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The demographic characteristics, drug use behaviour, and sexual practices of intravenous drug users (IDUs) were studied at the Montefiore Medical Center in the Bronx, NY from 1984-88. The IDUs situation was characterised by poverty, overrepresentation of minority groups (more than 80% were Black or Hispanic), and initiation to injecting drug use at an early age. From the findings the research concluded that a complex interaction between high-risk demographic characteristics, drug use and sexual behaviour contributed to the spread of HIV in this population.
Consequently, prevention interventions to interrupt transmission of HIV need to consider the complexity of these characteristics (Schrager et al., 1991).
A wide variety of interventions aim to develop community based HIV prevention and health promotion amongst drug users. These include outreach, low-threshold crisis centres, methadone programmes, needle exchanges and peer or street education projects (Hartnoll and Hedrich 1996) Drug users are confronted with widespread discrimination and disgust. In the context of HIV/AIDS prevention the US government and media policies is said to have been characterised by racial scapegoating and scapegoating of drug users. A culture of individual blame and responsibilities had been created (Friedman 1997).
4.1.7 Gay men and socio-economic differences in HIV infection
Of the few studies which have been published in Europe and other industrialised countries on HIV/AIDS and its interrelation with class or socio-economic status most have focused on gay men. It has, however, to be acknowledged that most surveys on HIV/AIDS and gay men are biased with reference to class-related social criteria, such
as education level, locality, occupation etc. (US: Baumann and Siegel 1987; UK:
Davies 1986; in Australia: Connel et al., 1988).
“In many studies one could be forgiven for thinking that a university degree is mandatory to be a fully fledged gay men!.. Our understanding of homosexuality is drawn from the sexual practices and meanings of affluent, highly-educated men. … We cannot be confident that sexual meanings and practices of middle-class gay and bisexual men are equivalent to those of working-class men. We need to recognise this if preventive education on HIV/AIDS is to be effective.“ (Dowsett et al., 1992) In France Michael Pollak carried out surveys via a gay magazine in the years 1985-89.
Although most respondents were well-educated middle class men, the study found that among the lower classes high-risk sexual behaviour was more common than in the middle class. People with less than high school education practised riskier sex. It was found that lower levels of education correlated with an ambiguity concerning their sexual identity and lack of information on AIDS. Individuals who completed high school and university were generally well informed about AIDS and clearly identified themselves as homosexual.
Pollak interpreted his findings that intellectual gay men, living in big cities, would have more sexual contacts and be more at risk. As the threat of infection with HIV is more obvious to them, they are more motivated to get information on HIV/AIDS, and consequently practise safer sex. Pollak argued that the circulation of the virus via social networks and contacts at the beginning of the HIV/AIDS epidemic had made AIDS a disease of the urban middle class, with high levels of education and information. These classes, however, were the quickest to develop a response to the virus and to protect themselves. Consequently, the trend moved from the higher classes towards the lower classes (Pollak 1990; Biechele 1996).
The results of a more recently conducted nation-wide survey in France in 1995 on gay men and HIV/AIDS infection confirm the conclusions from the previous studies, showing differences in HIV-infection between lower class, lower middle class and middle class gay men. The study also reports class-related vulnerability for HIV infection (Schiltz et al., 1995, Bochow 1998).
In four surveys from 1987/88 in western Germany and 1991/92 in east and west Germany, modelled on M. Pollak’s work in France, Michael Bochow studied living conditions, information behaviour and knowledge in relation to HIV and AIDS, sexual behaviour and prevention behaviour and their changes over time (Bochow 1994). In his sample middle-class men were also over-represented. While classspecific considerations were not a high priority for Bochow, he nevertheless, found that gay men with lower education and professional position and those living in small towns and rural areas derive less benefit from the prevention campaigns. They also seemed to have a less thorough knowledge of means of infection than middle class-men in big cities, identified as ‘core groups’.The reasons are to be found in insecure identity as gay men and less involvement in the gay community, as well as less access to gay-specific prevention and information services from AIDS support groups (Bochow 1994, Biechele 1996).
A long-term study in the Netherlands on the prevention of HIV infection among homosexual men identified only one class-specific correlation: among unemployed men the incidence of inconsistent safer sex behaviour was relatively high; those employed by contrast seemed to maintain safer sex behaviour once they had adopted it. No class specific effects are reported from the other criteria under study, such as risk behaviour, condom use, unsafe sex, and unsafe anal intercourse (John de Wit 1994, Biechele 1996).
In Great Britain four surveys have been carried out by SIGMA Research between 1984 and 1992 investigating sexual behaviour and the significance of sexuality among gay men. In this set of studies, where well educated white middle class gay men again were over-represented, relationship and age have been identified as influencing factors. No effects have been found in relation to the places where people live. Class-related parameters have not been included in the study. As mentioned above, the authors have been reluctant to look at marginalised groups, because they are concerned to be seen as chauvinistic and paternalistic. They argue, they do not want to divide between the ‘good guys’ with reasonable behaviour and the ‘bad guys’ with unreasonable behaviour. Besides, they do not see empirical evidence of distinctions among middle class gay men living in big cities and workers, black people, young people, and those from rural areas. The responses of their interviewees when asked about their sex with lower-class gay men did not lead to the assumption that there were considerable differences (Davies et al., 1993).
