Alcohol Use Among HIV-Positive Latinas and African American Women

Abstract

This analysis of focus group dialogues about the intersection of race/ethnicity, HIV/AIDS, and alcohol use among HIV-positive Latinas and African American women explores consumers’ and providers’ perspectives on issues that influence the misuse of alcohol, the mechanisms of that influence, and factors that are critical to addressing the misuse of alcohol successfully in this population. The findings highlight the social structural influences of gender, race/ethnicity, and poverty and the interpersonal influences of family relationships, the disclosure of HIV, trauma and abuse, romantic partnerships, and motherhood on the misuse of alcohol. The discussion highlights suggestions for gender-specific and culturally responsive elements of alcohol treatment for HIV-positive Latinas and African American women.

Women constitute only 25% of people who are living with HIV/AIDS in the United States, but the vast majority are Latinas and African American (Centers for Disease Control and Prevention [CDC], 2011). In 2008, Latinas and African American women together made up 26% of all women in the United States but 82% of all women who were diagnosed with HIV/AIDS in the United States (Kaiser Family Foundation, 2011). These women face the challenges of HIV/AIDS in the context of many competing social–structural and psychosocial issues (CDC, 2011). Thus, even though HIV/AIDS treatment options and health outcomes have improved, HIV-positive women of color have continued to experience disparities in access to care, quality of care, health care coverage, and health outcomes (Kaiser Family Foundation, 2011; Redelings, Frye, & Sorvillo, 2005).

HIV-positive women of color are often young at HIV seroconversion, poor, and subject to gender and race/ethnicity-based power inequities that compromise their health and survival (Hader, Smith, Moore, & Holmberg, 2001). The lack of awareness of the risk of HIV makes them vulnerable to infection and contributes to delays in diagnosis and treatment (CDC, 2011; McNair & Prather, 2004). These women frequently balance multiple caregiving responsibilities with limited resources, which leads to the prioritization of their families’ and children’s demands over their own needs for HIV care (Land & Hudson, 2002; Stein et al., 2000). Many are also subject to stigmas that are associated with poverty, ethnic minority status, early sexual activity, early parenthood, substance abuse, and sex work that further affect their health and well-being (Sandelowski, Lambe, & Barroso, 2004).

HIV-positive African American women are often low-income (McNair & Prather, 2004) single parents (Jones, Beach, Forehand, & the Family Health Project Research Group, 2001) who are frequently unemployed and/or rely on public assistance. They are more likely than other HIV-positive women to engage in substance abuse and subsistence sex work (Wyatt, Carmona, Loeb, & Williams, 2005) and to be diagnosed and treated late in the course of their illness (CDC, 2011). They are frequently affected by histories of childhood sexual abuse (Wyatt et al., 2005), verbal and physical abuse in adult intimate relationships (Jones, Beach, Forehand, & the Family Health Project Research Group, 2003), and depression (Devine et al., 2000; Jones et al., 2001).

The limited literature on HIV-positive Latinas in the United States suggests that for many, recent immigration status and the associated lack of legal documentation and/or fluency in English interfere with their access to formal health care. The evidence also suggests that the stress of acculturation and isolation from social support by extended family members also create obstacles to self-care (Moreno, 2007). Many HIV-positive Latinas live in communities in which substance abuse and violence against women are common (Ortiz, 2005) and may be at a high risk of intimate partner violence (Moreno, 2007; Raj, Silverman, & Amaro, 2004).

