Socio-Economics Issues in HIV/AIDS

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Provisional Report: HIV and AIDS in Americas: an epidemic with many faces- Nov 2000 (Latin American and Caribbean Epidemiological Network.)


Facts related to pandemic in the Caribbean

¨      The HIV prevalence rate was around 1.96 percent, in the most sexually active age bracket in the Caribbean (nearly 4 times the rate in North America and Latin America). (UNAIDS/WHO/PAHO figures)

¨      The Caribbean sub-region is the second worst affected in the world, second only to Sub-Saharan Africa.

¨      Around 360,000 in the Caribbean are now living with HIV.

¨      557,000 people that have already died of AIDS in the Region, (Latin America and the Caribbean), since the epidemic began two decades ago.

¨      Most HIV in the Caribbean sub-region spreads during sex between women and men.

¨      However, the highest rates of HIV infection in Latin America and the Caribbean are found in sub-populations of people whose behaviors leaves them extremely vulnerable to contracting the virus, including men who have sex with other men, men and women who inject drugs, prisoners, street children and other marginalised groups, including some ethnic minorities. 

¨      Because members of sub-populations with high risk behavior are also part of the wider population, the behaviors that expose them to HIV infection may also eventually expose the men and women with whom they interact, even when those men and women do not share the risk behavior.

¨      Over half of all the cases of AIDS reported since the beginning of the epidemic in Puerto Rico have been in injecting drug users, although the proportion seems to be diminishing over time.

¨      A lot of adults have casual partnerships, and multiple partners are not uncommon. In almost every country where data are available, men are far more likely to have casual partners than women.

¨      Condom use varies enormously between countries, between sexes and between different age groups. In general, men are more likely to use condoms in casual relationships than women are, and younger people are more likely to use them than older people.

¨      In most of Latin America and the Caribbean, a predominantly macho culture has stunted the development of gay identities and has led to widespread denial of male-male sex. Getting appropriate HIV prevention services to men who have sex with men but who do not consider themselves gay has proven a major challenge.

¨     Perhaps the greatest danger of a spillover from drug injectors to the general population comes through men and women who sell sex to support finance their addiction.

¨      A 1995 study among 1500 young men and women aged 15 to 24 in Trinidad, showed that:

1.  Both boys and girls engage in risky sex.

2.  Nearly 25% of sexually active men and women had sex with more than one partner

3.  Less than 20% reported always using condoms.

4.  67% did not use condoms at all.

5.  Most young boys had sex with girls their age mates or younger

6.  28.5 % of girls said they had sex with older men.

7.  Perhaps as a result, five times more girls than boys aged between 15 and 19 are HIV positive in Trinidad.

¨      Cost of antiretroviral treatment is between US$ 1,500 and US$ 10,000 dollars per person per year depending on the mix of drugs.

¨      In the English-speaking Caribbean alone, a child is born with HIV or infected through breast-milk every day.
 

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Meaning Constraints

Heterosexual sex:

Risks for spreading of infection increases with:

¨     Unprotected sex e.g. no use of condoms.

¨      Unprotected sex with multiple partners.

Proposed Solutions:

¨      Use condoms

¨      Be aware of partner's sexual history

¨      Having one partner

¨      Regular testing

Blocks:

¨     Religion does not support condom usage e.g. Catholicism.

¨      Using condoms takes away some of the pleasure.

¨      Don't have money to buy condoms.

¨      Person thinks he can withdraw in time.

¨      Embarrassment at questioning partner's sexual history.

¨      Culture that supports, to a certain extent, that "macho" and "real" men can have multiple partners.

¨      Culture that supports serial monogamy, but has not yet drilled down the importance of testing.

¨      Embarrassment at being tested- what about if someone found out?

¨      Don't have money/time for testing.

¨      Belief that "it can't happen to me."

¨      Belief that it won't happen if it's "just one time."

¨    As a result of religion, some parents still promote an ideal of sex after marriage and a single, lifelong partner, especially their daughters. However, statistics show that high proportions of young people are having sex and that high proportions also seem to be having unprotected sex with multiple partners, thus exposing themselves to the risk of sexually transmitted infections, including HIV. This means that young people are often deprived of the information and the services they need to protect themselves from HIV.

