The United States will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.
—President Barack Obama, July 13, 2010INTRODUCTION
In July 2010, President Barack Obama unveiled a National HIV/AIDS Strategy for the United States, acknowledging in the above statement that social status shapes one's risk of infection, the experience of living with HIV/AIDS, and the epidemic's impact on particular communities. The Centers for Disease Control (CDC) (2009) report that Blacks, representing approximately 12% of the U.S. population, account for almost half (46%) of people in the United States living with HIV, as well as nearly half (45%) of new infections each year. In 2004, HIV infection was the leading cause of death among Black women aged twenty-five to thirty-four, and the third leading cause of death among Black women aged thirty-five to forty-four.Footnote 2
The relationship between HIV, poverty, and geography has been extensively documented (Auerbach Reference Auerbach2009). The CDC (2010) has suggested that 2.1% of heterosexuals living in high-poverty urban areas in the United States are infected with HIV, a rate well above the 1% that designates a generalized epidemic. Although gay and bisexual men continue to represent the majority of new infections, the CDC identifies poverty as “the single most important demographic factor associated with HIV infection among inner-city heterosexuals” (CDC 2010, p. 1). As such, the AIDS epidemic in poor Black urban neighborhoods marks a deadly convergence of race, poverty, and place that exposes residents to “limited health care access, which can reduce utilization of HIV testing and prevention services; substance abuse, which can increase sexual risk behavior; and high rates of incarceration, which can disrupt the stability of relationships” (CDC 2010, p. 2).Footnote 3
We contend that, given the social complexity of the AIDS epidemic in poor Black urban communities, scholars and policymakers must consider neighborhood context to address high infection rates by acknowledging the institutional resources and deficits of these areas. Institutions serve as buffers against (or facilitators of) such macrostructural forces as poverty, racism, sexism, and homophobia that affect HIV transmission. Neighborhood institutional resource theory suggests that community organizations are key sites for translating individual attitudes, strategies, and behaviors into neighborhood-level resources and opportunities through organizational networks, specialized knowledge, and ability to bundle resources (Jencks and Mayer, Reference Jencks, Mayer, Lynn and McGeary1990; Small Reference Small2009). AIDS service and advocacy organizations, as well as medical providers offering HIV/AIDS prevention and treatment services, are the most engaged and effective institutions operating in communities. Less conventional settings such as churches, salons and barbershops, and, in some cases, prisons, have also been constructively deployed in HIV prevention and treatment efforts (Grinstead et al., Reference Grinstead, Zack and Faigeles2001; Linnan and Ferguson, Reference Linnan and Ferguson2007; Watkins-Hayes et al., Reference Watkins-Hayes, Pittman and Beaman2011).
While acknowledging that such institutions have facilitated important HIV/AIDS responses, our task is to identify new venues that might reach even more inner-city residents. Inspired by the film, we examine mental health services to address childhood sexual trauma; HIV-related health messaging and services within non-medical human service bureaucracies that work closely with poor and minority residents; and opportunities for grocery stores, restaurants, and homes in poor communities to assist in the provision and preparation of disease-fighting food. These environments represent potential new organizational frontiers for neighborhood-based HIV/AIDS intervention.
WHY PRECIOUS? DIFFICULT DIALOGUES, NEIGHBORHOOD RISK, AND HIV
Precious depicts the educational, economic, and familial experiences of a low-income African American teen living in Harlem in the 1980s. The main character, Precious, is sexually and verbally abused by her mother, struggles with illiteracy, and is ostracized due to her physical appearance. She is sexually abused by her father, impregnated twice, and learns late in the film that he infected both her and her mother with HIV. The narrative arc of the film traces Precious's experience at an alternative school where she learns to read, gains self-esteem, and joins a community of young women that offers her social support as she prepares to give birth to her second child.
