**Impact of Socio-Medical Factors on the Prevention and Treatment of HIV/AIDS Among Specific Subpopulations**

La Fleur F. Small *Wright State University USA* 

#### **1. Introduction**

286 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

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The first cases of what would later be known as AIDS were first identified in the United States in June of 1981 (CDC, 1981). Since this recognition of the HIV/AIDS epidemic in the United States, patterns of morbidity and mortality have been altered, sexual practices scrutinized, and healthcare institutions overwhelmed. Today there are an estimated 1.1 million adults and adolescents living with HIV infection (CDC, 2008), and approximately 56,000 new HIV infections are occurring in the U.S. every year (CDC, 2010; Hall et al., 2008). Current HIV incidence rates have been stagnant since 2000 and are considerably lower than the mid 1980's peak of new HIV infections (*see figure 1).* Incident rates during the 1980's reached 130,000. The advent of highly active antiretroviral therapy (HAART) has helped to slow the progression of HIV to AIDS. However, antiretroviral drug resistant HIV-1 has been noted since 1993 (Eshleman et al., 2007). Today it is possible for people to contract a strain of HIV-1 that is resistant to up to three antiretroviral drug classes (Eshleman et al., 2007). Despite stagnant rates of new HIV infections, and modern biomedical convention that indicates equal susceptibility to contraction of HIV, the epidemic still disproportionately impacts specific subpopulations in the United States and some specific groups show increased incidence of HIV when compared to the general population. These groups often experience political and economic subordination, disenfranchisement, and stigmatization.

The most frequently researched of these subpopulations include; persons who are substance abusers (specifically injection drug users), men who have sex with men (MSM), Latino and African American women, older adults (over the age of 50), and adolescents (ages 13-24). What factors contribute to increase prevalence of HIV among these groups? Access and utilization of health services in the early stages of HIV infection can positively impact survival time (Andersen et al., 2000; Bozzette et al., 2003; Montgomery et al., 2002). The use of HAART is credited with declining rates of HIV associated morbidity, hospitalizations and mortality (Bozzette et al., 2003; Montgomery et al., 2002). Interventions for modifying risk behavior and providing current, appropriate health education and medical care have been tested and proven effective in subpopulations. However, in order to develop and fund effective interventions, an understanding of the social determinants of illness within these groups proves advantageous.

Impact of Socio-Medical Factors on the

techniques, and sexual risk taking behavior.

HIV among MSMs.

2006. (Sources; CDC, 2010.)

engaged in same sex behavior in the last five years.

Prevention and Treatment of HIV/AIDS Among Specific Subpopulations 289

quality of life and prevention. The demography of HIV/AIDS has changed in the United States, but the majority of newly HIV infections continue to occur among MSM (Benotsch et al., 2002; Brennan et al., 2010). CDC surveillance data indicate that while MSM represent only 2 %2 of the U.S. population they account for 53% (*n*=28,720) (*see figure 2*)of the newly reported HIV infections (Bachmann et al., 2009; Brennan et al., 2010; CDC, 2008; CDC, 2011;Hall et al., 2008; Office of National AIDS Policy, 2010). Men who have sex with men is one of the only at risk populations that have reported a steady increase in annual numbers of new HIV infections (CDC, 2010; Hall et al., 2008). Diagnoses of HIV in this subpopulation increased 17% from 2005- 2008 (CDC, 2008: CDC, 2010). After initial momentum to decrease HIV/AIDS in the LBGT population, what factors have promoted increase in the rates of infection among MSMs? Emerging factors that may contribute to increased risk for MSMs include "AIDS burnout," (Wolitski et al., 2001) treatment optimism, faulty harm reduction

AIDS burnout stems from years of exposure to prevention messages and long term efforts to promote safe sex among MSMs and is an independent predictor of unprotected anal intercourse among this group (Wolitski et al., 2001). Often the outdated or overly simplistic safer sex messages ("no glove, no love") have decreased the visibility of HIV prevention messages in some MSM communities (Wolitski et al., 2001). AIDS burnout, coupled with a series of interconnected contextual factors, helps to elucidate the increase in prevalence of

Fig. 2. Estimates of New HIV Infections in the United States, By Transmission Category,

