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A multi-state surveillance project in 11 US state and city health departments between 1990 and 93 interviewed 2,898 persons reported with AIDS. The project’s aim was to characterise the socio-economic status of persons with HIV/AIDS. The indicator ‘education level’ revealed that among men who have sex with men, white men reported the lowest percentage (9%), and Central/South American (50%) and Mexican men (40%) reported the highest percentages of less than 12 years of schooling.. Among intravenous drug users (IDUs) 35% of white men, 64% of black men, 67% of Puerto Rican men, 29% of white women and 63% of black women had less than 12 years of schooling. The authors conclude that HIV prevention programmes must be oriented to the educational level of the populations served (Diaz et al., 1994).

A study of the relationship between perception of risk of HIV infection and riskrelated sexual behaviour was conducted with attenders at a genito-urinary medicine (GUM) clinic in the UK. Significant differences between social class groups were found for knowledge level, with the highest level among professionals and the lowest among the unemployed. Increasing age was significantly associated with better knowledge. Significantly more young people did not perceive themselves as ‘at risk’, and had lower knowledge than older people who did not perceive themselves to be at risk. From the heterosexuals who reported having sex with other people in addition to their partner, 79% did not perceive themselves to be at risk of HIV infection, and in these, 64% reported only infrequent use of condoms with casual sexual partners. Significantly more heterosexual men (67%) than women (44%) reported multiple sex partners (James et al., 1991).

4.1.4 Ethnicity as risk marker “Just as homophobia and sexism have fuelled this epidemic, so too has racism.” (Alcorn 1997) HIV/AIDS has disproportional affected people of colour in the United States, the UK and some European countries (Alcorn 1997). Recent studies, especially in USA, have acknowledged that migration into industrialised countries has caused a shift in the population affected by HIV and AIDS. In the United States the AIDS incidence was found to be 6,5 times greater for black people and 4 times greater for Hispanics than for whites (Vancouver 1997). In the UK 59 % of those diagnosed with AIDS, infected through heterosexual contact were black or Asian in June 1994 (Alcorn 1997).

A disproportionately high rate of HIV prevalence among African Americans and Latinos and continuing high rates of new infections among younger gay and bisexual men of all ethnic groups have been identified in a work at the Centre for AIDS Prevention Studies at the University of California, San Francisco. The study calls for the development of more carefully refined research methods for AIDS prevention interventions, particularly designed for population subgroups at high risk for HIV, such as minorities, young gay and bisexual men and injecting drug users (Centre for AIDS Prevention Studies (1997). Socio-economic differences were not considered.

UNAIDS documented that the decrease of 11% in AIDS cases in the USA in 1997 only occurred among homosexual men, the group which is said to have most benefited from the multitude of prevention activities, which since the early years of the epidemic have enabled open exchange of information about risky sexual behaviour.

However, in some disadvantaged sections, AIDS continues to rise: among the African-Americans, and Hispanic communities. Gender issues have not been considered. This rise can partly be explained by the fact that these communities once infected by HIV may have problems to access the expensive new drugs, which may delay the onset of AIDS, and partly, because prevention efforts in minority communities with mainly heterosexuals infected have been less successful than in the predominantly well-educated and well organised white gay community (UNAIDS 1997), and consequently more people get infected by HIV.

As epidemiological evidence indicates that African-American adults as well as adolescents have a disproportionately high risk of AIDS, programmes are urgently needed which are designed to increase “self-protective behaviour” and consequently to decrease risk behaviour. At the same time, it is stated that there is little understanding of African-American socio-cultural factors that may influence the acceptance of HIV information and the adoption of HIV preventive behaviour. In respect of this, emphasis needs to be put on exploring the cultural values which may be related to risk behaviour. At the same time the barriers for the effective adaptation of the HIV education messages need to be identified in order to enable the implementation of culturally-appropriate HIV behavioural modification programmes (Airhihenbuwa et al., 1992).

Several articles discuss the different prevalence and incidence rate on HIV/AIDS for ethnic minorities in industrialised countries. However, ethnicity itself is not a risk factor, and most of these studies lack of an analysis of the role of social class and socio-economic status in relation to HIV infection. By focusing solely on ‘ethnicity’ rather than on socio-economic factors attention is drawn from the fact that a disproportionate number of African-American and Hispanics are poor, and also that at least 10 % of white people live in poverty (US Bureau of the Census, 1991).

Vicente Navarro looked closer at the increasing mortality differentials between white and black people in the USA, which caused alarming concerns within government and public and called for urgent activities to reduce race differentials. (Navarro 1990) He argued that these differentials cannot be explained merely by looking at race, because, as he states, “…after all, some blacks have better health indicators (including mortality rates) than some whites, and not all whites have similar mortality indicators. Thus we must look at class differentials in mortality in the US, which are also increasing rather than declining...” (Navarro 1990).

