«Der Open-Access-Publikationsserver der ZBW – Leibniz-Informationszentrum Wirtschaft The Open Access Publication Server of the ZBW – Leibniz ...»
4.1.1 Social inequality and HIV/AIDS globally The WHO report on the Global HIV/AIDS Epidemic documents differences in the spread of the HIV virus in the different parts of the world, with important variations in patterns of spread in different communities and geographic areas within the same country (WHO 1997). The report refers mainly to differences between industrialised and developing countries, where the majority (90%) of people infected with HIV live, and within developing countries. “In some places there is clear evidence of increasing spread among poorer and less educated parts of the population. The report concludes: “This will require a much greater focus on meeting the special prevention needs of marginalised and impoverished populations.” (UNAIDS 1997) According to the UNAIDS report 1997, epidemiological data prove that the epidemic disproportionally affects the people in the developing world. Generally, urban and trading centres show higher prevalence of HIV infection than rural areas, although even in rural areas HIV infection continues to increase. Open conflicts, wars, natural disasters, environmental damage, and economic needs encourage many people to leave their homes in seek of better prospects. In some cases, the report concludes, the social and economic needs may encourage risk behaviour, i.e. unprotected (commercial) sex (UNAIDS 1997).
Socio-economic differences in the spread of HIV infection are more likely to be admitted in reports from developing countries. However, little is known about socioeconomic differences in industrialised countries, and their relation to HIV/AIDS.
Most epidemiological information is on demographic factors, such as geographic distribution, gender, and risk exposure.
For example, the WHO country information on health status in Europe reports about Switzerland, which has the highest rate of AIDS cases in Europe, a “gradual increase in the proportion of heterosexually infected people, a decline in the proportion of people infected through intravenous drug consumption by using contaminated syringes and a stable proportion of persons infected through homo-/bisexual contacts.” (WHO Country Information 1997) The defined population groups at risk are not characterised in more detail by socioeconomic differences.
Similarly, a study in STD (sexually transmitted disease) clinics in Paris, France, to assess trends in HIV infection among clinic attenders defined specific subgroups which should be targeted for prevention (HIV/positive or older homosexuals, heterosexuals from Africa and Caribbean). After adjustment by age the study found that despite a decrease in general STD incidence and HIV infections among patients aged under 25 years, overall HIV incidence has not decreased, but increased in homo-/bisexual men and in those aged 35 years and more (Meyer L et al., 1996).
Socio-economic differences within these groups were not studied.
The comprehensive comparative study on sexual behaviour and HIV risk reduction strategies among gay and bisexual men in 8 European countries (Bochow et al., 1994) which gained important insight in risk behaviour and response strategies to HIV/AIDS did not consider class-related or socio-economic inequalities within the study population.
In the following, an overview will be given on what is known about socio-economic differences and the risk of HIV infection.
Although the focus of this report is mainly on European countries, examples from other industrialised countries such as US, Canada and Australia are included. At the same time, examples from developing countries are given, to illustrate the issues analysed in this report, and also to refer to experiences and prevention and policy approaches in these countries.
4.1.2 HIV and income related inequality: the poor are more likely to be infected
Since the beginning of the epidemic gay men and intravenous drug users (IDUs) in industrialised countries have been epidemiologically identified as the two largest groups at risk for AIDS. Analysis of demographic data, as documented in the previous chapter, have also shown that some ethnic minorities are increasingly infected with HIV at much higher rates than white people (Dondero 1987, Krueger et al., 1990).
However, demographic risk factors, such as ethnicity, are known to be associated with income, and research has shown that impoverished population in general are differently affected by public health problems (Krueger et al., 1990). A study of demographic and behavioural risk factors for infection with HIV in a HIV counselling and testing clinic in Seattle, Washington, USA, found an independent association between income and HIV infection after controlling for other demographic and risk factors known to be associated with HIV infection. People with lower income were found to be more likely to be infected with HIV. This result supports the hypothesis that the impoverished are at increased risk for HIV infection because of the social and physical circumstances in which they live (Krueger et al., 1990).
Explanations may be that poor people have not adapted reduced-risk behaviours to the degree that other groups have during the last years, and that HIV prevention activities have been less effective in reaching the impoverished population groups.
Messages might either not have been accessible for the poor population (not reached the locations or not published in the media preferred by the poor) or the messages have not well been understood or were perceived as not being relevant (Krueger et al., 1990).
These findings highlight the additional risk among impoverished people and stress the importance of designing risk-reduction messages which are able to reach all socio-economic levels (Krueger et al., 1990).
