HIV/AIDS: State of Washington Mandatory 2 Hour Training

Part 6. Psychosocial Issues, Con't.


Introduction

Part 1. Etiology and Epidemiology of HIV and AIDS

Part 5. Ethical and Legal Issues

Conclusion

Glossary

Resources

References

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Select populations

Although HIV infection affects people from all ethnic groups, genders, ages, and income levels, some groups have been significantly affected by the AIDS epidemic. These groups have included men who have sex with men, injecting drug users, people with hemophilia, women and people of Color. The following information details how these different populations may be uniquely affected by the AIDS epidemic.

Men Who Have Sex With Men

Among MSM overall, there were more new HIV infections in young black MSM (aged 13-29) than any other age/racial group of MSM. The number of new infections among young, black gay and bisexual men was roughly twice that of whites and of Hispanics/Latinos (5,220 infections in blacks vs. 3,330 among whites and 2,300 among Hispanics/Latinos) (CDC, 2008e). White MSM accounted for close to half (46%) of HIV incidence in 2006. Most new infections among white MSM occurred in those aged 30-39 (4,670), followed by those aged 40-49 (3,740) (CDC, 2008e). Among Hispanic/Latino MSM, most new infections occurred in the youngest (13-29) age group (2,300), though a substantial number of new HIV infections were among those aged 30-39 (1,870) (CDC, 2008e).

American society still has issues with homosexuality. Grief may not be validated when relationships are considered "unacceptable." An example of this may be the reaction of churches to those who are living with, or have families living with AIDS. Many congregants report that they do not get the support they need from their church families because of the stigma attached to HIV, AIDS and homosexuality.

Self-esteem issues and psychological issues (including depression, anxiety, diagnosed mental illness and risk-taking behaviors) may also complicate the lives of these men.

Additionally, there are the issues with HIV-negative men who have sex with men. Most of the attention, resources and services are focused on HIV-positive gay men. As with any behavior change people can become "tired" with safer sex messages, and may make choices that place them at risk. Some may feel that HIV infection is inevitable (although it is not) and purposely engage in unprotected sex.

Men who have sex with both men and women (who do not exclusively self-identify as "gay") face additional challenges. Most of the HIV-prevention activities are more successful at reaching those who identify themselves as "gay." Bisexual men face many of the same challenges as "gay" men but may not have the social and community resources they need.

Injecting Drug Users

American society also has issues with illegal drug use and the way we view marginalized individuals such as those in poverty and the homeless. People who continue to use injecting drugs, despite warnings and information about risks, may be viewed by some as "deserving" their infection. However, it is important to remember that addiction is an illness and rarely does "just say no" work to stop the addiction; indeed it trivializes the seriousness of addiction.

Harm reduction measures like syringe exchange programs, have been proven to reduce the transmission of blood-borne pathogens like HIV, HBV, and HCV. These programs are controversial because some people believe that providing clean needles and a place to exchange used needles constitutes "approval" of injection drug use.

In addition to poverty, self-esteem issues and psychological issues, including depression, anxiety, diagnosed mental illness and risk-taking behaviors, may also complicate the lives of injection drug users. The desire to stop using illegal drugs and the ability to do so may be very far apart. The reality about inpatient treatment facilities is there are very few spaces available for the demand. Many substance abusers are placed on "waiting lists" when they want treatment, and by the time there is a place for them, the individual may be lost to follow-up.

People with Hemophilia

Hemophiliacs lack the ability to produce certain blood clotting factors. Before the advent of antihemophilic factor concentrates (products like "factor VIII" and "factor IX," which are clotting material pooled out of donated blood plasma), hemophiliacs could bleed to death. These concentrates allowed hemophiliacs to receive injections of the clotting factors that they lacked, which in turn allowed them to lead relatively normal lives. Unfortunately, because the raw materials for these concentrates came from donated blood, many hemophiliacs were infected with HIV prior to the advent of blood testing.

During the 1980's, prior to routine testing of the blood supply, 90% of severe hemophiliacs contracted HIV and/or HCV through use of these products. There is anger within this community because there is evidence to show that the companies manufacturing the concentrates knew their products might be contaminated, but continued to distribute them anyway.

While some people considered hemophiliacs to be "innocent victims" of HIV, there had been significant discrimination against them. The Ryan White Care Act, funding HIV services, and the Ricky Ray Act, which provides compensation to hemophiliacs infected with HIV, were both named after HIV-positive hemophiliacs who suffered significant discrimination (arson, refusal of admittance to grade school, etc.) in their hometowns.

Women With HIV

According to the CDC, in 2005, HIV/AIDS was diagnosed for an estimated 9,708 women in the US. This number is a decrease from the 11,941 females in 2001. Women accounted for 26% of the estimated 37,163 diagnoses for adults and adolescents in 2005.

Women with AIDS made up an increasing part of the epidemic. Worldwide, at the end of 2005, according to the World Health Organization (WHO), 17.5 million women worldwide were infected with HIV (NIAD, 2006). In 1992, women accounted for an estimated 14% of adults and adolescents living with AIDS in the 50 states and the District of Columbia. By the end of 2005, this proportion had grown to 23% (CDC, 2008c).