Alcohol Use in the Context of HIV/AIDS

Alcohol use can have multiple serious consequences for both clinical and behavioral aspects of HIV treatment and survival. Heavy alcohol use among people with HIV has been directly linked to the reduced efficacy of HIV medication and acceleration of the progression of HIV, as demonstrated by higher levels of HIV ribonucleic acid and lower CD4 counts (Samet, Horton, Traphagen, Lyon, & Freedberg, 2003). It has also been linked to amplified medication toxicity and the increased odds of hospitalization over time at progressive levels of severity (Palepu, Horton, Tibbetts, Meli, & Samet, 2005). The misuse of alcohol in the context of HIV/AIDS also frequently leads to comorbidity with hepatitis, anemia (Conigliaro, Gordon, McGinnis, Rabenack, & Justice, 2003), and cirrhosis of the liver (Flexner, Cargill, Sinclair, Kresina, & Cheever, 2001). It is also associated with patients’ diminished likelihood of being prescribed antiretroviral treatment (Flexner et al., 2001) and their nonadherence to HIV medication regimens (Cook et al., 2001; Flexner et al., 2001; Samet, Horton, Meli, Freedberg, & Palepu, 2004). Despite this evidence, rates of heavy drinking appear to be disproportionately high among people with HIV/AIDS, approaching twice the incidence seen in the general population (Galvan et al., 2002).

Women and Alcohol Use

Gender has a distinct influence on the processes and consequences of problem drinking (Kay, Taylor, Barthwell, Wichelecki, & Leopold, 2010). Although women tend to consume less alcohol than do men, they are more vulnerable to its negative effects in several ways (Redgrave, Swartz, & Romanoski, 2003). Women with alcohol problems are often described as “telescoping”; they typically begin drinking and drinking excessively later in life than do men but progress more quickly to the point of alcohol abuse. They evidence alcohol-related health problems after fewer years of problem drinking and at lower levels of alcohol intake than do men (Kay et al., 2010; Redgrave et al., 2003). Women are also less likely than men to receive treatment for alcohol abuse, more likely to delay treatment, and less likely to be treated in settings that primarily address alcohol problems (Green, Freeborn, & Polen, 2001).

Alcohol problems among women have been associated with many factors that are common in the lives of HIV-positive Latinas and African American women, including childhood physical, emotional, and sexual abuse (Galaif, Stein, Newcomb, & Bernstein, 2001; Zule, Flannery, Wechsberg, & Lam, 2002), intimate partner violence (Moreno, 2007), and entry into the welfare system (Dooley & Prause, 2002). Related to the substance abuse and high-risk heterosexual sex through which Latinas and African American women are most likely to become infected with HIV (Kaiser Family Foundation, 2011), alcohol use may also be a significant contributor to the HIV-related health disparities that the women experience after diagnosis (Myers et al., 2009).

Despite the awareness of the potential links between alcohol use and HIV/AIDS among women of color, virtually no research has explored the etiology and impact of alcohol use among HIV-positive Latinas and African American women. The analysis presented here examined a set of focus group dialogues by HIV-positive Latinas and African American women and service providers who work with them about the intersection of race/ethnicity, HIV/AIDS, and alcohol use. The goal of the analysis was to explore the issues that influence the misuse of alcohol among HIV-positive Latinas and African American women, the mechanisms through which this influence occurs, and the features that are critical to addressing the misuse of alcohol by HIV-positive Latinas and African American women successfully.

Method

Recruitment of Participants and the Sample

Between March and September of 2004, focus groups were conducted with HIV-positive Latinas and African American women and service providers who work with them as part of the preliminary phase of a study of alcohol use among HIV-positive ethnic minorities. Flyers and presentations at HIV/AIDS service organizations and clinics in Los Angeles County were used to recruit a theoretically driven purposive sample of HIV-positive Latinas and African American women who had personal experiences with heavy alcohol use in the context of living with HIV/AIDS and service providers who were experienced in providing HIV/AIDS and alcohol-related services to either Latinas or African American women.

The participants were assigned to specific focus groups on the basis of their service delivery experiences (as consumers or providers of services) and race/ethnicity (African American vs. Latina). Ultimately, four focus groups were created, consisting of (1) five HIV-positive African American women, (2) four HIV-positive Latinas, (3) five service providers to HIV-positive African American women, and (4) five service providers to HIV-positive Latinas. The participating service providers included nurses, case managers, social workers, and client advocates from a variety of HIV/AIDS and chemical dependence treatment settings. Reflecting the peer support emphasis of many programs for people with HIV/AIDS (Levitt & Rosenthal, 1999), several service providers self-identified as being in recovery and/or living with HIV/AIDS during the focus groups.

