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Select Populations
Although HIV infection affects people from all ethnic groups, genders, ages, and income levels, some groups have been significantly affected by the AIDS epidemic. These groups have included men who have sex with men, injecting drug users, people with hemophilia, women and people of Color. The difference with the grief process associated with HIV and AIDS can be the social and emotional issues associated with contracting the infection. The following information details how these different populations may be uniquely affected by the AIDS epidemic.
Men Who Have Sex With Men
American society still has issues with homosexuality. Grief may not be validated when relationships are considered "unacceptable." An example of this may be the reaction of churches to those who are living with, or have families living with AIDS. Many congregants report that they do not get the support they need from their church families because of the stigma attached to HIV, AIDS and homosexuality.
Self-esteem issues and psychological issues (including depression, anxiety, diagnosed mental illness and risk-taking behaviors) may also complicate the lives of these men.
Additionally, there are the issues with HIV-negative men who have sex with men. Most of the attention, resources and services are focused on HIV-positive gay men. As with any behavior, change people can become "tired" with safer sex messages, and may make choices that place them at risk. Some may feel that HIV infection is inevitable (although it is not) and purposely engage in unprotected sex.
Men who have sex with both men and women (who do not exclusively self-identify as "gay") face additional challenges. Most of the HIV-prevention activities are more successful at reaching those who identify themselves as "gay." Bisexual men face many of the same challenges as "gay" men but may not have the social and community resources they need.
Injecting Drug Users
American society also has issues with illegal drug use and the way we view marginalized individuals such as those in poverty and the homeless. Drug users are also stigmatized. People who continue to use injecting drugs, despite warnings and information about risks, may be viewed by some as "deserving" their infection. However, it is important to remember that addiction is an illness and rarely does "just say no" work to stop the addiction; indeed it trivializes the seriousness of addiction.
Harm reduction measures like syringe exchange programs, have been proven to reduce the transmission of blood-borne pathogens like HIV, HBV, and HCV. These programs are controversial because some people believe that providing clean needles and a place to exchange used needles constitutes "approval" of injection drug use.
In addition to poverty, self-esteem issues and psychological issues, including depression, anxiety, diagnosed mental illness and risk-taking behaviors, may also complicate the lives of injection drug users. The desire to stop using illegal drugs and the ability to do so may be very far apart. The reality about inpatient treatment facilities is there are very few spaces available for the demand. Many substance abusers are placed on "waiting lists" when they want treatment, and by the time there is a place for them, the individual may be lost to follow-up.
People with Hemophilia
Hemophiliacs lack the ability to produce certain blood clotting factors. Before the advent of antihemophilic factor concentrates (products like "factor VIII" and "factor IX," which are clotting material pooled out of donated blood plasma), hemophiliacs could bleed to death. These concentrates allowed hemophiliacs to receive injections of the clotting factors that they lacked, which in turn allowed them to lead relatively normal lives. Unfortunately, because the raw materials for these concentrates came from donated blood, many hemophiliacs were infected with HIV prior to the advent of blood testing.
During the 1980's, prior to routine testing of the blood supply, 90% of severe hemophiliacs contracted HIV and/or HCV through use of these products. There is anger within this community because there is evidence to show that the companies manufacturing the concentrates knew their products might be contaminated, but continued to distribute them anyway.
While some people considered hemophiliacs to be "innocent victims" of HIV, there had been significant discrimination against them. The Ryan White Care Act, funding HIV services, and the Ricky Ray Act, which provides compensation to hemophiliacs infected with HIV, were both named after HIV-positive hemophiliacs who suffered significant discrimination (arson, refusal of admittance to grade school, etc.) in their hometowns.
Women With HIV
The number of women with HIV (human immunodeficiency virus) infection and AIDS has been increasing steadily worldwide. By the end of 2003, according to the World Health Organization (WHO), 19.2 million women were living with HIV/AIDS worldwide, accounting for approximately 50 percent of the 40 million adults living with HIV/AIDS (NIAID, 2004).
Table 2. Proportion of AIDS Cases among Female Adults and Adolescents, by Transmission Category 2003-United States (CDC, 2005e)
CDC estimates that 71% of the 11,498 AIDS cases diagnosed among female adults and adolescents in 2003 can be attributed to heterosexual transmission: 13% of these cases are from heterosexual contact with an injection drug user and 58% from sexual contact with high-risk partners such as bisexual men or HIV-infected men with unidentified risk factors (CDC, 2005e).
Of the cases in female adults and adolescents, 27% were attributed to injection drug use and 2% to other or unidentified risk factors (CDC, 2005e).
Worldwide, more than 90 percent of all adolescent and adult HIV infections have resulted from heterosexual intercourse. Women are particularly vulnerable to heterosexual transmission of HIV due to substantial mucosal exposure to seminal fluids. This biological fact amplifies the risk of HIV transmission when coupled with the high prevalence of non-consensual sex, sex without condom use due to some women's inability to negotiate safer sex practices with their partners, and the unknown and/or high-risk behaviors of their partners (NIAID, 2004).
Younger women are also increasingly being diagnosed with HIV infection, particularly among African-Americans and Hispanics. Through December 2002, women aged 25 and younger accounted for 9.8 percent of the female AIDS cases reported to CDC (NIAID, 2004).
HIV disproportionately affects African-American and Hispanic women. Together they represent less than 25 percent of all U.S. women, yet they account for more than 82 percent of AIDS cases in women (NIAID, 2004).
Women suffer from the same complications of AIDS that afflict men but also suffer gender-specific manifestations of HIV infection, such as recurrent vaginal yeast infections and severe pelvic inflammatory disease, which increase their risk of cervical cancer. Women also exhibit different characteristics from men for many of the same complications of antiretroviral therapy, such as metabolic abnormalities (NIAID, 2004).
Frequently, women with HIV infection have great difficulty accessing healthcare; they may postpone taking medication, or going to their own medical appointments because of the heavy burden of caring for children and other family members who may also be HIV-infected. They often lack social support and face other challenges that may interfere with their ability to adhere to treatment regimens (NIAID, 2004).
Women (and also men) may fear disclosing their HIV status to others, out of fear of losing their jobs, housing, or other forms of discrimination. Single parents with HIV may feel particularly fearful because of their lack of support.
Many women have problems with lack of transportation, lack of health insurance, limited education and low income. They may have child-care problems that prevent them from going to medical appointments.
Many women who have HIV infection do not consider this to be their "worst problem". Their symptoms may be mild and manageable for many years. Meanwhile, they may have more pressing concerns, such as their income, housing, access to medical care, possible abusive relationships, and concerns about their children.
People of Color
African Americans and Hispanics specifically have disproportionately higher rates of AIDS cases in the U.S., despite the fact that there are no biological reasons for the disparities.
Figure 2. below illustrates the distribution of AIDS cases reported in 2003 among racial/ethnic groups. The pie chart on the right shows the distribution of the US population (excluding US dependencies, possessions and associated nations) in 2003.
Non-Hispanic blacks and Hispanics are disproportionately affected by the AIDS epidemic in comparison with their proportional distribution in the general population. In 2003, non-Hispanic blacks made up 13% of the population but accounted for 48% of reported AIDS cases. Hispanics made up 14% of the population but accounted for 18% of reported AIDS cases.
Non-Hispanic whites made up 69% of the US population but accounted for 31% of reported AIDS cases.
Table 3. Proportion of Reported AIDS Cases and Population, by Race/Ethnicity, 2003-50 States and D.C. (CDC, 2005b)
There is not one single reason that stands out as to why the disparities exist. Multiple factors contribute to racial/ethnic health disparities, including socioeconomic factors (e.g., education, employment, and income), lifestyle behaviors (e.g., physical activity and alcohol intake), social environment (e.g., educational and economic opportunities, racial/ethnic discrimination, and neighborhood and work conditions), and access to preventive health-care services (e.g., cancer screening and vaccination) (CDC, 2005c). Both legacies of the past and current issues of race mean that many people of Color do not trust "the system" for a variety of reasons. Thus, even when income is not a barrier, access to early intervention and treatment may be limited. And HIV may be only one of a list of problems, which also include adequate housing, food, employment, etc.
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Recent immigrants also can be at increased risk for chronic disease and injury, particularly those who lack fluency in English and familiarity with the U.S. healthcare system or who have different cultural attitudes about the use of traditional versus conventional medicine. Approximately 6% of persons who identified themselves as Black or African American in the 2000 census were foreign-born (CDC, 2005c).
Photograph by Lloyd Wolf for the U.S. Census Bureau, Public Information Office
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For blacks in the United States, health disparities can mean earlier deaths, decreased quality of life, loss of economic opportunities, and perceptions of injustice. For society, these disparities translate into less than optimal productivity, higher health-care costs, and social inequity. By 2050, an estimated 61 million black persons will reside in the United States, amounting to approximately 15% of the total U.S. population (CDC, 2005c).
Photo by the U.S. Census Bureau, Public Information Office |
Another factor may be the diversities within these populations. Diversity is evident in immigrant status, religion, languages, geographic locations and, again, socioeconomic conditions. Getting information out in appropriate ways to these diverse populations has been difficult.
There is a significant amount of denial about HIV risk, which continues to exist in these communities. As with other groups, there may also be fear and stigmatization of those who have HIV. Prevention messages need to be tailored in ways that are culturally appropriate and relevant. The messages must be carried through channels that are appropriate for the individual community. These channels may include religious institutions or through respected "elders" in the community. Ironically, it may be these institutions or elders who, in the past, have contributed to the misinformation and stigma associated with HIV. Many HIV prevention programs are recognizing the need to work within these diverse communities to let the communities lead the way in prevention the transmission of HIV.
HIV and Adolescents/Young Adults
The effects of HIV and AIDS among adolescents and young adults (ages 13 to 24) in the United States continues to be an increasing concern. The CDC reported 38,490 cumulative cases of AIDS among people ages 13 to 24 through 2003. Since the epidemic began, an estimated 10,041 adolescents and young adults with AIDS have died and the proportion diagnosed with AIDS is increasing. Also, the proportion with an AIDS diagnosis among adolescents and young adults has increased from 3.9 percent in 1999 to 4.7 percent in 2003 (NIAID, 2005).
Moreover, African-American and Hispanic adolescents have been disproportionately affected by the HIV/AIDS epidemic. Between the ages of 13 and 19, African-Americans and Hispanics accounted for 66 percent and 21 percent, respectively, of the reported AIDS cases in 2003 (NIAID, 2005).
Because the average duration from HIV infection to the development of AIDS is 10 years, most adults with AIDS were likely infected as adolescents or young adults. In 2003, an estimated 3,897 were diagnosed with HIV/AIDS, while an estimated 13,752 were living with HIV/AIDS. Health experts estimate the number of adolescents and adults living with HIV infection, however, to be much higher (NIAID, 2005).
Most HIV-infected adolescents and young adults are exposed to the virus through sexual intercourse. Recent HIV surveillance data suggest that the majority of HIV-infected adolescent and young adult males are infected through sex with men. Only a small percentage of males appear to be exposed by injection drug use and/or heterosexual contact. The same data also suggest that adolescent and young adult females infected with HIV were exposed through heterosexual contact, with a very small percentage through injection drug use. In addition, there are an increasing number of children who were infected as infants that are now surviving to adolescence (NIAID, 2005).
Table 4. AIDS Cases among Male Adolescents and Young Adults by Transmission Category, Cumulative through 2003-United States (CDC, 2005d)
Nationally, since the beginning of the epidemic, more than 3,100 adolescent males aged 13 to 19 years and approximately 23,000 young adult males aged 20 to 24 years have been reported with AIDS (CDC, 2005d).
The majority (65%) of males aged 20 to 24 with AIDS had a risk factor of male-to-male sexual contact and an additional 11% were among males who reported risk factors of male-to-male sexual contact and injection drug use (CDC, 2005d).
Approximately 25% of AIDS cases among adolescent males aged 13-19 were among those who had hemophilia and acquired their infection before blood products were heat treated to prevent HIV transmission. In contrast, 3% of AIDS cases among males aged 20-24 were attributed to receipt of blood products for hemophilia (CDC, 2005d).
