AIDS Behav DOI 10.1007/s10461-017-1771-0

SUBSTANTIVE REVIEW

Neighborhood Environments and Sexual Risk Behaviors for HIV Infection Among U.S. Women: A Systematic Review Chanelle J. Howe1

•

Hayley Siegel1 • Akilah Dulin-Keita2

 Springer Science+Business Media New York 2017

Abstract Empirical evidence indicates that aspects of the neighborhood environment may affect HIV prevention efforts. Therefore, the neighborhood environment should be considered when implementing prevention interventions. However, much of the empirical evidence is derived from studies conducted among drug users, men, or adolescents. Such evidence may not be as applicable to adult women whose primary risk for HIV infection is via heterosexual sexual behavior. Therefore, a systematic review examining the relationship between neighborhood environments and HIV sexual risk behaviors among adult U.S. women was conducted. Three databases were searched for articles published in English in peer-reviewed journals between 1/1/1980 and 12/31/2016 meeting relevant criteria. Seven articles identified from the three databases or additional hand searches met inclusion criteria and were summarized. Findings were mixed with several studies indicating associations between neighborhood environments and HIV sexual risk behaviors. However, all summarized studies were cross-sectional. Longitudinal studies conducted among women are needed. Keywords HIV
Neighborhoods
Women
Sexual risk behaviors

& Chanelle J. Howe [email protected] 1

Department of Epidemiology, Centers for Epidemiology and Environmental Health, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912, USA

2

Department of Behavioral and Social Sciences, Center for Health Equity Research, Brown University School of Public Health, Providence, RI, USA

Introduction In 2010 the White House issued the National HIV/AIDS Strategy that detailed primary goals and strategies for the United States (U.S.) government’s continued response to the domestic HIV epidemic [1]. These goals included reducing the number of new HIV infections, improving access to care and health outcomes among HIV-infected persons, and lessening HIV health disparities. In 2015 the National HIV/AIDS Strategy was reissued and reiterated the aforementioned goals while calling for the intensification of efforts to prevent HIV in groups most impacted by the HIV epidemic [2]. Such groups include men who have sex with men, Black/African American (AA) men and women, Latino/Hispanic men and women, transgendered women as well as persons who inject drugs, are age 13–24 years old, or are living in the South [2]. In 2013, Latkin et al. [3] reviewed the published literature regarding the relationship between neighborhood environments and engaging in risk behaviors for HIV infection. Most of the studies reviewed by these authors were conducted in U.S. populations. In their review, the authors specifically highlight that various aspects of the neighborhood environment (e.g., economic disadvantage, disorder, social cohesion, presence of same-sex partners) have been shown empirically to be positively or negatively associated with engaging in individual-level risk behaviors for HIV infection. Latkin et al. [3] postulated that observed associations between neighborhoods and HIV may operate through pathways that in part include psychological distress and stress. Given that aspects of the neighborhood environment may either serve as a barrier to or facilitator of HIV prevention efforts, the neighborhood environment should be considered when developing and implementing prevention interventions to meet the National HIV/AIDS Strategy goals.

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Although the aforementioned review by Latkin and colleagues was highly insightful, the majority of the research studies discussed by these authors were conducted among drug users, men, or adolescents. Therefore, the results derived from these research studies may not be as applicable to adult (i.e., C18 years old) women whose primary risk for infection is via heterosexual sexual behavior. The aforementioned results may also be less applicable to adult women given that gender norms often dictate what behaviors are acceptable for men versus women, where behaviors that are more socially acceptable for men (e.g., multiple sexual partners) can be less acceptable for women [4]. If such gender differences in socially acceptable behaviors hold true regardless of the neighborhood environment, then gender-specific neighborhood effects might occur. Karriker-Jaffe [5] and Bryden et al. [6, 7] also published reviews of studies related to neighborhood environment and risk behaviors for HIV infection that included studies conducted in U.S. populations. Examined aspects of the environment included area-level socioeconomic status [5], alcohol availability and marketing in the community [7], as well as community-level social factors (i.e., socio-economic deprivation; disorder and crime; norms; and social capital) [6]. However, these reviews focused solely on alcohol and drug use as outcomes, while ignoring sexual risk behaviors for HIV infection. Given the limitations of the aforementioned review papers, the aim of this paper is to first conduct a systematic review of the quantitative literature focused on the relationship between neighborhood environments and sexual risk behaviors for HIV infection among adult U.S. women. Second, we aim to discuss potentially relevant theoretical frameworks that may explain any observed relationships between neighborhood environments and engaging in sexual risk behaviors among adult U.S. women. Third, we aim to pinpoint gaps in the published literature to identify future research directions. Completing all of the aforementioned aims should aid in identifying intervention targets for preventing new HIV infections among an important at-risk population, adult U.S. women, especially AA and Latino/Hispanic U.S. women who likely disproportionately reside in adverse neighborhood environments [8, 9] and are listed in the 2015 National HIV/AIDS Strategy as groups requiring intensified HIV prevention efforts.