Because of the stigmatizing nature of HIV/AIDS, the small size of the community being sampled, and concerns about confidentiality, the participants were not required to provide identifying information for sample descriptions. On the basis of the literature on sampling hard-to-reach populations in qualitative research (Abrams, 2010), data saturation and variability (Guest, Bunce, & Johnson, 2006), and focus group research (Fern, 2001; Kreuger, 1994), the sample size and data density created through these focus groups are believed to be appropriate and extremely useful for the qualitative exploration of the issues and populations under study.

Focus Groups

The focus groups were conceptualized and conducted according to the methods outlined by Kreuger (1994) and Fern (2001). Each focus group was facilitated by a pair of researcher–clinicians, at least one of whom was matched to the participants by gender and race/ethnicity. The focus groups were conducted in the private conference room of an HIV/AIDS research center during nonbusiness hours. The participants were asked to discuss a series of open-ended questions about the intersection of HIV/AIDS, alcohol use, and race/ethnicity:

Do you see alcohol abuse and alcoholism as significant problems among African American women or Latinas with HIV?

What do you think influences the use of alcohol among African American women or Latinas with HIV?

If you were going to design an alcohol treatment program exclusively for HIV-positive African American women or Latinas, what would you include in that program?

Each focus group lasted 2–3 hours, was recorded using a tabletop microphone, and transcribed verbatim. The focus group for HIV-positive Latinas was conducted in Spanish, transcribed in Spanish, and then translated into English by bilingual study personnel. The participants were provided with light meals and, at the conclusions of the focus groups, cash incentives of $35 per participant. These four focus groups generated more than 10 hours of audiotaped dialogue and, once transcribed, more than 60 single-spaced pages of rich data.

Data Analysis

The data were analyzed by the authors using the constant comparison method of content analysis. Following the methodology of “coding, consensus, co-occurrence, and comparison” outlined by Willms et al. (1992), the analysis was rooted in grounded theory development, deriving theory from data, and illustrating it with examples from those data (Glaser & Strauss, 1967; Strauss & Corbin, 1998). First, through multiple close readings and repeated revisions, each coder created an open coding system based on general ideas and themes to condense the data into analyzable units. Next, the content analysis feature of QSR Nvivo 7 was used to examine the association between a priori and emergent categories in each set of codes and to identify the existence of previously unrecognized categories and subcategories. When each investigator’s coding was complete, content analysis resumed through the contrast and comparison of data within and across codes and, finally, between the coders.

Findings

Causes and Consequences of Alcohol Misuse

Social structural issues: Gender

Women in all four focus groups noted that being a woman of any ethnicity meant attending to others' needs ahead of her own. A Latina provider commented, “It's about being a woman and being raised to think that…everyone else's needs come first. Whether you're Black, Asian, Latina or whatever, your mom raises you that way because that's how she was raised and it just keeps going.” Many echoed one HIV-positive African American woman's sentiment that womanhood involves being over burdened: “It takes a lot to be a woman, cleaning the house, raising the kids, dealing with the man, with a mother… God puts women's bodies through a lot and we go through a lot.” An African American provider related these patterns to women's alcohol misuse: “We end up not taking care of ourselves, physically, mentally, spiritually, because we've put all our energy into taking care of everyone else…I think when we try to deal with those stresses, some of us may turn to alcohol.”

The focus group participants noted that being a woman with HIV/AIDS meant dealing with a variety of double standards around sexuality that contribute to problem drinking. One African American participant commented: “A man can have two or three women, but for us to go and have two or three men is not allowed. You’re a ‘ho’ then. Even having kids out of wedlock is a big deal [for women].” One HIV-positive Latina observed that under the rubric of such double standards, women seemed be at fault no matter what: “There’s a perception that ‘those’ people get HIV: sex workers, drug users, homosexuals. So if you’re a woman, there’s a question of how you got it and if it’s because your husband cheated on you; it’s like, what did you do that made your husband cheat on you?”

