This report aims to understand social and behavioral factors driving the HIV/AIDS epidemic. Inequalities fuel the spread of HIV/ AIDS on many different levels such as poverty, gender, education and health. Poor and vulnerable populations are most at risk from HIV/AIDS whereas wealthy countries that can afford access to anti retro viral drugs , have functioning health care systems and education policies in place; have a significantly lower rate of infection. The stigma surrounding HIV compounds these effects and the vulnerable remain marginalized and most at risk.
The Nature of HIV/AIDS: A Global Pandemic:
HIV/AIDS is a new epidemic in our history There currently is no cure and no vaccine for HIV/AIDS. HIV is transmissible through sexual contact both homosexual and heterosexual, injecting drug users and other rare occurrences of transmission such as blood transfusions. HIV has a long period of infection and between infection and illness.
The world wide population of people living with HIV in 2008 was 33.4 million, with 31.3 million being adults, 15.7 million being female and 2.1 million being children under 15 years of age. In 2008, 2.7 million people were newly infected with HIV; 2.0 million people died from AIDS related illnesses and today it remains one of the leading causes of death globally.
There is large variation between countries and regions of HIV/AIDS prevalence and according to epidemiological patterns; the disease is evolving with changing epidemic patterns in different regions globally. In Australia at the end of 2008 18,000 people were living with HIV.
The transmission of HIV in Australia is primarily through sexual contact between homosexual men however the infection has also been transmitted through heterosexual contact and injecting drug users.
In Thailand the population living with HIV/AIDS is 610,000, HIV/AIDS is primarily transmitted through heterosexual contact, injecting drug users and sex workers. In Thailand more than 1 in 100 adults of a population of 65 million is infected with HIV, and AIDS has become a leading cause of death.
Sub-Saharan Africa is the most heavily affected HIV/AIDS area, in 2008 two thirds (67%) of the HIV/AIDS infected population worldwide remained in Sub-Saharan Africa. Sub-Saharan Africa in total has 22.4 million people living with HIV/AIDS. Heterosexual exposure is the primary mode of transmission of HIV with females being more heavily affected by HIV. In the year 2008 there were 1.4 million AIDS related deaths in Sub-Saharan Africa.
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The Life Course of HIV/AIDS Infection:
The greatest challenge facing developing countries is the HIV/AIDS pandemic and the realization that it threatens not only human life but decades of development (Polgar, 2002). The disease attacks and destroys families and communities that place heavy financial burden on the economy (World Health Organization, 2010). Globally, the most vulnerable are the poor, women and young girls, prostitutes, injecting drug users and children of infected mothers. Dependent upon the mode of transmission, location and availability of treatment, the survival rate is between 1 to 11 years. A reduction of 80% of the disease has been achieved with treatments such as the anti-retroviral drugs, but the long term effects can cause secondary infections and malignancies that are associated with a compromised immune system. The increased spread of HIV/AIDS has affected social networks by conflict and displacement. Biologically women are more susceptible to contracting HIV than males due to hormonal changes, vaginal microbial ecology and physiology, and a higher prevalence of sexually transmitted diseases (Quinn & Overbaugh, 2005). The individual determinants of female vulnerability to HIV include gender inequity, poverty, cultural and sexual expectations, violence and lack of education.
A large majority of older people that are living in low or middle-income countries can account for 70% of the ageing population worldwide (World Health Organisation, 2010) The opportunity to build the infrastructure necessary to address this demographic trend is much briefer because population ageing is occurring faster in countries, such as South Africa. There is a high risk of people falling into poverty in older age that may increase with reduction of family size. The prevalence of HIV/AIDS and the high mortality rate among adults has increased in numbers and skipped whole generations. Increasing numbers of the younger generation have died in the AIDS epidemic, leaving the surviving adults to take on the responsibility in caring for the sick, especially the poorer families (Stover et al, 2002 pp.73-77)
The economic affects of HIV/AIDS at the Micro and Macro Levels:
Developing countries bear the burden of the cost of HIV/AIDS. HIV not only negatively impacts households but also business and the pool of available workers. The result is a reversal of development and the United Nations (2007) argue that HIV/AIDS is the single most significant factor in this. (United Nations Development Programme, Human Development Report, 2007). The damage that the epidemic has done to the economy, which, in turn, has made it more difficult for countries to respond to the crisis illustrates this negative development.