Yet, a study on class-based inequalities amongst gay and bisexual men is underway.
The study, conducted by the HIV project in London, aims to assess the extent to which current sexual health promotion materials (including HIV prevention) meet the needs of working class gay and bisexual men. The research will identify to what extent working class gay and bisexual men differ from middle class gay and bisexual men in terms of identity, lifestyle, and community attachment. It will also investigate to which extent the current HIV prevention messages are able to meet the needs of this groups of people, and, subsequently, what factors need to be considered in the design of health promotion materials targeted to working class gay or bisexual men (NHPIS 1997). First results are expected to be available mid 1998.
In 1989, Gagnon stated that in the USA nothing was known about the situation of men who have sex with men and who belong to minorities or the working class, and how HIV is spread in small town and rural areas. Research has been limited to places where well-educated middle-class gay men are living (Gagnon 1989). Since then the situation has not much changed. Theoretical conceptualisation of gay socialisation and development of gay identity in lower-class gay men are still missing. In most studies focusing on the sexuality of gay men, class parameters are collected, but not analysed (Gerrard et al., 1993).
As mentioned above, in a multi-cultural country like USA a definition of ‘lower class’ can hardly be made without the consideration of ethnic minorities. Belonging to a non-white-ethnic minority correlates strongly with social deprivation (UNAIDS, 1997, Centre for AIDS Prevention Studies, 1997). However, within the different ethnic groups there are huge differences which make a generalisation of ethnic minorities unreasonable. One of the few studies on homosexuality in ethnic minority groups has been carried out by Carballo Dieguez and Colezal (1994). They looked at Puerto Rican men who have sex with men and found that men with higher education levels and higher income are more likely to identify themselves as gay men, than men in lower class settings. However, no difference was found in safer-sex behaviour. Factors hindering safer-sex behaviour seem to be poverty, lack of professional education, language problems, housing, and a general feeling of deprivation (Dieguez and Delozal 1994; Biechele 1996).
In his study of gay men’s social network in the light of AIDS in Germany, Biechele characterised the specific situation of lower-class men as marked by high degrees of depression and alcohol dependence. Depression is associated with feelings of uselessness and powerlessness. Self-identification as a homosexual is considered as having an important influence on the social network to be built up. Those who are living in a homosexual relationship with a close partner or those men who are having sex with men but are married used the gay community only as a gatekeeper to meet sexual partners (Biechele 1996).
The gay community mostly comprises gay men who define themselves as homosexual, and is mainly situated in big cities, where most gay men live. In relation to the use of safer sex, Biechele distinguished three different concepts which have emerged to prevent HIV infection: the situation related (referring to the safer-sex concept of the AIDS support groups), the person related (only having sex with a person supposed not to be infected), and a fatalistic approach (has problems other than AIDS). Most people practised a mixture of situation- and person-related strategies. Risk factors were “love” and “alcohol”. One common response to HIV/AIDS for men who are not close to the gay community is to engage in a close relationship. However, all the men interviewed who were living in a partnership did not practise safe sex. An agreement of practising safer sex outside the relationship existed only in a few relation ships. Talking about safe sex is perceived to destroy confidence within the relationship.
A specific risk factor for gay men from lower classes was inconsistent knowledge about infection. For example, having sex with a married man was perceived to be safe, as sex was also thought to be safe outside the scene of the gay community (Biechele 1996).
In Australia several studies confirmed the findings of similar studies in US and Europe: Men of lower socio-economic status are more vulnerable to become infected with HIV (Connell et al., 1991, Connell et al., 1993, Dowsett et al., 1992, Dowsett 1996).
A study on the base of the results of a previous study on the social aspects of the prevention of AIDS (SAPA), a survey of 535 gay and bisexual men in Sidney and non-metropolitan New South Wales, had uncovered social class influences in the men’s response to HIV/AIDS. Men with lower education levels and those who were distanced geographically and socially from organised gay communities had received less information about safer sex. Changes in partner relations and sexual practices toward safer sex were also related to education level, geographic location and gay community attachment. Those who continued to practice unsafe sex were more likely to be in lower-status occupations and were less attached to gay community life. The looser attachment to the gay community was found to be an important factor, because prevention activities are almost exclusively delivered by gay community AIDS service organisations. Informed social support was found to be a vital ingredient in a collective response to the epidemic. This response worked on different levels: The gay community organisation created a safer-sex culture, using the idea of the community protecting itself. There was also an informal aspect where gay men were providing information, support and encouragement to each other. It was, however, acknowledged that gay community based prevention programmes were not reaching all homosexually active men equally (Dowsett et al., 1992).