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As a response to the risk of HIV infection, and in order to increase the ability to communicate about risk behaviour and safe sex the creation of new social networks or support which build on existing networks has been found to be useful for successful empowerment of individuals and groups (Gillies et al., 1996).
Some community-based HIV prevention and sexual health promotion activities are following the idea of empowerment (Freire 1973), enabling people to analyse their own situation, to decide on their priorities, develop solutions to their problems and take collective action to improve particular aspects of their life. For example, a female prostitute outreach programme in Rio de Janeiro, Brazil, initiated by prostitute workers in partnership with local health officials, and which promotes advocacy for prostitute rights and support provides a social network of support (Peterson and Szterenfeld 1992). Similarly, in a women’s health programme in Gujarat, India, aimed at empowerment of women, local village women were trained as women’s health workers, promoting knowledge, but also analysing and supporting women’s role in existing social networks (Khanna 1992).
Since the attachment to gay community organisations is vital for successful HIV prevention, over-proportionally many working class gay men, however, are excluded, there is a need for adaptation of prevention interventions towards the needs of these people.
“The processes of subcultural appropriation and inclusion/exclusion need to be recognised if preventive education, care and support programmes for such men are to work effectively” (Dowsett et al., 1992).
Social networks are very important in the support of their members as part of community development programmes providing active support e.g. in child care, health and social services, housing, advocacy etc. (Gillies et al., 1996), when they are built on existing social networks of local communities.
The importance of social networks for the well-being of communities in developed and developing countries is known. A study in Italy (Putnam 1993) provided evidence that networks of support by people of equal status enabled a profound framework for citizen engagement, economic growth and healthy citizens. Social networks are characterised as the ‘glue’ of ‘social capital’, with voter participation, community participation and co-operation, trust, civic engagement in terms of community planning and policy making as fundamental elements of it (Putnam 1993).
6.4 Social Issues of information distribution
The ways of distribution of information on prevention of HIV infection need to be improved to ensure that people outside the social networks (e.g. gay communities) are also reached by the information. At the same time, understandable information on HIV infection has to be published via mass media, such as popular TV and radio programmes, and local newspapers.
Information needs to go where these people live and work or spend their free time.
Outreach work has been found to be successful to communicate with people who are otherwise difficult to access (Biechele 1996, Dowsett et al., 1992).
Condoms as the most popular method of safe sex may not provide total protection, but they will help considerably if used properly and consistently. Therefore they need to be available when required and it may be worthwhile encouraging local chemists, pubs and clubs and the local health authority to improve availability, as well as aiming to improve image and acceptability (Johnson A., MW Adler 1993).
A rational policy is recommended to prevent the infection with HIV among drug users, which includes harm reduction principles as ensuring the convenient free availability of risk reduction resources and programmes including drug treatment (e.g. methadone maintenance) and supplies such as syringes and condoms, build and/or maintain solidarity and responsible relationships between drug injectors and other people. Furthermore to build a culture of lower risk, policies should encourage drug injectors and other drug users to organise against HIV (Friedman 1997).
6.5 Cognitive Issues
Prevention messages have to be improved and adapted to the knowledge and sociocultural level of disadvantaged population groups (Krueger 1990, Biechele 1996).
Emphasis should be put on the personal communicative element of outreach work for lower class homosexual men, without neglecting the use of mass media, such as radio, TV and print media for the dissemination of understandable HIV prevention messages (Biechele 1996).
There is considerable evidence in informal learning, information exchange and support for safer sex practices between working class gay men and men who have sex with men. Men talk to other men in beats, informal places where they have sex.
These ‘barefoot educators’ could be used as volunteer educators in their local areas and social networks (Dowsett et al., 1992).
The concept of these informal barefoot educator activities is similar to processes of collective action in adult literacy work (Freire 1973).
“These men may … be the only ones who can reach other homosexually active men using public sex environments - the married men, the closeted, the frightened. This is a strategy which must be integrated with other, more conventional public-health prevention strategies, but these programmes are definitely possible and should be developed. …These educators are a cautious reminder that researchers’ and educators’ downward-looking gaze, …our familiarity with words, images, concepts and abstractions, are perhaps not the best bases on which to develop educational strategy” (Dowsett et al., 1992).
Similarly, experienced gay men who are both sexually and socio-culturally interested can be used as gatekeepers facilitating access to the gay community and supporting access to information (Biechele 1996, Bochow 1998).
The discourse of HIV prevention must shift in emphasis from individual and group behaviour to include systematic, societal, political, as well as cultural factors (Gillies et al., 1996).