Methods This systematic review was informed by the PRISMA Statement [10]. The PubMed, Web of Science, and Google Scholar databases were searched for full-text original

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research articles that were written in English, published in peer-reviewed journals between 1 January 1980 and 31 December 2016, and reported quantitative results for the relationship between neighborhood-level factors and sexual risk behaviors for HIV infection among adult (i.e., C18 years old) U.S. women. Neighborhood-level factors of interest in this systematic review included factors previously linked to HIV in the abovementioned review by Latkin et al. [3]. Previously linked neighborhood-level factors include neighborhood socio-economic disadvantage or deprivation as well as neighborhood disorder. Neighborhood disorder has been defined by Gracia [11] as ‘‘…observed or perceived physical and social features of neighborhoods that may signal the breakdown of order and social control, and that can undermine the quality of life.’’ Included in neighborhood disorder are factors like social disorder (e.g., neighborhood violence and perceived level of neighborhood safety/danger) and physical disorder (e.g., broken windows and vacant buildings). Neighborhood collective efficacy (e.g., the social cohesion of a neighborhood and the extent to which residents are willing to intervene to supervise youth and preserve order in their neighborhood) and neighborhood social capital were also previously linked factors of interest [3, 12–15]. This systematic review also allowed for the potential inclusion of neighborhood-level characteristics not mentioned in previous reviews to facilitate the identification of neighborhood-level factors that may be uniquely important to adult women. However, this review excluded social and risk networks not explicitly operating at the neighborhood level because such networks may include individuals who do not reside in an individual’s neighborhood (e.g., friend or relative) which is consistent with prior work [16]. Included among the sexual risk behaviors for HIV infection of interest were unprotected sexual intercourse, inconsistent condom use, and having sexual relations with someone at high risk for HIV [17, 18]. Potential markers of sexual risk taking such as HIV or sexually transmitted disease diagnoses or pregnancy were excluded from this review’s definition of sexual risk behaviors since an individual can engage in sexual risk taking without becoming pregnant or acquiring HIV or a sexually transmitted disease. Search terms included in Table 1 were entered into the aforementioned three databases. Both the terms ‘‘neighborhood’’ and ‘‘community-level’’ were used in the search terms to aid in finding papers that included neighborhoodlevel factors while keeping the number of articles returned to a manageable level. As shown in Fig. 1, the search yielded 4984 articles. After duplicates were deleted, 3331 articles remained. The titles of the 3331 remaining articles were searched and from those, 329 were retained. The

AIDS Behav Table 1 Search terms entered into PubMed, Web of Science, and Google Scholar databases Database

Type of search

Search

PubMed

All fieldsa

Neighborhood AND women AND HIV AND risk AND behavior

PubMed

All fieldsa

Neighborhood AND female AND HIV AND risk AND behavior

PubMed

All fieldsa

Community-level AND women AND HIV AND risk AND behavior

PubMed

All fields

a

PubMed

All fieldsa,b

Neighborhood AND women AND AIDS [sb] AND risk AND behavior

PubMed

All fieldsa,b

Neighborhood AND female AND AIDS [sb] AND risk AND behavior

PubMed

All fieldsa,b

Community-level AND women AND AIDS [sb] AND risk AND behavior

PubMed

All fieldsa,b

Community-level AND female AND AIDS [sb] AND risk AND behavior

PubMed

Title/abstractc

PubMed

Title/abstract

c

PubMed PubMed

Title/abstractc Title/abstractc

Neighborhood AND women AND sexual Neighborhood AND women AND sex

PubMed

Title/abstractc

Neighborhood AND women AND condom

PubMed

Title/abstractc

Neighborhood AND female AND HIV AND risk

PubMed

Title/abstract

c

PubMed

Title/abstractc

Neighborhood AND female AND sexual

PubMed

Title/abstractc

Neighborhood AND female AND sex

PubMed

Title/abstractc

Neighborhood AND female AND condom

PubMed

Title/abstractc

Community-level AND women AND HIV AND risk

PubMed

Title/abstract

c

PubMed

Title/abstractc

Community-level AND women AND sexual

PubMed

Title/abstractc

Community-level AND women AND sex

PubMed

Title/abstractc

Community-level AND women AND condom

PubMed

Title/abstractc

Community-level AND female AND HIV AND risk

PubMed

Title/abstractc

Community-level AND female AND HIV AND behavior

PubMed

Title/abstract

c

PubMed PubMed

Title/abstractc Title/abstractc

Community-level AND female AND sex Community-level AND female AND condom

Web of Science

Topicd

Neighborhood HIV

Web of Science

Topicd

Community-level HIV

e

Google Scholar

Title

Google Scholar

Titlee

a

Community-level AND female AND HIV AND risk AND behavior

Neighborhood AND women AND HIV AND risk Neighborhood AND women AND HIV AND behavior

