still receptive to forming life practices. Policy to

address higher rates of HIV among minorities involving schools has largely focused on condom distribution, but

even these initiatives are blocked by stigma. Only 0.35% of all districts and 2.2% of high schools nationwide

provide condoms for students, 42% of which are located in Massachusetts (Blake 955). The concern is that

providing condoms will encourage sexual activity, but studies have shown that students in schools with programs

are just as likely to become sexually active as students in schools without programs (Blake 959). The key difference

is the fact that the sexually active students in schools with programs were two to three times more likely to have

used protection (Blake 955). It is advisable that interventions should also teach condom negotiation skills,

encourage discussion with parents, and address perceptions and beliefs about condom use. Barriers such as

embarrassment of obtaining condoms from school officials might be broken by providing vending machines. Public

health should take the initiative to encourage community discussion around condom education in schools, as it
was shown that districts that organized public discussion were more likely to implement the program (Blake 959).

Clearly, communication is an important element in the equation to educate these high-risk groups.

Public health interventions must focus on increasing partner to partner communication among minority

populations to treat the HIV rate disparity. It is clear from the above examples that gender power issues are more

prevalent amongst minority women than white women, and that this dynamic is leading to less safe sexual

practices. Interventions that encourage couples to talk about sexual behavior might help break the link between

trust and talking about sexual health. It might be an ineffective strategy to place reproductive and sexual

responsibility on the shoulders of the women, which is typically done in the United States, when men play such a

prominent role (Moore). It is advisable for public health to focus on the couple in its prevention activities instead

of the individual units. Couples need to talk about expected partner reactions to condom use to dispel any

misconceptions, and address decision making in the relationship. A study focusing on the power of decision

making in the Hispanic population noted higher condom usage rates (41%) when the decision was made jointly as

opposed to individually by either the man or woman (24% - 28%) (Soler 82). It is also important to cater

prevention messages according to ethnicity. As pregnancy prevention is a priority amongst the Hispanic

population, programs targeted towards Hispanics might preach correct use of condoms for birth control.

Continual provision of these resources is essential for this strategy to be effective.

Free condom distribution programs are important to continue to maintain distribution, as it has been

shown time and time again that charging a price decreases usage rates. In 1993, Louisiana launched its free

condom campaign, and the demand for condoms quickly surpassed the budget to purchase them. A localized

study examined the effects of charging a low price to deal with this budget issue, and found that overall condom

distribution and use decreased, and it was ultimately more costly in time to find businesses willing to participate

than what was saved by charging a price (Cohen 567). It was not clear if it was the cost or embarrassment of

having to buy the condoms that evaded customers.

Clearly, stigma associated with sex and condom use is an important consideration when making policy.

Religious stigma amongst minority groups might be less pervasive than what is commonly believed. A study
among Catholic migrant worker men showed that over 50% used contraceptives despite conflicting religious

beliefs. The real stigma seems to stem from HIV, and this stigma is leading to dangerous sexual practices. A study

observed that within a group of HIV positive African American women, only 60% used condoms consistently due to

not wanting to bring up issues related to their HIV status. These women also reported high levels of social

isolation, so catering to this particular population of minority women might continue to be a challenge for public

health (Wilson 597).

On the public health side, policy must be created that focuses on correct condom use and

communication. High usage rates make it clear that the public health sector has successfully tackled condom

distribution, and high HIV prevalence has made it apparent that distribution isn’t enough. A study in Thailand

demonstrated that intense behavioral intervention amongst commercial sex workers led to lower incidence of

unprotected sex and disease. Even with this knowledge, a quarter of the women in the study were not persuaded

(Artz 240). Addressing these barriers is clearly a challenge for public health, especially because intensive

intervention is arguably not feasible for an entire population. In this case, widely dispersed forms of cost effective

media may be useful, which gives appeal to social marketing.