Since the introduction of HAART in 1996, being diagnosed with HIV is perceived as less serious because of the availability of drugs to mitigate the impact of the virus (Bakeman, 2007; Brennan, 2010).This concept defined as treatment optimism is theorized to play a role in increased sexual risk taking behavior among MSMs (Brennan et al., 2009; Brennan et al., 2010). HIV positive MSMs were more likely to report increased treatment optimism than HIV negative MSMs. This belief is grounded in some scientific research that suggests that

2 The estimate of 2% is based upon the range of 1.4-2.7% in the overall population age 13 and older who

Fig. 1. Estimates of Annual HIV Infection and People Living with HIV/AIDS (1977-2006). (Source: The White House Office of National AIDS Policy, 2010)

This article is a meta-analysis that synthesizes research focusing on the five aforementioned groups. The impetus of this article is to illustrate the unique impact of HIV on each subpopulation by evaluating social factors, social networking, barriers to the receipt of care, unique factors that influence pathogenesis among each group, and to highlight specific interventions developed for each group. Thus, a socio-medical perspective that includes the use of biomedical data, demographic statistics, and an understanding of the individual illness and treatment experience, will be used to analyze increased HIV/AIDS rates amongst these groups.

#### **2. Men Who Have Sex with Men1 (MSM)**

At its onset the HIV epidemic was disproportionately present in the gay community and in resources focused on addressing death and dying (Beckerman & Fontana, 2009). Sexual activity between same sex male partners and intravenous drugs represent some of the most frequent routes of HIV transmission and both groups were highly stigmatized by the general public. In the infancy of HIV/AIDS a strong relationship existed between the stigmatization of persons with same sex orientation and the stigmatization of HIV (Brooks et al., 2005; Edgar et al., 2008). Early in the epidemic, the gay, lesbian, bisexual and transgender (LGBT) community developed its own education campaigns and institutions to reduce HIV in the wake of inaction by government and other institutions (Office of National AIDS Policy, 2010). This coupled with the 1996 introduction of highly active antiretroviral therapy (Beckerman & Fontana, 2009; Brennan et al., 2009; Brennan et al., 2010) changed the perception of HIV as a terminal disease and placed emphasis on adherence to medication,

 1The term men who have sex with men (MSM) is used in CDC surveillance systems. It indicates behaviors that transmit HIV infections, rather than how individuals self –identify in terms of sexuality.

Fig. 1. Estimates of Annual HIV Infection and People Living with HIV/AIDS (1977-2006).

 **(MSM)** 

At its onset the HIV epidemic was disproportionately present in the gay community and in resources focused on addressing death and dying (Beckerman & Fontana, 2009). Sexual activity between same sex male partners and intravenous drugs represent some of the most frequent routes of HIV transmission and both groups were highly stigmatized by the general public. In the infancy of HIV/AIDS a strong relationship existed between the stigmatization of persons with same sex orientation and the stigmatization of HIV (Brooks et al., 2005; Edgar et al., 2008). Early in the epidemic, the gay, lesbian, bisexual and transgender (LGBT) community developed its own education campaigns and institutions to reduce HIV in the wake of inaction by government and other institutions (Office of National AIDS Policy, 2010). This coupled with the 1996 introduction of highly active antiretroviral therapy (Beckerman & Fontana, 2009; Brennan et al., 2009; Brennan et al., 2010) changed the perception of HIV as a terminal disease and placed emphasis on adherence to medication,

1The term men who have sex with men (MSM) is used in CDC surveillance systems. It indicates behaviors that transmit HIV infections, rather than how individuals self –identify in terms of sexuality.

This article is a meta-analysis that synthesizes research focusing on the five aforementioned groups. The impetus of this article is to illustrate the unique impact of HIV on each subpopulation by evaluating social factors, social networking, barriers to the receipt of care, unique factors that influence pathogenesis among each group, and to highlight specific interventions developed for each group. Thus, a socio-medical perspective that includes the use of biomedical data, demographic statistics, and an understanding of the individual illness and treatment experience, will be used to analyze increased HIV/AIDS rates

(Source: The White House Office of National AIDS Policy, 2010)

amongst these groups.