Increasing attention has recently been paid to social and cultural factors which influence behaviour. Gillies et al., highlighted the important influence of the social and economic context of HIV/AIDS and risk behaviour associated with HIV transmission. They confirmed previous findings that in a developed country socioeconomic impoverishment is a significant factor in HIV infection, regardless of the number of sexual partners, age, race or injecting drug use habits of individuals (Gillies et al., 1996, Krueger et al., 1990). They also explored a relationship between poverty and AIDS in relation to global economic development, industrial developments and rural to urban migration, homelessness, the breakdown of social networks within neighbourhoods, migration and systems of labour and production.
Although the individual situation of homeless people may vary concerning their education, their health and personal history, their vulnerability towards discrimination and assault was found to be a common daily life experience (Centrepoint, 1989).
Relative poverty is seen to make individuals and populations vulnerable to HIV/AIDS (Gillies et al., 1996). For example, HIV infection is not a top priority in homeless people’s lives, concerns about finding a place to sleep or getting some hot food predominate (Smith 1991).
Another explanation why HIV prevention messages are not successfully accepted is that it is impossible to ‘build in’ behaviour change into the habitualised lifestyle and into the given living conditions.
In the context of rural to urban migration and industrialisation it has been found that e.g. in Thailand most migrants were young females looking for employment in the commercial sex industry in major cities like Bangkok. At the same time, studies have found extremely high levels of HIV among female prostitutes in Thailand (Gillies et al., 1996). In the country’s poor economic situation Thai families are dependent on their daughter’s income. Many women experienced that the low salaries they got in industrial companies were not enough to fulfil their duty to send money to their families, and chose to move from the manufacturing industry to the commercial sex industry with higher financial benefits (Gillies et al., 1996).
Social, occupational and economic systems may shape sexual life and facilitate the spread of HIV. On the example of the migrant workers in the South African mining industry Jochelson et al., identified how working condition enables the spread of the virus: Separation of their wives and families, poor living conditions in hostels, and low wages make migrants feeling miserable. Contact offered by prostitutes promises not only sexual satisfaction but also female company. Subsequently, a market for prostitution for poor and poorly educated women has been organised to provide sexual and domestic service for men. Epidemiological studies have shown that the HIV prevalence amongst these migrant workers and prostitutes is higher than for the general population (Jochelson et al., 1991, Gillies et al., 1996).
The same in Nigeria, where the working and social life of long-distance truck drivers and the economic needs of women who provide sexual and domestic services along the route for money, has shown to influence sexual behaviour and facilitate the transmission of STDs (sexual transmitted diseases) and HIV (Orubuloye et al., 1993, Gillies et al., 1993).
As demonstrated on these examples, economic growth, urbanisation, industrialisation, education, the status of women and the economic need to migration to find work can make populations vulnerable to HIV infection (Gillies et al., 1996).
4.1.3 Educational level and HIV-prevalence Few studies in Europe and USA focused an socio-economic differences in HIV prevalence. Some of the studies which looked closer at links between AIDS and poverty (Hoover et al., 1991, Birn et al., 1990, Mielck A., 1992) suggested that the rate of HIV infection increases with decreasing educational level and that low maternal education is associated with high HIV prevalence of newborns (Morse et al., 1991).
A study on white homosexual men, non intravenous drug users involved in the Chicago cohort of the Multicenter AIDS Cohort Study (Kaslow et al 1987, Mielck
1992) tested the hypothesis that the risk of HIV infection increases with decreasing socio-economic status, and that unsafe sex practices and intravenous drug use, suggested risk factors to HIV infection, are more common in lower socio-economic groups. The study was restricted to white men, because ethnicity was seen as a potential confounder (Mielck 1992).
The study confirmed that the most important risk factor for non-IV drug using homosexual men is risky sexual behaviour, mainly unprotected receptive anal intercourse. The study indicates further that HIV-prevalence increases with decreasing educational level. However, the study did not confirm the hypothesis that risky sexual behaviour increases with decreasing educational level (Mielck 1992).
The study concluded that since educational level per se does not cause HIV-infection the risk associated with educational level after controlling for sexual behaviour
remains unexplained. Three possible explanations were identified:
! Men with less education could have a higher prevalence of sexually transmitted diseases than men with more education.
! The partners of men with lower education could be more likely to be infected with HIV than the partners of men with higher education.
! The immune system of men with less education could be weaker than that of men with higher education (Mielck 1992).
The results from the Multicenter AIDS Cohort Study indicate that decreasing educational level is a risk factor for HIV infection even after controlling for sexually transmitted diseases (Chmiel et al., 1987, Mielck 1992).
The study calls for more research to confirm these study findings and to study other risk factors which can be used to explain associations between educational level and HIV infection (Mielck 1992). The study also highlights the importance of its results for public health issues and stresses the need for more preventive initiatives in the group of those with low education (Mielck 1992), but the study fails to mention, the link between lower education level and poverty, which, as discussed, is a risk factor for HIV.