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Men who have sex with men (non-infected)

Risks for spreading of infection increases with:

¨      Unprotected sex e.g. no use of condoms.

¨      Unprotected sex with multiple partners.

Proposed solutions:

¨      Use condoms

¨      Be aware of partner's sexual history

¨      Having one partner

Blocks:

¨  In most of Latin America and the Caribbean, a predominantly macho culture has stunted the development of gay identities and has led to widespread denial of male-male sex. Getting appropriate HIV prevention services to men who have sex with men but who do not consider themselves gay has proven a major challenge.

HIV Negative Culture/Seroconversion (Subculture within a subculture)

¨      Deliberately living a lifestyle that will increase chances of contracting the disease, as in the case of the seroconverts.

¨      The seroconvert is the young gay man who "chooses positive" and adopts the positive lifestyle.

¨      Gay men's identification of illness and early death as their destiny has moved more fully into this subculture. They are beginning to see seroconversion and entry into the AIDS system as a gesture of solidarity with their fellows, a rite of passage and a political act.

Factors related to increase in Seroconvertism are:  

¨      Dealing with constant fear of becoming close to anyone, as either lover or friend, for fear any intimate involvement will be terminated by early death.

¨      Increasing numbers of uninfected gay men now experience "Survivor guilt". It often involves the feeling that one should not have survived- and the hope that one will not survive.

¨      Continuous doubting of negative results leads to the strain of continuous testing. This doubting of negative results is built into the administration of the testing system itself. Positive results are said to be never wrong, but negative results may be "premature" or "false negatives" etc. When a person is tested negative, s/he is encouraged to restrain relief, and to return regularly to the Test Site.

¨      HIV negative men tend to be profoundly clinically depressed, anxious, disoriented, hypochondriacal, uncertain about the future, sexually dysfunctional, deeply demoralised and physically numb.

¨      There is a common feeling that the struggle to stay negative is simply too difficult, and takes away all of the joy in life.

¨      Anxieties about gayness and about intimacy now frequently express themselves as fear of viral contamination.

¨      Some uninfected men express the view that HIV positives lives are:

1.  Richer

2.  More complex

3.  More "authentic"

4.  More attention is received- a range of social services, support groups, medical benefits and other perks become immediately available.

5.  Better able to take risks- including, the "risk of intimacy"

As a result, a growing number of gay men see HIV infection and subsequent AIDS not as something that can or should be avoided, but as something "fundamentally linked to gay identity."

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Sharing of Needles

Risks for spreading of infection increases with:

¨      Sharing needles with other drug users.

¨      Functioning as a sex worker in order to get money to sustain the habit- Unprotected sex with multiple partners.

Proposed solutions:

¨      Decrease amount of intravenous drug users.

¨      Programmes to give out needles so that sharing is not necessary

¨      Use condoms

¨      Be aware of partner's sexual history

¨      Having one partner

Blocks:

¨      Low success rates in recovery from substance abuse.

¨      Difficulty in getting government's to support needle donation programmes, since intravenous drug use is illegal. Risk is that you substitute one social problem for another one.

¨     Willingness to engage in risky behaviour in order to get money to support drug use (prostitution/sex worker).


 Societal Response

¨      HIV+ person may be perceived as different from the rest of the society.

¨      Determination, by society, as to whether the person's contracting the virus was:

1.      "Preventable"

·       The person engaged in behaviour that is known to place them at risk for HIV infection, for instance:

Ø     Acquiring disease from prostitute/sex worker.

Ø     Acquiring disease due to cheating on spouse.

Ø     A drug user who gets infected by sharing needles.

Ø     A gay man who gets infected by his partner.

·        Did the person contract HIV from actions that are morally or legally wrong?

If "yes" to either, then blame the victim. For instance, one typical reaction is:

Ø      "They got what they deserve."

Gay people or IV drug users do not deserve care and compassion because they acquired the disease performing "unnatural" and "immoral" acts, and now they should bear the consequence of that.

Prejudice plays a very important part in this.
 

2.  Innocent Victim

·        Was the infection the result of an accident, or out of the person's control?

·        The person did not engage in behaviour that is known to place them at risk for HIV infection.

