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Above all, however, the basic health-policy decision implied the necessity to organize publicly communicated learning processes in order to influence peoples’ behavior in areas involving taboos and feelings of shame. This task was tackled in numerous countries in often surprisingly creative fashion with effective cooperation between the concerned parties’ organizations, social scientists and state agencies. Numerous models of behavioral prevention were developed, these models being differentiated according to paths of transmission and thereby oriented to the three most important target groups in epidemiological terms (gay men, intravenous drug users, the heterosexual population). Those models often transcended merely behavioral II approaches by taking into account relevant factors of the social environment of these groups.
In the course of this development the concepts changed and became more refined:
the original focus on risk groups shifted to risk situations. Different mixtures of motives were discovered behind the situations in which risks are encountered. This was accompanied by problems involving intent as well as the conditions that inhibit or are conducive to the formation of such intent in terms of individual and social psychology. Phases of life (e.g. youth), power structures (e.g. between men and women), elementary mental states (e.g. being in love), elements of life styles (e.g.
scenes, meeting places), orientation of the relations involved (e.g. matrimonial, romantic, prostitution-like, hedonistic), types of social embeddedbess (e.g. sexual networks), coping resources (e.g. self efficacy), types of risk perception (e.g. danger vs. risk) commodity-type relationships (prostitution), sequestration experiences (e.g.
stigma management), etc. were, in view of their significance and ability to be manipulated for preventive purposes, included in the scientific investigation and sometimes also used for the implementation thereof.
Great scientific and practical attention was also given to the channels and forms of the message imparted by the media. Only some of this knowledge may have gone into practical intervention, but it would still seem plausible to attribute a notable portion of the indisputable preventive success to this constant refinement and the interventions based thereon.
Surprisingly, refinement of the target-group concept and consideration of psychosocial factors influencing behaviour, were not matched by any similar development in regard to the social differences within the target groups. The fact, for instance, that gays and junkies are also found throughout every social class (however that may be defined) was given far less attention. And, as is usually the case when no thought is given to socially related differences in the conditions underlying peoples’ lives and the resulting differences in their perception and actions, the concepts and methods of Aids prevention were often infiltrated, without any questions being asked, by the conceptions of mankind, forms of communication, styles of congregation, value systems, ideals of beauty, etc. of those who produced the respective campaigns and messages. As a result, Aids prevention in industrialized countries often turned into an event sponsored by members of the middle classes for members of the middle classes. Socially related inequalities of health-specific opportunities were formulated and dealt with in some countries (primarily the USA and, in part, in Great Britain as well) mainly as problems of ethnic groups, but, above all in terms of a global relationship, as inequality between the south and north, and much less so as a challenge to rich and industrialized countries.
This approach is running up against its limits as new HIV infections increasingly occur with disproportionate frequency in the lower social classes of developed industrial societies as well. Aids is therefore taking the path of all contagious diseases. It can be seen that orientation to the groups affected will have to be supplemented with the intersecting criterion of different social classes.
III That confronts science, practice and politics with challenges that may appear unfamiliar in respect to HIV/Aids but which, in fact, represent the link-up of Aids prevention with the public health agenda. The reduction of socially related inequality in health opportunities has always held a prominent position there. And for good reason: after all, for instance, in all phases of life members of Germany’s bottommost fifth of the population, as defined in terms of education, occupation and income, run approximately twice as much risk of falling seriously ill or dying as members of the topmost fifth.
The development of concepts and the practice of Aids prevention will have to connect with this challenge to public health and health policy, a challenge that rests on epidemiological facts. This implies attention to different class-specific life situations with their implicit differences in forms of perception, motivation, styles of communication and health resources. That means attention is now focusing as well on the concept of health promotion formulated in the Ottawa Charter of WHO (1986), which aims at the development and structural enabling of social and healthrelated self-determination – with suspension of risk-specific strategies. Class-specific concepts and forms of intervention oriented to target groups could find a common roof under this paradigm.
With greater attention being paid to social differences within the groups targeted for prevention the phase of “Aids exceptionalism” should draw to an end and “normalization” should be pushed. The social innovation of Aids prevention will remain a torso if attention is not given to socially related inequality in the conditions of peoples’ lives.
The report by Lisa Luger (Imperial College, London, UK) therefore embeds her portrayal and discussion of class-specific differences in the effectiveness of Aids prevention in the general debate about equity and health. It can only be hoped that it will help to strengthen the theoretical and practical efforts being made to lessen this inequality.