**2. Men Who Have Sex with Men1**

quality of life and prevention. The demography of HIV/AIDS has changed in the United States, but the majority of newly HIV infections continue to occur among MSM (Benotsch et al., 2002; Brennan et al., 2010). CDC surveillance data indicate that while MSM represent only 2 %2 of the U.S. population they account for 53% (*n*=28,720) (*see figure 2*)of the newly reported HIV infections (Bachmann et al., 2009; Brennan et al., 2010; CDC, 2008; CDC, 2011;Hall et al., 2008; Office of National AIDS Policy, 2010). Men who have sex with men is one of the only at risk populations that have reported a steady increase in annual numbers of new HIV infections (CDC, 2010; Hall et al., 2008). Diagnoses of HIV in this subpopulation increased 17% from 2005- 2008 (CDC, 2008: CDC, 2010). After initial momentum to decrease HIV/AIDS in the LBGT population, what factors have promoted increase in the rates of infection among MSMs? Emerging factors that may contribute to increased risk for MSMs include "AIDS burnout," (Wolitski et al., 2001) treatment optimism, faulty harm reduction techniques, and sexual risk taking behavior.

AIDS burnout stems from years of exposure to prevention messages and long term efforts to promote safe sex among MSMs and is an independent predictor of unprotected anal intercourse among this group (Wolitski et al., 2001). Often the outdated or overly simplistic safer sex messages ("no glove, no love") have decreased the visibility of HIV prevention messages in some MSM communities (Wolitski et al., 2001). AIDS burnout, coupled with a series of interconnected contextual factors, helps to elucidate the increase in prevalence of HIV among MSMs.

Fig. 2. Estimates of New HIV Infections in the United States, By Transmission Category, 2006. (Sources; CDC, 2010.)

Since the introduction of HAART in 1996, being diagnosed with HIV is perceived as less serious because of the availability of drugs to mitigate the impact of the virus (Bakeman, 2007; Brennan, 2010).This concept defined as treatment optimism is theorized to play a role in increased sexual risk taking behavior among MSMs (Brennan et al., 2009; Brennan et al., 2010). HIV positive MSMs were more likely to report increased treatment optimism than HIV negative MSMs. This belief is grounded in some scientific research that suggests that

 2 The estimate of 2% is based upon the range of 1.4-2.7% in the overall population age 13 and older who engaged in same sex behavior in the last five years.

Impact of Socio-Medical Factors on the

at high risk for HIV.

could no longer be ignored.

**3. Substance abusers: Injection Drug Users (IDUs)** 

Prevention and Treatment of HIV/AIDS Among Specific Subpopulations 291

behaviors ;(3) promotion of condom use ;and the (4) detection and treatment of sexually transmitted diseases (CDC, 2011). Two of the latest prevention strategies include cyberspace educational prevention approaches and Pre-exposure Prophylaxis Initiatives (PrEP). The internet is emerging as an important venue for forming sexual networks among MSMs (Benotsch, et al., 2002). To create effective interventions that are specific to MSMs cyberspace interventions have varying components that include safer sex guidelines, emailing systems for partner notification and psychosocial components designed to increase motivation for behavior change (Benotsch, et al., 2002). Pre-exposure prophylaxis is designed to prevent the acquisition of HIV infection among persons uninfected but exposed to MSMs. Preliminary findings indicate that daily orally administered antiretrovirals may partially reduce HIV among MSMs when provided with regular monitoring of HIV status and ongoing risk reduction adherence counseling (CDC, 2011).The CDC and other U.S Public Health Service (PHS) agencies are developing guidelines for the use of PrEP among MSMs

Transmission of HIV in persons who use illicit drugs remains a major public health challenge. Intravenous (IV) drug use has been a driving force for the spread of HIV/AIDS and contributes substantially to the current HIV burden in the United States (Des Jarlais et al., 1989; Riley, et al., 2010; Rudolph et al., 2010a; Rudolph, et al., 2010b). People who inject drugs are a relatively small share of the U.S. population, but they are disproportionately represented in the HIV epidemic. Of the 16 million drug injection drug users (IDUs) worldwide, an approximately 3 million are HIV infected (Mathers et al. 2008; Vlahov et al., 2010). In the United States there are an estimated 1 million IDUs, yet injection drug use accounts for approximately 16% of new HIV infections (Brady et al., 2008; Hall et al., 2008). Intravenous injection of drugs provides the user with the strongest drug effect with the least cost. Injection into the vein leads to a strong drug reaction (effective crossing of the blood brain barrier) and it's dissolution in liquid prior to injection insures usage of most of the purchased drug, unlike the lost of product associated with smoking or inhaling drugs (Des Jarlais & Seman, 2008). Unfortunately, the injection process also allows a direct route for HIV to enter the human body. While the CDC acknowledged the first cases of HIV among MSMs in 1981, Friedman and colleagues have argued that HIV was present in the IDU New York city population since the mid to late 1970's (2007) (figure 3.1). However infections in this sub-population were ignored due to a hostile legal and sociopolitical environment, influenced by the federal government's "War on Drugs" (Des Jarlais et al., 1989; Des Jarlais et al., 1994; Des Jarlais et al., 2000; Freidman et al., 2007; Santibanez et al., 2006; Stoneburner et al., 1988). This slowed the public health response to the epidemic among IDUs. However, by the mid 1980's the visibility of characteristics of AIDS among IDUs was evident and

