Skip to main content


Log in

Sexual Behaviors of US Women at Risk of HIV Acquisition: A Longitudinal Analysis of Findings from HPTN 064

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript


We describe the sexual behaviors of women at elevated risk of HIV acquisition who reside in areas of high HIV prevalence and poverty in the US. Participants in HPTN 064, a prospective HIV incidence study, provided information about individual sexual behaviors and male sexual partners in the past 6 months at baseline, 6- and 12-months. Independent predictors of consistent or increased temporal patterns for three high-risk sexual behaviors were assessed separately: exchange sex, unprotected anal intercourse (UAI) and concurrent partnerships. The baseline prevalence of each behavior was >30 % among the 2,099 participants, 88 % reported partner(s) with >1 HIV risk characteristic and both individual and partner risk characteristics decreased over time. Less than high school education and food insecurity predicted consistent/increased engagement in exchange sex and UAI, and partner’s concurrency predicted participant concurrency. Our results demonstrate how interpersonal and social factors may influence sustained high-risk behavior by individuals and suggest that further study of the economic issues related to HIV risk could inform future prevention interventions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others


  1. Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007–2010. HIV Surveillance Supplemental Report. 2012;17(4).

  2. Chen M, Rhodes PH, Hall HI, Kilmarx PH, Branson BM, Valleroy LA. Prevalence of undiagnosed HIV infection among persons aged ≥13 years—National HIV Surveillance System, United States, 2005–2008. MMWR Morb Mortal Wkly Rep. 2012;61(02):57–64.

    PubMed  Google Scholar 

  3. Hodder SL, Justman J, Haley DF, Adimora AA, Fogel CI, Golin CE, et al. Challenges of a hidden epidemic: HIV prevention among women in the United States. J Acquir Immune Defic Syndr (1999). 2010;55(2):69.

    Article  Google Scholar 

  4. Tillerson K. Explaining racial disparities in HIV/AIDS incidence among women in the U.S.: a systematic review. Stat Med. 2008;27(20):4132–43.

    Article  PubMed Central  PubMed  Google Scholar 

  5. HIV Prevalence Estimates—United States. 2006. MMWR Morb Mortal Wkly Rep. 2008;57(39):1073–6.

  6. Characteristics associated with HIV infection among heterosexuals in urban areas with high AIDS prevalence—24 cities, United States, 2006–2007. MMWR Morb Mortal Wkly Rep. 2011;60(31):1045–9.

  7. Brewer RA, Magnus M, Kuo I, Wang L, Liu TY, Mayer KH. The high prevalence of incarceration history among black men who have sex with men in the United States: associations and implications. Am J Public Health. 2014;104(3):448–54.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Carson EA, Sabol W. Prisoners in 2011. Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice; 2012. NCJ 239808.

  9. Maruschak LM. HIV in prisons, 2001–2010. AIDS. 2012;20:25.

    Google Scholar 

  10. Pouget ER, Kershaw TS, Niccolai LM, Ickovics JR, Blankenship KM. Associations of sex ratios and male incarceration rates with multiple opposite-sex partners: potential social determinants of HIV/STI transmission. Publ Health Rep. 2010;125(Suppl 4):70–80.

    Google Scholar 

  11. Adimora AA, Schoenbach VJ, Taylor EM, Khan MR, Schwartz RJ, Miller WC. Sex ratio, poverty, and concurrent partnerships among men and women in the United States: a multilevel analysis. Ann Epidemiol. 2013;23(11):716–9.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Doherty IA, Schoenbach VJ, Adimora AA. Sexual mixing patterns and heterosexual HIV transmission among African Americans in the southeastern United States. J Acquir Immune Defic Syndr (1999). 2009;52(1):114.

    Article  Google Scholar 

  13. Leichliter JS, Chandra A, Liddon N, Fenton KA, Aral SO. Prevalence and correlates of heterosexual anal and oral sex in adolescents and adults in the United States. J Infect Dis. 2007;196(12):1852–9.

    Article  PubMed  Google Scholar 

  14. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV. N Engl J Med. 1994;331(6):341–6.

    Article  PubMed  Google Scholar 

  15. Nicolosi A, Correa Leite ML, Musicco M, Arici C, Gavazzeni G, Lazzarin A. The efficiency of male-to-female and female-to-male sexual transmission of the human immunodeficiency virus: a study of 730 stable couples. Italian Study Group on HIV Heterosexual Transmission. Epidemiology (Cambridge, Mass). 1994;5(6):570–5.

  16. Risser JM, Padgett P, Wolverton M, Risser WL. Relationship between heterosexual anal sex, injection drug use and HIV infection among black men and women. Int J STD AIDS. 2009;20(5):310–4.

