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A re-examination of the study findings to explore the differences between socially
advantaged and disadvantaged homosexual men focused on three key dimensions:
education level, income, and labour-market vulnerability. The study shows, that while the levels of sexual and social engagement in the gay community do not show class effects, involvement in gay community politico/cultural activities does, with the less advantaged less likely to participate. It was found that men with lower incomes are less likely to use condoms, and receptive anal intercourse with casual partners is most likely among those with least education and lowest economic position. There is also a tendency for the less advantaged to be sexually initiated younger; they are also less likely to have an HIV-antibody test. There was an indication that less educated men are more segregated from the gay community compared with more affluent gay men, and that they had less access to educational and informational resources about HIV/AIDS (Dowsett et al., 1992).
In their study about ‘homosexual desire and practice among men in working-class milieux’ Connel et al., confirmed that widespread homophobia in working class settings makes the acknowledgement of the sexual preference quite difficult. Entry into networks where sexual preference is easily realised means a major step. The commonest occasion for this step is the discovery of ‘beats’ (public meeting-places for casual sex encounters between men) and the possibility of frequent free sex with a range of partners. The beats fit with working-class tradition: they are informal, egalitarian, self-made, communal and anti-authoritarian. A relationship with an older men, who acted as sexual and social ‘mentor’, was most often found to be the means of entering the networks (Connell et al., 1993).
The two main settings of sexual activity were found to be beats and homes. These correspond to distinct relationships and distinct erotic practices. Venues (bars, clubs etc.) are common settings for the social pleasures of conversation, joking, and drinking rather than direct occasions for sex. Monogamous stable couples are the hegemonic rather than the normal thing. Anal-genital practice is much more likely in relationships than at beats, because for these men anal sex is associated with intimacy and trust.
This has important consequences for safe sex strategy: When safe sex is identified with using condoms for anal sex, and anal sex at the same time is identified with intimacy and relationship, then the less intimate sexuality in the beats may seem not to require precautions. A relationship based on the ideal of monogamy may be seen as safe. Most respondents in the study who were currently engaged in couple relationships practised unprotected anal sex with their lovers whether or not they were sure their partners had no other sexual contacts (Connell et al., 1993).
4.1.8 Excursus: Socio-economic status and shorter survival
Although the focus of this report is on socio-economic status in the context of prevention of HIV infection, it is worth having also a look at the effect of socioeconomic status once a person is infected with HIV, considering access to health care, health status and disease progression. These findings underline the importance of successful prevention interventions.
A Canadian study looks at the effects of socio-economic status on those already infected with HIV. This research on socio-economic status and survival in HIVinfected homosexual men during 1982-84 confirmed a significant higher risk of disease progression for low income men, despite adjustment for age at infection, health status and treatment (Hogg et al., 1994).
This finding is consistent with the experiences in other diseases. A link between lower socio-economic status and higher morbidity and mortality rate becomes increasingly evident for several diseases, including various cancers and cardiovascular disease (Wilkinson 1992; Hogg et al 1994). The relation between low economic status and HIV-mortality is of growing concern, particularly as the HIV/AIDS epidemic is shifting toward the more socially and economically disadvantaged (Centres for Disease Control and Prevention 1993, Hogg et al., 1994).
Most studies on HIV positive patients have concentrated on pathophysiological and clinical issues and viral load measures as predictors of disease progression. Much less attention has been paid to the social determinants of HIV disease progression (Hogg et al., 1994).
There are several explanations for the relation between low economic status and disease progression.
• One explanation is that low income is a consequence of more rapid HIV disease progression. This is also known from other disease groups, e.g. an association was found between schizophrenia and lower socio-economic status, which was assumed to contribute to a downward drift in the individual patient’s status (Marneros et al., 1990; Hogg et al., 1994). In relation to HIV, this means that those infected are less likely to remain fully employed or to maintain their income as their disease advances. The decline in income due to the disease would therefore be the cause of a more rapid HIV morbidity, although ultimately caused by the disease itself.
• Another explanation is that the shorter survival in people with lower income is a consequence of less access to medical care. Evidence has shown that Black and Hispanic patients seem to progress more rapidly from AIDS to death than nonHispanic white patients (Rothenburg et al., 1987, Hogg et al., 1994). However, this also depends on the stage of diagnoses. Black people are found to present rather late for health care.
The shorter survival of HIV-infected patients was explained as stemming from limited resources for the complex treatment of the infection and its subsequent complications (Stein et al., 1991, Hogg et al., 1994). However, in British Columbia, where this study took place, HIV-infected patients receive free antiretroviral therapy.
This may be the reason why no differences were found between low- and highincome men in their use of treatment. Nevertheless, even after adjustment for use of treatment the association between lower income and shorter survival still remained (Stein et al., 1991, Hogg et al., 1994).