Social marketing, the commercialization and marketing of health products to encourage behavior change,

is both a tool and a barrier to attacking the disparity between white and minority women and HIV rates (Vitellone

20). The main problem with social marketing relates to incentives. While public health might be driven by concern

for equality and safety, social marketers are driven by monetary incentives, and do not consider the effect of their

campaign on promoting behavioral changes. Western advertising for condoms has primarily focused on images of

powerful men, arguably because their analysis has proven the profitability of this group. The most successful

brands of condoms in the United States are “Trojan” and “Ramses,” powerful male figures in history (Katz 2). This

campaign might have negative implications because it reinforces power rules during sexual interaction, which, as

discussed above, is a barrier to communication. These campaigns also illustrate women as victims and carriers of

disease, as the 1987 Grim Reaper campaign in Australia, which further empowers men (Kaplan 175). These

advertisements relate condoms and consequently safe sexual practices to whiteness (Vitellone 28). By ascribing
race and class to good sexual health, these advertisements arguably make it more difficult for minority men to

respond positively to condoms and the values regarding safer sex that they promote. (Kaplan 175).

The public nature of social marketing makes it a lot harder to implement. A history of extensive rules and

regulations with regards to condom advertising has demonstrated the difficult decision of whether or not to

broadcast advertisements (Kaplan 176). On the one hand, condoms are necessary to slow the spread of HIV.

Studies have found a positive correlation between exposure to condom advertising and condom use among

minority youth (Kennedy 1811). On the other hand, selective audiences might be appalled with a broadcaster that

promotes a product so closely tied with political and religious stigma. For example, advertising to sell condoms in

sub Saharan Africa has led to moral panic as it conflicts with the church’s focus on the family (Kaplan 175). It is not

clear whether churches or advertisers are in the wrong because the prohibition of condoms by religious

institutions has led to thousands of new HIV infections in a year’s time (Altman 267). Many argue that the

seductive nature of the images and language in condom advertisements actually promote promiscuous behavior

(Wilke 2). Although social marketing might reach a larger population, these religious and political winds make it a

lot harder to implement.

The interrelation of unequal rates of condom usage and HIV infection amongst women of different

ethnicities reflects positively on the public health sector’s ability to create awareness, and negatively on its ability

to cater these messages to specific ethnic groups. As condom use is promoted to put a damper on the spread of

HIV, the latter is arguably the more significant disparity, and should be the focus of public health. The greatest

barriers to healthy sexual behavior seem to have a lot to do with relationship dynamics, mainly communication in

minority relationships. Perhaps due to socioeconomic, environmental and social factors, white women are

primarily in relationships with men that engage in less high HIV risk behaviors. In this context, white women’s

lower use of condoms compared to minority women may not be a huge issue for public health.

The most effective strategy to fight this disparity seems to involve individuals harnessing a proactive,

confident, and open role in their sexual health. African American and Hispanic women have demonstrated that

protection is possible even within cultural and environmental constraints. This success might also be attributed to
public health’s success with free distribution programs and social marketing’s ability to commercialize condoms

(Catania 176). Public health and social marketers can both have a negative or positive influence, and arguably

must learn to coexist. There might always be stigma and a moral tradeoff between preserving cultural and social

norms and saving lives, but ultimately, it is the action of the individual that has the most profound effect on

preventing HIV transmission. Dealing with a complex situation with many players and different incentives, what it

comes down to is providing resources and the skill and ability to implement them in the context of different

cultures. Even with imperfect programs, this case study has demonstrated the remarkable ability of a population

to overcome barriers while maintaining their cultural norms. As public health officials continue to address the

environmental, social, and cultural barriers to safer sex practices, they can hopefully find some comfort that the

populations they are targeting are on the same page, even if they are not aware of it. This element makes the

human being very powerful in the face of adversity: this is the human element of adaptation.
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I have adhered to the Duke Community Standard in completing this assignment.

Vanessa Villamia Sochat