The HIV-positive participants also described feeling that their femininity and sense of being “whole women” had been compromised by HIV. They described experiencing a diminished sense of their own sexuality and sexual desirability and mourning the compromise of their healthy bodies and physical appearance. They reported feeling that although women were not “supposed” to have HIV or substance abuse problems, troubles with alcohol were seen as a lesser evil for women. One African American woman noted, “If you’re a woman and you’re seen having a drink, it’s more socially acceptable than smoking a rock,” while another asserted, “I’d rather have you think I am a drunk, not that I’m dying of HIV. I don’t want you to think I have something wrong. I’d rather you think I’m an alcoholic.”

Social structural issues: Race and ethnicity

Both the Latinas and African American women noted that race and ethnicity colored their experiences with both HIV/AIDS and the misuse of alcohol. The Latina participants described chronic worries about documentation issues and the lack of access to health care and educational and other resources (based on residency status) as contributing to feelings of hopelessness. Many women reported that they were stereotyped as “loose women” or prostitutes on the basis of their race/ethnicity and related these experiences to their use of alcohol. One HIV-positive African American woman stated that “African American women have been labeled as prostitutes, as promiscuous women who drink too much,” and noted, “When you get the disease, it’s like, oh well, that’s what she deserves. And when you get angry [about it], you want to drink too much because you want everything to go away.”

Both the Latinas and African American women also described culturally based expectations as driving and reinforcing their failure to express their pain and sorrow to others. One Latina provider noted that her clients will not burden family members with their feelings and related their reluctance to do so to the culturally specific force of Marianismo, or Latinas’ internalization and idealization of “the woman being . . . compared to the Virgin Mary and being the sole caregiver, having to put everything else before her own needs.” One Latina concurred that “you’re the stronghold of that family, so you’re going to do everything in your might not to make it weak or break . . . and that means not telling anybody . . . sucking it up and taking care of your man and your family.”

Similarly, one HIV-positive African American woman described the perceived need to subjugate her own feelings as part of being a “strong black woman,” and another responded by saying “we are women who stuff things, and that’s our biggest problem!” A third African American woman directly related this “stuffing” to the misuse of alcohol:

Black women have had this image to uphold, we had to be strong for family . . . And now who do I have to depend on? . . . Alcohol becomes a friend, it becomes a lover, it becomes a parent, it becomes everything because here is one thing I know I can depend on.

Social structural issues: Poverty

One service provider noted, “If you’re struggling economically, you’ll be more prone to see alcohol as an escape than as just a social thing.” Indeed, the participants described living in poverty as both a consequence of and a motivating factor for the misuse of alcohol by HIV-positive women. The consumers of services specifically described the context of poverty for women of color in terms of undesirable measures they felt forced to take to subsist, including a reliance on public assistance and engaging in sex work. They identified both financial hardship and these means of securing income as sources of stress, depression, and hopelessness that fueled their misuse of alcohol. Both the HIV-positive African American women and the service providers identified entry into the public welfare system as a frustrating marker of being a woman in poverty. Some envisioned this system as a source of necessary and temporary help that could aid women in tough times. Others, though, expressed the belief that involvement with Aid to Families with Dependent Children and other forms of housing and financial assistance was a self-defeating misstep that undermined the self-esteem and efforts to become self-sufficient on which recovery is predicated. One such participant asserted: “When you become dependent on the system, it drives your drinking. It becomes a crutch.”

Both the Latinas and African American women described entry into sex work as a unique consequence of poverty for women and as both a cause and a consequence of the misuse of alcohol. They described sex work as an exchange turned to in desperation out of the drive to meet basic needs, provide for children, or obtain substances of abuse. One Latina reported being willing to take such desperate measures only to care for her children: “Because of necessity, you enter into prostitution and begin to drink alcohol . . . I prefer to be with these men . . . and take food to my children and watch them laugh and eat. Then it does not matter, being with these men.”

Another Latina participant linked sex work to both the misuse of alcohol and HIV, noting that “prostitution is a cause for alcohol use and for HIV. It is a topic of great importance to women . . . It is also a way due to lack of finances, or lack of solace, not having papers, documents, or a job.” Finally, one service provider to African American women noted that sex work is both facilitated by heavy alcohol use and motivates increased drinking, stating that “if you were sober, you would not go out and get reinfected with HIV or another STD [sexually transmitted disease] or be in a situation where you’re selling your body or whatever to get drunk.”

Interpersonal issues: Families and disclosure

The participants described HIV-positive Latinas’ and African American women’s relationships with family members as key to the interpersonal context of their alcohol use. Their descriptions revealed three distinct patterns related to the disclosure of HIV status and the quality of subsequent relationships that seemed to influence the misuse of alcohol. The first was the experience of being rejected by extended family members in response to their disclosure of being HIV positive, ranging from complete alienation to contact that involved proscribed behavior in relatives’ homes. The women described these rejections as intense motivators for their use of alcohol, and one provider commented, “I’ve heard people say that their parents make them use special plates, towels, toilet seat covers, bedding. I’ve heard people break down and cry about that. That keeps them drinking.”

The second pattern was one of relationships, intimacy, and support constrained by the women’s failure to disclose their HIV status to family members because of their fear of rejection. These scenarios involved secrecy and shame and were also described as an impetus for drinking because of feelings of isolation and forced detachment. One HIV-positive Latina noted, “Women with HIV who are still drinking, it’s because their families don’t understand. They want their families to get educated and understand, but how many women do you know who say their families don’t even know?” Another woman concurred, “it hurts to carry that around; it eats you alive and breaks you down.”

Finally, a few women described family contexts in which they were “out” as HIV-positive women and received full support and even increased respect from family members after they disclosed their HIV status. This experience was described by one woman in recovery from alcoholism as a source of pride and sustenance for her continued focus on both her health and her recovery: “I am HIV positive, and none of my kids and none of my family have turned their backs on me . . . If anything, they look at me as the Trojan . . . I am still going strong.”

Several participants stated that women who were not willing or able to disclose their HIV status to the entire family often disclosed only to their mothers. This relationship was described as a pivotal one that might then serve as their central supportive relationship with another adult. In some cases, the HIV-positive women’s mothers encouraged or supported further disclosure, while in others, they remained the women’s sole confidents regarding their HIV diagnosis. Several women described this revelation as making it possible to repair the mother–daughter relationships that have been fractured by their prior misuse of alcohol and as one of the invaluable “gifts” of recovery.

Interpersonal issues: Trauma and abuse

The women in all four focus groups described experiences of childhood physical, sexual, and emotional abuse as contributing to the vulnerability of women in their communities to both HIV/AIDS and the misuse of alcohol. A number of women referred to their personal histories of trauma and abuse, and women in every focus group described feeling chronically at risk of sexual and physical assault in their day-to-day lives. The women described these experiences as having socialized them into feelings of low self-esteem and low self-worth that contributed to both the initiation and the continuation of their misuse of alcohol.

Several women directly related childhood exposure to parental alcoholism and abuse to their own misuse of alcohol. One provider identified her clients’ failure to address the pain associated with past traumas as a significant contributor to alcohol problems:

Most of the people I have done therapy with have been sexually abused as children and they have all these layers of pain. When they become 13, 14, 15 years of age they're already starting to use substances and becoming sexually active… and by the time they're 21, they're full blown addicts of alcohol with AIDS.

Many women also connected childhood experiences of trauma and abuse to their subsequent tolerance of alcoholism and abuse by male romantic partners. When asked if there was anything else anyone wanted to add before closing a discussion, one HIV-positive Latina exclaimed, “because of the abuse from childhood, that’s why we are prepared for these abusive husbands!” When asked to elaborate, she continued that “the problem comes from childhood; if you have been abused as a girl, the self-esteem is very low, and it’s basically the same, having to tolerate the situation because of emotions, as it is when you are young.”