Before analyzing the lessons offered by the film, we pause to acknowledge its very mixed and emotionally fraught reception. While many mainstream White critics lauded the film and its actors, Mo'Nique and Gabourey Sidibe, Black audiences were split. In spite of the legitimacy that executive producers and media moguls Oprah Winfrey and Tyler Perry granted the film, several Black opinion leaders criticized the film's negative images of Black life on screen, citing Hollywood's seemingly insatiable appetite for stories emphasizing shameful behavior amongst Black characters while overlooking internalized, interpersonal, and institutionalized racism and economic exclusion as contributors to the hardship experienced by Blacks.Footnote 4
Scholars of social inequality must engage these representations in order to problematize simplistic constructions of urban life, poverty, and racial stratification, and draw attention to the resources and needs of these communities.Footnote 5 The film's social significance and widespread popular and critical reception cannot be ignored. Through dramatic presentations—external representations of internal reflections and emotions—viewers embrace ideas and realities presented in holistic (cognitive, affective, aesthetic, and moral) and lasting ways (Freeman et al., Reference Freeman, Sullivan and Fulton2003). The story and images presented in the film Precious could, therefore, prove useful in suggesting new and creative directions in HIV/AIDS-related scholarship, policies, and programs.
So what makes Precious relevant to a discussion on HIV? Individual and family experiences within inner-city communities are notably diverse and are certainly not all identical to Precious's story. Ultimately, although few scenes focus on HIV, the film challenges us to ask important questions about the AIDS epidemic. By exploring how the main character navigates the kind of community that now represents a key site of HIV transmission among heterosexuals, we use the film as a lens through which to review the biomedical, epidemiological, and social scientific evidence pertaining to interaction between individual factors that increase women's personal risk and the spatially bound dynamics that drive the epidemic. Notably, the film's raw familial and individual dynamics take place in a neighborhood context in which there are various economic, social, and medical vulnerabilities.
The Neighborhood Context of Precious's World: How HIV/AIDS Has Become Spatially Situated
Scholars have increasingly emphasized neighborhood effects to generate and test hypotheses on the effects of community and individual factors on health outcomes (Cenè et al., Reference Cenè, Akers, Lloyd, Albritton, Hammond and Corbie-Smith2011; Massey Reference Massey2004; Arnold et al., Reference Arnold, Hsu, Pipkin, McFarland and Rutherford2009).Footnote 6 We use the film Precious to show how institutions can act as mediators to these processes. To be sure, as Paula Treichler (Reference Treichler1999) and others have noted, the risks of HIV are associated with behavior rather than demographic characteristics or places of residence. However, in the film, Precious navigates at least three community-level conditions that, when experienced by a multitude of people living in the same area, lead to a collective vulnerability that challenges residents' abilities to protect themselves from HIV infection.
First, social policies of the 1980s, and, more recently, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, have gradually eroded welfare state resources, increasing psychological and economic vulnerability among poor families (Bok and Simmons, Reference Bok and Simmons2002). Simultaneously, widespread economic disinvestment from inner-city communities has limited the availability of capital and jobs (Wilson Reference Wilson1987),Footnote 7 creating a class of chronically unemployed and underemployed workers with few opportunities for economic mobility. Second, HIV/AIDS in these communities received scant attention from community leaders, politicians, and public health officials in the early stages of the epidemic (Cohen Reference Cohen1999). Third, the infiltration of crack cocaine and the targeted marketing of legal and illegal substances in communities like Precious's are associated with highly risky sexual and drug-related behaviors (Forbes Reference Forbes1993; Fullilove et al., Reference Fullilove, Golden, Fullilove, Lennon, Porterfield, Schwarcz and Bolan1993). The accompanying physical stress and health neglect that afflict many remaining residents are associated with heightened HIV risk (Berger Reference Berger2004).
Several scholars have also highlighted the long-term health consequences of the mass incarceration of Black women and men (Freudenberg and Ramaswamy, Reference Freudenberg, Ramaswamy, Braithwaite, Taylor and Treadwell2009). As Adimora and Schoenbach (Reference Adimora and Schoenbach2005) observe: “The partner entering prison is now at risk of forming new (sometimes coercive) sexual connections with a pool of individuals among whom the prevalence of high-risk behaviors, HIV infection, and other STIs are high…. The partner who remains behind in the community forfeits the social and sexual companionship of the incarcerated partner and may pursue other partnerships to satisfy those needs” (p. S119; also see Kim et al., Reference Kim, Page-Shafer, Ruiz, Reyes, Delgado, Klausner, Molitor, Katz and McFarland2002). In sum, fewer economic opportunities and state services, a laggard response to the epidemic, and the simultaneous expansion of the drug epidemic and incarceration rates, have had lasting effects on the health and quality of life of poor families within inner-city communities, increasingly concentrating the AIDS epidemic within spatially bound parameters.
Gender also clearly affects how neighborhood conditions impact HIV infection rates (Berger Reference Berger2004).Footnote 8 From 1981 to 1995, Black women accounted for 15% of new HIV cases, a figure that almost doubled, to 27%, from 2001–2004 (Hodder et al., Reference Hodder, Justman, Haley, Adimora, Fogel, Golin, O'Leary, Soto-Torres, Wingood and El-Sadr2010). Black women represent 14% of the female population, yet they currently account for two-thirds of new infections among women. Young poor Black women are particularly vulnerable to HIV infection because of their increased exposure to community, sexual, and economic violence (Gilbert and Wright, Reference Gilbert and Wright2003; Hammonds Reference Hammonds, Bobo, Hudley and Michel2004; Kaplan Reference Kaplan1995; Voisin Reference Voisin2005; Wyatt et al., Reference Wyatt, Myers, Williams, Kitchen, Loeb, Carmona, Wyatt, Chin and Presley2002). Women living in an impoverished social landscape are more likely to engage in a host of “survival-focused” behaviors: transactional sex for money, food, accommodations, protection, and other basic needs; sex for drugs; power-imbalanced relationships between younger women and older men; and other intimate partnerings that may reduce their abilities to protect themselves from infection (Farmer et al., Reference Farmer, Connors and Simmons1996; Parker et al., Reference Parker, Easton and Klein2000). Higher mortality and incarceration rates among Black males also determine the sex ratio in many Black communities, contributing to dense social-sexual networks within an economically and racially segregated context (Adimora and Schoenbach, Reference Adimora and Schoenbach2005; Wilson Reference Wilson1987). Particularly because of the relatively low rate of interracial dating among Black women, “the shortage of men places women at a disadvantage in negotiating and maintaining mutually monogamous relationships” (Adimora and Schoenbach, Reference Adimora and Schoenbach2005, p. S118). These economic, social, and sexual relationships often leave one partner in a position of power over another, limiting the less-powerful partner's ability to dictate the terms of the relationship regarding condom use, monogamy, and HIV testing. While these relationships are neither always heterosexual nor always organized around traditional gender roles, these dynamics are likely to leave women particularly vulnerable.
THE INSTITUTIONAL CONTEXT OF PRECIOUS'S WORLD: ORGANIZATIONS AS NEIGHBORHOOD RISK BUFFERS
Research suggests that residents of neighborhoods with abundant institutional resources are more likely to experience improved outcomes on a number of fronts (Jencks and Mayer, Reference Jencks, Mayer, Lynn and McGeary1990; Leventhal and Brooks-Gunn, Reference Leventhal and Brooks-Gunn2000; Small Reference Small2009). The institutional resources available to help Black women living in poor neighborhoods address what Deborah King (Reference King1988) terms “multiple jeopardy” are, therefore, likely to facilitate place-based HIV prevention and treatment efforts. We also posit that neighborhood institutions can help protect women even if their services are only indirectly rather than directly targeted toward HIV prevention and treatment. In what follows, we explore three domains in which it is possible to incorporate neighborhood-level HIV prevention and treatment efforts into existing organizational functions: (1) community mental health services that address traumatic life events such as childhood sexual abuse; (2) HIV-related health messaging and services within local street-level bureaucracies; and (3) food access and use issues within grocery stores, restaurants, and homes in poor communities.
Childhood Sexual Abuse and Community Mental Health
In Precious, mother and daughter harbor silence around the sexual, physical, and verbal abuse that Precious experiences at the hands of her parents. Dissociating herself from the violence, Precious constructs a fantasy world rife with celebrity, romance, and social possibilities. Being victimized at such a young age renders Precious powerless in deploying self-protective actions, thus reminding us that some have limited control over their exposure to HIV. To break this type of structured silence and mitigate its effects on mental and physical health, we seek institutional interventions that acknowledge childhood sexual victimization as a public health threat with implications for HIV/AIDS.
Retrospective studies using interview and public agency data suggest that neighborhood poverty is strongly correlated with reported child physical abuse and moderately correlated with reported child sexual abuse (Drake and Pandey, Reference Drake and Pandey1996).Footnote 9 Childhood sexual abuse has been linked to behaviors that put individuals at risk for HIV infection. In a study of mostly White gay men, Allers and Benjack (Reference Allers and Benjack1991) found that a majority of their HIV-positive participants experienced some type of sexual abuse during childhood. Cohen et al. (Reference Cohen, Deamant, Barkan, Richardson, Young, Holman, Anastos, Cohen and Melnick2000) suggest that childhood sexual abuse can be an entry point into a physical and sexual abuse continuum that places women at risk for HIV infection.Footnote 10 Teens who experience sexual abuse may be more likely to engage in risky behaviors such as substance abuse, multiple sex partners, or failure to self-protect, ultimately putting themselves at risk of contracting HIV/AIDS (Voisin Reference Voisin2005). Women who have been sexually abused as children may be more likely to experience nonconsensual sexual contact or find it more difficult to negotiate the parameters of safer sex. Wyatt et al. (Reference Wyatt, Myers, Williams, Kitchen, Loeb, Carmona, Wyatt, Chin and Presley2002) show how risky behaviors can become coping mechanisms for survivors of childhood sexual abuse, as survivors may use multiple sex partners or substance abuse as a form of self-medication.
Post-Traumatic Stress Disorder (PTSD) afflicts many people living with HIV/AIDS who suffered childhood sexual abuse or similarly traumatic events (Cohen et al., Reference Cohen, Alfonso, Hoffman, Milau and Carrera2001). PTSD has been found to alter the immune system, the main site of HIV attacks (Uddin et al., Reference Uddin, Aiello, Windman, Koenen, Pawelec, Santos, Goldmann and Galea2010). Both depression and low self-efficacy have been linked to increased symptomatic invasion in HIV-positive heterosexual women (Mosack et al., Reference Mosack, Weinhardt, Kelly, Gore-Felton, McAuliffe, Johnson, Remien, Rotheram-Borus, Ehrhardt, Chesney and Morin2009). The depression and memory loss commonly associated with PTSD have been found to deter some infected persons from seeking treatment or taking daily medications (Leserman et al., Reference Leserman, Whetten, Lowe, Stangl, Swartz and Thielman2005).
Given the relationship between neighborhood poverty, child sexual abuse, and HIV/AIDS, community health services represent a first line of defense by helping individuals cope with traumatic experiences that may lead to risky behaviors and encouraging infected people to seek treatment. Educating communities about childhood sexual abuse, providing mental health services to both the abused and abusers, and framing the eradication of childhood sexual abuse as an HIV/AIDS prevention strategy could vastly change the evolution of the AIDS epidemic.Footnote 11
Re-Imagining the Urban Street-Level Bureaucracy in the AIDS Era
Precious demonstrates the futility of compartmentalized institutional approaches to fighting the AIDS epidemic. Health organizations might lead the way, but they require a diverse network of community-based organizations to carry and reinforce their message. In this regard, street-level bureaucracies within poor Black urban neighborhoods, such as public aid offices, housing authorities, and schools, remain underutilized as potential facilitators of AIDS prevention and care. Interventions by street-level bureaucrats who routinely interact with community residents may challenge or reinforce how people understand and address personal and neighborhood-level risk.
