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Consequently, instead of applying safer sex strategies to protect themselves from infection with HIV many individuals take up more selective strategies, such as reducing the number of partners, paying attention to the appearance of the prospective partner, avoiding partners from the gay scene who are supposed to be highly infected, picking up sexual partners who are probably distant to the gay community, preferably married men who are supposed to be not infected, all strategies whose protection is quite illusory, or they turn to a monogamous relationship (Biechele 1996).

5.9 Social issues of risk perception Evidence suggests that individuals from lower socio-economic background have less health awareness. They take part less frequently in prevention programmes and health check-ups (Siegrist 1989).

However, as evidence shows, impoverished people are at increased risk for HIV infection because of the social and physical circumstances in which they live (Krueger 1990). It is reported that persons with lower socio-economic status do less often come forward for HIV testing, because they do not perceive themselves to be at risk. Many of them present late to the health services with severe symptoms of the disease, not knowing their HIV positive status (Krueger 1990).

The longevity and uncertainty of the risk of HIV infection hinder prevention. HIV prevention requires risk reduction behaviour, the consequences of which might be relevant in 5 or 10 years time. The fact that the outbreak of the disease is delayed for many years after infection makes the threat of HIV/AIDS less imminent for people with a less reflective perspective of life. Preventive behaviour is therefore dependent whether a long-term perspective exists (Rosenbrock 1987) As the ways of transmission of the virus is known and defined to certain situations the prevention message appears to be very simple: safer sex and sterile needles and syringes (Rosenbrock 1987) However, with sexuality and drug use areas of life are addressed in which behaviour is not necessarily a result of rational reflection (Clement, 1986, Quensel, 1982) An education campaign appealing only to reason will not be successful. The importance of sexual behaviour and drug abuse behaviour must be addressed, too. These differ significantly according to social environment, ‘scene’, age, sexual orientation, region and social stratum (Rosenbrock 1987).

In addition, many individuals from disadvantaged population groups might have other problems currently more pressing than HIV/AIDS infection. Injecting drug users may need a place to sleep, immigrants may have problems with their residence permit, for others economic worries, unemployment, and poor living conditions may displace anxieties about HIV infection. So, HIV infection is not a priority for them (Smith 1991). As a long-term problem which manifests itself in the future, it does not attract immediate attention. So, the degree of ignorance is quite high.

5.10 Specific vulnerability People from lower socio-economic groups more frequently have untreated genitourinary infections because of sexual transmitted diseases, which increases their vulnerability to infection with the HIV virus (Daker-White et al., 1997).

The spread of HIV infection depends on the distribution of risk behaviour and the effectiveness of transmission of the virus. HIV transmission is encouraged by the existence of ulcerating infections (STDs). This means that the physical condition of the genitalia and the overall physical health are predictors of HIV transmission (Rosenbrock 1993).

Consequently, people from the lower classes are at higher risk of infection: They are physically more vulnerable and have fewer social and health-care choices. They have cognitive problems understanding and accepting prevention messages, and they have fewer resources for coping with the disease (Rosenbrock 1993, Mielck 1989).

Physiological reasons for women’s specific vulnerability:

Women are more likely to acquire HIV from sex with men than vice versa. Estimates of the efficiency of transmission vary, but it is suggested that vaginal intercourse with an HIV infected person is between 2 and 20 times more risky for a women that for a man (Alcorn 1997).

Added to this vulnerability is the fact that throughout the world women are becoming infected with HIV at a younger age than men. Women tend to have relationships with men who are at least a few years older than themselves. In some countries women are up to 10 years younger, for reasons of child bearing etc. Men generally are more likely to have had more sexual relationships and therefore are more likely to be infected with HIV. In the light of HIV/AIDS recently some men particularly started to have sexual relationships with young girls, preferable virgins, to avoid the threat of HIV infection (Berer 1993).

In immature female genital organs the vaginal walls are thin, and trauma during intercourse is more likely, which facilitates HIV acquisition by girls and young women (Alcorn 1997).

Additionally, women who have had a circumcision have a higher vulnerability as sexual intercourse will often cause bleeding (Alcorn 1997). As the practice of circumcision is often hidden and illegal and/or carried out in poor hygienic circumstances, the operation itself can create a risk of infection in the reproductive organs which increases the risk for HIV infection.

Even infections in the genital tract and the uterus, which may be caused by chronic irritations of contraceptives, such as IUD’s (Intrauterin device), are expected to increase the vulnerability towards HIV infection (Denenberg R. 1994).

The presence of sexually transmitted diseases increases the risk of HIV infection (Grosskurth et al., 1995, Mayoud et al., 1997). Women who acquire sexually transmitted infections may not be aware of the infection (many infections are initially symptomless in women, whereas men may develop symptoms rapidly), or if they are aware, treatment facilities may not be available (Alcorn 1997). These infections are more likely to be found in poor women, who are more vulnerable as well as having less access to health services for prevention and treatment (Berer 1993, Siegrist 1989).

