Transactional sex and HIV risk among incarcerated African-American women in North Carolina (NC)

Background: HIV is twice as prevalent among incarcerated African-American (AA) women in NC as among their unincarcerated AA counterparts. Transactional sex (TS), sex for money, goods, or services, is a well-described risk factor for HIV. Methods: We conducted audiotaped qualitative interviews with 25 AA women (11 HIV-positive, 14 HIV-negative) within three months after entry into the state prison system. We explored potential pre-incarceration HIV risk factors on multiple levels, ranging from community-level (e.g. resources for information about HIV) to intrapersonal (e.g. personal sexual practices). Two researchers thematically coded interview transcripts and a consensus committee reviewed coding. Results: Twelve (four HIV-negative, eight HIV-positive) of the 25 women discussed conducting TS before incarceration. Crack cocaine use was pervasive, with 10 women reporting trading sex for drugs. Half the women reporting TS reported consensual sex with both men and women or with women exclusively. TS was both a primary and supplemental source of income as some women had trouble finding employment, often due to prior felonies. The majority of women had experienced sexual and/or physical violence during TS. Conclusions: Individual and community-level pressures led these women to engage in TS, exposing them to disease, physical/sexual violence, and continued drug use. As none of the women in this sample were incarcerated on TS-related charges, identification of women at risk for TS on release may be difficult. The social harms conveyed by TS, crack cocaine, and lack of economic power warrant development of interventions to decrease HIV risk and improve lifetime health for these women.