Neighborhood AND female AND HIV AND behavior

Community-level AND women AND HIV AND behavior

Community-level AND female AND sexual

Neighborhood HIV Community-level HIV

Searches all the fields that PubMed allows—title, abstract, author, text word, etc

b

AIDS Subset Strategy last modified in February 2016

c

Searches for text in the title, abstract, collection title, other abstract, and keywords of citations

d

Searches within the title, abstract, author keywords, and Keywords Plus

e

Searches only in the title field

abstracts of these 329 papers were reviewed. This review of abstracts yielded 98 relevant articles for full-text review. Of the 98 articles, 4 were selected after full-text review as meeting the inclusion criteria for summarizing study findings. Two additional articles were identified for inclusion and summary from full-text review of relevant articles encountered during hand searches of the references of the 98 abovementioned articles ascertained from the three databases and the references of the 4 aforementioned review

papers. Furthermore, 1 additional article was identified for inclusion and summary from a full-text review of this 1 additional article that was found during hand searches of the references of the 2 articles that were identified for inclusion and summary in the reference section of other articles. Therefore, in total 7 articles are summarized in this systematic review. Given that drug use may serve as an important intermediate between neighborhoods and sexual risk behaviors for HIV infection [19] and in turn potentially

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Eligibility

Screening

Identification

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Articles identified through database search n = 4,984

Articles after duplicates removed

Articles excluded based on title

n = 3,331

n = 3,002

Article abstracts examined

Articles excluded based on abstract

n = 329

n = 231

Full-text articles examined

Full-text articles excluded for not meeting inclusion criteria

n = 98

n = 94

Inclusion

Articles summarized in review based on searching the three databases n=4

Articles summarized in systematic review

Additional articles meeting inclusion criteria based on full-text examination that were identified from hand searches of reference sections of database identified articles, review papers, and non-database identified articles

n=7

n=3

Fig. 1 Flow diagram depicting process used to select articles for summary in systematic review

alter the impact of neighborhood environment [20, 21], studies are summarized by drug use in the study population.

Results Of the 7 summarized studies, 1 study, which is included in Table 2, examined the relationship between neighborhood-level factors and sexual risk behavior among a

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sample that potentially included adult U.S. women who either did not have a recent history of drug use or had a recent history of drug use solely via non-injecting routes. The other six studies, which are included in Table 3, examined the aforementioned relationship among a sample that potentially included adult U.S. women who either did not have a recent history of drug use or had a recent history of drug use via non-injecting and/or injecting routes.

AIDS Behav Table 2 Summary of quantitative studies published between 1 January 1980 and 31 December 2016 that examined the relationship between neighborhood environments and sexual risk behaviors for

HIV infection among a sample of adult U.S. women who potentially either did not have a recent history of drug use or had a recent history of drug use solely via non-injecting routes

Authors

Publication year

Study design and population

Neighborhood variable(s)

Outcome variable(s)

Main findings

Rudolph et al. [16]

2013

Cross-sectional study

Perceived neighborhood disorder

Exchange sex

Perceived neighborhood disorder was not significantly associated with exchange sex in adjusted analyses

Predominately African American women in Baltimore, Maryland ages 18–55 who had not injected drugs in the past 6 months, who had engaged in heterosexual sex in the past 6 months, and who had at least one specified sexual risk factor occur in the recent past (n = 417)

Studies Among a Sample That Potentially Included Adult U.S. Women Who Either Did Not Have a Recent History of Drug Use or Had a Recent History of Drug Use via Solely Non-injecting Routes The sole study that examined the link between neighborhood-level factors and sexual risk behaviors among a sample that potentially included adult U.S. women who either did not have a recent history of drug use or had a recent history of drug use solely via non-injecting routes was a cross-sectional study by Rudolph et al. [16]. Specifically, this study was conducted among predominately AA women in Baltimore, Maryland, ages 18–55 years old who had not injected drugs in the past 6 months, who had heterosexual sex in the past 6 months, and who had at least one specified sexual risk factor occur in the recent past. The authors did not find a statistically significant association between perceived neighborhood disorder and exchanging sex in their adjusted analyses. However, participants reporting higher perceived neighborhood disorder did more frequently report exchanging sex. Perceived neighborhood disorder was captured using a 10-item scale [22]. The scale asked participants about their perceptions of ‘‘vandalism, vacant housing, people who don’t keep up their property or yards, people who say insulting things or bother other people when they walk down the street, litter/trash in the streets, groups of teenagers hanging out on the street, people fighting and arguing, burglary, people selling drugs, or people getting robbed or beaten up on the street’’ on their block. Exchanging sex was captured by asking participants about how many people they had sex with in the last 90 days in exchange for food, drugs, money, or shelter. A main limitation of the Rudolph et al. [16] study was the cross-sectional design. Furthermore, adjustment for individual-level and network factors when examining the