Understanding the rates of HIV/AIDS among IDUs proves an arduous task. Drug users tend to be less conspicuous than other high risk groups. Additionally, there is a general lack of advocacy and support groups among persons with substance abuse addiction, often leading to limited information about HIV among this population. Moreover, IDUs represent a heterogeneous group of people whose behavior varies and often impacts seroprevalence. In addition to injection drug use, an IDU may also; (1) be a MSM; (2) or experience high risk heterosexual contact (Santibanez et al., 2006). However, decades of research has highlighted

HIV transmission can be mitigated when infected persons are receiving HAART therapy and has a reduced viral load (Brennan et al., 2010; Quinn et al., 2000). This coupled with the availability of postexposure therapy and viral load monitoring lessens the perceived risk of contracting HIV. However, even if risk is lessened on an individual level, increases in risk taking behavior have implications for population based concern for increased HIV transmission.Yet another social factor that has influenced treatment optimism is diminished public attention. Converse to reports of AIDS burnout, it's believed that in general, media and public attention to HIV/AIDS has decreased since the onset of the epidemic and many no longer view it as a public health emergency. A 2009 Kaiser Family Foundation survey found only 45% of respondents indicated hearing messages highlighting the plight of HIV/AIDS compared to 70% in 2004 (Office of National AIDS Policy, 2010).

In addition to AIDS burnout and treatment optimism, research indicates an increase in sexual risk behavior among MSMs (Benotsch et al., 2002; Blackwell, 2008; Brennan, 2010; Brewer et al., 2006; Parsons, 2005; Van Kesteren, 2007; Wolitski et al., 2001). It is possible that the practice of faulty harm reduction sexual techniques has contributed to the increase of new HIV cases among MSMs. Some of these techniques include HIV positive men positioning themselves as the receptive partner for unprotected anal sex, as a method of strategic positioning designed to reduce sexual risk (Parsons, 2005; Van De Ven et al., 2002). Other risk reduction efforts include serosorting or limiting sexual partners to seroconcordant (similar) HIV status (Barrett et al., 1998; Eaton et al., 2009; Parsons, 2005). Consequently, HIV positive males limit sexual intercourse to other HIV positive males. Conversely, HIV negative males will seek similar partners. Faulty rationalization assumes a skewed perceived susceptibility to contracting HIV, that sexual partners are aware of their HIV status, and/or willing to truthfully disclose this information (Eaton et al., 2009; Parsons, 2005).

Levels of HIV stigma associated with homosexuality reduced as universal susceptibility is encouraged via public health awareness campaigns. UNAIDS defines HIV stigmatizing as a "social process of devaluation that reinforces negative thoughts about a persons living with HIV and AIDS" (Brooks et al., 2005). However, social bias still remains, which in turn creates limited dating outlets (Brooks, 2005). Like other disenfranchised groups, MSMs have few places in which they can meet without fear of social consequences. Several outlets include gay pride cultural events, friendship networks, and sexually charged environments (gay bars, bath houses, and public places) (Bull et al., 2004; Parson, 2005; Van Kersteren, 2007). It is in these sexually charged environments that spontaneous, unexpected and unprotected sex take place. Intentional acts of unprotected sex have become colloquially known as "bare-backing" (Blackwell, 2008; Parsons, 1995). A newly emerging outlet that is of particular interest is the internet. This medium provides a new way of meeting sexual partners without scrutiny (Benotsch et al., 2002; Blackwell et al., 2008; Bull et al., 2004). Description of online sex partner seeking highlights a three stage process that often includes the use of MSM chat rooms, meetings in person, and then ultimately sexual activity (Benotsch et al., 2002; Bull et al., 2004).

#### **2.1 Interventions**

Strategies for reducing HIV among MSMs have included; (1) expanded HIV testing so that infected persons can be identified, treated and the risk of transmitting the virus is minimized; (2) individual, small group and community level interventions to reduce risk

HIV transmission can be mitigated when infected persons are receiving HAART therapy and has a reduced viral load (Brennan et al., 2010; Quinn et al., 2000). This coupled with the availability of postexposure therapy and viral load monitoring lessens the perceived risk of contracting HIV. However, even if risk is lessened on an individual level, increases in risk taking behavior have implications for population based concern for increased HIV transmission.Yet another social factor that has influenced treatment optimism is diminished public attention. Converse to reports of AIDS burnout, it's believed that in general, media and public attention to HIV/AIDS has decreased since the onset of the epidemic and many no longer view it as a public health emergency. A 2009 Kaiser Family Foundation survey found only 45% of respondents indicated hearing messages highlighting the plight of

In addition to AIDS burnout and treatment optimism, research indicates an increase in sexual risk behavior among MSMs (Benotsch et al., 2002; Blackwell, 2008; Brennan, 2010; Brewer et al., 2006; Parsons, 2005; Van Kesteren, 2007; Wolitski et al., 2001). It is possible that the practice of faulty harm reduction sexual techniques has contributed to the increase of new HIV cases among MSMs. Some of these techniques include HIV positive men positioning themselves as the receptive partner for unprotected anal sex, as a method of strategic positioning designed to reduce sexual risk (Parsons, 2005; Van De Ven et al., 2002). Other risk reduction efforts include serosorting or limiting sexual partners to seroconcordant (similar) HIV status (Barrett et al., 1998; Eaton et al., 2009; Parsons, 2005). Consequently, HIV positive males limit sexual intercourse to other HIV positive males. Conversely, HIV negative males will seek similar partners. Faulty rationalization assumes a skewed perceived susceptibility to contracting HIV, that sexual partners are aware of their HIV status, and/or willing to truthfully disclose this information (Eaton et al., 2009; Parsons,

Levels of HIV stigma associated with homosexuality reduced as universal susceptibility is encouraged via public health awareness campaigns. UNAIDS defines HIV stigmatizing as a "social process of devaluation that reinforces negative thoughts about a persons living with HIV and AIDS" (Brooks et al., 2005). However, social bias still remains, which in turn creates limited dating outlets (Brooks, 2005). Like other disenfranchised groups, MSMs have few places in which they can meet without fear of social consequences. Several outlets include gay pride cultural events, friendship networks, and sexually charged environments (gay bars, bath houses, and public places) (Bull et al., 2004; Parson, 2005; Van Kersteren, 2007). It is in these sexually charged environments that spontaneous, unexpected and unprotected sex take place. Intentional acts of unprotected sex have become colloquially known as "bare-backing" (Blackwell, 2008; Parsons, 1995). A newly emerging outlet that is of particular interest is the internet. This medium provides a new way of meeting sexual partners without scrutiny (Benotsch et al., 2002; Blackwell et al., 2008; Bull et al., 2004). Description of online sex partner seeking highlights a three stage process that often includes the use of MSM chat rooms, meetings in person, and then ultimately sexual activity

Strategies for reducing HIV among MSMs have included; (1) expanded HIV testing so that infected persons can be identified, treated and the risk of transmitting the virus is minimized; (2) individual, small group and community level interventions to reduce risk

HIV/AIDS compared to 70% in 2004 (Office of National AIDS Policy, 2010).

2005).

(Benotsch et al., 2002; Bull et al., 2004).

**2.1 Interventions** 

behaviors ;(3) promotion of condom use ;and the (4) detection and treatment of sexually transmitted diseases (CDC, 2011). Two of the latest prevention strategies include cyberspace educational prevention approaches and Pre-exposure Prophylaxis Initiatives (PrEP). The internet is emerging as an important venue for forming sexual networks among MSMs (Benotsch, et al., 2002). To create effective interventions that are specific to MSMs cyberspace interventions have varying components that include safer sex guidelines, emailing systems for partner notification and psychosocial components designed to increase motivation for behavior change (Benotsch, et al., 2002). Pre-exposure prophylaxis is designed to prevent the acquisition of HIV infection among persons uninfected but exposed to MSMs. Preliminary findings indicate that daily orally administered antiretrovirals may partially reduce HIV among MSMs when provided with regular monitoring of HIV status and ongoing risk reduction adherence counseling (CDC, 2011).The CDC and other U.S Public Health Service (PHS) agencies are developing guidelines for the use of PrEP among MSMs at high risk for HIV.