Interpersonal issues: Romantic partnerships with men

The participants described relationships with male partners as another central feature in patterns of alcohol misuse. They related many accounts of relationships colored by addiction, anger, conflict, abuse, betrayal, and abandonment, experienced as both the causes and the consequences of misusing alcohol. Some women described the men in their lives as absentee fathers who failed to provide adequate support and companionship. Others lamented that even when present, their male partners did not contribute fairly to parenting or household responsibilities. The Latinas more often described long-term relationships involving sexual and emotional subjugation and physical abuse. The African American women more often described unstable relationships and periods of living without partners as single parents.

Several women noted that their misuse of alcohol originated in relationships with alcoholic partners. One provider to Latinas noted, “If their male partners are drinking, it affects them in terms of domestic violence.” Another provider said that many women of color are exposed to HIV through sexual infidelity by male partners and that they experience feelings of both anger and shame about this situation: “If . . . she was with a man who was sleeping with men and women, the shame of not being able to tell . . . she’ll have some guilt about that. ‘I should have known better . . . I should have known something was up.’” One HIV-positive African American women concurred that “[HIV-positive women] have men issues, and that keeps them drinking.”

Many of the HIV-positive women described having problematic and/or abusive relationships with male partners, having relationships with male partners who drink, and having contracted HIV through betrayal or infidelity by a male partner all as strong motivators for using alcohol. Despite these assessments, though, both the HIV-positive women and the service providers repeatedly described women maintaining these troubled relationships at all costs. Several women attributed this preservation of unhealthy romantic partnerships to the fear that being HIV positive precluded better options in selecting partners. Another related these choices to both HIV and alcohol use issues:

Women will hang on to men who are still drinking . . . even when it means they lose their kids . . . because this is the only man who knows they have HIV and who will still sleep with them and drink with them, even though it’s the same man who got them in trouble . . . The same man who infected you is going to make you lose your housing and your kids, and women are willing to do that.

Interpersonal issues: Motherhood

In varying terms of exuberance and melancholy, HIV positive women consistently described motherhood as a defining feature of their lives and illustrated how both HIV/AIDS and alcohol misuse complicated their experiences as mothers. They described both concrete struggles as sole caregivers and psychic struggles over the complexities of motherhood in the context of HIV/AIDS as strong motivators for alcohol misuse. Both service consumers and service providers described the negative impacts of maternal alcohol misuse on parenting practices. Finally, both consumers and providers described the power of motherhood to motivate recovery and promote self care.

Several HIV-positive mothers ruefully described alcohol-driven scenarios of role reversal, wherein young children were charged with caring for themselves, other siblings and their mothers. One African American woman noted: “Alcohol will do that to you too; you'll lock your kids in the house and leave them for days.” Participants also described alcohol misuse as contributing to familial involvement with child welfare agencies and sometimes to the loss of custody of their children. One mother described the vigilance required to prevent this as another source of self-perpetuating shame and isolation for women and children, noting: “We teach our kids not to go outside of the house and tell anybody anything. If you let them stay with somebody, kids will tell what's going on in that household.”

The women also described parenting in the context of fear about disclosing their HIV status to their children, attributed to a resistance to “burdening” their children and to ambivalence about teaching their children to keep secrets. They expressed guilt over perceived maternal failings, worry about leaving their children uncared for if HIV hastened their incapacitation or death, and grief over past losses of custody. Some women described feeling overwhelmed by their children’s emotional responses to the disclosure of their HIV status. Others described intense sorrow over their actual and anticipated losses of children to whom they had transmitted HIV and described this grief as driving their misuse of alcohol. An HIV-positive African American woman said, “I would look at my baby and think that eventually my baby was going to die, which made me want to drink and hate myself.”

Finally, the participants described motherhood as inspiring the desire to be in their children’s lives as long as possible and thus as a major motivation to address their alcohol problems and engage in HIV self-care. One Latina observed that her children’s affection helps her when she is feeling emotionally low, noting that “if I’m sad or thinking about alcohol, I look at them and say ‘No, I’m not going to do that’ because I can’t help them in the same way. For them I have to fight and get beyond this.” The service providers, aware of this powerful motivator, described using it to urge women to take action. One noted that “for women with children, you can work on talking about what will happen to their children if they’re gone, if they drink themselves to death, if they don’t take their medication. Who’s going to take care of those children?”