    Article  CAS  PubMed  Google Scholar 

  17. Baggaley RF, White RG, Boily MC. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention. Int J Epidemiol. 2010;39(4):1048–63.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Novak RM, Metch B, Buchbinder S, Cabello R, Donastorg Y, Figoroa JP, et al. Risk behavior among women enrolled in a randomized controlled efficacy trial of an adenoviral vector vaccine to prevent HIV acquisition. AIDS. 2013;27(11):1763–70.

    Article  PubMed Central  PubMed  Google Scholar 

  19. Adimora AA, Schoenbach VJ, Taylor EM, Khan MR, Schwartz RJ. Concurrent partnerships, nonmonogamous partners, and substance use among women in the United States. Am J Public Health. 2011;101(1):128–36.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Soc Sci Med. 2004;59(8):1581–92.

    Article  PubMed  Google Scholar 

  21. Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behavior in the United States: results from a national probability sample of men and women ages 14-94. J Sex Med. 2010;7(Suppl 5):255–65.

    Article  PubMed  Google Scholar 

  22. Jenness SM, Begier EM, Neaigus A, Murrill CS, Wendel T, Hagan H. Unprotected anal intercourse and sexually transmitted diseases in high-risk heterosexual women. Am J Public Health. 2011;101(4):745–50.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Sales JM, Brown JL, Diclemente RJ, Rose E. Exploring factors associated with nonchange in condom use behavior following participation in an STI/HIV prevention intervention for African-American adolescent females. AIDS Res Treat. 2012;2012:231417.

    PubMed Central  PubMed  Google Scholar 

  24. Kalichman SC, Cain D, Knetch J, Hill J. Patterns of sexual risk behavior change among sexually transmitted infection clinic patients. Arch Sex Behav. 2005;34(3):307–19.

    Article  PubMed  Google Scholar 

  25. Hodder SL, Justman J, Hughes JP, Wang J, Haley DF, Adimora AA, et al. HIV acquisition among women from selected areas of the United States: a cohort study. Ann Intern Med. 2013;158(1):10–8.

    Article  PubMed Central  PubMed  Google Scholar 

  26. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Behav. 1988;15(4):351–77.

    Article  CAS  Google Scholar 

  27. DiClemente RJ, Salazar LF, Crosby RA, Rosenthal SL. Prevention and control of sexually transmitted infections among adolescents: the importance of a socio-ecological perspective—a commentary. Public Health. 2005;119(9):825–36.

    Article  CAS  PubMed  Google Scholar 

  28. Latkin CA, German D, Vlahov D, Galea S. Neighborhoods and HIV: a social ecological approach to prevention and care. Am Psychol. 2013;68(4):210–24.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Eshleman SH, Hughes JP, Laeyendecker O, Wang J, Brookmeyer R, Johnson-Lewis L, et al. Use of a multifaceted approach to analyze HIV incidence in a cohort study of women in the United States: HIV prevention trials network 064 study. J Infect Dis. 2013;207(2):223–31.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Gallagher KM, Sullivan PS, Lansky A, Onorato IM. Behavioral surveillance among people at risk for HIV infection in the U.S.: the National HIV Behavioral Surveillance System. Publ Health Rep (Washington: 1974). 2007;122 Suppl 1:32–8.

  31. Radloff LS. The CES-D scale a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.

    Article  Google Scholar 

  32. Prins A, Ouimette P, Kimerling R, Camerond RP, Hugelshofer DS, Shaw-Hegwer J, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Int J Psychiatry Clin Pract. 2004;9(1):9–14.

    Google Scholar 

  33. Heagerty P, Liang K-Y, Zeger S. Analysis of longitudinal data. Oxford: Oxford University Press; 2013.

    Google Scholar 

  34. Adimora AA, Hughes JP, Wang J, Haley DF, Golin CE, Magnus M, et al. Characteristics of multiple and concurrent partnerships among women at high risk for HIV infection. J Acquir Immune Defic Syndr. 2014;65(1):99–106.

  35. Bartholow BN, Buchbinder S, Celum C, Goli V, Koblin B, Para M, et al. HIV sexual risk behavior over 36 months of follow-up in the world’s first HIV vaccine efficacy trial. J Acquir Immune Defic Syndr. 2005;39(1):90–101.

    Article  PubMed  Google Scholar 

  36. Metsch LR, Feaster DJ, Gooden L, Schackman BR, Matheson T, Das M, et al. Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial. JAMA. 2013;310(16):1701–10.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  37. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372(9635):337–40.

