Clinical Newswire February 18, 2010 (San Francisco, California USA)-
HIV risk and transmission in the United States are strongly impacted by social and structural factors not addressed by current HIV intervention programs that focus on targeting individual behaviors, according to a presentation at the 17th Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco, California from 16-19 February 2010.*
According to Kevin Fenton, MD, PhD, Director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention of the Centers for Disease Control and Prevention (CDC), “The HIV statistics in the US are stark. To effectively prevent HIV infection it is important that we are not looking at the virus in isolation but we also need to focus on the social contexts that are driving transmission both in the US and other parts of the world.” In the US, there are more than 1 million people infected with HIV and over 200,000 people are unaware of their infection. An estimated 56,300 new infections are expected annually.
Four broad factors contribute to HIV risk vulnerability in the US: Policies and social norms; individual socioeconomic position; psychosocial and social factors; and access to healthcare. First, policies and social norms that shape the culture play an important role in contributing to HIV risk. For example, laws that criminalize HIV transmission or that prohibit needle exchange programs can hinder HIV prevention efforts. Discrimination codified into laws affect employment, ability to access health insurance, enter into and maintain legally protected primary relationships, and provide care for a partner. Social norms that reinforce homophobia and discrimination can cause individuals to conceal their sexual orientation and avoid seeking HIV testing and other HIV prevention services.
Second, factors such as education, income, housing, gender, and ethnicity and race are closely related to HIV risk. People living with HIV infection are more likely to be unemployed. In 2006, 5% of the US population were unemployed, while about 62% of HIV-infected individuals were unemployed. Another study found that the survival after an HIV diagnosis was worse in people living in countries that were poor, that have more unemployment, lower household income, and less education.
Third, psychological and social factors help shape individuals’ knowledge and beliefs about sexual relationships, which affect their sexual behaviors. Some of these factors include a person’s communication skills and negotiating safer sex with partners, attitudes about condoms and contraception, and basic knowledge about HIV transmission and prevention. In addition, broader issues such as an level of healthy attachment to family, school, or faith communities, can also have an impact on sexual risk behavior.
“Finally, an extensive body of research shows that access to healthcare translates into better health outcomes for a wide range of diseases and conditions and HIV certainly is no exception,” Dr. Fenton said. However, people living with HIV have relatively limited access to healthcare. More than one-quarter of people living with AIDS in the US are uninsured, about half are on Medicare or Medicaid, and only 16% have private insurance. Dr. Fenton pointed out that there are tremendous disparities across racial and ethnic groups in the proportion of individuals who are uninsured, with the highest levels of uninsurance occurring among Hispanics, American Indians and Alaskan natives, and African Americans. Only one in five African Americans have health insurance. HIV infected individuals who do not have access to healthcare are more likely to be diagnosed late in the course of their infection, often within a year of receiving an AIDS diagnosis when treatments are less likely to be effective.
“To address the root causes of HIV disparities we need interventions that focus not only on the individual driving factors but on the social and structural factors as well. These approaches go well beyond the traditional scope of HIV prevention and will require a new way of doing business,” Dr. Fenton said. The CDC is collaborating with other Federal agencies to examine the impacts of these factors on HIV risk and transmission. CDC is undertaking studies on microenterprise, especially among African American women, to examine the impact of providing economic opportunity on HIV risk. Among other efforts, the CDC is working with the Dept of Housing and Urban Development (HUD) on ways to ameliorate the impact of homelessness on HIV risk, teaming with community partners to mobilize communities, and the Act Against AIDS initiative to reduce the stigma of HIV.
“So, while we’ve made great strides in developing prevention interventions that target individual risk behavior, the bottom line is that behavioral change programs are not enough to get ahead of the curve. We urgently need a more comprehensive approach to HIV prevention that confronts the root causes of this disease,” concluded Dr. Fenton.
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