The film illustrates how marginalized individuals interact with, receive messages from, and access resources from a variety of human service institutions or street-level bureaucracies. Precious's alternative school, for example, clearly serves as a safe space and has the potential to deepen its role as a conduit for the exchange of ideas and information about sex and health. Public aid offices have similar potential, exemplified in Precious when routine inquiries by a welfare caseworker about Precious's home life evolve into painful confessions of abuse that explain how Precious and her mother came to be infected with HIV. Such “catch-all bureaucracies” and their personnel routinely respond to a variety of challenges, often directly or indirectly related to clients' health. As Watkins-Hayes (Reference Watkins-Hayes2009) states, because alternative community and individual resources are so few, catch-all bureaucracies take on unique roles in the lives of disadvantaged families, “even if their circumscribed organizational missions and policy mandates are simultaneously trying to limit clients' reliance on them and increase the demands made of them” (p. 31).
How might a wider variety of such bureaucracies address the issues of HIV prevention and treatment? While they may be poorly suited to provide health education due to extensive caseloads and work demands and limited health expertise, street-level bureaucracies could host satellite public health clinics that market HIV-related messages to clients who seek other services. Moreover, social service agencies could partner with public health organizations to address the economic and social needs, such as employment, education, and housing assistance, of those living with (or at greater risk of contracting) HIV. Finally, partnerships with prisons represent significant prevention and treatment opportunities, both during incarceration and after release. As Hammett et al. (Reference Hammett, Gaiter and Crawford1998) highlight, “Many recently released inmates require primary care for HIV/AIDS, other STDs, and TB. Consequently, timely discharge planning is essential, as are linkages with community-based organizations and agencies that can provide medical care, health education, and necessary supportive services” (p. 99). While such arrangements between prisons and local human service institutions have been controversial, they have been found to be effective disease-prevention mechanisms.
This call for increased partnerships involving medical providers, the public health community, and street-level bureaucracies reflects the reality that law enforcement organizations, public aid offices, and other institutions are already playing a role in HIV prevention and treatment efforts for inner-city residents. For example, it is not uncommon that women diagnosed with HIV while in prison receive their first critical pieces of information about the implications of HIV from prison health officials or other prisoners (Watkins-Hayes et al., Reference Watkins-Hayes, Pittman and Beaman2011), information that they often use to inform their health management practices. Unfortunately, public aid offices typically offer no resources for sexual health and do not network with other institutions that might take the lead. Yet clients cannot avoid hearing about at least one cost of unprotected sex within these institutions, receiving explicit warnings not to have additional children while receiving benefits. The irony is that these conversations about sexual consequences focus almost exclusively on state economic interests, completely ignoring women's interests in sexual protection. The goal, therefore, is to reframe conversations already taking place in street-level bureaucracies about sex, drug use, and health to better support the health management of community residents. Such work represents a promising institutionally-based HIV/AIDS prevention and treatment strategy that reflects neighborhood context. As government resources for social and medical services become scarcer, health organizations in inner-city communities must become savvier in their response to the AIDS crisis by seizing opportunities to develop creative partnerships that reach as many people as possible in these neighborhoods.
Food, Culture, and Economics among Black Women Living with HIV/AIDS
In addition to the strategies previously outlined, a third way to address blights at the neighborhood and community levels targets resources that encourage people to eat nutritiously, which is conducive to better health in the wake of an HIV diagnosis. Chronic deficiencies in vital nutritional resources have been shown to directly impact HIV-positive individuals (Mahadevan and Fisher, Reference Mahadevan and Fisher2010), among whom malnutrition increases oxidative stress and immune suppression while reducing nutrient absorption (Haddad and Gillespie, Reference Haddad and Gillespie2001). HIV-infected youth are at high risk of obesity and poor diet quality, causing increased metabolic abnormalities (Kruzich et al., Reference Kruzich, Marquis, Wilson and Stephenson2004). Here again we must identify unique opportunities through which advocates of food access and affordability can partner with AIDS treatment advocates to help reframe food access and use to support community-based HIV wellness efforts.