    Article  PubMed  Google Scholar 

  38. Guest G, Shattuck D, Johnson L, Akumatey B, Clarke EE, Chen PL, et al. Changes in sexual risk behavior among participants in a PrEP HIV prevention trial. Sex Transm Dis. 2008;35(12):1002–8.

    PubMed  Google Scholar 

  39. Kaul R, Kimani J, Nagelkerke NJ, Fonck K, Keli F, MacDonald KS, et al. Reduced HIV risk-taking and low HIV incidence after enrollment and risk-reduction counseling in a sexually transmitted disease prevention trial in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2002;30(1):69–72.

    Article  PubMed  Google Scholar 

  40. Nunn A, Dickman S, Cornwall A, Kwakwa H, Mayer KH, Rana A, et al. Concurrent sexual partnerships among African American women in Philadelphia: results from a qualitative study. Sex Health. 2012;9(3):288–96.

    Article  PubMed Central  PubMed  Google Scholar 

  41. Grieb SM, Davey-Rothwell M, Latkin CA. Concurrent sexual partnerships among urban African American high-risk women with main sex partners. AIDS Behav. 2012;16(2):323–33.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Poundstone KE, Strathdee SA, Celentano DD. The social epidemiology of human immunodeficiency virus/acquired immunodeficiency syndrome. Epidemiol Rev. 2004;26:22–35.

    Article  CAS  PubMed  Google Scholar 

  43. Satterwhite CL, Kamb ML, Metcalf C, Douglas JM Jr, Malotte CK, Paul S, et al. Changes in sexual behavior and STD prevalence among heterosexual STD clinic attendees: 1993-1995 versus 1999-2000. Sex Transm Dis. 2007;34(10):815–9.

    PubMed  Google Scholar 

  44. Cooper HL, Linton S, Haley DF, Kelley ME, Dauria EF, Karnes CC, et al. Changes in exposure to neighborhood characteristics are associated with sexual network characteristics in a cohort of adults relocating from public housing. AIDS Behav. 2014. doi:10.1007/s10461-014-0883-z.

  45. Fisher RJ. Social desirability bias and the validity of indirect questioning. J Consum Res. 1993:303–15.

Download references


The authors thank the study participants, community stakeholders, and staff from each study site. In addition, they acknowledge Lynda Emel, Jonathan Lucas, Nirupama Sista, Kathy Hinson, Elizabeth DiNenno, Ann O’Leary, Lisa Diane White, Waheedah Shabaaz-El, Quarraisha Abdool-Karim, and Sten Vermund., LeTanya Johnson-Lewis, Edward E. Telzak, Rita Sondengam, Cheryl Guity, Stephanie Lykes, Khadijah Abass, Eileen Rios, Manya Magnus, Christopher Chauncey Watson, Ilene Wiggins, Adongo Tia-Okwee, Joseph Eron, Cheryl Marcus, Valarie Hunter, and Christin Root.


The views expressed herein are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, the National Institutes of Health, the HPTN, or its funders.

Grant Support

By the National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, and National Institute of Mental Health (cooperative agreement no. UM1 AI068619, U01-AI068613, and UM1-AI068613); Centers for Innovative Research to Control AIDS, Mailman School of Public Health, Columbia University (5UM1Al069466); University of North Carolina Clinical Trials Unit (AI069423); University of North Carolina Clinical Trials Research Center of the Clinical and Translational Science Award (RR 025747); University of North Carolina Center for AIDS Research (AI050410); Emory University HIV/AIDS Clinical Trials Unit (5UO1AI069418), Center for AIDS Research (P30 AI050409), and Clinical and Translational Science Award (UL1 RR025008); Terry Beirn Community Programs for Clinical Research on AIDS Clinical Trials Unit; Johns Hopkins Adult AIDS Clinical Trial Unit (AI069465), Johns Hopkins Clinical and Translational Science Award (UL1 RR 25005); Robert W. Woodruff pre-doctoral fellowship of the Emory University Laney Graduate School; the National Institute of Mental Health (F31MH105238); and Columbia University Irving Institute Clinical and Translational Science Award TL1 TR000082-07.

Author information

Authors and Affiliations


Corresponding author

Correspondence to J. Justman.

Additional information

On behalf of the HPTN 064 Study Team. NCT00995176.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Justman, J., Befus, M., Hughes, J. et al. Sexual Behaviors of US Women at Risk of HIV Acquisition: A Longitudinal Analysis of Findings from HPTN 064. AIDS Behav 19, 1327–1337 (2015).

Download citation

  • Published:

  • Issue Date:

  • DOI: