By Stella Liu, Community Engagement Director
The human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) epidemic has wreaked havoc on humans for decades. HIV has claimed 33 million lives since it was first identified, with an estimated 38 million people currently living with the disease. Although developing countries within central Europe, central Asia, the Pacific, the Middle East and North Africa account for 95% of new HIV infections, HIV/AIDS persists within key populations in developed nations, including men who have sex with men (MSM), injection drug users (IDUs), commercial sex workers (CSWs) or clients of CSWs. HIV/AIDS distribution amongst populations in developed countries indicates persisting socioeconomic disadvantage.
Increases in HIV virulence can only be prevented by targeting high-risk CSWs, and addressing characteristics underpinning treatment non-compliance. Health systems in developed nations cannot solely rely on free universal healthcare and advanced biomedicine. The ongoing AIDS epidemics and the resulting health burden on developed nations can only be resolved by socioeconomic development, health policy initiatives targeting high-risk groups, and improving ease of access for lower socioeconomic status (SES) populations.
Socioeconomic Status (SES)
Given that HIV/AIDS epidemics in developed nations originated from resource-poorAfrican countries, the impact of poor SES on HIV infection risk must be understood. Intriguingly, initial HIV epidemics in sub-Saharan Africa predominantly affected high-income well-educated individuals. By the early 2000s however, HIV infection predominantly occurred within poorer low-education populations. This demographic shift was due to behavioural changes within highly educated and wealthy gay communities, although poorer, less-educated communities have not undertaken similar changes. Distribution of HIV in developed nations is heterogeneous, with concentrated HIV epidemics in impoverished urban areas. In such regions within the US, HIV prevalence reaches as high as 5%, well above the national average.
There are similar concerns regarding HIV prevalence among low SES groups in Australia, primarily gay and other homosexually active men, Aboriginal and Torres Strait Islander people, people who inject drugs, people in custodial settings, sex workers, and people from culturally and linguistically diverse (CALD) backgrounds. Socioeconomic disadvantage leads to risky health practices such as substance use and reduced condom use which amplifies HIV infection risk. As such, HIV prevalence is characterised by key indicators of SES: education, annual household income, poverty level, employment, and homeless-status.
Hopelessness is a major contributor to HIV-risky behaviour among all at-risk groups aside from MSM. Substance abuse and unprotected sex is concerningly high among low SES individuals who exhibit a lack of hope for future improvements. Education is universally protective for all areas of SES as it mitigates hopelessness by increasing economic opportunity. As such, education improvements for low SES individuals has the potential to reduce HIV prevalence in developed countries. Ultimately, health systems must look beyond a biomedical understanding of HIV infection and resolve the socioeconomic determinants of HIV/AIDS epidemics.
Commercial Sex Workers (CSW)
Healthcare systems must shift their focus to CSWs, a low SES population at high risk of HIV. HIV is transferred in blood, semen, rectal and vaginal fluids, and breastmilk. Thus, infection predominantly occurs in sexually active individuals. Increased rates of HIV transmission among CSW populations concerningly favours HIV virulence, as this allows the virus to frequently mutate, leading to more virulent strains. For CSWs and clients of CSWs who have multiple sexual partners, rapid HIV replication provides selective pressure that favours higher infectability and increased survivability. Thus, host survival becomes insignificant for the survival of HIV and accordingly, more virulent HIV strains quickly incapacitate the host immune system and AIDS progression occurs quicker.
In developed countries, low SES individuals facing economic insecurity engage in ‘survival sex’; high-risk sexual behaviour with multiple partners, possibly without condom use, to meet basic financial needs. However, whilst CSWs generally have a higher HIV infection risk, legal brothel sex workers, unlike illegal street workers, are able to mitigate these risks through behaviour changes. Women working in brothels generally support and care for one another, and the business’ management can establish a safe client atmosphere with consistent condom use. For street CSWs however, it is up to the sex worker themselves to demand condom use. Faced with physical threat and coersion from clients, absence of legal protection, social isolation, and no community support, practicing safe sex easily becomes challenging. Social pressure from clients and challenging economic situations push street CSWs to believe that the cost of demanding condom use is greater than any health benefits.
Disappointingly, Australia’s sex industry predominantly consists of migrants from Thailand, China, or South Korea who’s working rights are compromised an uncertain immigration status or language barriers. Thus, they resort to street sex work rather than legal and safer brothel work. The lifestyle of street workers is an additional indicator of low SES, as they report higher levels of drug, alcohol, and cigarette use than brothel workers. With sharing needles and drug paraphernalia further contributing to the HIV risk of-street CSWs, it is clear why HIV/AIDS remains prevalent among this low SES group.
Public health systems need to address systemic issues that influence this evolution. Other indicators of low SES – primarily homelessness and heavy drug use – are seen in high-risk CSWs. Given that street CSWs face a lifestyle of irregularity, instability, and social isolation, maintaining the requirements for brothel employment can be difficult, even with the relevant working rights. Thus, education is necessary to change these behaviours and improve the economic opportunities for high-risk CSWs.
Access to Therapies (HAART)
The 1980s North-American AIDS epidemic was a period of uncertainty as healthcare professionals were unable to cure or control the disease. Stigma and rejection surrounding homosexuality, intravenous drug use, poverty, racism, and fear of contagion hindered support for HIV/AIDS prevention and research, leaving affected individuals unable to seek appropriate treatment. Slowly, HIV/AIDS research progressed, and by 1984, the viral cause of AIDS was identified, and laboratory HIV tests became available.
Although HIV testing is now widely available in developed countries, low SES groups still face difficulties in receiving a diagnosis. Late AIDS diagnosis and healthcare delivery is a significant issue in Australia, with 55% of all cases remaining undiagnosed until progression to AIDS. Unsurprisingly, this mainly affects heterosexual individuals from CALD populations who faced socioeconomic disadvantage. These individuals were typically diagnosed in routine screenings during pregnancy, or following symptoms of AIDS. Healthcare systems in developed countries need to be wary that healthcare remains inaccessible to some populations, and stronger efforts are needed to ensure equitable access for low SES groups.
The 1990s saw a paradigm shift in the treatment of HIV/AIDS. Highly active antiretroviral therapy (HAART) could reduce viral loading of HIV and increase white blood cell count, transforming it into a chronic disease rather than a death sentence. HAART has the potential to eliminate transmission between sexual partners, serving a dual purpose of treatment and prevention. However, the effectiveness of HAART has been questioned following studies that failed to show a decline in HIV incidence following treatment implementation. The possible connection between reduced HAART compliance within low SES populations and these results must be investigated.
In the UK, low SES is strongly associated with HAART non-compliance, with the US showing a similar trend regarding SES and virological and immunological outcomes. More shockingly, in Canada where universal healthcare is provided free of charge, 40% of patients with HIV/AIDS related deaths never accessed treatment. As developed countries are capable of treating HIV/AIDS, it is unacceptable that benefits of medical innovation are not accessed by certain populations. Adverse effects of low SESgo beyond inability to pay for treatment, but rather individuals with knowledge, money, or social connections are disproportionately benefiting from advanced health systems. HAART, despite reducing overall HIV/AIDS deaths, has exacerbated health inequalities for low SES groups. In resource-rich countries, poverty, addiction, depression, and homelessness prevents HIV affected individuals from adhering to HAART medications despite access to health infrastructure, whilst unfavourable attitudes towards healthcare providers further damages health outcomes.
HIV infection and transmission are ultimately mitigated by-behavioural interventions. Whilst biomedical advances provide more options for HIV/AIDS prevention and treatment, safer sex and adherence to treatment regimes relies on individuals adopting behavioural and lifestyle changes that maintain health and reduce infection. Developed European countries spend approximately €1 million to treat HIV/AIDS, representative of around 1% of the total healthcare costs of these countries. This is a significant economic burden given the low HIV/AIDS prevalence within these populations, and despite these efforts, AIDS epidemics persist within these developed countries.
A purely medical approach fails to address the stigma and discrimination, stress, trauma, and lack of social support for marginalised low SES populations which inherently increases their HIV risk. Developed nations must shift resources towards HIV prevention in impoverished urban areas, and provide community level and structural interventions to improve socioeconomic conditions. Programs such as Medicaid in the US and universal healthcare in other nations have reduced HIV/AIDS mortality, and can be built to include interventions specifically targeting lower SES groups with fewer accessible resources. Social services that address drug use behaviour, homelessness and poor education can work in conjunction with healthcare systems that provide treatment options to ultimately reduce and eliminate AIDS epidemics within developed countries. HIV/AIDS continues to be a global public health risk and speaks to the worldwide threat of infectious disease. Only by reconciling the biological understanding of HIV/AIDS with the socioeconomic determinants of infection and transmission, can developed-nations set an example of effective HIV/AIDS prevention.