Although there is evidence that within each class black people and other ethnic minorities often have a worse health status than white people (National Centre for Health Statistics 1990), Navarro pointed to the fact that the overwhelming majority of black people (and people from other ethnic minority groups) belong to the poorly educated working class, with low income, poorly housing, who have generally higher morbidity and mortality rates than people with high income and better education. Navarro concluded that the growing mortality differences between white and black people cannot be explained by only looking at race, they are part of class differentials (Navarro 1990).

In Europe and the United States the particular issues facing black and other ethnic groups in relation to HIV and AIDS have widely been neglected. The disadvantages which characterise black peoples lifes stem from the long-term marginalisation and low economic status from black people in white-dominated societies, but also from racism experienced by black people. These disadvantages which increased the risk of HIV infection have been failed to recognise (Alcorn 1997). Few HIV prevention services are directed to black communities and mainstream AIDS organisations have been criticised for failing to provide appropriate services to black communities (Alcorn 1997).

Sexual transmitted diseases (STDs) and ethnicity as risk markers for targeting HIV prevention intervention The prevalence of infectious diseases is higher in areas of marginalisation and poverty all over the world. Since poverty is disproportionately concentrated in black communities in the developed and developing world it is not surprising that HIV has seriously affected black communities all over the world (NAM 1997).

Infection with sexually-transmitted diseases (STDs) is identified as a risk indicator of HIV infection, and the successful treatment of STDs has been proven to reduce the incidence of HIV infection (Grosskurth H. et al., 1995, Mayaud P. et al., 1997). A study was carried out on the socio-demographic characteristics of heterosexuals who attended the genito-urinary medicine (GUM) clinic at St. Thomas’ Hospital in South London because of gonorrhoea with the aim of enabling the targeting of HIV prevention strategies (Daker-White and Barlow 1997).

The study followed the example of research in Colorado Springs (US) where the social, demographic and sexual characteristics of gonorrhoea-infected patients and their sexual contacts were studied. It was found that those most at risk of gonorrhoea were young, non-white heterosexuals connected to the military and living in certain neighbourhoods (Potterat 1985). A study in Washington found that gonorrhoea incidence was associated with age, gender, ethnicity, socio-economic status and area of residence. The highest incidence was found for black female teenagers residing in urban areas of low socio-economic status. The authors concluded that interventions to control the disease should be focused on age-specific and culturally sensitive behavioural and social strategies (Rice et al., 1991).

The same is true in London: The patients admitted to St. Thomas’ with gonorrhoea were also more likely to be young and black African-Caribbean. St. Thomas’ catchment area has at 21.8% one of the highest proportions of black Caribbean, black African and ‘black other’ residents in London, which, “however, does not itself explain the high incidence of gonorrhoea in these minority populations” (DakerWhite et al., 1997). These findings correlate with other studies in London (Lewis et al., 1995) and are of special concern considering the high incidence rate of HIV infection in the Caribbean and also the high sexual activity among travellers to that region (Daker-White et al., 1997).

The authors defend their use of ethnic groups as possible indicators of risk of gonorrhoea and possible subsequent HIV infection with the argument, that they perceive ‘race’ as a social explanation rather than a biological one. They assume that the possible variations in disease prevalence result from social and economic factors.

“We view race not as a risk factor or determinant of gonorrhoea incidence, rather, follow Rice et al., who see both race and ethnicity as ‘risk markers’ for behaviours of subgroups within racial or ethnic categories that lead to exposure to or persistence of gonorrhoea“.

(Daker-White et al., 1997; Rice et al., 1991).

The results highlight the need for sexual health interventions with young people both before and after they reach the clinic. Successful prevention interventions are expected to reduce the risk of HIV infection as well as reduce the health and social costs (Daker-White and Barlow 1997). However, sexual health interventions who focus on behaviour change rather than taking into account the socio-economic background which may drive risk behaviour may have limited success in reducing risk. They may instead be used for blaming the victim for his or her risk behaviour.

‘Ethnicity’ is a very sensitive issues, and research on ethnicity may raise many concerns of racism and discrimination.

“Is research into ethnicity and health racist, unsound, or important science?” asks Raj Bhopal from the Department of Epidemiology and Public Health, University of Newcastle (Bhopal 1997). The reason behind his question is that much historical research on ethnicity, intelligence, and health was found to be racist, unethical, and ineffective (Bhopal 1997). The concepts of race and ethnicity are difficult to define;

however, they have been routinely applied to the study of health of migrant and ethnic minority groups in the hope of advancing the understanding of the causes of diseases. Bhopal is concerned that, much of these studies may be “black box epidemiology”. He argues that as researchers have not advanced in the understanding of ethnicity and health, it may occur that by emphasising the negative aspects of the health of ethnic minority groups, research may damage their social position and withdraw the attention from their health priorities (Bhopal 1997).

4.1.5 Women and socio-economic differences in HIV infection Increasing numbers of women are acquiring HIV (Berer 1993, Gorna 1996) Currently, after gay and bisexual men, those most vulnerable to HIV are women who have sex with men (Gorna 1996).

Reasons for the rapid increase are a complex mix of biological, economic, social and psychological factors. Additionally women are affected by inequity between the sexes in terms of socio-economic and political factors (Gorna 1996).

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