Those who contract the disease are generally young and come from the most productive age group in society (18-40 year olds). The income of the family is eroded, not only due to the loss of the sick member’s income, but also because other family members stop working to care for their ill family members (Aus.Aid, 2001). Any savings a family has is soon eaten away by increased health related costs and the decreased income. The children are then forced into work and education is abandoned resulting in a cycle of poverty and disease that it is difficult, if not impossible to get out of. This results in a knock on effect in the broader community by reduced spending and lower demand for goods, which in turn may affect business output and the entire countries economic growth (Dhai, 2008).
HIV/AIDS also affects the labour force. As the virus devastates an entire generation of people, skilled and experienced workers are lost, resulting in decreased productivity and reduced business prosperity. Amongst those who are able to work, productivity is likely to decline as a result of HIV-related illness. This in turn can affect the international competitiveness of a country and, foreign investment resulting in new opportunities, will go elsewhere. The World Bank identifies determinants for economic growth and HIV has undermined some of the most important; social capital, human capital and household savings (Bonnel, 2000). Falling tax revenue means decreased government revenue. This, combined with pressure to spend on health care to respond to the expanding epidemic often results in negative national growth. Thus, in countries that can least afford it HIV/AIDS has reduced economic growth and increased poverty (Bor, 2007). Poverty in turn, fuels the spread of the disease.
Discrimination and Stigma of HIV/AIDS:
In recent years there has been increasing recognition of the importance of analyzing the social and environmental aspects surrounding individuals living with HIV/AIDS. One social aspect in particular that has received a lot of interest within research is HIV/AIDS related stigma and discrimination. It is widely recognized that the negative social responses to this epidemic can have an extremely negative impact on the lives of people living with the disease (Parker and Aggleton, 2003). One person to voice the extensive impact of stigma and discrimination in relation to HIV/AIDS was Jonathan Mann, the founding director of the world health organization’s former global program on aids. Mann distinguished between 3 different phases of the HIV/AIDS epidemic in any community. The first being the epidemic of HIV/AIDS infection, secondly HIV/AIDS itself as a disease and thirdly, the epidemic of social, cultural, economic and political responses to the disease which, he stated , was characterized in a large part by extremely high levels of stigma, discrimination and collective denial. He claimed this to be “as central to the global AIDS challenge as the disease itself” (Parker & Aggleton, 2003). Stigma and discrimination are part of complex systems of beliefs that people have relating to illness and disease and, can be caused by a number of factors including a lack of knowledge about the disease, and fear of contamination. It can also derive from other existing inequalities relating to race, gender, class and sexuality (Parker & Aggleton, 2003 ; Anderson, Elam, Gerver, Solarin, Fenton & Easterbrook, 2008) Stigma and discrimination cause numerous social inequalities and reinforce negative stereotypes which can lead to status loss and unequal outcomes for those with the disease (Castro & Farmer, 2005). Stigma and discrimination are also associated with increased levels of anxiety, depressive symptoms, engaging in avoidant coping strategies, loneliness and suicidal ideation (Courtenay-Quirk, Wolitski, Parsons, Gomez & Seropositive Urban men’s study team, 2006).