relationship between perceived neighborhood disorder and exchange sex in the authors analyses may in part explain the absence of an observed significant association by removing indirect effects of interest. Such removal would occur if individual-level and network factors serve as mediators between neighborhood disorder and exchange sex. If individual-level and network factors do in fact serve as mediators, then controlling for them may also introduce selection bias [23]. Studies Among a Sample That Potentially Included Adult U.S. Women Who Either Did Not Have a Recent History of Drug Use or Had a Recent History of Drug Use via Non-injecting and/ or Injecting Routes The six studies that examined the link between neighborhood-level factors and sexual risk behaviors among a sample that potentially included adult U.S. women who either did not have a recent history of drug use or had a recent history of drug use via non-injecting and/or injecting routes included cross-sectional work by Forney et al. [24]. This work was conducted with adult women in inner city Miami and in rural areas of Georgia. These women were presently regular users of crack cocaine and in the month before study recruitment had exchanged sex for money to purchase crack cocaine or exchanged sex for crack cocaine. Based on unadjusted analyses, urban (Miami) and rural (Georgia) women had similar ages of sexual debut as well as when they first started to exchange sex for money or drugs. Urban and rural women were also similar on the frequency of time spent engaging in prostitution, the type of sex that they engaged in, and the extent to which they relied on sex to obtain crack cocaine in the prior 30 days. However, urban women did have a greater proportion of male sex partners and a smaller proportion of female sex partners than rural women. A greater proportion of rural

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AIDS Behav Table 3 Summary of quantitative studies published between 1 January 1980 and 31 December 2016 that examined the relationship between neighborhood environments and sexual risk behaviors for Authors

Publication year

Forney et al. [24]

1992

Collins et al. [25]

2005

Latkin et al. [19]

2007

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HIV infection among a sample of adult U.S. women who potentially either did not have a recent history of drug use or had a recent history of drug use via non-injecting and/or injecting routes

Study design and population

Neighborhood variable(s)

Outcome variable(s)

Main findings

Cross-sectional study

Rural or urban residence

Sexual behavior

Based on unadjusted analyses, urban (Miami) and rural (Georgia) women had similar ages of sexual debut as well as when they first started to exchange sex for money or drugs. Urban women did have a greater proportion of male sex partners and a smaller proportion of female sex partners than rural women. A greater proportion of rural women relied on sex to obtain crack cocaine, while urban women spent more time engaging in prostitution. Furthermore, urban women had significantly more sexual partners than rural women

Victimization due to crime

Number of sexual partners, inconsistent condom use, and high risk sex

In multivariable analyses, among single females, higher levels of victimization due to crime was significantly positively associated with a greater number of sexual partners and likelihood of high risk sex, but not significantly associated with inconsistent condom use. Among partnered females, higher levels of victimization due to crime was significantly positively associated with a greater likelihood of high risk sex, but not significantly associated with inconsistent condom use

Perceived neighborhood disorder

Multiple sexual partners, exchanging sex, and sexual partners who inject drugs or smoke crack cocaine

Based on structural equation modeling, for women, perceived neighborhood disorder was significantly associated with selling sex to receive drugs or money, but not significantly associated with having multiple sexual partners or sexual partners who inject drugs or smoke crack cocaine

Adult women in inner city Miami and in rural areas of Georgia who were presently regular users of crack cocaine and in the month before study recruitment had exchanged sex for money to purchase crack or exchanged sex for crack (n = 60)

Cross-sectional study Sexually active young adults (n = 1626 females and 1275 males)

Cross-sectional study Predominately African Americans in Baltimore who were at least 18 years old and recruited as part of an HIV prevention study with drug users (n = 344 females and 494 males)

AIDS Behav Table 3 continued Authors

Publication year

Bobashev et al. [29]

2009

Walsh et al. [27]

2012

Ramaswamy and Kelly [31]

2015

Study design and population

Neighborhood variable(s)

Outcome variable(s)

Main findings

Cross-sectional study

Perceived neighborhood disorder, perceived neighborhood violence

Transactional sex (i.e., purchasing and selling sex)

For women, higher perceived neighborhood violence was significantly positively associated with purchasing sex and not significantly associated with selling sex in adjusted regression analyses. For women, higher perceived neighborhood disorder was not significantly associated with selling or purchasing sex in adjusted regression analyses

Exposure to community violence

Number of sexual partners, number of sexual acts without a condom, frequency of alcohol or drug use before sex, and engaging in sex work

