The overarching goal of the ESSENCE project is to evaluate the impact of neighborhood-level characteristics of the built and social environment on forced sex and, in turn, elucidate how forced sex and physiological factors influence behavioral mechanisms that increase the risk for HIV acquisition. The study focuses on at-risk, HIV-negative African American women in Baltimore, one of the top 10 most HIV-impacted areas in the United States. Forced or coerced sex contributes directly or indirectly to women’s risk for HIV. Although forced sex has been shown to be associated with engaging in riskier sexual behaviors, no research has assessed how physiological changes of the stress response in the hypothalamic-pituitary-adrenal (HPA) axis following forced sex experiences can weaken the immune system, thereby increasing women’s susceptibility to infections including HIV. Additionally, neighborhood-level factors such as neighborhood disorder and poverty have been studied as contributors to violence against women (VAW) and HIV risk behaviors, but no studies have examined modifiable characteristics of the built and social environment as contributors to forced sex specifically.

As such, the specific aims of the ESSENCE project are to:

1. Examine the association between features of the built and social environment and forced sex and HIV risk factors.
2. Determine the physiological effect of a recent or chronic history of forced sex on the stress response within the HPA axis, represented by cortisol awakening response, accounting for environmental factors.
3. Assess whether features of the built and social environment and physiological factors moderate the relationship between forced sex and HIV risk factors.
4. Qualitatively elucidate a) the built and social environment’s role in increasing one’s likelihood of experiencing forced sex and b) a woman’s perception of stress related to forced sex and its relationship to sexual risk behaviors.

To meet these aims, we recruit 400 HIV-negative African American women at increased risk for HIV from low-income health clinics into a retrospective cohort mixed methods study in Baltimore, MD. By study design, at least one-third of the sample will have experienced forced sex since the age of 18 and two-thirds will not have experienced any abuse in their lifetime. Participants complete a quantitative cross-sectional survey and physiological assessment to examine Aims 1-3. A subset of women with a history of forced sex (n=20) participate in qualitative in-depth interviews to contextualize the complex interplay of factors assessed in our study (Aim 4).  The proposed study is the first to evaluate the independent and combined influence of environmental factors and physiological HPA axis alterations that may contribute to increased vulnerability to HIV. Because the relationship between forced sex and HIV risk can be influenced by several potentially interconnected pathways, the long-term goal of our work is to inform multi-level interventions that act on those pathways, and when combined together, maximize reductions in incident HIV infections.