Recovery From Alcohol Misuse in the Context of HIV/AIDS

Peer support and mentoring

The participants repeatedly identified HIV-positive women in recovery as the most critical sources of strength and inspiration for one another. One African American woman commented, “Women need to help other women; that’s the only way we’re going to come out of this.” Another concurred that “females working together is important—we all need to work together,” and a third explained, “We can always help each other because we know what we go through.” Several participants described with pride ways in which they had used their own painful experiences to help other women. One HIV-positive African American woman stated that she is able to help other women in a manner unique to someone who has experienced the same trials they face: “I give talks and use my own life, my son’s death, to make a very strong impression on women who are very scared and who are still drinking because they are afraid to disclose to their kids.”

An African American service provider stressed the need for the larger community to express support to younger people facing these challenges and described the sometimes deeply emotional toll that this work takes on her:

I’m in a group called [X], where we go out to schools and speak to classes, educating them on alcoholism, drugs, and how it leads to becoming HIV positive. A lot of times when I go out to speak to children, . . . they say ‘why are you here? Do you care about me?’ And that really hurts . . . [but] the young people who are positive and drinking need to know that there are people outside their families who do honestly care if they live or die.

Another African American woman stressed her belief that HIV-positive women in recovery must help others like themselves, even in the face of resistance: “When you're a woman with experience, you have to target the people whom you know most need the strength from you. And do it even if they cut you because they’re feeling bad. Do it and don’t lose hope.”

Finally, a few women offered heartfelt stories about their efforts to overcome alcohol problems and their recovery-driven opportunities to contribute positively to others’ lives. One HIV-positive Latina expressed great pride in her efforts to break a cycle of abuse, shame, and dependence that she feared would otherwise have engulfed her daughter and grandchildren:

I’m searching for happiness by helping my daughter, supporting her, taking care of her son so she can get her degree. And if I never have another partner, oh well. That’s what I get, but I’m happy that I finally did the right thing, supporting this girl, and if I were to die the day after tomorrow, she can live her life decently with more propriety. I know she won’t need a husband to support her because with her degree she could support her son, and if she finds someone to marry, it will be very different.

Alcohol treatment: Context

Participants provided a multitude of suggestions for the design and implementation of alcohol treatment for HIV-positive women of color. Both Latinas and African American women placed paramount importance on engaging women's entire families in treatment and not residentially separating women from their families. One Latina urged “in some inpatient treatment centers, when she goes into the facility, she can't talk to her family and that's probably not the best thing… because she will be constantly worrying about her family rather than worrying about herself.” An African American provider emphasized the importance of family involvement by saying “don't just send me to rehab. Who am I living with? They need to… learn how to help me stay in rehab. Anyone who is interested in the family… should be educated with the person who is abusing the substance.” Providers also stressed the need to educate women about family systems issues associated with alcohol misuse by “explaining those cycles and defining them through stories and appropriate examples… tying them into domestic violence and unhealthy relationships, which is where most of the substance abuse happens… and making sure it gets pointed out and is seen as a problem.”

Alcohol treatment: Content

The participants’ recommendations began with the assertion that services should be provided by other women, preferably those with personal experience with HIV/AIDS and alcohol issues, and should include individual counseling, family therapy, and women-only support groups. The women in all the focus groups stated that any such program must attend to women’s concrete needs by providing child care and transportation. Others suggested offering structured exercise and self-care regimens and incorporating prayer and/or a religious emphasis into treatment. Several Latinas suggested offering practical training in how to apply for jobs and act and dress in the workplace to help prepare women for employment. They suggested that teaching practical skills, such as sewing and offering lessons on clothing and makeup application, may improve women’s self-esteem and keep them busy and “out of trouble.”