Based on adjusted analyses, experiencing relatively high levels of community violence was not significantly associated with number of sexual acts without a condom, but was significantly positively associated with a greater number of lifetime sexual partners, not using condoms, alcohol use before sex, drug use before sex, and engagement in sex work

Neighborhood violence, perceived neighborhood social capital and trust, neighborhood incarceration density

Trading sex for drugs, money, or necessities

Adjusted analyses indicated that women who lived in neighborhoods with a higher density of incarceration were significantly more likely to have a history of trading sex for drugs, money, or necessities, however neighborhood social capital, neighborhood violence, and trust in institutions were not significantly associated with trading sex

Men who have sex with men, injection drug users, non-injection drug users, and their sexual partners in four counties in North Carolina (n = 677 females, 1043 males)

Cross-sectional study Women attending an urban publicly funded sexually transmitted disease clinic who engaged in sexual activity in the past 3 months (n = 481)

Cross-sectional study Women in 3 urban jails in Kansas City (n = 290)

women relied on sex to obtain crack cocaine, while urban women spent more time engaging in prostitution. Furthermore, urban women had significantly more sexual partners than rural women in the prior 30 days. Limitations of the study by Forney et al. [24] include the small sample size and cross-sectional design. Furthermore, there was a lack of detailed characterization of the aspect of the rural versus urban environments that may have contributed to the observed study findings. In addition, there was no control for any potential confounding factors.

Another cross-sectional study was conducted by Collins et al. [25] in sexually active young adults. In multivariable analyses, this study found that among single females, higher levels of victimization in the past 3 years stemming from crime was not significantly associated with inconsistent condom use. However, a higher level of victimization was significantly positively associated with a greater number of sexual partners and likelihood of high risk sex in the last year. Similar results were observed for single males.

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Results among partnered females indicated that a higher level of victimization in the past 3 years stemming from crime was not significantly associated with inconsistent condom use. However, a higher level of victimization was significantly positively associated with a greater likelihood of high risk sex in the last year. Similar results were observed for partnered males. Victimization stemming from crime captured sexual victimization, physical assault victimization, and theft victimization. Reports of not consistently using condoms and having multiple sexual partners were considered high risk sex. A main limitation of the work by Collins et al. [25] is the cross-sectional study design. Another limitation is that although the authors state that their victimization from crime measure may be a marker of ‘‘a generally dangerous life-environment’’, the employed victimization measure may not strictly include sources of victimization that occur beyond a participant’s home like related violence measures [26, 27]. Regardless, the authors hypothesize that the observed relationships between their victimization measure and engaging in sexual risk behavior may potentially be due to inadequate opportunities and stress stemming from exposure to more dangerous environments. A cross-sectional study by Latkin et al. [19] was conducted with predominately African Americans in Baltimore, Maryland who were at least 18 years old and recruited as part of an HIV prevention study with drug users. Among women, this study found based on structural equation modeling that perceived neighborhood disorder was significantly associated with selling sex to receive drugs or money in the prior 90 days. Other examined sexual risk behaviors including having multiple sexual partners as well as sexual partners who inject drugs or smoke crack cocaine in the prior 90 days were not significantly associated with perceived neighborhood disorder. Similar results were observed among men concerning exchanging sex and multiple sexual partners, where perceived neighborhood disorder was significantly associated with purchasing sex with drugs or money, but not significantly associated with having multiple sexual partners in the prior 90 days. However, in contrast to women, for men, perceived neighborhood disorder was significantly associated with having sexual partners who inject drugs or smoke crack cocaine in the prior 90 days. The Perkins and Taylor’s Block Environmental Inventory [28] was used to measure perceived neighborhood disorder. The Inventory assessed the degree to which ‘‘vandalism, litter or trash in the streets, vacant housing, groups of teenagers hanging out on the street, burglary, people selling drugs, and people getting robbed’’ was a problem on a participant’s block. The authors assert that perceived neighborhood disorder may act as a stressor. They provide evidence through additional analyses that the observed significant association