Precious offers insights to scholars interested in exploring how food, place, and sociocultural practices are interrelated with health. The movie's subtext shifts from the main character's struggle with her body image, to the use of food as both comfort and punishment, to the food choices Precious makes in a community offering limited healthy food options. In several scenes, we see Precious cook and consume low-cost foods following methods that reduce nutritional value and increase fat and caloric content. The film also reminds us how depression and low self-efficacy can suppress internal health maintenance resources through culinary culture (Geyskens et al., Reference Geyskens, Dewitte, Pandelaere and Warlop2008; Siefert et al., Reference Siefert, Heflin, Corcoran and Williams2001). When cognitive resources are taxed, “good eating” is often sacrificed. Precious's narrative illustrates the complex relationship between HIV and nutrition, suggesting that food quality must be explored by scholars as well as medical and public health professionals at the individual, family, and community levels if we are to understand fully how it affects wellness in the context of HIV infection.
Poor urban communities are virtual food deserts at the retail level, rife with fast food establishments and stores offering processed foods that undermine healthy living (Cummins and Macintyre, Reference Cummins and Macintyre2006; Kwate Reference Kwate2008). Residents of low-income neighborhoods also must spend a higher percentage of their income on food, so they struggle with access and affordability (Barnes Reference Barnes2005). Nutritional interventions for individuals in such neighborhoods produce modest improvement in the selection of healthier options, but structural strategies that lower food costs and increase availability of healthy food choices have been associated with more significant dietary improvements (French et al., Reference French, Jeffrey, Story, Hannan and Snyder1997). To inculcate healthy food practices among HIV-positive residents, nutritional prescriptions must be accompanied by sensitivity to identity and place in acknowledging the generational transmission of food consumption practices and the limited resources characteristic of poor urban neighborhoods (Boarradaile et al., Reference Boarradaile, Sherman, Veur, McCoy, Sandoval and Nachmani2009; Moisio et al., Reference Moisio, Arnould and Price2004).
CONCLUSION
Increasing the availability, accessibility, affordability, and quality of community-based institutional resources, including mental health facilities, street-level bureaucracies that address HIV-related health needs, and sources of healthy foods, could influence a host of individual- and neighborhood-level outcomes with respect to HIV prevention and treatment. This could involve direct intervention through services and education designed to stop the spread of HIV/AIDS and to help those infected manage their health, and indirect influence through better institutional messaging around HIV prevention and overall wellness. The institutional examples that are highlighted in Precious suggest promising opportunities for organizations to help individuals heal from sexual abuse that may increase their HIV risk; offer HIV-related health messages and services to a broader population of individuals pursuing social and economic services; and promote physical wellness and slower HIV disease progression through diet. Such organizations can also generate social capital, which can provide a protective function by reducing psychological and financial stress, connecting residents to other community resources, and recalibrating normative healthy living standards among families and individuals.
Although the film is set in Harlem in the 1980s, the depictions of Precious's community are representative of many impoverished inner-city neighborhoods today. We have abundant evidence that local environmental factors can create an economic, political, and social context in which HIV/AIDS proliferates; therefore, scholars and policymakers must focus on the structural and institutional dynamics that might mitigate these factors (Auerbach Reference Auerbach2009). Certainly, individual attitudes and behaviors matter in the fight against AIDS, but we cannot change personal behavior without changing the environment in which it occurs. Interventions are likely to be much more effective when they capitalize aggressively on place-based opportunities to address the epidemic's neighborhood context. The film Precious should encourage scholars and policymakers to imagine new frontiers in the fight against AIDS, particularly by acknowledging the increasing role of geography and considering how institutions can address individual-level risk behaviors in the neighborhood context.
