Whatever I got, you gonna get: HIV risk and perception of male condoms among incarcerated African American women in North Carolina

Background: HIV is five times more prevalent among incarcerated African-American (AA) women in North Carolina (NC) than among unincarcerated AA women. Outside prison, HIV transmission is primarily driven by sex with men; however, decision-making surrounding condom use is incompletely understood. Methods: We recorded qualitative interviews with 29 AA women (15 HIV-positive, 14 HIV-negative) newly entered into NC prisons. Following social ecological theory, we explored pre-incarceration HIV risk factors from community-level (e.g. condom accessibility) to intrapersonal (e.g. sexual practices). Two researchers thematically coded interview transcripts and a consensus committee reviewed coding. Results: Women reported low rates of consistent condom use with male partners and no barrier methods with female partners. At the individual level, women worried about HIV and sexually transmitted infections (STI) and described the importance of condoms. However, prevalent transactional sex and crack cocaine use among HIV-positive women was described in association with low condom use. Interpersonal-level barriers to condom use included relationship power dynamics and widespread intimate partner violence (18/29). Condoms were described in contrast to relationship trust: among women with children (n=23), few used condoms with fathers of their children. Several women described continued unprotected sex with men who gave them STIs or had concurrent female partners. At the community level, all participants described ready availability of condoms. Conclusions: Study participants described a high level of condom awareness and accessibility, however, multiple factors limited consistent condom use. HIV risk reduction efforts must extend beyond condom promotion to address women's agency or provide female-controlled methods of HIV prevention.