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between perceived neighborhood disorder and selling sex to receive drugs or money among women may be operating through psychological distress and drug use (i.e., injection drug use and crack cocaine use). However, a main limitation of the work by Latkin et al. [19] is the cross-sectional study design. Another limitation is the absence of control for any potential confounders during analyses as well as the potential for there to be bias due to measurement error because of the use of self-reported data. Bobashev et al. [29] conducted a cross-sectional study among men who have sex with men, injection drug users, non-injection drug users, and their sexual partners in four counties in North Carolina. In unadjusted logistic regression models, this study showed that for women, higher perceived neighborhood disorder and higher perceived neighborhood violence were significantly positively associated with selling and purchasing sex in the prior 6 months. However, after regression adjustment for several factors (e.g., demographics, alcohol and drug use, sexual history), the aforementioned relationships were no longer significant with the exception of perceived neighborhood violence and purchasing sex, which retained a significant positive association. Similar results were observed for men in analyses involving unadjusted and adjusted logistic regression. However, higher perceived neighborhood violence remained positively and significantly associated with selling sex in the prior 6 months in the adjusted logistic regression model. Furthermore, higher perceived neighborhood disorder remained positively and significantly associated with purchasing sex in the prior 6 months in the adjusted logistic regression model. Perceived neighborhood violence and perceived neighborhood disorder were captured using the Exposure to Violence subscale and Neighborhood Disorder subscale, respectively, of the City Stress Inventory [30]. To measure whether a participant purchased sex, the following question was asked regarding each of up to 6 recent sex partners: ‘‘In the past 6 months, did you give ____ drugs, money, or other goods in exchange for sex?’’. To measure whether a participant sold sex, the following question was asked regarding each of up to 6 recent sex partners: In the past 6 months, did you receive drugs, money, or other goods from ___ in exchange for sex?’’ A limitation of the work by Bobashev et al. [29] is the cross-sectional study design. Furthermore, the potential for there to be bias due measurement error because of the use of self-reported data exists. Lastly, in adjusted regression analyses the authors control for potential mediators which may remove indirect effects of interest or introduce selection bias [23]. Other cross-sectional research by Walsh et al. [27] was conducted among women attending an urban publicly

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funded sexually transmitted disease clinic who engaged in sexual activity in the past 3 months. Based on adjusted analyses, this research showed that experiencing a relatively high level of community violence was significantly positively associated with engaging in sexual risk taking behaviors (i.e., more lifetime number of sexual partners, not using condoms, alcohol use before sex, drug use before sex, and engagement in sex work). The authors measured exposure to community violence using five items in the Exposure to Violence subscale of the City Stress Inventory [30] which captured how frequently a given participant was exposed to violence against another person in their neighborhood. Sexual risk behaviors were ascertained by asking participants about their lifetime and recent (i.e., past 3 months) number of sexual partners, the number of sexual acts in the past 3 months without a condom, whether they used alcohol or drugs before sex in the past 3 months, and whether they ever engaged in sex work (i.e., ‘‘engaged in sex to get money, drugs, food, or a place to stay’’). The authors hypothesized that stress, psychological distress, perceived safety/security, as well as neighborhood norms may underlie the observed positive relationship between exposure to community violence and sexual risk taking. However, a main limitation of the work by Walsh et al. [27] was that some of the sexual risk measures may have captured behaviors that occurred temporally prior to exposure to community violence. Furthermore, the community violence measure solely focused on witnessing violence and not being a victim of violence. Adjusted results based on recent cross-sectional work by Ramaswamy and Kelly [31] found that among women incarcerated in 3 urban jails in Kansas City, women who lived in neighborhoods with a higher density of incarceration prior to their incarceration were significantly more likely to report a history of trading sex for drugs, money, or other necessities. Women reporting higher perceived neighborhood social capital, greater perceived neighborhood violence, victimization by neighborhood violence, and greater level of trust in institutions were more likely to report trading sex; however the aforementioned latter relationships were not significant. Neighborhood density of incarceration was captured based on the zip codes of where participants lived just prior to their incarceration. Two measures were used to capture neighborhood violence. The first measure captured perceived neighborhood violence by asking participants about the level of violence in their neighborhood during the 6 months before their incarceration, specifically asking ‘‘if participants had heard about a fight in which a weapon was used, a violent argument between neighbors or friends, a gang fight, a robbery or mugging, or a murder.’’ The second measure captured victimization by neighborhood violence by asking participants about

whether they had been victimized by the violence in the neighborhood they lived in prior to incarceration, specifically asking ‘‘did anyone ever use violence, such as a fight (hitting, pushing, and shoving), against you or any member of your family?’’ Two measures were used to capture perceived neighborhood social capital and trust. The first was a 10-item measure of perceived neighborhood social capital that ‘‘asked participants about their level of trust in neighbors, the feeling that neighbors would help them, that the neighborhood had prospered, and an overall assessment of neighborhood safety.’’ The second measure assessed participants trust in institutions by asking ‘‘how much confidence participants had in the legal system, the police, and the government?’’ A main limitation of the work by Ramaswamy and Kelly [31] was the cross-sectional design of the study. Furthermore, the study had a small sample size. Lastly, the results from this work may not generalize to non-incarcerated populations.