Another Canadian study (Schechter et al., 1994) compared non-progressors (with stable CD4 count, no antiviral treatment or treatment against opportunistic infections) with rapid progressors (defined as those who had developed AIDS). It was found that a significantly higher proportion of the non-progressors had annual incomes above 10,000 dollars. They were more likely to have finished secondary school, and reported employment in management and professional positions. These associations cannot be explained by unequal access to care, since all subjects were covered by universal health insurance and received a standardised approach to disease management within the context of the study. Differential access to therapy cannot be considered responsible either, since none of the non-progressing group had ever received these treatments. The socio-economic differences were present at baseline, so that downward socio-economic drift due to advancing disease cannot explain these observations. The authors conclude that other factors than access to care but affected by socio-economic status are likely to be involved. They propose that psychological or nutritional factors have to be considered (Schechter et al., 1994).
The observations in these studies are supported by the findings of other studies, which confirm that people with lower incomes experience higher rates of mortality.
Income, for example, has also been found to be a predictor of survival in multiple myeloma, Hodgkin’s disease, and lung, gastric and pancreatic cancers (Cella et al., 1991; Hogg et al., 1994). Significant differences in mortality across income groups have been found in children and adults in Canada and elsewhere (Wilkins et al., 1989; Wise et al., 1985; Hogg et al., 1994). In the US, disparities in mortality by income groups have significantly increased since 1960 (Pappas et al., 1993; Hogg et al., 1994).
The fact that two-thirds of the mortality rates in developed countries can be accounted for by income distribution strengthens the association between health and income distribution, and suggests that overall health within a society is less dependent on the population’s material circumstances, than on the social inequities that exists within the society (Wilkinson 1992; Hogg et al., 1994).
5. Factors which explain the different effectiveness of prevention intervention
While the previous section gave an overview on what is known about socioeconomic or class-related factors and their role in HIV infection, the following chapter presents the reasons for higher vulnerability for HIV infection which lead to differences in effectiveness of prevention intervention. It also shows the complexity of motivations for risk behaviour which have their roots in marginalisation and socio-economic inequality.
The fact that most of the available literature on socio-economic differences in the context of HIV focused on gay men is reflected in the provision of possible explanation. Only few aspects from a women’ perspective contribute to the pattern of explanation. Literature on ethnic minority groups or drug users did not propose explanations nor intervention strategies.
5.1 Sexual Identity Various studies documented a relation between sexual identity, socio-economic status and HIV infection (Dowsett et al., 1992, Connell et al., 1993, Bochow 1994, Biechele 1996).
Homosexuality is easier to practice openly in the presence of a supportive environment, with the acceptance from family, friends, and colleagues. This is generally more common in a middle class environment. Homophobia and discrimination of people with other sexual preferences is more common in working class settings. This limits the development of a homosexual identity for working class men (Connell et al., 1993).
In addition, sexual identity itself is an important factor in terms of prevention of HIV infection. A person, whether homosexual or heterosexual, who is aware of her or his sexual needs and desires is more likely to express needs, desires or even anxieties in terms of HIV/AIDS infection. Such a person is more likely to communicate about sexuality, sexual risk behaviour and strategies to prevent HIV infection (Gorna 1996).
Being able to express sexual needs, discuss sexual risky behaviour or demand strategies for HIV prevention requires self-confidence. Self-confidence is strongly related to social status. Individuals who perceive themselves as inferior (e.g. working class gay men, women, drug users, immigrants) are more likely to lack selfconfidence. The fear of discrimination, humiliation, ridiculing or even punishment or violence limit the ability to express desires on sexual behaviour or to insist on safe sex (Gorna 1996, Lurie et al., 1995).
The specific situation of lower class men is marked by a high degree of depression, which goes together with feelings of uselessness and powerlessness and a general feeling of deprivation. This does not help to increase self-confidence (Dieguez and Delozal 1994, Biechele 1996) The experience of cultural exclusion through inadequate education erodes the self confidence of working class people too (Dowsett 1996).
5.3 Emotional issue Emotional aspects are closely related to sexual identity and self-confidence. They may limit communication about safe sex, and therefore influence the effectiveness of prevention intervention (Biechele 1996).
A person who is shy or feels intimidated to talk about sexuality, about his or her preferences, needs and desires will not easily be able to talk about methods of HIV prevention, such as safe sex, changing risky sexual behaviour or insist on the use of condoms (Mann 1995).
Other emotional risk factors for HIV infection may be ‘love’ and ‘partnership’. Love can make risk of infection seem irrelevant. Fear of losing a partner may make people accepting and tolerating risky behaviour. Perceived trust in partnership may make safer sex methods within partnership and in outside sexual relationships taboo subjects, because they are implying mistrust and unfaithfulness (Biechele 1996, Gorna 1996).
Persons who lack self-confidence or see themselves in a inferior position are more vulnerable towards these issues (Gorna 1996, Mann 1995, Gillies et al., 1996).