The Global Challenges of HIV/AIDS and the Living Environment:
The course of HIV/AIDS can vary considerably among individuals with the disease, and when analyzing these differences a number of factors should be taken into account. It is important to not only reflect on the behavior and actions of the individual, but to also to consider the environmental factors surrounding them as they can have a significant effect on the likelihood of individuals seeking and receiving appropriate care. The challenges to receiving care can vary greatly depending on a large number of factors including, but not limited to, location, gender, culture and socio-economic status. However, there are a number of environmental factors that appear to have the greatest effect on the course of the disease. A study named the HIV aware/not in care project (cited in Nichols, Tchounwou, Mena & Sarpong, 2009) identified a number of these Environmental barriers to productive living and care. These barriers included difficulty in receiving care, negative provider patient relationships, lack of family support, funding for care and societal attitudes toward HIV/aids. A similar study named the effects of environmental factors on persons living with HIV/AIDS. Nichols et al.(2009); found that the environmental factors that had the most negative effect on patients living with HIV/AIDS were transportation, surroundings, government policies, attitudes and the natural environment. Both studies demonstrated that if these environmental factors are addressed, there negative effect is reduced which often improves the lives of people living with HIV/AIDS.
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HIV/AIDS and Social Justice :
Social justice is quite simply defined as being the right to fairness and reasonableness, especially with the way people are treated or how decisions regarding their health are made. Every human being has a right to good health. To remove this right is an act of social injustice (Gostin & Powers, 2006). In western countries, such as Australia, anti-retroviral drugs are available on the PBS for the treatment of HIV. How can this be fair, when there are countries with millions of people suffering from HIV/AIDS and, who, do not have access to these life changing drugs. Out of 6 million people worldwide that require anti-retroviral drugs, only 8% are receiving them (Galvao, 2005). This is highlighted by the research showing that in sixty five countries throughout the world, that are of low or middle income, with a combined population of four billion people, patenting is very rare and there are limited drugs available, one of which is the anti-retroviral drugs needed for treatment of HIV/AIDS (Attaran, 2004). This, quite simply, is a prime example of the drug manufacturers being concerned only for their profit, not for the health of the people that this drug would benefit. The universal declaration of human rights, as stated in (Heywood, 2010) declares that “a standard of living that is adequate for the health and well being of oneself, which includes basic housing, food and treatment to medical care, is a right that should be available to everyone, regardless of geographic location”.
HIV/AIDS and the Health Care System:
Many factors contribute to the rate of clinical progression of HIV /AIDS and that can include age, gender, cultural beliefs, discrimination and stigma, host susceptibility, immunity, co-infections and access to appropriate healthcare. Globally, tuberculosis is the largest co-infection health concern and can be directly cause by HIV/AIDS. The morbidity rate is extremely high in developing countries and approximately a third of all HIV- positive individuals will develop tuberculosis before they die. The overlap between the epidemiology of HIV and tuberculosis has put a huge burden on the health systems especially in Africa. A reduction of both these infections can only be achieved by locating and screening cases, reducing reactivation and transmission of tuberculosis and reducing HIV transmission (Godfrey-Faussett & Ayles, 2003).
Although there has been a substantial improvement to healthcare, some nurses believe there is still a degree of risk when caring for those infected with the AIDS virus. Some of the personal and social factors that may contribute to this are the associated stigma of the disease, attitudes of the health professionals and community, acquired AIDS knowledge and personal safety (Preston & Esther M. Forti, 2000). Available healthcare, increased life expectancy and better health outcomes are determined by social environments and life style behaviours. The necessary improvements can only be made by health development and simple policy changes. These changes, such as redistribution of income, targeting of taxation systems and implementing social programs focus towards primary care as well as community participation (Peters & Garces, 2009). Approaches to prevention and the spread of HIV can be influenced by the social, cultural and religious beliefs in a country. The majority of people living with HIV/AIDS in the poorer countries seek international advocacy to assist financially and provide access to the antiretroviral drugs. By assisting partner countries, the Australian Government has implemented strategies to significantly reduce and reverse the spread of HIV and AIDS (Meier, 2007).