Discussion/Conclusions A primary objective of this systematic review was to summarize the quantitative literature that examined the relationship between neighborhood environments and sexual risk behaviors for HIV infection among adult U.S. women. Only 7 studies were identified and summarized as part of this systematic review which indicates that more studies are needed to thoroughly characterize the relationship between neighborhood-level factors and sexual risk behaviors for HIV infection among adult U.S. women. Of the studies that were identified and summarized, the findings were mixed. In some studies, neighborhood-level factors such as neighborhood disorder [19], urban versus rural residence [24], neighborhood/community violence [27, 29], neighborhood incarceration density [31], and victimization due to crime [25] were significantly associated with at least one examined sexual risk behavior for HIV infection. However, in other studies neighborhood disorder [16, 29], neighborhood social capital [31], neighborhood violence [31], and trust in institutions [31] were not significantly associated with sexual risk behaviors for HIV infection. Among the studies that yielded significant associations [19, 24, 25, 27, 29, 31], findings indicated that more adverse neighborhood environments (e.g., greater disorder and greater violence) were associated with a higher likelihood of engaging in sexual risk behaviors for HIV infection. Similar to the Latkin et al. [3] review, the authors assert that the significant observed relationships may be operating through pathways involving psychological

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distress, stress, drug use, perceived safety/security, and neighborhood norms. Consistent with the stress-coping model [32] discussed in recent work by Senn et al. [33] and supported by the earlier mentioned work by Latkin et al. [3, 19] adverse neighborhood conditions may specifically act as a stressor resulting in fear as well as poorer mental health (e.g., psychological distress and depression). Drug use and risky sexual behaviors can in turn occur as a means of coping [34]. Based on the ‘‘broken windows’’ theory [35], adverse neighborhood conditions such as physical disorder may also normalize sexual risk taking within a neighborhood and in turn contribute to women in more adverse neighborhood environments being more likely to engage in sexual risk behaviors [33]. Despite the aforementioned potential explanations for the observed significant results, inference was limited in all studies demonstrating significant associations because of either the cross-sectional study design [19, 24, 25, 27, 29, 31], use of self-reported measures [19, 24, 25, 27, 29, 31], a small sample size [19, 24, 27, 31], removal of indirect effects of interest [29] or potential for confounding [19, 24] or selection [29] bias. The studies that did not show significant evidence for an association may similarly have been limited by the cross-sectional design [16, 29, 31], small sample size [16, 31], use of self-reported measures [16, 29, 31], removal of indirect effects of interest [16, 29], or selection bias [16, 29]. Another source of the mixed results beyond the above listed potential sources of systematic and random error includes differences in the employed study design such as the specific neighborhoodlevel exposure(s) examined, outcomes, measures, and study populations. When studies were considered by the drug use status of the women included in the study population, perceived neighborhood disorder was not significantly associated with exchange sex among a sample of women who either potentially did not have a recent history of drug use or had a recent history of drug use solely via non-injecting routes [16]. Among women who either potentially did not have a recent history of drug use or who had a recent history of drug use via non-injecting and/or injecting routes, perceived neighborhood disorder was significantly associated with exchange sex in one study [19] and not associated with exchange sex in another study [29]. The above-described differing results may be because the significant study did not adjust for other factors, while the non-significant studies did. Regardless, too few relevant studies with well-characterized study populations regarding drug use have been conducted, including studies among women without a recent or long-term history of drug use, to appropriately assess the impact of drug use on the relationship between neighborhood-level factors and engaging in sexual risk behaviors.

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Important to also note is that in summarized studies that included both men and women [19, 25, 29], inference was frequently the same for both genders in terms of at least one neighborhood-level factor being significantly related to at least one examined sexual risk behavior. However, the types of sexual risk behaviors that are influenced by neighborhood-level factors as well as associated mechanisms including the relevant aspect of the neighborhood environment may differ by gender because of societal norms as well as differences in responses to stressors including coping strategies [4, 29, 33]. Identifying gender differences in the sexual risk behaviors that are influenced by neighborhood-level factors and mechanisms is important because such differences will likely affect the targets that are selected for intervention as well as the outcomes that are used to evaluate implemented interventions among women versus men. For instance, recent work by Senn et al. [33] indicated that even though mental health may serve as a mediator between adverse neighborhood environments and sexual risk behaviors, poor mental health stemming from exposure to adverse neighborhood conditions may increase the likelihood of engaging in sexual risk behavior for women, but lower the likelihood among men due to gender differences in response to poorer mental health. If poorer mental health in fact only increases the occurrence of sexual risk behaviors among women, then targeted mental health interventions aimed at lowering sexual risk taking may only be appropriate for women while interventions targeted at other intermediates such as drug use may be more important for men. Similarly, as mentioned by Bobashev et al. [29], women are more likely to sell sex while men are more likely to purchase sex, again perhaps stemming from societal gender norms [4]. Therefore selling sex may be a more relevant outcome to examine among women in evaluation studies. Unfortunately, to date few relevant studies have been conducted among women to adequately identify gender differences in sexual behaviors that are influenced by neighborhood-level factors and mechanisms and in turn better tailor interventions by gender if necessary. A limitation of this review was the summary of two studies [29, 31] that may have included women below our minimum age cutoff of 18 years old. In their study among women incarcerated in three urban jails in Kansas City, Ramaswamy and Kelly [31] do not specify a minimum age as part of their inclusion criteria or in their summary of study findings. However, to include as many relevant studies as possible in this review, we assumed that all women included in this study were at least 18 years old. The fact that the mean (standard deviation) age of study participants was 33.9 (9.8) years and the authors at no point in the article refer to any of the three jails where