Of the 126,964 women living with HIV/AIDS in 2005, 64% were black, 19% were white, 15% were Hispanic, 1% were Asian or Pacific Islander, and less than 1% were American Indian or Alaska Native (CDC, 2008c).

High-risk heterosexual contact was the source of 80% of these newly diagnosed infections (CDC, 2008c). An estimated 1 in 5 new HIV diagnoses for women are related to injection drug use (CDC, 2008c).

Worldwide, more than 90 percent of all adolescent and adult HIV infections have resulted from heterosexual intercourse. Women are particularly vulnerable to heterosexual transmission of HIV due to substantial mucosal exposure to seminal fluids. This biological fact amplifies the risk of HIV transmission when coupled with the high prevalence of non-consensual sex, sex without condom use due to some women's inability to negotiate safer sex practices with their partners, and the unknown and/or high-risk behaviors of their partners (CDC, 2008c).

The rates of HIV diagnosis and the risk factors for HIV infection differ for women of various races or ethnicities-a situation that must be considered when creating prevention programs. For example, even though the annual estimated rate of HIV diagnosis for black women decreased significantly-from 82.7 per 100,000 population in 2001 to 60.2 per 100,000 population in 2005-it remained 20 times the rate for white women. Overall, the rates of HIV diagnosis are much higher for black and Hispanic women than for white, Asian and Pacific Islander, or American Indian and Alaska Native women. The rates for black women are higher than the rates for all men except for black men (CDC, 2008c).

Women suffer from the same complications of AIDS that afflict men but also suffer gender-specific manifestations of HIV disease, such as recurrent vaginal yeast infections, severe pelvic inflammatory disease (PID), and an increased risk of precancerous changes in the cervix including probable increased rates of cervical cancer. Women also exhibit different characteristics from men for many of the same complications of antiretroviral therapy, such as metabolic abnormalities (NIAD, 2006).

Frequently, women with HIV infection have great difficulty accessing healthcare. According to a recent CDC study of more than19,500 patients with HIV in 10 US cities, women were slightly less likely than men to receive prescriptions for the most effective treatments for HIV infection (CDC, 2008c).

Women may postpone taking medication, or going to their own medical appointments because of the heavy burden of caring for children and other family members who may also be HIV-infected. They often lack social support and face other challenges that may interfere with their ability to adhere to treatment regimens (NIAID, 2006). Women (and also men) may fear disclosing their HIV status to others, out of fear of losing their jobs, housing, or other forms of discrimination. Single parents with HIV may feel particularly fearful because of their lack of support.

Many women have problems with lack of transportation, lack of health insurance, limited education and low income. They may have child-care problems that prevent them from going to medical appointments.

Many women who have HIV infection do not consider this to be their "worst problem". Their symptoms may be mild and manageable for many years. Meanwhile, they may have more pressing concerns, such as their income, housing, access to medical care, possible abusive relationships, and concerns about their children.

People of Color

Populations of minority races/ethnicities are disproportionately affected by the HIV epidemic (CDC, 2008c). African Americans make up 12% of the total U.S. population, yet represented 46% of new HIV infections in the United States in 2006 (CDC, 2008e). Of the 1.1 million persons living with HIV infection in the US, the majority were nonwhite (65.4%), and nearly half (48.1%) were men who have sex with men (MSM). The HIV prevalence rates for blacks (1,715.1 per 100,000) and Hispanics (585.3 per 100,000) were, respectively, 7.6 and 2.6 times the rate for whites (224.3 per 100,000) (CDC, 2008d).

African Americans and Hispanics specifically have disproportionately higher rates of AIDS cases in the US despite the fact that there are no biological reasons for the disparities. African American and Hispanic women make up less than 25% of the total US population, but account for 77% of all reported AIDS cases in women. African Americans make up about 12% of the population, but account for 37% of all AIDS cases in the US. Hispanics made up 13% of the population but accounted for 20% of reported AIDS cases.

There is not one single reason that stands out as to why the disparities exist. One factor is health disparities, which are linked to socioeconomic conditions. Another factor is distrust of the healthcare system. Both legacies of the past and current issues of race mean that many people of color do not trust "the system" for a variety of reasons. Thus, even when income is not a barrier, access to early intervention and treatment may be limited. And HIV may be only one of a list of problems, which also include adequate housing, food, employment, etc.

Another factor may be the diversities within these populations. Diversity is evident in immigrant status, religion, languages, geographic locations and, again, socioeconomic conditions. Getting information out in appropriate ways to these diverse populations is challenging.

There is a significant amount of denial about HIV risk, which continues to exist in these communities. As with other groups, there may also be fear and stigmatization of those who have HIV. Prevention messages must be tailored and presented in a culturally and linguistically appropriate manner. The messages must be carried thorough channels that are appropriate for the individual community. These channels a\may include religious institutions or through respected elders in the community. Ironically, it may be these institutions or elders who, in the past, have contributed to the misinformation and stigma associated with HIV. Many HIV prevention programs are recognizing the importance of working with diverse communities. Input from these communities must be included in planning, delivering, and evaluating HIV prevention activities.

For blacks in the United States, health disparities can mean earlier deaths, decreased quality of life, loss of economic opportunities, and perceptions of injustice. For society, these disparities translate into less than optimal productivity, higher health-care costs, and social inequity.

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