Injection drug use is more common among the 20 to 24 year old males reported with AIDS than among adolescents with AIDS, but less common than among males over 24 years. Eight percent of AIDS cases among males aged 13 to 19 and 7% of cases among males aged 20-24 years were reported with heterosexual contact as their transmission category (CDC, 2005d).
Table 5. AIDS Cases among Female Adolescents and Young Adults, by Transmission Category Cumulative through 2003-United States (CDC, 2005d)
Approximately two-thirds of AIDS cases among adolescent and young adult females were attributed to heterosexual contact as the mode of exposure to HIV. Cases among adolescent females were less likely to be attributed to injection drug use than were cases among young adults (18% vs. 28% of cases) (CDC, 2005d).
Photo by Lloyd Wolf for the U.S. Census Bureau, Public Information Office
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Photograph by Heather Schmaedeke for U.S. Census Bureau, Public Information Office
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Approximately 25 percent of cases of sexually transmitted infections (STIs) reported in the United States each year are among teenagers. This is particularly significant because the risk of HIV transmission increases substantially if either partner is infected with an STI. Discharge of pus and mucus as a result of STIs such as gonorrhea or chlamydia infection also increase the risk of HIV transmission three- to five-fold. Likewise, STI-induced ulcers from syphilis or genital herpes increase the risk of HIV transmission nine-fold (NIAID, 2005).
Adolescents and young adults tend to think they are invincible and, therefore, deny any risks. This belief may cause them to engage in risky behavior, delay HIV testing, and if they test positive, delay or refuse treatment. The inability to link them to medical care can lead to increased transmission of HIV. Healthcare providers report that many young people, when they learn they are HIV-positive, take several months to accept their diagnosis and return for treatment (NIAID, 2005).
The U.S. Department of Health and Human Services (DHHS) has developed documents that address the standard of care for the treatment of HIV, including information about how to treat HIV in adolescents. The documents Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents and Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection are available from AIDSinfo (http://aidsinfo.nih.gov/guidelines/).
According to the Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, adolescents exposed to HIV sexually or via injection drug use appear to follow a clinical course that is more similar to HIV infection in adults than in children. Most adolescents with sexually acquired HIV are in a relatively early stage of infection and are ideal candidates for early intervention that includes education and counseling, identifying high-risk behaviors, and recommended therapies and behavioral changes (NIAID, 2005).
Adolescents who were infected at birth or via blood products as young children, however, follow a unique clinical course that may differ from that of other adolescents and adults. Healthcare providers should refer to the treatment guidelines for detailed information about treating HIV-infected adolescents (NIAID, 2005).
HIV and Persons Aged 50 and Older
A growing number of older people now have HIV/AIDS. About 19 percent of all people with HIV/AIDS in this country are age 50 and older. Numbers of cases are expected to increase, as people of all ages survive longer due to triple-combination drug therapy and other treatment advances (NIA, 2005; NAHOF, nd).
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| Photos Courtesy of Administration on Aging |
But there may even be many more cases than we know about. Why? One reason may be that healthcare providers do not always test older people for HIV/AIDS and so may miss some cases during routine check-ups. Another may be that older people often mistake signs of HIV/AIDS for the aches and pains of normal aging, so they are less likely than younger people to be tested for the disease. In addition, they may be ashamed or afraid of being tested. People age 50 and older may have the virus for years before being tested. By the time they are diagnosed with HIV/AIDS, the virus may be in the late stages (NIA, 2005).
Older people with HIV/AIDS face a double stigma: ageism and infection with a sexually-or-IV-drug transmitted disease (NAHOF, nd).
The number of cases of HIV/AIDS for older women has particularly been growing over the past few years. The rise in the number of cases in women of color age 50 and older has been especially steep. Most got the virus from sex with infected partners. Many others got HIV through shared needles (NIA, 2005).
Because women may live longer than men, and because of the high divorce rate, many widowed, divorced, and separated women are dating these days. Like older men, many older women may be at risk because they do not know how HIV/AIDS is spread. Women who no longer worry about getting pregnant may be less likely to use a condom and to practice safe sex. Also, vaginal dryness and thinning often occurs as women age; when that happens, sexual activity can lead to small cuts and tears that raise the risk for HIV/AIDS (NIA, 2005).
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