title: Socioecological factors influencing women's HIV risk in the United States: qualitative findings from the women's HIV SeroIncidence study (HPTN 064).
abstract: We sought to understand the multilevel syndemic factors that are concurrently contributing to the HIV epidemic among women living in the US. We specifically examined community, network, dyadic, and individual factors to explain HIV vulnerability within a socioecological framework.
  
  
  
  We gathered qualitative data (120 interviews and 31 focus groups) from a subset of women ages 18-44 years (N = 2,099) enrolled in the HPTN 064 HIV seroincidence estimation study across 10 US communities. We analyzed data from 4 diverse locations: Atlanta, New York City (the Bronx), Raleigh, and Washington, DC. Data were thematically coded using grounded theory methodology. Intercoder reliability was assessed to evaluate consistency of team-based coding practices.
  
  
  
  The following themes were identified at 4 levels including 1) exosystem (community): poverty prevalence, discrimination, gender imbalances, community violence, and housing challenges; 2) mesosystem (network): organizational social support and sexual concurrency; 3) microsystem (dyadic): sex exchange, interpersonal social support, intimate partner violence; and 4) individual: HIV/STI awareness, risk taking, and substance use. A strong theme emerged with over 80 % of responses linked to the fundamental role of financial insecurity underlying risk-taking behavioral pathways.
  
  
  
  Multilevel syndemic factors contribute to women's vulnerability to HIV in the US. Financial insecurity is a predominant theme, suggesting the need for tailored programming for women to reduce HIV risk.
  
  
  
  Clinicaltrials.gov, NCT00995176.
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 1760 Haygood Road, Suite 300, Atlanta, 30322, GA, USA. pfrew@emory.edu.|Department of Behavioral Sciences and Health Education, Emory Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, 30322, GA, USA. pfrew@emory.edu.|Hubert Department of Global Health, Emory Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA, 30329, USA. pfrew@emory.edu.|Emory Center for AIDS Research, Emory University, 1518 Clifton Road NE, Suite 8050, Atlanta, GA, 30322, USA. pfrew@emory.edu.
authors.forename: Paula M
authors.identifier: 0000-0002-3078-9124
authors.initials: PM
authors.lastname: Frew
authors.affiliation: Department of Health Studies, Texas Woman's University, CFO Bldg - 1007, PO Box 425499, Denton, TX, 76204, USA.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Parker
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 1760 Haygood Road, Suite 300, Atlanta, 30322, GA, USA.
authors.forename: Linda
authors.initials: L
authors.lastname: Vo
authors.affiliation: Department of Behavioral Sciences and Health Education, Emory Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, 30322, GA, USA.
authors.forename: Danielle
authors.initials: D
authors.lastname: Haley
authors.affiliation: Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA.
authors.forename: Ann
authors.initials: A
authors.lastname: O'Leary
authors.affiliation: SisterLove, Inc, 3709 Bakers Ferry Rd, SW, Atlanta, GA, 30331, USA.
authors.forename: Dazon Dixon
authors.initials: DD
authors.lastname: Diallo
authors.affiliation: Department of Medicine, UNC School of Medicine, University of North Carolina Chapel Hill, 130 Mason Farm Rd, Chapel Hill, NC, 27599, USA.
authors.forename: Carol E
authors.initials: CE
authors.lastname: Golin
authors.affiliation: George Washington University Milken Institute School of Public Health, 950 New Hampshire Avenue NW, Suite 500, Washington, DC, 20052, USA.
authors.forename: Irene
authors.initials: I
authors.lastname: Kuo
authors.affiliation: National Institute of Allergy and Infectious Diseases, Washington, DC, USA.
authors.forename: Lydia
authors.initials: L
authors.lastname: Soto-Torres
authors.affiliation: Statistical Center for HIV/AIDS Research and Prevention (SCHARP), Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
authors.forename: Jing
authors.initials: J
authors.lastname: Wang
authors.affiliation: Department of Medicine, UNC School of Medicine, University of North Carolina Chapel Hill, 130 Mason Farm Rd, Chapel Hill, NC, 27599, USA.
authors.forename: Adaora A
authors.initials: AA
authors.lastname: Adimora
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 1760 Haygood Road, Suite 300, Atlanta, 30322, GA, USA.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Randall
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 1760 Haygood Road, Suite 300, Atlanta, 30322, GA, USA.|Hubert Department of Global Health, Emory Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA, 30329, USA.|Emory Center for AIDS Research, Emory University, 1518 Clifton Road NE, Suite 8050, Atlanta, GA, 30322, USA.
authors.forename: Carlos
authors.initials: C
authors.lastname: Del Rio
authors.affiliation: West Virginia University School of Medicine, One Medical Center Drive, HSC-South 2244, Morgantown, WV, 26506, USA.
authors.forename: Sally
authors.initials: S
authors.lastname: Hodder
mesh_terms: D000293:Adolescent; D000328:Adult; D005069:Evaluation Studies as Topic; D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006306:Health Surveys / Q000706:statistics & numerical data; D006801:Humans; D009519:New York City; D011203:Poverty; D015203:Reproducibility of Results; D012307:Risk Factors; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology; D014861:Washington; D016387:Women's Health / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: HIV risk reduction; HIV/AIDS; Minorities; Sexual health; Socioecological model; Women