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participants were enrolled from as a juvenile detention center or an equivalent supports this assumption. Similarly, in the study by Bobashev et al. [29] among men who have sex with men, injection drug users, noninjection drug users, and their sexual partners, initially enrolled participants were males who were at least 18 years old. However, the authors do not appear to specify a minimum age requirement for the sexual partners of the initially enrolled participants who were also included in the study sample. The aforementioned means that some of the female sexual partners in the study population may have been below 18 years old. Although the authors report that more than half of the women in their study were at least 35 years old, they do not provide a minimum age for these women. Despite the limitations of this systematic review, the results of this review indicate that to aid in pinpointing the most appropriate theoretical framework for how neighborhood-level factors may influence engaging in sexual risk behaviors among adult U.S. women, future studies should examine neighborhood effects among adult U.S. women based on longitudinal rather than cross-sectional study designs with larger sample sizes. Such longitudinal studies should control for potential sources of confounding and selection bias while paying close attention to the temporal orderings of measures during data collection and analysis to minimize the likelihood of inappropriately adjusting for covariates on causal pathways of interest and in turn introducing selection bias or removing effects of interest. To have sufficient evidence to assess the impact of drug use on the relationship between neighborhood-level factors and engaging in sexual risk behaviors among adult U.S. women, additional studies need to be conducted among drug using and non-drug using women where drug use history is well characterized in terms of type and route of use, when relevant. So that results are as comparable as possible across studies, future studies should also aim to use reliable and valid measures of the neighborhood environment and sexual risk behaviors that have been used in prior relevant studies. The majority of measures of the neighborhood environment that were used in the studies summarized in this review were self-reported measures. While self-reported measures may be ideal for capturing perceptions of the neighborhood environment, such measures may not accurately characterize physical aspects of the environment (e.g., physical resources). The accuracy of self-reported measures of the physical neighborhood environment may potentially be enhanced by capturing the neighborhood environment for a given study participant based on the reports of several study participants [36]. Combining the self-reports of study participants with physical observations of a given neighborhood

environment by researchers or assessing the neighborhood environment based on data available through government (e.g., U.S. Census Bureau) or other (e.g., ReferenceUSA [Infogroup, Inc.]) sources may also promote more accurate measurement of the physical neighborhood environment [3]. However, neighborhood audits by researchers may be too cumbersome or expensive [3, 24] and defining neighborhoods based on administrative boundaries (e.g., census tracts) provided by government or other sources of data that are meaningful to study participants may be difficult [37, 38]. For example, when using administrative boundaries to define neighborhoods, census tracts or block-groups have historically been preferred over using zip codes because census tracts and block-groups better capture homogenous populations in terms of economic, social, and demographic factors than zip codes [37, 38]. However, using census tracts or block-groups requires obtaining detailed residential address information from study participants which may be difficult in less stable populations such as drug users or women engaging in sex work who may also be homeless [39]. Therefore, theory, prior work, available resources and information, as well as the population under study should guide the selection of the specific neighborhood measures that are used in future studies. Given the few relevant studies that have been conducted among women, additional studies should be conducted among women or assess effect measure modification by gender when the study population includes both men and women. Even when an analysis indicates no statistically significant difference between men and women based on p-values, gender specific point estimates and confidence intervals should still be reported in the event that the study is not adequately powered to detect effect measure modification. Studies should also report the minimum and maximum ages of their study participants, rather than solely the median or mean age or another summary statistic so that readers/consumers of the published literature can accurately characterize to whom study findings apply. Because only one of the summarized studies examined the relationship between neighborhood-level factors and sexual partner characteristics (e.g., behaviors) [19], more quantitative studies looking at the aforementioned relationship are needed. Studying the relationship between neighborhood-level factors and sexual partner characteristics is important given that for some women their sexual partner’s behavior may be one of their main risk factors for HIV infection [18, 40, 41]. Lastly, once associations between neighborhood-level factors and risk behaviors for HIV infection have been established based on longitudinal data, additional longitudinal studies aimed at identifying potentially modifiable intermediates should be conducted

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to supplement/inform interventions on the neighborhood environment. Compliance with Ethical Standards Conflicts of interest The authors declare that they have no conflicts of interest. Human and Animal Rights This article does not contain any studies with human participants or animals performed by any of the authors.

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