For the past decade women have born the brunt of the HIV/AIDS epidemic. In Africa women constitute 60% those infected with AIDS. In many societies women have a lower social and economic standing than men simply because they are women. In Africa this makes women more at risk of being infected with HIV, and then HIV causes women to fall deeper into poverty in a terrible cycle. Women often lack the social and economic power to insist on practising safe-sex leaving them vulnerable to HIV transmission from their sexual partners. In comparison it is interesting to note that in Thailand and Cambodia, as a result of education programs, condom use amongst sex workers has risen to 90% and these behavioural changes have had a positive impact on the spread of the disease. In Australia, HIV/AIDS has had little impact on the female population and remains predominately confined to the gay community and intravenous drug users . Women have a higher social standing in the community, are able to demand safe sex practices with partners and are educated, as a result of government programs about the virus. As a result the infection rate amongst Australian women is relatively low with 18,000 people infected but only 1200 of those are women . (un.aids.org, 2008). This comparison shows how beneficial education programs can be, even in countries where women struggle to achieve a higher social and economic standing and how raising the standing of women will assist in the shrinking of the spread of the disease.
Women in developing countries also bear the burden of care that results from the virus. Often they are infected with the virus by their sexual partners and also are left to provide for the household if the male dies. This leaves women in developing countries trapped in a vicious cycle. The poverty they face leaves them vulnerable and often in a position where they are unable to demand safe sex practices. Removing the stigma associated with HIV enables women to seek medical care and the life prolonging drugs that allow them to remain the sole provider and carer for the family.
The disease is not just about health, Its also about education. Education is an agent of change bringing economic independence to both males and females. Education is seen as a basic human right but many people in developing countries lack access to even basic literacy and numeracy skills. In many societies sex is a difficult subject to address and it needs to be openly and publicly discussed to educate vulnerable groups about minimising the risk of transmission and remove some of the stigma that surrounds HIV. In Australia, public health education campaigns were used early in the disease’s lifespan to educate the population about the safe sex message and methods of transmission. As a result of these campaigns a public discourse was opened, sex became a more acceptable topic of discussion and some of the stigma surrounding the disease was removed. The use of condoms became socially acceptable and widely demanded. Thailand, too, tackled these difficult social issues and the results are evident in the decline of new infection rates, especially amongst women. However, African nations were and are slow to act. Condom use remains a difficult topic to address; this is compounded by many religious groups who refuse to advocate for condom use. Whilst developed countries are better able to fund these campaigns and provide free condoms; the social and economic cost to Africa and other developing nations may have been greatly reduced if action in this area was swift.
Embroiled in gender and education is poverty. Poverty restricts access to health care, education and economic independence. Poverty prevents governments taking effective action on a national level, restricts health care access on a community level and impacts on the everyday lives of those living with the disease. By addressing poverty in communities most at risk, people will remain in their communities and not travel away for work and bring the disease back. It would be hoped this lessens the spread of HIV. Increased access to health care allows those already living with HIV to access drugs and those at risk of the disease to become educated on paths of transmission. We have discussed how wealthy nations have minimised the rate of infection through education and public health campaigns but these rely on the funds being available to initiate such programs.
Universal access to life saving drugs is a concept that is widely discussed in relation to HIV/AIDS and whilst this would undoubtedly be beneficial it requires political and business leaders to show goodwill. Yet it would also bring many challenges; how would these drugs be distributed? In many countries health care workers are dying of HIV and health care systems and distribution networks are almost non existent. Who would educate the general public about the treatments and monitor compliance? In countries like Papua New Guinea, the mountainous terrain and numerous languages add another barrier to effective education and distribution of treatments.
At some point since HIV/AIDS was first identified it stopped being solely a health issue and became an issue of inequality. Inequalities between developed and developing countries mean that the disease has hit hardest where the people can least afford it. Gender inequalities have meant that women find themselves in a position that leaves them vulnerable to being infected. Economic inequalities make access to drugs difficult . Poverty results from the disease and also fuels the disease. Lack of access to education leaves people unable to break free of the poverty cycle and helps fuel the stigma that surrounds the disease. Lack of political will and action has condemned millions of people to a cycle of disease and poverty. Greed on behalf of large pharmaceutical companies has denied millions of people life improving drugs.
Never before has an illness affected entire countries from the poorest person to the most powerful and every facet of that country from the economic system, through to the health care and education systems. HIV/AIDS is not just an illness, it is also socially determined and as such a vaccine or a cure is only part of the required solution.
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