6.6 Specific Vulnerability Specific vulnerability can be decreased by an improved quality of health service and improved health promotion programmes. Health promotion programmes have to be targeted specific to people from lower socio-economic background, in order to increase health awareness and a positive attitude towards the use of prevention programmes (Siegrist 1989).
At the same time consideration has to be given to the increasing numbers of sexual transmitted diseases (STDs). As the presence of STDs increases the risk of HIV infection sexual health intervention are needed to prevent and/or treat STDs in order to reduce the risk of HIV infection (Daker-White et al., 1997, Grosskurth et al., 1995).
Specific attention has to be given to the specific vulnerability of women which has already been documented in 5.8 (Gorna 1996, Berer 1993).
6.7 Unspecific vulnerability
Unspecific vulnerability is strongly related to the general social and labour market policies of a particular country. A re-orientation of social and economic policies would be urgently needed to decrease the gap between the rich and the poor. These more long-term strategies are crucial if prevention interventions were to be successful in preventing HIV infection.
However, the available literature on HIV/AIDS is very vague in this aspect, although in general (see 3.3) there are calls for measures, such as integration in the economic life, reduced unemployment, material security and smaller income difference which are expected to provide the material base for a more cohesive society (Wilkinson 1997). And, there is a recognition that poverty is an issue that needs special attention and those who are particular disadvantaged need special care and consideration (Calman 1997).
Interventions of empowerment (see 6.2) are expected to be successful in improving the unspecific vulnerability of marginalised population groups. They can increase one’s self esteem and give a sense of control over one’s life. People experience that they can have influence and make change in their own and other people’s lives (Gorna 1996, Parker 1996). The gained ‘sense of coherence’ (see 5.11) makes them less vulnerable to health risks (Rosenbrock 1996).
A long-term strategic human-rights based approach is used by Jonathan Mann, who demands a rethinking of the public health concept in the light of HIV. He argues that, as marginalisation, stigmatisation and discrimination are issues of modern human rights, public health should engage in a new strategic approach based on human rights analyses. This means to identify and address the violation of human rights, which creates vulnerability of a particular group of people to becoming infected with HIV (Mann 1995).
Examples of systematic rights violations which interfere with HIV prevention include: discrimination against women, gay and lesbian people, the deaf, minority populations, and youth; violations of the right to information about HIV and safer sex, including condoms; lack of access to education; lack of access to health care etc.
A human rights analysis would break down a large problem into many component parts, so that action can occur at the local level. For example: the unequal role and inferior status of women is a fundamental problem which increases women’s vulnerability to HIV. One way of improving women’s status is to increase their access to education, which involves two vital rights, the right to education and the right to non-discrimination according to gender. The next step is community action,
to make schooling more accessible to girls. Another right can be selected for action:
such as the right to information, or the right to equal status before the law.
Improvement of any aspect of women’s rights will make a solid, incremental, contribution to improving women’s status and to women’s health. The author finally concludes, that without commitment to change the societal conditions which constrain health, the positive impact of public health work will be limited (Mann 1995).
7. Conclusions The findings in this report clearly document that people with lower socio-economic background are at greater risk of contracting HIV. They have fewer possibilities to cope with the risk of HIV infection.
These factors need to be considered by clinicians, public health staff and others engaged with preventive interventions for HIV infection. Risk reduction messages have to be designed and adapted to the knowledge level and culture of disadvantaged people in order to reach all socio-economic levels.
The relationship between low socio-economic status and ill-health is already well known (see chapter 3.3) With the HIV/AIDS epidemic this issue becomes more visible and present a challenge that needs to be addressed (Rosenbrock 1993).
This literature review identifies gaps in the research carried out on HIV and the effectiveness of HIV prevention strategies. Little is known about class and socioeconomic related inequalities and their relation to HIV infection in Europe. From the few studies which look more closely to these issues, most studies relate to inequalities in developing countries. In Europe and other industrialised countries the studies which considered socio-economic differences in the relation to HIV infection predominantly have looked at gay men. Some studies also looked at ethnicity as a risk marker. Little research was carried out in respect to women or to drug users.
The reluctance to study socio-economic inequalities in the context of HIV infection could be due to a tendency to ignore the high level of poverty in Europe. It may be far easier to focus on developing countries, where poverty is more obvious and supposedly beyond one’s own responsibility and ability to change.
However, poverty is increasing in Europe with a widening gap documented between the rich and the poor (Wilkinson 1997, Siegrist 1989).
The reluctance of many researchers to conduct studies in disadvantaged population groups with lower educational level, poor living and working conditions may be due to fearing to be seen as a highly educated middle-class researcher, perceived as voyeuristic and patronising, particularly in a study about sexual risk behaviour.