Finally, both the Latinas and the African American women stressed the need for a “woman-friendly” treatment environment, meaning that programs should incorporate an emphasis on women working together, supporting, and nurturing one another. They suggested that the ideal treatment environment for HIV-positive women is a positive, compassionate one in which no confrontational methods (attacks) or vulgar language are used. They emphasized that services should focus on improving women’s self-esteem and self-worth. One Latina participant emphasized the importance of exercising patience with women who are ashamed, frightened, resistant, or not fully ready to seek or accept help, asking “How can you tell someone, you can’t be here or don’t come with that attitude; only come when you’re happy? Then they will never come: They will always feel rejected or always feel sad because they have problems with alcohol.”

Conclusion

All the focus group participants agreed that the misuse of alcohol is a significant problem for HIV-positive Latinas and African American women. Their dialogue presented this problem as being contextualized by social structural issues and interpersonal relationships that perpetuate the cycles of hopelessness and despair that are associated with alcohol problems (Brewer, 2006). Their descriptions highlighted the ways in which living with HIV/AIDS and misusing alcohol mutually reinforce the shame, denial, and isolation that limit access to social support and the use of formal and informal recovery resources. Many participants, for example, identified both the denial of alcohol problems and of being HIV positive as triggers for the misuse of alcohol and shame and denial as sources of isolation that led to depression and the intensified use of alcohol.

These dialogues also revealed women’s fears of being judged, both within and outside their own communities, and the ways in which this fear inhibited them from expressing their needs and help-seeking behaviors. Their comments illustrated the ways in which HIV-positive women of color are marginalized in multiple ways within multiple communities (racial/ethnic communities, recovery communities, and HIV/AIDS communities), resulting in a truncation and fragmentation of familial and social relationships and the support that these relationships may otherwise provide. Nevertheless, many participants described critical personal victories in their struggles with HIV/AIDS and misuse of alcohol and proudly identified themselves and other HIV-positive women in recovery as the best possible resources for women who are struggling with these issues. Many of their stories highlight their agency, strength, and intensely compassionate mutuality.

Limitations of the Study

This analysis used qualitative methods to identify and illustrate the etiology of the misuse of alcohol among HIV-positive Latinas and African American women. As such, it provided nuanced, in-depth information about a specific set of phenomena, detailed through the lived experiences of a small group of individuals, and is best characterized as “thick description.” The findings are limited by the study’s reliance on a single mode of data collection and by the fact that, because of confidentiality concerns related to the stigma of HIV and the small size of the community begin sampled, the participants were not asked to provide identifying information, and thus no member check was possible.

Implications for Service Delivery and Recommendations for Future Research

The focus group participants’ descriptions of recovery-related needs and resources as well as their suggestions about alcohol interventions, echo many points (such as the desirability of sex-segregated treatment) that have been long debated in the literature on women and addiction but not often enacted in treatment programs (Greenfield, 2002). Their ideas suggest that the need to attend to gendered issues in the structure and content of alcohol interventions for women may be intensified for HIV-positive women, who constitute a small minority (females) within another small stigmatized minority (people living with HIV/AIDS; Barroso & Sandelowski, 2004). They also suggest that to engage and retain HIV-positive women in alcohol treatment, programs must adapt to women’s recovery needs by attending to gender-specific HIV-related medical and social service needs and addressing structural and interpersonal issues related to race/ethnicity, poverty, parenting and family relationships, physical and sexual violence, and practical needs for economic and educational empowerment.

In relation to community-based HIV/AIDS care, these dialogues suggest the need to integrate alcohol education and support into HIV/AIDS case management, medical, and psychosocial support services. They highlight the importance of addressing the misuse of alcohol as an element of poly-substance abuse in recovery and sobriety maintenance programs offered in HIV/AIDS service settings, where the focus is typically on the use of illegal substances. These findings also suggest that the mixed-gender 12-step approach that dominates recovery services at most HIV/AIDS service organizations may not offer the optimal recovery environment or tools for HIV-positive women of color, who face multiple, nested barriers to addressing alcohol problems (Greenfield, 2002). As such, these findings highlight a number of issues that are essential to identifying and addressing what may be a quiet but dangerous problem for a multiply marginalized and vulnerable population. It is hoped that by explicating the issues, processes, and relationships that underlie this problem, this analysis will contribute to the development of translational research that focuses on addressing the unmet needs articulated here.