Berlin, March 1998
1.1 Background There are indications that despite a multitude of prevention activities people continue to be infected by HIV. Prevention programmes seem not to be as successful as intended. One possible explanation is that prevention programmes have focused on risk behaviour and behaviour change rather than considering factors which may encourage risk behaviour or make individuals vulnerable to infection with HIV. This could be factors such as poor education, poor living and working conditions and poverty. Another explanation is that prevention messages have failed to reach certain disadvantaged population groups. The messages may not have been accessible to certain groups, have not well been understood by them, or have not been related to their social and cultural context, and therefore have not been perceived as relevant to them. Prevention programmes may not have taken into account possible class- and socio-economic differences and their implications on HIV/AIDS.
This work aims to provide an overview of what is known about class- and/or socioeconomic factors and their influence on HIV infection. It presents reasons why prevention interventions have had limited success and draws on the complex factors which may limit behaviour change. It tries to find an answer why there has been a reluctance to study social inequalities in connection with HIV, and stresses concerns around racism, paternalism and ignorance. Finally it aims to provide recommendations how prevention strategies could be improved in order to more successfully prevent HIV infection.
1.3 Methodology This report is based on a review and analyses of international published reports and literature on this subject.
Several data bases have been used via Internet to access a wide range of publications (Medline, Medline express, Somed, Internet publications from WHO, UNAIDS, and UNDP, databases of libraries at King’s Fund, London, London School of Hygiene and Tropical Medicine, and Health Education Authority, London).
Keywords for the search were HIV prevention in relation to socio-economic factors, socio-economic status, class differences, socio-economic differences, marginalisation, disadvantaged population groups, knowledge level, unemployment, and poverty.
Researchers active in the field have been contacted, and unpublished papers, conference presentations and grey literature were included.
Although the main focus is on European countries, examples from other industrialised countries, and also from some developing countries are included to illustrate the findings.
1.4 Structure Background information is given in Chapter 2 on the context of the subject and the dimension of the HIV/AIDS epidemic. It will be pointed out that HIV infection is continuing despite extensive prevention programmes, and cited as possible explanations that prevention programmes may have focused solely on behaviour change rather than taking into account possible class and socio-economic differences and their implications on HIV/AIDS.
Chapter 3 provides a definition of class and discusses the implications of class- or socio-economic inequalities in health.
Chapter 4 considers the relation of class and socio-economic related inequalities to the risk of HIV infection. On the basis of the available literature an overview is given on what is known about socio-economic differences among people with HIV/AIDS, focusing on different population groups at risk, such as ethnic minority groups, drug users, women and gay men. An excursus looks at the effect of socio-economic status once a person is infected with HIV, in respect to access to health care, health status and disease progression.
Chapter 5 identifies from the available literature factors which explain the diverse effectiveness of prevention intervention, such as sexual identity, the importance of social networks, or cognitive issues.
Chapter 6 presents strategies how to improve prevention programmes in order to overcome social inequalities in relation to HIV infection.
The final analysis identifies gaps in the research information and offers recommendations where additional information is needed, where to explore more in detail the implications of socio-economic inequalities on HIV infections and the consequences for prevention interventions.
2.1 Dimension of the HIV/AIDS Epidemic World-wide “AIDS is not over, not even close”, admitted Peter Piot, Executive Director of UNAIDS, at the World Economic Forum, in Davos, 3 February 97.
On the contrary, the HIV/AIDS epidemic is expanding. The latest UNAIDS report on the Global HIV/AIDS Epidemic estimates for the year 1997 5.7 million newly infected people, with close to 16,000 new infections per day, and a total number of people living with HIV/AIDS of 30,6 million and 11.7 million AIDS deaths since the onset of the epidemic. 46 % of the 2.3 million people who died of AIDS in 1997 were women (UNAIDS 1997).
However, the virus is not equally distributed. There are important differences in the spread: socially and geographically, within communities and countries, and also between them. The overwhelming majority of HIV infected people (more than 90 %) live in the developing world, where HIV is spreading explosively. In some places the epidemic has just started, e.g. in Eastern Europe and China, and the numbers of infected people are still low. Most infected people live in Sub-Saharan Africa (20.8 million) and in South and South East Asia (6,0 million). North America counts an adult prevalence rate of 0,6 % with 860.000 total infections, Europe reports only 0.3 % with 530.000 infected people (UNAIDS Report 1997).
Whereas in developing countries heterosexuals, prostitutes, intravenous drug users (IDUs) are the main population groups at risk, in North America, Australia, and Europe gay men still remain the most affected population group, but injecting drug users also play an important part in the dynamics of the epidemic.