Sexual violence restricts the ability of women to protect their health in Britain, as throughout the world (Gorna 1996) The high prevalence of rape, coercive sex and sexual abuse of adult women and girls is of a major concern for HIV, not only that condom use is unlikely, but the act may well involve violence and force which causes trauma and a greater risk of transmission (Alcorn 1997).

5.11 Unspecific vulnerability Studies on strengthening of health resources and the psycho-social immune system look at factors which enable individuals even under great burden and stress and risky health behaviour to remain healthy.

The concept of ‘salutogenesis’ has been the leading model of various researchers in this field. It states that individuals and groups have a bigger chance to stay healthy when they are able to predict and categorise demands, when they are able to react and interfere and influence the situation, and when individual or collective objectives can be aspired and achieved (Antonovsky 1987, 1991, Rosenbrock 1996).

The factors ‘comprehensibility’, ‘manageability’ and ‘meaningfulness’ together build the ‘sense of coherence’, the sense of living under conditions which are better understood and more controllable (Rosenbrock 1996). This means that people with a higher sense of coherence have more influence in their life and have an unspecific higher resistance against health risks. People who lack this sense of coherence are more vulnerable to health risks.

Adapted to HIV /AIDS this would confirm that people with lower socio-economic status, who have less sense of coherence because of their living and working conditions and status, are less able to influence or manage or have an global understanding of their health. Instead they rather feel powerless and lost, which makes them more vulnerable to diseases.

6. Intervention strategies to overcome social inequalities in relation to HIV infection In response to the previous section which identified factors which limit the effectiveness of prevention programmes, intervention strategies are presented in this chapter which aim to overcome social inequalities in relation to HIV information and to increase the effectiveness of prevention activities. Similarly to the previous chapter, the majority of literature focuses on gay men. Some of the intervention strategies can be adapted to the needs of other disadvantaged people amongst ethnic minorities, drug users, and women. However, there is an urgent need to look more in detail at socio-economic differences in these population groups and to develop appropriate strategies to enable them to successfully prevent infection with HIV.

6.1 Sexual Identity The successful development of a clear sexual identity requires a supportive environment. Activities against homophobia and discrimination of people with other sexual preferences or lifestyles are urgently needed and have to be directed toward the lower socio-economic population groups (Biechele 1996). At the same time the stigma of HIV/AIDS needs to be addressed within the working class setting, but also within the whole society, including health workers (Biechele 1996).

6.2 Empowerment Empowerment goes beyond the development of self confidence.

The importance of empowerment, community mobilisation and social change in the face of HIV/AIDS was highlighted by Parker (Parker 1996). He argued that an important shift has begun to take place in the understanding of and response to the HIV/AIDS epidemic. A growing awareness of the complex social, cultural, political and economic forces which are shaping the epidemic and of the link between social injustice and increased vulnerability to HIV, has led to a recasting of both the theory and the practice of HIV/AIDS prevention: The focus of HIV/AIDS prevention efforts has increasingly shifted from models aimed at changes in individual risk behaviour to models aimed at community mobilisation. The earlier emphasis on informationbased educational campaigns has been displaced by intervention programmes aimed

at enablement and empowerment. The author concludes:

“These developments have been linked to a new awareness of the fundamental connection between public health and human rights, and to a new understanding of the fight against AIDS as part of a much broader process of social change aimed at redressing structures of inequality, intolerance and injustice” (Parker 1996).

Robin Gorna calls for empowerment for women in all domains of their lives, to make sexual decision-making possible in the context of their whole live. This means also enabling women to explore and enjoy the full range of their sexuality. She describes empowerment as a potential transformation from victim to victor. Such empowerment frequently improves not only the quality but also the quantity of life (Gorna 1996).

Empowerment in this understanding means a reorientation of power towards the powerless on a individual, interpersonal, collective and environmental level. The focus is hereby on the context of decision-making and action. The individual level requires access to information, money and support, and also includes self-esteem and the development of a ‘critical consciousness’, which is the recognition of the link between personal problems and social structural problems (Freire 1983) The personal power also includes autonomy and needs to be transformed into interaction with others, to the interpersonal level, with the ability to influence and control others. The collective level refers to familial, communal, political and economical issues and means, having the power to access and participate in the planning and decision making. The environmental empowerment encourages women to develop their skills in community participation, social action and to create changes in health and nonhealth related environments, such as schools, community, and work place.

Gorna concludes, that the development and interaction of personal, communal and environmental power lead to safer sex. It increases one’s self-esteem and give a sense of control of the life and a belief that they can make a difference in their own life in the lives of others around them (Gorna 1996).

6.3 Social Networks

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