·        The person did not engage in behaviour that is that is considered morally wrong. For instance:

Ø      A person infected by a blood transfusion, or an organ transplant.

Ø      A health-care worker infected by a needle-stick injury caused by someone else.

Ø      A child born to an HIV positive mother.

Ø      A faithful spouse who is infected by his/her partner.

Society, therefore, withholds blame for the victim, and is empathic to their situation. Despite this, fear of infection can still result in the person being isolated, marginalised and discriminated against.

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Key elements in HIV/AIDS care and support

The needs of PLHA (people living with HIV/AIDS) include:

1.  Social support to alleviate the socio-economic impact of HIV (e.g. basic needs for food, soap, clean water, school fees and shelter)

2.  Psychological support to cope with the implications of having a life-threatening condition

¨      Counselling

¨      Spiritual support

¨      Support to enable disclosure and risk reduction strategies

¨      Medication adherence

¨      End of life and bereavement counselling

Means of providing support include:

¨      Counselling

¨     The establishment of peer support groups for those found positive, and caregivers themselves. Those most affected often create such groups through a need for solidarity in the face of broader public stigma and discrimination.

¨      Education

¨      Training

¨      Provision of material and financial support.

3.   Emotional support

4.   Protection against discrimination (housing, jobs, healthcare and public assistance and stigma).

5.   Social support for orphans left behind.

6.   Protection in employment

7.   Right to confidentiality

8.   Medical care including access to new treatments.

Socio-economic issues that emerge include:

¨      Individual vs. Public Rights (Right to Disclose)

¨      Costs of treatment/associated services

¨      Strain on health/mental health services


Critique of Current AIDS Prevention programme:

It does not deal comprehensively with complex psychosocial issues such as:

1.   Feelings about sex and sexuality

2.   Feelings about death and dying.

3.   Personal worth

4.   Goals

5.   Intimacy


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Fear of HIV

AIDS is a deadly disease, and it is logical to have fear of it. Different people display different degrees of fear of this disease. Asking the participants to fill in the following questionnaire is simply supposed to help people to understand their degree of fear of the disease.

The questionnaire is anonymous and there is no following discussion.

Fear of HIV

Would you do the following things?

Certain questions could have a different answer, depending on the situation. All the situations we refer to in this questionnaire should be considered as "everyday life" situations, under "normal" conditions.

To be in the same room with an HIV+ person  yes no
To eat food prepared by an HIV+ person yes no
To have an HIV+ surgeon yes no To have an HIV+ dentist yes no
To have an HIV+ doctor (primary care physician) yes no
To share the house with an HIV+ person yes no
To eat from the same dish of an HIV+ person  yes no
To share the bathroom with an HIV+ person yes no
To have your kids go to a school with HIV+ teachers yes no
To have some form of safe sex with an HIV+ person yes no
To share the office with someone with HIV  yes no
To kiss (on the lips) an HIV+ person yes no
To sleep in the same bed with an HIV+ person yes no
To shake hands with an HIV+ person yes no
To kiss (on the cheek) an HIV+ person yes no
To talk to an HIV+ person yes no
To send your kids to a school that accepts HIV+ kids yes no

What are your beliefs on AIDS?

The goal of the following exercise is to help you identify what you think about some social and ethical issues concerning AIDS. It is an excellent way to bring to the surface many of the prejudices that we have but we do not think we have.

Do you agree or disagree with the following statements?

- Dentists and doctors should be required to treat HIV positive patients, even if they do not want to.

Agree                                                               Disagree

- HIV positive women should be strongly discouraged from having children.

Agree                                                               Disagree

- Given the promising results of the new combination therapy treatments, all people with AIDS should receive treatment.

Agree                                                               Disagree

- People who are suffering terribly with AIDS are better off dead.

Agree                                                               Disagree

- Addicts are more responsible for their HIV infection than a hemophiliac exposed through blood transfusions.

Agree                                                               Disagree

- Given the realities in HIV in our society, it should be easy for a person to give up multiple sex partners.
Agree                                                               Disagree

- Women who don't make their sexual partners use condoms are being self-destructive.

Agree                                                               Disagree

- Children with AIDS should always be allowed to attend public school.

Agree                                                               Disagree

- Men who have sex with men should be routinely tested for HIV.

Agree                                                               Disagree

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