Poor young women need information and empowerment.

Abstract

Sexually transmitted diseases are exacting a disproportionately heavy toll among impoverished young women, especially women of color. The presence of sexually transmitted diseases in a population is a harbinger for further morbidity, such as infertility and HIV infection. AIDS is now the third leading cause of death in women aged 25 to 44 in the United States.1 It is the leading cause of death in African American women in this age group. The study by Ruiz et al confirms the higher prevalence of sexually transmitted disease and HIV among women with low incomes, predominantly from ethnic minorities, in northern California. The authors repoort a disturbing rate of HSV-2 infection and a prevalence of HIV infection that is 4 times the estimate for women in the state. It is important for primary care providers to understand how these statistics apply at the community level and in individual practices. Well-designed population-based surveys can provide the most accurate data about disease prevalence. They also reveal the associated risk behaviors that can identify targets for primary prevention measures. The report by Ruiz and colleagues advances our knowledge of the actual prevalence of sexually transmitted diseases and HIV infection, as well as ongoing behaviors likely to transmit these infections. Perhaps most concerning, it shows that these women have an alarming rate of drug misuse and unprotected sexual contact with men at high risk of HIV and sexually transmitted diseases. Why are these women exposed to such risks? This study does not directly address this question, but much is known from other studies.2,3,4 Women frequently have difficulty negotiating the use of condoms with their partners. Many women experience anger and violence from their partners when they suggest condom use. Women who are financially dependent on their partners may feel powerless to insist on condom use. When sex is exchanged for drugs or money, condoms may not be part of the bargain. Finally, judgment may be impaired under the influence of drugs or alcohol. A high percentage of women in this study reported being intoxicated during sex. What does this mean for primary care physicians? The epidemic of sexually transmitted diseases and HIV infection in women is, first and foremost, a social problem—poverty, violence, substance misuse, ignorance, and relative powerlessness are often at the root of transmission. There are no simple solutions for complex social problems, but primary care physicians must address the challenge. One simple step involves taking a more detailed sexual history for all patients. In the AIDS era, most clinicians have become more comfortable with asking openended, nonjudgmental questions about sexuality—for example, “Do you have sex with men, women, or both?”—and condom use. But we should go further. For women who do not use condoms, we should ask about the power balance in their intimate relationships and their sense of personal safety. We should routinely try to identify if their partners have risk factors for HIV or sexually transmitted diseases. We may ask them about the use of drugs and alcohol in relation to sexual activity. Finally, we must ask about the trading of sex for money or drugs. The prevention of the transmission of HIV and other sexually transmitted diseases is more challenging than treating the diseases. It is difficult for physicians in busy practices to spend time obtaining the necessary information from patients at risk for these diseases. Creativity and a multidisciplinary team effort are needed. When patients at risk are identified, we must offer appropriate counseling in risk reduction, cervical screening, screening for HIV and other sexually transmitted diseases, and referral for social and psychological services and drug treatment, when indicated. The ultimate goal in the battle against the growing crisis of HIV infection and other sexually transmitted diseases among poor young women, and the responsibility of primary care physicians, is to inform and empower women at risk so they can better protect themselves and their families.